Class ftJK*, " / Book_J Copyright^ . COPYRIGHT DEPOSIT. u MEDICAL AND SURGICAL LECTURES ON THE DISEASES OF WOMEN, CLINICAL AND SYSTEMATIC TKEATISE. R. LUDLAM, M. D., Professob of the Medical and Surgical Diseases of Women in Tfl.& Hahnemann Medical College and Hospital, of Chicago; Late President of the Amer- ican Institute of Homeopathy, and of the Chicago Academy of Medi- cine; Corresponding Member of the Homeopathic Medical Societies of Great Britain, France, Massachusetts, and New York; Author of a Volume of Clinical Lect- ures on Diphthebia; Membeb of the State Boabd of Health of Illinois, ^ ETC., ETC. LECTUBES DELIYEKED FKOM 1870 TO 1887. sixth edition; revised, enlarged and illustrated. 'JAN 301888 7 CHICAGO: HALSEY BROTHERS, i 1888. k~\ Entered according to Act of Congress, in the year 1888, by HALSEY BROTHERS, in the office of the Librarian of Congress, at Washington. PEESS OF J. L. REGAN PRINTING CO., CHICAGO. PREFACE TO THE SIXTH EDITION. For more than a year past the fifth edition of this work has been out of print. It therefore became incumbent upon the author to revise and to correct it, to withdraw a portion of its old matter and to substitute new paragraphs and new lectures to the end that it might be in every way more complete and satisfactory than before. In the present edition the briefer articles and the new cuts have been interspersed through the volume wherever they were needed to modernize it and the better to illustrate the text. Many new cases have been added and the clinical character of the work has been preserved throughout. Of the new lectures that were not included in former editions there are, beside the Introductory Lecture, two upon the Path- ology of Ovarian Tumors; one on Explorative Laparotomy and Tapping; one upon Ovariotomy; one on the After Treatment and the Results of Ovariotomy, and one upon the Diseases of the Uter- ine Appendages, including the Battey-Tait operation. The surgi- cal treatment of Lacerations of the Perineum and of the Uterine Cervix, and also of Uterine Cancer have been reconsidered and treated of in the light of increased hospital and special experience. The text, which is closely printed and compact, does not discuss those theoretical and historical questions which are better suited for separate monographs, or for an encyclopaedia, and which man- ifestly are out of place at the bedside or in the clinical amphithe- atre. All this literary baggage, with which gynecology is being encumbered, is laid aside for what is more direct, important and useful. The result is submitted with a sincere regret that, even in its amended form, the work is not more perfect and complete; 3 4 PKEFACE TO THE SIXTH EDITION. but also with the hope that it may continue to be as useful and as acceptable in the future as it has been in the past. The thanks of the author are again due to Dr. Belle L. Reynolds, who for the past eight years has been his faithful assistant in the practice of this specialty, for the careful supervision of the work as it passed through the press. New Years, Chicago, 1888, 1823 Michigan Avenue. CONTENTS. INTRODUCTORY LECTURE. LECTURE I. THE SEVEN CRITICAL PERIODS IN THE LIFE OF WOMAN. GENERAL PATHOLOGY. PAGE. 1. Puberty 35 Childhood— Girlhood— Womanhood— Clinical history of— Com- paiative risks of— Not identical with nubility — Early marriage and ; delayed. 2. Menstruation 40 Causes of suffering in— Three steps in— Influence of diathesis upon— Ditto of travel— Ditto of the hsemorrhagic tendency- Effect of intercurrent disease upon — Ditto of the cachexias— Ditto of mal- treatment— The menstrual cachexia. LECTURE II. general pathology— continued. 