A system of practical medicine. By American authors. Vol. 4 (part 2 of 6)

A system of practical medicine. By American authors. Vol. 4 (part 2 of 6)

During an attack of dysmenorrhoea the patient should remain in bed for the benefit of rest and warmth. In those cases where the flow is not too free, and especially when relief follows its appearance, active measures to promote this end may be instituted by hot drinks and hot fomentations. In married patients a hot sitz-bath, during which the vaginal syringe is used to douche the uterus, is an efficient measure. Pain being the prominent symptom, and remedies for its relief being at hand and reliable, the indication is clear and the treatment can be briefly stated. In execution, however, it is not a simple problem: immediate relief is not alone to be considered. If opiates be resorted to for frequently-recurring pain, a habit will soon be formed that is no less a calamity than the disease itself. While, therefore, opium and its preparations are reliable remedies, and in many cases indispensable, they should be administered as seldom and as sparingly as possible, and always with an appreciation of possible injurious consequences. Many cases can be successfully managed with chloral hydrate, or belladonna, or Indian hemp. When opiates are resorted to, they should be combined as much as possible with other medicines by which their effects are modified, and relief afforded with the smallest possible dose. Thus in cases attended with vascular excitement these ends may be attained by the union of opium with tartar emetic or aconite; when there is marked disturbance of the nervous system, it may be combined with an antispasmodic, as the compound spirit of ether. Administration by the rectum will produce a local as well as a general effect, and injections of starch and laudanum or suppositories of opium and belladonna may be administered. The speediest and most certain relief is afforded by the hypodermic syringe. Resort to it should, however, be rigidly controlled; it should be used as a miser uses his gold, and it need scarcely be added that only very exceptional, if any, circumstances will ever justify placing the syringe in the hands of friends or attendants, no matter with what restrictions. Unfortunately, this is sometimes done, but very rarely without great injury resulting.

During the intervals general treatment should be instituted according to the indications. All functions at fault are to be regulated. Anæmia is to be corrected, the debilitating effects of malaria counteracted, good digestion promoted, and a weakened nervous system strengthened. These indications are met by tonics in various forms, notably iron and zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by the judicious use of wine. There are other remedies quite as useful as drugs--cold sponging and shower-baths, followed by vigorous rubbing, general electrization, and, when the patient cannot or will not take outdoor exercise, massage. Change of scene and air is sometimes beneficial or even necessary. In many cases of pronounced neuralgic form, or in which the nervous system has been shattered by the severity or long duration of the attacks, there can be but little hope of amelioration without a thorough change of habits and mode of life in every respect.

The local treatment will be according to the conditions present. In the {199} obstructive form, polypi are to be removed if present, and in stenosis the patency of the canal restored. Dilatation may be accomplished by tents. Should these fail, resort may be had to surgical measures, as the frequent passage of bougies gradually increasing in size, forcible dilatation with steel dilators under an anæsthetic, or by incision. Each of these measures has its advocates, and with all cures have been effected. Flexions should be corrected as far as possible by a vaginal pessary. Intra-uterine pessaries more certainly correct the deformity, but great care should be exercised in their use. If inflammation be present, uterine or pelvic, they will not be tolerated or will do positive injury; nor should a patient with any instrument of this kind ever be allowed to pass out of reach of the physician unless she can herself remove it.

The treatment of many cases of congestive dysmenorrhoea is very similar to that of suppressed menstruation from cold--warm drinks, hot foot- and sitz-baths, fomentations, and douches.

Particular attention should be paid to the bowels, not alone to correct constipation, but to give full relief to a clogged portal system by saline purgatives. If there be prolapsus, a pessary should be adapted so as to keep the uterus up in its place; by this means passive congestion is much relieved. Bromide of potassium is a reliable remedy as a corrector of pelvic congestion. In the congestive cases of anæmic subjects iron will act beneficially; in inflammatory congestion it does injury. Dysmenorrhoea dependent upon hyperplasia or endometritis should receive the treatment appropriate to those affections.

In neuralgic dysmenorrhoea the general treatment is far more important than the local. All those hygienic and therapeutic measures already detailed should be faithfully persevered with. For the relief of pain and control of the nervous symptoms enemata of asafoetida are useful. Chloral may also be administered in the same way or by the stomach, with camphor, valerian, and the æthers as required. In this form apiol has been successfully used; the evidence as to its value is clearer than the explanations of its mode of action. It may be given in capsules, each containing five grains, one, two, or three daily.

Some local measures often render good service: among them is the passage of bougies, which sometimes modify the sensitiveness of the cervical canal, as they do that of the male urethra. The galvanic current, both continuous and Faradic, has effected cures, but the cases to which it is best adapted or in which it is most likely to be good cannot be clearly indicated. A galvanic stem-pessary may be used, observing due caution. This instrument has been modified and much improved by Thomas: being made like a string of metallic beads, it is extremely flexible, and many of its former objectionable features are removed.

A successful treatment of membranous dysmenorrhoea has not yet been promulgated. The great difficulty of its cure is admitted by the highest authorities. Some cases associated with stenosis of the cervix have been cured by dilatation--a fact which but strengthens the general principle of correcting all anatomical changes whenever possible. Strong caustics have been applied to the interior of the uterus with a view of exerting an alterative influence upon the seat of the disease. The course seems correct in theory, but in practice it has not proved fruitful of good results, and treatment in the majority of cases is limited to palliation.

{200} In regard to marriage in females afflicted with dysmenorrhoea, it may be stated to be advisable in many cases of the neuralgic form and in anæmic subjects where the flow is so scanty as to border on amenorrhoea. In cases of the congestive form, if dependent on inflammation or on organic lesions, as fibroids, there is very great probability that the symptoms will be aggravated by this radical change of mode of life.

Menorrhagia.

The term menorrhagia signifies excessive menstrual flow. The excess may be by increased rate of discharge during the usual time, by lengthened duration, or by too frequent returns of the periods.

There are wide physiological limits to the amount of discharge and the duration of a menstrual period. While the average time is from three to five days, and the average amount from three to five fluidounces, both these terms may be doubled, or, on the other hand, they may be diminished to a single day and a single ounce, without detriment to the health. Menorrhagia may be said to exist when the flow is in excess as compared with what is usual with the individual, or when the loss is so great as to affect her general health.

The periodical return of the flow is of prime importance in establishing the existence of menorrhagia. Repetition at periods approximating the menstrual is the keynote of diagnosis. By this menorrhagia is distinguished from the hemorrhage of a miscarriage and from metrorrhagia. A profuse flow of blood after an absence of menstruation for one or two months is held by patients, in perfect good faith, to be the effect of taking cold: with almost absolute certainty such a train of events indicates an abortion. Metrorrhagia is uterine hemorrhage occurring independently of the menstrual periods. More surely indicative of organic disease than menorrhagia, it is often most closely allied to it; many cases which in the early stages present an increased menstrual flow as a symptom are at a more advanced period accompanied by metrorrhagia.

Thus far the diagnosis of menorrhagia is easy. Not so that differential diagnosis upon which alone can therapeutic measures be based.

This derangement depends upon as many and as widely diverse causes as the others. It is often one expression of affections of the general system, is sometimes caused by disease of organs neither pelvic nor generative, is a common symptom of a number of organic diseases of the uterus, or it may be simply functional. The necessity for a thorough physical examination is apparent. By touch, single and bimanual, by the speculum, and by the uterine sound the condition of all the pelvic organs should be investigated. These means failing to reveal the cause of the menorrhagia, the examination should be pushed farther. The cervix should be dilated by tents and the cavity of the uterus explored. Very frequently this measure, and this alone, will reveal the cause of the derangement. Such an examination is often as valuable for its negative as for its positive results. No practitioner fulfils his duty to his patient or is just to himself who treats a menorrhagia for any length of time without making a physical examination. It may seem unnecessary to emphasize so plain a duty, yet consultants very frequently find cases in {201} which palpable causes of the disease exist and where a direct examination has not even been proposed.

The following schedule will indicate the widely diverse conditions which may give rise to menorrhagia, and will serve as a guide to the study of the subject:

CAUSES OF MENORRHAGIA.-- I. Diseases of the General System: Plethora; Chlorosis and anæmia; Debility, as from excessive lactation; The exanthemata and typhoid fever; Hæmophilia; Scorbutic, uræmic, and malarial cachexiæ. II. Local Affections, not Uterine: Cerebral, as psychical influences; Cardiac and pulmonary affections, as valvular disease, emphysema, and phthisis; Hepatic diseases, as cirrhosis and the changes produced by residence in tropical climates; Splenic and renal disease; Abdominal tumors and loaded bowels; Peri-uterine inflammations; Ovarian influences. III. Uterine Causes: Subinvolution; Areolar hyperplasia; Endometritis, with fungous growths; Laceration of the cervix, with eversion; Ulceration of the cervix; Displacement of the uterus; Polypi and fibroid tumors; Retention of products of conception; Malignant disease; Congestion.

I. Menorrhagia, the result of the first class of causes, but rarely occupies more than a subordinate position. The acute affections, as the exanthemata, do not afford time for more than a single flow, and this has been well termed uterine epistaxis. The condition of plethora is manifest. The cachexiæ are generally well marked and evident. An exception may be made in this regard as to the effect of prolonged residence in malarious locations. There can be no question that menorrhagia is frequently of malarial origin, and even when the patient does not present a cachectic appearance. The disease may be produced by hepatic and splenic derangement, by deteriorated sanguinification, or by depression of nervous force. Menorrhagia is not infrequently a result of Bright's disease; an examination of the urine would determine this point. That the opposite conditions of plethora and anæmia should both cause menorrhagia is not difficult of explanation; in the one there is excess of blood with increased vascular pressure; in the other, a changed condition of the blood favoring transudation, with loss of tone of the vessels.

II. That menorrhagia, as well as amenorrhoea, may have a purely {202} emotional origin there can be no question, although this cause is not generally recognized. The following case is an illustration: A healthy young married woman, while menstruating, saw a neighbor's son thrown from his horse; his foot became entangled in the stirrup, and he was trampled to death before her eyes. She was immediately taken with flooding, and profuse menstruation occurred for several succeeding periods. Siredey expresses doubts as to cardiac and pulmonary diseases so frequently causing menorrhagia as they are generally believed to do. In a considerable experience during several years, and paying special attention to this point, he found but one case thus caused. The mechanical effect of disease of the abdominal organs in producing passive congestion in distal parts is more direct and the influence in producing menorrhagia more apparent. The same may be said of accumulations in the bowels and the pressure of abdominal tumors. Peri-uterine inflammations rank very high in the list of causes: their presence and results, direct and indirect, as abscesses, displacements of the uterus, etc., should never be overlooked. Ovarian influence is naturally a potent etiological factor; menorrhagia is a frequent result of sexual excesses, and is often seen in prostitutes and where there is great disparity of age between the husband and wife.

III. Affections of the uterus itself are by far the most frequent cause of menorrhagia. The necessity of investigating accurately the condition of the great central organ of menstruation, and of ascertaining to what particular disease the derangement of the flow is to be attributed, will bear repetition. That an anatomical or pathological diagnosis can always be made is not maintained, but when examination has failed to reveal a basis for such a diagnosis, the practitioner should distrust his position and consider his diagnosis provisional only, awaiting more information from renewed examination or from further progress of the case. The cases are few in which such a diagnosis cannot be made. They are recognized by the term congestion as a cause in the schedule given above. Congestion is of course the prominent factor in many cases of menorrhagia, as in those from polypi and fibroids, those produced by ovarian influences, and others which are evident. But the class here recognized consists of those cases in which no anatomical or other cause can be found, excess of the congestive element of menstruation alone affording a rational explanation. Such cases occur most frequently at the two extremes of life--at puberty and at the menopause. During both these periods menorrhagia often occurs unexpectedly and inexplicably.

The grosser forms of uterine growths, as malignant disease, polypi, and fibroid tumors, are generally discovered without difficulty. The touch reveals them, or the sound or bimanual examination indicates their possible presence, which is confirmed by dilatation of the cervix and exploration of the cavity of the uterus. This class of cases gives rise more frequently to metrorrhagia; only exceptionally is the hemorrhage confined to the menstrual periods.

A recent delivery in the history of the patient will indicate with some probability one of several conditions which may give rise to menorrhagia. Especially is this the case if the complete generative cycle has been broken in any part of its course. If there has been a miscarriage, there will be great probability of retained portions of the placenta or membranes; {203} if from death of the child or other cause nursing has not been performed, the conditions will be favorable for subinvolution of the uterus; if labor has been instrumental or precipitate, laceration of the cervix may be suspected. The first two far exceed in frequency the last as causes of menorrhagia. Laceration of the cervix exists often without producing this functional disturbance, while subinvolution and retention of products of conception are very often active agents.

Displacements of the uterus, either prolapsus or versions and flexions, often have menorrhagia as a symptom.

The chronic inflammatory affections of the uterus are fruitful causes, and menorrhagia is often found associated with, and sometimes dependent on, the condition known as chronic corporeal metritis or areolar hyperplasia, with consecutive erosions or ulcerations. Inflammation of the lining membrane of the uterus accompanied by granulations or fungous growths is one of the most frequent causes of menorrhagia. Opinions differ as to the part inflammation plays in producing this condition. Its entire absence in some cases is not improbable, the fungosities springing from the seat of the placenta. By Winckel the affection is termed adenoma diffusum et polyposum corporis uteri; by Olshausen it is called endometritis fungosa. Under various names the condition is well known and recognized as one of the most frequent of all the uterine causes of menorrhagia; Siredey believes it to be the origin of nearly one-half the cases. Due consideration of this cause is especially important, because especial investigation is required for its detection. The cervix must be dilated and the blunt curette passed over the internal uterine surfaces. This will furnish ocular and tangible evidence by detaching and bringing away some of the fungous growths, and a diagnosis will thus be made impossible in any other way.

In considering the treatment of menorrhagia the management of the patient during the intermenstrual periods must first engage attention. The general health is to be promoted in every possible way and sound hygienic regimen enforced. Two points demand especial attention--the clothing and the bowels. All tight bandages around the abdomen should be loosened, and all skirts and underclothing which hang upon the hips be supported from the shoulders. The beneficial influence of free action of the bowels cannot be overrated. Regular daily movement is required in all cases, but much more is often of decided benefit. In menorrhagia of the menopause in patients who have accumulated considerable adipose tissue, especially about the abdomen, in those where there is evident hepatic derangement, and in some others free purgation with salines is one of the most efficient measures of treatment.

During the menstrual intervals cachexiæ are to be treated according to their nature. Chlorosis and anæmia will require iron, quinine, nux vomica, and other tonics--the malarial cachexia the same, with the addition of arsenic, which often renders especial service under these circumstances. Then, too, the various uterine lesions giving rise to menorrhagia must be corrected. Subinvolution is to be remedied, polypi removed, the evil effect of fibroids combated by hypodermic injections of ergot, displacements corrected by suitable pessaries, the tone of the vessels and tissues of the pelvis increased by cold bathing, and all indications fulfilled according to the nature of the case. For details of treatment the reader {204} is referred to the articles upon the various general, local, and uterine diseases which have been shown to cause menorrhagia.

Especial attention should be given to girls whose menstrual life begins with menorrhagia, lest a vicious habit become fixed. The evils of school-life or those of sedentary indoor occupations should be corrected, and rest in the recumbent position during menstruation enforced. For the menorrhagia of puberty tonics, especially nux vomica and brief applications of cold to the pelvic region, are particularly indicated.

During an attack of menorrhagia the first remedy, and one without which all others are useless, is rest in the recumbent position. If the attack be severe recumbency should be absolute. Food should be light in quality and moderate in amount, while all drinks are to be taken cold, as ice-water, iced lemonade, or water acidulated with sulphuric acid and sweetened to the taste, the beneficial effect of acids in addition to cold being generally recognized. The bed should be hard and the clothing light, and the foot of the bedstead may be raised some inches. Many cases require no more active measures of repression. In subjects about the menopause, in some cases of malignant tumor, and in some others the hemorrhage seems to be a vent, and in moderate degree is rather beneficial. Such cases are to be watched, but need not necessarily be actively treated, certainly not with repressants and astringent applications, until regimen and mild measures have been tested.

In proceeding to medication the state of the general system first demands consideration. If there be increased vascular action and temperature, with evidences of active congestion of the pelvic region, manifested by pain, distension, and tenderness of the hypogastric region, with heat and throbbing of the passages, arterial sedatives and relaxants will be demanded. Aconite or veratrum viride may be given until an effect is produced on the pulse, and they may be combined to advantage with salines, as the liquor ammonii acetatis. It is in these conditions, of rare occurrence, that nauseants, such as ipecacuanha, are of service.

Medicines having a more direct action in checking uterine hemorrhage produce their effect by exciting contraction of the uterine walls and blood-vessels, moderating congestion, and modifying the condition of the nervous system. They are ergot, digitalis, bromide of potassium, quinine, cannabis indica, and cinnamon.

Ergot stands at the head of the list from its well-known effect in causing uterine contraction, and although reliable in proportion to the increased size of the uterus and the distension of its cavity, it is indicated in almost all cases for its hæmostatic action on the capillaries, as well as for its specific action on the uterus. Digitalis slows the action of the heart and excites the contractility of the arterioles, while experience has proved it to be an efficient remedy for menorrhagia. Bromide of potassium moderates vascular and nervous excitement of the pelvic organs, and is especially indicated in cases having an ovarian origin. Several of the French writers give very strong testimony in favor of the efficacy of cinnamon as a remedy, having tested it in a large number of cases without other medicines. It may always be used as an adjuvant.

All these medicines may be combined in various proportions, and they should be given in full doses. Infusion is the best form for the administration of digitalis. Sulphate of quinia in doses of gr. vj-x is often an {205} efficient remedy, and especially in cases where there have been malarial influences. Cannabis indica is stated, by very high authority, to be one of the best remedies, although its mode of action is not clear. Iron should be administered as an hæmostatic tonic, and not merely because there is some uterine disease or derangement.

The action of medicines may be supplemented by local applications. Cloths wrung out of cold water or vinegar and water may be applied to the hypogastric region or to the vulva. A bladder or rubber bag filled with pounded ice may be laid on the abdomen above the pubes, or applied to the lumbar region for its effect upon the spinal cord. One of the most efficient means of applying cold is by an enema of cold water, or, this failing, of ice-water. The rectum and uterus being contiguous, the cold is applied almost directly. Siredey speaks highly of the cold douche to the soles of the feet, the water being projected in jets from a sprinkler. During the application uterine contractions are felt and the flow stops. This is more especially adapted to debilitated and anæmic patients with loss of vascular tone. Patients will often object to the application of cold to check a flow of blood from the uterus, knowing well the bad effects of suppression of menstruation which often results from exposure to this agent. It is believed that evil results never follow the application of cold when the flow is excessive; perhaps because the system and the organs concerned have been relieved.

The application of heat is also an efficient remedy--hot-water bags to the spine on Chapman's plan, or hot vaginal injections may be administered, as recommended by Trousseau and Emmet, the water being at a temperature as high as the patient can bear. To be properly administered the aid of a nurse is required, as the flow should be kept up for some time, at least a gallon of water being used.

There is only apparent contradiction in the use of both cold and heat to check uterine hemorrhage. Various explanations of the action of both have been given, and much argument presented why one should act better than, or be preferred to, the other. The truth is, that both are efficacious, and the value of both is based upon clinical experience.

The flow in menorrhagia is sometimes, if rarely, so excessive as to demand mechanical means of restraint. A well-applied tampon gives absolute control, and should never be omitted when the hemorrhage is severe and the practitioner is not within easy reach of the patient. Plugging the cervix with a sponge tent, supported by a vaginal tampon, is to be preferred as most reliable, and also because upon its removal the uterus can be explored for diagnosis or is prepared for direct applications. Should a vaginal tampon alone be trusted, it must be thoroughly applied to be reliable. This can only be done through a speculum, preferably with Sims's duckbill. Pledgets or discs of cotton, the first provided with strings to facilitate removal, squeezed out of a carbolized saturated solution of alum, should be packed carefully and firmly around and over the cervix, and the vagina filled. A folded napkin to the vulva, supported by the usual T bandage, sustains the whole. Such a tampon may remain, if necessary, thirty-six hours, the catheter being used to relieve the bladder.

Direct applications to the interior of the uterus are sometimes necessary both to check the flow and, in some cases, especially those dependent {206} upon fungous growths of the endometrium, as a means of cure. They may be either fluid by application or injection, or solid. The former may be by swabbing the interior of the uterus by means of an applicator armed with cotton dipped in the liquid, or by injection. The drugs used for application are carbolic acid diluted with glycerin or pure tincture of iodine, or the stronger tincture known as Churchill's, Monsell's solution, or the liquor ferri perchloridi diluted or of full strength. The preparations of iron are objectionable from the hard, gritty, and disagreeable coagula formed, and the tincture of iodine is generally quite as efficient as a hæmostatic and more active as an alterative.

For efficient application the cervix should be dilated if not sufficiently patulous, and a cervical speculum should be used, or the solution will be squeezed out of the cotton before it reaches the seat of the disease. For injection the same articles are used, beginning with weaker solutions and gradually increasing the strength. They should never be resorted to without the utmost caution. The os should be patulous as a sine quâ non, and the injection carefully administered. In case the os is open the instrument may be the common extra long-pipe rubber syringe bent to a suitable curve by heating. This having been charged with a drachm or so of the liquid, the end is served with cotton like an applicator; over this several clove-hitch turns with a string are taken, so that the cotton may be withdrawn if pulled off in the uterus. The pipe is then carried to the fundus and the piston very slowly depressed. Buttle's syringe is a more elegant and a safer instrument in cases where the os is not thoroughly opened. The terminal pipe of this instrument is very slender and perforated with minute openings, and the piston is forced in by screw-action of the handle, so that the fluid is expelled drop by drop.

Nitrate of silver is sometimes applied in solid form to the interior of the uterus, both as a means of checking excessive hemorrhage and to effect a cure by modifying the condition of the endometrium. It may be done with a probe, the end of which has been coated with the substance, passed in detail over the inner surface of the organ. A piece of the solid caustic is also sometimes carried into the uterus and left there, the application à demeure of the French, some of whom claim that in their hands this measure has never failed to check the hemorrhage.

In those cases where positive evidence has been gained that the disease depends upon fungous growths of the endometrium there is yet another and a more reliable remedy. It is the curette. By this instrument the growths which are the origin of the menorrhagia can be certainly and safely removed, their return prevented by a thorough application of iodine to the surface from which they spring, and a cure often effected when all other means have failed.

Intra-uterine applications, injections, and surgical measures affecting the interior of the uterus have been detailed, as they are advised and used by authorities. It remains to give an opinion as to their merits, and to state the precautions which should be taken when they are resorted to.

First, it must be said that there is a very considerable difference of opinion as to the safety of these measures. While some do not hesitate to apply to the interior of the uterus fuming nitric acid, and introduce pieces of nitrate of silver to dissolve there, others are extremely careful {207} about making any applications to this part, and reject intra-uterine injections altogether. Nor can it be denied that very severe symptoms have frequently, and death sometimes, followed the application of these remedies. In resorting to them, therefore, the practitioner cannot be too minute in observing every precaution, and they should never be resorted to if evidence of peri-uterine inflammation exists. No intra-uterine injection should be given unless the os be patulous, and the fluid should be thrown in with the utmost gentleness. The milder articles should be tried first, and the severer only as the temper of the uterus is tested. Always treat the patient afterward as the subject of an operation, keep her in bed strictly, and combat the first symptoms of trouble with opium.

While the writer would not be just to the reader if he did not state that some very high authorities are strongly opposed to intra-uterine injections and applications, he would not be just to himself did he not state that his own experience has been favorable to them. While he once saw severe and dangerous symptoms follow syringing the cervix with water to cleanse it of mucus, he never in a single instance saw any evil effects from intra-uterine injections properly administered, nor from nitrate of silver à demeure or the application of nitric acid. But while these measures have often ameliorated cases of menorrhagia where the endometrium was affected, they have seldom cured, as compared with the curette. Indeed, the general statement may be made that as of late years the value of the curette has become more and more recognized, resort to severe intra-uterine applications has proportionally diminished. From his experience he is fully prepared to believe with Courty, that "there are cases of uterine hemorrhage which cannot be mastered in any other way," and with Siredey, that "the operation cures in the great majority of cases." It should be noted, in this connection, that some of the warmest advocates of the instrument explain its beneficial effects otherwise than by the removal of fungosities. Thus, Thomas attributes them to "the fracture of tortuous and distended blood-vessels," and Siredey to "the irritation and excitation produced by its introduction and action during reflex contractions."

{208}

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.

BY B. F. BAER, M.D.

The subject of inflammation of the tissues surrounding the uterus and its appendages would be very much simplified, especially for the general practitioner, by debarring it of all new and superfluous names and subdivisions, and by treating it on a broad clinical basis. It will be my aim in this paper to keep that idea constantly in view, rather than to follow the history and varying pathological views by which it has been surrounded and complicated.

The importance of this disease is probably greater in its influence on the health and future usefulness of the woman than any other; and its causes and prevention, as well as its early recognition and treatment, should be fully understood by the physicians who are most likely to be first consulted in the matter, those engaged in general practice. I feel safe in making the statement that were this so, many of the chronic cases of almost incurable displacement of the uterus, Fallopian tubes, and ovaries, resulting from thickened, indurated, and contracted ligaments, with their distressing symptoms, would never reach the gynecologist, because they would not then exist. In many cases the disease would have been prevented; in others it would have been arrested in its incipiency.

Whether we understand the primary pathological lesion to be inflammation of the cellular tissue, the peritoneum, the lymphatics, or the veins, matters very little, practically, if we recognize the immediate location of the process; for there can be no doubt that the disease, once started, soon involves to a greater or less degree all of the tissues and organs adjacent to it, and the therapeutic requirements will be much the same in either case.

That inflammation of the cellular tissue can exist without also involving the peritoneum in its neighborhood is scarcely to be conceived, and vice versâ; but the one has always a predominating influence over the other, and differs somewhat in its cause, course, and consequences. When the inflammatory process has its origin in the cellular tissue, it is more likely to run through a regular course and end in abscess than if it had started as a peritonitis, in which case the course of the disease is often more chronic, resulting in the formation of false membranes which bind the uterus and other pelvic organs in permanent displacement. For these reasons, and for the more systematic study of the subject, I think it best to follow the plan of those authors who describe the disease separately under the two general heads, Parametritis and Perimetritis.

{209} Parametritis.[1]

[Footnote 1: Virchow, Duncan.]

DEFINITION AND SYNONYMS.--By parametritis is understood an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds--viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. I think it a better name than pelvic cellulitis or peri-uterine inflammation, because it more correctly expresses the primary location of the disease than any other. The disease has been described under many other appellations, among which have been pelvic abscess and peri-uterine phlegmon.

ETIOLOGY.--Parametritis does not occur before puberty, and rarely before the great predisposing causes, abortion and injury at parturition, have prepared the parts--opened up the channel--for the more ready advance of the inflammatory process. This is easily understood when we remember how compactly bound together are these ligamentous folds, and how small the cellular-tissue spaces are before impregnation when compared with the condition of the parts after the function of gestation has been performed. Even were no accident to occur to interfere with the perfect involution of the parts which enter into the process of the expulsion of the product of conception, the tissues would probably always remain more vulnerable than before the gestation had occurred. But when the retrograde change which is necessary to perfect involution is retarded, a condition of relaxation and looseness of the parts results which increases many fold the liability to the affection. The blood-vessels and lymphatics remain large, and the connective-tissue cells are not only larger in size, but a cell-proliferation is probably induced as a result of the increased amount of blood-supply. Then a certain low condition of the general nutrition, a diathesis or an inflammatory tendency, no doubt act as predisposing causes of this disease. Now, add to the predisposing causes the injury which probably always attends abortion, and that which so often results from parturition proper, and a condition results which I believe to be the cause of parametritis in the majority of the cases.

Abortion the result of accident or design is a most prolific cause of parametritis, because abortion is so often followed by endometritis, which is frequently the starting-point of the former. Abortion results in a wounding of almost the entire surface of the uterine cavity, from which the placenta is torn, and often also in direct injury to the tissues of the neck of the womb. This almost necessarily interferes with involution; and if nothing worse follows immediately, there is left a strong tendency to a low grade of inflammation or hyper-nutrition, which may practically result in the same condition of induration and thickening of ligaments. It is seldom that the subject of an abortion of this character escapes from a certain degree of parametritis. If it does not manifest itself at the time in violent symptoms, the results are found afterward, when the patient is forced to consult her physician for the relief of suffering the consequence of the thickening and induration mentioned above.

{210} Parturition without injury or accident is a predisposing cause, as before mentioned, of parametritis, and renders the patient more susceptible to the disease from cold, fatigue, etc., and from septic influences; but when the labor has resulted in injury to the soft parts, as laceration of the cervix, endometritis, injury to the vessels outside of the uterus, in the broad ligaments from pressure, the disease is far more liable to follow.

Parametritis may result from the various operations on the perineum, vagina, and uterus; from the application of medicines to the uterine cavity; and it is even said that the disease has been excited by the introduction of the uterine sound. I cannot believe that the simple introduction of the sound, when properly done, can be the means of so much harm. If harm follows, it must result from carelessness or want of skill. Of course there are contraindications to the use of the sound, and if these are violated evil will often follow. The use of the instrument ought not to be thought of if a suspicion of pregnancy exists, or when there is marked tenderness of the uterus or of the parts around it, or just before, during, or immediately after menstruation, and certainly not when active inflammation is present. Then the awkward manipulation of the sound when the uterus is fixed as a result of a former inflammation is very apt to relight anew the process.

If the same restrictions are applied and care used in the medication of the uterine cavity, the cases in which parametritis will follow as a result will be almost nil. The same will apply to operations. The danger lies in proceeding with the treatment of cases as they present themselves, by a hurried method and without fully investigating the condition of the tissues and organs outside of the uterus itself.

There is probably no place where experience is of more value than in the manipulations and instrumental measures necessary for the diagnosis and treatment of the various diseases of the pelvic organs--where more depends upon the skill and care of the operator. I believe, with Duncan, that pelvic inflammation and abscess are always secondary, and that these tissues are not specially inclined to idiopathic inflammatory action. But, undoubtedly, certain low conditions of the system or certain individual peculiarities furnish such a strong predisposing influence that a mechanical cause otherwise inactive will be sufficient in some of these cases to produce the disease. We probably see this expressed most fully in the low types of puerperal inflammations which develop gradually and without apparent cause, so far as injury at labor is concerned, and which often persistently progress to a fatal termination. It will be said that these are cases of septic origin; and it may be true, but I believe the poison is developed autogenetically.

COMPLICATIONS.--Parametritis is usually associated with perimetritis, and it may be complicated by ovaritis, endometritis, and salpingitis. Uterine displacement also often complicates this disease; and I wish here to emphasize the statement that no attempt should be made at restoring the organ to its normal position until all evidence of active inflammation shall have subsided. I have seen great harm result from such attempt having been made on the supposition that the symptoms were due to the displacement rather than to the parametritis.

ANATOMY, PATHOLOGY, COURSE, AND TERMINATION.--Everywhere in the pelvis, below the peritoneum, connective tissue is found in sufficient {211} abundance to serve the purposes for which it exists--viz. first, as a bond of union between the pelvic viscera and organs, bladder, uterus, rectum, ovaries, and Fallopian tubes; second, to surround, support, and protect the numerous blood-vessels, lymphatics, and nerves from injury during the mechanical disturbances to which the pelvic tissues are subjected in the performance of their various functions.

If it were not for the padding of the pelvic connective tissue, which allows a free range of movement to the pelvic contents, the ordinary sudden jars from walking, coughing, etc. could not be sustained without pain, nor could the functions of the rectum and bladder be fulfilled properly; much less could the functions of coition and gestation be performed. This cellular tissue most abounds where it is most needed--in the locality or spaces where the vessels and nerves are found in greatest number; viz. at the sides of the uterus and upper portion of the vagina, extending outward between the folds of the broad ligaments toward the pelvic wall and the under surface of the Fallopian tubes and ovaries; next, within the folds of the utero-sacral ligaments and the vesico-uterine space beneath the peritoneum. There is little between the peritoneum and posterior vaginal wall, between the bladder and its peritoneal investment, as well as between the rectum and peritoneum; and there is none between the latter membrane and the posterior, superior, and anterior surfaces of the body of the uterus.

This areolar tissue is the seat of the disease under consideration, and from a priori reasoning it would be inferred that the inflammatory process would be found most frequently and in greatest severity in the locality where this tissue and the vessels most abound; and this is true, for parametritis almost always has its starting-point immediately at the sides of the uterus, in the lower inner edge of the broad ligaments.

But there is another reason why the disease so often begins here. It is the point, which, with the cervix, must bear the brunt of the pressure and injury during parturition and abortion, as well as from many of the operations which are performed upon the uterus. That inflammation of these tissues is secondary to injury is proven by the fact that we so often find the results of it, induration and thickening of the broad ligaments, in the cases of laceration of the cervix which come under our care. I have constantly observed that the inflammatory indurations were greatest on the side on which the laceration was most extensive, and that were the laceration unilateral the evidences of inflammatory action would be unilateral also. I have so frequently met with this condition in connection with laceration of the cervix that I have come to regard its entire absence as quite exceptional. I refer now to the deeper lacerations. Of course these inflammatory products are met with when the cervix is entire and apparently healthy, but this does not disprove the statement that they are probably invariably secondary, and very often secondary to injury at labor; for while the cervix may have escaped laceration, the tissues and vessels may have been so contused from pressure and instrumental measures as to result in the disease. But, however originated, the inflammation and infiltration advance in the direction of least resistance--i.e. along the course of the connective-tissue spaces between the various ligaments. The product of the inflammation, the pus, would therefore most likely follow these channels in making its exit. If the primary inflammation arise at {212} the base of the broad ligament, it may travel within the folds of the ligament outward to the lateral wall of the pelvis and upward to the iliac fossa. This is probably the course which is most commonly taken by the process in puerperal parametritis, and to which is due the induration and tumor which so often exist in that region during the course of the disease. Tumor in the iliac fossa, however, is not at all uncommonly met with in the course of a severe parametritis in the non-puerperal state, and it is doubtless of the same pathological character. Or the infiltration may propagate in the folds or under surfaces of the utero-sacral ligaments, resulting in the formation of a tumor which may eventually surround the rectum. In rare cases, and probably only in the puerperal, the process may develop higher up and more anteriorly, finally taking the direction and following the course of the round ligaments; but I have never met with an instance of it. And it would be impossible to tell correctly in a case opening in the groin--without a post-mortem demonstration, the opportunity for which, fortunately, does not often occur--whether the pus had not descended subperitoneally along the pelvic brim toward the inguinal region. Of course the inflammation and infiltration may be general, so that the uterus may be surrounded by exudation tumors, but this is the exception. Inferiorly, the parametritic process is limited by the pelvic fascia which covers the levator ani muscle.

Parametritis, as phlegmonous inflammations elsewhere, has three stages: 1st, that of active congestion; 2d, that of effusion of serum; 3d, that of suppuration. But the disease does not reach the third stage in all cases. It may be arrested in the first stage or end by resolution in the second. I believe, however, that resolution in the second stage is the exception and not the rule. First, because to end in suppuration is the natural course of the disease; and secondly, because in many of those cases which are carefully observed the ordinary symptoms of the formation of pus, as chill, etc., are usually manifested, and followed by its evacuation. The fact that pus is not discovered should not be accepted as proof that the disease has not advanced to the suppurative stage; for it may be so small in quantity as to escape observation, or it may be discharged into the bowel so high up as to mix with the fecal matter, so that its character is lost by the time it is expelled from the anus, or the point of exit may be so small as to allow it to escape guttatim, and thus elude detection.

Further, pus is sometimes formed and reabsorbed harmlessly, or it may remain deeply seated in a cavity--usually, under these circumstances, a number of small cavities--where it may undergo decomposition and result in the absorption of septic material and destruction of the patient before it finds exit. Then, again, it may become encysted and be retained indefinitely, when it is a source of constant and sometimes obscure suffering, as well as an abiding cause of a renewed attack of the disease.

It is probable also that the process is sometimes arrested in the second stage, neither resolution nor suppuration taking place, the serous portion of the liquor sanguinis being absorbed, the remainder undergoing a change to plastic lymph, so called, which proceeds to organization, resulting in persistent induration of the affected parts; or, instead of being absorbed, the serum may remain encysted within cavities formed for it by the lymph. This likewise subjects the patient to the constant menace of a renewal of the inflammation. The late D. Warren Brickell of New {213} Orleans has called special attention to what he named the serous form of pelvic inflammation, and which he thought had been too much neglected.[2] I have met with at least one well-marked case which supports Brickell's views.

[Footnote 2: "The Treatment of Pelvic Effusions," Amer. Journ. of the Med. Sciences, Philada., April, 1877.]

The usual course, however, of an acute parametritis which has advanced to suppuration is evacuation of the pus by the most favorable channel--i.e. through the rectum or vagina. If through the latter organ, the point of perforation is either directly posterior to, or a little to the side of, the cervix. But if the inflammation be located in the vesico-uterine space--which is rare, however--the point of rupture may be anterior to the cervix. Less frequently the bladder is perforated and the pus discharged with the urine. More rarely the abscess is discharged through the abdominal wall, groin, or saphenous opening, and still more rarely through the sacro-ischiatic and obturator foramina. It may also find exit through the floor of the pelvis near the anus, and it may rupture into the peritoneal cavity, but the latter termination is fortunately the least common. This is probably due to the fact that the slightest irritation and pressure, under these circumstances especially, result in adhesive inflammation between the peritoneal surface of the abscess and that of the intestine with which it may be in contact, thus favoring rupture into the intestinal tract. Then, rupture into the intestine is conservative and protective, and the other is not, for should the pus be discharged into the peritoneal cavity the patient would most likely perish.

When the abscess opens at its most dependent portion, which is the rule, it is kept thoroughly drained of the pus, and if a single cavity exists it gradually contracts, and under favorable circumstances soon disappears, the trouble ending by absorption of the wall of the abscess. This is the most favorable termination of a parametritis, and belongs only to the acute form.

When the pus has not been evacuated from the bottom of the sac, or when there is more than a single cavity and only one is drained, or where the pus has taken one of the circuitous routes mentioned above, the disease merges into the chronic form, and may then be indefinitely prolonged by the formation and evacuation of abscess after abscess, until the pelvic cellular tissue becomes involved throughout and riddled by fistulous tracts connecting them.

SYMPTOMATOLOGY.--Pain is probably the first symptom to attract the attention of the patient, and if the attack is sudden or acute the pain is usually attended by a chill of more or less severity. The pain may be so sharp and lancinating as to cause the patient to cry out in agony, or it may be of a throbbing, aching character. If the former, it indicates either intense congestion of the vessels and tissues involved, or that the peritoneum is largely implicated, probably both. Where the pain is of this character the attack is usually of shorter duration, since it is soon followed by the second stage, exudation, when the symptom is at once modified, becoming less acute and resembling now the pain attending an attack of less severity. Of course the location of the pain corresponds to the seat of the inflammatory process. If it is in one or the other broad ligament, the pain is greater in the right or left iliac regions, most {214} frequently in the left. Pain is often experienced in the hypogastric and sacral regions in the beginning of, or preceding, an attack of parametritis, and it is due to congestion of the endometrium and uterus, from which the disease is spreading to the looser cellular-tissue spaces in the ligaments. If, however, sacral pain persists throughout the course of the disease, or exists in that region chiefly, it indicates that the inflammation has become general or has invaded the utero-sacral ligaments. But it would not be correct to estimate the extent of the disease by the amount of pain complained of, for that symptom depends so largely upon the temperament of the patient and her station in life that it is not trustworthy. Some women suffer so much that they become inured to it or acquire the habit of suffering in silence; others, from temperament, do not actually experience pain; whilst others, again, from a love of hardihood, do not complain, although they may be enduring constant and severe pain. To one of these classes those cases must belong which are said to pass through an attack of parametritis without suffering. That cases do rarely present themselves, on account of mild but persistent symptoms, which are found on examination to contain a large pelvic exudation, I can attest; but I have so constantly found on careful questioning that the usual symptoms of pelvic inflammation were present at some time during the course of the existing illness that I cannot agree with the statement made by some authors that this disease may develop "without causing any particular disturbance" (Emmet).

As a rule, the bladder and rectum are reflexly affected, the former sometimes becoming very irritable, so that there often exists a constant desire to micturate. Constipation is the rule, though I have known a severe diarrhoea to accompany the disease, the result, I thought, of reflex irritation. The stomach also is often sympathetically affected, nausea, and sometimes vomiting of an aggravated form, being present.

With a subsidence of the chill the temperature begins to rise, and continues to increase, with evening exacerbations, until it reaches 102° to 103°, usually its highest point. It may, however, rise suddenly and reach as high as 104° or even 105°--rarely above the latter point. The pulse is usually full, and beats from 112 to 120 per minute, sometimes oftener.

In severe cases tympanites exists, with great tenderness in the hypogastric region; the thighs are also flexed upon the abdomen to protect the parts from pressure and to relieve the abdominal muscles from tension. But when these symptoms are marked it may be confidently concluded that the peritoneum is extensively involved.

Within a few days to a week from the initial symptoms the stage of effusion is probably completed or well advanced, when the symptoms are usually ameliorated. Pain is diminished and the temperature decreased, and if, happily, resolution begins, the patient may gradually recover during the succeeding two or three weeks. But, unfortunately, this very favorable course is not the usual one. Instead of it, the disease often advances to the third stage, that of suppuration. This stage is very commonly ushered in and manifested by rigors or chill, followed by a rise in temperature and an increase in the pulse-rate. There may now be daily afternoon exacerbations of temperature, followed by sweating, until the pus is disposed of, usually by evacuation.

PHYSICAL SIGNS.--If an opportunity is afforded for making a vaginal {215} examination during the first stage, it will be found that the local temperature is markedly increased, that great tenderness exists, and that the parts involved are rigid from congestion. A little later this rigidity or erection subsides, and a bogginess may be discovered at the point or points where effusion is now taking place. Still later, a rather firm and, it may be, irregular swelling of variable size and location can be detected, usually in one of the broad ligaments, and from the size of a hen's to that of a goose's egg. If the inflammation has existed on both sides of the uterus, the pelvic roof, so called, may be found as hard and firm as a board. If pus has formed, fluctuation may be felt, and later a softening process may be detected, indicating the point where Nature is attempting to rid herself of the product of the inflammation.

The uterus is usually displaced by the exudation to an extent depending upon the size of the swelling, to which it is fixed more or less firmly. If the effusion has taken place in one of the broad ligaments, the organ will be displaced to the opposite side, but if the inflammatory process has extended to the cellular tissue in the posterior region of the cervix and in the utero-sacral ligaments, the organ may be displaced forward as well as laterally. If the cellular space between the bladder and cervix alone be involved in the inflammation, the resulting effusion may displace the uterus backward, but the disease is rarely met with in this location. Retroversion of the uterus frequently complicates parametritis, but in that case the abnormal position is not necessarily due to displacement by the exudation. It may have existed previous to the attack.

It must not be forgotten, however, that the symptoms and physical signs, as described above, apply only to the acute form of the disease, and that they do not exist in the same degree nor in the same regular order when the inflammatory process has been subacute, as it often is, from its commencement. When the disease is subacute from the start, the patient may be enabled to go about, and even to pursue a laborious occupation, but not without suffering. There will always be more or less pain experienced in the affected region, and the temperature and pulse will be slightly increased. In rare cases the manifestations of the disease may be so slight or so little complained of that the physician is surprised to find, on examination, a large exudation in one or both broad ligaments.

DIFFERENTIAL DIAGNOSIS.--It is of the greatest importance that this disease should be recognized early, so that prompt measures may be taken to arrest it if possible, or at least to modify the severity of its course. Fortunately, as a rule, the subjective symptoms of pelvic inflammation are so marked that the attention is at once directed toward seeking for their confirmation by eliciting the physical signs; and for diagnosis these local manifestations of the inflammatory process are to be relied upon entirely, as the subjective symptoms of inflammation of the other tissues and organs of the pelvis somewhat resemble those of parametritis.

The diseases the local signs of which approach more nearly those of parametritis are--pelvic hæmatocele, fibrous tumor, the early stage of extra-uterine pregnancy, the early stage of parovarian and ovarian cystic degeneration, and perityphlitis.

In pelvic hæmatocele the symptoms occur suddenly, and often with hemorrhage; there are also constitutional signs of loss of blood, as pallor and coldness of the surface of the body, and if the hemorrhage is great {216} failure of the pulse and syncope. The tumor caused by the escape of blood into the pelvic cavity is generally post-uterine, distending Douglas's cul-de-sac and crowding the uterus forward toward the symphysis pubis, while that formed by parametritis is oftenest located at the side of the uterus. The hæmatocele at first is soft and compressible, becoming hard within a short time--a few days--as a result principally of the surrounding wall of lymph which nature throws out as a protection. The symptoms of parametritis, on the other hand, are more likely to come on gradually, and to present the pulse- and temperature-signs of inflammation, while the resulting swelling or tumor is rigid at first from congestion of the tissues, then hard, becoming soft later as the process advances to suppuration. Mere location of the tumor, however, cannot be depended upon; we must be guided by the history of the case and the special character of the tumor.

Fibroid tumor is not attended with the usual acute symptoms of parametritis, such as pain, increase of temperature, and accelerated pulse; the tumor is hard from the beginning, or at least never soft; it is circumscribed, usually smooth, and not sensitive to the touch. Its attachment to the uterus is also different from that of the tumor caused by parametritis. The former shows a tendency to pedunculation, while the latter has always a broad surface attachment.

The tumor resulting from the arrest and development of a fecundated ovum in the Fallopian tube or ovary resembles very much in its locality, and somewhat in its characteristics, a parametritic tumor; for usually more or less inflammatory exudation is present in connection with extra-uterine pregnancy, giving at times a fixity and hardness to the gestation-sac not unlike that sometimes observed in a tumor parametritic in origin; besides, there may also be constitutional signs of an inflammatory action. But the presence of some of the ordinary signs of pregnancy and a little time will clear up the difficulty; for as the case progresses the tumor will increase in size and change in character, while the mammary and other signs of gestation will develop. In addition, the pain attending tubal pregnancy is never like that of parametritis: it is more persistent, lancinating, and cramp-like in character, and is unattended by rise in temperature. Soon also the placental bruit may be detected, which of course never exists in parametritis.

The early stage of normal pregnancy is said to have been mistaken for this disease. I can hardly conceive how this mistake in diagnosis could be made, although I have met with several cases where the congestion consequent upon fecundation was so violent as to result in actual pelvic inflammatory symptoms with subsequent exudation.

The following case, which I saw with H. A. M. Smith of Gloucester, N. J., markedly illustrates and confirms this opinion: Mrs. B----, æt. 21, had been married five years, but had never conceived. Her catamenia had always been regular in time, but the flow had been slight in quantity. In the latter part of November, 1884, or about three months before I first saw her, she was attacked with severe pain in the pelvis, accompanied by rise in temperature and accelerated pulse. She was compelled to go to bed, where she had remained up to the time of coming under my care. During this time she suffered from great tenderness over the hypogastrium, some tympanites, and considerable nausea and vomiting. She {217} did not menstruate in November--the period was due when she was first attacked with pain--but in December she had severe uterine tenesmus and a profuse metrorrhagia--symptoms of abortion. Pregnancy had not been suspected, however, as she had been so long sterile, and the inflammatory symptoms had been so violent that the signs of gestation had been masked by them. At the time of my first visit (March, 1885), there was great tenderness of the hypogastrium with slight tympanites; nausea and at times vomiting; great nervous prostration; loss of flesh; menses absent since November, except the uterine tenesmus and hemorrhage in December, as above stated; and at each menstrual cycle afterward she had the symptoms of uterine contraction with a profuse leucorrhoeal discharge, but no hemorrhage. The mammary glands showed the usual signs of gestation at about the fourth month; the vagina was purplish; the cervix uteri low down on the floor of the pelvis, and the mucous membrane around the os hypertrophied, soft, and abraded. The body of the uterus was anteverted and symmetrically enlarged to about the size of the organ at the third month of gestation. The uterus seemed to be fixed--incarcerated within the pelvic cavity--by an indurated exudation in the lower portion of the right broad ligament. I diagnosticated pregnancy, and accompanying parametritis as a result. The treatment consisted in painting the right side of the fundus of the vagina opposite the base of the broad ligament with iodine; the application of iodized glycerin on pledgets of cotton, together with the use of the hot-water douche; internally, opium enough to relieve pain and an alterative tonic in the form of the four chlorides, the formula for which will be given at another place. She began to improve at once, but as she was still threatened with abortion and the uterus was still incarcerated within the pelvis, ether was administered for the purpose of attempting to release it. With two fingers of the left hand in the vagina and the right hand upon the hypogastrium to exert counter-pressure, gentle manipulation was made with the view of stretching the adhesions. This resulted in a slight elevation of the womb, and from this time pregnancy went on to full term without further trouble.

This case is introduced chiefly to show the possibility of the existence of parametritis with normal gestation. It is true that the inflammation, which developed simultaneously with fecundation, may have had a latent existence before the occurrence of that event, and that the stimulus of pregnancy served simply to bring about an attack of an active character, but nothing in the previous history of the case indicated such a condition.

Perityphlitis may somewhat resemble in its subjective symptoms, as pain and rise of temperature, an attack of parametritis. A careful study of the physical signs, and also of the exact position of the tumor in each case, however, ought to be sufficient to differentiate between the two diseases. The tumor of perityphlitis is always on the right side, and situated high up in the false pelvis; that of parametritis may be on either side--it is oftenest on the left--and is usually located low down in the true pelvis. The latter is easily reached per vaginam, while the former is almost or quite out of reach from this direction.

Parovarian cystic disease in the early stage, before the tumor has developed sufficiently to rise above the pelvic brim, resembles in its location parametritic exudation; but the history of development and the physical {218} characteristics of each are different. There is an absence of hardness and tenderness to the touch in the former, which always exist in the latter. Parovarian tumor develops without the constitutional phenomena of inflammation; parametritis, I believe, never.

It must not be forgotten, however, that either one or more of these various diseases may exist in connection with, and as complications of, parametritis, rendering the diagnosis at times exceedingly difficult, requiring time and patience to clear the way. A case in point may be stated in brief as follows: Mrs. H---- was sent to me some months ago. She complained of great pain in both iliac regions--more in the right--extending into the pelvis and sacrum and down the limbs. There were also menorrhagia, and profuse leucorrhoea during the intermenstrual periods. She dated the trouble from an abortion which had occurred nine years before, and which was followed by symptoms of acute parametritis, from which she never fully recovered. Physical examination showed the uterus to be considerably hypertrophied and fixed, as in a vise, by an indurated mass on either side of it, which seemed to occupy both broad ligaments or to be closely adherent to them. The cervix uteri was also badly lacerated; its mucous membrane presented a surface so hypertrophied, abraded, and jagged that I was at first strongly impressed with the fear that epitheliomatous degeneration had begun to develop. I pursued a plan of treatment designed to reduce the congestion and hypertrophy of the diseased neck, and at the same time to induce an absorption of the plastic and indurated lymph around the uterus, to render the organ mobile, so that an operation might be made safe. I only partially succeeded, for while the uterus became much more mobile, there still remained a swelling or tumor on either side of it. These tumors had ill-defined borders--were not circumscribed, but elongated and rather cylindrical in form, and fixed to the lateral pelvic walls as well as to the uterus, though not very firmly to either. I now suspected disease of the Fallopian tubes, and probably also of the ovaries. The patient entered my private hospital in February, 1885, when I operated upon the cervix, dissecting away a large quantity of tissue for the purpose of making proper adjustment of the labia and to get rid of the cicatricial tissue; it was not epitheliomatous. I had hoped by this operation to not only restore the cervix to health, but at the same time to induce, by a derivative action, a retrograde metamorphosis in the diseased tissues and organs appended to the uterus. I succeeded in the former, and also in modifying all of the symptoms except the pain in the ovarian regions. This seemed to be made worse, or at least to become more prominent, as the other symptoms were improved. The patient was sent to her home, and advised to rest in the recumbent position for at least a part of every day. Later, when she did not improve, a local treatment, consisting of an application of the tincture of iodine to the fundus of the vagina at intervals of a week, with boro-glyceride tampons almost daily, was renewed. At the same time, counter-irritation, applied to the hypogastrium by means of blistering, was faithfully pursued. But nothing proved of more than temporary avail. She began to lose flesh and to fail in strength. The old fulness at the sides of the uterus, instead of diminishing, had increased. She again entered my private hospital. Under the influence of ether I now determined that the {219} Fallopian tubes were distended to the size of a small sausage, that the ovaries were also enlarged, and that the tubes, ovaries, and ligaments were all adherent to one another by plastic lymph. I now advised laparotomy for the removal of the diseased uterine appendages. The patient very readily assented; indeed, she urged the operation.

A week later I made an incision three inches in length through an abdominal wall fully two inches in thickness, and came upon the omentum, which was very fat. This was adherent by its lower border to the pelvic tissues and organs, so that I was compelled to dissect it off on the right side before I could reach the uterus with my fingers. All the parts--Fallopian tubes, ovaries, broad ligaments, uterus, omentum, and intestines--were so adherent and matted together that it was difficult to differentiate between them. The tubes were greatly distended and contained--the right pus, and the left serum. The fimbriated extremities were glued to the lateral pelvic walls. The ovaries were as large as a good-sized hen's egg, and closely adherent to the posterior surface of the broad ligaments. I dissected with my fingers--two being introduced--until the right tube and ovary were released, when they were drawn to the incision, ligated, and removed. The left ovary and tube were released with still greater difficulty, but I finally succeeded in ligating and removing them.