3. Pregnancy - 45 The physiology of— The diseases that are caused by— Relation of, to uterine displacements— Ditto to cervicitis— The common dis- eases of pregnancy— Changes of the blood in— Ditto of the heart —Rheumatism in — Ditto nervous affections — Ditto metro-cere- bral disorders — Ditto pulmonary — Digestive and urinary de- rangements—The diseases that are cured by pregnancy — The vis medicatrix of— Diseases that co-exist w tli pregnancy— Ovarian and fibroid tumors, etc. LECTURE III. general pathology— continued. 4. Parturition 55 Effects of, on the nervous sy-tem— In primiparse; ditto on mul- tiparas— Traumatic lesions of. •5. PUERPERALITY ' . . . . 57 Diseases ol— Uterine involution, results if defective— Laceration 5 O CONTENTS. PAGE, of the cervix as a cause of post-puerperal diseases— The ca- chexia. 6. Lactation 60 A necessary condition of uterine retraction, and a natural pro- phylactic of post-puerperal disease — Effects of non-lactation in abortion— Why nursing is prophylactic of uterine disease — Weaning may be either harmful or salutary -Effects of undue lactation. 7. The Climacteric .... 65 The diseases of, are plethoric, anaemic, or nervous— The class of affections that are caused by this crisis, those that are cured by it and those that co-exist with. Post- climacteric affections. LECTURE IV. physical diagnosis in gynaecology. 1. Inspection 66 The four varieties of— Abdominal do. of the external parts ; ditto by the uterine speculum ; ditto by the forcible eversion of the rectum. 2. Mensuration ... ....... 74 Modes of applying. 3. Palpation 75 Abdominal and vaginal— Cases to which the former is applicable — The t; touch " per vagmam— Conjoined manipulation and when it is of use— The uterine " touch " and the conditions requiring it. LECTURE V. PHYSICAL DIAGNOSIS— CONTINUED. Physical Diagnosis 7S The three kinds of rectal touch— Manual exploration of the rec- tum, or Simon's method— The kt touch" by the bladder— The touch by the sound, why and when it should be employed — Di- rections as to time and mode of its introduction— The position of the patient— The conjoined use of the speculum and the sound— A rare Case — Sims' elevator as a sound. The sound in fibromata ; ditto instead of the tenaculum. 4. Percussion 95 Object, and range, and use of, in pregnancy, in ascites, ovarian dropsy, and uterine tumors. 5. Auscultation . . . 96* Use and range of, cases to which it is adapted. CONTENTS. LECTURE VI. PAGE. CHLOROSIS 97 Digestive, cerebral h,nd cardiac symptoms— Scrofulous ditto- Blood changes in— The nervous symptoms— The pulse, the appe- tite, menstrual derangements, the skin— Etiology of— Diagnosis of, from jaundice and anaemia— Prognosis— Treatment for the general and emotional causes— The cachexia, 2ron in— The citrate of iron and strychnia in— Special indication© for remedies— The diet — Exercise and travel. LECTURE VII. AMENORRHEA. 3. 2>EL^YE.l> MENSTRUATION 13 Etiology or— symptoms of— diagnosis, prognosis, and tt >tment. 2. Suppressed Menstruation .'.."'. . . . , . .117 Etiology— Symptoms, diagnosis, and treatment— Special indica- tions for remedies. 3. Retention of the Menses . . 128 Etiology, symptoms, diagnosis, prognosis, and treatment, both medical and surgical. LECTURE VIII. amenorrhea— continued . Amenorrhcea, with Prolapsus Uteri and Obstinate Vomit- ing • . , 132 Resembling perforating ulcer of the stomach— Reposition of the uterus— Subsequent history— Note. Amenorrhcea with Choreic Spasms 138 Remote disease from an arrest of the menses — Forcing the flow — Effect of rest and quiet. Amenorrhcea with Supra-Orbital Neuralgia . . . 143 Varieties of menstrual neuralgia— Local and Specific treat- ment. Jpinal Irritation, with Amenorrhcea, Vicarious Vomiting, etc 144 Convulsions— Causes of— Theories in— Treatment— Subsequent history. Amenorrhcea in Advanced Phthisis '. 149 Remedies and prognosis. CONTENTS. LECTURE IX. Menstrual Headache . .151 Often overlooked— From uterine deviations— Ovulation and cephalalgia— Diagnosis— Prognosis— Treatment. Menstrual Retention a Cause of Uterine Displacements . 160 May become chronic— Treatment. Uterine Colic .."... 164 Cause— Symptoms— Palliatives— Internal remedies. LECTURE X. Menstrual Epilepsy 168 Uterine and ovarian epilepsy— From amenorrhcea— Inter-men- strual epilepsy— Epilepsy after dysmenorrhea— Sequela?, and non- sexual causes of— Prognosis— Treatment. Irregular Menstruation with Epileptiform Hysteria . 175 A compound affection— The two distinctive stages of the fit- Diagnosis— Prognosis and treatment. Too Frequent Menstruation in Incipient Phthisis . . 179 Menstruation and tuberculosis— Menorrhagia and ditto— Signifi- cance of the aphonia— Treatment, remedies, season and cli- mate—Mental worry. LECTURE XL Dysmenorrhea ,183 Definition and varieties— Causes— Symptoms, complications, sequels— Diagnosis— Prognosis— Surgical treatment. Obstructive Dysmenorrhea from Post-Puerperal Atresia 197 Dates from puerperalitv— The result of adhesive inflammation and stenosis— A clinical lesson — A contra-indication for anaes- thetics— The use of the uterine stem. LECTURE XII. Obstructive Dysmenorrhea from Stenosis of the Uterine Cervix and Pelvi-Peritonitis . . . . . . .201 Rule for operations on the cervix— Post-surgical peritonitis. Obstructive Dysmenorrhea from Retroflexion of the Uterus 202 Causes— Symptoms— Diagnosis— Sequelae and treatment. Neuralgic Dysmenorrhea .210 The importance of physical signs— A neurosis— Symptoms- Relation of the flow to the degree of pain— Treatment. CONTENTS. 9 s PAGE, Spasmodic Dysmenorrhea 215 Effects of stimulants— Ditto of opiates— Medicinal aggravations — Gelsemium and other remedies. LECTURE XIII. Membranous Dysmenorrhcea 219 Causes, anatomical peculiarities of the membrane, its clinical confirmation— Shape and size of the membrane— Its expulsion- Practical deductions— Diagnosis from abortion— Special thera- peutics—Other expedients— The sponge tent. LECTURE XIV. Membranous Dysmenorrhcea from Repelled Eruptions . 234 Treatment— Sterility as a sequel. Borax in Membranous Dysmenorrhea . . . .241 Treatment. Membranous Dysmenorrhcea from Exfoliative Endometritis 243 Rarity of this form— Pessaries in— Version as a factor in— Pecu- liar remedies in. Ovarian Membranous Dysmenorrhcea . . . . . 245 The button-hole os uteri— Oldham's theory illustrated— Gel- semium the remedy. LECTURE XV. Menorrhagia 247 Definition of— Differential diagnosis— Remedies— Surgical treat- ment. Nitric acid in Menorrhagia 252 Metrorrhagia after abortion— Clinical deductions— Post-dysmen- orrhoeal haemorrhage— Haemorrhage at the climacteric— Practi- cal conclusions. Menorrhcea— Cervical Epistaxis 255 Its relation to menstruation— A diagnostic rule— A physiologi- cal reason— Peculiarity of the flow— Its critical nature— Neces- sity of physical examination— Sterility from— Medicine versus Surgery— Not to be confounded with unavoidable haemorrhage —General therapeutics— The different cachexiae— Nitric acid. Menorrhagia with Remittent Eever 262 Complication with malarial fever— Uterine disorders not always easy of cure. Menorrhagia with Rheumatism 263 10 CONTENTS. LECTURE XVI. ^ PAGE Menorrhagia— Continued 263 Menorrhagia with hemiplegia — Menorrhagia from a uterine libroid. Menorrhagia with Convulsions . . ... . . .265 Sudden Suppression of Menorrhagia by Astringents the Cause of Subsequent Illness 271 Menorrhagia sometimes critical— Digestive disorders from vag- inal and uterine injections— Menorrhagia from polypi. Vicarious Menstruation 275 Treatment. LECTURE XVII. The Differential Diagnosis of Pregnancy .... 