It will be sufficient to say here that the patient recovered without an untoward symptom, and that she has been entirely free from pain--since her recovery--for the first time within the last nine years.

PROGNOSIS.--A very guarded prognosis should always be given as to the course and termination of a case of pelvic inflammation. The disease may run a very acute course, and result in recovery by resolution or suppuration, or it may become chronic and be indefinitely prolonged. An acute parametritis without complications usually runs its course and ends in recovery in from four to six weeks. But the cases which are acute and uncomplicated are vastly in the minority; certainly this is my experience. The course of the disease, as has been stated above, is often chronic, and requires all the patience and fortitude which can be mustered, both by the patient and physician, to bring about a cure. Generally, the prognosis is good where a rational treatment can be pursued. The tendency of the disease is toward recovery, and comparatively few cases die. It is less favorable in cases occurring just after parturition, and which are probably of septic origin. Where the disease is complicated by peritonitis the prognosis, as to life, becomes less favorable.

TREATMENT.--In the acute form, if the patient is seen during the first stage--i.e. before exudation has begun--she must immediately be placed in a warm bed. All sources of excitement must be at once removed, the nervous system quieted, and pain relieved by a full dose of morphia administered hypodermatically. I never give less than a quarter of a grain of the sulphate, and seldom more, but I repeat it within an hour if pain is still severe. If reaction from chill has not yet occurred, it should be hastened by the application of dry heat to the lower extremities in the form of vessels filled with hot water, preferably, while moist heat, in the form of a hot flaxseed poultice or some other convenient vehicle, should be applied to the hypogastrium. Great care must be taken that the moisture from the poultice does not escape and wet the clothing of the patient, for that {220} would not only be a source of great discomfort, but it might also be the means of inducing another chill. The heat and moisture are best retained in the poultice by a covering of waxed paper or oiled silk. At the same time, a hot lemonade, to which may be added a teaspoonful of the sweet spirit of nitre, will often be found useful. According to Emmet, hot water per vaginal injection is a sine quâ non in the treatment of this disease. He says: "It is the only means we possess for aborting an attack of cellulitis, which it will do, if thoroughly employed at the beginning."[3] This is strong language, and doubtless the eminent author feels warranted in its use from his experience with the remedy; but I am sure that I have seen reaction brought about and the disease arrested in the first stage by the plan recommended above, and without the use of hot water by injection. There can be no doubt that the first principle to be carried out in the treatment of this disease is rest--absolute and persistent physical and mental rest. This can be obtained by the use of morphia hypodermically or by opium--administered best by the rectum--and probably by nothing else; certainly by nothing else so well. Hot-water injections are objectionable during the first stage of the disease, because of the fuss and movement of the patient necessarily connected with their administration. Further, I think it is impossible to say of any remedy that it aborted an attack of pelvic inflammation, for the disease cannot be said to be unquestionably established until the stage of exudation has been reached. Indeed, intense pelvic congestion may occur, giving rise to symptoms of the first stage of inflammation, and subside spontaneously.

[Footnote 3: Prin. and Prac. of Gynæcology, 3d ed., p. 261.]

When it is found that the disease cannot be arrested in the congestive stage, or when it has already passed into the stage of effusion before the patient is seen--which is often the case--exudation should be facilitated by the exhibition of the proper remedies. Happily, the principle to be followed in the treatment of this stage of the disease is the same as that of the first stage--viz. rest, relief of pain, and the local application of heat and moisture, with the addition now of counter-irritation. The first and second are to be obtained by the use of opium. The patient must not be allowed to suffer pain, and immunity can only be secured by the free use of the remedy. This drug is of more value in controlling the heart's action and quieting reflex irritability than all the others combined. The patient should be kept under its influence as long as pain lasts. I usually order twelve suppositories, as follows:

Rx. Ext. opii aq., gr. xij; Ol. theobromæ, q. s.; M. et ft. supposit., No. xij.

Sig. One to be placed in the rectum every two hours if necessary to quiet pain.

But we should not wait for the rather slow action of the opium administered in this way. It is best to begin with the administration of morphia hypodermically, as stated above, repeating it until the desired result is secured. It is then not difficult to keep up its influence by the use of the suppositories. If the suppositories cannot be obtained, the tincture of opium may be administered by injection into the rectum. The opium should not be given by the mouth where it can be avoided, as it is more apt to interfere with the appetite and digestion when thus {221} administered. The proper action of the skin and kidneys should be maintained by the administration of the liquor ammoniæ acetatis in dessertspoonful doses. Irritability of the bladder is often a troublesome symptom during the progress of the disease, and is best relieved, in my experience, by the following formula, which combines a diaphoretic and diuretic as well as an antispasmodic:

Rx. Tr. belladonnæ, fluidrachm j; Sodii bicarbonatis, drachm iij; Spts. etheris nitrosi, fluidounce j; Mist. potass. citratis, q. s. ad fluidounce vj.

M.--Sig. Dessertspoonful three or four times a day, or half the quantity oftener. I have also known this combination to relieve the persistent nausea which often accompanies this disease.

As soon as the skin becomes moist the remedy should be given at longer intervals, and if sweating is induced it should be discontinued entirely for the time, as that only serves to weaken the patient.

If the pulse does not beat oftener than 112, and the temperature does not rise above 102°, nothing more in the way of medication will be required. The patient will recover best if not treated too much. On the other hand, should the pulse be strong and rapid and the temperature high, quinine becomes a valuable remedy. It is more efficient when given in large doses at long intervals than when given in small doses at short intervals. If the temperature rises above 102°, it is my rule to administer ten grains and wait six hours, when, if it has not decreased, the quinine is repeated. If, however, the temperature has increased instead of diminishing, twenty grains are given at the second dose, and the effect carefully noted. Should marked cinchonism result, the remedy must be withheld, even though it has had no influence on the temperature. Quinine is said to have the power of so contracting the capillaries as to prevent the migration of the white blood-corpuscles. If this is true, the remedy ought to have great value in modifying or limiting the third or suppurative stage of the disease.

The tincture of aconite-root is also of value in controlling the pulse and lowering the temperature in certain cases. But its use should be limited to those cases of marked sthenic character, for, as a rule, the tendency of the disease is toward depression. It may be given in doses of two to five drops, repeated every two hours until three or four doses are taken, when, sometimes, the pulse will be found to have decreased ten to twenty beats per minute. The remedy should then be withheld until the effect is shown to have passed off by an increase of pulse-rate, when it may be again exhibited; provided always that the heart continues strong and vigorous and that it has shown no sign of weakness. In the latter circumstance the continued use of the medicine would be extremely dangerous. Under any circumstances its use should be limited to the first and early part of the second stage of the disease.

The diet should be carefully attended to, and should be of the most nutritious character, as milk, eggs, beef-essence, etc.

Locally, in addition to the poulticing, but not to the exclusion of it, counter-irritation by means of iodine will be found useful. The whole surface of the hypogastrium should be painted each time the poultice is changed until the skin shows signs of irritation, when it should be {222} discontinued and the poulticing alone kept up. The abdomen must not be exposed longer than is just necessary to remove one and place another poultice, which should be at hand and not in another room. The poultice must never be permitted to become cool on the patient. Turpentine may be used instead of iodine, and if tympanites is a troublesome symptom it will be found valuable. A few drops should be sprinkled over the poultice, or its action may be more quickly obtained by the use of the remedy in the form of the stupe until marked redness of the surface is produced, when the poultice can be resumed. Tympanites is most troublesome when the disease occurs during the puerperal state, and in these cases I regard the turpentine as a most valuable remedy, not only as a counter-irritant, but also when administered internally. It should be given by enema in teaspoonful doses, repeated every six hours until the desired effect is produced. It improves the secretions and allays pain by relieving distension. If the bowels should move as a result of the enemata, it is all the better. If fecal matter occupies the lower bowel, it should be removed under any circumstances.

Blistering, by means of cantharidal collodion or by the pure cantharides spread in the form of a plaster, I regard as the most efficacious counter-irritant; and if the beneficial effects of the remedy could be obtained without the discomforts, and often positive suffering, attending its action, I would probably employ it to the exclusion of all others. But these cannot be obtained. During the acute stage of the disease, when the pulse and temperature are high and the skin hot, the blister should not be used. It is then more likely to produce strangury; if not that, the other sufferings of the patient are at least increased in the pain and burning produced on the surface of the abdomen. This is not compensated for by relief of pelvic pain, for we have relieved this long since by opium. I think blistering should be confined to the chronic stage or form of the disease.

Resolution by reabsorption of the effused product may now terminate the disease; but that is not the rule when the process has once advanced beyond the first or congestive stage. If it is found that suppuration is likely to take place, that the disease is following its natural course, the third stage must be facilitated. The therapeutic plan laid down above will serve to limit the amount of pus-formation and tend to concentrate it to one point for evacuation. The hot fomentations should be continued, as well as the counter-irritation by the iodine. It will probably be observed that the patient has rigors of more or less severity, followed by rise in temperature. These symptoms should be looked upon as an indication of pus-formation. The patient should be examined from time to time by the digital touch per vaginam and by the combined vagino-hypogastric palpation for the purpose of determining the presence of an abscess and its location, so that the proper treatment may be applied and at the proper time.

These examinations must be conducted with the greatest care and gentleness, and the patient protected from undue exposure. When the disease has advanced to the third stage means for the disposition of the pus should be kept constantly in view, and the case treated as one of pelvic abscess.

Treatment of Pelvic Abscess.--Authorities differ widely as to the proper method of disposing of the contents of a pelvic abscess. Some {223} favor a let-alone plan, believing that Nature is competent to relieve herself more effectually and better than art can do; others, equally eminent, believe that the pus should be evacuated when pointing has positively occurred and made the evacuation easy and safe; while others, again, more radical in their views, believe that much can be gained by liberating the pus as soon as it is known to exist, although it may be deep-seated and as yet have shown no tendency toward pointing.

The same therapeutic principle should guide us in the management of a pelvic abscess that we would unhesitatingly apply in the treatment of an abscess in any other portion of the body. It is a settled law in surgery that if a pus-cavity is evacuated and not allowed to burrow, much tissue may be saved, the duration of the disease shortened, and the prognosis rendered more favorable. I believe that the pus should be liberated promptly as soon as it is certain that an abscess has been formed and can be reached without danger to important structures--emphatically so when the way is being pointed out. True, Nature is competent in some instances to discharge the accumulation, and usually by the least dangerous channel. But it is also true that in many other cases she is not. Instead of taking the shortest, most direct, and safest course to the surface, the pus frequently takes the most indirect route, riddling and destroying the tissues in its track; or it may rupture into the bladder or peritoneal cavity, in the latter case to be followed by death from peritonitis. Evacuation of the pus by artificial means when the way has been shown, if done carefully by aspiration, is attended with almost no danger. Where, on the other hand, the abscess is deeply seated and there is no tendency toward pointing, the question of evacuation becomes one requiring great deliberation; for the dangers of puncture increase as the thickness of the tissues to be traversed in reaching the abscess is greater. But, even though the pus be deeply located, when a positive diagnosis of its presence can be made I still favor early evacuation. Mere exploratory puncture in the hope of finding pus is a most dangerous practice, and should not be thought of in connection with pelvic abscess. Delay, even at the risk of spontaneous rupture, is the proper course until the diagnosis can be rendered positive; for when the abscess is deep-seated the progress of the disease is often slow. Of course the condition of the patient should always be taken into account in deciding the question whether or not to interfere. If signs of septic absorption appear, or evidences of constitutional failure become prominent in spite of the means used for staying the progress of the disease, prompt measures must be taken to get rid of the product of the inflammation. The strongest argument in favor of early operative evacuation of the abscess is the danger that the disease may become chronic when the pus is not promptly discharged. Many cases have occurred in which abscess after abscess had been formed and discharged, until the patient became a mere wreck of her former self, and finally died from septicæmia or exhaustion. This is the result of non-interference. I am so fully convinced of the value and necessity of operative measures in the treatment of pelvic abscess that the following questions at once present themselves to me when called upon to decide in a case where spontaneous evacuation has not already taken place: 1st. When shall the abscess be opened? 2d. Where shall the opening be made? and 3d. How shall the operation be done?

{224} The first of these questions has been answered in a general way by the preceding remarks, and it is only necessary to add here, by way of recapitulation, that the time for opening the abscess will depend upon its location and the condition of the patient. If the pus is near the surface and can be easily and safely reached, whether pointing has occurred or not, it is ripe for evacuation and should be liberated at once, even though the patient be in the best possible condition and show no evidence of deleterious effect from its presence. Nothing whatever can be gained by permitting it to open spontaneously, but much may be lost. If, however, the situation of the abscess be such that it would be necessary to traverse healthy tissues to a considerable extent in order to reach it, and the patient shows no evidence of septic absorption, it would be highly injudicious to attempt to open the abscess: first, because under the circumstances you could not be positively certain that a collection of pus existed; and, secondly, because it is doing no harm. Delay, with careful observation, is now the proper course. Within a few days the apparent abscess tumor may either show decided signs that it is diminishing in size and undergoing resolution, or it may approach the surface, so that evacuation will become safe. On the other hand, should symptoms of blood-poisoning develop and the patient show signs of rapid exhaustion, our attitude must be one of action instead of delay. The pus must then be liberated even at some risk. I still insist, however, that a positive diagnosis must be established, and that the operative measure shall be in no sense exploratory.

2d. Where shall the opening be made? This question is often decided for us by Nature. The puncture, as a rule, should be made where pointing has occurred. If pointing has not occurred, a position from which the abscess can be most easily reached through the vagina or abdominal wall should be selected. The vagina should be given the preference, because the opening would then be at the most dependent portion. The rectum should not be selected as the channel through which to evacuate the pus artificially, although spontaneous discharge into that tube occurs almost as frequently as into the vagina. The patient does not recover as quickly, however, when the abscess opens into the rectum, and more cases of septic poisoning occur from decomposition of the pus as a result of the entrance of air and fecal matter into the abscess-cavity. Further, it may become necessary to keep the opening patulous and to wash out the cavity of the abscess. This could not be done properly if the opening were in the rectum. I believe it to be the best practice to open from the vagina rather than from the rectum, even at greater risk to intervening structures, because it may greatly facilitate the after-management of the case.

If the tumor should be located high up in the iliac fossa or in the hypogastrium, the point of election for opening must be somewhere on the abdominal surface in the region of the abscess.

3d. How shall the operation be done? The opening of a pelvic abscess should never be regarded as a simple operation. As much care and deliberation should be taken in the selection of the proper method of evacuation of the pus, and in the operation itself, as was previously given to the diagnosis of its presence. Always begin with the administration of an anæsthetic. This not only protects the patient from unnecessary mental agitation and physical pain, but it better enables the {225} physician to confirm his previous opinion of the case, as well as to be more deliberate in the election of the point of puncture. With the patient in the dorsal position, if it be determined that the pus is contained in a single cavity, and there be no evidence of its decomposition, shown by the absence of symptoms of systemic poisoning, it should be liberated by aspiration. By this means a smaller puncture will be required and the entrance of atmospheric air prevented. If, happily, the operation has been performed early, before the formation of the so-called pyogenic membrane, or at least before sinuous tracts have resulted from burrowing, the abscess-cavity may then collapse and disappear. But should the patient not improve after the pus has been removed, or should the cavity again fill up, it is probable either that there is another pus-cavity, which had not been reached by the trocar, or that there has been developed on the internal surface of the sac an unhealthy fungous, granular condition. Under these circumstances a free incision should be made into the cavity of the abscess, so that a drainage-tube may be introduced and the cavity washed out by an antiseptic fluid. The opening should then be kept patulous, so that healing can take place from the bottom of the sac. It may become necessary to introduce a finger and scrape away with the nail the fungosites from the wall of the sac. But great care must be used in this manipulation, as well as in making the incision, for there is danger of wounding large blood-vessels and of rupturing the wall of the sac. If the cavity be now kept pure by daily injections of a 1:1000 solution of the bichloride of mercury or of a 2½-5 per cent. solution of carbolic acid, its surface may become healthy, the secretion diminish, and the sac close up.

The best method of washing out the cavity is by the fountain syringe, to which a long double canula can be attached; or, probably better, the syphon. It would be unsafe to force water into the sac.

It is well for the patient if the situation of the abscess be such as to render its evacuation through the vagina feasible, for then the opening is made at the most dependent portion, and consequently drainage is more easily and thoroughly accomplished; but, unfortunately, the location of the tumor may be so high up as to compel the removal of the pus through the abdominal wall.

Almost the same rules as to the selection of the method of operating and of the election of the point for puncture or incision will apply here as in the operation through the vagina, provided pointing has taken place. I am less favorable to aspiration, however, when the puncture must be made through the walls of the abdomen--first, because reaccumulation is almost certain to take place; and, second, because there is danger of leakage of pus into the peritoneal cavity, since it is difficult by this means to thoroughly empty the sac, and impossible to wash it out and keep it drained.

If pointing has occurred, a free incision should be made at once and the cavity thoroughly emptied, and, if necessary, washed out. The opening must not be permitted to close until the cavity has healed from the bottom.

Where pointing has not occurred and the abscess is so deeply seated that it cannot be safely reached from the vagina, and does not distend the abdominal walls, I would urge greater delay, in the hope that it may {226} approach the surface more nearly. If, however, the condition of the patient be such as to demand immediate action, the operation of laparotomy should be selected as the more thorough and less dangerous method of releasing the pus and of after-treating the abscess.

An incision two inches in length should be made through the linea alba, midway between the umbilicus and pubes, and, after all bleeding is stanched, the peritoneal cavity opened. The index finger should then be passed in and the surface of the abscess-wall explored. It will be a fortunate circumstance if the sac be found adherent to the peritoneal surface, where the incision is made, for it can then be opened without entering the peritoneal cavity. To prevent the escape of pus into this cavity the sac should now be evacuated with great care. For this purpose the aspirator is well adapted, but a small trocar, to which a few feet of rubber tubing has been previously attached, through which to conduct the pus into a convenient receptacle, will answer almost as well. The opening in the sac should next be slightly enlarged by an incision (not torn); it should then be included in the sutures, which are now placed to close the abdominal wound. After the sutures have been introduced the pus-cavity should be washed out with the bichloride or carbolic-acid solution, and a glass drainage-tube placed in the lower angle of the incision, when the edges can be brought together and adjusted around it.

The after-treatment required will be the same as if the opening had been made through the vagina.

The sac must be made to close from the bottom. It may become necessary to stimulate the surface by the injection of a weak solution of nitrate of silver, four to eight grains to the ounce of distilled water, or with the tincture of iodine, one part to four of water.

Cases are sometimes met with in which the pus has burrowed and formed sinuous tracts which are difficult to reach and drain. It may then be necessary to make a counter-opening in the vagina after first cutting through the abdominal wall. These are usually old, neglected, chronic cases, in which the abscess has discharged spontaneously into the bowel too high up to be properly emptied, or which have opened into the bladder or somewhere on the abdominal wall, or possibly taken one of the circuitous routes alluded to under the head of Pathology.

No fixed rule can be set down for the management of these grave cases. Each one must be treated on its individual merits. A ripe experience and judgment are necessary here to decide whether it is best to operate or to pursue a course of masterly inactivity, depending upon the use of hygienic and tonic remedies and time to bring about a cure. I have known instances where patients have recovered spontaneously after having been reduced to the lowest extremity. I have also known others who have died soon after submitting to operative interference. Some of the spontaneous recoveries, however, are only apparent, for the old sinuses often reopen and discharge pus as before, or the pus may be discharged at some new and remote point, the patient finally succumbing to the ravages of a disease from which she flattered herself she had escaped.

The most careful attention must be given to the hygienic surroundings of the patient, the diet liberal and of the most nutritious character. The appetite should be sharpened by the administration of the bitter tonics, {227} the best of which is probably the old tincture of bark (Huxham's). Quinine should be given in doses sufficient to control the temperature when necessary, and for its tonic properties. The blood should be improved by the exhibition of iron, arsenic, and the bichloride of mercury in the form of the mixture of the four chlorides, first used, I believe, by Tilt of London. There can be no doubt as to the value of the combination in cases of plastic exudations. The following is the formula which I am in the habit of using:

Rx. Hydrarg. chloridi corrosivi, gr. j; Liq. arsenici chloridi, fluidrachm j; Tr. ferri chloridi, Acid. muriatici diluti, aa. fluidrachm iv; Syr. simplici, fluidounce ij; Aquæ, q. s. ad fluidounce vi.

M.--Sig. Dessertspoonful, well diluted, after meals.

The dose of the arsenic and bichloride of mercury can be increased, after it is found that the mixture does not disagree with the stomach, to six drops of the former and a sixteenth to a twelfth of a grain of the latter. The effect of the medicine must be carefully watched, however. After the remedy has been taken two weeks it should be discontinued and some other form of tonic substituted for a week or two. The syrup of the iodide of iron, or the iodide of iron in pill form, will serve well as the substitute. If the patient should tire of the above or the remedies should not agree, some other form of tonic must be given. I have found the following an excellent tonic pill:

Rx. Strychniæ sulphatis, gr. j; Acidi arseniosi, gr. j; Quininæ sulphatis, gr. xlviii; Ferri sulphatis, gr. xlviii; Ext. hyoscyami, gr. xij; Ext. gentianæ, q. s.

M. et ft. pil. No. xlviii.--Sig. One to two pills after each meal.

As soon as practicable the patient should have a change of air and scene.

Perimetritis.

Having treated the subject of inflammation of the pelvic tissues generally, in the acute form, under the head of Parametritis, with sufficient fulness to answer the purposes of the practical physician, whether the disease dominate the connective tissue or the peritoneum covering it, I shall, under the head of Perimetritis, consider the subject in its chronic aspect principally.

DEFINITION AND SYNONYMS.--I have defined parametritis to be an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds--viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. I cannot more clearly or more simply define perimetritis than by stating that it means an inflammation of the peritoneum {228} which serves as a covering and boundary-line for the connective-tissue spaces involved in parametritis. As the term parametritis is used to conveniently express the idea of the existence of an inflammation in the connective tissue near the uterus, so the term perimetritis conveniently and tersely expresses the idea that the inflammatory process exists around the uterus in the pelvic peritoneum. In the acute form it is difficult to differentiate between them clinically, nor is it necessary, from a therapeutic standpoint, to do so. The term perimetritis is synonymous with pelvic peritonitis.

ETIOLOGY.--All of the causes which have been enumerated as capable of producing parametritis may be included in the etiology of perimetritis. If, however, the great predisposing causes of the former--abortion and injury at parturition--be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. Parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. Perimetritis, on the other hand, is frequent in the single and sterile woman. But, as a rule, it does not run the same typical acute course. It is usually subacute or chronic from the beginning, and results in the formation of false membranes which bind the pelvic organs to one another.

Perimetritis of the adhesive form may be produced by the pressure and irritation resulting from displacement of the pelvic organs, as retroflexion of the uterus, incarcerated fibroid or ovarian tumor, prolapse of the ovary and Fallopian tube, fecal impaction, and from ill-fitting and improperly-adjusted pessaries. Under these circumstances the disease usually comes on insidiously, with no acute symptoms, and runs a slow course. It may be discovered accidentally when making an examination on account of pelvic pain obscure in character, or when the attention has not been called especially to it by the presence of specific symptoms.

Perimetritis may result from regurgitation of menstrual fluid through a too patulous Fallopian tube. This is most likely to take place when the egress to the flow has been prevented by a flexion of the uterus sharp enough to practically destroy the calibre of the cervical canal, as when the organ has become retroflexed from subinvolution or some other cause of hypertrophy of the body of the organ. It may, however, occur as a result of the intense engorgement which sometimes attends acute suppression of the catamenia. It may occur from disease in the tube itself, as where a collection of pus or serum has been formed and thrown into the peritoneal cavity either from rupture of the tube or discharge through the natural opening at the fimbriated extremity. Or it may result from hemorrhage following the rupture of a Graäfian follicle, especially where the disease of the tube has resulted in the destruction of its calibre or the power of the fimbriæ to grasp the ovary so as to convey the discharge safely to the uterine cavity. Hemorrhage from any other source, as from the rupture of a blood-vessel or of an extra-uterine gestation-sac, usually results in the development of perimetritis.

Coitus is capable of causing perimetritis when the act is awkwardly performed, or where there is a disproportion in the relative sizes of the organs involved, or where the physiological mechanism of copulation is destroyed by displacement of the uterus, free mobility being lost as a result.

{229} According to Noeggerrath,[4] a very common cause of perimetritis is what he is pleased to call a latent gonorrhoea in the male. He believes that the disease, once contracted, is probably never entirely eradicated, but that it always exists in a latent form, and that it is capable of producing a specific inflammation of the pelvic peritoneum years after an apparent cure had been effected. It is of course impossible to positively verify this, although he gives some very striking cases in support of his position. That gonorrhoea in the acute form may extend by propagation from a vaginitis through the uterine cavity and Fallopian tubes to the peritoneum, and produce an inflammation of that membrane, is probable. Cases have been met with where a history of specific infection was undoubted, in which an attack of perimetritis followed soon after the initial symptoms and physical signs of gonorrhoea were manifested. But it is quite another thing to believe that the specific poison may remain latent and harmless in the genital system of the male to be transferred years afterward to that of the female.

[Footnote 4: "Latent Gonorrhoea, etc.," Trans. Amer. Gynæc. Soc., vol. i. p. 268.]

Tuberculous or carcinomatous disease of the pelvic organs is nearly always complicated by a certain degree of perimetritis.

Perimetritis may result from external injuries, as blows, kicks, and the like; and under the head of traumatic agencies most of the causes which have been enumerated would stand as examples; but under this head I wish also to emphasize the statement that I believe that perimetritis may result from an unwarranted and unnecessary force used on the part of the physician in his efforts to outline and locate the position of the pelvic organs, especially that of the ovaries and tubes. When the latter organs are in their normal position and not enlarged, it is usually impossible to outline them by the bimanual touch, nor is it necessary. When they are diseased the greatest care in manipulation should be used; and it is often best to administer an anæsthetic, so that less force may be necessary to determine their exact condition. The disease may also result from injury inflicted in the medication of the uterine cavity and in the various operations on the uterus. A most prolific cause is induced abortion.

Recurrent perimetritis should be regarded as the result of the persistence of one of the above-mentioned causes. It sometimes recurs with each menstrual period. Such attacks are often associated with dysmenorrhoea of the congestive type.

PATHOLOGY, COURSE, AND TERMINATION.--When the pelvic peritoneum becomes inflamed, and the disease runs through an acute course, the pathology and termination will be much the same as that described under Parametritis, for the connective tissue will then be involved in the process, as well as the peritoneum; not to the same extent, however, as when the disease begins as a cellulitis. The position of the exudation tumor, should one form, will be more directly posterior to the uterus in Douglas's cul-de-sac; it is sometimes larger, and may displace the uterus far forward. This is more especially the case where the disease has advanced to the third stage and resulted in abscess.

In the subacute and chronic forms of the disease the course is usually a slow one. The exudation soon becomes plastic, or is so from the beginning. This leads to the agglutination of the pelvic organs to one another, and finally to the production of organized pseudo-membranes {230} of more or less strength. If the Fallopian tubes and ovaries are displaced, which is frequently the case under these circumstances, they are bound more or less firmly in the abnormal position. The adhesions are sometimes extremely delicate, and embrace the displaced organs as a net. At other times, or later, they may be so large and firm as to be readily felt through the vagina. Again, the false membranes may be broad and ribbon-like, and occupy a position so as to imprison the displaced organs as though elastic bands were stretched from the anterior to the posterior portion of the pelvic brim. When Douglas's cul-de-sac is bridged over and shut off from the abdominal cavity proper, serum or pus, sometimes both, may collect within it and give rise, from its round, fluctuating character and rather insidious formation, to the supposition that it is an incarcerated ovarian cyst; especially so since it may progressively increase in size and attain such dimensions as to distend the abdominal walls. This course of the disease is rare, however.

Under favorable circumstances the course and termination of chronic pelvic inflammation would probably be much the same as where the disease is acute--i.e. it would run its natural course and end in resolution by absorption of the effused product. But, unfortunately, the symptoms of the disease are not violent enough to compel the patient to go to bed and remain at rest, so as to place the organs in the most favorable condition for recovery. The affection comes on so insidiously sometimes that when the patient is finally compelled to seek relief it may be found that extensive adhesions and considerable displacement, if not serious disease--especially of the ovaries and Fallopian tubes--exists. The inflammatory process is progressive, and will continue to be so until its cause shall be rendered inactive by the continuous and increasing severity of the symptoms, which force the sufferer to give up the struggle to remain on her feet and pursue her usual round of duties.

SYMPTOMS.--If the attack is acute the subjective symptoms of perimetritis will differ from those described as belonging to parametritis only in the greater violence of their onset and progress. The pain, which is usually preceded by a chill, is likely to be sudden, sharp, and persistent--sometimes agonizing. The pulse, especially during the first stage of the disease, is small, wiry, and quick, ranging from 120 to 140 beats per minute. But its character is likely to change as the affection progresses, and to become full, as when the connective tissue is the seat of the inflammation. The temperature also reaches a higher point, rising frequently as high as 104°-105°, sometimes even higher.

When the disease is chronic from its commencement, the pain is more obscure, and cannot so certainly be relied upon as a diagnostic sign. True, a sharp pain existing low down in the pelvis in either iliac region--pain persistent in character and coming on rather suddenly--should always direct attention to the probable existence of an inflammatory condition. The pain of chronic pelvic inflammation is not attended with the rise in temperature and acceleration of pulse which have been described as accompanying the acute form of the disease. There is, doubtless, a slight degree of increase in both, but not enough to attract attention as a rule. There may be many reflex symptoms, chief of which are irritability of the bladder and stomach, the latter manifesting itself in nausea and sometimes vomiting.

{231} PHYSICAL SIGNS.--Physical examination may reveal no evidence of exudation or of the presence of an inflammatory condition, and may lead the physician to infer that the attacks are not inflammatory in character, but that they are of a neuralgic nature. As a rule, however, examination will show a thickening or an absence of the usual mobility of the surfaces, and deep pressure may elicit considerable tenderness. On the other hand, the physical signs may be marked, and the surfaces may be felt to be quite thickened and very rigid, so that it will be evident that there is exudation on the surface of the peritoneum. Usually, the vaginal examination reveals a fixation and induration posterior to the uterus. If that organ is retroflexed, it is bound firmly in that position. If the uterus is in its normal position, there will not usually be the same amount of fulness posteriorly. If an ovary and Fallopian tube have been displaced, it will probably be fixed in the post-broad-ligament space or in the cul-de-sac of Douglas. The pelvic roof, so called, may be found as hard and tense as a deal board, as was first described by Doherty. The exudation may be so great as to displace the uterus forward or laterally, and to fix it as though it were surrounded by hardened lymph. This is especially felt in the post-uterine space, gluing the uterus, ovaries, tubes, and broad ligaments together. If there is a small ovarian or fibroid tumor, it may be likewise fixed in this posterior position.

A later examination may show a change in this condition. The exudation material may have been reduced by absorption, or there may have been an increase. If the latter, the disease will probably run an acute course and end by resolution or suppuration--more likely the latter--and practically it will then run the course described under the head of Parametritis.

DIAGNOSIS.--The diagnosis of perimetritis is made with comparative ease. The subjective symptoms are sometimes obscure, but the physical signs are perfectly plain. When there is exudation posterior to the uterus, especially if it has bound the organ in a retroverted position or incarcerated a foreign body, it is almost absolutely certain that agglutination is due to peritoneal exudation. This exudation is, as a rule, not so extensive as that which occurs in parametritis, and if a tumor is present--which is uncommon--its location is different. Where a tumor is present as the result of pelvic inflammation, I think that it may be safely ascribed to connective-tissue inflammation rather than to peritoneal. On the other hand, where there is simply agglutination, and where the effusion seems thin and spread out, the organs and ligaments rigid and thickened, instead of a somewhat circumscribed tumor, the disease may be ascribed to perimetritis rather than to parametritis. Where the condition just described is found there can be no doubt as to the existence of perimetritis.

A small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid tumor, fecal impaction, and hæmatocele might be mistaken for this disease, but these tumors are, as a rule, more or less circumscribed, while the exudation due to perimetritis is not often so. Perimetritis, however, may coexist with any of the conditions just mentioned. These tumors may be bound to adjacent tissues, forming one large mass, as the result of intercurrent attacks of perimetritis. In such cases the peritoneal inflammation would exist as a complication.

{232} PROGNOSIS.--When the inflammation is acute, or where the peritoneum becomes largely involved, the disease may run a very violent and fatal course. Those cases in which pelvic inflammation is of such severity as to cause death are usually of this character. As a rule, however, the prognosis, so far as life is concerned, is favorable.

The prognosis regarding the restoration of the ligaments and the thickened surfaces to their natural condition, and the restoration of the displaced organs which complicate the disease, will depend upon the extent and duration of the affection and upon the treatment. As a rule, the prognosis is good where the patient has sufficient courage and fortitude to submit to a prolonged course of treatment, with the abstemious habits of life which may be necessary.

TREATMENT.--In order to present systematically the therapeutics of perimetritis it should be divided into the acute and chronic forms, and the treatment of the latter form will necessarily include to a certain degree the management of the complications. All that has been said under the head of the treatment of parametritis will apply to the treatment of acute perimetritis. As the symptoms of acute perimetritis are ushered in with greater violence than where the connective tissue is simply involved, so the remedies for the relief of these symptoms must be more vigorously applied. The patient must be placed at absolute rest, and be kept there, for the favorable termination of the disease will be largely dependent on the faithfulness with which this measure is carried out. The pain, which is usually great and acute in character, must be relieved at once by the administration of morphia subcutaneously in full dose, and the remedy is to be repeated until the pain is under control, when the effect of the drug may be maintained by the administration of opium in the form of suppositories containing one grain of the aqueous extract. As in the treatment of parametritis, so here, I insist upon the administration of the drug by the above method, rather than by the mouth, because nausea and interference with the function of digestion are less likely to follow.

In the peritoneal form of pelvic inflammation the pulse is usually more rapid and the temperature higher than where the connective tissue alone is involved. Both of these symptoms may be controlled by the free administration of opium. If this is not successful, a resort to the tincture of aconite in small and repeated doses will be indicated. If necessary, quinia should be administered. This remedy, however, should not be given unless the temperature remains persistently high; and, as advised under the head of Parametritis, the dose should not be less than ten grains, repeated in from four to six hours if the temperature is not decreased. The action of the tincture of aconite should be carefully watched, and if its administration is not soon followed by a lowering of the pulse-rate, its use should be abandoned.

If the disease is of a marked sthenic character, the local abstraction of blood by the application of leeches to the hypogastrium is often of great benefit, and poulticing should be most faithfully and persistently carried out, together with hot applications to the lower extremities in the form of hot water, as previously directed. I strongly recommend the application of heat to the hypogastrium in preference to cold. If the patient be seen quite early in the first stage of the disease, which is unusual, the application of cold might be more beneficial than heat; but when the {233} process has advanced toward the second stage, that of exudation, the application of heat will facilitate this process, while cold would probably retard it.

By the above plan of treatment--viz. the immediate relief of pain by full and repeated doses of morphia--it is possible to arrest the disease in the first stage, but this is not the rule. It usually advances to the second stage, that of exudation, if it has not already reached this stage before the patient is seen. A vaginal examination may now show the uterus to be fixed, but there may be an entire absence of tumor. Should an exudation tumor exist, it will probably be found posterior to the uterus, crowding that organ forward rather than laterally, as would be the case were the inflammatory process seated in the cellular tissue; or, what is oftener the case, we have mere fixity of the organ, with thickening of the pelvic peritoneum lining Douglas's pouch and the posterior surface of the broad ligaments. Later an exudation tumor will more likely be found. If this is so, it should be inferred that the connective tissue has become largely involved in the process, and it should rather be expected that the disease will pass through the regular course of pelvic inflammation and advance to the third stage, that of suppuration, as though the disease had originally begun as a parametritis. It should then be treated on the general principle laid down for the management of that form of pelvic inflammation. The case should, however, be regarded with greater solicitude as to prognosis where the peritoneum has been largely involved, and the symptoms should be more carefully watched and counteracted by the application of the proper remedies. There is in such cases more danger of the disease spreading and involving the peritoneum generally, and of course becoming an affection of great gravity. When the peritoneum is largely involved, tympanites, as a rule, becomes a troublesome symptom, more especially if the disease has occurred during the puerperal period, and it requires special attention. The remedy which I have learned to rely upon in the treatment of this troublesome complication is turpentine, administered preferably by enema.

Should the disease advance to the suppurative stage, the case then becomes one of pelvic abscess, and should be managed on the principle enunciated for that stage of the disease. (See Treatment of Pelvic Abscess.)

Treatment of Chronic Perimetritis.--When the disease exists in its chronic form, the uterus, ovaries, and Fallopian tubes may be found fixed either in the normal position or in some form of displacement, usually the latter. The peritoneum lining Douglas's pouch, as well as that covering the uterus, broad ligaments, tubes, and ovaries, will be found more or less thickened, or the ovaries and tubes may be prolapsed and retained by false membranes; or the uterus itself may be retroflexed and fixed by adhesion of the peritoneal surfaces lining Douglas's pouch and that covering the uterus; or false membranes may have been formed so as to roof over the pelvis, thereby incarcerating the uterus and its appendages within that cavity. This condition gives rise to pains which are rather diffused throughout the pelvis, at one time affecting the ovarian region in which the disease exists, and at another being experienced low down in the pelvis and radiating along the course of the sacral nerve down the posterior portion of the thigh, always sharp and distressing in {234} character. Where the ovary and tube are involved the pain usually radiates to the groin and anterior portion of the thigh. Examination should be conducted with great care, because, although the uterus and its appendages seem to be fixed firmly, there are often new adhesions forming or weak ones existing which may be easily severed; and this especially applies to manipulation of the ovary and tube, the adhesions of which are, as a rule, not so firm as those fixing the uterus.

The management of these cases must of course be different from that of the acute form of the disease. The patient often suffers from nervous exhaustion, indigestion, and loss of flesh as a result of the long suffering which she has endured during the course of the disease. I believe that here the most efficacious plan of treatment is that which embraces REST as its guiding principle, for the disease probably had its origin in over-exertion and derangement of the proper relations of the organs one to another, as in those cases in which it is developed as a result of prolapse or retroflexion of the uterus or the ovaries, or from the presence of a tumor incarcerated in the pelvis, which displaces and holds in malposition the above organs. It is unquestionably true that where the patient is allowed to exercise and follow her usual avocation the attrition of the inflamed surfaces upon each other will tend to keep up the inflammatory condition. It is my plan, where I can get the consent of the patient, to place her at absolute rest, and begin the treatment by paying strict attention to the evacuation of the bowels, for constipation is one of the most troublesome accompaniments of perimetritis. It often stands in a causative relation, and nearly always as a complication of the disease; and of course first attention should be paid to the relief of this condition.

Strict attention should be paid to the diet. The food should be of the most nutritious character, calculated to improve the digestive organs, and through them to build up the general system.

The Local Treatment.--The local treatment should embrace those remedies which are thought to possess the power of producing absorption of plastic material, either by a counter-irritant or stimulating action. The persistent use of the tincture of iodine, both to the hypogastrium and to the fundus of the vagina opposite the seat of exudation, is of great value. Where the iodine is found to be so irritating to the skin as to make it necessary to discontinue its use, and also for the relief of pain, I have found the following formula very useful:

Rx. Tincturæ aconiti, Tincturæ opii, aa. drachm j; Tincturæ iodinii, drachm vj. Misce.

Sig. Poison. To be applied externally as directed.

This may also be applied to the fundus of the vagina instead of the iodine alone, either by a camel's-hair brush or by the cotton-wrapped uterine applicator. The vaginal application of iodine should be made not oftener than once in three days, and sometimes a longer interval is advisable, especially if the remedy is used in a concentrated form. If it is found that irritation or ulceration has been produced, its use must be discontinued for a time, and remedies of a milder form substituted, as, for instance, the application of iodoform and glycerin (one drachm to the ounce), or of glycerin alone on the cotton tamponade.

{235} In the intervals between the application of iodine and the other remedies the hot-water douche should be used daily. When the hot water is administered the patient must be in the recumbent position. I am opposed to indiscriminately advising walking patients to use hot water, because, as a rule, it is not given as intended--that is, hot and in large quantity--and the object for which it has been recommended is not attained. The water is either used at too low a temperature or in too small a quantity, or both. When administered by the patient herself she becomes tired of the pumping and of the position which she must assume, and fails to keep it up during the length of time required for the injection of the quantity of water usually advised--that is, a gallon or two--and the constrained squatting position is of itself injurious. I believe that the long-continued use of hot water is followed by relaxation of the pelvic organs, and this would constitute another objection to the indiscriminate recommendation of this measure, for when it is placed in the patient's hands she is apt to continue its use for too long a period. The remedy is no doubt most efficacious in the treatment of these chronic cases of pelvic peritonitis, and great credit is due Emmet for introducing it to the profession. It should, however, be administered in accordance with fixed rules and under certain restrictions, and these I would class as follows: 1, the patient must always be in the recumbent posture; 2, she must not administer the injection herself; 3, the water should be at a certain temperature, which is best determined by the sensations of the patient. It should be used as hot as can be easily borne, and the temperature gradually increased during the administration of the injection, for the patient will be able to bear it at a higher temperature after the current has been flowing a few minutes than when the application is first made. I believe that the douche is better than pumping, as by Davidson's syringe, because the application is more likely to be thorough and the effect to be maintained longer, for even when the injection is given by the physician or nurse the hand is apt to become tired and the application stopped, for a time at least. It is the continuous application of the remedy which is beneficial. In other words, the organs should be kept as it were in a hot bath. For use in my private hospital I have had constructed a tripod five feet high, with a hook in the centre on which a bucket is easily hung. This bucket holds two gallons of water, and near the bottom is placed a stopcock, to which is attached a tube provided with a nozzle and stopcock at its distal end. The patient is placed on a bed-pan, which is modified after that devised by Meriman. The nozzle is then introduced into the vagina, and the stopcock at the bucket turned by the nurse, the water being at a temperature of at least 110°. The patient can then regulate the flow herself. The water is allowed to enter the vagina, dilating it and flowing off slowly, so that the tissues are in a continuous hot bath, which may be kept up as long as desired--from ten minutes to an hour--care being taken to see that the proper temperature of the water is maintained by the addition of a fresh supply from time to time. The important point is not so much the amount of water as its temperature and constant contact. If the vagina could once be filled to distension and the temperature kept up, it would not be necessary to renew the water, but to keep up the temperature a regular flow of hot water must be provided for. The rapidity of the flow may be regulated by the stopcock. The {236} application of this remedy should be made once or twice a day, depending on its effect upon the patient.

After all tenderness has subsided much may be accomplished by gentle massage of the pelvic organs. This is best carried out by the introduction of one or two fingers of the left hand into the vagina, while the right hand is placed upon the hypogastrium; then the contracted ligaments, thickened membranes, and fixed uterus, ovaries, and tubes should be gently manipulated and moved from side to side or upward and downward, care being taken that the force used is not sufficient to lacerate adhesions or even to so stretch them as to cause their irritation. The proper amount of force is best regulated by the sensation of the patient, and if pain is produced by the manipulation it should not be persisted in. This massage may at first be employed at intervals of two or three days, but later it may for a time be used almost daily, and it will almost invariably be found that the organs gradually become more mobile--that the adhesions become attenuated, and in many cases finally absorbed. On the other hand, adhesions of such size and strength may exist that many months may be required to produce any marked effect, and in some cases the adhesions may be of such a character as to be permanently organized and almost incurably fixed.

I have also found the stretching of the fundus of the vagina by firmly packing it with absorbent cotton, sometimes repeated almost daily or at intervals of two, three, or four days, of great benefit in stretching the adhesions and promoting their absorption. Sometimes, where adhesions are persistent, the use of the rubber colpeurynter distended with hot water is of value.

Where there is a foreign body, as a tumor, fixed posteriorly to the uterus, or where the uterus is fixed in a retroflexed position, the patient may be placed in the knee-chest position, Sims's speculum introduced, and the vagina packed with cotton while the patient is in that posture; or, instead, the vagina may be simply distended with air. The air may be admitted by the introduction of Campbell's glass tube or by the separation of the walls of the vagina with the fingers, which may be done by the patient herself. These measures are often of decided benefit.

I wish to repeat what has already been stated, that the treatment of chronic perimetritis, to be carried out successfully, requires that the patient should be in bed and placed under such circumstances and surroundings that the physician may be enabled to pursue personally the plan of treatment. Of course much will be gained if he is aided by a trained nurse. This in many cases involves the removal of the patient from the cares of her home.

Advantage may often be derived from the application of small blisters to the hypogastric and iliac regions, the counter-irritation being kept up almost continuously for two weeks at a time. The blisters should not be larger than two inches square, and should be moved from place to place; for instance, one blister may be placed on the hypogastrium, and before this has healed a second should be placed one side of it. This should be kept up for two weeks at a time, or until four or five blisters have been applied, when, if benefit is to follow, it will be apparent.

When the organs which are agglutinated to one another become more mobile, and the thickened membranes more flaccid, much benefit {237} sometimes results from the application of a pessary if a displacement of the uterus, ovaries, or tubes exists and persists; but before the use of this instrument is thought of, it must be positively ascertained that no tenderness remains as a result of the inflammatory process; the inflammation must have entirely subsided, the effects alone remaining. It is sometimes advised that an instrument large enough to constantly stretch and over-stretch the false membranes and adhesions is advisable. It has also been recommended to over-stretch these adhesions by manipulation. Of the two, I much prefer the latter method; that is, stretching by manipulation rather than by continuously acting upon them by means of a pessary large enough to stretch the vagina and through it the adhesions. In stretching by manipulation, with the patient under ether, you have your own sense of touch to guide you, and the action of your efforts ceases with the cessation of the manipulation, while that carried out by means of a pessary is continuous and may result in great harm from irritation, if not from ulceration of the vaginal surface from pressure; or it may result in rupture of the adhesions. If a pessary is adjusted, it should be used, not for the purpose of over-stretching adhesions, but simply for its stimulating effect on the pelvic circulation, or as a support to the pelvic circulation rather than as a support to the uterus. A larger instrument should not be used than one which will occupy the vagina without stretching it--simply unfold any doubling up which may have resulted from retroversion or prolapse of the uterus--and its action should be carefully watched. It should be learned, not from the sensation of the patient, but from actual examination, that it is not making undue pressure; this examination should be made daily at first, and afterward at longer intervals. The use of the pessary should be discontinued as soon as possible. This statement should be qualified by saying that the words as soon as possible mean when all symptoms have subsided, and the uterus and other organs are maintaining a normal or nearly normal position, or when the pessary seems to have ceased to be of value. It may then be removed on trial.

There is a method of using the pessary, in which it is advised that the instrument shall be large enough to span the angle of flexion which may exist, for the purpose of making pressure on the fundus of the uterus, which is incarcerated in the cul-de-sac of Douglas by adhesions between its peritoneal surface and that lining the sac. This I believe to be a bad principle, for an instrument long enough to do this must either take its point of support against the pubic arch or from an external attachment--a principle of using the pessary which should be most emphatically condemned.

The above treatment should be carried out with the patient in bed, if possible, during which time general measures for the improvement of the muscular and nervous system should also be employed. The application of electricity to the thickened peritoneum and adhesions is another measure which should not be allowed to pass without comment. Much good may be done by the daily application of faradism, with one electrode in the vagina and the other on the hypogastrium, and continued for from fifteen to thirty minutes. I have thought that in some cases great benefit followed this application. Galvanism is also of service, and by some is thought to be of more value than the faradic current.

{238} The time for getting up should be determined by the results of treatment; usually a period of from four to six weeks is sufficient to determine whether or not the treatment at absolute rest is going to be of benefit. Of course it is not to be understood that cure will follow in severe and long-standing cases within this period, because if this hope is entertained disappointment will follow nearly always. What we hope and expect to attain is rest, both physical and physiological, during which time local treatment can be carried out with greater facility and thoroughness and the general condition improved. As a rule, the ligaments soften, the false membranes become attenuated, and during the time stated the patient is very much benefited, and sometimes cured. She should now begin to sit up and to exercise moderately; the amount of exercise should be regulated by its effect. If pain follows walking or riding, it should not be persisted in until such time as exercise can be taken without the production of these symptoms.

There are no specific remedies for internal administration. The general medication of the patient should consist in the use of such remedies as we have learned to depend upon as capable of building up the blood and nervous system, embracing especially that class of tonics which are said to have the power of inducing such changes in plastic material as favors its absorption. To this class belong the chlorides, as the chloride of arsenic, the chloride of iron, the chloride of ammonium, and the bichloride of mercury. These remedies should be placed at the head of the class. The next are the iodides, as the iodide of iron, the iodide of potassium, and the bromide of potassium. Whether or not these remedies have the powers ascribed to them is questionable, and their administration for this purpose must always be, to a certain extent, empirical. As tonic remedies the administration of iron and the bichloride of mercury is of course always indicated. Cod-liver oil is also a remedy of much value in some cases where it can be digested. The whole plan of treatment should rather be of a local than of a general character, while at the same time very great importance should be given to the building up of the general system, without which nothing can be gained by local treatment. The patient should have a change of scene and air as soon as practicable. A sojourn at the seaside for a time, and then in the mountains, will be of great benefit always.

The fact should always be borne in mind by the physician and impressed upon the patient that a previous attack of perimetritis will serve as a predisposing and abiding cause for a recurrence of the disease, so that all exciting causes may be avoided as far as possible.

{239}

PELVIC HÆMATOCELE.

BY T. GAILLARD THOMAS, M.D.

HISTORY.--Prior to the present century the pathological condition which we are about to investigate had no place in the category of diseases peculiar to the sexual organs of the female. Very slowly have its pathogenic features, its etiology, and its importance as a not uncommon factor in pelvic disorders, assumed a systematic basis, and even now considerable diversity of opinion exists upon these points. The reasons for this are not far to seek. In the first place, hæmatocele is a symptom of an accident occurring in the pelvis and resulting in hemorrhage; in the second, the source of the flow which creates the hæmatoma or tumor of blood cannot ordinarily be recognized by any diagnostic measures known to science; and in the third, death rarely occurring from the accident and as a direct consequence of it, autopsic evidence is wanting upon which to base accurate and scientific data.

Although these statements are undoubtedly true, it may nevertheless be asserted with confidence that we are to-day no longer in the dark as to the general pathology of this interesting disorder, and that we are in position to map out a plan of treatment which meets the indications which present themselves in an intelligent and reliable manner. There are, however, several sources of hemorrhage which result in pelvic hæmatocele, and it is highly probable that the day will never come when that one which has created the accident can be ascertained with certainty. But while such accuracy of diagnosis would be gratifying to the ambition of the modern diagnostician, neither the prognosis nor treatment of the disorder would be influenced by it.

Long before our day practitioners had recognized by touch the occasional presence of tumors, more or less marked by fluctuation, which occupied the pouch of Douglas, and by their mechanical influence pushed the uterus out of its normal place; but it was not until the early part of our century that it was discovered that these tumors were sometimes, and that not rarely, composed entirely of coagulated blood; and, curious though it may appear, it was not until the year 1850 that pelvic hæmatocele became a well-recognized disorder.

As early as 1737, Ruysch of Amsterdam appears to have come to the verge of discovering it, but it was left for Récamier, to whom gynecology owes so much besides, to make it known when in 1831 he opened a post-uterine tumor, gave vent to a large accumulation of coagulated blood, and described the case in the Lancette Française for that year. In 1850 the {240} subject attracted the attention of Nélaton, became a recognized pathological condition, and has since received a great deal of attention in all the civilized countries of the world.

DEFINITION AND SYNONYMS.--Pelvic hæmatocele--which has likewise received the names of retro-uterine hæmatocele and uterine hæmatoma--may be defined as an effusion of blood into the pelvic cavity of the female, either into or under the peritoneum. Some authors have limited this definition to blood escaping from utero-ovarian vessels and to blood enclosed either by anatomical structures or by previously-existing inflammatory products. I do not adopt these restrictions, because their assumption appears to me to be unwarranted and the validity of the reasons given for their adoption more than doubtful. The location of the blood-mass differs widely in different cases: sometimes, and usually, it is behind the uterus--high up when obliteration of Douglas's pouch has occurred, low down and near to the perineum where such obliteration has not occurred; at other times it exists both behind and in front of the uterus; and at others still, in front of the uterus alone, adhesions preventing its percolation to the posterior parts of the pelvis.

FREQUENCY.--It may be said, in general terms, that this affection is by no means rare, every one of large experience in gynecology meeting necessarily with a large number of cases of it. But no reliable statistics of its frequency have been collected up to the present time. Olshausen of Halle declares that in 1145 gynecological cases he saw 34 hæmatoceles; Beigel in 2000 cases found 38; Schroeder, 7 in 1000; and Seiffert of Prague reports 66 seen in 1272 cases of female pelvic diseases. Barnes says that in ten years' practice he met with 53 cases, and in twenty years Tilt has seen but 12.

Without doubt, the validity of the statistics of this disorder is vitiated by erroneous diagnosis, as is the case with all affections which generally end in recovery. Here cases of cellulitis, pelvic peritonitis, imprisoned cysts, etc. offer prolific sources of error, as I can aver from the results of my own experience.