279 False conception— Molar pregnancy— Morbid anatomy of— Prob- able signs of pregnancy. Excessive Abdominal Development in Pregnancy . . 287 Diagnosis— Prognosis— Treatment— Pulsatilla in mal -presenta- tions. LECTURE XVIII. Bilious Colic During Pregnancy ....... 293 Treatment— Local palliatives— Prophylaxis— Diet— Mental and physical exercise. Albuminuria in Pregnancy 297 Signs of convulsibility— Mercurius cor. in— No infallible pro- phylactic for convulsibility. Abdominal Cramps and Pains in Pregnancy . . . . 2°9 Diagnosis— Spurious peritonitis— Diagnosis from cutaneous neu- ralgia, uterine colic— Prognosis— Treatment — Remedies. The Nausea and Vomiting of Pregnancy .... 304 May occur at any period of pregnancy— Significance of a coinci- dent jaundice— Treatment— Special indications for remedies- Stretching the cervix— The expediency of abortion— Dangers from hepatic and urinary complications— Varicose veins. LECTURE XIX. Morning Sickness of Pregnancy and Retro- version . . 311 Morning sickness may be salutary— The prognosis of inevitable abortion, unwarranted— Treatment — How to replace the womb if retro-verted — The uterine sound — The indication for a pes- sary— Tyler Smith's case. CONTENTS. 11 PAGE. Chorea during Pregnancy ........ 318 Etiology— Nature — Anaemia — Symptoms — Localized chorea — Prognosis— The fatal form— Treatment— Remedies. LECTURE XX. Abortion with. Misplaced P^ins 326 The habit of aborting — Intermittent abortion — Treatment— Gelsemium in. The Sequelae of Abortion . 329 Causes of aborting — Quickening not the first sign of life— Dis- ease that may follow— Differential diagnosis between spontan- eous and induced abortion— Treatment— Remedies. LECTURE XXI. Stomatitis Materna.. Nursing sore Mouth .... 339 Nature — Peculiarities— A constitutional disease — Reaal and vesical symptoms— The anaemia— Diagnosis— Prognosis — Treat- ment—Expedients for arresting the disease— Weaning the child —Indications for arsenicum alb , mercurius sol., calcarea carb., etc. — Local treatment. LECTURE XXII. Sub-involution of the Uterus 353 Etiology— Treatment— The physiological action of ergo!— Indi- cations for secale, china, etc, SUB-INVOLUTION AND RECURRENT ABORTION . . . .361 Types of abortion— Peculiar cause of— Treatment — Peculiar sus- ceptibility—Remedies. sub-involution and chronic metritis of eighteen years Standing . 364 Causation— Physical signs. Sub-involution, Chronic Metritis, Menorrhagia and Pro- lapsus , . 365 A practical lesson. LECTURE XXIII. Pelvi-peritonitis .... 367 Clinical history— Varieties— Symptoms- -Temperature and pulse —Three points to be observed in local examination— The peri- toneal tumor— Reflex, digestive, and other disorders— Causes— —Diagnosis— Prognosis — Treatment — A substitute for opium in 12 CONTENTS. PAGE. —Remedies— Macrotin— Pel vi-peritonitis, prolapsus, with um- bilical hernia — Pelvi-peritonitis with partial stenosis of cervix uteri— Pelvi-peritonitis and laceration of cervix. LECTURE XXIV. Pelvic Cellulitis, Pelvic Abscess ♦ . 385 Synonyms— The four stages of — First, or congestive— Second — or stage of effusion — Third, or that of resolution— Fourth, or suppurative— Seat of the fluctuation— Diagnosis of the presence of pus— Essential nature of pelvic cellulitis— Is probably allied to erysipelas— Causes— A contingent 10 uterine surgery— Diag- nosis— Sequelse— Prognosis. LECTURE XXV. Pelvic Cellulitis Continued 399 Qualifying conditions— (1) The cause— (2) The complicating lesions— (3) The condition of the menstrual function— (4) The treatment to which the patient has been subjected— (5) Her puerperal experience— (6) The dyscrasia upon which the cellu- litis has been engrafted— Pelvic cellulitis with intestinal fistulae Pelvic cellulitis with abscess, following delivery— Treatment- General indications for remedies— Stimulants— To promote sup- puration —After-treatment. LECTURE XXVI. Pelvic Hematocele 418 Definition and clinical history— Etiology— The hemorrhagic dia- thesis— Pachy-peritonitis— From cervical stenosis— Source of the haemorrhage — Symptoms— Signs per vaginam — Voisin's descrip- tion of the formation of the tumor — General symptoms— The pain— The anaemia— Diagnosis— Pelvic hsematocele and extra- uterine pregnancy— The aspirator and exploring needle in— Prognosis— Medical treatment— Surgical treatment— Tapping. LECTURE XVII. Cervical Metritis .... ..... 437 Acute cervical metritis— Varieties of— Differential diagnosis Prognosis— Treatment— The hot rectal douche. Chronic Corporeal Cervicitis 443 Symptoms— Menstrual disorders— Nature and cause— Diagnosis Prognosis — Treatment — General indications for treatment — Remedies. CONTENTS. 13 PAGE. Corporeal Cervicitis and Scanty Menstruation . . 447 Query— Treatment— Tartar emetic- -The sponge tent as a means of diagnosis. LECTURE XXVIII. Chronic Cervical Endo-metritis, Uterine Leucorrhcea . 451 A glandular lesion— Cervical leucorrhoea is not uterine catarrh — A sequel of labor — The scrofulous cachexia a predisponent — Tuberculosis a predisponent — Biliary disorders an exciting cause— The exciting causes — Symptoms — The leucorrhcea a symptom— Pelvic pains and suffering— Constitutional effects- Examination by the speculum— Diagnosis — Prognosis— Treat- ment— Remove the cause— Necessity for a good diet— The top- ical use of glycerine, calendula and hydrastis— Pessaries are contra-indicated— Escharotics— Natural secretions and abnor- mal discharges— Remedies for reflex ovarian disease — Ditto for various symptoms and groups of symptoms. LECTURE XXIX. Abscess of the Mammary Gland 471 Treatment— A domestic expedient— The knife— A good diet ad- visable. On Weaning a Child .and the Subsequent Treatment of the Mammary Glands 474 111 effects of too prolonged lactation— The proper time for wean- ing— Treatment— An tigalactics— Local applications. Excoriated Nipples 480 Most frequent in primiparae— Symptoms— The excoriation— The ulceration— Treatment— Prophylactics— Applications for various conditions— Precautions— Remedies. LECTURE XXX. Recurrrent Abortion from Mal-lactation .... 487 Leucorrhcea. the Cause of Impaired Lacteal Secretion . 489 Leucorrhcea and scrof ulosis— Illness of the child and leucorrhcea of the mother— Uterine leucorrhoea and sterility— Treatment- Weaning the child— A proper diet— Lymphatic stimulants. Loss of Nipples from Erysipelatous Inflammation . . 494 Belladonna— Glass nipple-shields. Anemia from Conjoined Lactation and Menstruation . 495 Unilateral Neuralgia from Prolonged Lactation . . 