PATHOLOGY.--It is a fact, thoroughly proved by physiological experiment, that blood injected into serous cavities very soon encysts itself by the enveloping influence of lymph which is poured over it, forming false membranes, or, as the French term them, néo-membranes. The clot, once formed, clings to the serous membrane in contact with it, and soon becomes roofed over by lymph, which, according to Vulpian, begins to show traces of organization as early as the end of twenty-four hours. Should the effused blood be poor in fibrin, the coagulation and encysting do not occur, a rapid absorption taking the place of these processes.

Pelvic hæmatocele consists, as has been already stated, in the collection of a mass of blood in the pelvis, either above or below its roof, without reference to the source of the flow. Such a flow ordinarily occurs from one of the three following sources: first, rupture of vessels in the pelvis; second, reflux of blood from the uterus or tubes; third, transudation of blood in consequence of dyscrasia or pelvic peritonitis.

From this it becomes evident that hæmatocele is not a disease, but a symptom which marks a number of different pathological conditions of quite various significance. As, however, we cannot discover the original accident or pathological condition, we are forced to compromise with {241} taking its most prominent sign as the exponent of a state which is beyond the powers of diagnosis.

Autopsic evidence has revealed the following as the special and most frequent sources of the hemorrhage:

1st. Rupture of blood-vessels in the pelvis: Utero-ovarian; Varicose veins of broad ligaments; Vessels of extra-uterine ovisac. 2d. Rupture of pelvic viscera: Ovaries; Fallopian tubes; Uterus. 3d. Reflux of blood from the uterus: Menstrual blood. 4th. Transudation from blood-vessels: Purpura; Scorbutus; Chlorosis; Hemorrhagic peritonitis.

It is then clear that the mere presence of a large clot of blood in the pelvis, apart from general symptoms, is a matter of very doubtful significance, since on the one hand it may be the result of a mere regurgitation of menstrual blood due to imperviousness of the cervical or tubal canal, or on the other of the rupture of a Fallopian tube which has become the nidus of an extra-uterine foetus.

Whatever be the source of the blood which escapes, it coagulates, unless very poor in fibrin, either in the most dependent part of the peritoneum or in the pelvic areolar tissue beneath it. Here the watery portions of the mass are gradually absorbed, leaving a hard, small tumor remaining; or, suppurative action being excited, the hard mass is softened down and discharged into the rectum, vagina, bladder, or peritoneum as a grumous material somewhat resembling currant-jelly in appearance.

CAUSES.--These must be divided into predisposing and exciting, for it is rare to meet with the disease in a woman who has previously been in perfect health. The predisposing causes which can be cited with confidence are--the period of ovarian activity (fifteen to forty-five years); disordered blood-state, plethora or anæmia; the menstrual epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the hemorrhagic diathesis. The exciting causes have been found to be sudden checking of the menstrual flow; blows or falls; excessive or intemperate coition; obstruction of cervical canal; obstruction of Fallopian tubes; violent efforts; and ectopic gestation.

VARIETIES.--The two great classes of the affection are the peritoneal and the subperitoneal. In the former the blood collects in the peritoneal cavity and becomes encysted there; in the latter it collects in the cellular tissue beneath the peritoneum, and there forms a solid mass.

Some authors have opposed the consideration of these two varieties under the same head; among them, Aran, Bernutz, and Voisin. But from a clinical standpoint such a consideration appears to me to be valid. Not only have distinct instances of subperitoneal hæmatocele been recorded by such observers as Barnes, Simpson, Olshausen, and Tuckwell, but {242} cases have been met with in which the subperitoneal variety has ruptured the peritoneal roof of the pelvis, and thus broken down the theoretical barrier which pathologists have been inclined to establish between the two varieties.

Of the two varieties, there can be no doubt that the peritoneal is that which presents itself the more frequently. In 41 autopsies Tuckwell found the tumor to be peritoneal in 38.

SYMPTOMS.--As a rule, long before the occurrence of pelvic hemorrhage the patient will have complained of more or less decided symptoms of disease, or at least of disorder, of the genital system. The symptoms which mark blood-dyscrasia or pelvic peritonitis or menstrual irregularity will probably have attracted attention.

When the accident occurs the gravity of the symptoms will depend in great degree upon the character of the lesion which has taken place. Sometimes the blood-accumulation takes place so insidiously that the existence of the tumor created by coagulation takes the practitioner by surprise. At other times what Barnes has called a cataclysm occurs, and in a few hours puts the unfortunate patient beyond the sphere of hope or the resources of art.

In portraying the symptoms of this affection a writer can therefore merely approximate the truth, satisfying himself with the description of a case of ordinary severity, avoiding the description of cases in either extreme, and guarding the reader against supposing that all attacks give the same intensity of symptoms.

Most prominent among the immediate symptoms are--severe and sudden pelvic pain; pallor, faintness, and coldness of the extremities; a sense of exhaustion; nausea and vomiting; metrorrhagia; uterine tenesmus; enlargement of the abdomen; interference with the bladder and rectum; small and rapid pulse; subnormal temperature.

These are the symptoms of invasion, those which may be termed immediate, and which depend upon loss of blood and a sudden traumatic influence exerted upon living tissues. Very soon, generally within forty-eight hours, a reaction occurs which is sometimes slight, and at other times decided. The secondary symptoms are usually the following: tendency to chilliness; constipation; suppression of urine; tympanites; high temperature; rapid pulse; and tenderness over abdomen.

These symptoms are due to a combination of two causes--loss of vital fluid and the invasion of the peritoneum or pelvic areolar tissue by a mass of blood which becomes coagulated and irritant, on the one hand, and inflammatory processes resulting from such invasion on the other. Half of them might be produced by metrorrhagia, and half by sudden and complete retroversion; but a union of the whole will point toward hæmatocele and prompt a physical examination.

PHYSICAL SIGNS.--A tumor will be felt by vaginal touch, usually, though not always, posterior to the uterus and vagina, and partially occluding the latter. This will, if the examination be made very early, be found to be soft and obscurely fluctuating, but it soon becomes a smooth, dense, and solid body. The uterus is very generally found pressed upward and forward, so that the body lies against the abdominal wall and the cervix is on a level with or a little above the symphysis {243} pubis. In some rare cases the blood-tumor is anterior to or obliquely to one side of the uterus, but these are very rare.

Abdominal palpation reveals the presence of a tumor of varying size, and which sometimes extends up to the navel in peritoneal hæmatocele, but in the subperitoneal variety no tumor whatever may be discoverable by these explorations, unless conjoined manipulation be added to it for the sake of deeper and more thorough search.

DIFFERENTIATION.--Hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst.

The tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia.

Retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms.

The development of extra-uterine pregnancy is slow and gives the signs of gestation.

Fibrous tumors grow slowly, are painless, and move with the uterus, and they are hard, irregular, and do not lift the uterus against the symphysis.

Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia, and yield fluctuation readily to palpation.

COMPLICATIONS.--The complications to be feared in this disease are septicæmia, suppuration and abscess, and peritonitis.

COURSE, DURATION, AND TERMINATION.--The hemorrhage may be so severe as to destroy life immediately. Five such instances have been recorded by Voisin; I have met with one; and Ollivier d'Angers mentions two in which death occurred in half an hour from a varicose utero-ovarian vein. Such a termination is, however, very rare.

As a rule, absorption takes place unaided by art; in some cases suppuration occurs, and the mass is discharged as if it were a large abscess by the vagina, rectum, bladder, or abdominal walls; and at other times septic absorption, accompanied by septic peritonitis, destroys the life of the patient.

PROGNOSIS.--The prognosis will depend in great degree upon the severity of the constitutional symptoms. As a rule, it is decidedly favorable unless the surgical tendencies of the attending practitioner alter its natural inclination. The prognosis of the peritoneal form is graver than that of the subperitoneal, and when the tumor is very large the danger is greater than when it is small. A large tumor argues great loss of vital fluid, which may in itself destroy life, and the necessity for the absorption of a large amount of coagulated material which may poison the blood.

The usual causes of death are loss of blood, shock from sudden invasion of the peritoneum, peritonitis, secondary discharge of the encapsulated mass into the peritoneum, or septicæmia.

TREATMENT.--Should the physician be called in the inception of the attack, the patient should at once be placed in the recumbent posture, all excitement around her be quelled, the head be kept low, warmth be applied to the soles of the feet, and perfect quiet enjoined. An effort should be made to check the flow by applying bladders of ice or cloths wrung out of hot water over the hypogastrium, pain and tendency to {244} shock met by the use of morphia hypodermically, and ammonia and brandy freely administered by the mouth. This is all that promises benefit, and further efforts should be avoided as calculated to do absolute harm.

After reaction has occurred let it be borne in mind that the factors which tend to the production of death are--1st, peritonitis; 2d, septicæmia; 3d, suppuration and discharge through some dangerous outlet; and let all efforts be directed toward the prevention of these events.

All pain should be quieted by opium or one of its salts, hypodermically or by mouth or rectum; the patient should be thoroughly nourished by milk and strong animal broths, given as often as every two hours; febrile action should be controlled by the coil of running ice-water and quinine; and strict quietude observed, all unnecessary examinations being avoided, as belonging to the most pernicious class of perturbing influences.

Should the case progress favorably, no surgical procedure looking toward the artificial evacuation of the accumulated blood either by bistoury or by the aspirator should be thought of, however large the accumulation be; for experience has proved that cases left to nature, as a rule, do better than those interfered with.

On the other hand, the great value of surgical interference in those cases in which suppurative action occurs, or in which septicæmia develops itself either in acute or chronic form, must not for a moment be lost sight of. Should the case not progress toward recovery, should the symptoms of septicæmia develop as a sharp attack or as the insidious hectic fever, the accumulated blood or pus and blood should at once be evacuated, and the nidus from which it is discharged be thoroughly washed out with a 2½ per cent. solution of carbolic acid or a solution of the bichloride of mercury, 1 to 2000 of water. Should the accumulation be attainable, tuto, cito, et jucunde, by the vagina, an exploring-needle should be carried into it, and as soon as the fluid is seen to flow a sharp-pointed bistoury should be slid along this and a free opening be made, all the contents of the sac evacuated, and antiseptic washing be at once practised by means of Davidson's syringe and a glass tube.

Should the accumulation point toward the abdominal walls, the opening may with perfect safety be accomplished there. I have operated thus upon 3 cases, with recovery in all, but the accumulation had at the time of operation assumed the character rather of an abscess than of an hæmatocele. A. Martin of Berlin has operated by abdominal section upon 8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden has done so upon 1 case, with recovery. Zweifel has collected 30 cases operated upon by free vaginal incision, with a result of 3 deaths, giving a mortality of 10 per cent. Mere puncture through the vagina he found followed by a mortality of 15 per cent.

The question of surgical interference in pelvic hæmatocele is still sub judice. In my judgment, the rule of practice may, with the present light which we have to guide us, be safely formulated thus: So long as the symptoms are good and the case progresses toward recovery, avoid surgical interference of all sorts, however great be the sanguineous effusion. So soon as symptoms of decided septicæmia or septic peritonitis develop themselves, evacuate the accumulation by a free opening practised by the safest outlet which presents itself, and use antiseptic washings thoroughly.

{245}

FIBROUS TUMORS OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.

RELATIONS AND STRUCTURE.--These tumors grow from the muscular and connective tissues of the uterus, and consequently partake of the character of these tissues. Sometimes the substance of the tumor consists principally of connective, at others of muscular, tissue. The variations in the relative proportion of these two fibrous substances constitute the main differences in the characters and appearances of the tumors, and lead to the different terms applied to them, as myomata, fibromata, myo-fibromata, etc. The firmer the tumor the more connective tissue it contains. When we inspect, either ante- or post-mortem, a uterus with a fibrous tumor attached or contained within its wall, it will be found to present a much darker hue than natural. Instead of the normal light rose-color, it is generally dark, sometimes almost of a purplish tint. The time of menstruation makes some difference; just before it is darker than soon after the menstrual flow. The color also varies with the character and size of the tumor. In large solid tumors the color is darker than in the large fibro-cystic variety; indeed, in some of the latter the pearly color strongly reminds one of an ovarian cyst. We cannot therefore depend on the color or shape of surface for a diagnosis. Even after the abdominal cavity is opened the contour of the uterus is usually not regular. If we make an incision into the tumor, we find that it is surrounded by a distinct capsule, which limits and defines its boundaries and separates it from the adjacent substance. This envelope is not a cyst or other form of membrane: it is continuous with, and inseparable from, the muscular structure of the uterine walls. It, in fact, is a condensed layer of the fibrous substance of the uterus. In cases of true encysted tumors the cyst-wall is the generating portion of the growth. In fibrous tumors of the uterus the growth produces the capsule by displacing the surrounding substance in every direction, pressing it strongly against the unaffected fibrous tissue and condensing it into the smooth capsule. It is thus engendered in, and enveloped by, the muscular walls of the uterus. These latter of course grow to dimensions sufficient to keep pace with the increasing tumor. The growth may, as a consequence of such a connection, be hulled out or enucleated, and will not be reproduced. Inflammation or other degenerating processes may occasionally cause adhesion of the capsule and tumor, but this is an accident of uncommon occurrence. To understand this mode of encapsulation we must remember that the uterine muscles are irregularly stratified, {246} and that the tumors are developed between the strata as between the leaves of a book, separating them sufficiently to gain lodgment and room.

The appearances of the substance of the tumor are not uniform. In many cases the color of the interior of the tumor is dark gray; in some it is dull red; again, sometimes almost livid. The surface of the tumor after the capsule has been removed is often marked by sulci denoting a division into lobules. In other cases the tumor is smooth and symmetrical in shape, and the fibres distinctly visible to the naked eye. The smooth tumor is apt to be very dense and comparatively difficult to destroy, while the lobulated variety is less dense and sometimes easily broken to pieces. But the difference of density does not correspond altogether with the color or shape of surface.

We seldom find large tumors of uniform structure. In some places they are of solid fibrous structure; in others there are cavities of greater or less size, containing a tenacious red serum. These cavities, which seem to be made by localized disintegration of the fibrous tissue, are sometimes of great size, containing several pounds of serum (Atlee). Much more frequently they are small and hold a small amount of fluid. I have met with several where the substance of the tumor seemed to be made up of alveoli filled with a tenacious fluid the color of milk.

Besides this effect upon the density of the tumor resulting from what might be called its usual course, there are numerous modifications in it and in the other properties of the tumors arising from spontaneous degeneration.

It may be said, I think, that without adventitious or supplementary vascular supply the life of a fibrous tumor is self-limited, and it ceases to grow after it has attained to a certain size, and that then it either remains stationary or undergoes degeneration. As I shall have occasion to say farther on, the original supply of blood-vessels cannot be increased to an indefinite degree, and the tumor that grows indefinitely derives a supplementary supply of blood by contracting adhesions to the viscera or abdominal walls. Such adhesions are common and mischievous.

After a tumor has attained its growth, degeneration into the more elementary forms of tissue sets in, as the cartilaginous degeneration, and there is often a deposition of earthy material found in it which reduces it to a hard, dense, stationary, and indestructible body. In such cases there is almost a complete loss of vitality in the tumor, and it becomes a calcified mass.

We may easily demonstrate that the structure of these tumors is essentially fibrous. By maceration and careful dissection the fibres are traceable to a greater or less degree in all of them, the proportion and characters of which, as before said, differ greatly. In the smooth, symmetrically-developed tumor the fibres are usually long and distinctly traceable, while in the lobulated light-gray tumor the fibres are more rudimentary and not so easily followed up by dissection.

MODE OF DEVELOPMENT.--It has already been stated that the fibrous tumor of the uterus grows in or on its wall and originates in the fibrous structure of the organ. The point of beginning is in one or more fasciculi of the muscular system or the connective tissue of the uterus. If in one fasciculus, the point of origin is very minute, as indeed it is generally at first.

The development consists in an hypertrophy of the bundle of fibres {247} affected and a deposit of material similar in structure to that first involved. Sometimes there are numerous nuclei, and nearly all the fibrous structure of the uterus is involved in fibrous degeneration. In the case where the deposit is defined and occupies a small space, it should be borne in mind that the future tumor, however large it becomes, must occupy the same nidus in which it first originated. The nidus becomes enlarged sufficiently to accommodate the growing tumor.

The nucleus of development is enlarged by the accretion of substance similar, if not identical, in character to its own proper material. The nature of the tumor is determined by this fact, and its fibres are rudimentary in organization, instead of being hypertrophied and highly developed, as those of the uterine wall by which it is surrounded. As the tumor grows the fibrous structure surrounding it is pressed aside in every direction in such a way as to completely embrace the growth and encapsulate it. The tumor does not incorporate the adjacent fibres and grow by inducing degeneration in them, but, as before said, it presses them aside. As it thus moulds and shapes a bed in the solid substance of the interior wall, it impresses upon the embracing muscular fibres an increased vitality, and they grow by hypertrophy of a character similar to that of pregnancy. The fibres become longer, and apparently, if not really, more numerous. This hypertrophy of the uterine fibres surrounding the tumor is equal to the capacity demanded by the increasing size of the growing tumor. In this description of the method of development and the embracing capacity of the hypertrophied fibres surrounding it the reader will trace the formation of the capsule in which the tumor is contained. The inner surface of the capsule is smooth, and there are many feeble fibres of connective tissue seen to connect it with the surface of the tumor. There is no adhesion proper between the surface of the tumor and its capsule.

I must call attention to another point that governs the extent and limits of the growth of the tumor--viz. the number and distribution of its vessels. The vessels entering the tumor represent the minute twigs that supplied the fasciculus in which it originated. They arrive at the point of morbid deposit from the parts constituting the capsule, and there are always several of them. The number of these vessels always remains the same, and their calibre is increased with the hypertrophy of the surrounding tissues. They cannot grow at the demand of the trophic energies of the tumor to an unlimited degree, but their size is limited by the growth of the surrounding parts. As the tumor grows and its capsule expands, the vessels are separated farther from each other, until after a while the area becomes so large that the supply of blood will not admit of further growth and the tumor comes to a standstill. Thus their growth, from the nature of their supply, is limited; hence the usual history of the tumor is one of self-limitation. It is all-important in forming an opinion in reference to the greater or less vitality of the fibrous tumor, therefore, to remember that it is not supplied by one large arterial trunk entering at one place and spreading over its capsule, but that the supply is by a number of small vessels penetrating the tumor at different points; that their number cannot be increased and their growth is limited; that as the tumor grows their capacity to supply it grows gradually less until entirely exhausted: then the growth stops.

{248} There is another and adventitious source of nutritious supply, and I think it is essential to very large growths: at least, so far as I know, it is always present. I mean the adhesion of the uterus or tumor to the wall of the abdomen, the pelvic or abdominal viscera, or, what is more common, the omentum. When adhesions occur from whatever cause, the vessels of the tumor increase in size and supply it with a vast increase in the amount of blood. All the large tumors I have had an opportunity of examining were to a greater or less extent covered by a network of large vessels contained in the omentum. These vessels penetrate the uterus, carrying a deluge of blood into its substance. These large vascular adhesions are a source of embarrassment in operations for their removal. Operators allude to them and give instructions how to overcome the difficulty presented by them. The uterine vessels alone would never be sufficient to supply the forty- or fifty-pound tumors so often mistaken for ovarian tumors.

EFFECTS UPON THE UTERUS.--I have already said that the fibres immediately surrounding the growth undergo a true hypertrophy, acquiring dimension, susceptibility, and capacity similar to the hypertrophy of gestation. All the fibres of the uterus undergo a similar change, only less in degree; the more remote from the tumor, the less marked the hypertrophy. This remark must be modified somewhat by the consideration of the locality of the tumor. A polypoid tumor growing from the fundus causes universal hypertrophy of the uterine fibres. A submucous tumor will usually cause a general hypertrophy of the uterine fibres, but greater on the side of the tumor. A subserous tumor is attended by a slight hypertrophy, and in a centrally-located intramural tumor the hypertrophy would be much like that in the submucous variety, only less in degree. But this augmentation of tissue is not confined to the fibrous structure: it extends to the vascular and nervous apparatus and to the serous and mucous membranes. With this growth of the tissues comes change in the properties and functions of the uterus itself. It is more sensitive, the secretions are increased, and almost parturient contractility is acquired.

But probably as remarkable and uniform a symptom as any arising from the general hypertrophy is hemorrhage. The mucous membrane of the uterus is hypertrophied in all its constituents and proportions. The membrane acquires larger superfices and greater thickness, its glands are enlarged, and its blood-vessels augmented. Its functions, as a consequence of these changes, are exaggerated. The glands secrete greater quantities of mucus, and the vessels when ruptured in the processes of menstruation pour out a superabundance of blood. Indeed, I know of no other way to account for the hemorrhages so generally present in cases of fibrous tumors of the uterus, except upon the ground that the endometrium, a natural hemorrhagic surface, has its properties and functions enhanced by a general hypertrophy.

LOCATION OF THE TUMOR.--For the purpose of considering the relation of these tumors to the different regions of the uterus we may call that part situated above the entrance of the Fallopian tubes the fundal zone, and that above the internal os uteri the corporal zone; all below this the cervical zone. Fibrous tumors may and do originate in all of these zones or regions, but they spring more frequently from the corporal {249} than either of the others, and less frequently from the fundal zone. The part of the corporal zone in which these tumors more frequently grow is the lower or cervical portion. There is another important view of the relation of the tumors to the uterus. The muscular fibres of that organ run in every direction with reference to the latitude and longitude of the uterine circumference--transversely, longitudinally, obliquely, spirally, etc. There is probably not much more definiteness in the layers constituting the walls of the uterus. If they cannot be completely separated into regular strata, there is sufficient distinctness in the layers to justify us in employing the term strata in connection with their arrangement, and this term will enable us to get a more exact understanding of the language used in the description of tumors. Authorities differ as to the exact number of strata to be found in the body of the uterus, but for clinical purposes it is convenient to describe them as follows: By drawing a line through the middle of the uterine wall longitudinally we will indicate a central stratum of fibres. A tumor originating in that line or stratum is what is usually called an intramural tumor. The number of tumors growing in this stratum is not very great as compared with those situated nearer the two surfaces.

If we run one line between the serous and another between the mucous membrane and the central line, as in the diagram, other strata with intervening spaces will be indicated. a would represent the centre stratum of the wall; b, the space immediately outside of that; c, a stratum still farther out; e, the subserous; and d, a deeper one. When we look at the inner layers of fibres, we find f situated immediately beneath the mucous membrane; g, farther out; and h, next the median line. The nucleus of a tumor may be first manifested in any of the strata or spaces marked by these lines, and its position with reference to the central line will, to a great extent, govern the direction it takes during development. A tumor the nucleus of which is situated in line a will, as it develops, press the muscular fibres equally in every direction, and when large, the prominence caused by pressure of the tumor would be equal in the uterine cavity and on the peritoneal surface. In marked contrast to this, when the nucleus is at f the growing tumor presses the mucous membrane before it until it becomes pendulous, and then the name of polypus is given to it; or if the origin is at e, the serous membrane is pressed before it, and the tumor is called subserous. When the nucleus is at d, the tumor elevates the serous membrane and becomes a prominent hemispherical protuberance. It is also called a subserous tumor, although situated some distance from the membrane. When a tumor takes its origin at g the mucous membrane is crowded before it, and a marked prominence into the cavity of the uterus is observed. This is the submucous tumor. These illustrations are intended to call the attention of the student to the fact that practically these tumors spring {250} from any one or all the fibrous strata of the uterus instead of only the central, submucous, and subserous layers, and that it is profitable, on account of the difference in their effects upon the shape and functions of the uterus, to study them in this aspect of their growth.

ETIOLOGY.--While we know many of the conditions under which fibrous tumors exist, we have really very little, if any, definite and reliable information as to their causes, either remote or proximate. We know that they occur much more frequently near the time when the uterus begins to undergo senile degeneration, although they do originate in earlier years. They very seldom, if ever, are observed in the foetus or child, nor is it common for them to commence growing after the menopause. Women belonging to the African race are the most frequent subjects of these tumors.

The married or single status does not seem to have any effect in predisposing to these tumors. We do not know what physiological or pathological states of the uterus or other organs predispose to them. There is probably no tumor in the body strictly analogous in structure, mode of origin, supply, or development to the fibroid tumor of the uterus. There is no other organ in the body that undergoes analogous normal trophic changes. The vast multiplication of tissue that takes place in the uterus during gestation, and the more rapid but equally great changes toward degeneration or atrophy, would naturally suggest pathological possibilities of a peculiar nature. The rhythmical changes of menstruation are like no other functional condition. They too involve the processes of hypertrophy and atrophy. When the menstrual and generative changes are normal every part of the body of the uterus is simultaneously and proportionately hypertrophied and atrophied. Local derangements of these processes of hypertrophy and degeneration must sometimes occur, probably from defective or excessive innervation of loculi in the fibrous structure. Congestion or hyperæmia may thus result, and consequently very great influence be exerted upon the nutrition of the parts concerned after the deposit has begun; its presence increases the hyperæmia and thus perpetuates its growth indefinitely.

CLINICAL HISTORY.--Probably the earliest, most frequent, and constant symptoms connected with fibrous tumors of the uterus are hemorrhage and leucorrhoea. They are both the result of active or arterial hyperæmia, and doubtless come from the endometrium. Polypi, submucous, and intramural tumors are more likely to give rise to these two symptoms. The nearer the mucous membrane, and the greater that membrane is expanded, the greater the amount of hemorrhage and leucorrhoea, and, as a counter-fact, the nearer the serous membrane, the less the amount of these two discharges. While this statement in reference to the effects of the proximity of the tumor to the two membranes is usually true, it is not always so.

Hemorrhage is sometimes not very great, but at others it is appalling, and constitutes an imperative reason for the employment of desperate remedies. The hemorrhage is usually first noticed in connection with the menstrual flow, and it may even be confined to the periods: sometimes it extends over the whole of the interval. The leucorrhoea is generally constant, and sometimes thin and watery, especially after the hemorrhagic paroxysm has subsided, and at others it is constituted {251} mainly of mucus with the débris of the mucous membrane and blood-corpuscles.

Other symptoms are pelvic pressure, vesical and rectal, with tenesmus, distension, and dysmenorrhoea. The pelvic pressure and tenesmus are observed early in the development of the growth, and may be relieved as the tumor becomes large enough to rise out of the pelvic cavity. The abdominal distension of course comes later. Solid tumors do not often attain to such a size as to cause great abdominal distension. The fibro-cystic generally are inconvenient, if not fatal, from this cause.

The above are the more direct and common symptoms. A less frequent yet important effect and symptom is oedema of the lower extremities from pressure upon the venous trunk passing through the pelvis. In rare cases this symptom is aggravated to a degree constituting phlegmasia alba dolens. As the tumor rises and enlarges the pressure may embarrass or interrupt the function of any or all the abdominal viscera.

In many cases none of these symptoms present themselves to an inconvenient degree, and the tumor is discovered by accident. Again, we meet with cases in which the symptoms are formidable for a time, and then entirely subside, leaving the patient free from suffering the balance of her lifetime. While this subsidence may take place at any time during the growth of the tumor, it is very apt to take place at the menopause.

The clinical history of the fibrous tumor may be very much modified by the intervention of various circumstances. As organized bodies they are subject to those affecting the organs of the body. We must regard them as adventitious growths acted upon by organs in a state of disease and reacting in turn upon them. They may become inflamed, undergo suppuration and gangrene, and produce symptomatic fever, hectic fever, prostration, gastric, hepatic, and nervous derangement in a degree sufficient to prove fatal.

When situated near the mucous membrane, nature sometimes turns these organic changes into a means of cure by destroying the portions of the capsule near the uterine cavity and permitting the pus or gangrenous material to escape. They are also subject to pressure from the development of other tumors, and either disappear, become inflamed and adherent, or cause great trouble to adjacent organs. Their clinical history is sometimes modified by complication with pregnancy.

This complication is rare, because the uterus in most cases, on account of the effects produced upon its circulation, nerve-supply, and mucous membrane especially, will not retain the ovum, and conception does not take place. The uterus being more vascular, and subject to congestions that affect the placental attachment injuriously, miscarriages are likely to occur. It is also morbidly sensitive to the pressure of the ovum, while the mucous membrane is rendered incapable of decidual changes. The retentive power of the uterus is further interfered with from the irregularity of its growth: the fibres where the tumor exists, being under a morbid influence, cannot partake of the regular hypertrophy necessary to normal gestation. There is something of uniformity in the circumstances under which the coexistence of pregnancy and fibrous tumor is observed. The nearer the tumor is situated to the mucous membrane, the less likelihood of pregnancy--the more remote, the greater the tolerance of pregnancy. Tumors that occupy the wall of the corporal portion {252} are conducive of sterility. Those in the cervical portion of the corporal and the cervical zone are more likely to be accompanied with pregnancy than those situated in other parts of the organ. While the reader will find these statements borne out by his experience as general facts, he will also discover that pregnancy is occasionally compatible with almost any form, variety, or position of tumor. When this complication occurs, it does not generally influence the process of gestation or the condition of the tumor. The main symptoms depending on it are those caused by pressure. When small this is not very considerable.

Complication with labor generally gives rise to more apprehension than difficulty. Most of the cases of labor terminate spontaneously and happily, and the others are generally within reach of the less destructive modes of delivery. Labor more frequently decidedly affects the growth of the tumor, in the majority of cases causing its disappearance during the process of involution. The cervical polypi affect labor less, and are less affected by labor, than any other variety of the tumor. If small, they are sometimes merely pressed to one side or into the hollow of the sacrum, and the head passes by them; if a polypus is large, the head of the foetus carries it before it beyond the vulva, where it remains until the child is expelled, when it may recede into the vagina.

DIAGNOSIS.--The history usually includes hypersecretion, hemorrhage, pressure, and enlargement. These, while suggestive, are not conclusive, hence physical examination becomes indispensable to accuracy. The methods of examination vary with the size of the tumor. It is generally near the truth to say that the uterus is enlarged, and may be shown to be so by the introduction of the sound; yet the cavity is not always enlarged, and it is often so tortuous that the ordinary sound may be arrested before reaching the fundus. The sound, therefore, should in such condition be flexible. The fine whalebone or the sound of Jenks will generally pass obstructions caused by tortuosities. The most skilled and dexterous use of the inflexible sound is often delusive. We may generally determine the size by bimanual examination--one finger in the vagina or rectum while the hand is passed down into the pelvis from above. The uterus of normal size cannot be felt with any distinctness from above in this way, while an enlargement of 50 per cent. may be thus determined. The finger below will sometimes recognize the pressure from above when the upper hand will not feel the fundus distinctly. Small tumors of the uterus may be mistaken for many other conditions, and the converse. If one is situated in the posterior wall, it may be mistaken for retroflexion. We may make the distinction by means of the inflexible sound and the finger in the rectum. If the case is one of retroversion, the finger in the rectum will pass behind it and overlap it above. If a retro-uterine tumor is in the cul-de-sac, the finger will not reach above the uterus. If the case is one of retroflexion, a strongly bent sound may be made to enter it, especially if the fundus is slightly raised by the finger in the rectum. If there is a tumor in the posterior wall, the sound with slight flexion will pass above it; which is clearly ascertained by the finger in the rectum. When the sound is introduced in the case of retroflexion, the fundus may be elevated to its proper position by turning the sound upon its axis. In making these examinations with the sound the finger should be made to co-operate with it by being kept in {253} the rectum. A small tumor in the anterior wall may be distinguished from anteflexion by the sound passing upward instead of forward, or into the part lying on the bladder. When a small tumor is intra-uterine, the uterus will occupy its natural position, with the mouth directed slightly backward; and if the polypus is large, the cervix can be moved forward with considerable difficulty. A flexible sound, especially the thin whalebone, may sometimes be made to partially or wholly surround it, and its size or connections be determined. But the diagnosis may be more definitely made out by dilating the cervical cavity and introducing the finger. The difference between a polypus and an intramural submucous tumor may be determined in this way. In the case of a polypus the finger will pass around it, while if the tumor is intramural or submucous the finger will be arrested at the point of attachment. A polypus or intramural submucous tumor presenting at the os externum may sometimes be mistaken for a partial inversion. Such a mistake may be prevented by using the sound. In the case of a tumor the flexible sound will pass to more than the normal depth. In one of inversion the sound will pass very much less or not at all. When a polypus has escaped from the mouth of the uterus and occupies the vagina, the sound will pass beyond it into the enlarged uterus, whereas in complete inversion it cannot be passed into the uterus in any direction. We cannot rely upon consistence or shape as marks of distinction in these two conditions. When the tumor rises above the pelvic brim and is not very large it generally displaces the os from its normal position. If in the front wall, the os will be too far back; if in the posterior, it will be displaced forward. In the former, when a sound is introduced, it will pass backward and upward; in the latter, the sound will pass forward and upward. In both cases the bimanual examination will enable us to determine that the tumor above the pelvis is continuous with or attached to the uterus. With the hands in this position, if we move the uterus the tumor will move with it, and vice versâ. Tumors of this size are usually more or less uneven in their outline, and of greater consistence than the uterus when enlarged from other causes. Tumors of this size may be generally distinguished from the pregnant uterus by the history of pregnancy, by the consistence, and by the size of the cervix. When pregnancy and a tumor are associated, this may be determined by a part of the enlargement being very hard and other parts quite elastic, and by auscultation. I need not caution the reader against the use of the sound where there is any suspicion of pregnancy. When a doubt exists, we should await the progress of the case until pregnancy becomes obvious. We may generally determine whether a tumor is uninuclear by the fact that a single tumor is nearly round, when if there are several points of origin it will be irregular and nodular.

When the tumor is large enough to nearly or quite fill up the abdominal cavity, the flexible sound may be made to pass a great distance into it. It is not often that a solid tumor grows large enough to fill the abdominal cavity. Before it grows to such dimensions it generally undergoes cystic degeneration. When the tumor is solid, generally its very great hardness, and often its irregular shape, will distinguish it from other abdominal tumors. The condition with which I have seen these tumors most frequently confounded is enlargement of the liver or spleen. {254} In the South and West an enormously enlarged spleen is not infrequently met with. It sometimes spreads over the whole anterior part of the abdomen, completely covering the intestines. Less frequently the liver is found similarly enlarged. In this condition the organ becomes greatly indurated, and sometimes nodular. The distinguishing features of these enlargements are--first, that the abdomen does not present the prominent rotundity it does when filled by a growth; second, that somewhere in the extent of abdominal surface by careful manipulation the edge may be discovered and the fingers be made to sink beneath and grasp it; third, percussion will elicit general deep resonance, in some parts quite obvious, and in others less so. In the case of tumor none of these signs will be present. Again, the enlarged liver or spleen, while it may reach to the brim of the pelvis, does not reach into that cavity far enough to be recognized by the finger in the vagina, while the tumor does.

Sometimes inflammatory effusions form indurated masses in the abdomen that are mistaken for fibrous tumors. These of course have the history of inflammation, are generally if not always tender, and yield obvious intestinal resonance upon percussion. The large fibro-cystic tumor may be mistaken for pregnancy, ovarian tumor, cystic degeneration of the kidney, and omental tumors. Pregnancy can generally be established by absence of the menses, by the shape, size, consistency, and position of the cervix, together with auscultation. It may be said that in case of fibro-cystic tumor the cervix is greatly displaced in some direction, indurated, and not enlarged. In pregnancy none of these conditions prevail.

The fluctuation of the fibro-cystic tumor is more obscure than that of the ovarian tumor, and, although sometimes noticeable over a large space, it is usually more constricted in extent. There is also usually less regularity in the shape of it. In large ovarian tumors the uterine cervix is not changed in shape and size. The whole organ generally lies beneath the tumor, and the elastic sound will not pass very deeply into the cavity. If the uterus is attached to the anterior part of the tumor, which sometimes happens, the elastic sound will pass into it and the depth will not be very great. The fibro-cystic tumor may be distinguished from the enlarged encysted kidney by the facts that the kidney is traceable to one side more than the other, and it cannot be reached by the finger through the vagina or rectum. Still, if we cannot make the differentiation clear in any other way, we can generally do so by aspiration. In most cases we cannot draw the fluid from the fibro-cystic uterine tumor; in almost all cases the quantity removable in that way is small. When fluid is drawn, it usually coagulates, contains hæmatin, and none of the cells so generally found in ovarian tumors.

The fluid drawn from the kidneys presents epithelial cells, is not coagulable, certainly does not coagulate spontaneously. The abdominal cavity is sometimes more or less filled with peritoneal serum. After this is withdrawn from the peritoneal cavity the uterine attachment of the tumor may be made out by bimanual examination, as above directed, if undertaken immediately after the evacuation.

PROGNOSIS.--Less than twenty years ago the general prognosis to be made upon the discovery of a tumor of the uterus was very grave. The profession knew so little about the clinical history and diagnosis of these {255} tumors that they were invested with many of the bad qualities of other tumors, with which they were so often confounded; and we had so little knowledge of their nature and the measures which would influence their growth that we felt an entire helplessness in the treatment of them. Fortunately, there have been many favorable changes in these respects. We understand their clinical history better, and can make a pretty clear diagnosis. We know that relatively few of them prove fatal even when left wholly to nature. Compared to all other uterine and ovarian growths, they are innocuous. Most of them are self-limited in consequence of the mode of blood-supply. A goodly number not only stop growing, but disappear without the application of any remedial measures. Then, as I shall have occasion to show, they may be often cured by the judicious administration of medicines, and the surgery for their extirpation has become a reliable resort in extreme cases. These considerations render the general prognosis of the true fibrous tumor quite hopeful. The menopause generally starves them out, and thus removes all the bad qualities they may possess.

When they lead to fatal results, they generally do so through three different conditions--viz. hemorrhage, pressure, and complicating inflammations--and probably in the order mentioned. Hemorrhage is by far the most fatal symptom. The kind of fibrous tumor accompanied with severe hemorrhage is usually the submucous variety. The submucous tumor with a broad base is the most mischievous, because it induces great hypertrophy in the vascular system of the mucous membrane especially, and also the vessels of the whole organ. A sessile submucous tumor arising from one nucleus is worse than one in the same situation with several nuclei of origin. The intracorporal polypus or pendulous tumor is almost as bad in this respect as the sessile submucous, especially if it originates at or near the fundus. Fortunately, these forms of the tumor are more amenable to the effects of medicine and more accessible to surgical treatment. The tumors located in the central stratum of fibres are next to these in mischievous qualities. The more remote the tumor is located from the mucous membrane, the less hemorrhage will attend its development.

When the tumor becomes cystic the danger from pressure is very much greater; yet the solid form becomes sometimes so large as to do much mischief from pressure upon the abdominal organs; and any of these, except perhaps the polypoid variety, may be so situated as to cause mischievous if not fatal pressure upon the pelvic organs.

It is rare, however, that the pressure in either of these cavities proves fatal, especially when the case is under intelligent management. The supervention of inflammation in the tumor, even to a moderate degree, is very apt to lead to gangrene and death from peritonitis, shock, or septicæmia. Sometimes subacute inflammation of the peritoneal surface of the tumor gives rise to serous effusion or dropsy in the abdominal cavity that proves fatal; and, as before stated, peritonitis sometimes causes adhesions which result in augmented vascularity and consequent increase of blood-supply. This condition, I believe, often changes a solid to a fibro-cystic growth, a more highly vitalized tumor, and consequently a more mischievous one.

Do these tumors ever become sarcomatous or malignant? I do not {256} believe they have any innate tendency of that kind. Where they are found complicated with malignant growths I believe the malignancy is an independent quality, and is an invasion resulting from some cause extraneous to its organization, and in that respect is analogous to an attack on the cervix or other portions of the uterus.

The prognosis when complicated with pregnancy is of course more grave, but experience has demonstrated the practicability of complete and normal gestation. Conception will not often occur where these growths have attained any great size, but may sometimes. Of the nine cases which I have met and had an opportunity to follow, not one has been attended with abortion or premature labor. In one the pregnancy seems to have been protracted at least four weeks. The foetus was in a state of decomposition, and had probably been dead four or five weeks before labor began. What is not less remarkable also is that labor did not seem to be seriously affected in but one case, and in that the difficulty was easily overcome by turning.

Until lately there were several supposititious sources of danger at the time of confinement--viz. inefficient uterine contractions, and consequent tedious or impracticable labor, and after expulsion or artificial removal of the foetus dangerous hemorrhages from the same cause; also, the possibility of the placental connection being made at the site of the tumor, with the imperfect closure of the sinuses that was supposed to follow.

Reports of cases occurring within the last few years, while they have not completely swept away the grounds for such apprehensions, prove that the accidents so greatly feared do not in fact occur. Chadwick reports a case where the placenta was attached to the mucous membrane over the tumor, yet the placenta was spontaneously expelled and there was no considerable hemorrhage. The efficiency of the expulsive efforts were not materially affected in any of the cases I have attended. And this is what we might expect, because conception and gestation would not be perfect where there is not a sufficiency of healthy mucous membrane, upon which a normal decidua could be formed, and of fibrous structure to permit the hypertrophy of gestation.

The apprehension of obstruction from the tumor lying in such a position as to intercept the expulsion of the foetus is not often realized; for those in the cervix, either pendulous or otherwise, are pressed out of the external parts in advance of the head, while those in the body and fundus are lifted up into the abdominal cavity, where there is plenty of room. It must indeed be rare that the tumor becomes impacted in the pelvis so as to interfere with the passage of the foetus.

Neither does the puerperal condition seem to be rendered materially more dangerous in consequence of the presence of these tumors.

What effect does pregnancy have upon the growth of these tumors? It might be supposed, from the plentiful supply of blood afforded them by the growth of the vascular system of the uterus, and from the fact of their being situated in and surrounded by tissues in a state of active hypertrophy, that the tumors would grow in a corresponding degree with the uterus itself; but this is not generally, if it is ever, the case. I have not witnessed a decided increase in the size of the tumor in any of my cases. Pregnancy usually produces the opposite effect; and this can be easily understood when we remember that the tumor is subjected to great {257} and uniform pressure, which prevents its own circulation from becoming as great as it otherwise would be; and I think this pressure often inaugurates a retromorphosis that results in the final disappearance of the tumor. Whether degeneration begins during pregnancy or not, the tumor is very apt to disappear after pregnancy and labor. In six of my own cases the tumor disappeared by a slow process of some kind after labor. Speculating as to what might be, another apprehension of danger arises out of the tumultuous excitement and terrible pressure to which it is subjected during the throes of parturition. But this apprehension is rarely if ever realized.

TREATMENT.--The treatment of fibrous tumors of the uterus consists largely of the means calculated to relieve such symptoms as endanger the life of the patient or materially affect her general health. When these are unavailing resort is had to measures calculated to get rid of the tumor. Some remedies necessary to the relief of symptoms act as very powerful curative agents; hence, while it is convenient to speak of the treatment of symptoms under one division of the subject, and the methods employed for radical cure under another, we cannot, in fact, completely separate these two branches.

Hemorrhage is by far the most important of the symptoms connected with these growths, because it is at the same time the most frequent and hazardous. It is also the symptom that leads to most suffering in consequence of depriving important organs of the blood necessary to support them in their functions. Every reasonable means should be made use of, not only to prevent fatal losses, but also to prevent moderate hemorrhage. In the outset, therefore, I would insist upon watching with great vigilance to prevent any unusual loss of blood. It is not advisable to temporize by adopting the milder and less efficient measures as being sufficient for cases not likely to prove fatal, but we should treat all hemorrhages arising from this cause with promptitude and energy. Fortunately, in many cases we can anticipate the attacks of hemorrhage, because we know when they will occur, and we are generally able to judge of their probable severity. To discharge our duty in this respect effectually, our patient should be properly provided with remedies and fully instructed how to use them. She should be made to understand that unusual hemorrhage at the menstrual period may be checked without endangering her general health. Among the remedies are--dorsal recumbency with the hips elevated, cold to the hypogastric region and cold to the dorsal spine and sacrum, ergot, and some form of tampon. The best fluid extract of ergot in drachm doses, if the stomach will bear it, is probably the most efficacious, but the fresh drug in the form of infusion is also very efficient. Full doses should be given every half hour when there is much loss, until some effect is produced upon the hemorrhage, and then continued every four hours as long as necessary. Compressed sponges saturated with the solution of sulphate of alum make the best tampons for the patient to make use of. These may be made and kept in readiness, so that they can be introduced as soon as they are found necessary. The patient or nurse can make them by taking a fine sponge, large enough to fill the vagina, passing a piece of string through the centre to aid in its removal, and then, after dipping it in the solution, winding it with twine from one end to the other, compressing it into as small {258} a space as possible. The twine should so compress the sponge as to make it assume an elongated form. It should then be laid aside and permitted to dry. Several sponges should be thus prepared. When necessary the twine may be unwound and the sponge introduced. Its size when in the dry condition will allow of an easy passage into the vagina, where the moisture will cause it to expand, and fill up and seal the vagina so as to absolutely check the discharges. If the attending physician is present, he may tampon the vagina with pellets of cotton secured by thread and moistened with a solution of alum. The inconvenience experienced from this plug will be more than counterbalanced by the saving of blood. This form of tampon has the additional advantage of being antiseptic. I have allowed it to remain for three days, and upon removing it satisfied myself that there was no decomposition of the blood or the vaginal secretions. When the tampon is removed it will not be found difficult to wash out all the granular clots caused by its presence. It may be repeated as often as necessary, but usually, if allowed to remain forty-eight hours, the hemorrhage will not return. It may be said that for small losses this is unnecessary, but it is convenient and harmless, and will answer the purpose. In dangerous cases no one will question the propriety of its employment.

Another very important means of arresting hemorrhage which can be used by the physician when necessary is the introduction of a compressed sponge into the cervix uteri. This will temporarily act as a tampon and stimulate the uterine fibres to contraction. The free incision of the cervix, as directed by I. Baker Brown, may be tried between the times of the paroxysms of hemorrhage.

The pressure of the tumor upon the pelvic viscera is another inconvenience which calls for attention. This takes place usually at a time when the tumor has acquired a size sufficient to fill the pelvic cavity. Consequently, the elevation of the tumor above the pelvis is the remedy. This may be done sometimes by placing the patient in the knee-elbow position and pressing the growth upward. The powerful influence of atmospheric pressure called to our aid by the position and opening of the vagina is a very material auxiliary in the process of elevation. If this is not sufficient, we may pass the fingers into the rectum and elevate the tumor. I once succeeded in this operation by using an ivory-headed cane in the rectum when the fingers failed to reach high enough. If we cannot elevate the tumor by any of these means, we may introduce into the vagina or rectum a gum-elastic bag, and by means of a powerful syringe fill it with water to as great distension as the patient will bear, permit it to remain, and thus do the work more gradually.

Dysmenorrhoea is another symptom of fibrous tumors, and sometimes a very distressing one. It depends, no doubt, on the imprisonment of blood in the uterine cavity in consequence of the tortuosity of the canal causing the closure of some part of it. The remedy consists in dilating these narrow places. I know of nothing so well calculated to effect this object as the slippery-elm tent. One or more of these tents, long enough to reach the fundus uteri and of sufficient size, moistened so as to render them very flexible, may be passed up through the tortuous places with great facility. If introduced as soon as the symptom begins to manifest itself, and allowed to remain an hour or two, the relief will be pretty {259} certain. If used once a day for four or five days before the attack, and three or four hours at a time, dysmenorrhoea may be generally avoided.

Curative Treatment.--When we broach the question of the permanent cure of these affections, we find that great difference of opinion exists among the members of the profession as to the value of medicines. One party, perhaps a majority of the profession, believe that no medicine has any direct effect upon them, and these ignore any means of permanent relief but surgical. There is, however, a respectable number of medical men who place great reliance upon the administration of certain medicines, and, if I am not greatly mistaken, recent observation has added greatly to their number. They do not, however, wholly agree as to the therapeutic processes that should be instituted, and consequently do not employ the same kind of medicines. Some gentlemen have more confidence in what I will term the sorbefacient medicines and processes of treatment. They endeavor to institute measures that will cause the absorbents to attack and remove the neoplasm in the same way that tumefactions caused by effusions are removed. This they do by friction, pressure, and the administration of the old-fashioned sorbefacient medicines. The most popular among these are the iodides, chlorides, and bromides of mercury, potassium, sodium, calcium, and ammonium. Reports may be found in books and periodical medical literature of cures by several if not all of these articles and their combinations. The late W. L. Atlee, whose experience was very extensive, had great confidence in the action of hydrochlorate of ammonia. He administered it internally, applied it externally, and used it as vaginal injections. The iodide of potassium has long enjoyed a great reputation in causing the absorption of these and other forms of tumors. There is no professional fairness in assuming that the faith in these remedies derived from the observation of their effects or the promulgation of cures from the use of sorbefacient measures are fallacious. Some of the men arrayed in favor of the opinion that cures may be effected by a patient and long-continued administration of some one of the articles I have mentioned stand high as men of honesty, accuracy of observation, and faithfulness in their records; and therefore I give full confidence to their statements. Yet I must also say that I have not witnessed the good results which I unhesitatingly believe others have seen from the sorbefacient treatment alone.

Others who expect much from medicinal treatment look to that class of medicines which cause contraction of the unstriped muscular fibres as the most promising. With these medicines they expect to diminish the supply of blood to the tumor by causing contraction of the arterioles traversing their substance, and thus disturbing their nutrition to such a degree as to stop their growth, lessen or destroy their vitality, and so render them subject to the influence of the absorbents, whereby they may be removed. Some of the more energetic of these medicines--as ergot and belladonna, for instance--often affect these growths very promptly. Ergot not only lessens the calibre of the small blood-vessels, and thus causes a diminution of their nutrition and disappearance, but it causes strong contractions in the muscular fibres of the uterine walls, which lessen more decidedly their supply of blood. It sometimes squeezes and chafes the tumor until it is disintegrated and rendered a foreign substance. {260} The capsule finally becomes ruptured, and the tumor is expelled either piecemeal or en masse.

When properly administered, ergot frequently greatly ameliorates some of the troublesome and even dangerous symptoms of fibrous tumors of the uterus--e.g. hemorrhage and copious leucorrhoea; it often arrests their growth; in many instances it causes the absorption of the tumor, occasionally without giving the patient any inconvenience: at other times the removal of the tumor by absorption is attended by painful contractions and tenderness of the uterus; by inducing uterine contraction it causes the expulsion of the polypoid variety of the submucous tumor; in the same way it causes the disruption and discharge of the intramural tumor. There are many cases on record to substantiate every one of these propositions.

From what I consider well-authenticated sources, including the cases under my own observation and in the practice of my friends and neighbors, I have collected 136 cases of fibrous tumors treated by ergot. Of these, 25 cases were cured without giving the patients any inconvenience from painful contractions. In 46 cases the tumors were diminished in size and the hemorrhage was cured. In 27 others the hemorrhagic symptom was relieved, while the size of the tumor was not affected. In 8 other instances the tumors were broken to pieces and expelled piecemeal.

For examples of cases in which the first conditions obtained, I would refer to those cured by Hildebrandt; of the other examples, 4 were reported to me by the late J. P. White of Buffalo, N. Y., 1 each by the late Hodder of Canada and Jukes, and 11 that occurred among my immediate acquaintance and in my own practice.

Among those in which the hemorrhage was cured and a diminution of the tumor took place, 11 occurred to Hildebrandt, 2 to Chrobak, 5 to White of Buffalo, and the remainder to gentlemen upon whose veracity I have implicit reliance. The most remarkable case of which I have any knowledge was reported to me by the late G. C. Goodrich of Minneapolis, in which absorption of a large tumor took place under the administration of ergot and belladonna. I subjoin his description: "The treatment was commenced in 1870, and continued two years. The uterus filled the whole space between the ilia, and measured in the transverse diameter twelve inches and in the vertical nineteen inches--extended up under the ensiform cartilage and close up to the margin of the cartilages of the ribs. The treatment was followed by cramps in the uterus, which produced a wild enthusiasm in the mind of the patient and inspired her with strong hopes of recovery. Without consulting me she doubled the dose of medicine, which was administered internally, and as a consequence she was attacked with very strong uterine contractions and symptoms of metritis. This caused me to abandon treatment for about one month, and had it not been for the urgent determination of the patient I would not have resumed it. She insisted that as this was the first medicine which had ever affected the enlarged organ, she believed it would cure her, and promised to obey my directions if I would proceed. She so promptly and rapidly improved that I doubted if it were not a coincidence with, rather than a consequence of, the treatment. Prompted by this doubt, I abandoned the use of the ergot and belladonna and continued alterative {261} treatment. The patient soon assured me that she no longer felt the griping pains caused by the remedy, and that the tumor was softer and larger than when she took the ergot prescription. The ergot and belladonna were again resumed, and in four months she was able to make a trip to Boston alone. While absent she continued to take the medicine. From this time she continued rapidly convalescing, and is now in the enjoyment of fine health."[1]

[Footnote 1: The author's address before the American Medical Association at its meeting in 1875.]