496 Extraordinary Lactation .497 14 CONTENTS. LECTURE XXXI. „, PAGE. The Menopause 499 Duration of menstrual life — Importance of the change— Diseases incident to puberty may return— Symptoms— Haemorrhage at— Alimentary symptoms— Nervous symptoms— Epilepsy— Disor- ders of the generative system— Prognosis— Treatment— Reme- dies The Comparative Frequency of Various Diseases at the Climacteric .509 Skin Diseases and Hysteria at the Climacteric . . . .511 Treatment— Character of the eruption may indicate the remedy —Hysteria incident to menstrual life— Treatment. LECTURE XXXII. Incipient Paralysis ai the Climacteric 517 Critical disease may precede the arrest— Significance of the dis- charge at the change— Remedies for the acrid flow. Post-Climacteric Neurosis ......... 520 Climacteric Rheumatism 520 Remedies for. Bilious Colic at the Climacteric ....... 522 Chamomilla. Prolapsus Uteri with Dropsy, at the Climacteric . . . 523 Parturition a cause of uterine deviation— Treatment— Internal remedies. Post-Climacteric Anasarca 525 LECTURE XXXIII. Affections of the external Generative Organs . . .527 Pruritus of the vulva— Various causes of — Pruritus with dys- menorrhea and amenorrhoea— Pruritus at the climacteric— Pru- ritus during pregnancy— Prognosis— Treatment— Remedies. Abscess of the Labia Majora and of the Vulvo- Vaginal Glands 534 Special pathology of— Symptoms— Diagnosis. Eczema of the Vulva 538 Vulvo- Vaginitis, Prurigenous Vulvitis 538 Symptoms— The eruption— Causes— Diagnosis— From granular vaginitis— Erom follicular vulvitis— Prognosis— Treatment. CONTENTS. 15 PAGE. Infantile Leucorrh^ea ... » 543 Causes— Treatment— Isolation . LECTURE XXXIV. Vascular Tumor of the Meatus Urinarius 546 Nature and location— Symptoms— Necessity for physical exam- ination—Treatment—Excision—A new mode of operating- After-treatment. Non-Specific Urethritis . . 551 Causes— Symptoms— Character of the urine— Diagnosis from stone— From gonorrhoea— From cystitis— Treatment. Urethral Fever, and Fissure of the Urethra . . . .557 Pathology of— Treatment— For the vesical and renal complica- tion, and for the laceration of the urethra. LECTURE XXXV. Cystocele — Hernia of the Bladder,— Vaginal Cystocele . 560 Cystocele— Symptoms— Varieties— Signs of— Treatment— Opera- tions for cystocele and rectocele. Dilatation of the Urethra as a Means of Diagnosis in Dis- eases of the Bladder and Urethra in Women . . 565 The sponge tent in urethritis— Vesical inspection and palpation — Intra-vesical inspection and palpation. Hysterical Ischuria 571 Varieties of— Physiological complications in— The secondary form— Internal remedies. LECTURE XXXVI. Cystitis 575 Causes— Symptoms— Diagnosis— Treatment local, general, surgi- cal and dietetic— Washing out the bladder— Re medies for— Cystotomy— Mode of performing, the after-treatment— Objec- tions to, results of, the artificial eversion of the bladder, drain- age—The milk diet in— The Clysmic spring water in. The Irritable Bladder 584 Causes of — Hysteria as a factor in— Three points in the diagnosis of— Treatment. Stone in the Bladder and in the Urethra 585 Relative frequency of in women— Causes— Symptoms— Prognosis —Lithotripsy and vaginal cystotomy— Supra-pubic lithotomy— Spontaneous discharge of a calculus weighing thirty-six and one-half grains. 16 CONTENTS. LECTURE XXXVII. PAGE, Uterine Deviations and Displacements 589 General considerations upon— The natural position and mobility of the uterus— The uterine ligaments and the cellular tissue as a means of support— The etiology of uterine displacements— The predisposing, and avoidable causes of— The intrinsic, extrin- sic, and accidental ditto— Symptoms of — Diagnosis— Treatment The scope and value of internal remedies exclusivei/— Cardinal symptoms in the choice of a remedy —The use and abuse of pes- saries — Reasons for objections to them — Harmful varieties of— Contra-indications for— Indications for— Abdominal belts and supporters— Dr. Hodge's experience with them. LECTURE XXXVIII. Prolapsus Uteri and Procidentia 602 Pseudo-prolapse of the uterus — Consequences of incorrect diag- nosis — VVhat remedies may do in prolapsus. Prolapsus Uteri, with Superficial Ulceration of the Cer- vix .