I subjoin two cases in which the tumors were expelled piecemeal under the administration of ergot, which came under my own observation:

A woman of Sterling, Illinois, called on me December 13, 1875. She was thirty-five years old, married, and had never been pregnant. On the first of the preceding June she noticed a circumscribed hard lump two inches below and to the left of the umbilicus. She was the subject of serious uterine and sympathetic symptoms, for which she had at different times had treatment. She had profuse menorrhagia, leucorrhoea, and great sense of weight in the pelvis. Upon examination I found a hard, round, movable tumor extending up to within two inches of the umbilicus, filling up the whole of the right iliac, the hypogastric, lower half of the umbilical, and more than half of the left iliac regions. The contour of the tumor was somewhat uneven, though not distinctly nodular. The cervix was long, pointed, and thrown backward and to the left. The sound entered the small uterine mouth and passed upward, backward, and to the left five and a half inches. The diagnosis was a fibrous tumor of the right anterior wall of the uterus. I prescribed thirty drops of Squibb's fluid extract of ergot, to be taken three times a day. She went home, but did not commence taking the medicine until the 20th of December. On the 26th of December J. B. Crandall was called to see her, and describes her condition as follows: "The patient was in a state of great nervous prostration and worn out by severe pain and loss of sleep. The pains commenced soon after taking the second dose of ergot, and were excruciatingly severe for about three hours, after which they continued less severely for two days and nights. She had more or less hemorrhage from the uterus after taking the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin was hot and dry, and she complained of great pain and tenderness over the uterus and lower bowels. The feet were drawn up, and the face wore a pinched and peculiar expression." Under these circumstances the doctor administered anodynes, tonics, and nourishment, to the great relief of the patient. On January 11, 1876, the patient began to pass from the vagina small masses of fibrous substance, from the size of a chestnut to that of an English walnut. The substances thus discharged were firm and gray in color, and were exceedingly fetid. This discharge continued up to the 21st of January, when the uterus was very much diminished in size, the tenderness had subsided, and the patient appeared comparatively comfortable. Up to that time she had taken but three doses of ergot--on the 20th of the preceding month--and the doctor ordered it to be resumed again. This time the ergot produced no pain, and after three or four days was discontinued. From the 21st of January there were no more pieces discharged, but up to February 1st a yellowish, thin, offensive fluid passed from the vagina in considerable {262} quantities. On the first day of February the ergot was again ordered and continued two weeks, when, as no results ensued, it was finally dropped. Crandall states that on the 14th of February the uterus was reduced to its normal size, and on the 26th the patient was up and about her work, completely cured. He remarked, in this connection, that the first three doses of ergot taken by the patient was the cause of her recovery.[2]

[Footnote 2: This case is published in the August (1875) number of the Chicago Medical Journal and Examiner, as reported by Crandall.]

Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the anterior wall of the uterus, which, with the enlarged uterus, arose to within two inches of the umbilicus. She commenced taking thirty drops of the fluid extract of ergot on the 22d of September, 1876, and was to increase gradually the dose with the object in view of causing the disruption and expulsion of the tumor. The ergot at first produced no perceptible effect until she had taken it ten days, when she began to experience the pain of contraction. The pain became so severe and continuous that it was necessary to omit it for two or three days at a time. The patient was intelligent and understood the object and mode of action of the ergot, and when the pain entirely subsided she courageously resumed it in the smaller doses, and increased again until the pains became intolerable. On the 13th of January, 1877, small pieces of the tumor showed themselves in the vaginal discharges, and by the 26th of the same month the whole of it had been discharged piecemeal. She wrote me on the 30th of January, saying, "I think I wrote one week ago to-day. At that time the tumor was passing. It continued to pass until the 26th, when, I think, the last was expelled. To-day I send you by express a portion of the last that came. I think the whole of it, including the portion I send you, would have weighed one and a half pounds. I do not believe a quart can would hold it if the whole had been preserved. It commenced to come on Saturday, and from Saturday evening to Sunday morning there was a pint or more. After that the stench was so disagreeable that we could not cleanse it; consequently we threw it away. Wednesday and Thursday it seemed to be in one continuous mass. I cannot better describe it than to say that it came like sausage-meat from a stuffer. I would cut off about four inches a day--that is, on Wednesday and Thursday. On Friday morning the last of it came away." During and for some days after the expulsion she suffered slight symptoms of septicæmia, but recovered from them, and in the course of a month afterward she visited me, when I found the uterus measured two inches and a half in depth. She then had some leucorrhoea, but was fast regaining her health. She is now perfectly well, and has passed in safety the menopause.[3]

[Footnote 3: This case--the abstract of which I have here given--was in the May (1877) number of the Archives of Clinical Surgery, N. Y.]

I have known 9 cases in which the tumors were expelled piecemeal by ergot, with but 1 death. The death occurred in a patient who rode one hundred and fifty miles on a railroad train to see me with pieces of the tumor hanging from the vagina, which she would not allow her physician to remove. When she arrived I passed my fingers up into the contracted capsule and scooped out the remaining portion of the tumor. She was so exhausted, however, by the journey and the sepsis that she died three {263} days afterward. I cannot help believing that if she had remained at home and submitted to the treatment of her physician, her life need not have been sacrificed.

The influence of ergot over the uterus has been a familiar fact to the profession for a long time. It is not long, however, since we were aware of its effects upon the muscular fibres entering into the formation of other organs. We now know that this medicine acts upon the unstriped muscular fibre wherever found, whether in the viscera or in the vessels of the body.

The fibres of the uterine walls, and the arteries supplying them with blood, both belong to this class; this fact in the formation of the uterus renders it particularly susceptible to the action of ergot. The drug acts upon the uterus[4] in a threefold manner, and causes a diminished flow of blood to the morbid as well as healthy tissues in the uterine structure.

[Footnote 4: From the author's address before the American Medical Association, 1875.]

First: the calibre of the arterial tubes is diminished by the contraction of the muscular fibres which enter into their composition. Second: the arterioles are diminished in size by compression from the contraction of the uterine muscular fibres which surround them. Third: these vessels are distorted and drawn in diverse directions by both the contraction and compression, and hence are rendered less fit for sanguineous conduits.

Another consideration of prime importance is that, under the influence of these medicines, the nutrition of fibrous tumors is interfered with, not only from diminution of blood in their tissues, but also from compression of their substance by the proper fibres of the uterus, and are therefore made more susceptible in the process of disintegration and absorption.

The great influence exerted by ergot over the circulation of the uterus is rendered more efficacious in the removal of fibrous tumors of that organ, because of the peculiar organization of the growths. It is now pretty well understood that this neoplasm is not very generously supplied with arterial blood, and that its supply is derived from numerous minute vessels instead of one or two of large calibre. From these circumstances it results that its vitality is very low, its circulation easily disturbed, and consequently its nutrition impaired.

I think we are justified from observation in assuming that the action of ergot may be graded from an almost imperceptible to a very intense degree. Probably the first degree affects the vascular supply; the second, in addition to this, causes so much contraction as to merely render the fibres tense without causing pain; and the third prompts the uterine fibres to vigorous and painful contraction.

This inference is plainly deducible, I think, from the several modes by which tumors are made to disappear under its action, as well as from direct observation of the uterine fibres.

I will now venture to call attention especially to the manner of expulsion of the polypoid and submucous intramural varieties. It will be seen that when the uterus contracts all the fibres unite in pressing the polypus through the cervical canal, which is usually already shortened, and rendered dilatable in consequence of its increased vascularity. The cervical canal dilates, and after more or less painful efforts the polypus is expelled entire, covered by the mucous membrane. This membrane is often in a {264} state of gangrene, but so far as I have observed these cases the tumor is not broken to pieces.

A submucous intramural tumor has a thin layer of fibres separating it from the mucous membrane, and a thick and heavy layer spread over its external hemisphere. A greater part of the muscular wall is therefore applied to the outer side of the tumor. If in this position all the fibres of the uterus vigorously contract, the fibres near the mucous membrane must be overcome by the heavy layer outside. But the opposite wall plays an important part by supporting the weaker layer at the fundus of the tumor, and adding its own force in overcoming the capsule, where it usually gives way. The position of the tumor makes its escape from the concentric action of all the fibres of the uterus impossible, and every one knows that when the resistance is partially overcome the uterus is stimulated to more vigorous action, and the pains will not abate until the mass is expelled. If not too large, it is driven out without undergoing great laceration, but if its size and attachments are such as to make this impracticable, it will be broken into fragments and expelled piecemeal.

In subperitoneal tumors there is, next the uterine cavity, a thick and strong stratum of fibres, while immediately under the peritoneum the layer is very thin and comparatively weak. When the uterus is acting with vigor the former contract forcibly, and the mass becomes pedunculated; but that is all, for the tumor lies outside the field of concentric action and escapes the crushing influence to which the submucous variety is subjected. The amount of force exerted upon it is that exercised by the weaker layer of fibres in a state of conquered antagonism, and the rupture of the capsule is impossible.

In the case of a fibroid tumor situated in the central stratum of fibres the antagonism is equal at all points, and it is evident that there is no tendency to rupture of the capsule, and much less crushing influence exerted upon it than if it were situated slightly nearer the mucous membrane. This variety of the tumor, therefore, yields to ergot only as it may be starved out by diminution of its blood-supply and as the effect of pressure, which we all know are the two conditions most favorable to absorption.

Now I think we have arrived at a point in this investigation where we can draw inferences as to the forms of tumors likely to be effected by ergot in different ways, as well as those that will not be effected by it. We do not expect ergot to cause painful and efficient contractions in the healthy unimpregnated uterus; its fibres are not capable of such contraction, and it is not until the fibres have become greatly developed that they are susceptible to the impressions of ergot. In cases of early abortion its action is very unreliable, but after the fourth month of pregnancy it acts quite efficiently.

In tumors of the uterus the development of the fibrous structure is sometimes so slight that it is incapable of contraction; there may be so many nuclei of degeneration that there are not enough sound fibres left for efficient contraction. Then, where there are many small tumors developed in the uterine walls, the circulation is cut off to such a degree that they degenerate into a cartilaginoid substance, and sometimes they are infiltrated with calcareous material. In none of these cases will ergot cause any appreciable results. When, however, there are {265} but one, two, or three nuclei of morbid growths, as they increase in size the fibres undergo the development necessary to enable them to contract with great efficiency and render them susceptible to the influence of ergot.

Another condition which influences the hypertrophic growth of the fibres is the situation of the tumor. Subperitoneal tumors do not cause as great growth in the fibres of their neighborhood as the intramural or submucous varieties. A single intramural tumor causes great development of the whole uterine tissues, but the development of the wall in which it is situated decidedly predominates. The submucous neoplasm so soon gains the uterine cavity that the development is nearly the same in the whole organ. When, therefore, we administer ergot for the cure of fibrous tumors of the uterus, the beneficial action of the drug will depend upon the degree of development of the fibres of the uterus and the position of the tumor with reference to the serous or mucous surface. The nearer the mucous surface, the better the effects. If the tumor is very near the lining membrane, we may hope for its expulsion en masse or by disintegration.

We can often select the cases in which good results may be expected. There are four conditions which are usually reliable for this purpose: they are--smoothness of contour, hemorrhage, lengthened uterine cavity, and elasticity. A smooth, round tumor denotes, for the most part, uniform textural development, hemorrhage, a certain proximity to the mucous membrane, a lengthened cavity, great increase in the length and strength of the fibres; and elasticity assures us of the fact that cartilaginoid or calcareous degeneration has not begun in the tumor.

An even, nodulated tumor may be composed of many separate solid masses. These displace and prevent the growth of the fibres to such an extent as to render contractions inefficient. When hemorrhage is not present the tumor is probably near the serous surface, and consequently not surrounded by fibres. A short cavity denotes short, undeveloped fibres, while hardness is indicative of unimpressible induration.

Although I have no experience in the use of ergot in such cases, I should expect large fibro-cystic tumors to resist the action of ergot.

From this view of the subject it will be seen that I freely admit that there is a large number of cases in which ergot cannot produce any good results, in consequence of the nature of the cases; but there is another reason of equal moment why ergot may fail to act upon such cases as would seem to be favorable--by the worthlessness of the drug and its preparations. Squibb of New York, a high authority, says in reference to this subject: "The molecular constitution of the active portion of the drug seems, however, in its natural condition to be loose, and, like a slow fermentation, to be undergoing slow molecular changes, so that by age its peculiar activity is slowly diminished until finally lost." And again: "The ergot in the grain, however well kept, is known to become inactive without any known change in appearance, though the sensible properties, such as odor and taste, may and probably do not change. Ergot in powder is known to diminish in activity much more rapidly than when in grain, and probably soon becomes inert. The tincture and wine of ergot are believed to change, though more slowly than the ergot in substance, whilst the extracts and so-called ergotins are all supposed to change more rapidly."

When all these causes of failure are considered, the variety of {266} experience met with in the reports upon its trial in the treatment of these tumors is not surprising. It should not, however, be discouraging, but should prompt us to more care in selecting the cases and securing reliable preparations of ergot. I have implicit faith in the action of ergot when all the conditions I have pointed out are present. I do not believe it to be uncertain in its action.

In addition to the above conditions, I believe perseverance an indispensable condition to success, as it often requires several months to get the best results.

The mode of administration should be governed by the objects to be attained. If we desire to cause the painless absorption of the tumor, the doses ought to be moderate in size and not too frequently administered. Hildebrandt administered by hypodermic injection a preparation containing from fifteen to twenty grains of the crude drug to the dose once daily or once every other day; and once a week will often be sufficient, as proven by cases cited in my address, quoted above. If we desire to have the tumor expelled, we should administer full and increasing doses often repeated, and continued until the object is attained. It will sometimes be necessary to vary the quantity and times of giving it to suit the susceptibility of the patient--less or more according to the amount of pain caused by it.

It is not essential to give it hypodermically, although when it does not produce much inconvenience this is a very efficacious method; it may be given by the mouth, in suppositories, per rectum, etc.

In conclusion, I desire to disclaim any expectation that ergot will supplant other modes of treatment. The expert surgeon will, as he always has done, use his instruments to the neglect of remedies less summary in their effects, and in his hands the maximum of safety will obtain; but there are very few general practitioners who ought or would be willing to undertake enucleation of fibrous tumors of the uterus.

Surgical Treatment.--The surgical processes resorted to for the cure of fibrous tumors of the uterus vary in their nature and gravity with the relations of the growth to the different strata of the uterine fibres. The nearer the mucous membrane, the simpler, safer, and more successful the operation for their removal; the more remote from it, the greater the difficulty and danger. Proximity to the cervix is another element of facility and safety. The removal of the cervical polypus is scarcely ever followed by serious consequences. While a polypus situated at the fundus requires greater complexity in the operation for its removal, and must be regarded as a serious one, the difficulty of removing the submucous tumor more remote from the mucous membrane is increased the higher up in the organ it is situated.

Polypi may be removed by torsion, excision, and écrassement; any one of these operations may be successfully and safely employed. No preparation of the patient is usually necessary for the removal of the cervical polypus, because it is accessible under ordinary circumstances. In very rare instances in the virgin or senile condition the vagina may require dilatation. The polypus attached at the body or fundus is not accessible to any of these operations until the mouth of the uterus is sufficiently dilated to permit the introduction of the instruments in the uterine cavity, or until the tumor is in part or wholly expelled.

{267} It will therefore generally be necessary to completely dilate the cervix with sponge, tupelo, or laminaria tents or the fingers. The fingers, when the object can be accomplished by them, are much the better instruments for dilatation. I have several times accomplished the dilatation of the cervical cavity and removed an intra-uterine polypus in the course of half an hour by the fingers.

I prefer torsion, and believe that when properly performed it is the most simple, expeditious, and safe plan of removing a polypus. The tissues entering into the formation of the neck of a polypus are an extremely thin layer of fibres and mucous membrane. We cannot always be sure of placing the écrasseur or applying the knife or scissors exactly at the point of junction between the substance of the polypus and uterine wall; but, as that is the weakest point, it invariably yields to the force applied in the operation of torsion. The tumor is thus completely removed, and without protracted manipulation. No hemorrhage results, for two reasons: (1) there are no large vessels entering the tumor, and the small ones are torn instead of being cut, as in amputations; (2) septicæmia does not occur, for no portion of the tumor is left to slough. In performing this operation the operator must guide a vulsellum with his fingers high enough on the tumor to enable him to fasten the instrument upon or near the central part of the polypus. In two instances, when the tumor was too large to be firmly held by any forceps at my command, I introduced the hand inside the uterus and detached the tumors by rotating them, afterward making traction with the forceps. I brought them into the vagina and delivered them with the obstetrical forceps. One of these weighed forty-six ounces.

To perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position, should be careful to twist it enough to be sure of its detachment before commencing traction. Not less than from four to six complete revolutions should be effected. This procedure will prevent the danger of lacerating the tissues of the uterus.

The greatest objection urged against the operation of torsion is the likelihood of lacerating the wall of the uterus at the point of attachment. If we call to mind what was said about the relative thickness of the muscular strata upon each side of the different kinds of fibrous tumors, we will at once perceive the groundlessness of this objection. In the pendulous variety the whole wall of the uterus is outside the point of attachment, and is strong enough to resist the very few fibres that are carried down with it. Indeed, the polypus has almost no substantial attachment except that formed by the investing mucous membrane. If, therefore, the torsion is performed with sufficient thoroughness before traction is begun, laceration of more than the superficial tissues surrounding the neck of the tumor is next to impossible; consequently the operation is perfectly safe.

Hemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife or scissors, or even by the écrasseur. The danger of hemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. I have never seen hemorrhage succeed torsion. The contractions of the uterus which take place after removing the polypoid growth from the cavity of the uterus in the great {268} majority of cases is as effective in the prevention of hemorrhage as it is when its contents are expelled at the time of labor. I trust that it is not necessary to dilate further upon this part of the subject. However, hemorrhage, although improbable, is yet possible, and we should therefore be prepared for it. After what has been said under palliative treatment about the management of this complication, it will not be necessary to enlarge upon that point. I would therefore refer the reader to the remarks there made.

After an operation of this kind the only treatment necessary is perfect quietude for a few days, cleanliness by injections if needful, and the administration of anodynes to quiet pain. When a tumor has been removed from high up in the uterus, the patient of course should be carefully watched, and if symptoms of inflammation or septicæmia arise they should be treated by suitable remedies.

I will commence what I have to say on extirpation of deeper tumors by assuring the inexperienced that the formidable operations required for their removal are very seldom necessary, and should not be resorted to until all other and less hazardous efforts have been made.

The operation of enucleation is applicable only to cases of sessile submucous tumors, such growths as are nearer the mucous than the serous membrane. If enucleation is practicable in tumors which have their origin in the central stratum of the wall of the uterus, the operation must be regarded as equally hazardous, if not more so, than laparo-hysterectomy. I am aware that such operations have been recorded, but it is so easy to be at fault with reference to the exact point of origin that I must be permitted to doubt--not the honesty of the operators, but the accuracy of their observations. In many cases of submucous tumors the cervix is dilated so much that immediate dilatation with the fingers or hard-rubber olive-shaped dilators will be practicable. When that is not the case, the cervix must be thoroughly opened by sponge, sea-tangle, or tupelo tents or bilateral incision: the more patent the mouth of the uterus can be made the better. The operation is so serious in its nature that the competent surgeon will study his preparations so carefully as to avail himself of every means that will enable him to perform it in the most expeditious and complete manner. Expedition, rendered possible by thorough preparation, is a most important item; for it must be understood that every superfluous moment spent in enucleation increases the peril of the patient. I would not counsel haste, but the earnest and careful despatch acquired by reflection and experience. When the patency of the mouth of the uterus is secured, the uterus should be drawn to or near the vulva by a strong vulsellum and firmly held by an assistant. The operator may then make an incision with scissors entirely across the most dependent part of the tumor, completely through the capsule. After this is done, another incision is to be made from the centre of this cross-cut upward upon the most prominent part of the tumor, as high as the instrument can be guarded by the fingers. The fingers should then be inserted between the tumor and the capsule, and the latter separated as extensively as possible from the former. In some cases a large part of the tumor may be thus detached from its envelope. When the whole of it cannot be detached by the fingers, Sims's enucleator may be made to finish that task. It can be passed up and around the upper and less {269} accessible portion. The detachment should, when possible, be complete before traction is begun. The traction is affected by a strong vulsellum. By that instrument the tumor, after being firmly seized, can often be rotated upon its longitudinal axis to assure the operator that it is loosened at every point. Simple, firm, but slow traction, aided by pressure of the hand on the upper part, will assist the uterus in expelling the growth. Should the tumor be too large to pass the mouth of the uterus and vagina, it may be divided by well-directed efforts with the scissors or knife and removed in pieces. When the tumor is semi-pedunculated the capsule may be separated by Thomas's serrated spoon in a much more expeditious manner. As the tumor is drawn out of its cavity the uterus usually contracts, and thus prevents the hemorrhage that might otherwise occur. The surgeon, however, must always be prepared with plenty of cotton saturated with the subsulphate of iron with which to plug the uterine cavity. It will very seldom be necessary to use the ironized cotton, and it should not be employed until its necessity is apparent. The after-treatment consists locally in detergent and disinfectant injections, and in such general measures as will aid in reaction where there are symptoms of shock and counteract the tendency to inflammation. For both these purposes a liberal amount of opium will be very useful.

When the symptoms in connection with a tumor situated in or slightly outside the centre of the wall of the uterus are so urgent as to demand surgical interference, the choice of operations lies between laparo-hysterectomy and öophorectomy. In the light of recent observation I have no hesitancy in recommending the former for large tumors and the latter for small ones. As before stated, I regard enucleation in such cases as hardly practicable, and when successful I believe it is attended with as much danger as the entire extirpation of the uterus.

Without entering into details of this operation, I will state that it is so like ovariotomy as to be governed by the same principles and require to a great extent the same methods. The incision should be sufficiently free to permit the removal of uterus and tumor without the necessity of cutting away the tumor in pieces, as thus mutilating it gives rise to great and dangerous hemorrhages and of necessity soils the abdominal cavity. I have always used silk ligatures with which to secure the pedicle. In most instances we will be obliged to ligate the uterus near its junction with the vagina. Extra-peritoneal treatment is probably safer.

Where a small intramural tumor is attended with exhausting hemorrhage, menacing the patient with a probable fatal loss, and other remedies have been found inadequate, öophorectomy may with great propriety be resorted to.

I would refer the reader to the description of this operation as given elsewhere. There is no other surgical operation by which a large fibro-cystic tumor can be gotten rid of than laparotomy or laparo-hysterectomy. Recently I have removed a large fibro-cystic tumor that grew from the anterior surface of the fundus and body of that organ without removing the uterus. The tumor was detached by a sort of enucleation, and the detachment left a large bleeding surface. Hemorrhage from that surface was profuse, and seemed to issue from numerous cavernous openings instead of veins and arteries. The hemorrhage was checked by {270} passing silk ligatures one-eighth of an inch beneath the surface from one side to the other of the bleeding surface in several places. When these ligatures were tightened the tissues were so condensed as to entirely control the bleeding.

This was my fourth laparotomy for fibro-cystic tumor of the uterus, and the only one that recovered. In all the other three I ligated the uterus and removed it at the internal os.

Large subserous, fibrous, or fibro-cystic tumors are almost always covered with a network of great vessels, generally furnished by adhesions to the omentum. These vessels should be ligated in bundles by two ligatures around each bundle at least two inches distant from the uterus. If the two ligatures are not thus widely separated from each other, when the division between them is made the collapse and retraction of the vessels will be so great that they will not hold. If in detaching adhesions a bleeding surface is left on the tumor or abdominal wall, the bleeding should be arrested by ligatures applied before the tumor is lifted from its bed. When it is necessary to remove the uterus, a double ligature around its substance should be applied; also, when practicable, before the tumor is lifted out. In this method of securing the vessels we will avoid the terrible hemorrhage that would otherwise follow the removal of the tumor. The pedicle should then be brought out and secured by pins in the wound. The cleansing of the peritoneal cavity and closure of the wound should be done as in ovariotomy. The after-treatment is also the same as in bad cases of ovariotomy.

I have not thus far mentioned the treatment of fibrous tumors by electrolysis; and as the profession has not generally consented to the adoption of this measure as safe and efficacious, I will refer the reader to an account given of that process and its results in my work and other standard works on gynecology.

{271}

SARCOMA OF THE UTERUS.

BY W. H. BYFORD, M.D.

This disease is as much entitled to the clinical definition given to cancer as any of the varieties of that malignant affection. Miller, as quoted by West, says: "Those growths may be termed cancerous which destroy the natural structure of all the tissues; which are constitutional from their very commencement or become so in the natural process of their development; and which, when once they have infected the constitution, if extirpated, invariably return and conduct the person who is affected by them to inevitable destruction." If we substitute the word malignant for cancerous in the above quotation, the definition would include sarcoma as well as carcinoma. It will be found upon comparing sarcoma with fibrous and cancerous tumors that it possesses clinical and histological features common to both. If it is not indeed the result of a transition of fibrous tumors into a malignant form of disease, it is a connecting link between fibromatous and carcinomatous affections, and illustrates in a remarkable manner a relationship of these two forms of growths--viz. the morbid proliferation of the tissue resembling those of the structure in which they originate. Sarcoma has its origin in the fibrous portion of the connective tissue, as do many of the fibrous tumors. It consists of a redundant proliferation of the cells of that tissue, while the fibrous tumor is constituted of a morbid proliferation of the fibrous element of the connective and muscular tissues. Cancer now is admitted to be an excessive production of the cells of the epithelium; this excessive growth of the cells inhabiting these structures, sarcomatous and epithelial, seems to give to them respectively the feature of malignancy. The fibrous tumor is contained in a capsule; both forms of these malignant growths invade the tissues without any such limitation. In this respect the two latter resemble each other and differ from the former. In sarcoma the cells are mingled intimately with the fibres, and are not generally contained in alveoli, or nests, as they are sometimes called. Cancerous cells are always surrounded by alveoli. Sarcoma in many instances resembles very closely the fibrous tumor. In malignancy it is very much like the cancerous tumor.

CLINICAL HISTORY.--The early symptoms of sarcoma are leucorrhoea, hemorrhage, and tumefaction. The discharge from the genital organs resembles that of fibrous tumors. This does not generally possess an offensive odor, but as the disease advances necrosis of the tumor occurs to a greater or less extent, and then the smell of the discharge comes to {272} resemble that of cancer. The necrosis does not take place at the expense of the uterine tissues, but is a process of disintegration going on in the growth. The ulcer resulting does not corrode the uterus, but it eats away the tumor. It in this respect resembles epithelial fungus. The tumor formed by the sarcomatous deposit is sometimes polypoid, and presents the appearance of the fibrous polypus. In other instances it resembles to the touch a submucous fibrous tumor, and again in others it is diffusely disseminated into the whole structure of the uterus. When thus diffused, like cancer it invades the neighboring organs. When the tumor projects from the inner surface of the womb, and has attained a considerable growth, limited necrosis occurs, and sloughs of varying size take place, and offensive sanious discharges occur very similar to the flow observed in cancer.

The general symptoms at first are slight, consisting of obscure pelvic pains and pressure and increased discharge. Gradually septicæmia is developed, and this is the condition in which the patient usually dies.

DIAGNOSIS.--There is nothing in the symptoms by which we can arrive at a correct diagnosis, as in the early periods they resemble those of fibrous tumors so closely as to be undistinguishable from them, and in the latter cancer neither manual nor ocular examination will give us any more definite information. Their qualities in this respect also are in the early stages of development those of fibrous tumors, and in the latter of some forms of cancer. We are therefore reduced to the evidence afforded by microscopical examination.

When the tumor is in such a position and of such a consistence that we can remove a fragment from it, we can study its histology. There are two varieties, as distinguished by the shape and size of the cells. One variety is called the small-celled sarcoma, from the size of the cells; they are round, or nearly so, in shape. The other is called the spindle-celled sarcoma. In some specimens of this variety the cells are much larger than others; and hence there is the large and small spindle-celled sarcoma. The cells are different among the fibres of the tissues affected, and in rare instances some of the cells are contained in imperfectly-formed alveoli, in this respect showing a further analogy to the growth in cancer.

PROGNOSIS.--The malignancy of sarcoma is now universally recognized in the known facts of its persistency in returning when removed, and its simultaneous existence in many organs of the body. This acquired or innate constitutional dissemination is not constant--no more than in cancer, perhaps less so. Hence when the size of the tumor is small and apparently isolated there is some encouragement to attempt a cure.

The comparative prognosis is also probably better than cancer, as it pursues a less rapid course of development, and hence the patient may survive for a longer time.

The local dissemination of the cells cannot always be measured, and that their dissemination into the surrounding tissues may reach much beyond the boundaries of the apparent tumor must be regarded as an important element in considering the subject of prognosis in connection with treatment by ablation or cauterization. The widespread local dissemination of the cells of this growth is doubtless an explanation of the term at first applied to it--viz. recurrent fibroid.

{273} TREATMENT.--It will not be necessary to consume the time of the reader by giving the treatment of sarcoma in detail, as most of it is identical with that of Cancer, and may be found under that head. I will only call attention to the excellent palliative effects of ergot: this drug will often arrest, and generally modify, the hemorrhage so often one of the most annoying symptoms. When the tumor is in a state of progressive necrosis, protrudes like a submucous fibrous tumor, or is pendulous, resembling the fibrous polypus, it may, by inducing contraction of the uterus, be expelled, partially if not completely, and thus for the time being do away with the source of sepsis. I have in several instances been highly gratified with its effects in this way. In one case, when the patient was so overwhelmed with symptoms of septic fever as to cause apprehension of immediate dissolution, the administration of ergot expelled large masses of sloughing tissue, and so cleansed the uterus that the symptoms subsided, the patient rallied, and lived several months in comfort. Not less than four times this process of expulsion was successful in relieving the same patient for long intervals: each time the medicine was administered relief was so marked that both she and her friends anticipated recovery.

{274}

CARCINOMA OR CANCER OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.

While it is possible that in very rare instances the scirrhous or colloid form of cancer may attack the uterus, the practitioner will seldom meet with either. I will therefore describe but two varieties--the soft or medullary, and the epithelial. Although there is much difference histologically and microscopically, they are so nearly allied in their clinical history that I feel justified in placing them together. In the clinical description of carcinoma I shall be governed more by what I have seen at the bedside than by the observation of others.

Medullary or Soft Cancer.

I use this term in a comparative sense. By it I mean a tumor caused by a carcinomatous deposit that infiltrates, enlarges, and renders more fragile than natural the parts attacked, which after a greater or less time undergo necrotic ulceration, death, or solution of the morbid growth, giving rise to extensive ulceration. I have never seen this variety convert the uterus into a tumor of encephaloid consistence. The deposit usually begins in the extremity of the cervix and extends up to the body, and without reference to the boundaries of different tissues attacks and involves the fibrous, mucous, and serous tissues, extending to any organ or substance that may be contiguous, thus infiltrating the bladder, rectum, connective tissues in the broad ligaments, and ovaries. The necrotic ulcerations of the part where the disease began, and the extension of the deposit in the more distant parts, progress simultaneously, the one diminishing while the other is increasing the bulk of the parts involved. This kind of progressive local dissemination and necrosis of cancerous matter often results in the more or less complete destruction of the uterus, bladder, and rectum.

Accompanying these morbid processes in the pelvis, cancerous cells migrate to other and distant portions of the body, creating new centres of carcinomatous disease. These multiple centres of disease are probably in all instances caused by the errant products of the pelvic disease. This view of the subject makes the general carcinomatous disease a constitutional infection, the same as the wandering cells of the chancre give rise to constitutional syphilis.

ETIOLOGY.--No one circumstance seems so intimately connected with {275} the origin of cancer of the uterus as age, more than half the cases occurring between the fortieth and fiftieth years, 33 per cent. between the thirtieth and fortieth; this leaves only 20 per cent. for all other ages. It very seldom attacks the young under twenty-five years or the old over fifty. So far as I have been able to examine statistics, I am not sure that cancer occurs any more frequently among multipara than nullipara. The fact that the number of childbearing women far exceeds those who are not married nor fruitful is likely to mislead us in this respect. Race does not seem to afford even comparative exception. The negro and North American Indians seem to be subjects of cancer as frequently as the European races.

If there is anything in the idea of heredity as a causative influence, it must be rather through physiological similitude of children to parents than the transference of taint from the former to the latter. If cancer is a degeneration of tissues, as the effect of a law that organs in certain individuals undergo dissolution at a particular age, we can understand that the child may inherit such physiological effect from the mother. The cell-formation of the organs of the child will be capable of reaching the same period at which the disease was developed in the mother, when the normal histological changes will be interrupted and dissolution begins. In this view of the subject the child would by virtue of its organization inherit the mode of dying evinced in the mother.

Old writers, assuming that cancer was the result of a peculiar dyscrasia, described the state of general health as a causing condition. It does not seem, however, that the majority of people in whom cancer is developed exhibit any signs of ill-health until the local disease has made sufficient advance to account for their symptoms. Indeed, many present the appearance of a faultless condition of general health until the disease is discovered to have made hopeless progress. The same may be said of the local condition. It so often happens that we are assured by a patient that she had been congratulated by her friends as one especially favored by exemption from female weaknesses. I have yet to witness any evidence that chronic inflammation, congestion, or laceration of the uterus predisposes to malignant disease of any kind.

I do not mean by this to say that patients having chronic uterine ailments may not become the subjects of cancer of the uterus. There is nothing in the gross anatomy or the histological construction of cancer to indicate an analogy to inflammation. The allegation that the long-continued irritation of laceration invites a malignant deposit in the tissues involved is mere assumption, and should rank as an unproved hypothesis.

The location of the primary lesions is usually in the cervix, but occasionally it attacks other parts of the uterus, the body next in frequency to the cervix, and less commonly the fundus.

CLINICAL HISTORY.--The early stage of cancerous development is not marked by obvious symptoms. Judging from my own observation, a bloody discharge more frequently attracts the attention of the patient than any other symptom, and this does not appear until the deposit is somewhat extensive, and it indicates necrosis. The loss of blood is sometimes copious, but generally moderate in quantity. It may be intermittent or continuous. Not infrequently in menstruating women {276} it assumes the form of menorrhagia. The next symptom generally is a discharge of ichor, usually colored, sometimes entirely clear. With the appearance of the serous discharge the cancerous odor becomes apparent and continues. These two exhausting and disgusting symptoms continue alternating with each other with the persistence of fate.

Another symptom of cancer of the uterus is pain. It is not, however, generally an early symptom. Often it is entirely absent until the disease has made great progress. When noticed early, the pain is sharp and lancinating, consisting of recurring twinges rather than of continuous pain. When it does not occur until later in the progress of the case, it is such as arises from the accompanying congestions and inflammations.

GENERAL SYMPTOMS.--No general symptoms are manifest until the disease has made considerable advance, and often not until there begin to be degenerations in the tumor. It would seem, indeed, that the growth of cancer was not a morbifacient process, and that constitutional disturbance results from the septic influence exerted by the necrosis of the tumor.

The absorption and circulation of the products of decomposition at the extremities of the tumor through the nervous centres and secreting organs soon induce nervous ailments and derange the functions of all the important vital organs. A continuance of the derangement thus inaugurated, and kept up, eventuates in fully-developed septic fever, by which the energies of the patient are exhausted. The uniformity with which septicæmia terminates the existence of these unfortunate patients renders the exceptions to the above description very rare indeed. While patients think they are being eaten up by cancer of the womb, they are really dying from slow poison caused by absorption of dead tissues.

DIAGNOSIS.--In the great majority of cases the diagnosis of cancer is easily arrived at. For reasons already stated the disease is not suspected until the deposit is extensive and obvious changes in the shape and consistence of the cervix occur. It is enlarged, very hard, and generally irregular in shape. In most instances it is very much enlarged, measuring from one to ten times its natural diameter; the tissues are devoid of elasticity; and nodosities, projections, and sulci deform the cervix in a manner and to a degree that change the shape of the organ as nothing else does. Add to this the stinking sero-sauguinolent discharge, and the diagnosis is complete. By the time these physical changes become diagnostic features of the case the uterus becomes fixed, the immobility being obviously dependent upon the extension of the deposit to the vagina, bladder, and contents of the broad ligament. The invaded tissues become as hard and unimpressible as the uterus. We could hardly mistake cancer in this stage of development for any other disease, and as the general practitioner will seldom see it before the most of these changes have occurred, the diagnosis will generally be easy. When the tissues break down to a considerable extent the ulcers, if they can be so called, are very irregular in shape, greatly excavated, have a hard, rough, granular bottom, and are not tender to the touch. Generally they bleed upon being handled. The hardness, enlargement, irregularity of shape, and fixedness are as conspicuous features during the process of destruction as they are in the stage of deposit.

{277} The demonstrative portion of the diagnosis, however, is derived from the histology of the deposit. "Histological examination of the changed uterine tissues shows, as in every carcinoma, a stroma of small alveoli filled with polymorphous cells, generally arranged without order; sometimes those of the periphery are implanted regularly on the wall of the alveolus. The stroma composed of connective tissues frequently contain also smooth, muscular fibres."[1]

[Footnote 1: Cornil and Ranvier, translated by Shakespeare and Simes, p. 696.]

PROGNOSIS.--This form of carcinoma uteri will bear no other than a desperate prognosis. I doubt whether it is ever discovered until the deposit has reached an extent locally that renders complete ablation impracticable. In addition to this consideration the malignant cells are disseminated, if not degenerated, in distant parts.

Nature in an infinitesimal number of cases institutes curative processes. These processes consist of extensive sloughing and a species of atrophy in the morbid growth. The growth ceases to enlarge, becomes smaller, and finally disappears. Very few men are lucky enough to witness the fortunate results of these processes. Art is powerless to cure, but may do much to palliate the suffering connected with the fatal march of carcinoma.

The duration of uterine cancer is greater in the old than in the young. In the former it may last several years; in the latter it often terminates fatally in a few months.

TREATMENT.--Taking the above history of the disease as true, it will not be necessary to say much about curative treatment. If we should find a case of cancer in which the cervix is not enlarged as high up as the junction of the cervix and vagina, I would advise amputation of the cervix and excavation of the uterine tissues as extensively as possible. The amputation and excavation may be performed by means of hooks and scissors, as in epithelioma. Taking the statistics of Freund's operation, as practised and modified by himself and others, as my guide, I am not disposed to sanction or advise the complete extirpation of the uterus for this form of cancer.

The subject of palliative treatment of cancer for the relief of local symptoms, and the amelioration of the general suffering caused by the septic fever, with which the patient usually dies, is more hopeful. The local symptoms requiring palliation are the sometimes disastrous hemorrhages, fetor, acridity of the sanious discharges, and pain.

The tampon made of cotton saturated with the solution of the subsulphate of iron is generally a very effectual means of treating the hemorrhages, while it also temporarily removes the fetor and acridity of the discharges. The tampon saturated with a strong solution of alum is also very effective. Frequent injections and ablutions with a weak solution of carbolic acid or permanganate of potassium will also be very useful in keeping the discharges free from odor. Much comfort may also be derived from small pellets of absorbent cotton introduced just within the vulva to absorb the discharge. Their frequent removal will of course be necessary, but they will be found to protect the external parts from excoriations that would otherwise occur. Applications of tincture of the chloride of iron or solution of hydrate of chloral carefully made to the raw surface upon the cervix very materially correct the foulness {278} of the discharges and lessen the process of necrosis which is continually taking place.

The local and general use of anodynes is about our only means of relieving pain. They may be used locally in suppositories introduced into the rectum or vagina, or hypodermically or by the stomach in such quantities as may be required. Further detail is unnecessary in reference to the use of anodynes, as the quantity, quality, and mode of administering them will depend so much upon the urgency of the pain and the character of accompanying symptoms.

The treatment of the septicæmia is both general and local.

The general treatment consists of such measures as will sustain the vital powers. Tonics of quinine and iron are the remedies that will be of most service, and judiciously used will greatly ameliorate the symptoms of exhaustion. A very important item in the treatment of these prolonged cases of septic fever is a well-selected diet--the more nutritious and easy of digestion the better. It should consist largely of fresh mutton, beef, poultry, game, milk, and butter. The bowels will be generally troublesome in the early part of the time by constipation, and in the later by diarrhoea. For the former a diet containing fruit and coarse flour bread will often enable us to dispense with cathartics, which are generally both exhausting and annoying. For the diarrhoea opiates can be used freely, as also bismuth, pulverized charcoal, etc. etc.

But the most important as well as the most effective measure with which to combat this destructive fever is to keep the raw surface of the tumor as free as possible of necrosed material. This is done most effectively by the sharp curette or Simon's spoon. The whole of the ulcerated surface should be thoroughly scraped off with one of these instruments. The parts completely exposed by Simon's retractors should be scraped energetically until the solid tissue is reached. It should be remembered that the tissues exposed are not sound, but are cancerous deposit. The sacrifice of it, therefore, is not a matter of importance, so that the excavation if not fearlessly should be thoroughly done. An operation of this kind is attended with two dangers. One is the removing so much substance as to open the peritoneal cavity, bladder, or rectum; and the other is hemorrhage. Care will enable us to avoid the former; and, when formidable, the latter may be staunched by the astringent tampon already mentioned.

This operation is only intended as a palliative measure, and it sometimes proves remarkably beneficial. After it the patient will occasionally rally so much and become so comfortable as to indulge in the belief that she is on the road to recovery. The amelioration lasts sometimes months. It will often be profitable to repeat the scraping several times, especially if the case is advancing slowly. It will usually not only make the patient more comfortable, but greatly protract her existence.

Epithelioma of the Uterus.

This malignant disease differs in several respects from the cancer already described. The morbid cell-growth in that form of cancer takes place in the lymph-spaces of the connective tissues of the cervix {279} and uterine body. The lymph-spaces are converted into alveoli or nests in which the cells are developed until they become greatly distended and changed in shape. The lymph-spaces thus occupied freely communicate with each other, and of course with the lymphatic vessels. Hence, the rapid dissemination of the cells locally and the ease with which they find their way to distant parts of the system.

The cells in epithelioma are developed on the free surface of the mucous membrane. From this surface the cells seldom travel to any great distance, and consequently the disease often does not become general. Epithelioma is cancer of the mucous membrane of the uterus, while the other form is interstitial cancer of the uterus. The dense mucous membrane serves as a barrier to the passage of the cells into the surrounding tissues. After the disease has existed for a long time, the surface of the mucous membrane is impaired, and it does not resist the dissemination of the cells. Then the process of cell-dissemination is a result of partial destruction of the membrane. In cancer of the uterus they are disseminated early, and possibly from the beginning, because they are generated within the lymph-spaces, with which the lymphatic vessels are continuous.

Epithelioma of the uterus very rarely assumes the form of an ulcer; generally it is a deposit upon, or growth from, the surface of the mucous membrane. The growth assumes shapes that vary with the different localities. If the extremity or external surface of the cervix is the seat of the disease, it usually projects into the vagina as a fungus which may grow large enough to fill up that cavity. Much more frequently the cervix is enlarged and is covered with a stratum of epithelial deposit very frail in texture that bleeds freely when rudely touched. This fungous growth or deposit does not affect the mobility of the uterus, even when the cervix is considerably enlarged. When the morbid deposit takes place in the cavity of the uterus, it often does not project from the os uteri to any extent, but is confined to the cavity. When the cavity is filled up by an epitheliomatous growth emanating from the entire surface of its lining membrane, we seldom see anything more than an ashy-looking substance filling up the external os uteri. Sometimes the growth covers the whole of the mucous membrane of the body and neck, including the external covering of the latter part.

CLINICAL HISTORY.--The clinical history of epithelioma is essentially the same as that of the other form of cancer, and consequently need not be given in detail. The main symptom is hemorrhage, with an abundant and stinking sanious discharge.

DIAGNOSIS.--In examining with the finger and with both hands it will be found that the uterus is movable and not much, if any, enlarged. If the case is of the ulcerated variety, the finger may not detect the lesion; if, on the contrary, there is a fungus, it will at once detect it. Should the deposit not project from the os externum, the finger may not recognize its presence. Upon exposing the cervix to view in the ulcerative variety an ulcer of a light ash-color will be seen, presenting an irregular outline slightly excavated, and if the probe is applied to it the bottom and sides of the ulcer will be found of the same firmness and consistence as the uterine tissues. It is not indurated. If a fungus exists, it can be seen and examined. When not bleeding it is also ash-colored. The {280} consistency of the projecting mass is sometimes tolerably firm, but more frequently it is quite frail and gives way under moderate pressure. Should the deposit be inside of the uterus, the os will be slightly dilated and filled with a gray substance.

The probe will readily pass through this frail material and enter the uterine cavity. In cases presenting such an appearance the cavity is generally enlarged and filled with this fungous deposit. These facts may be ascertained by the use of the probe while the parts are exposed to view.

The microscope will verify and correct our diagnosis. For microscopic examination some substance from the surface of the ulcer or fungoid projection may be collected and submitted for inspection. The appearances are nests or spaces of greater or less size filled with epithelioid cells.

PROGNOSIS.--Without judicious treatment practised at an early period epithelioma may be said to be invariably fatal. There is, however, much promise of great amelioration in this form of disease with the present improved methods of treatment, and in some cases we may succeed in effecting a permanent cure.

TREATMENT.--The general palliative treatment is the same as that described in the other form of cancer, and need not be repeated. While I have failed to see any other than palliative effects result from amputation of the cervix and excavation of the body of the uterus in the first form of cancer described, I have seen cures of epithelioma effected by thorough extirpation of the diseased mass. One of these cures was in a case where the disease was confined to the posterior lip of the cervix; another, where the deposit apparently occupied the whole surface of the mucous membrane of the body and cavity of the cervix. In other cases I am sure the life of the patient was prolonged and her comfort greatly enhanced. I am persuaded, from a good deal of observation, that the younger the patient the more promising the result of operations. The worst and most rapidly fatal cases of epithelioma I have seen have been in patients beyond the menopause. This is contrary to what I have witnessed in the other form of cancer, as in it the younger the patient the more rapid the progress of the disease and the least beneficial the operations were.

After a trial of the several methods pursued in the removal of epithelioma, and the different instruments used for the purpose, I prefer using the scissors, aided by hooks and vulsellum, to cut away as much of the diseased tissue and the sound structure upon which it is implanted as possible, and then burn the surface with the cautery in some of its forms or the strong caustics. When the disease is confined to the cervix, the whole of the intravaginal portion should be cut away and the excising process carried as high up as possible, carefully avoiding the peritoneal cavity on the one hand and the bladder on the other. With the cervix exposed and fixed by a vulsellum, the sharp-pointed curved scissors may be insinuated beneath the external covering, and the tissues removed by pieces until the operation is completed. When the utmost attainable portion is thus removed, I prefer applying to the whole of the cut surface pellets of absorbent cotton thoroughly moistened with the solution of the pernitrate of mercury (the acid nitrate, as it was formally called), and then filling the upper part of the vagina with dry absorbent cotton, {281} tightly packing it so as to absorb any of the free acid. This last is necessary to defend the sound parts from the superfluous cauterization which would otherwise follow. The dressing may be removed in twenty-four hours, and the whole of the surgical cavity as well as vagina washed out with pure warm water twice a day afterward. If the cavity thus formed does not fill up, and the surface assumes a malignant aspect, it should be scraped out with a view to remove its entire surface and treated again with the acid. This last operation may be repeated again and again. It will sometimes be found that the cavity will grow less after each scraping with the sharp curette, and finally fill up.

If the disease is developed in the cavity of the uterus, Simon's sharp curette should be used to scrape out and destroy the whole mucous membrane. When this is done the cavity should be carefully filled with the cotton pellets saturated with pernitrate of mercury, as recommended for the cervical operation. And this operation should be repeated also with the same thoroughness as at first as soon as evidence of a return is manifested. When the scraping and cauterizing have been beneficial the uterine cavity will become smaller, and when the discharges indicate a reproduction of the morbid deposit the surface to be operated upon will be sensibly diminished, until finally it will be apparently almost closed. I say almost, because one of my patients, while she seems to have been cured, still menstruates.

While I do not pretend that many of these cases can be thus cured, I am sure some of them can be. Hence I do not hesitate to recommend an effort to be made in all cases in which the disease has not spread to the adjoining organs or tissues. When a cure is not thus effected, such great amelioration will so often occur as to make an operation justifiable.

The hemorrhages encountered in these operations are generally unimportant, but occasionally so much blood will be lost as to require hæmostatic measures. The practitioner should therefore be supplied with an astringent tampon and use it if necessary.

If an operation for the complete extirpation of the uterus is ever justifiable for malignant disease, I think it is in this form. The operation which I think the simplest and easiest to accomplish is that performed first in this country, so far as I know, by S. C. Lane of the Medical College of the Pacific, and in Germany by Langenbeck.

{282}

DISEASES OF THE OVARIES AND OVIDUCTS.

BY WM. GOODELL, M.D.

The ovaries are two almond-shaped glands attached to either side of the womb by a ligament of contractile tissue called the ovarian ligament, and they are enclosed between the two layers of the peritoneum known as the broad ligament. It has recently been contended that this envelopment in the broad ligament is not a complete one, but that the peritoneum is absent from the posterior surface of the ovary. This has been denied, but even if it be so, the fact does not seem thus far to have any physiological or any pathological bearing.

The ovarian nerves and blood-vessels run between the two layers of the broad ligament, the former coming chiefly from the renal plexuses of the sympathetic, the latter from the spermatic arteries. The ovaries being themselves movable bodies and attached to a movable organ, the exact position of which remains yet a moot question, their own natural situation has not yet been authoritatively determined. His,[1] from an examination of three suicides, holds that the ovary in the adult virgin hangs with its long diameter almost vertical, and with one side against the wall of the pelvis, but below the brim, the free border being behind and the attached end below. Each oviduct is looped over the ovary, rising along the front and falling over behind it. Hence the ovary lies on the fimbriæ which turn back and spread over the summit of the ovary. The ovaries are generally situated on a level with the inlet of the true pelvis, the left one being in front of the rectum, the right one surrounded by a coil of small intestines. When healthy they keep so high up as to be beyond the reach of the examining finger, and consequently they are not impinged upon during coition.

[Footnote 1: British Medical Journal, Dec. 10, 1881, from Archiv f. Anat. u. Entwick., 1881, Nos. 4 and 5.]

The important and special function of the ovaries--that of secreting and excreting the Graäfian follicles or ovisacs--and their monthly engorgements are the causes of many of the diseases to which they are subject. Hence it is that affections of the ovary, being due most commonly to perverted function, rarely occur before puberty.

Malformations.

Absence of the ovaries is a congenital condition very rarely met with. It is usually associated either with the absence also of the womb or {283} with an imperfect development of the other portions of the sexual apparatus. The breasts will be flat, the vagina generally imperforate, the vulva small, the pubic hair absent, and sexual feeling wanting. Menstruation never takes place. Very commonly the growth of the body is arrested, and the stature is dwarfed to that of a child. Occasionally, however, there is an approach to the masculine type in the size, the figure, the voice, and in the growth of hair on the face and on the body.

An arrested development or a rudimentary condition of the ovaries is a more common malformation than the preceding one. The womb is then infantile in size, and the vulva and vagina are small and the pelvis is narrow. Puberty either fails to take place or it is postponed. When menstruation is present it is scant and appears at long intervals. General development is impaired, and the figure and mental characteristics may be those of advanced childhood. Sexual feeling is either wholly absent or very imperfect.

DIAGNOSIS.--Whenever the ovaries are wanting, their absence cannot be positively made out by a digital examination of the parts, for even fully-formed ovaries often elude the finger. The diagnosis depends mainly on the symptoms previously given. If the ovaries are rudimentary, the finger passed high up the rectum while the woman is anæsthetized will sometimes recognize them. But the diagnosis rests usually on some manifestation of puberty, and the greater these manifestations the greater the curability.

TREATMENT.--For the complete absence of the ovaries all treatment is of course useless. Whenever these organs are in a rudimentary condition more can be done for the woman, but success is by no means assured. Every treatment that tones up the body is of service. The rest-cure, with its accessories of massage, general faradization, and over-feeding, promises much. Electricity has done good when one pole is applied directly over an ovary and the other pole placed either on the sacrum or on the cervix uteri. It is still more efficacious when the reophore in the form of a properly insulated sound is passed into the uterine cavity. Should the interrupted current fail to do good, the galvanic current may cautiously be tried.

From the vascular and nervous kinship between the ovaries and the womb all stimulants to the latter tend to invite blood to the former, and from this flux may come growth. It is therefore good practice to irritate the womb by tents, by applications of iodine and of silver to its cavity, and especially by the use of galvanic stems. The marriage relations sometimes quicken dormant ovaries into life, and development, followed by pregnancy, has been the result. But the remedy is a hazardous one, for if the sexual sense be not awakened, as often it will not, the union leads to much unhappiness.

Inflammation of the Ovary; Ovaritis.

Acute inflammation of the ovary rarely exists per se, but it is by no means an infrequent accompaniment of pelvic peritonitis and pelvic cellulitis, the causes of each being the same. It is then so masked by the {284} greater inflammation that its symptoms are lost in the general ones. Following the same course as that of pelvic inflammations, it begins with fibrinous exudation and ends either in resolution or in suppuration, or in chronic hypertrophy.

The TREATMENT of this inflammation is the same as that of pelvic inflammation--viz. rest, poultices, vaginal injections of hot water, and morphia and quinia in large doses. Sometimes the local abstraction of blood will be useful. Should pus form, it must be evacuated by the aspirator, and preferably per vaginam. After such an inflammation, and especially if caused by gonorrhoea, the ovary usually remains permanently injured, its functions being crippled by fibrous bands, adhesions, hardening of its stroma, and thickening of its investing peritoneum. If both ovaries be thus affected, sterility inevitably ensues.

Chronic Ovaritis.

By chronic ovaritis is meant either persistent congestion of the ovaries, or such tissue-changes in the stroma or in the follicles of the ovary, or in both conjointly, as are brought about from a previous attack of acute inflammation or from persistent hyperæmia. In its early stages it appears to be characterized by passive congestion, followed by infiltration of sero-sanguinolent fluid and by increase in bulk. Later on, if the congestion be not dispersed or it passes the health-limit, it becomes formative, or nutritive; the capsule thickens, the follicles enlarge, and a general hypertrophy takes place. According as the brunt of these changes falls on the stroma or on the follicles, the degeneration is termed either interstitial or follicular. When the stroma is chiefly attacked, the ovary becomes hard and rugous; when the follicles are diseased, they increase in size, and one or two of them are usually found to be distended into miniature cysts. There are indeed good reasons for the opinion that an ovarian cyst is a dropsy of many ovisacs, and is caused by ovaritis. The left ovary is the one more commonly affected--a fact accounted for by the pressure of the distended rectum and by the emptying of the left ovarian vein into the renal vein instead of into the vena cava, which is the course of the ovarian vein on the right side. It is a very common form of disease, very rarely coming from an acute attack, but starting subacutely with all the symptoms of chronicity.

CAUSATION.--Whatever induces a lasting congestion of the reproductive apparatus tends to create ovaritis--a torn cervix, a lacerated perineum, an arrest of involution after labor, dysmenorrhoea, and uterine tumors, flexions, and displacements. Barren women are very liable to this disease, and so especially are women who shirk maternity by preventive methods; for in both the menstrual congestions continue without that much-needed break which gestation and lactation bring, and in the latter the sexual congestions arising from incomplete intercourse are not relieved. So repeated erectility from self-abuse, by ending in a passive congestion of the womb and of the ovaries, will tend to produce this lesion. The prevalence of this habit in unmarried women is, I think, very much overrated, and yet I have seen from this cause several cases of ovaritis accompanied with prolapse of the ovaries. In one the ectropion {285} of the cervical mucosa was so marked that it leads me to think that this is the cause of the occasional inversion of the womb in virgins. My notebook shows also cases of ovaritis from such imperfect sexual relations as come from the ill-health or the advanced age of the husband, and not a few from immoderate sexual intercourse. Some of the most common causes of chronic ovaritis are emotional in character, such as long engagements, disappointments in love, single life, the reading of corrupt literature, unhappy marriages, nerve-exhaustion, and hysteria. These causes operate by producing circulatory disturbances which keep up a constant congestion of such exacting organs as the ovaries.

SYMPTOMS.--Pain in one or in both ovarian regions, especially in the left one, is a prominent symptom. It is increased by walking or by standing, and is lessened by the recumbent posture. Starting usually from the ovary, it radiates to the small of the back or down the inner side of the thigh. It often begins from a week to ten days before the monthly period, and goes on increasing until the flow appears, when it commonly abates. Menorrhagia may usher in the disease, and may continue during the remainder of menstrual life, which then is usually prolonged. Ordinarily, however, menstruation becomes scant and irregular, postponing rather than anticipating. Sometimes amenorrhoea takes place. Sterility is usually present, and so almost always is nerve-exhaustion with all its emotional manifestations. Pressure over each ovarian region elicits pain and causes a contraction of the rectus muscle on the affected side. The finger per vaginam or per rectum will often discover behind the cervix uteri or to one side of it the very tender ovary, of the form and size of an almond. Pressure on it gives a sickening pain, very unnerving in its character. Reflex nervous symptoms are very common, especially those of hysteria. In the form of pain they show themselves in backache, spine-ache, nape-ache, and headache; in pain under the left breast, in the scalp on the top of the head, and in the stomach, bowels, womb, and coccyx. Nervous dyspepsia is common, accompanied by costiveness, nausea, vomiting, flatulent distension, and noisy eructation. Wakefulness and bad dreams are not infrequent. Other reflex neuroses may appear, such as paralysis or spasm of the sphincter muscles, the latter producing asthma, dysmenorrhoea, irritable bladder, and painful defecation. Then, again, there may be nervous disturbances, taking the form of low spirits, violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive mental aberration.

PROGNOSIS.--This disease is rarely fatal, but it is always very stubborn, and often incurable. The patient grows anæmic and she tires on the slightest exertion. Very soon nerve-exhaustion with its protean symptoms sets in. She takes to her back and becomes a sofa-ridden invalid. If the patient has contracted the habit of taking stimulants or anodynes, her chances for recovery will be greatly lessened.

TREATMENT.--The pelvic organs should be carefully examined, and any discoverable lesion of the womb and of its annexes be remedied. Pelvic engorgement must be met by keeping the bowels soluble, by scarification of the cervix, by large vaginal injections of water as hot as can be borne, and by vaginal suppositories of belladonna and by rectal ones of iodoform. Tenderness and hardness in either broad ligament is first treated by applications of a strong tincture of iodine both to the roof of {286} the vagina and to the skin overlying the ovarian regions. Flying blisters may also be placed there with benefit. Sexual intercourse should not be indulged in unless the desire for it be strong or there is a possibility of conception, for, by the prolonged rest which it gives to the ovaries, pregnancy usually brings about a cure. The patient should keep on her back during her menstrual period; but, while rest in the recumbent posture should be taken morning and afternoon, she should be encouraged to move about and exert herself in some light household work, yet not to over-fatigue herself.

As far as medicines are concerned, those should be chosen which lessen the engorgement of the reproductive organs. Thirty grains of potassium bromide and ten drops of tincture of digitalis, given in compound infusion of gentian before each meal, will tend to quench all erectility of these organs. After the patient has been kept for some time on these anaphrodisiacs, alteratives will come into play: very good ones are ammonium chloride and mercuric bichloride, which can be advantageously administered after the following formula:

Rx. Hydrargyri chloridi corrosivi, gr. j-ij; Ammonii chloridi, drachm ij-iv; Misturæ glycyrrhizæ comp. fluidounce vj. M.

S. One dessertspoonful in a wine-glassful of water after each meal.

The paregoric in this mixture helps to control the aches; the antimony adds its quota to the needed alterative action; and the licorice disguises the harsh taste of the ammonium chloride.

Another very excellent alterative and nervine is the chloride of gold and of sodium. It is best given in pill and after each meal in doses of from one-eighth to one-quarter of a grain.

As there is in this disease a craving after stimulants and anodynes, which often degenerates into intemperance and into the opium-habit, the physician should be very careful how he prescribes such remedies, reserving their use wholly for emergencies.

In plethoric cases marked with menorrhagia iron is hurtful, but in anæmic cases with scant menstruation it rarely fails to do good, especially when given conjointly with arsenic. An excellent combination is one part of Fowler's solution of arsenic to nine of the syrup of the ferrous iodide. Beginning with ten drops after each meal, the patient increases the dose daily by one drop until thirty drops are reached. She then continues this last dose as long as it does good or it can be borne. In stubborn cases a sea-voyage may prove of lasting benefit.

The best of all treatments, however, and by far the best, is that devised for nerve-exhaustion by S. Weir Mitchell, which goes by the name of the rest-cure. It consists of prolonged rest in bed, seclusion from friends, massage, electricity, muscular movements, and a diet consisting largely of milk. By this treatment the circulation of the blood is made equable and the ovaries and other pelvic organs are thus relieved of their turgescence. I have had wonderful cures from this treatment, and can recommend it with the utmost confidence. Bed-ridden patients have been restored to health and chronic invalids returned to society.

Once in a while, lasting tissue-changes take place in the ovaries which medication cannot reach. The question then comes up, whether the woman shall be doomed to drag out the rest of her menstrual life {287} burdened with distressing ovaralgia, with crippled locomotion, and with pelvic aches and pains and throbs, or whether the source of all these mischiefs, the ovaries themselves, shall be extirpated. This is a very important question, and the removal of these organs should not be decided upon without careful deliberation and without the conviction that the disease is otherwise incurable.

Prolapse of the Ovary.

This displacement of the ovary is almost always one of the lesions of chronic ovaritis, and as such might have been discussed under that general heading. But as it displays certain symptoms peculiar to itself, and needs a special treatment aside from the general one, it seems to me best to describe it by itself.

At every monthly period the ovaries become turgid with blood, and from their weight sink low down. They can then be often felt, and even outlined, in Douglas's pouch. When this congestive period is over they discharge their over-freight of blood and again float up out of reach. Unfortunately, however, they sometimes keep turgid--blood-logged, so to speak--and consequently become permanently displaced. Accompanying this dislocation there will generally be some uterine lesion which will stand in the relation either of cause or of effect.

Nor could it very well be otherwise, for very close is the vascular and nervous kinship between the two--so close, indeed, that turgidity in the one means erectility in the other. Hence it is not always easy to decide which lesion was primary and which is secondary. When one ovary is displaced, it is usually the left one, because the left ovary, as explained under the heading of Ovaritis, is the one more liable to disease. When both ovaries are displaced, the left one will be the lower and the more easily reached, because the left round ligament is the longer and the left side of Douglas's pouch the deeper.

CAUSATION.--Any condition tending to a lasting congestion of the reproductive apparatus is very likely to lead to a descent of the ovaries. The causes, therefore, are the same as those of chronic ovaritis, to which subject the reader is referred.

SYMPTOMS.--First and foremost is pain in locomotion. Since the ovary now lies between the womb and the sacrum, it is liable at every step to be pinched between them. This pain is referred to the inguinal and sacral regions, and is of a sickening and an unnerving character. It often occurs suddenly, and then runs down the corresponding thigh along the track of the genito-crural nerve. One of my patients would, while walking, be unexpectedly seized with such a pain, which would either momentarily cripple her or else last so long as to compel her to call a carriage. Her left ovary, until cured by treatment, behaved like a loose cartilage in the knee-joint, and slipped down so low as to get pinched.

A second symptom is a throbbing pain while the rectum is loaded, and an agonizing pain during defecation. This arises from the grating of the hardened feces over these tender glands. In one of my cases[2] rectal enemata or the presence of hardened feces kindled up sexual throbs of the {288} most painful and exhausting character, which thrilled through the whole body for hours at a time.

[Footnote 2: Lessons in Gynæcology, by W. Goodell, M.D., ed. 1880, p. 332.]

A third symptom is painful coition, for the ovaries are now so low down as to be bruised by the male organ. A fourth is gusts of pain radiating from either groin. Lastly, there is usually present a morbid state of the mind, accompanied by low spirits. I have seen suicidal tendencies evoked by dislocation of the ovaries and relieved by their replacement.

DIAGNOSIS.--A digital examination will discover in Douglas's pouch a very tender almond-shaped body on one side of the womb. If both ovaries are dislocated, two such bodies will be found; but the left one, for reasons previously given, will be lower down and more easily defined. Pressure upon one of them produces a sickening pain, like that when the testicle is squeezed. If the pressure be increased, and be so made that one of these bodies slips abruptly away from under the finger, such a thrill of indescribable pain darts through the groin and down the side of the corresponding thigh that the woman screams out and grows pale or becomes nauseated.

A dislocated ovary is sometimes mistaken for a pedunculated fibroid tumor of the womb or for the fundus of a retroflexed womb. But the uterine growth is not sensitive to the touch, and the flexion of the womb can always be told by the sound.

TREATMENT.--Whenever the dislocated ovaries are congested or they display signs of chronic inflammation, the same remedies will of course be useful as those for ovaritis. In addition, pessaries are important adjuvants, and especially in those cases in which the womb has a backward displacement. In the simple, uncomplicated cases of ovarian dislocation, in which the womb is in its proper position, a pessary often does more harm than good. To be of service it must be long enough to obliterate Douglas's pouch, and the pressure on the rectum or on the sacral nerves then becomes unbearable. If, on the other hand, it be too short, the ovary slips down behind it and gets badly pinched. These requirements practically exclude the resort to Hodge's pessary or to any of its modifications, with the exception, perhaps, of Fowler's. In the long run, a thick elastic and soft ring-pessary will do the most good, by offering a broad shelf on which the ovaries will sometimes, but not always, lodge. The air-cushion pessary and Gariel's air-bag will often answer the purpose better than any other, but, being of soft rubber, they soon become fetid and soon collapse.

A very excellent way of keeping up the ovaries is the knee-chest posture devised by H. F. Campbell of Georgia. Two or three times a day, or more frequently if needful, the woman unbuttons her dress, unhooks her corset, and loosens her underclothing. She then kneels on her bed with her body bent forward until her chest is brought down to the surface of the bed, while her head is turned to one side and the lower cheek supported in the palm of the corresponding hand. Her knees should be about ten inches apart and the thighs perpendicular to the bed. The trunk of the woman's body is now supported, like a tripod, by her two knees and the upper portion of her thorax. If she now refrains from straining and breathes naturally, a reversal of gravity will be established. With the fingers of her free hand she next opens the vulva. Air will {289} rush in, distending the vagina, and the contents of the abdomen will at once sink toward the diaphragm. This will, of course, draw the womb and the displaced ovaries out of the pelvic basin. As it is rather awkward for a woman while in this posture to free one hand to reach the vulva, Campbell advises that previously to taking this attitude she should insert into the vagina a small glass tube open at each end and long enough to project externally. This will leave an air-way and dispense with the use of the fingers. After staying in this posture for a few minutes, the woman removes the tube and slowly turns over on her side, where she is to lie as long as she can. Such constant replacements are of great service, for they lessen the throbbing and they give the limp ligaments a chance of shrinking and of keeping the truant ovaries at home.

In this intractable disorder an abdominal brace will sometimes do good. It may not cure, but it often blunts the edge of the aches, and thereby gives much comfort. By pressing the abdominal wall upward and inward the brace forms a shelf on which the viscera rest, and thus it takes off a portion of the load from the womb and from its ovaries. By virtually narrowing the pelvic inlet it lessens the space into which the bowels tend to crowd, and to that extent protects the pelvic organs. By swinging the pelvis backward it makes the axis of the superior strait lie more obliquely to the axis of the trunk, and the sum of the visceral pressure now converges, not in the pelvic basin, but on the portion of the abdominal wall lying between the symphysis pubis and the umbilicus.

There is yet another treatment which, combined with the knee-chest posture, I deem the best of all. It is Mitchell's rest-cure, to which I have before referred. After the patient begins to improve and to fatten, as she usually does under this treatment, she is taught how to replace the ovaries by atmospheric pressure, and the result is that in my experience they finally stay up. The explanation is as follows: By this treatment the circulation of nerve-fluid and of blood is equalized, and the ovaries, relieved of their turgescence, grow lighter. Then the increased deposit of fat in the abdominal walls, in the omental apron, and around the viscera, to say nothing of the needful fat-padding in all the pelvic nooks and crannies, increases the retentive power of the abdomen. Finally, by its gravity the now fat-laden and overhanging wall of the abdomen tends to draw toward itself--that is to say, upward--the movable floor of the pelvis. The behavior is like that of a rubber ball half filled with air, in which bulging at one pole causes a corresponding cupping at the other. This explains the ascent of the womb in women who get fat after the climacteric.

In exceptional cases the hypertrophied glands keep heavy and refuse either to go up or to stay up under any treatment whatever. The only known remedy will then be their extirpation--an operation which will be discussed under its appropriate heading.

Hernia of the Ovary.

This is usually a congenital displacement, and, according to Englisch,[3] is, when double, almost always so. The ovary is then found either in {290} the inguinal canal or outside of this canal in the corresponding labium majus. The oviduct then accompanies it. When the hernia is acquired, the ovary, with or without the oviduct, makes one of the contents of the sac of an inguinal, a crural, a ventral, or an ischiatic hernia. Of these, the inguinal is by far the most common. Thus, out of 67 cases observed in 9 years by Langlon at the Truss Society, all were inguinal with 1 doubtful exception. Of these 67, 42 were congenital, 25 acquired.

[Footnote 3: New Sydenham Soc.'s Biennial Retrospect, 1871-72, p. 291.]

The character of the lesion is told by the peculiar tenderness and nausea following pressure, and by the swelling of the tumor just before the menstrual flux. In one case mentioned by Routh[4] pressure on the tumor produced distressing sexual excitement; but this is an unusual symptom, although I have seen it produced by the pressure of hardened feces.[5] It is not always easy to decide whether the displaced glands are ovaries or testicles; and repeated mistakes in regard to sex have thus been made.[6] So difficult, indeed, is it sometimes that the microscope can alone settle the question.

[Footnote 4: Trans. Royal Medical and Chir. Soc., Lancet, Jan. 28, 1882.]

[Footnote 5: Goodell, Lessons in Gynæcology, 2d ed., chap. xxvi. p. 332.]

[Footnote 6: Chambers, Trans. London Obstet. Soc., 1881.]

TREATMENT.--In a reducible hernia, taxis and an appropriate truss comprise the treatment. If irreducible, a truss with a concave pad may be used to protect the ovary from injury. If the ovary be fixed by adhesions and it give much discomfort, it should be removed by operation.

Öophorectomy; Battey's Operation.

There are certain forms of diseases of women peculiar to the menstrual period of life. The attendant lesions are found either in the reproductive organs themselves or outside of them in remote organs, but with such monthly exacerbations as show their participation in the catamenial excitement. They are always very hard to cure, and often prove to be wholly unmanageable until the climacteric has been established.

In this category may be classed fibroid tumors of the womb, chronic pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia, ovarian insanity, ovarian epilepsy, and, in short, all those phenomena or those lesions which are embraced under the term of pernicious menstruation.

Fibroid tumors of the womb are, fortunately, pretty manageable. Usually, the womb, like a generous host, hospitably entertains them; but once in a while an unwelcome one presents itself which arouses all the resentment of that organ. If, then, it stubbornly resists all treatment, it slowly but surely destroys life by the pain which it evokes and by the loss of blood it gives rise to. In such a case the woman is virtually bed-ridden from her floodings and sufferings, and she looks forward to the climacteric as her only hope. But the change of life is then always postponed for several years beyond the natural term--oftentimes so many years as to be overtaken by the death of the patient.

Then, again, there are those cases in which, despite all treatment, the ovaries remain turgid with blood, acutely neuralgic, and to the last degree sensitive. They become dislocated and lie in Douglas's pouch, or irremediable tissue-changes take place, attended by follicular or by {291} interstitial degeneration. A woman with such a lesion is usually a helpless invalid, racked with atrocious pains, weakened by exhausting menorrhagia, and wholly unable to fulfil her duties as wife or as mother. Usually she seeks relief in anodynes and becomes a confirmed opium-eater.

There are also many distressing cases of salpingitis or of pelvic peritonitis and pelvic cellulitis which cripple a woman past all hope by monthly exacerbations. Such cases are by no means rare, and the woman, reduced to skin and bone, finally dies, because in spite of all treatment the inflammation is rekindled at every monthly period.

Further, there are cases of epilepsy which seem to come wholly from the sexual organs--cases with an ovarian aura, so to speak. The fits begin at puberty, very generally last through life, and end in impairment of the mind. Often the first convulsion is ushered in by the first menstruation, and ever after it is around ovulation as a storm-centre that future eclamptic attacks revolve. Such an epileptic is the terror of her family and a valueless member of society. Generally she dies insane or with enfeebled mind, and if she marries she is very likely to transmit her infirmities to her children, either in the same form as her own or in kind.

Finally, what insane asylum does not hold incurable women whose mental infirmities seem to depend wholly upon the act of ovulation? Some there are who, indeed, never exhibit symptoms of insanity excepting during the monthly flux.

For these menstrual affections there is a remedy which, while yet in its infancy, promises much--one first proposed and performed by R. Battey of Rome, Georgia. This able surgeon reasoned that, since these disorders are kept up by the monthly afflux of blood to the sexual apparatus, and therefore incurable during menstrual life, the only chance of immediate relief lies in the establishment of an artificial menopause. To bring about this change of life he advocated the extirpation of both the ovaries, and labeled the operation normal ovariotomy. With this name fault has been found, because it does not cover the whole ground, for often the ovaries themselves, together with the oviducts, are found diseased. Now, since it is important to distinguish this operation from that of ovariotomy proper, and since the term spaying, which technically defines the character of the operation, is obnoxious from its association with the lower animals, the terms öophorectomy, or Battey's operation, have been adopted.

In well-selected cases this operation has been followed by wonderful results; but it has been greatly abused. By it I have restored to perfect health cases of otherwise incurable fibroid tumors of the womb, cases of dysmenorrhoea and of menorrhagia, and cases of pernicious menstruation in which the sufferers were reduced to the last degree of emaciation and feebleness. Out of 5 cases of ovarian insanity I have also cured 4; the fifth, while not wholly restored, is yet very much better.

This operation has been performed both by the vaginal and the abdominal section. For some years I was a warm advocate of the vaginal method, but I have wholly given it up, because by this method of operation adherent ovaries cannot be safely dislodged, the ovaries cannot always be reached, the vaginal wound cannot be dressed antiseptically, {292} and because the abdominal mode is more simple and less dangerous. Only when the ovaries are dislocated and low down in Douglas's pouch would I possibly resort to the vaginal incision.

If the abdominal operation be performed, the incision should be made between the navel and the pubes in the median line, and not over each ovary, as advised by some authors. One great caution must, however, be observed, and that is not to wound the intestines. In ovariotomy the cyst is in front of the intestines, and there is very little danger of injuring the latter. But in cases of öophorectomy, no tumor being present, the bowels lie in contact with the wall of the abdomen, and are very likely to be wounded by the knife when the peritoneum is incised. The incision should be long enough to admit two fingers. These, being passed behind the womb, are conducted to the ovary by gliding along the oviduct as a guide. Each ovary, together with its oviduct, is in turn brought up to the opening. It is then seized by a fenestrated polypus-forceps and its stalk transfixed, tied on either side with fine silk, cut off, and dropped back into the abdominal cavity. Should the stalk be so short that ovarian tissue is left behind in the button of the stump, it should be destroyed by Paquelin's cautery, for it is astonishing how small an amount of this tissue will keep up not only menstruation, but even menorrhagia. On the other hand, it will not answer merely to ligate the pedicles without removing the ovaries. This has been tried, and not only did menstruation continue, but in one instance pregnancy took place.[7]

[Footnote 7: Murphy, British Medical Journal, April 18, 1885, p. 787.]

The dressing is precisely the same as in ovariotomy, and, like it, the operation should be performed with every detail of antiseptic surgery.

In the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. I am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration--an untoward circumstance which cannot happen in the dorsal position. A duckbill speculum is introduced, and the perineum pulled downward. The cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. The post-cervical mucous membrane is next caught up by a uterine tenaculum and snipped open for about an inch. The index finger of the left hand is then passed in, and each ovary brought down to the incision by the finger-tip hooked into the sling made by the oviduct. The ovary is seized by a fenestrated forceps and brought into the vagina, where its stalk is transfixed by passing a needle armed with a double thread between the ovarian ligament and the oviduct, and each half is securely tied. The ovary and the fimbriated end of the oviduct are then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. To close the vaginal opening one or two stitches will be needed, and finally the wound is covered with iodoform and the vagina gently packed with pads of carbolated or salicylated cotton.

It is a fact worthy of note that during the week following the ablation of the uterine appendages a sanguineous discharge from the womb usually takes place. This is in no wise a menstruation, but a metrostaxis {293} set up by the irritation of the ovarian nerves, caused by the means adopted to secure the pedicles. Candor, however, compels me to say that for some inexplicable reason the removal of the uterine appendages--viz. ovaries and oviducts--does not always bring about the change of life. These cases are exceptional, and they are supposed to be due to either the presence of a third ovary or to some small portion of ovarian stroma left behind.

This operation in no wise unsexes a woman or changes her appearance or character. It simply brings on the change of life with its attendant phenomena. Her instincts and affections remain the same, her sexual organs continue excitable, her breasts do not wither up, and she is no less a mother or a wife.[8]

[Footnote 8: Lessons in Gynæcology, by Wm. Goodell, M.D., chap. xxvi.]

Extra-Ovarian Cysts.

There is a class of tumors which, while not ovarian, lie so near to the ovary as often to involve it, and usually need precisely the same treatment as cysts of that organ. In their extirpation the ovary is almost always also involved. This close anatomical relationship makes it needful to describe them in conjunction with ovarian tumors. They comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called the Hydatid or Vesicle of Morgagni.

Cysts of the Parovarium.

These are formed from the dropsical distension of one of the tubules of the parovarium, or organ of Rosenmüller, which lies between the folds of the broad ligament and between the ovary and the oviduct. Usually, one tubule alone is affected, and the cyst is then unilocular; but exceptional cases have been met with in which several of the tubules have become dilated, and the cyst is then bilocular or even multilocular.[9] These cysts are often called cysts of the broad ligament.

[Footnote 9: "Bursting Cysts of the Abdomen," by Wm. Goodell, Trans. American Gynæc. Soc., 1881, p. 231.]

By examining cysts in their early stage Albert Doran has demonstrated that "the vertical tubes of the parovarium are lined with epithelium, sometimes ciliated, but oftener cubical, the original, primitive form of the tubes of the Wolffian body. From these tubes and from the hilum of the ovary, full of Wolffian relics, spring the multilocular papillary cysts which give so much trouble to the operator. At the outer end of the horizontal tube of the parovarium is a cystic dilatation which is lined with a structure resembling endothelium. Apart from the parovarium, between the folds of the broad ligament, minute cysts are frequent. It is from these and from the terminal cyst of the parovarium that the simple unilocular so-called parovarian cyst arises. The terminal cyst of the Fallopian tube never attains a large size, and no true cysts of the broad ligament appear, when young and minute, to arise from that tube."[10]

[Footnote 10: British Med. Journal, Oct. 21, 1882, p. 792.]

{294} These cysts are more commonly found in young women. From the thinness of their walls and the limpid character of their fluid, they yield very marked waves of fluctuation which are equally distinct at every point. They can usually be distinguished from ovarian cysts either by a lack of that tenseness so characteristic of the latter or by varying conditions of tenseness and flaccidity, as if the fluid were sometimes absorbed more quickly than at other times. They also grow more slowly than the ovarian cyst, and do not exert the same profound constitutional impression. The facies ovariana is absent, and the health of the woman may in no wise be disturbed. They, indeed, in the majority of cases, seem to do no harm, and are merely annoying from their bulk. The fluid they contain is with rare exceptions as limpid and clear as spring-water, but with refractive powers so high as to magnify the fibres of the wooden pail into which it has been drawn off.

Owing to their very thin walls and delicate structure these cysts on very slight provocation are liable to burst. On account of the blandness of the contained fluid this accident is rarely followed by collapse or by peritonitis. The rent heals up and the cyst usually refills; but in a large proportion of cases it does not, and the woman remains permanently healed.[11] Sometimes they are pedunculated, but often they lie between the two folds of the broad ligament, having no proper stalk.

[Footnote 11: "Bursting Cysts of the Abdomen," by Wm. Goodell, Trans. American Gynæcological Society, 1881, p. 226.]

Cysts of the broad ligament must not be confounded with those ovarian cysts which, instead of growing free in the peritoneal cavity, develop between the two layers of the peritoneum--intra-ligamentous ovarian cysts, as Garrigues very aptly calls them in his paper on the "Diagnosis of Ovarian Cysts."[12] In this excellent paper, from which I have gleaned much, he says that sometimes the anatomical relations are so lost that nothing short of a microscopic examination of the outer epithelium can determine the character of the cyst. Thus, "a tumor covered with columnar epithelium is ovarian, and cannot be anything else; while the cyst of the broad ligament, being covered with peritoneum, has flat peritoneal endothelium. In cases of intra-ligamentous development of an ovarian cyst the lower portion is covered by peritoneum, but the upper part has the columnar epithelium characteristic of the ovary." There are, however, certain macroscopic characteristics which will generally tell the nature of the cyst. For instance: usually by a careful examination the corresponding ovary will be found either stretched out and spread out in the wall of the sac, or, what in my experience is more common, elongated and forming a part of the stalk. These cysts are in the vast majority of cases monocysts, while unilocular ovarian cysts are very rarely if ever met with. Their walls are thin, of a conjunctival blue, and fretted with a delicate network of blood-vessels. The oviduct is usually imbedded in the cyst, and by transmitted light its fimbriæ can be traced out in the cyst-walls in long fronds as delicate as those of dried and pressed seaweed. Then, again, the peritoneal coat is readily stripped off. On the other hand, in an ovarian tumor the oviduct is not ordinarily incorporated in the cyst-wall; in fact, a meso-salpinx usually exists; and, further, the peritoneal coat, being nailed down to the cyst-wall proper by the cicatrices of ovulation, is not capable of being stripped off.

[Footnote 12: Am. Journ. of Obstetrics, April, 1882, p. 394.]

{295} TREATMENT.--Since these cysts do not ordinarily affect the general health or grow to a very large size, they should, as a rule, be let alone. Whenever grounds for interference arise the cyst should be aspirated, for sometimes after being wholly emptied it does not refill. Should, however, the fluid return, the cyst must be extirpated in precisely the same way as an ovarian tumor. When it is without a pedicle it will have to be carefully enucleated from between the folds of the broad ligament, which then cover it. If this cannot be done, all of the cyst possible should be removed, the edges stitched to the abdominal wound, and a drainage-tube put in. This is the advice ordinarily given, but I have not yet met with a cyst of this variety which could not be removed. Were such a one to occur in my practice I should be tempted to remove all of the cyst possible, and to close up the adherent portion in the cavity of the abdomen without resorting to a drainage-tube. The fluid secreted by a parovarian cyst is so bland that I believe no mischief would arise. The late Washington L. Atlee was accustomed to make merely a large circular opening in the cyst, without attempting to remove it.

Cysts of the Oviducts, or Fallopian Dropsy.

These tumors may contain either fluid or pus. In the former case the cyst is called hydro-salpinx; in the latter, pyo-salpinx. They are caused by salpingitis, or inflammation of the oviduct, which exists rarely per se, unless of gonorrhoeal origin, but is one of the sequels of pelvic peritonitis. The distension of the tube is due to the occlusion of each of its ends. Thus by pelvic inflammation the fimbriæ become glued to the ovary, sealing up the ovarian end, while an endometritis closes the uterine opening. In addition to the dropsy of the tube, I have repeatedly met with small cysts, or bladder-like bodies outside of the tube proper, very analogous to those found on the umbilical cord.

This affection is by no means an uncommon one, every age being liable to it, and it is often the unrecognized cause of ill-health. Since Tait first called the attention of the profession to the frequency of the disease and the means for its cure, many cases have been reported in which obscure pelvic symptoms were cured by the removal of the ovaries and of the oviducts--the uterine appendages, as they are called.

DIAGNOSIS.--This is difficult, because the symptoms are those of pelvic peritonitis or of pelvic cellulitis, the disease of the oviduct being usually associated with that of the broad ligament. In some cases the womb will be found movable, with a sausage-like tumor behind it; the diagnosis is then easy. Usually, the symptoms are negative, and the diagnosis is based upon constant groin-pains and recurring attacks of pelvic inflammation.

TREATMENT.--Like hydrocele of Nuck's canal, hydro-salpinx occasionally heals spontaneously, but more frequently it will need aspiration, together with injections of iodine or of carbolic acid. When pus is present, absorption probably never takes place, and an operation will be needed. If the symptoms are grave enough to warrant an exploratory incision, and dropsy of the tubes be discovered, both the tube and its ovary should be extirpated, for in the great majority of cases the {296} corresponding ovary will have undergone follicular or interstitial degeneration. Unless there are very good reasons for adopting a different course, both ovaries and tubes should be removed, because the sound ovary, together with its tube, is liable to become diseased. The incision should always be abdominal, and not larger than to admit two fingers. The broad ligament is transfixed between the tube and the ovarian ligament by a double ligature and tied on either side. The operation is, in fact, analogous to that of öophorectomy. When the tubes contain pus, they are liable to become adherent to the sigmoid flexure, to the rectum, or to the small intestines, making their removal very difficult--sometimes, indeed, impossible. The separation of such adhesions requires the greatest care and delicacy.

Cysts of the Terminal Vesicle of the Oviduct.

A little bladder-like body, not larger than a pea, is often found hanging by a thread-like stalk from one of the fimbriæ of the oviduct. It is a relic of foetal life, being probably the remains of the Wolffian body, and sometimes goes by the name of the hydatid or vesicle of Morgagni. The walls are very thin and covered by peritoneum. What rôle these vesicles play in the economy is uncertain, but they have been found to undergo cystic degeneration. They rarely attain to a size larger than that of an orange, and then either remain stationary or else burst. I have met with several examples of cysts which, after reaching the above size, did not grow any larger. I have also met with one case in which, after attaining the bulk of a small apple, the cyst burst, and immediately refilled, to burst again and again at intervals of from four to six weeks.[13] The collapse of the sac was attended each time by colicky pains, but of no great severity.

[Footnote 13: "Bursting Cysts of the Abdominal Cavity," by Wm. Goodell, Trans. Amer. Gynæcol. Soc., 1881, p. 228.]

Other small cysts I have met with which either burst under the pressure of the examining finger or were designedly burst by bimanual pressure. These, I am disposed to think, were cysts of the terminal vesicle of the oviduct. These cysts are of but little surgical importance, as they rarely need operative interference. If such should arise, they are to be treated by aspiration, and if this fails by extirpation.

Solid Tumors of the Round Ligament.

These are occasionally met with, and usually on the right side. They belong to the connective-tissue group, being either myoma, fibroma, or sarcoma. They form at any point of the round ligament, and may therefore be either intra-peritoneal, intra-canalicular--that is, in the inguinal canal--or extra-peritoneal. The symptoms are those arising from pressure, and are not at all diagnostic. The only treatment of these tumors is removal, but, as their growth is very slow, they are not to be touched unless the symptoms become exacting.[14]

[Footnote 14: Medical Times and Gazette, Dec. 1, 1883.]

{297} OVARIAN TUMORS.

The morbid growths of the ovary are conveniently divided into the solid and the cystic.

The solid ones are either benign, under the form of fibroma, or malignant, being then either carcinoma or sarcoma.

Fibroid Tumor of the Ovary.

Fibroid degeneration of the ovary is so rare a form of disease as to be denied by excellent authorities, who contend that all the cases reported under that term were pedunculated uterine fibroids, which had so grown around and so involved the corresponding ovary as to be mistaken for an ovarian fibroid. Yet while such mistakes have undoubtedly been made, there can be no question that ovarian fibroid does occasionally present itself as a rare form of disease.[15] Out of 155 cases of ovariotomy thus far performed by myself, I have met with 4 undoubted cases of ovarian fibroid. The tumors weighed respectively 2, 3, 4, and 15 pounds, and in each, with the exception of the first, abdominal dropsy was the prominent symptom. All but one of these cases promptly recovered.

[Footnote 15: Brit. Med. Journ., March 18, 1882, p. 384.]

According to Francis Delafield,[16] "The structure of a fibroid of the ovary resembles that of the ordinary fibroid tumors of the uterus. That is, they are composed of connective tissue and smooth muscular fibre. The tumor, therefore, is a myo-fibroma. There has been some question whether ovarian tumors ever contain smooth muscle, but the best authorities now admit that it does sometimes exist in such tumors."

[Footnote 16: Boston Med. and Surg. Journ., Nov. 17, 1881, p. 461.]

Occasionally these tumors arise not from a general hypertrophy of the whole ovary, but from a nodule or a tumor growing in and from the stroma of the ovary. Solid ovarian fibroids are of slow growth and rarely attain a large size. When, however, they are of the geode variety, with numerous cystic cavities, they grow rapidly and may reach enormous proportions.

DIAGNOSIS.--The only other abdominal tumor for which it is very likely to be mistaken is a pedunculated fibroid tumor on the peritoneal surface of the womb, and with our present knowledge it seems impossible to tell them apart.

When they float about in ascitic fluid they often give the sign of ballottement in a very perfect manner. From carcinoma of the ovary they can generally be told by their smooth surface.

PROGNOSIS.--Fibroid tumors of the ovary grow so slowly that, like pedunculated fibroid tumors of the womb, they ordinarily do not attain a very bulky size. When the climacteric is reached they tend, like the latter, to stop growing and to undergo a calcareous degeneration. More often, however, they cause by their presence a dropsical effusion of the abdominal cavity, which has to be repeatedly drawn off; and it is for this reason that they usually have to be extirpated. They are removed precisely in the same way as an ovarian cyst, and the prognosis is equally {298} good, but they are liable to have short and broad pedicles which need to be tied very carefully in sections.

Malignant Diseases of the Ovary.

These affections are either primary or secondary. When secondary, they follow analogous diseases of the womb or of the pelvic structures. When primary, they appear under different forms, as in other portions of the body, being either encephaloid, scirrhous, melanotic, or papillary. Colloid cancer of the ovary may be practically excluded, because it is of extreme rareness. The term colloid when applied to ovarian cysts refers more to the gluey consistency of the contained fluid than to the question of malignancy. In my experience the most common form is that of papilloma, which, however, like villous growths elsewhere, is not always malignant. I have removed papillary cysts and villous growths of the ovary, yet the subsequent history of the cases proved that the tumors were benign. The only macroscopic distinction between the benign and the malignant form which I have hitherto attempted to make is, that in the malignant form papillary growths will be found in patches upon adjacent structures, or else the womb and the broad ligaments are also involved in one cauliflower-like tumor. But Tait observes that he has had two cases of ovariotomy in which he left large masses of papilloma, fixing the womb, yet in each case these masses wholly disappeared, and the patients are both in perfect health.[17]

[Footnote 17: Diseases of the Ovaries, 4th Am. ed., p. 147.]

There is, however, no question that malignancy lurks in many ovarian cystomata which present to the naked eye an innocent appearance.

The patient recovers promptly from the operation for their removal, but dies a few months later from cancer of the peritoneum or of other organs. Every ovariotomist has met with such examples. In one of my own cases, in which not the slightest sign of malignancy was apparent, the patient wholly recovered from the operation. Shortly after her convalescence an effusion took place in the right pleural cavity. The chest was tapped three times before her death, which was due to cancer of the liver and of the broad ligament at the site of the ablated ovary. In my first case of ovariotomy, one in which the clamp was used, menstruation took place regularly for several months from the cicatrix, which within a year became affected with cancer.

Both ovaries are usually involved in cysto-carcinoma, and this fact should be borne in mind in making a diagnosis. From the marvellous changes often produced progressively in the epithelial linings of ovarian cysts, by which they are transformed into tufts of villous cancer, Tait inclines to the opinion that their growth is associated with a tendency toward malignancy. He believes that tapping hastens on this degeneration, and that after an accidental rupture of such a cyst the peritoneum will be found studded with patches of papillary cancer. Hence he argues that ovarian cysts should never be tapped, and that they should be removed in the earlier stages of their existence, before these malignant transformations have taken place.[18]

[Footnote 18: Op. cit., p. 148.]

DIAGNOSIS.--Since, as has been shown, this cannot always be made {299} out, even by the eye, after the removal of the cysts, it follows that in a large proportion of cases the malignant character of the degeneration cannot be recognized. There are, however, certain symptoms pointing to malignancy which will often throw much light. These, in the order of their frequency, are--

(a) The presence of ascitic fluid or of oedema of the lower extremities when the tumor is too small to produce such pressure symptoms.

(b) General cachexia, rapid emaciation, and grave constitutional disturbance out of all proportion to the size of the tumor.

(c) The hardness and solidity of the tumor, together with its nodulous and irregular surface.

(d) The concurrent development of two ovarian growths.

(e) The retraction and burying of the cervix in the vaginal vault.

(f) Pain in stabs, starting from the groin and running down the inside of the thigh. But pain is not a trustworthy symptom, as it is often absent, especially in cysto-carcinoma, and may be caused by benign growths as well.

TREATMENT.--Whenever no doubt exists as to the malignancy of an ovarian growth, an operation looking to its removal should not be urged by the physician. On the other hand, since a positive diagnosis on this point is rarely attained, and since cancer of the ovary tends for a long time to remain localized, whenever a suspicion of malignancy exists ovariotomy should be performed early, before adhesions have been contracted with neighboring structures. In such a case I should incline to burn off the pedicle in preference to using the ligature.

In those cases in which, on account of adhesions, no operation is justifiable, palliative treatment can alone be resorted to. This comprises the removal of the ascitic fluid or the contents of the cyst by the aspirator whenever the pressure becomes uncomfortable. Symptoms should be treated, and, that of pain being the most urgent, opium will be needed up to the last in increasing doses.

Dermoid Cyst, or Piliferous Cyst of the Ovary.

A dermoid cyst is a congenital tumor having a wall composed of elements like true skin, with its appendages of hairs, sebaceous glands, etc., and contains teeth, hair, bone, cartilage, muscle, and a cheesy material very like vernix caseosa. These cysts are solitary, two never being found in the same person, and, further, they are always unilocular. They are either external or internal--that is, they affect either the surface of the body or else the cavities of the body, as "under the tongue, in the pharynx, oesophagus, cranial cavity, peritoneal cavity, lung, ovary, testis, bladder, and kidney."[19] No tumors are more curious, and none are more puzzling to explain. The theories accounting for their origin are very remarkable, and are as follows: Excess of formative nisus. Parthenogenesis, or virgin birth; that is to say, imperfect imitation of transmitted fertility--a property peculiar to many insects, by which, without any renewal of fertilization, successive generations of procreating individuals start from a single ovum. Inclusion of abnormal structures, {300} where there is a dipping in of the epiblast to meet the hypoblast during foetal life, and the pinching off of the same. Foetus in foetu--viz. the inclusion of an imperfectly developed ovum within another which matures perfectly. Hypererchesis; which means that "the ovum has in it the origin-buds of certain tissues, which under exceptional hypererchetic action may go on to the rudimental formation of these tissues without a fusion with the male germ."[20] According to Elsner, who has written last on this subject, and to whom I am indebted for much information, "dermoids occur externally and internally in places where the epiblast dips down to meet the hypoblast, and where by processes of grooved involution new bodies are formed, such being, first in order, the testicle and ovary, and that they are therefore all (without exception) embryonal in their first structure."

[Footnote 19: Elsner, Dublin Journal Medical Sciences, May, 1882, p. 380.]

[Footnote 20: Diseases of Ovaries, by L. Tait, 4th ed., p. 177.]

SYMPTOMS.--These congenital tumors begin early in life, and usually remain dormant until puberty. Then the periodic congestions of menstruation usually stimulate them into growth. Sometimes they need the increased vascularization of pregnancy. They are more liable than ovarian cysts to inflammation and suppuration, but they grow much more slowly, and very rarely reach the large size of the latter. They are also very liable to contract adhesions to every structure they touch, making their extirpation very difficult and sometimes impossible. Often they create pain out of all proportion to their size. Occasionally, they break and empty their contents through fistulous communications with the intestines, bladder, or the abdominal wall. But collapse of the usually thick walls of the cyst does not take place, and a cure results far less frequently than in pelvic abscesses, which empty themselves through analogous channels. The cyst ordinarily does not lessen in size; suppuration goes on with hectic fever and exhaustion, which finally carry off the patient.

DIAGNOSIS.--Quiescent or slow-growing pelvic tumors, semi-solid to the feel, and first discovered at the age of puberty, are usually dermoid cysts. Their small size is also an aid to diagnosis, for they very rarely reach the bulk of the adult head. On several occasions I have found them in Douglas's pouch, fig-shaped and flattened in their antero-posterior diameter. From its attachments to neighboring structures a dermoid cyst is very liable to be mistaken for the cyst of an extra-uterine foetation. But the exclusion of the history of pregnancy and the slow growth of a dermoid cyst, unless suppuration has taken place, ought to distinguish the one from the other.

TREATMENT.--While quiescent the cyst should not be touched, as it is very vulnerable and liable to resent the slightest injury, even from the slender trocar of the aspirator. If suppuration takes place and the tumor points to the surface, it should be treated, like any other abscess, by a free incision, by the evacuation of its contents, by the introduction of a drainage-tube, and by the injection of antiseptic solutions. Small cysts lying in Douglas's pouch can sometimes be cured by aspiration; at least I have twice succeeded in obliterating them in this way. The operation was, however, followed by suppuration of the cyst, the abscess bursting into the vagina. If after an exploratory incision an abdominal cyst turns out to be dermoid, it should be extirpated. But if extensive adhesions {301} preclude such an operation, the cyst should be opened, evacuated, and thoroughly cleansed. The edges of the opening should then be stitched to those of the abdominal wound and a drainage-tube put in. The after-treatment of such a case will be analogous to that of an ovarian cyst under like conditions, to which the reader is referred.

Cystic Tumors of the Ovary.

These represent by far the most frequent variety of ovarian tumors, and as such demand our best attention. They consist, in probably the majority of cases, in a dropsical enlargement of one ovisac or of more--viz. in a follicular dropsy. Indeed, as Cazeaux has aptly said, the ovisacs, or Graäfian follicles, are ovarian cysts in miniature. These cysts are divided into three classes, which depend wholly upon the number of ovisacs involved. Thus, a single, or barren, cyst, containing merely fluid, is called a monocyst or unilocular cyst. Such a cyst would be due to the dropsical enlargement of but one ovisac. It is extremely rare--so much so that its existence is denied. The probability is that a one-chambered sac does not begin as such, but it becomes so through the breaking of the walls of other contained cysts. A multiple cyst is caused by the simultaneous growth of two or more ovisacs, one of which usually takes the lead in growth and keeps the others dwarfed. This form of cyst is by far the most common. It grows with great rapidity, and may reach a weight of over one hundred pounds. I have successfully removed one weighing one hundred and twelve pounds. A proliferous cyst is a mother-cyst packed with innumerable child-cysts of varying size. These endogenous cysts multiply by exogenous and endogenous growth. The proliferous cyst rarely attains to the size of the multiple cyst, but surgically it is a solid tumor, because it cannot be emptied by tapping, and therefore often needs a long incision for its removal. It also usually possesses a very thin wall, which is liable to be torn during the needful manipulation for its removal. Racemose cysts are occasionally met with. They consist of a number of isolated cysts of varying size attached to one common stalk like a bunch of grapes. I have met with two such examples. Tait thinks that they are "produced by the retention of the ova in the Graäfian follicles, and the distension of their cavities by a continuous secretion of the liquor folliculi."

The pedicle or stalk by which an ovarian cyst is attached to the womb consists of the corresponding broad ligament, oviduct, ovarian ligament, and vessels. The pedicle is sometimes long and slender, at other times short and broad. There is one form of ovarian cyst which has no proper pedicle. It grows between the two layers of the broad ligament, and tends to develop downward into Douglas's pouch. It is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. Sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown.

The contents of ovarian cysts vary very greatly in color and in consistency. In monocysts the fluid is often limpid and colorless. In multiple cysts the contents are usually syrupy, thick, and turbid. Sometimes the {302} color is quite dark, as much so as weak coffee. The surface of the fluid, after standing, will be covered with a pellicle of cholesterin crystals, which sparkle in the sunlight. In proliferous cysts the contents are usually viscid, sometimes as much so as jelly, and to this the term colloid is applied. Foulis, who is an authority on this subject, states that he has "never found that an ovarian fluid, however long kept, ever deposited a precipitate spontaneously. Whereas very frequently in the case of an ascitic fluid such a spontaneous precipitate appeared within a period varying from a few hours to a few days."[21] Again he observes: "After ten years of observation made on fluids withdrawn by the aspirator, I found that ovarian fluids never throw down a precipitate of a fibrinous character. An ovarian fluid was always a pure cellular secretion. An ascitic fluid was always the result of obstruction to the circulation or of inflammatory action in the peritoneum, and ascitic fluids allowed to stand for a short time nearly always showed a precipitate with the character of felted material under the microscope. If they tapped the patient and subjected the fluid to this test, two or three days would suffice to tell in cases in which there was doubt. The deposit in ovarian fluids showed cellular, not fibrinous, elements under the microscope."[22]

[Footnote 21: Edinburgh Medical Journal, July, 1885, p. 76.]

[Footnote 22: Ibid., June, 1885, p. 1131.]

Chemically, the contents are mucous and albuminous, the albumen being readily detected by the tests of heat and nitric acid. Microscopically, ovarian fluid is found to contain fat-globules, epithelial, granular, and pus-cells, crystals of cholesterin, blood-corpuscles, and compound granular cells, also called the inflammatory globules of Gluge.

Whether ovarian fluid contains a cell or corpuscle peculiar to itself is yet a moot question. Drysdale contends that it has a characteristic cell. He describes it as "an albuminoid body containing little fatty particles which give it a granular appearance. It resembles in some particulars many other granular cells, but can be distinguished from all other cells found in the abdominal cavity.... The principal test I employ is acetic acid. If the cell is ovarian, the acid changes it but little, perhaps rendering it only a little more transparent. But if it be a white blood-cell, a lymph-corpuscle, or any of those granular cells which resemble them, it will nearly always take on a different appearance, the cells almost vanishing perhaps, and multiple (2-5) nuclei appearing, as in the pus-cell. Then, if the cell be suspected to be fatty, degenerated, or Gluge's cell, ether may be added, by which the fatty materials will be dissolved and disappear. If no fatty degeneration be present, it is sufficient to add acetic acid."[23] Garrigues, on the other hand, contends that the ovarian fluid does not contain a characteristic cell.[24]

[Footnote 23: Trans. Amer. Gynæcol. Soc., vol. i. p. 195.]

[Footnote 24: Ibid., vol. vi. p. 54.]

If I am not mistaken, the opinion of the best microscopists of Philadelphia is that the Drysdale cell, while not characteristic of ovarian fluids, is not found in any other fluid in such large numbers, and to that extent it is of diagnostic value.

CAUSATION.--In probably the very great majority of cases an ovarian cyst is a dropsy of several ovisacs, but the cause of such growths has never yet been ascertained. In the majority of cases it seems to depend upon some sexual disturbance.

Very recently the relation of the sexual condition to disease has been {303} made the subject of scientific inquiry. From a careful examination of the registrar's tables for France, M. Bertillon shows that marriage, by giving a comparative immunity from diseases of the sexual organs, prolongs life in both sexes. This statement is confirmed by the statistics of ovarian tumor. Of Lee's 136 cases, 88 were married, 37 were unmarried, and 11 were widows. Of Sir Spencer Wells's first 500 cases, 260 were married, 221 were unmarried, and 19 were widows. Out of 155 completed cases of ovariotomy performed by myself, 91 were married, 48 were single, 16 were widows. Of the married, 24 were sterile, 10 had one child, and 26 had but two children, and several confessed to using preventive measures. Out of a total of 791 cases of ovarian tumor, there are, then, 352 without husbands to 439 with husbands. Now, when one considers how small the proportion of single women and of widows is to married women whose husbands are living, the significance of these figures goes to show that childbearing women, and especially the prolific ones, are less liable to cystic degeneration of the ovaries, and that, unless the cycle of reproduction is completed in a woman, she is plainly violating some law of her being.

SYMPTOMS.--There are no symptoms pathognomonic of this affection, for they are mainly those of pressure, and therefore belong in common to all fluid collections in the abdominal cavity. But in proportion as the abdomen swells there is a marked emaciation of the extremities. The limbs waste away, the face becomes pinched, the eyes are hollow and staring, deep wrinkles and furrows appear on the forehead and around the mouth, and the nostrils are wide open. This facial expression is termed the facies ovariana. Sometimes, when both ovaries are simultaneously affected, hair will grow on the chin and on the upper lip.

THE NATURAL HISTORY.--The natural course of an ovarian cyst is to grow rapidly, and in about two years from the time of its discovery to destroy life by exhaustion through the embarrassing pressure which it makes upon the organs of respiration, circulation, and nutrition. Malignant cysts grow more rapidly than the benign, while the latter will, on the other hand, occasionally remain for years in a state of quiescence. I have kept stationary cysts under observation for ten years, and others have been reported which lasted twenty years without change.

As a cyst develops it is very likely to contract adhesions to the organs with which it lies in contact. The most common adhesion is that of the omentum. Next to this is adhesion to the abdominal walls. Then will happen more rarely adhesions to the bowels, womb, bladder, pelvis, liver, and stomach. A loop of intestine will sometimes be found fastened to the front wall of the cyst, but usually the bowels lie packed behind the tumor.

Rupture of the cyst sometimes takes place, either spontaneously, through over-distension, or through violence, as a kick, a rude fall, or from being run over by a carriage. This accident, if the fluid happens to be bland, may be followed by a cure; but more often a violent peritonitis sets in, which carries the patient off in a few hours. From a study of 257 cases, Aronson[25] rates the fatality at 41 per cent.; but without question the very great majority of cases of bursting cysts of the abdomen in which this accident was followed by a cure were cysts of the parovarium, which being {304} thin-walled are likely to burst, and which contain a bland, unirritating fluid. Bursting of the sac can be recognized by more or by less collapse and pain, by the disappearance of the cyst, and by the lessened size of the abdomen. If the patient does not at once succumb, excessive diuresis usually occurs.

[Footnote 25: American Journal of Obstetrics, Nov., 1883, p. 1210.]

It happens occasionally that the inner cyst-wall inflames, either spontaneously or in consequence of being tapped or from other injury. Suppuration then takes place, the contained fluid becomes fetid, and offensive gases are generated which give a tympanitic sound on percussion. There will be creeping chills, a red tongue, night-sweats, a frequent pulse, a general rise in the temperature with evening exacerbations: in one word, all the well-known symptoms of blood-poisoning will be present in a greater or less degree. Unless the cyst be at once removed the woman will speedily die.

Ulceration of the cyst, with perforation of its wall, may also occur. The decomposing contents will then be discharged, either into the peritoneal cavity or into any viscus to which the cyst may have contracted adhesions. In this way the purulent contents of an ovarian cyst have been discharged through the bowels, the bladder, the vagina, and even into the womb through the oviducts.

Hemorrhage within the sac is an occasional accident. When it takes place the tumor rapidly enlarges, great abdominal pain is caused by this sudden stretching, the complexion grows pale, the features become pinched; there will be collapse and all the symptoms of internal hemorrhage. If the bleeding does not stop, the patient will die in a few hours. On the other hand, if she survives the immediate danger, she is liable to succumb later to septicæmia, which arises from the decomposition of the now bloody fluid. The immediate removal of the cyst gives the woman, then, her sole chance of life.

Twisting of the pedicle of an ovarian tumor by axial rotation is another serious complication, which leads to its strangulation and gangrene, with consequent fatal peritonitis. The chief factors of this accident are, probably, the filling and emptying of the bladder and rectum, which may rotate an unadherent cyst with a long stalk. The symptoms of axial rotation, as carefully noted by Tait[26] and Aronson,[27] are sudden accession of severe abdominal pain and tenderness, a rapid increase in size, and incessant vomiting, the matter thrown up soon becoming green. The pulse rises, but the temperature is not always affected, and rigors are absent. Such a train of symptoms should lead at once to the abdominal section.