-....- 605 Irregular menstruation a cause of prolapsus — Prolapsus and paralysis— Hysterical complications — Cause of uterine abrasion —Uterine ulceration and abrasion— Treatment— Corxtsa- indica- tions for the pessary— Local expedients. Prolapsus Uteri with Right Latero- version . . . 612 Latero-version from an over-loaded rectum — Treatment. Prolapsus with Anterior Inclination of the Fundus Uteri 616 Procidentia Uteri 616 Elytronhaphy for— Episio-perineorrhaphy for. Procidentia Uteri from Pertussis . . . . . . 619 Cough a cause of uterine displacement— Labor a predisponent -Treatment. LECTURE XXXIX. Flexions and Versions of the Uterus 622 General remarks upon flexions— Varieties— Retro-flexion— Diag- nosis— The uterine sound and the touch in— Re-position of the organ— Stem pessaries— Ante-flexion— Comparative frequency of —Causes, diagnosis, and treatment— Latero- flexion — Causes- Symptoms— Contingent affections— Postural treatment. Versions of the Uterus . . . . . . ... .633 General remarks— Varieties— Retro-version of the uterus— Symp- CONTENTS. 17 PAGE. toms— Diagnosis — Treatment— Pessaries in — Internal remedies —Ante- version of the uterus— Symptoms— Diagnosis— Treatment Latero-version of the uterus— Peculiarities of— Physical signs of — Treatment. Inversion of the Uterus 641 Causes— Symptoms— Form of the tumor in — Diagnosis— The crucial test for— Prognosis— Treatment in recent cases— Manual treatment for the reduction of— Tate's vesico-rectal method— Courty's rectal method— Emmet's expedient— Sims' and Barnes' method— White's operation— Thomas' method of replacing — Amputation a dernier ressort. LECTURE XL. Ulceration of the Womb 649 General observations on uterine ulceration— Varieties of. Simple Ulcer of the Uterine Cervix 650 Subjective symptoms— Causes— Treatment. Apthous Ulceration of the Os and Cervix Uteri . . 653 The eruptive stage— Symptoms— Diagnosis— Causes— Treatment Reprehensible practice— Remedies for the various stages. Irritable Ulcer of the Uterine Cervix . . . .658 Reflex relations of uterus and stomach — The speculum not always needed— Appearance of the ulcer— Treatment— Cure the indigestion— Internal remedies— Local treatment. Diphtheritic Ulceration of the Os Uteri. . . . .663 Constitutional symptoms — Physical symptoms— A secondary disease— Cause— Treatment, local and medicinal. POST-FARTUM ULCERATION OF THE WOMB 665 Likely to be overlooked— Due to an impaired quality of the blood— Weaning the child— The diet— Exercise— Indiscriminate and exclusive local treatment— Arguments pro and con— Inter- nal remedies. LECTURE XLI. LEUCORRHCEA WITH CHRONIC OVARITIS ...... 671 General remarks on leucorrhoea— Reflex relations of the ovary Sympathy between the uterine cervix and the ovaries— Leucor- rhoea may substitute menstruation— Uterine and vaginal catarrh from ovaritis— Sterility from— Treatment. Chronic Leucorrhcea and the Scrofulous Dyscrasia . . 676 Leucorrhoea may be critical— Local and general causes— Consti- tutional causes— Scrofulosis in— Treatment— Remedies. 