[Footnote 26: London Obstet. Trans., vol. xxii. p. 97.]

[Footnote 27: American Journal of Obstet., Nov., 1883, p. 1211.]

DIAGNOSIS.--The diagnosis of ovarian cysts is often beset with so many difficulties that very humiliating blunders have been made by the best surgeons of the day. Lizars of Edinburgh performed laparotomy on a woman in order to remove a suspected ovarian cyst, and found nothing but fat. Others have done the same thing, and to their dismay have discovered merely an accumulation of wind in the intestines. The great Dieffenbach once opened the belly of a woman for supposed extra-uterine pregnancy, and found neither fat nor wind--not even, indeed, a trace of a tumor. Once an enormously distended bag of waters {305} broke just as a deservedly eminent British surgeon had rolled up his sleeves and was about to wheel his patient into an amphitheatre crowded with spectators to witness an ovariotomy. A surgeon of whom Great Britain can well be proud once drove his trocar into the shoulder of a foetus under the idea that he was tapping one of these cysts. These facts show the importance of knowing how to make an examination for a suspected ovarian cyst, and how to distinguish such a cyst from other tumors and other fluid collections in the abdominal cavity.

The usual history of an ovarian cyst is--a tumor first discovered in one groin, rapidly enlarging, without tenderness or soreness, giving no inconvenience save from its bulk. The general health remains good until the tumor begins to distend the abdomen; then emaciation takes place, the strength becomes impaired, and the features begin to assume that pinched expression described on a preceding page as the facies ovariana. By inspection and palpation there will be found an elastic but somewhat irregular tumor, yielding the sense of fluctuation. By percussion a dull sound will be elicited at every point, except in the flanks, which are more or less resonant. If the contents of the tumor are colloid or the tumor is thick-walled or very tense, the sense of fluctuation may be either obscure or wanting. Sometimes a feeling like that of fluctuation is conveyed by a fat-laden wall of the abdomen. To muffle this fat-thrill the ulnar edge of the hand of an assistant is laid along the linea alba while the surgeon percusses the abdomen. The pressure thus exerted acts precisely like the damper-wedge of the piano-tuner, which muffles the sound of one string while its fellow is being tuned. By these means fluctuation can be detected and the diagnosis of a collection of fluid unhesitatingly made out.

By the amount of solid and fluid portions of a cyst correct diagnosis can often be made out, whether it is simple or multiple, compound or proliferous; but this is a matter of comparatively little practical importance, because when once a growing tumor has been ascertained to be ovarian, its removal must follow as a matter of course.

There are, however, certain enlargements or tumors of the abdomen which are very liable to be mistaken for an ovarian cyst, and to these, in the order of their frequency, we shall call attention.

Ascites.--When the fluid is not encysted, but free, as in ascites, it is at liberty to go to the most dependent portions of the body. Hence changes in the posture of the woman will make corresponding changes in the level of the fluid. These level-changes are made evident by percussion. When the woman lies on her back the intestines float up to the surface, and the fluid gravitates to the flanks, making them bulge. In other words, percussion in the dorsal position elicits a clear note in the umbilical region and a dull note in each flank. In this posture the front surface of the abdomen is symmetrical and somewhat flattened. But when the woman sits up the belly becomes convex. Further, ascitic fluid is displaceable by pressure on the abdomen. But even these signs are not always trustworthy, because the intestines, glued down by adhesions, may not float up, and there will be dulness over the front of the abdomen, or a distended colon may make each flank resonant. For instance, I have known a papillary cancer of the omentum attended with dropsy of the abdominal cavity to give such signs of ovarian cyst as dulness in front and resonance {306} in the flanks. When the fluid is ascitic the floating or false ribs are not pushed outward. The womb is usually low down and movable; there will also be more or less of bulging in Douglas's pouch.

On the other hand, in an ovarian cyst the womb is usually not very movable, and it is displaced to one side, generally behind the cyst. While the woman lies on her back the front surface of the abdomen is convex and unchanged in form. The floating ribs bulge out, making the chest conical. There will also be dulness in the front wall over the tumor, but usually more or less resonance in the flanks and over the region of the stomach: this clearness on percussion has been aptly termed coronal resonance. These areas of dulness and of resonance remain constant whatever the posture of the woman. Yet in suppurating cysts or after a careless tapping, or in cysts communicating with the intestine, the sac may contain gas, which will give a tympanitic sound over all the elevated portions of the abdominal surface.

It must, however, be borne in mind that ascites may exist concurrently with an ovarian cyst, and especially if the tumor be malignant in character. This can usually be detected by deep palpation, when the cyst will be reached and recognized by the fingers; or by pressing lightly, and then more firmly during percussion, an upper and a lower stratum of fluctuation will be detected.

Pregnancy.--The question of pregnancy is a very serious one, for it is sometimes a most difficult one to decide, especially when dropsy of the amnion (hydramnios) exists. In making a diagnosis nothing must be taken for granted, not even the woman's statement. She may be mistaken, or, indeed, she may be wilfully deceiving in the hope of having a cheap abortion induced by the examination. She may be pregnant and yet menstruate. On the other hand, an ovarian tumor will sometimes arrest menstruation. A healthy, ruddy complexion coexistent with abdominal enlargement should always excite a suspicion of pregnancy. There is sometimes a jaded look in pregnancy--the facies uterina--but never the facies ovariana.

The various signs of pregnancy should be searched for, especially ballottement and the foetal heart-sounds. The cervical region should be most carefully examined per vaginam. A good broad rule to remember is, that when the womb is gravid the cervix is as soft as one's lips; when it is empty the cervix is as hard as the tip of one's nose. In all doubtful cases any operation should be postponed until time has revealed the true condition of things. Of course the introduction of the sound will settle the question of pregnancy, but this procedure is not to be thought of when any doubt exists, and it is therefore useless as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and may have to be tapped or be extirpated before the delivery of the woman. The history of the case, the unusual size of the abdomen, the sulcus between the two tumors, will generally reveal the condition.

Fibroid Tumors of the Womb.--These tumors often reach a very large size, and if of the soft variety give an obscure sense of fluctuation which so closely resembles that of a colloid ovarian cyst or of a tense thick-walled cyst as to make the differential diagnosis very puzzling. The hard myoma gives no sense of fluctuation, but, on the other hand, if pedunculated it can be very readily taken for a solid ovarian tumor. A {307} fibroid tumor of the womb can very generally be told by the history of menorrhagia, by its slow growth, by the uterine souffles and colics, by the effacement of the cervix, and by the tumor being felt to be continuous with the cervix and inseparable from the womb. Then, again, women burdened with a fibroid tumor so far from losing flesh usually become more fat, and their complexion, like that of many pregnant women, is mottled with patches of brown pigment. Further, the uterine cavity is usually much longer than natural, and when the tumor is moved from side to side the motion is communicated to the sound passed within the cavity. But every rule has its exceptions, for when an ovarian cyst has a close attachment to the womb the latter may become elongated and also follow the movements communicated to the tumor.

The positive diagnosis between an ovarian cyst and a fibro-cystic tumor of the womb is impossible, but, fortunately, the latter disease is exceedingly rare. The existence of the latter may be inferred if the woman's face has a jaded appearance and is disfigured by brown patches--the facies uterina--if the growth of the tumor has been very slow, and if the womb is implicated with it. After tapping there will be a partial collapse of the tumor, and the fluid withdrawn is usually bloody and it coagulates on being cooled. After an exploratory incision the tumor presents to the eye a dark-blue and vascular capsule covered with interlacing fibrous bands.

Renal Cysts.--Cysts of the kidney are very commonly mistaken for ovarian cysts. I have made this mistake, and it was not until after breaking up adhesions and emptying the cyst that I discovered the character of the tumor. It was successfully removed. Renal cysts start from below the floating ribs and extend downward and forward, while an ovarian cyst begins from below and grows upward. The former, being generally caused by impaction of a calculus in the ureter, are usually associated with urinary disturbances. They also push the intestines before them, which give a resonant sound on percussion, while the contrary holds good with an ovarian cyst. Since the transverse colon lies between the cyst and the liver, the line of resonance caused by it will show that the cyst is not hepatic. The fluid withdrawn from a renal cyst contains urea and the other constituents of urine, but the urinous odor will be either very faint, or, as in my case, wholly absent. It may as well be stated here that when renal cysts present great difficulties in the way of their removal, they had better be treated by a large drainage-tube.

A floating kidney may be mistaken for a small ovarian tumor. But the latter has a pelvic attachment and can readily be pushed down into the basin, while the former is kept from being pushed very low downward by an upper attachment. Again, the floating kidney usually keeps its peculiar shape, and it is frequently lost by slipping from under the fingers into its natural bed in the flank.

Spina Bifida.--Strange as it may seem, this spinal cyst, when internal on account of a deficiency in the anterior parietes of the lower vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am cognizant of two such errors of diagnosis made by two distinguished gynecologists. In each the sac was emptied by the aspirator, and the patient perished shortly afterward with the same kind of cerebral symptoms which follow the sudden withdrawal of the fluid from the cavity of an external spina bifida.

{308} Phantom Tumors.--In the diagnosis of an ovarian cyst one must be on guard not to mistake for it a phantom tumor. In this imaginary kind of tumor, which hysterical women have the knack of creating, the whole belly will be uniformly distended to the size of the gravid womb at term. This is caused partly by flatus and fat, and partly by the arching forward of the spinal column, with the recti muscles drawn so tense that they cannot be indented. I have frequently had patients with this kind of abdominal enlargement sent to me from a distance, under the impression that it was due to some kind of tumor. But the diagnosis is easily made from the uniform resonance all over the belly; if, moreover, the patient's attention be engaged by conversation, the rigidity of the recti muscles disappears, the abdomen becomes flaccid, and the hand can be made to sink in so as to feel the spine. In very nervous women it may be needful to administer an anæsthetic, when all the tokens of a tumor will promptly disappear.

Obesity.--A large accumulation of fat on the abdominal wall and in the omentum has frequently given rise to the suspicion of the existence of an ovarian cyst. This condition occurs, usually, at the climacteric, and on percussion the vibratile thrill of the fat-laden wall of the abdomen conveys a very misleading impression of fluctuation. Further, to add to the difficulty, if the layer of fat be a very thick one, the abdomen, instead of being resonant on percussion, yields a dull note. But in obesity the fat is not limited to the abdomen, for the breasts, face, and limbs partake of the general enlargement. The abdominal wall hangs in folds when the sitting posture is assumed, and the umbilicus is indented and not protuberant. My own method of making the diagnosis is to grasp the abdominal wall with both hands and ascertain the amount of fat. When this amount is excluded, there will not be found room enough behind it for a tumor of any size, and the enlargement will thus be satisfactorily accounted for.

A dilated stomach, cystic tumors of the omentum, and encysted abscesses of the peritoneal cavity, and, indeed, of the abdominal wall, have been mistaken for ovarian tumors; but these are very exceptional cases. In all doubtful cases an exploratory incision should be resorted to.

SURGICAL TREATMENT OF OVARIAN CYSTS.--In the consideration of this subject it may be divided into the palliative treatment and the radical treatment.

Palliative Treatment.--Tapping either by the trocar or by the aspirator comprises the only palliative treatment of ovarian cysts; yet, as a broad rule with but few exceptions, an ovarian cyst should not be tapped. The objections to this operation are--that, slight as it may seem, it is by no means devoid of danger. Even when the smallest hollow needle of the aspirator has been used inflammation of the cyst may follow, which will compel the immediate resort to ovariotomy and very greatly compromise the success of this radical operation.[28] This has repeatedly happened--once in one of my own cases, in which, however, the removal of the cyst saved my patient's life. Further, the fluid of a polycyst is usually acrid--so much so sometimes as to irritate the hands of the operator--and the escape of a few drops into the cavity of the peritoneum may set {309} up a violent and rapidly fatal peritonitis. Then, again, a fatal hemorrhage may take place from some wounded vessel, either in the cyst-wall, or in the adherent omentum, or in the vascular pedicle which may lie spread out in front of the cyst-wall, or, indeed in the abdominal wall itself, for the vessels here are often varicose from impeded circulation. In the fourth place, adhesions are very likely to form after tapping. Fifthly, innumerable child-cysts, which were very small before the tapping, being now relieved from pressure are liable to take on rapid growth and make the tumor more solid; and the more solid the cyst the longer the incision needed for its removal. Sixthly, in polycysts not only are the dangers attending the operation enhanced, but the cyst rapidly refills, and the woman becomes exhausted by the drain on her system. At the very best, 2 per cent. of cases of tapping in polycysts are fatal, even when performed by the most skilled specialists. Seventhly, a cyst once tapped rapidly refills, and soon needs repetitions of the operation. This drain on the system quickly tells upon the woman, and she is sometimes left too weak to have the radical operation performed. The first tapping, indeed, greatly hastens on this crisis, and it should therefore be put off as long as possible. Eighthly, a cyst emptied by tapping tends to rotate on its axis, and torsion of the pedicle may result, ending in gangrene and peritonitis. Ninthly, repeated tappings tend to convert benign papillary growths into malignant. Finally, Lawson Tait[29] draws attention to the fact that "repeated tappings deprive the blood of some element or elements included in the infinite variety of albuminous substances found in ovarian cysts, the deficiency of which predisposes to coagulation of blood." Hence after the removal of the cyst deaths have been "due to the formation of a firm white clot which started from the point of ligature of the pedicle, and slowly traversed the venous system until it reached the heart, death ensuing in from thirty to forty hours after the operation. The symptoms which precede death are swelling of the legs, rapid rise of the pulse, and its disappearance from the extremities some time before death, and breathlessness, ending in suffocation and slight delirium." He has met with several such cases of venous thrombosis starting from the pedicle, and they all occurred in patients who had been previously tapped. There are, however, cases in which tapping cannot be dispensed with; for instance--

1. Many women with ovarian tumors, having heard of cases of abdominal effusion or of cyst in which tapping was followed by a cure, will not submit to the radical operation until repeated tappings have proved to them the futility of the trocar.

2. Cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts.

3. When an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. Sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied.

4. In very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or {310} dyspnoea, tapping is a useful prelude to ovariotomy. By the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre.

5. In cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. But it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. It is well, therefore, to put off the first tapping as long as possible.

[Footnote 28: American Journal of Obstetrics, Nov., 1883, pp. 1169 and 1189; also Transactions American Gynæcological Society, vol. ii., 1877, p. 270.]

[Footnote 29: Midland Medical Society, Lancet, Feb. 18, 1882.]

Tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best.

Tapping through the Abdominal Wall.--For this operation either the aspirator may be used or else Wells's trocar with a long rubber tube attachment. Of the two, I much prefer the former. In aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. The preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. But if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. The reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. The skin is now thoroughly cleansed with soap and water and washed with a 5 per cent. solution of carbolic acid. The painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. After the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. Should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. Sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. This accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. Should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. When the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. A pad of cotton wool is now laid over the {311} scaphoid abdomen and a flannel binder applied. These afford a grateful feeling of support and take away that sense of goneness which is likely to occur. To avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly.

When Wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. The skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. This rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by Wells's trocar than by the aspirator. Yet I cannot help believing that the latter by its small size is by far the safer instrument, and I always use it when a simple tapping is aimed at. Should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. The same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. For it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. In such a case the pin ought to include the lips of the wound in the cyst. To avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. This is a rule without an exception. It is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. Several cases of death from this cause have been reported.[30] I lay stress on this point because in my Lessons in Gynæcology I advocate the practice.

[Footnote 30: American Journal of Obstetrics, April, 1876, p. 146.]

Tapping through the Vagina.--This operation is sometimes a very tempting one to perform when one of the cysts of a polycyst is pressing downward behind the bladder and causing dysuria. But it is by no means so safe as the supra-pubic mode of tapping. The reasons for this are--(a) The vessels are larger and lie closer together in the lower wall of the cyst near the stalk; (b) in a polycyst the larger cysts, growing where they have most room, usually develop in the abdominal cavity, while the more solid portion remains below in the pelvic region; (c) other organs, such as the bladder, womb, and rectum, are liable to become dislocated and lie in the track of the trocar; (d) the roof of the vagina responds to every respiratory movement of the diaphragm, and a cyst low down is not, from pelvic adhesions, so likely to collapse when tapped as one higher up: hence the cyst is liable to act as a pair of bellows, sucking in air and forcing it out. This inevitably causes suppurative inflammation with all its attendant evils. For these reasons this mode of tapping is never resorted to, except in cases of pelvic adhesion or in those in which the cyst starts from the lower side of the broad ligament and grows downward. Even then it is done only to relieve the distress caused by the double pressure upon bladder and rectum. In such cases the aspirator should be used, as it lessens all the risks. Should suppurative inflammation set in, the sac must be again emptied, the wound kept open by a {312} drainage-tube, and the cavity thoroughly cleansed by daily injections of antiseptic fluids.

Tapping through the rectum has long ago been abandoned by the profession, as it ought to be, except in some very rare cases of atresia vaginæ. It was at one time supposed to possess advantages over the vaginal method, because the subsequent offensive discharges could be retained at will like the other contents of the bowel. But the cavity of the sac always became distended with fecal gas, and fatal septicæmia was pretty sure to set in.

Radical Treatment.--Tapping, followed by the injection of iodine into these cysts, has sometimes been rewarded with a cure, and at one time this mode of treatment had very warm advocates. After the cyst is wholly emptied by aspiration the action of the instrument is reversed, and from two to ten ounces of the officinal tincture of iodine are thrown in. The tincture is used of full strength, because the residual fluid in the cyst will be enough to dilute it. The cyst-wall is next kneaded, and the patient made to turn from side to side and from back to chest, so that the tincture may come in contact with every portion of the secreting surface of the cyst. The fluid is then pumped out, but all cannot be brought away; enough usually remains behind to produce some slight constitutional disturbance. While the canula is being withdrawn, in order to prevent the escape of any of the irritating injection into the abdominal cavity the thumb and fore finger are made to grasp the fold of abdominal wall at the puncture-site and to press it firmly down on to the collapsed cyst-wall. Good and lasting cures have followed such a treatment; but since they can happen only in monocysts, which are almost always parovarian, and not ovarian, it is probable that the mere emptying of the cyst would have done as much. In polycysts such a treatment is not to be thought of, for it would be attended with far more hazard than even the operation of ovariotomy. At the present day injections of iodine are practised only by physicians who do not operate; ovariotomists never resort to them.

Tapping, followed by enlarging the wound in the cyst, stitching its edges to those of the abdominal wound, and permanently keeping it open by tents or by a large drainage-tube, has frequently been attended with success. But since extensive and prolonged suppuration must inevitably ensue, this operation has proved to be a far more dangerous one than that of ovariotomy. It should, therefore, not be resorted to excepting in cases of cysts which are too adherent to be removed. The after-treatment consists in treating the case precisely as if it were an abscess. The cyst is kept empty by draining, and sweet by such deodorizing agents as solutions of iodine, carbolic acid, potassium permanganate, and the liquor sodæ chloratæ. Early this year I had one such case, a patient of C. A. Currie, in which the cyst was wholly adherent to all the pelvic organs and structures, and had besides a communication with the bladder. Not daring, under such circumstances, to remove it, I treated it successfully by incision, drainage, and disinfecting injections; but it was a long time before the drainage-tube could be removed and the woman be released from her bed. Cases, indeed, have occurred in which six months elapsed before the drainage-tube could be taken out and the woman pronounced well.

Another exception in favor of this operation may be made in the case of small cysts growing downward and bulging out the hind wall of the {313} vagina. It may then be advisable to follow Noeggerath's plan. He snips open the vagina transversely behind the cervix to the length of one inch, and makes a corresponding incision in the cyst-wall. The edges of the two incisions are then stitched together and a drainage-tube put in. Thus, the cyst is left with a free and permanent opening into the vagina, through which such antiseptic solutions as have been noted above are thrown up. In time the collapsed cyst-walls adhere to one another and cease to secrete.

Electrolysis has of late also been lauded as a sure and harmless remedy for these cysts. But a careful examination of the subject made by Mundé shows that this agent has been greatly overrated as a specific, and that it "can in no wise supplant ovariotomy."[31]

[Footnote 31: Transactions American Gynæcological Society, vol. ii. p. 435.]

Rupture of ovarian cysts has occasionally taken place, either through over-distension or through such violence as a rude fall or an upset from a carriage. This accident, if the tumor were a monocyst or if the fluid happened to be bland, sometimes ended in a lasting cure. The hint was not thrown away, and several surgeons cut circular openings into the cyst to establish a permanent communication with it and the abdominal cavity. But this practice was soon given up, because it was found that the intrusion of ovarian fluid into the serous cavity usually set up a violent and rapidly fatal peritonitis. For such an accident, when followed by inflammation, there is but one remedy--the immediate removal of the cyst by ovariotomy. Desperate as this remedy seems, it has repeatedly been followed by success. The only cyst in which it might be held warrantable to establish a communication with the abdominal cavity is that of a cyst of the parovarium recurring after repeated tappings, and so bound down by adhesions or so covered by the broad ligament as to be irremovable. The fluid it contains is so limpid and bland as not ordinarily to inflame the peritoneum.

OVARIOTOMY.--The term ovariotomy comes from [Greek: ôarion], ovary, and [Greek: tomê], an incision. It is a barbarous compound of Latin and Greek, which is forced into meaning the operation for the extirpation of an ovary on account of some disease of its own structures which causes it to increase in bulk. A fibroid or a sarcomatous degeneration of this organ, as has been shown, will sometimes happen, but cystic degeneration is by far the most common form of disease to which the ovary is liable. When both ovaries are enlarged and removed the operation is called double ovariotomy. The terms ovariotomy and öophorectomy ([Greek: ôophoron] and [Greek: echtemnô], to cut out the ovary) really mean the same thing, the latter word, indeed, being the more appropriate. But by modern usage the former is limited to the operation for the removal of an ovary greatly enlarged by some intrinsic disorder. By öophorectomy is now meant the operation for the removal of both ovaries for the purpose of bringing on the menopause, and thus curing diseases kept up or caused by the functional existence of those organs, while they themselves may or may not be diseased.

Before the eighteenth century the operation of ovariotomy as a radical cure had been suggested by a number of physicians, but had never been put into practice. Later, John Hunter and John Bell both advocated the operation, but neither ventured to perform it. This honor was {314} reserved for Ephraim McDowell, a Virginian practising in Kentucky, who had attended Bell's course of lectures delivered in Edinburgh in 1794, and had imbibed the opinions of his teacher. He returned to Kentucky in 1795, and began at once to practise his profession, but it was not until 1809 that he first met with the opportunity for performing ovariotomy. The operation was successful, his patient having lived thirty-two years longer and having died at the end of her seventy-eighth year. Before his own death, which occurred June 25, 1830, in the fifty-ninth year of his age, McDowell had performed 13 ovariotomies, with 8 recoveries.

In spite of McDowell's success, and in spite of a large and growing percentage of recoveries reported by Atlee, Clay, and Spencer Wells, this operation was condemned so violently by the profession that its advocates were fairly ostracised, and fifteen years have hardly elapsed since it has been put upon as firm a basis as any other capital operation in surgery. "In 1843, Dieffenbach, the boldest of all surgeons then living, wrote that ovariotomy was murder, and that every one who performed it should be put into the dock. Now," writes Nussbaum, "we save lives with it by the hundred, and the omission of its performance in a proper case would in these days be looked upon as culpable negligence."[32]

[Footnote 32: British Medical Journal, Oct. 26, 1878, p. 617.]

The most common causes of death after ovariotomy are septicæmia or septic peritonitis, traumatic or frank peritonitis, shock, exhaustion, and hemorrhage; and it is against these foes that the operator must from the first aim all his efforts. In no other operation does the issue depend so largely on the experience of the surgeon. Every ovariotomist finds that his success grows with the number of his cases. Of 1000 successive ovariotomies, Wells lost 34 out of the first group of 100 cases, and but 11 out of the last group of 100. Out of his first 50 ovariotomies, Lawson Tait had 19 deaths.[33] The mortality of his last 313 cases was as low as 4.76 per cent.[34] Keith, who began with a mortality of about 20 per cent., lately had a series of 100 cases with 97 recoveries; 70 of these were successive. Schroeder had in the first 100 of his Berlin cases 17 deaths; in the second 100, 18; and in his third 100, 8 deaths.[35] Of my own first cases, I lost about 1 in every 3. Out of my last 22 cases there was but 1 death, and that occurred in a lady operated on at her home, too distant for me to see her again. In July, 1884, Peruzzi collected statistics up to date of Italian ovariotomists. Out of the first series of 100 cases, they lost 61. In the second 100 there were 36 deaths, but in the third series only 26 died.[36]

[Footnote 33: Medical Record, Jan. 3, 1885, No. 2, and British Medical Journal, April 15, 1882, p. 544.]

[Footnote 34: Medical Record, Jan. 3, 1885, p. 2, and American Journal of Obstetrics, July, 1882, p. 547.]

[Footnote 35: Maryland Medical Journal, July 1, 1882, p. 110.]

[Footnote 36: British Medical Journal, Sept. 16, 1882, p. 528.]

The statistics of the leading ovariotomists up to January, 1883, are as follows:[37]

Cases. Recovered. Died. Mortality, per cent. Clay 93 64 29 31.11 Sir Spencer Wells 1088 847 241 22.15 Keith 381 340 41 10.76 Knowsley Thornton 328 293 35 10.67 Lawson Tait 226 199 27 11.94

[Footnote 37: Medical News, Jan. 27, 1883, p. 117.]

{315} The statistics of general hospitals are by no means so good. In the Vienna General Hospital during the year 1881 "ovariotomy was performed 64 times, with 38 complete recoveries, 25 deaths, and 1 woman was discharged with marasmus."[38] Taking the profession at large, out of 5153 cases of ovariotomy collected by Baum, there was a mortality of 29.13 per cent.[39] Out of 2023 cases collected by Younkin, the mortality was 27 per cent.[40] By operative skill, by cleanliness, by wise hygienic measures, and probably by the use of antiseptic precautions, the fatality may be said to have been reduced by skilled specialists to about 10 per cent.; which, considering the size of the wound, the importance of the parts involved, and the delicacy of the exposed structures, is a remarkably low average. The average is indeed better than that of amputations. Before 1869, Sir James Y. Simpson stated that the average mortality of amputations of the extremities was 39.1 per cent. In the Glasgow Royal Infirmary the average mortality has been 25.5 per cent.--viz. of thigh cases there were 380 cases, with 113 deaths = 29.7 per cent.; of the leg, 182 cases, with 54 deaths = 29.6 per cent.; of arm cases, 167, with 33 deaths = 19.7 per cent.; of forearm cases, 93, with 12 deaths: mortality = 12.9 per cent.[41]

[Footnote 38: Medical News, Dec. 30, 1882, p. 745.]

[Footnote 39: Agnew's Surgery, vol. ii. p. 811.]

[Footnote 40: The New York Medical Record, Nov. 11, 1882, p. 560.]

[Footnote 41: Lancet, Sept., 1882.]

This brings up the question of simple or of aseptic ovariotomy--a very important question and one not yet fully settled. The objections to Listerism are--that it is very troublesome; that it is liable to poison the patient fatally, as well as to injure the health of the operator; that it is useless, indeed merely a surgical craze; and that it is not the carbolic acid which does good, but the cleanliness enforced by this system. But there is no doubt that since the introduction of antiseptic surgery the mortality has been much lessened in every land. For instance, "in Germany, where the success of ovariotomy has not been so good as in other countries, the mortality by means of the antiseptic treatment has been reduced from 90 to 20 per cent."[42] From an analysis of all the cases of ovariotomies performed by American surgeons, "the percentage of recoveries is overwhelmingly in favor of Listerism."[43] During the year 1881 in the Samaritan Hospital two of the surgeons used the carbolated spray of a strength of 1 in 40, and followed out every detail of antiseptic surgery. They had a mortality of 7 per cent. A third surgeon of that institution, after gradually lessening the strength of the spray until water was alone used, finally gave even it up altogether. He, however, for purposes of cleanliness always covered the instruments in the tray with water. The mortality of his operations showed the high rate of 30 per cent. The house committee, a body of laymen, thereupon "expressed a strong opinion against the performance of ovariotomy for the future without full antiseptic precautions."[44]

[Footnote 42: Agnew's Surgery, vol. ii. p. 800.]

[Footnote 43: H. C. Bigelow, American Journal of Obstetrics, July, 1882, p. 651.]

[Footnote 44: British Medical Journal, May 20, 1882, p. 747.]

On the other hand, Tait of Birmingham and Keith of Edinburgh, with a recent mortality each of only 3 per cent., have abandoned the spray. The latter claims now "to get as good results without it, and better results than any one has yet got with it."[45] My own practice is to adhere {316} to the spray and to every detail of antiseptic surgery; and I fully agree with Bigelow that "it would be a grave error to abandon a practice which has achieved brilliant results until something shall be brought forth which shall be as thoroughly protective, and in the use of which there may be no possible dangers. Time alone can demonstrate satisfactorily the relative values of Listerism and of perfect cleanliness without Listerism. The results of a large number of cases in which cleanliness and attention to detail have alone been used are the only criteria upon which we can strike a judicial balance."[46]

[Footnote 45: Brit. Med. Journ., May 27, p. 796.]

[Footnote 46: Am. Journ. of Obstetrics, July, 1882, p. 651.]

Contraindications for Ovariotomy.--An operation should be declined in far-advanced tuberculosis, in cancer of the ovary or of any other part of the body, in grave structural lesions of any of the vital organs, in ascites if caused by disease of the heart, the liver, or the kidney, in gastric ulcer, or in any serious disease of the alimentary canal. Extensive adhesions should not count as a contraindication, nor should age, since young girls and very old women have been successfully operated on. Albuminuria is often due to the pressure of the tumor on the kidneys, and, unless it existed before the appearance of the tumor or is positively known to be caused by Bright's disease, should not preclude the operation. Extreme debility dependent upon the ovarian disease makes the prognosis grave, but it should not prevent a resort to ovariotomy. I have indeed had several recoveries when the patient was so reduced in strength as to make it a very anxious and difficult task to keep her from dying on the table.

Indications for Ovariotomy.--This operation should not, as a rule, be performed when the cyst has first been discovered, but when it has grown so large as to distend the belly, and when the woman has become thin and her health has begun to fail. The reasons for waiting are--that the woman will have lived longer should the operation turn out to be a fatal one; that, the abdominal wall having become thinner both by being overstretched and by the absorption of fat, the incision will be proportionately shorter and shallower; that, the patient being now less full-blooded, both hemorrhage and inflammation will not be so likely to occur; that the bowels are crowded away from the line of incision; and that the pressure and rubbing to which the peritoneum has been for some time subjected will make it less vulnerable, and therefore less likely to take on inflammatory action. When, however, a woman broods over her condition and is anxious to have the tumor removed, the operation should be performed much earlier, especially if the surgeon be experienced.

Again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. Pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. Schroeder and Olshausen performed 21 ovariotomies in pregnant women, with only 2 deaths.[47]

[Footnote 47: Brit. Med. Journ., Dec., 1880, p. 1027.]

When septic peritonitis sets in; when the contents of the sac become purulent, as they sometimes do either spontaneously or after an unprotected tapping; when the cyst bursts and serious symptoms arise; when torsion of the pedicle occurs or when a free hemorrhage into the sac takes {317} place,--the radical operation should unhesitatingly be performed, and that without any delay.

Preparation of the Patient for the Operation.--The operation having been decided upon, every precaution must be taken to ensure a favorable result. The patient should avoid all exposure to contagious or to zymotic diseases, and she should be put in the very best condition of health possible under the circumstances. If the kidneys be inactive and the urine highly concentrated, depositing mixed urates in abundance, it will be well for the patient to make use of warm baths and to take saline cathartics in quantities sufficient to secure a daily action of the bowels. The alkaline carbonates, largely diluted, will also prove beneficial, and so will also the effervescent citrate of lithia. Sometimes, and especially when anasarca and oedema of the legs occur, it will be advisable to relieve the pressure-congestion of the kidneys by a preliminary tapping. Other organs will also be relieved, and valuable time for the action of medicines is often gained by emptying the cyst. Tonics, iron in the form of Basham's mixture, a generous diet, and fresh air may be needed. A trip to the seashore or to the country will often do much good in preparing a broken-down patient for the operation. If the patient comes from a malarial district, from twenty to thirty grains of quinia should be given during the twenty-four hours for two or three days before the operation, and ten grains a few hours before the time of the operation. If this be not done, a severe explosion of malarial fever after the operation may put the patient's life in jeopardy.

An operation of election should not be undertaken during a monthly period. It should be performed either about ten days before one or about a week after one. The very best time is midway between two fluxes. When, however, through some lesion or some accident, immediate relief is demanded, no regard whatever should be paid to the factor of menstruation. Some surgeons operate, indeed, in any case whether the woman is menstruating or not, and profess to find no difference in the result.[48]

[Footnote 48: T. Savage, Brit. Med. Journ., April 14, 1883, p. 712.]

For several days before the operation the bowels should be kept open, and the diet should consist largely of milk, eggs, rice, and of wholesome and easily-digested food. On the day preceding that of the operation the upper portion of the pubic hair should be cut off and the abdomen, if hairy, shaved. In the evening the patient takes a warm soap-bath, and is washed perfectly clean by her nurse, who must be an experienced woman, able to pass the catheter and take the temperature. She then puts on clean clothing and goes to bed, where she stays until the hour fixed upon for the operation. To ensure sleep, I am in the habit of giving at bedtime thirty grains of potassium bromide, combined sometimes with opium. Early next morning a dose of castor oil is administered, and it is much more easily swallowed if disguised in some vehicle and brought to the patient without any previous warning. When oil cannot be taken, I give, at bedtime of the previous evening and in one dose, two compound cathartic and two Lady Webster pills. To avoid ether-vomiting, breakfast should consist merely of one piece of dry toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk, and afterward she must eat nothing more. To calm the nerves another thirty-grain dose of {318} potassium bromide may be given, with or without opium as the case may be, and especially if the woman be at all agitated.

A very good time for operating is from noon to two o'clock in the afternoon, for by that time the oil will have acted and the light breakfast will have been digested. Some surgeons operate as early as nine and ten o'clock in the morning, in which case the cathartic will have to be administered in the afternoon of the previous day. At the hour fixed upon for the operation the woman puts on a flannel sacque, warm stockings, and drawers, and her nurse then passes the catheter.

The bedstead on which the woman is to lie after the operation should have a horse-hair mattress, and should be wide enough to permit her attendants to move her on a draw-sheet from one side of it to the other. I formerly placed my patients on narrow single bedsteads, so that they could be reached and be waited upon equally well from either side; but I found that an unchangeable position on the back soon became intolerably irksome. Next, indeed, to the thirst following the operation, my patients complain mostly of the supine posture which they are compelled to assume.

The room in which the operation is to take place ought to be a separate one, so that the lady can be etherized in her sleeping-room, and may not be unnerved by witnessing the needful preparations. Several days beforehand the carpet of the operating-room should be taken up and the curtains taken down. Every useless piece of furniture should be removed, the closets and bureau-drawers emptied, and the whole room thoroughly cleansed and ventilated. Several hours before the time of the operation this room ought to be heated to a temperature of 75°, and the air disinfected and made moist by a solution of carbolic acid kept boiling in a dish on the stove or over an alcohol lamp. Let me here say that, if possible, this operation should not be performed within the walls of a crowded general hospital nor in unhealthy localities, but, as statistics well show, in private houses or, far preferably, in small special hospitals.

Articles Needed for the Operation.--The following articles should be provided by some member of the patient's family. Following the example of the late Washington L. Atlee, I have a printed list of them, which is sent to the family physician some days before the operation:

One yard of rubber plaster; two rolls of raw cotton, made aseptic by being baked in the range-oven just before the operation; two yards and a half of fine white flannel, for two binders; six one-grain rectal suppositories of the watery extract of opium; two pounds of the best ether; two gallons of a 5 per cent. solution of the best carbolic acid, made at least two days beforehand; four ounces of Monsel's solution of iron; twelve ounces of undiluted alcohol for the spray-producer; some old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap; a pin-cushion, with large pins; two kitchen tables, or two dressing-tables; one small stand for the spray-producer; one small table for the basins and sponges; one chair without a back for a bucket of hot water; two new tin basins and one tin cup; a new bucket and a jug of hot water; a kettle of boiling water, ready on the range; a small tub and an empty bucket; six bottles filled with hot water and tightly corked; an empty wine-bottle for the aspirator; a rubber ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard and a quarter square, with an oval hole in the centre six inches wide and eight long; one kitchen apron for the operator; one {319} clean blanket for the patient's lower extremities; two large platters or two meat-dishes, to be used as trays for the instruments;[49] clean towels, clean sheets, clean blankets, clean comfortables, and clean pillows.

[Footnote 49: These platters are usually too shallow to hold a solution of carbolic acid deep enough to cover the bulkier instruments. It would therefore be well to have a tin tray made especially for the purpose, measuring nineteen inches long, twelve wide, and three deep; or a nest of smaller trays can be carried in the operator's bag.]

Instruments.--In simple cases very few instruments are needed; but as one never knows beforehand what complications may be met with, it is best to be always prepared for every emergency. One must therefore have on hand every instrument likely to be wanted in the most formidable operation. The following list comprises all the instruments and other articles that I carry with me in my operating-bag, but it will not suit every surgeon, who will after a few operations choose his own favorite instruments:

One steam spray-producer, which will work two hours; assorted silk ligatures on spools; Lister's antiseptic gauze or salicylated cotton; two dozen straight surgeon's needles; assorted needles with varying curves; two large needles for transfixing pedicles; an aneurismal needle; one needle-holder; one hypodermic syringe; two dozen assorted pressure-forceps; one uterine tenaculum; assorted hair-lip pins and acupressure needles; one grooved director; two scalpels; Baker-Brown's cautery clamp; ten fine surgeon's sponges of different sizes; two long and flat sponges; one wire écraseur; one wire clamp or Koeberle's serre-noeud; Paquelin's cautery or three cautery-irons; one Wells's trocar with rubber tubing; one aspirator; two Nélaton's cyst-forceps; one straight pair of scissors; one pair of scissors curved on the flat; one right-angled pair of scissors; Allis's improved ether-inhaler; one flexible male catheter; three glass drainage-tubes of different sizes and lengths, together with the rubber sheeting and the sponge used with them.

The twenty-four needles should be threaded, two on one thread of fine silk eighteen inches long--viz. No. 1 or 2, of an excellent quality furnished by Messrs. J. H. Gemrig & Son of Philadelphia. To keep these threads from becoming snarled they are rolled up in a strip of muslin gauze, each pair of two needles with their thread being covered up by one fold of the gauze. The two pedicle-needles should also be threaded, but with stouter thread (No. 4), fully two feet long. All these armed needles should be put into a 5 per cent. solution of carbolic acid for several hours before the operation. Assorted needles of varying curves come occasionally into use, and it is always well to have several very fine needles on hand, together with the finest Chinese silk, in order to close a wounded viscus, such as the bladder or the bowels.

As an aid to the memory it is well to have invariably at every operation the same number of sponges and the same number of pressure-forceps, for these are the only articles likely to be left behind and closed up in the abdominal cavity. The cautery-irons should be wedge-shaped; the iron spreader used by apothecaries in making plasters forms an excellent substitute. In my hands the best pressure-forceps is Koeberle's. Its pointed beak catches the tissues far better than that of Wells's forceps, which looks like a crocodile's muzzle. The ordinary hæmostatic bulldog clips, or the serres-fines, must on no account be used, because if {320} they should lose their hold and drop into the abdominal cavity they would be too small to be readily discovered, and might indeed be hopelessly lost in the coils of the bowels. Long strings attached to each one would, however, overcome this objection.

The ten sponges must be of the best quality and about the size of one's fist. Two of them should be flat, long, and thin, such as are called by the trade potter's sponges. When first bought, sponges almost always contain sand. To rid them of this they are beaten, then soaked for twenty-four hours in a 3 per cent. solution of muriatic acid, and afterward washed out in clear running water. Sponges should never be put into boiling water, which destroys their elasticity, shrivels them up, and spoils them. After every operation the sponges should be thoroughly cleansed in cold water and immersed for forty-eight hours in a solution of washing soda (sodii carbonas) containing four ounces to the gallon of water. They are then rinsed out in running water, and placed in a 5 per cent. solution of carbolic acid. At the end of a week they are to be taken out and hung up in a bag. Instead of a solution of soda, some prefer an 8 per cent. solution of sulphurous acid, in which the sponges are soaked for from two to four hours. This bleaches the sponges, but does not cleanse them so well as the alkaline solution.

Only three assistants are needed--two are enough if they are experienced--and they and the surgeon should take a soap-bath, and not see on that morning any patient ill from a zymotic or a contagious disease. Their clothes should also be scrupulously clean. To ensure still further protection, each one takes off his coat, waistcoat, and neck-tie if they are of a material which cannot be washed. The nurse must also wear clean clothing which can be washed. A few bystanders may be permitted, but they should wear clean clothing and take off their overcoats. They should also be cautioned not to visit before the operation any case of contagious disease.

Upon arriving at the patient's house the surgeon, together with his assistants and the nurse, proceeds at once to get everything in readiness. The two tables may be arranged in the form of a T, covered with several thicknesses of quilts, and with a pillow on the cross-table. When the tables are thus arranged a third one will be needed for the instruments and the spray-producer. In order to economize room and furniture, I am in the habit of putting one table at right angles to the other--viz. with its short arm to the left instead of to the right, thus: _|. The woman lies on the long arm of the _|, with her feet directed to the short arm, and on the projecting and free portion of the table forming the short arm are placed the tray of instruments and the spray-producer. As it takes time to get up steam in the necessarily large spray-producer, hot water should be poured into the boiler, and it should be one of the first things attended to. In order not to chill the patient, the spray solution of carbolic acid should also be heated before it is used. The edges of the oval hole in the rubber cloth are next smeared with some adhesive preparation, but a plaster suitable for all seasons of the year is not easy to devise. Keith's formula is the following, but it will not always stick:

Rx. Emplastri saponis, ounce iv; Emplastri resinæ, ounce iij; Olei olivæ opt., ounce i. M.

{321} After many trials, W. D. Robinson of Philadelphia has succeeded in making for me a very good plaster according to the following formula:

Rx. Emplastri saponis, ounce ij; Resinæ, drachm vi; Terebinthinæ albæ, drachm ij. M.

I must, however, add that I now very rarely use this rubber cloth.

Not all the instruments in one's bag, but only those likely to be needed, are now placed in the tray or in the platters, and covered over with boiling water, to which in a few minutes is added the same quantity of a 5 per cent. solution of carbolic acid. The best plan would perhaps be to pour into the tray a boiling 2.5 per cent. solution of carbolic acid. Into the same tray is also laid the roll of gauze containing the threaded needles. By its side on the table, and within easy reach, is placed a small bottle filled with a 5 per cent. carbolated solution in which are kept two small spools of Nos. 1 and 2 silk. The adhesive or rubber plaster is cut into strips of appropriate length, and the antiseptic dressing put in readiness. The trocar with tubing attached is hung on a nail near by. The sponges are carefully counted and placed in one of two basins arranged side by side on a table to the left of the patient. The other basin is one-third filled with a 5 per cent. solution of carbolic acid, which later on is reduced by the addition of pure hot water to a strength of 2.5 per cent. On a chair is placed a bucket of clean warm water.

Let me here say, once for all, that throughout the operation the assistant who looks after the sponges attends to them in the following way: Every soiled sponge returned to him is first cleaned in the bucket of warm water, next rinsed in the carbolated solution, then squeezed out and placed in the empty basin. This sequence must be rigidly observed, because, if the soiled sponge be plunged first in the carbolated water, the blood and serum which it contains will at once coagulate in its meshes, and become liable to be dislodged in the abdominal cavity as foreign bodies.

Meantime, the woman, in another room, has been inhaling the anæsthetic--the best being, in my opinion, the ether fortior of our leading manufacturing druggists. It should be administered by Allis's inhaler, which largely dilutes it with air. Wells and Thornton employ the bichloride of methylene; Keith uses pure ether; Bantock resorts to chloroform, and Tait to a mixture of two parts of ether and one of chloroform, given by means of Clover's apparatus.[50] When the patient is wholly unconscious her water is drawn off, and she is carried into the operating-room and laid on the table. To this table she is strapped down by a belt over her thighs, and her hands are also secured to the same belt. Her legs are wrapped in warm blankets, and her clothes are drawn up out of the way. Her chest and body are then covered by the rubber sheet, but the edges of its oval opening are made to adhere to the skin from just above the navel to the pubic hair, thus exposing only a limited portion of the abdomen. After this the spray is turned on, and the 5 per cent. solution of carbolic acid in the tray and in the basins is diluted with hot water down to 2.5 per cent. The operator and his assistants now take off their rings and cleanse their hands very carefully with carbolated soap and a nail-brush. They may clean and pare their nails with a penknife {322} before the use of the nail-brush, but not after, because the knife not only does not remove all dirt, but it loosens up that which remains. Arranging themselves in their places, the operator stands to the right of the woman, his chief assistant to her left, the one who gives the ether at her head, while the other, who attends to the sponges, takes his place near the basins at the side of the chief assistant. The nurse holds herself in readiness to hand towels when called for, and especially to see that a third basin always contains warm water, so that at any stage of the operation the surgeon can wash his hands without delay.

[Footnote 50: The Medical Record, Jan. 3, 1885, p. 2.]

When everything is ready the door is locked, and the exposed portion of the abdomen washed with the solution of carbolic acid. An incision about three inches in length is made with a free hand, and not by nicks, in the median line below the navel, where the blood-vessels are few in number. It should end about one inch and a half above the pubes; that is to say, low enough for the pedicle to be easily reached, but high enough to avoid cutting the fold of peritoneum reflected from the bladder to the abdominal wall. The brown line running below the navel is the surface guide, but after cutting through the skin and fat one cannot always hit the linea alba beneath. When the cyst is large the recti muscles have become separated from one another, and there is no difficulty in keeping within the wide tendinous interspace. But when the cyst is small the linea alba is, as its name indicates, a mere line, and the knife will often go astray into the anterior sheath of one of the recti muscles. The red muscular fibres pouting out of the opening will be the danger-signal of one's having got off the track into more vascular regions. To recover it a probe is passed in across the muscle to the right and to the left, and the nearest point of arrest will note the linea alba. The disadvantages arising from the wandering from the linea alba are--that the sheath of the rectus muscle being cut open, or the muscle itself being wounded, there results hemorrhage; that the wound is more jagged, and therefore less easily coaptated; that suppuration in the suture-tracts is more liable to take place; and, finally, that in cases of small cysts with but little abdominal enlargement a spasmodic contraction of the wounded muscle is very likely to embarrass the operator both in removing the cyst and in introducing the sutures.

Again, one cannot on a grooved director cut canonically through the different layers of tissue described with so much precision in the textbooks. On the contrary, all that one needs is to know when the knife is approaching the peritoneum. An excellent landmark is the thin layer of fat overlying the peritoneum. So, after pinching up the abdominal wall to estimate its thickness, the surgeon can boldly cut down through the skin and its underlying fat, but somewhat cautiously through the aponeurotic structures until the second layer of fat is reached. Practically, therefore, he need regard but the following layers: skin with its underlying fat, the intermediate tendinous or muscular structures, the supra-peritoneal fat, and the peritoneum.

Before the abdominal cavity is opened all bleeding is stopped by the use of pressure-forceps, of which one dozen will sometimes dangle from the wound. When the hemorrhage has been wholly stayed, and not until then, the peritoneum is hooked up by a delicate uterine tenaculum and nicked open. On a broad grooved director or on the finger this opening is slit up for a distance of about two inches, either by a {323} right-angled pair of scissors or by a probe-pointed bistoury. A little serum usually escapes and the nacreous wall of the cyst comes into view. This is called an exploratory incision, for by it the diagnosis is confirmed, the presence of adhesions ascertained, and the possibility of completing the operation determined. When it has been decided to go on with the operation, more working room will be needed, and the wound is therefore enlarged by the scissors, the finger being used as a guide to prevent injury to the omentum or to any chance knuckle of bowel that may lie in the way. The size of the incision will depend upon the character of the cyst and on the number of its adhesions. Hence it may range from a length of three inches to the distance from ensiform cartilage to symphysis pubis. An incision contained between the umbilicus and symphysis pubis is technically called a short incision, and one extended above the umbilicus a long incision. Should it be found needful to prolong the wound to a point above the umbilicus, the incision is usually carried to the left of the navel and brought back in a curved line to the linea alba. This is done to avoid the round ligament of the liver and its vessels, which come in there from the right side. Keith, however, cuts directly through the navel; and I find this straight incision to be superior in every respect to the curved one. Other things being equal, the short incision is safer than the long one; but it is a good rule to have an opening large enough for easy manipulation and for the easy withdrawal of the cyst. For instance, a large monocyst without adhesions after being emptied can, like a wet rag, be pulled out, hand over hand, through a very small opening, whereas a much smaller polycyst, which cannot be wholly emptied, and which is more or less adherent, will need a long incision. I once removed an oligo-cyst weighing one hundred and twelve pounds through an incision barely admitting my hand; while I had to open the abdominal cavity from ensiform cartilage to symphysis pubis in order to remove a solid ovarian fibroid tumor weighing but eighteen pounds. Both patients recovered, but the chances were, of course, more against the woman with the long incision. To avoid the escape into the abdominal cavity of any blood from the wound, and to prevent the soiling of the operator's hands, a clean napkin wetted with the carbolated water is doubled over each edge of the incision.

Whenever the cyst-wall in the line of the incision is glued by adhesions to the parietal peritoneum, the latter is liable to be mistaken for the former, and accordingly to be stripped off from the abdominal wall. To avoid this very serious error, either proceed with the cutting until the cyst-wall unmistakably comes into view or is opened, or else extend the incision upward until a point is reached where the cyst is free from adhesions. Adhesions binding the cyst to the abdominal wall are of importance only from the troublesome oozing their rupture often gives rise to. To lessen this risk, they are to be sundered by the finger whenever possible. Should the scissors be used, the adhesion bands must be snipped close to the surface of the cyst, and not to that of the abdominal wall. Thus, a free end is gained, which may, if needful, be subsequently tied or in which the dangling blood-vessels may the more readily constringe. All thick and long bands of adhesion should be tied in two places and be divided between the ligatures. These ligatures should consist either of very fine silk or of gut. For isolated vessels the latter {324} are the better ones, but the silk is more suitable for tying en masse a group of bleeding vessels or for pursing up an oozing surface by an in-and-out stitch. A very important rule, on the observance of which one's success greatly depends, is, never to let a bleeding point or an oozing surface get out of sight. It must either be ligatured at once, or else caught by pressure-forceps and tied later if needful. If the delicate omental apron be found glued to the cyst, it should be carefully detached with as little tearing and splitting as possible, for each shred will bleed, and so will the fork of the split. It should then be turned out of the abdominal cavity on a clean napkin wetted with the carbolated solution. If its bleeding vessels be few, each one may be tied with gut; but if they are many, the torn portion of the omentum should be tied en masse or in sections, and the ligatures cut off close to the knot. All shreds and ragged ends of omentum must be trimmed off, and it is then returned to the peritoneal cavity.

When all the adhesions within reach, and those that do not demand great force, have been severed, it will be time to tap the cyst. This should be done with a large-sized trocar, such as Wells's, which is furnished with spring teeth to prevent it from slipping out of the cyst. Any trocar will do, provided it has a large bore, so that the vent may be free and that none of the acrid fluid can escape along its side into the abdominal cavity. In order to save time, neither Schroeder nor Martin use a trocar. They incise the cyst, and try by pressure and the lateral position to direct the contents externally. Frequently, however, some of the fluid escapes into the abdominal cavity, but they contend that if antiseptic precautions be taken no harm accrues.[51] Although dissenting from this opinion, I must confess to having had the contents of the cyst escape repeatedly into the abdominal cavity without doing any harm whatever. Always tap at the upper angle of the wound, because as the cyst collapses the trocar is drawn downward toward the lower angle. Hence, were the trocar entered low down it could not travel with the collapsing cyst, which would therefore slip off. While the fluid is flowing flat sponges should be packed in between the abdominal wall and the cyst, and the edges of the incision should be pressed firmly against them, so that the peritoneal cavity may not receive a single drop of that which frequently escapes along the side of the trocar. To avoid this accident--which, without being a very serious one, is yet not to be invited--some ovariotomists before tapping turn the woman well over on her belly and over the edge of the table; but this is liable to cause a protrusion of the bowels; which is, in fact, a more dangerous accident than the entrance of some of the fluid into the abdomen. Rosenbach, indeed, reports that during the extraction of biliary calculi through an abdominal incision a cure resulted, although several calculi were lost in the peritoneal cavity.[52] Should the mother-cyst not collapse on account of its containing a few other large cysts, the point of the trocar, without being withdrawn, can be made to enter each one. But if the child-cysts are many and small, the trocar is withdrawn, the opening enlarged, its edge seized by several pressure-forceps, and the hand introduced to break up these cysts.

[Footnote 51: Berlin. klin. Wochenschrift, 1883, No. 10.]

[Footnote 52: Medical News, Feb. 3, 1883, p. 130.]

Before this hand can again be used for separating adhesions it must be {325} carefully cleansed with soap, and dipped into the carbolated solution in the tray of instruments.

The empty cyst is next gently pulled out through the abdominal wound. It is, however, so slippery that this cannot ordinarily be done with the hands alone. A strong forceps with a firm grip is needed, and one of the best is Nélaton's. While the cyst is being withdrawn the bowels are sheltered from the air and the spray by one large flat sponge, and the abdominal cavity must also be packed with smaller ones at every exposed point; and one of them should always be placed between the womb and the bladder.

In the majority of cases there is not much difficulty in freeing the cyst from its ordinary attachments and in reaching its pedicle. But should adhesions bind the cyst to the adjacent viscera, matters will not go on so smoothly. Such adhesions to bladder, liver, bowels, or to other important organs sometimes present difficulties which are insurmountable. The problem here is to sever these bands of adhesion without injuring the viscera to which they are attached. When these adhesions are numerous or very firm, much advantage will be gained by having the assistant put his hand within the cyst and stretch its wall while the operator severs the adhesions over it. By this means the adhesions can be better broken off close to the cyst, which is the all-important course to pursue in visceral attachments. Sometimes it will be needful to peel off the outer and non-secreting layers of the cyst and leave them behind--sometimes to cut off the adherent portion of the cyst and scrape off or strip off the secreting surface. Whenever the stalk of the tumor can be reached before all the adhesions are severed, it will be well to catch it with one or two pressure-forceps, or even to tie it and cut it off between two ligatures, like the umbilical cord. This will prevent bleeding from the torn surfaces of the cyst. When the cyst is closely adherent to the edges of the abdominal incision, either extend the wound upward until a free point is reached, and work downward on the adhesions, or else cut into the cyst, empty it, and seize with strong forceps its inner surface just beyond where the adhesions begin. The sac is then inverted by traction, which will break up its adhesions to the abdominal wall, the last portions to be freed being those attached to the edges of the incision. This prevents the stripping up of the peritoneum. Should the appendix vermiformis be so adherent to the cyst as not to be detached, it must be ligated in two places, between which it is to be cut, in order that its contents may not escape into the abdominal cavity. The fecal plug in each distal end should also be carefully squeezed out. Double ovarian cysts sometimes fuse together, and, rupturing at the point of fusion, form apparently one cyst. Such a cyst will have two pedicles, and will be very puzzling to the inexperienced operator.

When the cyst has been freed from its attachments and turned out of the wound, the very important question comes up of the treatment of the stalk or pedicle. Shall it be secured by a clamp? shall it be burned off by the actual cautery? or shall it be tied, cut off, and dropped back? The first is called the extra-peritoneal method; the others, the intra-peritoneal. For many years the clamp claimed the most advocates, but it has lost ground on account of possessing the following disadvantages: By keeping the wound open it prevents a strictly antiseptic treatment; {326} the stalk sometimes sloughs below the line of constriction and conveys putrilage into the abdominal cavity; the stalk always becomes united to the abdominal wall, hence when it is short the womb is dislocated or it is too much dragged upon. Then, again, in one-third of the cases the oviduct has a trick of remaining open, and the woman will menstruate indefinitely from the abdominal cicatrix. This is owing to the fact that the clamped portion sloughs off too early for a firm plug of cicatricial tissue to be formed, and the oviduct is therefore liable to stay open. In my first case of ovariotomy this happened, and one year later the cicatrix degenerated into a malignant growth which destroyed the life of my patient. It is, however, probable that in this instance the cystic disease of the ovary was malignant, although the sac did not look so at the time of its removal. Another disadvantage arising from the use of the clamp is the subsequent weakness of the cicatrix at its site, and the liability of ventral hernia to form there. These are the objections to the clamp, and they are so valid that at the present time all distinguished ovariotomists have abandoned its use.

The actual cautery, performed by Paquelin's instrument or by platinum-tipped irons, which do not scale off or discolor the tissues, is theoretically the very best way of dealing with the stalk. No foreign body besides the charred portion of the stalk is left within the abdominal cavity; but, on the other hand, it cannot always be trusted to close the vessels. On this account it is looked upon with disfavor by all ovariotomists with the exception of Keith. His method is as follows: The pedicle is spread out evenly within Baker-Brown's clamp, so as to get equable compression. The cyst is cut off, leaving a stump about an inch in height above the clamp. To protect the parts from heat a folded napkin wetted in the carbolated solution is tucked under the clamp. The stump is next carefully dried, and then burned slowly down to the level of the clamp by wedge-shaped cautery-irons at a brown heat. They give off a whistling sound during the process. The thick end of the stump can be more quickly burned down, but the thin end should be burned very slowly, and the blades of the clamp by prolonged contact with the cautery-iron must also be made hot enough to dry up and shrivel that portion of tissue which they compress. In order not to disturb the stump after it has been cauterized, it is best to clean out the peritoneal cavity first, and to leave this treatment of the pedicle for the last thing. Before removing the clamp, which is to be unscrewed very slowly and carefully, one side of the pedicle is seized by a pressure-forceps, by which it is kept in sight and out of harm's way if the peritoneal cavity needs further cleansing.

The plan of treating the pedicle most in vogue, and the one which I adopt, is that of the ligature--one of fine carbolated silk, the finest compatible with safety. The ends are cut off close to the knot, and the stump is dropped into the peritoneal cavity, where the silk, being animal tissue, will in time become disintegrated and absorbed. Now, when I say silk, I mean silk, and not silver or gut ligature. Silver, being inelastic, cannot bind a shrinking stalk, while the gut is a treacherous ligature, and will sooner or later bring one to grief. It slips in the tying, it is liable to untie, it gives instead of shrinking, and it is too short-lived for the obliteration of large vessels.

{327} The reasonable objection has been urged that since the abdominal cicatrix left by the use of the clamp is liable to reopen every month to give vent to menstrual fluid, the same phenomenon will by this intra-peritoneal method happen within the abdominal cavity and expose the woman to all the risks of a hæmatocele. But fact is here opposed to theory, for it has been found that either the oviduct in the stump atrophies into an impervious cord of fibrous tissue, or that its raw end, by contracting adhesions with the surrounding tissues, becomes hermetically sealed. It might also be supposed that the distal end of the ligatured stalk would slough and expose the woman to septic peritonitis. But such sloughing rarely happens, and for the following reasons: From shrinkage of the stump the constriction is lessened, and the capillary circulation is re-established; or the peritoneal surfaces on each side of the narrow and deep gutter made by the fine silk will bulge over and touch one another. Adhesion then takes place between the two, and the blood-vessels which shoot over from the proximal or uterine side of the ligatured stump will carry life into the distal end; or lymph exuded by the irritation of the ligature will throw a living bridge across the gutter in the stalk; or, what is the least desirable, the raw end of a long stalk glues itself to any peritoneal surface with which it may come in contact. I say least desirable, because sometimes such an adhesion makes a kink in the bowel, and may so constrict it as to give rise to fatal obstruction. To prevent this accident, Thornton stitches with gut the raw end of the stump to the broad ligament, to which it adheres; while Bantock catches it up out of harm's way by including it in the lowest abdominal suture, which, being of silkworm gut, can be left in for a long time. If the stump be short, it stands upright, and does not then need this treatment.

If the stalk be a thick one, it is transfixed by a blunt needle threaded with a double ligature, and is tied on either side, each half by itself, and then the whole is further tied by the free ends of one of the ligatures, or the Staffordshire knot, recommended by Tait, may be used. If it be a broad one, it is tied in three or more sections by cobbler's stitches. In thick or in broad stalks it is a good plan to catch the stalk in Dawson's clamp, which compresses it circularly, and to transfix and tie it in the furrow made by the clamp. This lessens the risk of secondary hemorrhage, which is usually caused either by the slipping off of the ligature or by its loosening through tissue-shrinkage. When this clamp is used the pedicle need not be tied until the wound is ready to be closed. The stalk must be cut off at a distance from the ligature of not less than three-fourths of an inch, so as to leave a button of tissue sufficiently large to prevent the loops from slipping off. In short and broad stalks the outer or broad ligament portion, which is thin and membranous and sustains most of the tension strain, is liable to slip out of its ligature and cause a fatal hemorrhage. To avoid this accident the ends of the corresponding ligature may, before being tied, be repassed in opposite directions through the stalk very near its margin to form the cobbler's stitch. Another way is to pass a fine silk thread through the thin portion of the stalk about one-third of an inch from its edge, and tie it. In the notch thus made, and below the knot, is laid and tied the outer ligature.

In anæmic cases Thornton ties the arterial side of the pedicle first, but in young and vigorous women he ties the venous side first, so as to {328} deplete the woman by gorging the tumor with blood. While cutting off the cysts the abdominal cavity must be so protected by sponges that not a drop of blood shall fall into it. A dilated oviduct in the pedicle tends to suppurate; hence in such a case the ligature should be applied as close to the womb as possible, so as to get below the expanded portion. Before the cyst is cut away the pedicle should be seized on one side by a pressure-forceps, and kept more or less in sight until the wound is ready to be closed up. This will also prevent the ligatures from being rubbed off by the sponges while the abdominal cavity is being cleansed.

Sometimes the cyst has no stalk, but lies between two folds of the broad ligament, or else it is bound to the bladder, womb, and the pelvic tissues by intimate adhesions which cannot be safely severed. Formerly, under such circumstances the abdominal wound was hastily closed up and the case abandoned. Now, thanks to Miner of Buffalo, New York, we can fall back on enucleation, and need rarely be foiled.[53] This operation is performed by slitting open the peritoneal capsule of the sac at points close to its attachments, by introducing one finger or more into the opening, and by stripping off this serous and vascular envelope up to where the vessels enter the cyst-wall and become capillary. The artificial stalk thus made is to be treated precisely like a natural one--that is to say, by clamp, ligature, and cautery, or, if it does not bleed, by nothing whatever. This operation I have repeatedly performed, but it is seldom easy, and is always anxious work. Should the cyst be so wholly adherent to the viscera as not to be even enucleated, an incision is made into it. It is then emptied, thoroughly cleansed, and the child-cysts are also crushed by the hand. The edges of the opening thus made in the sac are now included in the stitches of the abdominal wound, but the latter is kept open either by a large cloth tent at the lower angle or by two glass drainage-tubes, one at each angle running down into the sac. Sometimes it may be needful to tie the adherent portion in sections and to cut the free portion away. A drainage-tube must then be inserted at the lower angle of the wound. This expedient has the sanction of Atlee and Olshausen, who have reported successful cases thus treated.[54] My own practice in such cases would be, after breaking up the child-cysts, to gather together the free portion of the cyst and bring it out at the lower angle of the wound. A short nickel-plated steel drainage-tube of large bore is inserted, the sac firmly clamped to it by a small wire écraseur, and the redundant portion cut away. Into this metal tube is passed a glass drainage-tube long enough to touch the lowest portion of the sac.

[Footnote 53: Transactions International Med. Congress, 1876, p. 801.]

[Footnote 54: Monthly Abstract, July, 1877, p. 334.]

In such cases, when feasible, I think it would also be well to adopt Freund's plan of tying the pedicle and severing it, in order to lessen the blood-supply to the cyst.[55]

[Footnote 55: Boston Med. and Surg. Journal, Aug. 24, 1876, p. 219.]

The sac having been removed, the other ovary should be examined, and, if diseased, be tied and cut off. From the sundered bands of adhesion more or less bleeding has been taking place, which must now be attended to. It can usually be stopped by pressure with a sponge or with a finger, or with sponges wrung out of very hot carbolated water. For single vessels torsion will usually succeed, but if it does not, fine {329} carbolated silk or gut ligatures must be used; and it is wonderful how many can be applied without materially compromising the safety of the woman. I once tied over thirty vessels in a lady sixty-eight years of age, who recovered without any symptoms of peritonitis. The free ends of the ligatures should always be cut off close to the knot. Stubborn oozing surfaces can very generally be stanched by searing them with Paquelin's thermo-cautery, or by passing a needle armed with fine silk under and ligating any vessel that may be detected leading up to the seat of the oozing. In some cases nothing answers so well as the pressure of the finger moistened with alcohol or with a drop or two of the ferric subsulphate or of the tincture of iodine. In oozing from inaccessible points in the pelvis a sponge dipped in the undiluted solution of iodine or in Monsel's solution of iron, and afterward well squeezed out, may be pressed firmly down for a few moments into Douglas's pouch. When the oozing comes from a large surface of the abdominal wall, it may finally be arrested by the doubling of the raw surface on itself. The fold thus made is then secured either by a long acupressure needle or by cobbler's stitches passed through from skin to skin. Forty-eight hours after, this needle or these stitches should be removed. For this ingenious device we are indebted to the late Kimball of Lowell, Mass. Should all these measures fail, put in a drainage-tube, close up the abdomen in the manner about to be described, and temporarily lay over the dressings some heavy weights, such as bags of sand or of shot. This plan I have not been obliged to resort to, but it has the sanction of Nussbaum, who uses two large bricks, and it is worthy of being borne in mind.[56] In my hands an elastic flannel binder pinned very tightly over a large roll of cotton wool has made pressure enough to check the hemorrhage.

[Footnote 56: British Med. Journal, Oct. 26, 1878, p. 617.]

The toilet of the peritoneum next comes in order. By this is meant the peeling off from the peritoneum of plastic deposits, the removal of the sponges packed into its cavity, and the careful cleansing away of all fluids and of every blood-clot. In the search for all such foreign bodies, or, indeed, for obscure oozing-points, the reflector of the ophthalmoscope or Colin's illuminating lamp will give much aid. Douglas's pouch and the peritoneal fold between the bladder and the womb are favorite localities for the collection of blood or of serum, and should therefore be thoroughly mopped out by small sponges on holders, otherwise peritonitis or septicæmia may result, which are the two great factors of death in unsuccessful cases. When this has been thoroughly done, a clean sponge is placed in Douglas's pouch, another in the sulcus between the bladder and the womb, and a third, a large and broad flat one, is laid over the intestines under the wound to catch the blood that may drop from the needle-tracks. Each needle is passed from within outward a quarter of an inch away from the peritoneal edge of the wound, and is made to emerge at the same distance from its cutaneous edge. If the recti muscles are included in the sutures, there is said to be a liability to the formation of abscesses in the suture-tracks. Hence almost every ovariotomist advises that the peritoneum and skin should be pinched together, and that the needle should be passed through them alone without perforating the muscles. Yet I believe that from a too close observance of this rule come many cases of hernia in the track of the wound, and that were the recti muscles {330} more closely coaptated they would not recede from one another and thus aid in the formation of a rupture. My own rule is to include these muscles in the suture wherever they are exposed to view. The sutures should lie about one-third of an inch apart. The needles should be lance-pointed and held by a needle-holder. In fat women it is not always easy to get the two surfaces of the wound in exact coaptation; consequently, more or less puckering and eversion of the edges may take place. To avoid this, it will be well, before passing the needles, to bring the edges of the wound together, and make with a fountain-pen transverse lines at proper intervals across the incision as landmarks for the introduction of the sutures. These cross-lines are also of advantage whenever the abdominal walls are too tense for accurate coaptation, as after öophorectomy, after the removal of a small abdominal tumor, or after an exploratory incision for a solid tumor which cannot be removed. In these cases, indeed, it would be well to make the cross-lines the first step of the operation, before even the abdominal incision has been made.

The reasons why the needle is made to enter the peritoneum first are, that the stitches are lodged more evenly on that vulnerable surface, and with less injury to it, such as the stripping of it off from the abdominal wall; and, further, that a stray knuckle of bowel is not so likely to be wounded by the upward as by the downward thrust of the needle. The object of including the peritoneum in the stitches is to bring in contact two long and narrow ribbon-like surfaces of a membrane, which will quickly unite--so quickly as to forestall any formation of pus in the overlying tissues, and to bar the entrance of this or other septic fluids from the wound in the abdominal wall. Another advantage is, that this inclusion of the peritoneum by presenting an uninterrupted surface of parietal peritoneum to the visceral peritoneum prevents the adhesion of the omentum and of the intestines to the internal lips of the wound, which otherwise takes place.

When all the sutures have been passed, their ends on one side are loosely twisted together into a single strand, which is securely caught by a pressure-forceps. The same thing is done with the ends on the other side. A finger of each hand is now passed down into the centre of the wound, and the middle portion of all the upper sutures and of all the lower ones are separated from one another by being drawn to opposite angles of the wound. This permits the removal of the sponges, and, if they are stained with blood, the further search for some overlooked bleeding vessel. To guard against twisting of their convolutions, the bowels, still further disturbed by these final manipulations, are now restored to their natural position, and the omentum, after being again examined for some bleeding vessel, is gently spread out over them. The forceps and sponges are then counted to see that not one has been left in the abdominal cavity. The importance of this cannot be too strongly impressed upon the operator, for distinguished ovariotomists have overlooked these articles, and have left them behind in the abdominal cavity--a sponge and a bulldog forceps in one case.[57] Tait has heard of ten such cases.[58] It is indeed sometimes no easy task to find a missing sponge when lost in the {331} convolutions of the intestines. The sponges therefore should not be much smaller than the fist.

[Footnote 57: Lancet, May 26, 1877, p. 783; British Med. Journ., Jan. 28, 1882, p. 115; Ibid., Dec. 25, 1880; also, Ovarian and Uterine Tumors, by Spencer Wells, London ed., p. 336.]

[Footnote 58: Diseases of the Ovaries, by Lawson Tait, 4th ed., p. 261.]

Before closing the wound the operator removes the pressure-forceps and catches in one hand all the ends of the sutures on his side, his assistant does the same thing on the other side, and the edges of the wound are brought together by a firm pressure, which also chases the air out of the abdominal cavity. To stop the bleeding from the needle-tracks as soon as possible, each suture is rapidly tied and by the surgeon's knot. When the whole wound has been closed, and not till then, the ends of all the sutures are gathered together in one hand, and they are cut off about two inches from the knot by one snip of the scissors. This saves precious time, which would be lost were each suture by itself to be cut after being tied. At gaping points of the wound intermediate superficial stitches should be put in. In fat women several such stitches will usually be needed.

Dressing of the Wound.--After the wound has been closed the rubber apron is removed and the abdomen cleansed and dried. The wound may now be dressed according to Lister's plan. This consists, first, of a narrow protective of prepared oiled silk, moistened by a 1:40 solution of carbolic acid; next, of one broad layer of antiseptic gauze wetted with the same solution; and over this eight folds more of the dry gauze, having a piece of mackintosh interposed between the seventh and the eighth layer. The lamp is now blown out, and the spray-jet being directed away from the abdomen, the dressing is secured by an elastic flannel binder, the rucking of which can be prevented by tapes pinned to it around each thigh. Most of the leading ovariotomists, however, employ simpler dressings, which have been found equally antiseptic. Wells covers the wound with a dry dressing of thymol cotton, kept in place by long strips of adhesive plaster, going two-thirds of the way around the body. Over all is pinned a flannel binder. The thymol cotton is prepared by steeping absorbent cotton wool in a solution of one part of thymol to one thousand of water, and drying it. Keith dresses the wound with gauze wrung out of a 1:8 glycerole of carbolic acid. On this are laid several layers of dry carbolated gauze, next some cotton wool, and over all a flannel binder. Thornton uses Lister's gauze and the mackintosh, but without the protective. This dressing is secured by adhesive straps. On these are laid several folded napkins, and over all a flannel binder is pinned very tightly. Bantock resorts to dry thymol gauze. Tait uses nothing but ordinary absorbent cotton. Salicylated cotton I have found to answer so well that for years I used nothing else. It is made by steeping two parts of absorbent cotton in a solution of one part of salicylic acid to two of commercial ether, and afterward drying the cotton by a low heat. Lately I have been resorting to Keith's dressing, but it probably possesses no greater advantages.

The flannel binder having been pinned on, the night-dress is pulled down and the patient put to bed. The opium suppository containing one grain of the watery extract is slipped into the rectum, the six bottles of hot water are applied to different portions of the body, and she is covered with warm blankets. The tables, tubs, and other articles used in the operation are now removed, the room is darkened, and she is left alone with her nurse, who has positive instructions to admit no one besides the physician.

{332} Drainage.--When blood in small quantities is effused into the peritoneal cavity, coagulation usually takes place, the serum is then absorbed, the clot becomes organized, and no harm results. But when blood in large quantities collects in Douglas's pouch, it may behave as a foreign body and cause mischief. When, also, blood is mixed with serum, coagulation is not so likely to take place; the blood-corpuscles then are liable to break down, the fluid to become putrid, and septicæmia to set in. For these reasons the removal of these fluids by different modes of drainage has long been put in practice. The best mode is by a glass tube passed down to the bottom of Douglas's pouch through the abdominal wound, and not, as has been recommended, through a special opening made for it in the roof of the vagina. Drainage is at present very rarely resorted to by those operators who use strict antiseptic precautions, for they contend that septic changes in the blood do not then take place. Wells and Thornton have virtually given it up, while Keith, Tait, and Bantock, who have abandoned Listerism, are warm advocates of it. This question is a very important one, because a drainage-tube tends to the formation of a ventral hernia, and, being a foreign body, is in itself hurtful, and therefore should not be resorted to unless it will do more good than harm.

After a careful consideration of the subject I am forced from experience to believe that between the two extremes there lies a golden mean, and that drainage, even when the spray is used, is needed under the following conditions:

(a) Whenever a purulent or a colloid cyst has burst, and its contents have escaped into the cavity of the abdomen, either during the operation or some days beforehand.

(b) Whenever the contents of the cyst are putrid or purulent, and septic symptoms or those of peritonitis are present.

(c) Whenever a large amount of ascitic fluid is found in the abdominal cavity.

(d) Whenever four drachms or more of pure blood, or especially of a sero-sanguinolent fluid, can be squeezed out of the sponge in Douglas's pouch when removed just before the closure of the wound.

(e) Whenever the operator is in doubt what to do.

Should it be deemed needful for some of the above reasons to make use of drainage, a glass tube, open at both ends and about six inches in length, is passed through the salicylated cotton or other dressing, then between the two lowest stitches, down to the bottom of Douglas's pouch. A wire suture is first introduced between these sutures and left untwisted, its object being to close firmly the opening left by the removal of the tube and to hasten its union. Otherwise, a weak cicatrix results, tending to the subsequent formation of hernia. Keith's drainage-tube of three sizes is the one that I prefer. Its lower end is perforated with holes, and its upper end has a shoulder which keeps it from slipping into the abdominal cavity, and also enables it to hold a piece of thin rubber sheeting about eighteen inches square. In the centre of this a small circular hole is made, which, by stretching, is sprung over the tube. The mouth of the tube is covered by a cup-shaped sponge wrung out of a 5 per cent. solution of carbolic acid, and over this the sheeting is folded four times. The flannel binder may either be pinned over the drainage-tube, or else {333} it may be slit at the site of the tube and passed on each side of it, leaving the sponge and rubber sheeting outside of the dressing. They are then best held in place by a narrow strip of flannel, so as to permit inspection without interfering with the main dressing. Several times a day the sponge is removed, squeezed out, cleansed in a 5 per cent. solution of carbolic acid, and replaced. This in a hospital had better be done under the spray. Bloody serum collecting in this tube is sucked out either by a fine rubber tube attached to a syringe, or else by the long nozzle itself of the ordinary uterine syringe.

To prevent injurious pressure on the rectum, the tube must be lifted up occasionally about half an inch, and allowed to slip back of its own accord. It can be removed whenever the discharge has been reduced to not more than one or two drachms, and this usually happens within the first forty-eight hours. After its removal the opening left in the wound is closed by twisting the free ends of the wire suture placed there for this purpose.

AFTER-TREATMENT.--The subsequent treatment needs the greatest attention. The first care is to establish reaction. This is best done by stimulants, such as brandy and whiskey given in iced soda-water. Enemata of beef-tea and brandy or of milk and brandy will also be of advantage, while artificial heat is kept up. For the vomiting, which comes partly from the anæsthetic and partly from shock, repeated deep inspirations should be tried. They help by getting the blood rid of the anæsthetic as soon as possible. Chloral may also be given, or small lumps of ice may be swallowed. Sips of very hot water, or a tablespoonful every hour of a mixture containing equal parts of lime-water and of cinnamon-water, may also do good. A hypodermic of morphia will often allay vomiting, and I have seen it yield to small doses of atropia, and also to two grains of pure pepsin given every two hours in a tablespoonful of raw-beef juice. Twenty drops of ether given by the mouth will sometimes relieve it, and so also will a few drops of chloroform confined by a watch-glass over the pit of the stomach. In some cases I have tried, with the best results, the following effervescent mixture, recommended by Chèron:[59]

Rx. Potassii bicarb. | Potassii bromidi. aa | gr. xxxij; Aquæ, fluidounce ij. M.

Rx. Acidi citrici, drachm j; Syrupi, fluidounce j; Aquæ, fluidounce iv. M.

A dessertspoonful of the former is added to a tablespoonful of the latter, and given every hour. For vomiting, especially of the bilious variety, Lawson Tait recommends Monson's pepsin wine, given every ten minutes in drachm doses with a little ice-water.

[Footnote 59: Archives de Tocologie, Février, 1883, p. 122.]

Flatus is another annoying symptom, which, however, can very generally be dispelled by turning the patient over on her side and inserting a flexible catheter high up in the rectum. If this fails to relieve it, enemata of turpentine may be tried, or five-drop doses of the tincture of nux vomica may be given every two hours. Should the abdomen become painfully bloated, the binder must be loosened and the adhesive straps {334} nicked in several places. The painful tension on the stitches can be relieved by drawing the knees up and supporting them over a pillow doubled on itself. Should the flatus not yield, and symptoms of obstruction set in, the bowels must be opened at all hazards. Castor oil and Epsom salts are good cathartics for this purpose. When vomiting accompanies obstruction, calomel answers best, because it is not so liable to be rejected.

For the first thirty-six to forty-eight hours after the operation nothing whatever should be given to the patient excepting cracked ice, sips of hot tea or of barley-water, and an occasional teaspoonful of old whiskey. After that time tablespoonful doses of milk, of beef-tea, of thin oatmeal gruel, or of barley-water can be given every hour or two. The diet may then be cautiously increased, and especially after wind begins to escape from the rectum, the patient being enjoined not to hold it back from motives of delicacy. If the condition of the patient is such as to demand more nourishment, it had better be taken by the rectum. For a week the urine should be drawn off by the nurse, and the bowels kept quiet by a morning and an evening suppository. No other anodyne need be given unless called for by pain, wakefulness, or restlessness. Should the body-heat indicate a temperature of 101° or over, a bladder filled with broken ice, or, what is far better, a rubber ice-cap, should be kept on the head of the patient as long as it feels comfortable and does not chill her. If the temperature does not fall, and peritonitis or other septic symptoms set in, ice should also be applied to the pit of the stomach. Quinia and morphia must then be given in very large doses, preferably by the rectum, together with ten drops of the tincture of digitalis every hour until the pulse-rate is lessened and the temperature falls.

When a full week has elapsed the bowels should be opened; and, as this is a matter of importance, and is occasionally attended with symptoms of obstruction and with a good deal of constitutional disturbance, a few words will not come amiss. If the hardened feces can be softened down and dislodged by enemata, this is perhaps the best plan, clysters of ox-gall and water or of glycerin and water being the most efficient. But in my experience enemata have so often failed that I rarely resort to them in the first instance. If the woman's stomach is not irritable, I prefer to give her an ounce of castor oil. This is disguised in the compound syrup of sarsaparilla or in some other suitable vehicle, as warm milk, and is brought to her without any previous warning early on the morning of the eighth day. Should it be deemed unwise to try the oil, two Lady Webster pills and two compound cathartic pills can be given at bedtime of the seventh day, or a pill containing three grains of the compound extract of colocynth with one grain of the extract of hyoscyamus may be swallowed every four hours. The compound licorice powder of the German Pharmacopoeia, to which has been added potassium bitartrate, also answers well, provided the patient's stomach will bear teaspoonful doses every four hours. Should these remedies fail to act, they must be supplemented by enemata.

Fatal obstruction of the bowels from matting or from constricting bands of organized lymph has been frequently reported. Thus far, I have met with one fatal case, which, however, passed out of my hands after the operation. But occasionally I see cases of obstinate {335} constipation which give me great uneasiness and put me to my wits' ends. In one case, after the failure of other remedies the obstruction was overcome by broken doses of calomel combined with sodium bicarbonate, and by the distension of the lower bowel with very large enemata slowly given. Another desperate case yielded to repeated doses of tincture of belladonna. A third case, complicated by obstinate vomiting, was saved by ten grains of calomel given every two hours until the bowels were moved. Seventy grains were thus administered before the desired effect was attained, yet salivation did not occur.

When symptoms of obstruction once present themselves, they are likely to recur. The contents of the bowel should therefore be kept fluid, and for this purpose I know nothing better than the German compound licorice powder, given in teaspoonful doses at bedtime.

Suppression of urine sometimes follows ovariotomy, and in cases of diseased kidney is an alarming complication for this condition. For this symptom digitalis and the acetate of potassium should be given. Thornton treats it by baring the arms and packing them in towels which are kept wet with ice-water.

Tetanus may destroy the life of a patient while convalescing from the operation of ovariotomy. J. M. Bennett reports such a case.[60] The symptoms first showed themselves on the sixteenth day, and the woman died two days later. Chloral in drachm doses, administered by the bowel in the yolk of an egg, is perhaps the only remedy from which any good can be expected.

[Footnote 60: Lancet, Dec. 3, 1881.]

Occasionally, a few days after the operation, without any septic symptoms whatever or without any marked rise in the temperature, the parotid glands grow tender, swell up, and run through a course precisely like mumps, ending in resolution. This complication has been met with so frequently by myself and others that it cannot be a mere coincidence, but must be due to a reverse sympathy between the ovaries and these glands. It does not appear to increase the risk of the patient, for recovery took place in all the reported cases, of which three occurred in my own practice.[61] Parotid bubo may also take place after ovariotomy, but this sign of blood-poisoning, being a general one, happens as well after other grave surgical operations and during the course of specific fevers. Yet from the sympathetic relation between the parotid glands and the sexual organs it seems to occur more frequently in the septicæmia following ovariotomy.

[Footnote 61: Wm. Goodell, Transactions of American Gynæcological Society, 1885.]

Acute mania sometimes follows ovariotomy, especially when both ovaries have been removed. The attack is usually temporary, but it sometimes ends in insanity, and even in death, as in one of my own patients. Keith, Thornton, Tait, and other leading ovariotomists report analogous cases.[62]

[Footnote 62: The British Medical Journal, March 21, 1885, p. 597.]

SURGICAL TREATMENT.--The dressings, being antiseptic, need not, as a rule, be removed until the day following that on which the bowels are moved. Every other stitch may then be removed, and especially all that are loose or are cutting the tissues. The wound is then washed with a 2.5 per cent. solution of carbolic acid, and dressed anew with salicylated {336} cotton. I usually find the first dressing so sweet that I am able to reapply the unsoiled portion of it for a second dressing. A clean binder is now pinned on and the woman's clothing changed. Three or four days later all the stitches should be removed, the wound secured by narrow adhesive strips, and dressed as before. For fear of a weak cicatrix and the formation of a hernia at the site of the wound, the patient should not get out of bed until fully three weeks have elapsed, and should for as many months wear some kind of close-fitting gored binder or abdominal supporter.

If, before the week is over, the dressings become soiled or give out a bad odor, they should be at once renewed. They should also be removed whenever a high temperature, without being accompanied by tympanites, leads to the suspicion of cutaneous abscesses.

THE ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY.--When by the breaking up of adhesions to it the liver is wounded, the bleeding surface can usually be stanched, as Koeberle has shown, by the ferric subsulphate applied to the raw surface by the finger. If this fails the actual cautery at a dull heat should be used.

If, unfortunately, an adherent portion of the bowel is torn open, the wound should be carefully closed with very fine silk by the continuous suture. The sutured portion is then fastened to the lower angle of the abdominal wound as a safeguard in case of the subsequent formation of stercoral fistula.[63] Should the intestine be injured to any extent, the wound must be closed by two sets of fine silk sutures, the first set uniting the mucous edges of the wound by the continuous suture, the other set uniting one serous coat to the other at a line about one quarter of an inch distant from the wound. An ordinary cambric needle with fine sewing-silk will answer admirably for this purpose. In small wounds one continuous suture, carried through all the coats but the mucous, will suffice. A mere puncture can be closed by hooking it up and surrounding it by a single fine ligature.

[Footnote 63: "Discussion on a Paper by Garrigues," Am. Gynæcol. Soc. Trans., 1881.]

Wounds of the bladder have frequently happened, but they are by no means necessarily fatal.[64] These accidents are liable to occur when the bladder, being adherent to the cyst and carried upward by it, lies directly under the line of incision, or the bladder may be torn open while adhesions to it are being severed. The wound should at once be grasped by a pressure-forceps, the bladder emptied by the catheter, and the operation proceeded with. When the operation has been completed the wound in the bladder is attended to, and in one of the following ways: Either the vesical wound is brought up within the lips of the abdominal incision, and is closed by being included in the abdominal stitches, or it is closed by the continuous or Glover's suture, without including the mucous membrane in the stitches. A self-retaining catheter, such as the Skene-Goodman, must then be kept in the bladder for at least a week.

[Footnote 64: Eustache, Archives de Tocologie, April and May, 1880, pp. 193, 277; Boston Med. and Surg. Journal, Feb. 16, 1882, p. 153; British Med. Journ., Jan. 28, 1882, p. 115; Am. Journ. Med. Sci., Jan., 1883, p. 123.]

One of the ureters will sometimes be torn across while pelvic adhesions are being broken up. This accident is most likely to happen during the enucleation of a cyst growing downward because enveloped in the folds {337} of the broad ligament. It is almost always fatal, and is usually not discovered during the life of the patient, and, I am disposed to think, not often discovered after her death. Sometimes, however, urine will ooze out of the abdominal wound, and in rare cases the patient has recovered with a urinary fistula. In such a case Simon[65] successfully removed the corresponding kidney; Nussbaum[66] constructed an artificial ureter leading from the fistula to the bladder; and Tauffer[67] inserted the upper end of the divided ureter into the bladder by an artificial opening. It, however, failed to unite, and he later made an artificial ureter.

[Footnote 65: Annales de Gynécologie, June, 1877.]

[Footnote 66: Edinburgh Medical Journal, July, 1876, p. 1.]

[Footnote 67: Archives de Tocologie, Avril, 1880, p. 201.]

When an umbilical or a ventral hernia of moderate size is present at the time of the operation, efforts should be made for its radical cure. This is done by cutting out the thinned-out sac by two incisions meeting below and above, and by bringing together the thick edges of the abdominal wall in the final closure of the wound.

In cases of ascites complicating ovariotomy the ascitic fluid should not be wholly removed until the cyst has been cut off and the wound is ready to be closed. By this means any blood oozing from broken adhesions, or any fluid escaping from the cyst into the abdominal cavity, being diluted, is less likely to irritate the peritoneum, the cavity of which can also be more readily cleansed.

When a patient seems in danger of dying on the table from shock or from exhaustion the anæsthetic should be withheld while hypodermic injections of ether and enemata of brandy are given. Warmth should also be applied to the body by bottles of hot water, or, what is better, by rubber bags of the same. Theoretically, atropia administered subcutaneously would be the proper remedy, but I have not yet tested it. In all cases of ovariotomy, especially if prolonged, the woman should not be kept profoundly under the influence of the anæsthetic for any length of time, but should be allowed from time to time to come to at least enough to make her flinch or move about. This caution should especially be observed in very feeble patients and in those with very large cysts.

The Removal of Both Ovaries.

Whenever both ovaries are diseased there can be no question about the extirpation. But when only one has undergone cystic or other degeneration the question of the removal of the sound one may come up. There always is a tendency to the subsequent degeneration of the sound ovary after the diseased one has been removed. More especially is this tendency observed in sterile women and in those with malignant affections of the ovary. Many women, therefore, whose lives should have been imperilled but once, have been compelled to face the dangers of a second operation. In view of these facts, it seems to me wise to remove the sound ovary in all cases of sterility, in every case of malignant degeneration of one ovary, and in all women who have either passed the climacteric or are approaching it, provided its removal is not attended with great additional risk. Double extirpation should also be performed whenever the womb {338} contains a fibroid tumor or whenever it seems desirable to hasten on the climacteric. In these convictions I am further strengthened by the disappointment often expressed to me by my patients that one ovary had been left behind, and by their great fear afterward lest the remaining organ should also become diseased. On the other hand, in women who are in the prime of their menstrual life the sound ovary should be left untouched, unless there exist grave reasons for its removal.

{339}

DISEASES OF THE URINARY ORGANS IN WOMEN.

BY ALEXANDER J. C. SKENE, M.D.

ORGANIC DISEASES OF THE BLADDER.

Hyperæmia.

This is an acute congestion of the mucous membrane due to a disturbance in the balance of the circulation. It may be common to both bladder and urethra, or limited to either; may terminate within a short period of time (a few hours), or it may go on and end in hemorrhage or inflammation. If the mucous membrane is seen with the endoscope, it appears of a bright-red color; the blood-vessels are distended, more prominent, and apparently more numerous. The arteries are the first to be affected. If the cause is transient, this is all that is seen, the membrane returning to its usual color. When the congestion is of a higher grade, rupture of some of the vessels occurs either on the free surface or beneath the epithelium. The venous side of the circulation now becomes more prominent. In a few cases the above order may be reversed, the veins being the first congested, as in the case of a sudden interference with the portal circulation.

SYMPTOMS.--The attack occurs suddenly. Frequent but painless urination is the most prominent feature. There is a sense of heat and heaviness in the bladder, aggravated by standing. When the urethra is involved the patient complains of scalding during urination. The pulse and temperature are practically normal. The composition of the urine is but little changed; there may be excess of mucus and a few blood-corpuscles.

DIAGNOSIS.--This has to be made by exclusion. It is apt to be confounded with a neurosis of the bladder or a displacement.

ETIOLOGY.--The most frequent cause is exposure to cold, especially during menstruation; over-taxation in walking or using the sewing-machine; excessive venereal indulgence; disorders of the portal circulation; and the use of improper articles of food.

TREATMENT.--Every means should be employed to equalize the circulation. The most important element is rest in the recumbent position. Diaphoretics and warm applications to the feet and epigastrium, and, as a rule, a saline laxative. Where there is frequent urination and vesical tenesmus and pain, Dover's powder and camphor should be given, or a suppository of morphia and belladonna by the vagina.

{340} Hemorrhage.

This is a symptom rather than a disease itself. It is usually due to acute congestion or ulceration occurring in advanced inflammations, new growths, or the lacerations caused by foreign bodies and instruments. Hemorrhoids of the bladder due to obstructed circulation is not infrequently the source of the bleeding. The amount of blood transuded varies very greatly, though it is seldom so great as to prostrate the patient. In all cases when it is considerable it is of great importance to localize the bleeding point. The urethra can be excluded if there is no bleeding between the acts of micturition. The differential diagnosis between hemorrhage from the bladder or kidney is less easy. The old rule, that the blood and urine are more intimately mixed in renal hemorrhage than in cystic, is of little service. Sir Henry Thompson's method of detecting the source of pus in the urine may be employed in cases of hemorrhage. He introduces a soft catheter, and then washes out the bladder gently with warm water; if after a time the water comes out clear, the inference is that the bleeding point is higher up. To make sure, he corks the catheter until a drachm of urine has collected; if this is bloody, the diagnosis of its being extra-cystic is tolerably certain. With the endoscope it is occasionally possible, and always desirable, to locate the bleeding point.

The symptoms in hemorrhage from the bladder, besides the actual appearance of blood in the urine, are much the same as those in hyperæmia. Other symptoms liable to arise are from blood-clots forming and either being passed by the urethra, causing its distension and impeding micturition, or else such clots may be retained and accumulate in the bladder, giving rise to still greater functional disturbance, until they are either broken into small pieces by the surgeon and extracted, or else by the slower agency of decomposition they break down and come away.

TREATMENT.--The first thing is to obtain the advantages, both mechanical and physiological, of the recumbent position. A large number of hæmostatics have been used--tannic and gallic acids, ergot, and aromatic sulphuric acid. These are doubtless of some value, but we prefer giving opium in sufficient doses to allay the desire of too frequent micturition, and at the same time to render the urine more bland by alkaline diluent drinks. When the bleeding points can be discovered with the endoscope, they may be touched with caustic acid, nitrate of silver, or persulphate of iron. But such applications must be made with the greatest care, lest inflammation and ulceration result. Ice in the vagina and at the hypogastrium may be tried when other means fail. When the hemorrhage is hemorrhoidal, due to impeded venous return owing to pressure of the gravid uterus, the treatment will have to be purely palliative in the mean time, as the pathological condition of the veins usually rights itself after delivery. When a large blood-clot forms in the bladder, experience has abundantly shown that it is better not to meddle with it, but to let it break down itself and come away, the patient being kept easy--if necessary by opium and alkaline diluents.

{341} Cystitis.

Inflammation may be limited to the bladder alone, in which case we call it cystitis, or to the urethra alone, when it is termed urethritis. But, practically, the pathological processes and the causes of cystitis and urethritis are so closely allied that it will be convenient in our limited space to consider them together. Like inflammation of other mucous membranes, various forms or degrees of cystitis and urethritis are described: these classifications are useful clinically, but it should not be forgotten that the pathological conditions presented are only different stages of the same process. Inflammations of the bladder are divided according to the cause of the disease and the character of structural lesions into--the acute, including the catarrhal and the suppurative; and the chronic, including the ulcerative, interstitial (and peri-cystitis); and the specific, embracing the gangrenous, croupous or diphtheritic, and gonorrhoeal, in which the inflammation is the result of a special poison.

ETIOLOGY.--The causes of cystitis may be classed under four heads: (1) Direct injuries, such as blows in the vesical region, falls, fracture of the pelvic bones, violent copulation, sudden uterine displacements causing pressure, foreign bodies, rough catheterization, over-distension from retention of urine, and, above all, contusions and injuries during labor. (2) Abnormal urine, from improper food or malnutrition and certain irritating drugs (cantharides) and irritating deposits of urine salts. (3) Certain constitutional diseases (eruptive fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due to cold.

PATHOLOGY.--The acute forms always begin with hyperæmia, then follow swelling, perverted or hyper-secretion, then exfoliation of epithelium, giving rise to a roughened and denuded state of the mucous membrane, particularly on the top of the rugæ, the products of inflammation accumulating within the sulci, and finally the formation of pus. A description of these, the ordinary phenomena of inflammation of mucous membranes, it is quite unnecessary to give here, but there are one or two modifying conditions in cystitis that are of great importance and need consideration. The first of these is the effect which the function of the bladder as a reservoir of urine has on the inflammation. Normal urine is irritating to an inflamed mucous membrane, and in cystitis it soon undergoes decomposition, becomes alkaline, and hence more irritating. The main agent in producing this decomposition is mucus, which is secreted abnormally both in quantity and quality. It acts injuriously in two ways, its fixed alkali tending to neutralize the acid of the urine, which in the early stages of cystitis is often hyper-acid, and in promoting the decomposition of the urea and thereby liberating the volatile carbonate of ammonia. As the urine becomes more alkaline the precipitation of the phosphates of lime and magnesia occurs, and the formation of the triple or ammonio-magnesian phosphate.

The irritant effect of these salts, really deposits of foreign bodies, on the inflamed mucous membrane completes the vicious circle, the effect now aiding the original cause.

Another most important point in the pathology of cystitis is the effect of over-distension of the bladder. This is itself sometimes the primary cause of the trouble, as in certain neuroses, but more frequently it is the {342} effect of certain injuries during delivery. The mechanism of its production is not very clearly made out. It usually follows long, tedious deliveries, during which either the child's head or sometimes the forceps crushes the urethra against the unyielding pubic bones, giving rise to an acute urethritis, with swelling of the membrane and blocking up of the canal, causing retention. The primary injury is not done, as a rule, to the bladder in these cases, for if it were we should find the vesical neck the seat of sloughing of the mucous membrane; but, as a fact, this is the part (owing to its more loose connections with the underlying connective tissue) that most frequently escapes. This danger of over-distension is so clearly recognized that the catheter is nearly always used both before and after delivery if there should be retention. But a condition more apt to mislead both the doctor and the nurse is the urine dribbling away either constantly or intermittently. This is too often ascribed to an irritable bladder causing frequent micturition, when it is a sign of over-distension, the dribbling always occurring as soon as the mechanical pressure of the urine is sufficient to overcome the resistance of the swollen parts.

We have already referred to this condition of over-distension as a cause of inflammation; it will suffice to say that it may, if unrelieved, produce a partial or even total slough of the mucous membrane of the bladder; but, fortunately, this is rare.

Thus far we have spoken of the common forms of acute and subacute cystitis; it only remains to say a word with regard to its rarer manifestations. The inflammation may extend to the submucous coats, becoming interstitial cystitis. Again, this may limit itself here, or it may extend still deeper to the serous coat, in which case it is known as peri- or epi-cystitis. Peri-cystitis is almost always a secondary disease, arising sometimes from deep ulcerations of the inner coats of the bladder, such as occur in chronic cystitis. More frequently it is but a part of a pelvic peritonitis which originated outside of the bladder itself. The final result of peri-cystitis is to form adhesions between the bladder and the neighboring organs, and thereby prevent distension of the bladder.

A very rare form of gangrenous inflammation has been described, but it is more than doubtful if this ever occurs in women except as the result of mechanical violence or pressure, already described. The specific lesion of croupous or diphtheritic inflammation has occasionally been diagnosticated, either from shreds of false membrane passed by the urethra or by means of the endoscope. Gonorrhoeal inflammation of the bladder has been less carefully observed in women than in men. Still, it is known that this specific inflammation extends to the bladder in some cases, but it does not differ essentially in its pathology, history, or treatment from that arising from other causes; hence it is unnecessary to dwell upon it here.

The pathology of chronic cystitis is characterized by ulceration and sloughing of the tissues involved. They do not differ materially from the same processes elsewhere, except that the salts of the urine are apt to be deposited upon the shreds of dead tissue the products of destructive inflammation. The hard masses thus formed are passed with great pain. They block up the urethra, and are only expelled by extra strong efforts which cause intense suffering.

{343} Lastly, the ulceration may extend through the bladder into the peritoneal cavity and give rise to septic peritonitis and death, or the perforation may take place into the cellular tissue of the roof of the pelvis, and cause a fatal cellulitis.

SYMPTOMS.--The various forms of cystitis being but different stages and degrees of the same disease, their symptoms may be discussed all together. For convenience we shall consider them under three heads: (1) Referable to the organs themselves; (2) Symptoms referable to the neighboring organs; (3) General symptoms.

(1) In all forms of cystitis there is more or less derangement of function, as shown by pain, tenesmus, and frequent micturition. In the mildest form of the trouble there is a frequent desire to pass water, which often comes with unusual force. Micturition is followed by a desire to strain, as if the organ was not fully emptied. This sensation may pass off in a few moments, and not arise again till the next micturition, but in the severer cases it may last continuously. When urethritis is also present there is the additional and characteristic symptom of painful scalding as the urine passes over the inflamed track.

In urethritis alone there is often a desire to urinate frequently, but if the desire is resisted it passes off, and the patient can retain the urine for a long time. This symptom should not be mistaken for the tenesmus of cystitis. In the more advanced stages of the disease, especially as ulcerative changes occur, the tenesmus becomes more violent. The pains also are more diffused, often shooting to the umbilical region. There is often a dull, aching pain in the perineum, and in nearly all cases there is continuous backache, or, more correctly, sacral pain.

The composition of the urine is of great importance. The specific gravity in cystitis does not present any constant change, except that in the chronic forms it is often a little below the normal. The reaction in acute cystitis, at first, at least, is usually acid, whereas in the chronic forms it is almost invariably alkaline. The color at first is not particularly altered; later, unless discolored by blood, it is a pale, dirty yellow. The odor is normal in the acute type, unless where retention has been followed by decomposition, but in the chronic form it is not only ammoniacal, but has a characteristic fleshy or organic smell. The sediment in the acute varieties is mainly light and yellowish, composed of mucus, with some pus generally; in addition there may be blood, epithelium, and the amorphous and triple phosphates. In the chronic forms the sediment is usually heavier and of a darker brownish color. Flakes of pus, shreds of tissue, blood, and epithelium in all stages of growth are more or less present, and in the intensely alkaline conditions of the urine the pus and mucus form a jelly-like, ropy, opaque mass.

Albumen will be found if there is pus in the urine without there being any kidney disease. As the result of a careful analysis of a number of cases of chronic cystitis, the amount of albumen varied from one-sixteenth to one-fifth of the volume of urine. Microscopically, in addition to the pus, mucus, organic shreds, phosphatic and other crystals already spoken of, the most interesting appearances are the various kinds of epithelium. In the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. It is only in the earlier stages that normal and transitional forms of vesical epithelium are present, and again they {344} reappear on the subsidence of the inflammation. This fact is of great importance, because the transitional forms of bladder-epithelium are often indistinguishable from the permanent forms of the urinary tract higher up. It is thus often impossible to make a differential diagnosis between pyelitis and cystitis from this symptom alone. When renal disease is superadded to cystitis, the characteristic casts will be found and albumen will likely be increased in amount.

(2) The symptoms accompanying cystitis in women referable to the neighboring organs are of some importance, but they very often arise from some coexisting disease of other pelvic organs. It is therefore needless to give a list of all the pelvic pains coincident with cystitis which have been enumerated in the literature of this subject.

(3) The general symptoms are of two classes, toxic and nervous. While all agree that there is no doubt of direct blood-poisoning in cystitis, there has been a great deal of difference of opinion as to how this is effected. I think that there are various agencies at work in this. First, there may be organic renal disease or sympathetic renal hyperæmia leading to imperfect elimination. In cystitis caused by over-distension from long retention the kidneys simultaneously take on acute inflammation, which usually passes off when the bladder is emptied, but it may continue and give rise to all the constitutional symptoms of renal disease. Again, in chronic cystitis the thickening of the bladder-walls obstructs the ureters, so that the urine is dammed back upon the kidneys. This arrests their function, and in time leads to organic disease with all the consequent derangements of the nutritive and nervous systems. Secondly, absorption of the products of decomposed urine, or of pus and other septic materials the result of decomposing shreds of tissue, may take place.

Anæmia is another of the blood-changes which occur in chronic cystitis. In its origin and continuance it probably is much like anæmia due to long-continued inflammation elsewhere. The only peculiar symptom in this connection is the appearance of urohæmatin in the urine.

With this slow deterioration and poisoning of the blood various symptoms are developed. There is an effort made to eliminate urea by the mucous membrane of the alimentary canal. This is manifested by attacks of vomiting or diarrhoea. But when it does not come to these explosions, there is apt to be lack of appetite, especially at the morning meal, or there are perverted taste and constipation, interrupted by occasional attacks of diarrhoea. The skin in the chronic cases is at times sallow and clammy, and at times there is a distinct urinous odor about the body. Various more or less marked nervous symptoms are apt to be present. One set is characterized by the sluggishness of the patients, an inclination to sleep, despondent spirits, and occasionally dizziness and fainting. There can be little doubt that these and allied symptoms are referable to cerebral anæmia, for they are much aggravated by bromide of potassium, whilst digitalis and out-door life improves them. A second set of nervous symptoms are fairly attributable to blood-poisoning of one kind or another, and in the most severe cases are often promptly relieved by diarrhoea. Finally, a number of the irregular, wandering neuralgic pains and the headache are due to the general depression produced by bladder-pain and loss of sleep.

DIAGNOSIS.--Cystitis is easily made out, except in certain mild cases. {345} Similar symptoms, especially frequent urination, occur in prolapsus uteri, often in anteversion and in cases of pelvic adhesions and pregnancy and abdominal tumors, and lastly in certain neuroses. In most of these the recumbent position lessens the desire for frequent urination much more than when cystitis is present. Again, in the neurosis the attacks are irregular. Tenesmus is usually only present in cystitis, and lastly the examination of the urine and exploration of the parts should settle the question. We have spoken above of the method of differential diagnosis of blood coming from the bladder or the kidneys: the same method applies to localizing the source of pus. Urethritis with fissure at the neck of the bladder simulates cystitis in clinical history, and in the fact that pus in small quantity is found in the urine. To differentiate, the urine examined should be taken directly from the bladder with the catheter, when it will be found free from the products of inflammation. In addition to this, in some cases it will be necessary to make use of the endoscope, by which a good view can be obtained of the whole urethra and a portion of the mucous membrane of the bladder sufficient for diagnostic purposes.

TREATMENT.--The female bladder is so accessible, owing to the shortness of the urethra, that it is peculiarly amenable to local treatment. This is by no means, however, all that is required, for in all forms of cystitis, irrespective of the cause, the urine plays a very important part in keeping up the irritation. There are, therefore, always three indications to be met: (1) Removal of the cause; (2) constitutional treatment (diminishing the irritating character of the urine); (3) the cure of the local lesion.

(1) In many cases, of course, the cause is transient. The injury is done, and the inflammation resulting runs its course, longer or shorter according to the modifying influence of treatment. In a smaller number of cases, again, the cause is not removable, as in certain constitutional diseases or permanent pelvic adhesions, tumors, and the like. In such cases of course the treatment is but palliative, and, while relieving the immediate symptoms, aids the organs till a certain amount of toleration of the abnormal conditions is established. But in a large class of cases the cause, though more or less persistent, is removable. This includes the numerous cases of uterine displacement. Lastly, there is a certain number of uncomplicated cases which tend to recovery without treatment.

(2) The constitutional treatment should be first directed to reducing the amount of work the bladder has to do. For this purpose the bowels should be kept rather freely open, saline laxatives being the most valuable for this purpose. The skin too should be kept healthy and active. Next, the character of the urine should be as bland as possible. Food and drugs which are known to cause or keep up cystitis should be carefully avoided. Milk diet has proved successful in the hands of George Johnson. In all cases the diet should be carefully attended to, and should consist largely of fluid foods--milk, yolk of eggs, soups, etc. Lean meat in small amounts and easily-digested solids are allowable. Articles such as asparagus, alcohol, beer, and wine generally are to be avoided. Fruits, such as lemons and oranges, are usually grateful and at least harmless. The alkaline diluents, such as citrate of potassium or the alkaline mineral waters (Vichy), answer an admirable purpose. An infusion of buchu is an excellent agent, and may be combined with nearly {346} all other drugs employed in treating cystitis. Where pain is an urgent symptom in acute cases, it should be relieved by hot applications and by anodynes. Dover's powder is an excellent form in which to give opium. To relieve tenesmus vaginal suppositories of morphia, with or without belladonna, may be given. But in certain cases twenty-grain doses of potassium bromide every four hours relieve pain where opium fails. Benzoic acid or benzoate of ammonium in ten-grain doses in infusion of buchu, three times a day, is a most valuable remedy. The usual remedies, such as balsam of Peru or copaiba, oil of turpentine, etc., which are given in gonorrhoeal inflammation, are very useful in the chronic catarrhal forms of cystitis. To prevent or lessen the decomposition of the urine a vast number of remedies have been employed, all of the astringents and most of the antiseptics, but as a rule these remedies are much better administered locally than constitutionally. In various acute and transitory cases the constitutional remedies above described will be all that is necessary, but in the greater number local treatment is absolutely required.

(3) In local treatment the first point is not to do harm to the parts by the use of instruments. Dirty catheters and rough catheterization so often cause cystitis that it is easy to see that the same causes often perpetuate the mischief. Great care, then, should be used in selecting instruments for injecting. The ordinary metallic catheter with one or two large openings is much more liable to wound the sensitive mucous membrane than one with a number of small holes made either of hard or soft rubber. It should have a stopcock or something similar at the outer end, the better to regulate both the injections and the escape of the solution injected. In ordinary injections only about an ounce at a time should be in the bladder; this can be repeated four or five times, and the injection should be as slow as possible. To meet these indications I use a double perforated catheter made as follows: A small tube runs from one of the bifurcations to the extreme point. This is the supply-tube, and the catheter acts as the exhaust. The central tube can be removed for the purpose of cleaning the instrument. A piece of rubber tubing attaches the supply-tube to a fountain syringe, and this completes the whole apparatus. The calibre of the supply-tube being small and that of the exhaust large, a great quantity of fluid can pass through the bladder without distending it. The fingers can pinch the rubber tube and act as a stopcock to regulate the entrance and escape of the fluid used.

An injection of borax and water is often highly beneficial, and is alone sufficient in many cases. It should be frequently employed. It should always precede any topical application or medicated injection. Lukewarm water alone is employed, but the addition of a little salt (drachm j to pint j) or chlorate of potassium renders it more bland. Very often hot water is a most useful application. Of the medicated injections a vast number might be described, but they are referable to two classes, anodyne and astringent. The painful nature of cystitis suggests the use of opium preparations and chloral hydrate for injections, and they do give some relief. They should be well diluted to prevent their causing irritation.

Of the astringents, acetate of lead, sulphate of zinc, tannic acid, nitrate of silver are the most valuable. Many others--perchloride of iron, chlorate of potassium, hydrastis canadensis, salicylic acid and its preparations, carbolic acid, etc.--have been commended. In all cases the strength of {347} the injection should be short of causing the patient much pain. It is always best to begin with a mild solution and gradually feel the way up to stronger ones. Of all the astringents, I prefer nitrate of silver, which I use in strengths varying from one grain to twenty to the fluidounce. The general rule to be observed, if a strong solution is used, is to employ only a few drops; if a large injection is made, the solution should be weak.

Various antiseptics--iodoform, salicylate of sodium, etc.--have been used to prevent the decomposition which so complicates obstinate cystitis; but, as a rule, I think frequent washings out and astringent applications act much better. One of the most distressing obstacles encountered in making any such injections is where there is a tender or inflamed urethra. It is well then to carry the catheter only up to the sphincter of the bladder (as advised by Braxton Hicks), overcoming its resistance by the pressure of the injection. As a rule, the urethritis will not long survive the cystitis, but in some cases it exists as an independent affection; it is then usually gonorrhoeal, and should be treated as in the male. But when not, the same principles apply as in the local treatment of the bladder. Great care is needed, as the female urethra will only hold ten or fifteen drops at a time, and if a large injection is used it is almost sure to enter the bladder. To meet this difficulty I devised a reflux catheter for douching the urethra. It is grooved on the outside, and at the point there is an opening in each groove which lets a jet of the fluid used flow outward, bringing the injection in contact with all parts of the urethra.

In cases of ulceration, such as occur in bad cases of cystitis, applications should be made, if possible, to the part affected only. This can be accomplished by means of the endoscope when the ulceration is seated where it can be reached. Having located the point exactly by means of the endoscope, the inner or glass tube is withdrawn, and the application made directly to the required spot through the rubber tube. A glass pipette properly curved or any ordinary insufflator will answer perfectly, and when a solid is used a delicate long curved forceps will answer.

In chronic cases of cystitis in which all the above methods of treatment fail, it becomes necessary to give the parts complete rest by securing continuous drainage of the urine and products of inflammation. There are two ways of doing this--the one, to use a self-retaining catheter which may keep the bladder empty: this method answers very well when the inflammation is confined to the upper portions of the bladder, but when the neck of the bladder is involved the presence of the catheter gives rise to pain and irritation and cannot be tolerated. The other plan is to establish an artificial vesico-vaginal fistula, and keep it open for some months, until the bladder-walls have become normal again. This secures efficient rest to the inflamed parts; complete drainage is established, the patient wearing a cup, as she would a pessary, to catch the urine. If the inflammation is limited to the upper portion of the bladder, the drainage by the fistulous opening is all that is required; but if the neck of the organ is involved, frequent and continued medication will be required. This can be done by injecting through the urethra and letting the fluid escape through the opening in the bladder. This is not the place to discuss the steps of the operation or the indications when and how to close the artificial fistula. For these the reader is referred to works on this department of surgery.

{348} Suffice it to say, in conclusion, that this by no means easy operation should be only undertaken as a last resort, but that if properly done in well-selected cases it will cure where all other known methods of treatment have failed even to relieve.

Hypertrophy of the Bladder.

This lesion may be partial or total, involving any or all three coats of the viscus. But the term usually refers more particularly to increase of the muscular walls. As a rule, the hypertrophic changes are not confined to one portion of the viscus, all being more or less affected. The affection is much less frequent in the female than the male.

ETIOLOGY.--There are two varieties of this affection--one, concentric hypertrophy, in which the bladder is contracted as well as having its walls thickened; the other eccentric, in which there is dilatation. Its principal causes are--obstruction to the outflow of urine from stricture of the urethra, tumors, or foreign bodies; cystocele, preventing complete evacuation; cystitis, causing too frequent or too forcible contraction; and irritable bladder in certain of the neuroses. Accompanying such dilatation diverticulæ are sometimes formed, though rarely in the female.

SYMPTOMS.--There is sometimes present vesical spasm, some pain, and forcible ejection of urine. A certain amount of cystitis is almost always present, aggravating the original disorder. In the eccentric form there are sometimes superadded symptoms of over-distension.

DIAGNOSIS.--This is readily made by measuring the thickness of the bladder-wall between the finger in the vagina and the sound in the bladder. The capacity of the bladder is easily noted by measuring the urine passed at each micturition or by injecting a bland solution of salt and lukewarm water.

TREATMENT.--The treatment should be directed to the removal of the cause. When this is not possible, palliatives may be sought for in the use of the catheter, at regular intervals, to prevent over-distension. Cold baths, astringent injections, and electricity are often of use. By these means the evil results of the disease may be overcome, but the hypertrophy is usually permanent.

Atrophy.

Atrophy of the bladder is a rare disease in early life. In women, in addition to the ordinary decay of age, there is a special predisposition to degenerative changes in the pelvic viscera, the bladder-walls included, after the menopause. Extreme distension of the bladder is usually the exciting cause, giving rise to temporary or even permanent paralysis, and eventually causing either inflammation or atrophy and fatty degeneration. Interrupted nutrition, due to impaired circulation, is the immediate cause, but such altered nutrition may be purely nervous and due to atrophy of certain ganglion-cells in the spinal cord.

SYMPTOMS AND DIAGNOSIS.--Patients complain of difficulty in emptying their bladders, the urine coming away in interrupted jets. They are {349} apt to be irregular in their times of urinating, and are liable in consequence at times to have retention and over-distension. Pain and sometimes a slight cystitis are present. Finally, they completely lose the power of urinating and a catheter has to be used. The diagnosis is to be made as in hypertrophy, by a finger in the vagina and a sound in the bladder.

TREATMENT.--Regular catheterization, strychnia in full doses, electricity, and tonics, combined with washing out the viscus. Where the atrophy is due to nerve-degeneration these measures are purely palliative, in other cases they are of more avail.

FUNCTIONAL DISEASES OF THE BLADDER.

Under the name of functional diseases of the bladder are included a large number of varied affections of which the pathology is as yet very obscure. Where there are marked symptoms of vesical disorder, while no organic lesions are found in the tissues of the bladder, the affections must be classed under the name of functional derangements. As our knowledge increases the number of these is constantly diminished, and a still further and more rapid diminution will occur as the physiology and pathology of the nervous system innervating this viscus become better known. These diseases are much more common in children and women than in men--in children, because the controlling power of habit is only in process of formation; and in women, mainly because of the more complex organization of the genito-urinary organs, which are the more easily exhausted and deranged, especially by the functions of maternity. True, neuralgia of the bladder has been described under a variety of names, irritable bladder, cysto-spasm, etc., but it is rather a rare affection. The most prominent symptom is the painful micturition, and attendant on this a desire to pass water too frequently.

There is no particular change in the character of the urine, and no appreciable visible alteration in the appearance of the parts, though they are more sensitive than normal to the touch. This condition is best met by warm fomentations locally and sedatives either locally or generally, while nutrition is improved by appropriate tonics, nervines, and by the use of the galvanic current.

A much more common class of affections of the bladder accompany hysteria, sometimes grouped under the name of hysterical bladder. A great number of pathological conditions are grouped under this vague term, but they are held together by all having, as a more or less prominent symptom, varying degrees of incoördination. The disturbing effect of strong sudden emotion, as fear, upon the bladder is familiar to all, and in various organic diseases of the spinal cord and brain, such as myelitis and locomotor ataxia, a disturbance in the functional action of the bladder is among the first symptoms. It then becomes a matter of great difficulty, and yet of great importance, to make a differential diagnosis.

In hysteria the urine usually diminishes in specific gravity; it is apt to be increased in quantity, and, though clear in appearance, is irritating {350} to the mucous membrane. In such cases frequent urination, sometimes almost continuous, sets in; but it is an important point that during sleep the patient retains her urine the normal time. In others we get, on the contrary, retention, and this may be due to various causes. In some it is doubtless involuntary, as they say they cannot urinate, but in others it is assuredly will not. Many of these latter derive a morbid pleasure from catheterization. These are the patients who are given to the introduction of hair-pins, slate pencils, etc. etc. into the urethra.

Some authors claim that in the intense sexual excitement of hysteria the chronic erection of the clitoris makes pressure on the urethra, and so prevents the escape of urine, but this seems somewhat apocryphal.

Another class of cases resembling the hysterical in the frequency of urination are those addicted to masturbation; these are, fortunately, not very common.

In all of these cases the frequency and irregularity of urination is a much more prominent symptom than the pain. This latter is usually a slight scalding from the urine passing over the chafed and irritable urethra, especially at the meatus. (These symptoms sometimes occur in the miasmatic affections.) A number of neuroses of the bladder are reflex and dependent on peripheral irritation elsewhere. A typical example of this class of affections is what has been described under the title of ovarian irritation. In this condition there is very much heightened reflex irritability accompanying the increased tenderness and vascular engorgement of the affected ovary. It is difficult to explain the bladder symptoms which sometimes accompany the recurring crises of this disease, except as due to a nervous excitation spreading from the ovarian centres in the spinal cord to the adjacent bladder centres.

The diagnosis of this group of affections must be made by exclusion. We have some of the same symptoms--increased frequency of micturition, pain during and after the evacuation, tenesmus and shooting pains in the pelvis--as in organic disease. The most important guide is a careful examination of the urine, which shows the absence of abnormal constituents, thereby excluding organic disease. This diagnosis will be much strengthened by a digital examination, by the vagina, of the neck of the bladder, and the passage of a urethral sound, neither causing pain, as they would do in cystitis.

The PROGNOSIS is usually good, but it depends upon the length of time the affection has lasted.

The TREATMENT is mainly tonic and nutritive. The diet should be nutritious and simple, and the bowels regulated by mild purgatives. Constitutionally, small doses of strychnine are most valuable in improving the nerve tone; so also the constant electric current is of service. Locally, sedative suppositories in the vagina or enemata are advantageous, conium combined with belladonna or hyoscyamus seeming to act best. The liberal use of the bromides gives good results in some hysterical cases.

Paralysis of the Bladder.

This is the most grave of the functional affections, and, like paralysis elsewhere, it may be either peripheral or central. When the latter, as in {351} certain injuries of the brain or in certain well-marked lesions of the spinal cord, it hardly calls for more than mention here. Often, however, the cause is not recognizable in any organic lesion either of the bladder-walls or the central nervous system, and is to be sought for in more temporary and transient influences; thus as a result of over-distension most frequently, of impaired or lost nerve-conduction in fevers involving serious derangements of nutrition, all of which may be described as functional or temporary paralysis.

The invasion is usually gradual, except in apoplexy or traumatism. The patients, who are usually advanced in years, first observe that the urine is expelled from the bladder with less force than usual; the stream is smaller and comes slower, and straining takes place, the aid of the abdominal muscles being invoked. After a while the stream intermits, and finally partial or complete retention occurs. Then, if this condition continues, the sphincteric resistance gives way and constant dribbling occurs. In rare instances dilatation of the bladder-walls takes place, and finally cystitis. Dilatation of the ureters and hydro-nephrosis are not uncommon under these conditions.

Where the condition of retention obtains the DIAGNOSIS ought never to be difficult; the introduction of a catheter will conclusively settle it.

The PROGNOSIS in uncomplicated paralysis is usually good. When accompanying fevers, dysentery, peritonitis, etc. it usually disappears with the original disease. When due to centric lesions the outlook is about hopeless.

In all cases the bladder should be emptied at stated intervals. If the patient cannot do this herself, the surgeon should resort to the systematic use of the clean soft Jacques catheter. A most important point, too often overlooked, is the method of emptying an over-distended bladder. It is not safe to empty the bladder at once: the patient ought to be tapped at intervals, an abdominal binder being gradually tightened meanwhile. The too sudden removal of pressure from the vesicle walls which have been rendered anæmic allows of intense congestion, and in a condition of paralysis is the sure prelude to cystitis. The diet in these cases should be generous and stimulants are not contraindicated.

I cannot agree with those authors who recommend washing out the bladder with medicated solutions and forcibly distending the urethra, nor with those who use tincture of cantharides as a vesical excitant. Both plans are apt to produce cystitis. A far more rational though somewhat impracticable treatment is the use of electricity as recommended by Winckel--one pole (thoroughly insulated up to the point) in the bladder, the other on the symphysis or loins. The sitting should last about five minutes. But by far the most valuable therapeutic agent is strychnia, which should be exhibited in full doses, many of the reported failures with this drug being due to too small doses. In urinating the upright position is generally preferable to lying down, as the pressure of the abdominal organs to some extent compensates for the lack of tonicity in the bladder-walls.

Lastly, in these hopeless cases of complete paralysis an artificial vesico-vaginal fistula and the adaptation of an apparatus to catch the urine may be of service.

Functional disorders of the bladder are frequently met with, due to {352} abnormal constituents in the urine. As was mentioned above, these may be so grave or their irritant action continued so long as to give rise to cystitis. In the slighter forms, due to transient cause, the local trouble will speedily right itself, but in other cases, such as those dependent on functional derangements of other organs, as dyspepsia, the irritation is apt to return at varying intervals. In almost all these cases the immediate mechanism of the trouble is the presence of some urinary deposits. To this may be added the constitutional impairment, as in oxaluria, when the minute octahedral crystals are probably not more to blame for the local difficulty than the impairment of the nervous tone. Similarly, the poison of malaria and of certain of the exanthemata, and of many diseases marked by faults of assimilation and elimination, causes functional disturbance.

The prime indication in treating these cases is to render the urine more bland by dilution. For this purpose water, aided by the salts of potash and the alkaline mineral waters, is the best. This should always be given on an empty stomach, and the addition of infusion of buchu is excellent. In the condition known as oxaluria the alkaline salts are not called for, but instead thereof acids. Nitro-muriatic diluted and tincture nucis vomicæ tend to correct the faults of nutrition, and they should be largely diluted to relieve the local condition.

The last class of functional diseases are caused by lesions of position either of the bladder or of some of the neighboring organs. Here, again, we have conditions which if sufficiently prolonged may lead to organic vesical changes or may simply be temporary or intermittent. By far the greater number of these are dependent on malpositions of the uterus, which either drags or presses on the bladder. Either of these classes may be complicated with adhesions arising from a former cellulitis or pelvic peritonitis, the adhesions resulting therefrom maintaining a fixation of the pelvic organs which impairs the functions of the bladder.

Other causes of displacements are uterine and ovarian tumors, pelvic deformities, and fecal impactions of the rectum. Of the various displacements of the bladder it is needless to speak in much detail. The most important is the downward one. Various degrees of this are found up to complete cystocele, most commonly associated with prolapsus uteri. The bladder naturally sags inferiorly as age advances, and by far the most potent agent in causing this to become pathological is repeated pregnancy and injuries during labor.

It is a well-known fact that the first stage of vesicle prolapsus is apt to be marked by as great discomfort as the third, for after a while the organ seems to become accustomed to its altered relations. The treatment of this condition is difficult. The bladder should be replaced and kept there. As this usually necessitates the reposition and maintenance of the displaced uterus, it is extremely difficult, and in case of existing adhesions it is impossible. A great variety of mechanical means have been tried to furnish an artificial support to keep the parts in position. If the bladder alone is prolapsed, the pessary used for anteversion of the uterus will sometimes answer. The instruments devised by Thomas, Grailly Hewett, and myself are most commonly used.

{353} Acute Urethritis; Inflammation of the Urethra.

This affection may be simple or gonorrhoeal, and it is often difficult to tell the one from the other. There is a difference in history when we can get correct testimony from the patient. Simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease, while gonorrhoea comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. The chief symptom is painful urination. Sharp scalding is produced by the urine passing over the tender surface. There is often a frequent desire to urinate, but not so urgent as in cystitis. In some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. In quite a number of cases I have noticed hemorrhage, the source of blood being evidenced from the fact that it was not intimately mixed with the urine, and after micturition it oozed from the meatus urinarius.

An examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. Occasionally there is a discharge seen coming from the urethra, but if the parts have been recently bathed this may not be apparent. Introducing the finger into the vagina and pressing upon the urethra from above downward will cause a discharge, unless the patient has passed water immediately before. The appearance of the discharge corresponds to that of gonorrhoea in its various stages.

Cystitis, which is liable to be confounded with urethritis, may be excluded by using the catheter, and, after letting urine flow for a time, collecting the remainder for examination. The mucous membrane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. The instrument cannot be used in all cases, owing to the acute tenderness of the parts. Bleeding is very likely to occur in the examination, simply from the contact of the endoscope.

The TREATMENT of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. This will suffice in most cases of acute disease, but when it assumes the subacute form from the beginning, then the use of injections becomes necessary. I have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. For this purpose I use a catheter made like the fluted roller of a crimping-machine. The catheter conveys the water to the rounded point of the instrument. Behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. By this arrangement the water, as it flows back through the grooves, is brought in contact with every portion of the mucous membrane. The instrument is passed up to the neck of the bladder, and a fountain syringe attached to it, and the water as it flows away is caught in a cup.

The injection of solutions of nitrate of silver and sulphate of zinc will often prove useful. It must be borne in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where very slight force is employed while injecting. I use a large syringe, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. When the case is {354} of long standing, and the neck of the bladder appears to be involved also, I use a weak injection of one or two grains of nitrate of silver to the fluidounce, and inject it through the urethra with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. In old cases which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. While the bougie is passed once or twice a week, I apply to the vaginal portion of the urethra oleate of mercury or the unguentum hydrargyri. This will often suffice to stop the gleety discharge, as well as remove the thickening of the urethral walls.

Inflammation of the Urethral Glands.

These glands rarely, if ever, take on inflammation primarily, but vulvitis and vaginitis, especially if gonorrhoeal, often extend into them. When they do become inflamed, the disease usually remains without any tendency to subside. More than that, when a gonorrhoea affects these glands the inflammation will remain there after all traces of the disease have left the vagina, vulva, and urethra, and in time the discharge from these glands will light up the original vaginitis and vulvitis again. The symptoms of this inflammation are not diagnostic. The physical signs are the swelling and redness around the mouths of ducts which are located just within the labiæ of the meatus urinarius. This give a general redness to the meatus. By pressure made upon the urethra from above downward a purulent discharge from the ducts will be produced and can be seen escaping. The only effective treatment is to lay open the glands their whole length. They run upward in the posterior wall of the urethra, so that by passing a fine probe-pointed scissors they can be laid open on the vaginal surface. Care should be taken to prevent the incision from reuniting, and if the inflammation does not promptly subside applications should be made, as in the ordinary treatment of inflammation.

Another very troublesome affection of the urethra which usually results from urethritis is granular erosion, as it is called. The mucous membrane is covered with young, imperfectly-developed epithelium; the papillæ are hypertrophied and extremely sensitive. This gives rise to the most excruciating pain during micturition, and generally keeps up a distressing tenesmus. This disease is rarely seen except among old people. The diagnosis is made from the history and appearance of the urethra. The treatment is cauterization of the whole surface. The milder washes and injections do not accomplish much. Pure carbolic acid may be tried first, brushing it over the surface and repeating it in eight or ten days. This is the least painful application, and generally answers very well. When it fails a solution of nitrate of silver (one drachm to the fluidounce) should be used. In obstinate cases it is desirable, before using strong caustics, to dilate the urethra, and then touch it with a 50 per cent. solution of carbolic acid.

{355} Circumscribed and Subacute Urethritis.

Among the inflammatory affections of the female urethra there are mild forms which fall short of well-marked urethritis. Indeed, some of these attacks amount to little more than congestion or slight catarrh. In others circumscribed patches of the urethra become inflamed, the rest of the canal remaining normal.

The cause of this affection is generally some inflammation of other pelvic organs, such as cellulitis. In one case it occurred in a saleswoman who had been upon her feet many days from early morning until late at night. I found several small ecchymoses on several parts of the mucous membrane with zones of inflammation around them. The long-continued passive congestion had caused some of the small vessels to rupture, and the small blood-clots started the inflammatory process.

These cases tend to recovery if the patient is placed under favorable conditions. If there is much pain, and if the trouble appears to be tending to become chronic, mild injections may be employed.

Dilatation of the Urethra.

Dilatation of the whole urethra is not so common as dilatation of a portion of it. Even when the whole canal is larger than it should be, it is not, as a rule, uniformly so. In general, the urethral walls and the urethro-vaginal septum are usually enlarged, relaxed, and flabby. After a considerable time they may become indurated by infiltration or hyperplasia of the connective tissue. The mucous membrane is usually soft and loosely adherent to the subjacent tissues. Beneath the membrane there are sometimes masses of enlarged veins which give a dark bluish appearance to the parts. If the meatus be distended like the rest of the urethra, the mucous membrane with the large veins beneath it may protrude and form a tumor or tumors, which have quite the appearance of rectal hemorrhoids. This is especially so when the veins are large and numerous and the mucous membrane thin, so that the color of the veins can be seen through it. On the other hand, if the meatus remains normal in size, nothing will be seen by the examiner until the catheter or sound is passed into the urethra, when the distended or distensible condition of the canal will be detected. The dilatation can be easily detected, even when the meatus is normal in size, by observing that the sound can be moved about in the urethra, conveying the same impression obtained when the sound passes into the bladder. By making a digital examination of the vagina the enlarged urethra can be felt, and it is usually elastic and compressible. Through Sims's speculum the abnormal fulness or bulging of the anterior vaginal wall can be plainly seen and distinguished from displacement of the urethra. The points of difference between dilatation and displacement will be brought out more in detail farther on.

When the dilatation has existed for any length of time, the mucous membrane is usually hyperæmic, and sometimes catarrhal, secreting a muco-purulent material, which may be seen escaping from the meatus or lodged in the folds of the membrane, where it can be seen through the {356} endoscope. When the mucous membrane is prolapsed and forms a tumor outside of the meatus, it soon becomes fissured and ulcerated, and consequently very tender and painful. This condition is produced by the retarded circulation, chafing, and the irritation from exposure to the air and the urine passing over it.

Dilatation of the anterior or lower third is the rarest of all forms of urethral dilatation, and occurs usually as a consequence of some enlargement or swelling of the mucous membrane, neoplasm of the urethra, or mechanical dilatation. The dilatation may or may not include the meatus. In rare cases it does not at first, but in time the enlarged mucous membrane slowly, sometimes rapidly, dilates the orifice. The general appearances of the parts are the same as those of which I have spoken under the head of dilatation of the whole urethra. When the dilatation is due to any new growth in the urethra, the tumor can be seen on inspecting the parts.

I have only seen one case where the lower end of the urethra was dilated without any recognizable cause for it. This was a single lady, thirty-five years of age, a school-teacher. She had displacement of the uterus and catarrh of the cervical canal, for which she consulted me. She had no trouble with her urinary organs. While examining the uterus I noticed that the meatus urinarius was peculiarly formed. In place of the concentric corrugations of the mucous membrane which form the closed meatus, the orifice was funnel-shaped and lay open when the labia minora were separated. About half an inch of the lower end of the urethra admitted a No. 21 (Eng.) sound. The remainder of the urethra was normal, and there were no signs of disease about the mucous membrane of the dilated portion. I could obtain no history which pointed to the origin of the trouble, and it caused no discomfort to the patient.

Dilatation of the posterior or upper third occurs in connection with other pathological conditions, such as prolapsus of the bladder and urethra. On this account we will defer what is to be said on this subject until we come to dislocations of the urethra.

Dilatation of the middle third of the urethra is more common than that of any other portion of the canal. In this form the anterior wall of the urethra maintains its normal position, but the central position, being distended, settles down, so that in time the urethra, in place of being a straight or slightly curved canal, becomes triangular, the upper wall being the base, and the central portion of the wall (that is, midway between the neck of the bladder and the meatus) the apex. A sac or cavity is thus formed in the central portion of the urethra.

In the earlier stages of this affection the urethra in front and behind the pouch is really or apparently contracted; but as the disease progresses the upper part of the canal and the neck of the bladder become dislocated downward, and finally the upper portion of the urethra becomes also dilated to some extent.

There is in this as in the other forms of urethral dilatation frequent urination, usually more marked, but, unlike the others, there is difficulty in passing water. This frequency of urinating, and the straining efforts necessary to do so, affect the bladder, producing irritation, and in time hypertrophy of its walls. Cystitis also follows in the order of morbid developments; but whether that comes from the frequent and difficult {357} urination, or from extension of the inflammation from the urethra to the bladder, is a question.

ETIOLOGY.--The hyperæmia of the urethra which occurs in pregnancy, and which tends to produce over-distension of the veins, favors dilatation of the whole urethra. There is an apparent increase of tissue in the walls of the urethra during utero-gestation, and the dilatability of the canal is often increased also. Now, this condition of the parts disappears during the involution which takes place after delivery; but when from any cause the process of involution is interrupted, the enlarged vessels and relaxed condition of the urethral walls remain and sometimes increase. When to this state of the parts a catarrh of the mucous membrane is added, the enlargement of the membrane by swelling still further increases the calibre of the canal.

The dilatation caused by the passage of calculi may remain permanently, and the same may be said of the use of large sounds. Neoplasms obstructing the meatus or stricture at that point may so obstruct the escape of the urine as to cause dilatation at all points above. This is no doubt one of the most important and frequent causes of dilatation.

I have already stated that dilatation of the lower third of the urethra is rare, and is usually due to inflammation of the mucous membrane at that point or to abnormal growths, the distension remaining after the causes that produced it have been removed. This and mechanical dilatation from any cause cover the etiology of this form of the trouble. Baker-Brown says that the meatus is always dilated when there is stone in the bladder.

Regarding dilatation of the upper third of the urethra, I am inclined to believe that it occurs in consequence of a partial prolapsus of the bladder and the upper end of the urethra. The displacement of these parts implies a relaxation of the tissues, caused originally, it may be, by injuries during confinement, and the prolapsus permits an unusual pressure of the urine upon the upper end of the urethra, and dilatation is the result. On the other hand, the prolapsus and accompanying relaxation of the urethral walls may be sufficient to cause the dilatation. In all the cases that I have critically examined there has been displacement as well as dilatation, and the whole trouble could invariably be traced to childbearing or anteversion of the uterus.

One cause of dilatation of the middle third of the urethra (urethrocele) has been sufficiently dwelt upon in Bozeman's description of the pathology of that affection--that is, narrowing of the lower end of the urethra. This does not explain the etiology of all cases, however, for I have seen this form of dilatation where there was no stricture or hypertrophy of the lower end of the urethra. In such cases I have traced the cause to childbirth, during which the posterior wall of the urethra had been pushed downward and contused, while the upper remained in its normal position. The relaxation caused by this over-stretching of the urethral wall formed a small pocket in the central portion, which gradually dilated more and more by the pressure of the urine until the urethrocele was fully developed. This explanation of the cause may be rather hypothetical, but, so far as my observations go, it agrees with the facts found in those cases which cannot be accounted for by Bozeman's views on the pathology of this affection.

{358} SYMPTOMATOLOGY.--The symptoms vary according to the extent of the dilatation, the portion of the urethra involved, and the condition of the mucous membrane. When the whole urethra is dilated the only symptom present may be frequent urination. When there is inflammation or prolapsus of the mucous membrane, then pain will be caused by passing water, and the desire to do so will be more urgent and frequent. The patient may also be annoyed by a slight loss of control of the water, under the pressure of lifting heavy weights, coughing, or the like.

Dilatation of the lower third of the urethra does not cause any derangement of function, unless accompanied with inflammation or ulceration; then there will be frequent urination possibly, and painful urination certainly. The symptoms in this form of dilatation are less marked than in the other varieties.

When the trouble is located in the upper third of the urethra, the symptoms are sometimes very distressing. In addition to the frequent--it may be constant--desire to pass water, the patient is tormented with partial incontinence. Coughing, laughing, sneezing, stooping to lift anything, a jar on stepping from the curbstone in crossing the street, causes an escape of urine. This distresses the patient very greatly. From the constant wetting of the external parts they become inflamed, unless very great care is taken to keep them dry and clean. In some of these cases the mortification of mind is sometimes more distressing than the physical suffering.

The symptoms occuring in dilatation of the middle portion of the urethra are the same as those already given, with the addition of a slight mechanical obstruction which causes difficult urination; that is, more voluntary effort is necessary on the part of the patient to empty the bladder. The forcing, straining efforts made by some of these patients while urinating are even greater than the mechanical obstruction appears to account for. This may be due to the accumulation of urine in the urethra, which excites extra reflex action in the bladder and urethra out of proportion to the obstruction. This is the only way that we can account for the difficult urination and muscular hypertrophy found in those cases in which there is no great obstruction from stricture.

The constitutional symptoms arising from these urethral troubles are the same as those produced by urethritis, and are not peculiar to this class of affections. In fact, the symptoms here given may all be produced by other pathological conditions, and consequently cannot alone guide to a correct diagnosis. The true character of the trouble can only be discovered by physical exploration.

DIAGNOSIS.--A digital examination by the vagina will detect the increased space occupied by the urethra. The canal encroaches upon the anterior vaginal wall, and feels like a ridge extending from the meatus to the neck of the bladder. This elevation or thickening of the urethra is elastic and compressible in recent cases; in those of long standing the tissues are firm to the touch, but still the canal is compressible. The extent of the dilatation, if general or located in the lower parts, can be measured by the size of the sound that can be easily passed. If at the middle or upper portions, an ordinary female catheter or sound may be used to explore it. By introducing that instrument and pressing it first against the anterior wall and then upon the posterior, the distance between {359} the two can be approximately made out. While the catheter or sound is in the urethra the finger should be introduced into the vagina to ascertain the thickness of the urethral wall. This will differentiate between dilatation and hypertrophy.

When the meatus is dilated and the mucous membrane and enlarged vessels are prolapsed, care is necessary to distinguish that condition from urethral neoplasm. This can be done by observing that in prolapsus the opening is situated either at the upper side or in the centre of the protruding mass, whereas in abnormal growths of the urethra the meatus surrounds the tumor or its pedicle. More than that, by making pressure the distended vessels can be reduced in size and the prolapsed membrane pushed up into the canal. This cannot usually be accomplished with tumors.

PROGNOSIS.--There is no natural tendency to recovery in these affections. If left alone they generally get worse. Recovery under treatment depends upon the location of the dilatation and the duration of the trouble. The conditions upon which an unfavorable prognosis is to be based are--bladder complications, inflammation or ulceration near the neck of the bladder, great varicosity of the veins, and fatty degeneration of the muscular tissue. In the absence of all these complications a complete recovery may be expected. In all cases great relief can be secured by treatment and the patient guarded from getting worse.

TREATMENT.--In the management of all forms of urethral dilatation attention should be given to any inflammation of the mucous membrane that may exist, employing the usual treatment. When there is a relaxed and prolapsed condition of the mucous membrane, astringents should be used. Tannic acid or alum will answer well. When these fail, the redundant membrane should be retrenched, either by touching it with the thermo-cautery or excising a portion with the scissors. In employing the cautery for this purpose the long pointed tip of the instrument should be used, and, having protected one side of the urethra with the speculum, cauterize a narrow strip of the membrane parallel to the axis of the canal. Two or more of these cauterizations may be made at points equidistant on the circumference of the urethra. By operating in this way pieces of normal membrane are left between the portions cauterized, which prevents stricture from occurring after healing--a misfortune which is sure to follow if the mucous membrane is destroyed by cauterization all around.

In excising the prolapsed portion I prefer to remove one or more V-shaped portions on opposite sides and bring the edges together by sutures. This is preferable to clipping off the whole of the protruding mass, because the cicatrices left are less likely to give after trouble.

When the dilatation is caused by varicose veins it may be well to follow the example of Gustave Simon. He exposed the vessels by cutting through the vaginal wall, ligated the largest, and arrested the hemorrhage from the smaller ones by applying liquor ferri perchloridi. He repeated this operation several times on the same patient, who experienced little or no inconvenience from the proceeding and made a good recovery.

Dilatation of the lower third of the urethra is usually secondary to some other trouble, as I have already stated; and all that is necessary {360} to do for such cases is to remove the cause and treat any inflammation that may exist. The dilatation will then disappear; and if it does not, but little if any trouble will be caused by it.

The treatment of dilatation of the upper third consists simply in supporting the parts. This can be effectually done by using the pessary already recommended for the relief of prolapsus of the bladder. It may be necessary to have the instrument so formed as to bring the pressure where it is required. This is done by placing the pessary in position and observing what change of form, if any, is necessary, and then directing the instrument-maker to make the alteration. If the parts are well supported in this way, recovery will follow unless atrophy of the muscular wall has previously taken place. Even then the patient can be kept comfortable by wearing the pessary. If there is urethritis present, it may be necessary to remove that before using the pessary; otherwise the pressure of the instrument may cause pain and aggravate the inflammation.

In dilatation of the middle third Bozeman has proposed to make an opening into the most dependent part of the urethra through the vaginal wall, and maintaining it until all inflammation has been relieved, and then closing the opening by the usual plastic operation. By this means the urethra is perfectly drained of urine and the products of inflammation which accumulated there before. This, with appropriate cleansing and topical applications, soon restores the mucous membrane to its normal condition, and the removal of the redundant tissue during the operation of closing the opening effectually cures the whole trouble. This treatment is admirably adapted to marked cases of long standing, and should be employed. By using the thermo-cautery to make the opening the operation is easily performed. In recent cases of less magnitude I have obtained satisfactory results by dilating the lower part of the urethra and supporting the dilated portion either with a pessary or a tampon of marine lint. This permits the urethra to keep itself empty, and then, by frequently washing it out and applying such remedies as will cure the urethritis, recovery will sometimes follow.

Dislocations of the Urethra.

This is one of the affections most frequently met with in practice. I have found very few cases recorded in medical literature. This neglect of the subject by authors is perhaps due to the fact that in many cases of displacement of the urethra the bladder is also dislocated, and the whole trouble is described under the head of vesicocele or cystocele. Now, it is true that displacement of the two occurs together, but either may take place alone.

The extent of displacement varies exceedingly, but I shall describe only the partial and the complete. A clear comprehension of these two degrees will cover all intermediate forms. In partial displacement downward the upper two-thirds of the urethra are prolapsed, so that the direction of that portion of the canal is backward, instead of curving upward, as in the normal condition. In complete prolapsus the urethra runs from the meatus (which is in its normal position) backward, and rests upon the {361} perineum, or in extreme cases, accompanied with prolapsus of the bladder and uterus, its direction is backward and downward, the position of the vesical end of the urethra being below the level of the meatus. In this degree of displacement the urethra and bladder can be seen presenting at the vulva or lying between the labia minora. The urethra is usually shortened considerably when the prolapsus is marked.

ETIOLOGY.--Utero-gestation and delivery are the most important causes of this affection. In the advanced months of pregnancy I have observed that while the bladder rose above the pubes the urethra was pushed slightly downward by the settling of the enlarged uterus into the pelvis. In such cases when labor occurs the head of the child dislocates the urethra still more by pushing it still farther down. This process I have often watched in forceps delivery. When there is a partial prolapsus of the urethra existing before labor, the urethra and anterior vaginal wall are forced down before the advancing head, and that, too, while the attendant is making counter-pressure to prevent it. The displacement produced in this way is often restored during convalescence if proper care be taken to push the parts back into place and the patient is kept at rest until the tissues regain their tonicity. But in many cases the trouble is overlooked, and by permitting the patient to get up and be on her feet while there is still prolapsus it will slowly increase until the dislocation is complete. This will surely be the case if there is any loss of perineum. Indeed, rupture of the perineum is an accident which permits the urethra to descend from its place. The perineum supports the vaginal walls, which in turn support the urethra; and if it be lost, even in part, the vaginal walls become relaxed, or perhaps never regain their tonicity after delivery, and, settling down more and more, carry the urethra with them.

SYMPTOMATOLOGY.--The symptoms arising from displacement of the urethra are much the same as those found in dilatation and other urethral diseases. I need not, therefore, repeat them in detail. Suffice it to say that in dislocation of the upper portion of the canal there is, in addition to frequent urination, a partial loss of control of the bladder. Under the extra pressure of coughing, for example, the urine will escape. This loss of control does not exist, as a rule, in complete displacement. On the contrary, there is usually difficult urination, which requires increased voluntary efforts to empty the bladder. In all degrees of displacement the symptoms are increased in the erect position, and are markedly relieved on the patient's lying down.

DIAGNOSIS.--An examination of the vagina, either by touch or speculum, will reveal the downward projection of part or all of the urethra, which will show that there is either dilatation or prolapsus. The change in the direction of the canal will be shown by passing the sound, and dilatation can be excluded by observing that the urethra grasps the instrument firmly at all points. In dislocation of the upper two-thirds of the urethra the sound passes in the normal direction, but is arrested at a half or three-quarters of an inch from the meatus; but by pushing up the vaginal wall and the urethra the sound will then pass into the bladder. When the prolapsus is complete the instrument passes in easily, but takes a downward and backward direction.

PROGNOSIS.--Uncomplicated displacement of the urethra can be remedied in the great majority of cases. By placing the parts in proper {362} position, and holding them there, the relaxed tissues will usually contract sufficiently to support themselves. Should they fail to do so, the patient can at least be made comfortable by wearing some supporter.

TREATMENT.--When the displacement of the urethra is caused by any other trouble, such as defective perineum or prolapsus uteri, then these things should first be attended to. Should there be urethritis, that also should receive appropriate treatment. But the chief indication is to retain the urethra in place; and this can be easily accomplished by using the pessary which has been recommended for supporting the prolapsed bladder. Prolapsus of the upper part of the urethra can be relieved in this way quite satisfactorily. When the whole urethra is displaced, this pessary, while it supports the upper part, will still permit the middle portion of the urethra to settle down. This difficulty may be overcome by making the anterior portion of the pessary long enough to engage in the introitus vulvæ, and in that way keep the whole canal where it should be. Should this cause the patient much discomfort, a tampon of marine lint should be used to keep the parts in position until some restoration of the parts is obtained, and then the pessary will complete the treatment.

Prolapsus or Inversion of the Urethral Mucous Membrane.

The prolapse may be limited to one side or extend all around the canal. The size and extent of the protrusion vary considerably. If the meatus is of full size, the prolapsed portion will usually preserve its natural color for a time; but after a little, from chafing when wet with urine, and especially if not kept clean, it will become red and oedematous. When the meatus is small these changes occur sooner and in a more marked degree, because the prolapsed portion is partially strangulated. The longer the membrane remains exposed the more sensitive it becomes, and the frequency of urination and pain attending it increase. It also becomes very tender and painful to the touch. In marked cases the ordinary movements of the body irritate the parts, and in that way render walking painful.

These are symptoms that closely resemble those of irritable growths at the meatus urinarius, and, so far as history is concerned, it is not easy to make a differential diagnosis. To do this it is necessary to make a local examination. The physical signs and the points in the diagnosis between this affection and other diseases have been given briefly but sufficiently under the head of Dilatations of the Urethra, and need not be repeated here.

The causes of prolapsus of the urethral mucous membrane are numerous, but those that are best known are long-continued congestion of the membrane, urethral and cystic irritation causing frequent urination and vesical tenesmus. Chlorotic and greatly debilitated women are said to be predisposed to it, as also old prostitutes. The few cases that I have seen were in women over fifty years of age, and all of them were weak, nervous patients who had suffered from some organic disease or functional derangement of the urinary organs.

PROGNOSIS.--This disease does not yield promptly to mild treatment, {363} unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. But in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means.

TREATMENT.--When a case is first seen it is well to remove any inflammation or other complicating conditions. The prolapsed membrane should be replaced, and the patient kept quiet in bed to favor the retention of the parts in situ. Astringents, such as tannic acid, alum, or persulphate of iron in a weak solution, should also be used. Should these fail, the prolapsed portion of the membrane should be removed. The methods of doing this (by excision and the thermo-cautery) have already been described.

Stricture of the Urethra.

PATHOLOGY.--Obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. Still, it occurs sufficiently often to demand attention. There are some facts in the pathology of urethral stricture peculiar to women which we will first notice. Passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. Stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal.

SYMPTOMATOLOGY.--Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. In almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. The previous {364} history of cases in which stricture is suspected will aid in settling the diagnosis and etiology.

DIAGNOSIS.--A digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be detected in the same way. The use of the sound will determine the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascertained.

The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations.

PROGNOSIS.--Stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state.

TREATMENT.--The treatment of stricture will depend upon its location and cause. If it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. When due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. Dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as the stricture has given way dilatation should be suspended.

Incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively.

In contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation, and pass the sound from time to {365} time to see if there is any tendency of the stricture to return. The brilliant results obtained in the treatment of stricture in the male with electrolysis by Robert Newman should warrant a more extended trial of this method.

Stricture at the Junction of the Urethra and Bladder.

This form or location of stricture is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations have been limited, but sufficient, I think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal.

The causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. The point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. Contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. This is contrary to the history of stricture of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. It is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ.

The symptoms presented in this form of stricture are difficult urination and in some cases complete retention. I have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder.

In this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. Our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal.

Having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. To distinguish these from the stricture, the catheter should be passed when the bladder is well {366} distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. On the other hand, in paralysis and atrophy the stream is slow and without force--so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diagnosis may be confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. There is a slight yielding at all points except at the stricture, where a decided resistance is met.

Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. Rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present that is all that I have to offer on this subject.

{367}

DISEASES OF THE VAGINA AND VULVA.

BY EDWARD W. JENKS, M.D., LL.D.

DISEASES OF THE VAGINA.

The subject will be considered in the following order: Anatomy, Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina, Growths, and Vaginismus.

Anatomy.

The vagina is a musculo-membranous canal extending from the neck of the uterus--which it embraces--to the vulva. It is usually attached to the uterine neck at a point midway between the os internum and the os externum. This canal is composed of three layers or coats: the outer one is of fibrous and elastic tissue; the middle, of unstriped muscular fibre and fibre-cell; the inner coat or lining is mucous membrane, composed of connective tissue and elastic fibre and covered with squamous epithelium. The outer and middle coats spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. One of the peculiarities of the middle coat is that during utero-gestation it becomes much hypertrophied like the same structure in the uterus, and following labor undergoes a similar process of involution. The inner or lining coat extends to the fourchette.

Savage[1] has described the general form of the vagina as similar to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. The ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum; it is about two inches long, while the posterior wall or posterior column is twice that length. The anterior column or cord causes the investing mucous membrane to be puckered and thrown into folds or rugæ which run transversely toward the posterior column. "This mucous membrane is studded with papillæ which are covered with pavement epithelium. The papillæ of the vagina, which were first fully described by Franz Kilian, were regarded by him as having for their function the transmission of sensation. He represents them as being thread-like and filiform."[2]

[Footnote 1: Anatomy of the Female Pelvic Organs, London, 1870.]

[Footnote 2: Thomas on Diseases of Women, Philada., 1880.]

Anatomists have differed regarding the existence of muciparous glands {368} in the folds of the vaginal mucous membrane, some asserting that they are present, and others being equally positive that there are none. Notwithstanding this lack of uniformity, the fact that some have discovered muciparous follicles, while others have failed, enables recent writers to state that there is no doubt of their existence.

The vagina is lined with mucous membrane and covered with pavement epithelium, studded with projecting filiform papillæ. This membrane lies in folds, between which are numerous muciparous follicles.

Vaginitis.

DEFINITION.--Vaginitis is a term used to designate inflammation of the mucous membrane of the vagina.

SYNONYMS.--Colpitis, Elythritis.

VARIETIES.--Three distinct varieties of vaginitis are met with--viz. simple, specific, and granular.

ETIOLOGY.--Predisposing Causes.--Young girls are not unfrequently the subjects of vaginitis in consequence of want of cleanliness, exposure to cold, ascarides migrating from the rectum into the vagina, or the introduction of foreign substances. It also frequently appears in consequence of smallpox, measles, and scarlatina. In adults it may be caused by exposure to cold or wet, more particularly at or near a menstrual period. The insertion of a sponge into the vagina, as is not uncommon for the purpose of topical medication or uterine support, acts as an irritant if allowed to remain a few days, which may cause severe inflammation. Pessaries, irritating vaginal injections, gonorrhoeal infection, certain conditions of the urine, as in diabetes, acrid uterine discharges, childbirth--more particularly if there has been retention of putrefying secretions--and chemical agents used in treatment of uterine diseases, are sometimes causes. Uterine discharges which cause vaginitis are not generally irritating until they reach the vulva, where by exposure to the air they become changed, first causing vulvitis, and next inflammation of the vaginal mucous membrane.

Some women have slight attacks of vaginitis after each menstrual period, but they are generally slight and soon subside; others will have attacks after each coition or after great physical exertion, but with such patients the disease is not severe, and usually passes off without any signs remaining. It is quite common among prostitutes, independent of specific causes, in consequence of excessive coition. Chronic vaginitis or vaginal leucorrhoea is not uncommon with newly-married women in consequence of excess or awkwardness in coition.

Granular vaginitis is generally caused by pregnancy, but occasionally it seems to be produced by simple or specific vaginal inflammation. A strumous diathesis or a disordered state of the blood, as in phthisis or other constitutional disorders, are predisposing causes.

Mention has been made by some writers of diphtheritic and senile vaginitis. Diphtheritic inflammation of the vagina is sometimes seen during epidemics of the disease or among puerperal women in crowded lying-in hospitals. Senile vaginitis is occasionally met with in women after the climacteric period. Its cause is wholly in consequence of the physiological retrogressive processes incident to the change of life. The {369} epithelium is shed in patches, and, according to Hildebrandt, the raw surfaces adhere, causing contraction of the vagina.

SYMPTOMATOLOGY, COURSE, DURATION, PATHOLOGY, TERMINATION, AND COMPLICATIONS.--The subjective symptoms of the three varieties of vaginitis which have been mentioned are nearly identical, but in their physical signs a marked difference is perceptible. In the outset there is a sense of heat and burning in the vagina, a feeling of pain and weight in the perineum, and a frequent desire to urinate. The passage of urine causes pain and a feeling of scalding in the urethra. It is believed by many authorities that the sense of scalding is more pronounced in the specific variety. Not unfrequently there are backache and pain radiating down the thighs into the hips, along the spine, and into the head. Sometimes, with the other symptoms mentioned, there will be a decided febrile disturbance, chilliness alternating with heat, a rapid pulse, and a foul tongue. With such symptoms the thermometer will show an elevated temperature. Coincident with the beginning of pain and irritation the patient has an itching sensation, which sometimes becomes intolerable, and is generally worse at night when she is warm in bed. Emmet states that some cases are so severe as to require anæsthetics before relief can be obtained. After the lapse of from twenty-four to seventy-two hours these symptoms subside, and there is a profuse purulent discharge, yellowish or greenish in appearance and of an offensive odor. In many cases the discharge is of so acrid a character that it excoriates the vulva and surrounding parts. Walking, or even standing, is often painful, particularly the former, owing to the attrition of the inflamed or excoriated surfaces.

A physical examination causes pain, and if the inflammation has extended to the vulva, urethra, or the vulvo-vaginal glands, it will often produce intense suffering. When the vaginitis is acute, the labia are swollen, the vagina assumes a more or less intense red color in place of the light or pale rose-color of health; it will also be swollen, and at the beginning seem unnaturally dry, but very soon, although still red, it will be covered with a yellowish or greenish-yellow, muco-purulent discharge of an offensive odor. By careful examination with the speculum the vaginal canal will be seen to have a congested appearance, with abraded points, and sometimes follicular ulceration will be found. Generally, the appearance of thick mucus within the os uteri indicates an extension of the inflammatory process into the cervical canal.

Sometimes in gonorrhoeal vaginitis the full force of the disease seems to be chiefly expended in the urethra; when this is the case, and patients complain of intense scalding in passing urine, a finger pressed against the anterior vaginal wall will usually cause pus to exude from the urethral canal.

The duration of vaginitis depends largely upon the treatment. If appropriate treatment is begun early in the course of the disease, a cure can be effected in two or three weeks. On the other hand, it may continue an indefinite length of time or assume a chronic form, constituting a catarrhal condition of the vaginal mucous membrane, or vaginal leucorrhoea.

Sometimes inflammation of the lining of the vagina, more especially specific vaginitis, extends beyond the cervix into the cavity of the uterus, {370} along the Fallopian tubes to the ovaries and to the pelvic peritoneum, or it may travel along the mucous membrane until it reaches the lining of the bladder, causing a cystitis, or in a similar manner involve the vulvo-vaginal glands.

It is not unusual after all the signs of a vaginitis have entirely disappeared that the inflammation recurs without any apparent exciting cause, but wholly in consequence of a diseased condition of the mucous lining of the cervix uteri, designated cervical endometritis, chronic inflammation, or uterine catarrh. In consequence of this there is an increased and changed secretion, which acts as an irritant and causes vaginitis. These recurrent attacks of vaginitis can be prevented only by a successful treatment of the cervical disease.

Chronic vaginitis or vaginal catarrh occurs after repeated attacks of the acute form in persons of a strumous diathesis, and from uterine disorders, such as catarrh, displacements, or polypi of the uterus.

Vaginal catarrh from any cause may lead to other difficulties; thus, if it is the primary affection it may lead to catarrh of the uterus and of the Fallopian tubes. Its long continuance with or without the co-existence of uterine disorders may lead to relaxation and subsequent prolapsus of the vaginal walls.

In the beginning of vaginitis, as in inflammations of mucous membranes elsewhere, the vaginal lining becomes first very vascular, presenting a congested and swollen appearance, with a diminution in the quantity of normal secretion; but within a few days portions of the epithelium are cast off, leaving abraded spots which sometimes ulcerate and become covered with exudation. Occasionally complete casts of the epithelial lining of the vagina are desquamated. In lieu of the natural secretions, within thirty-six hours after the inception of the disease the vagina is filled with an acrid, foul-smelling muco- or sero-purulent fluid, having the appearance of unhealthy pus. The discharge consists of serum, numerous epithelium cells, pus-corpuscles, blood-globules, and infusorial animalculæ designated Trichomanas vaginalis, and mucus. When an attack is very severe a true phlegmonous inflammation is often developed in consequence of the submucous cellular tissue first becoming involved.

In specific vaginitis it not infrequently occurs that the disease is confined to the vaginal cul-de-sac--a fact which, according to Guérin,[3] explains how sometimes apparently healthy women communicate gonorrhoea to the male.

[Footnote 3: Mal. des Organes génitaux, Paris, 1864.]

In granular vaginitis the mucous membrane extending throughout the entire canal and over the neck of the uterus is covered with numerous minute elevations or granulations of about the size and shape of half a millet-seed. Thomas says: "This variety of the disease appears to bear about the same relation to simple vaginitis that follicular vulvitis does to the purulent form of that affection."[4] The same author mentions having seen a patient with granular vaginitis so striking in its features that the family physician believed it to be malignant disease developing, until convinced to the contrary.

[Footnote 4: Thomas on Diseases of Women, 5th ed., p. 219.]

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