18 CONTENTS. PAGE. Irritable Uterus— Rysteralgia 681 Has no definite lesion— Limited to menstrual life— Predisposing causes — Exciting causes— Symptoms — Diagnosis — Treatment Surgery contra-indicated— Remedies. LECTURE XLII. Uterine Cancer 692 General observations — Varieties — Causes — Symptoms — The haemorrhage— Diagnosis— Course and duration— The cancerous cachexia— The copraemia and cancerous complexion — Influence of pregnancy and labor upon — Prognosis — Carcinophobia — Causes of death from — Laceration of the cervix and uterine carcinoma— The local and medical treatment— Surgical treat- ment. LECTURE XLIII. Epithelioma of the Uterus ,708 Epithelial cancer of the cervix uteri — Nature and clinical his- tory of— Pathological anatomy of— Symptoms— Development of the cachexia— Diagnosis — Prognosis— Treatment — Sims' opera- tion for— Remedies. LECTURE XLLV. Ovaritis ...... 724 Synonyms— Causes; medical, mechanical, epidemic, traumatic- Symptoms— Prolapse of the ovary— Peritoneal ovaritis— Dysmen- orrhoea and menorrhagia in— Gonorrhceal do. LECTURE XLV. Ovaritis Continued ... 738 Morbid anatomy of— Abscess in— Diagnosis— Prognosis— Seque- lae— Menstrual disorders— Sterility— Treatment— Ditto, of the puerperal form— Remedies in the common form— Local Reme- dies. LECTURE XL VI. Ovarian Neuralgia— Ovaralgia 757 Etiology — Clinical history — Diagnosis — Prognosis — Treatment Remedies. Ovarian Irritation— Ovarian Dyspepsia ..... 768 A pathognomonic sign— Excising causes— Remedies. CONTENTS. 19 LECTURE XLVII. PACE. Hysteria „ ... 771 Menstrual disorders in — Incongruous symptoms of — Malingering —Diagnosis from cardiac disease. Insanity, dropsy of the heart .and from pectoral disease— Hysterical aphonia— Dr. Chairon's pathognomonic sign of. LECTURE XL VIII. Hysteria, Continued . 785 Hysteria complicating child-bed disorders, peritonitis, fevers, and hypocondriasis— May counterfeit labor— Diagnosis of from epilepsy— Nature— Prognosis— Treatment— Narcotics and anti- spasmodics. LECTURE XL1X. Treatment of Hysteria, Continued 804 Treatment during the fit— Treatment for the hysterical diathesis Do. for the accompanying lesions and complications— The utero- gastric and utero-cardiac disorders— Neurasthenia. Hysterical Hemiplegia . • . . 810 Hysterical mimicry— Diagnosis— Prognosis— Treatment— Reme- dies. LECTURE L. Spinal Irritation— Notalgia . S15 Causes— Peculiar organization a predisponent— Of nervous origin —Symptoms, reflex and direct— Spinal irritation and uterine dis- ease — Diagnosis— Prognosis— Treatment. PHYS03IETRA 830 Causes, diagnosis— Treatment. LECTURE LI. Uterine Surgery Versus Uterine Therapeutics . . . 835 Scepticism respecting medication— Surgery more popular— Dis- advantages of the specialist— A great error— Surgery and thera- peutics—New provings by women a necessity— Study diagnosis and pathology— Pathogenesis and symptomatology. The Gynaecological Chair or Table .813 20 CONTENTS. PAGE. Vaginismus ... 846 Symptoms— Causes— Diagnosis— Medical and surgical treatment Tilts' and Sims' operation for— Local anaesthesia in acute cases. LECTURE LII. Laceration of the Cervix Uteri . ■ 855 Discovery and description of— Clinical history— Causes— Symp- toms, subjective and objective— Varieties— Cervical ectropium Follicular degeneration— Cicatrization— Diagnosis — Complica- tions—Laceration with sub-involution— Epithelioma, peri-metri- tis, and sterility— Prognosis— Treatment, preventive, prepara- tory and operative— Trachelorrhaphy— The after-treatment. LECTURE LIU. Vesico- vaginal Fistula 870 The varieties of vesical and vaginal fistulas— Vesico- vaqinal jis- tuloe— Causes, from child-birth, from wounds, calculi, syphilis, t cancer, etc.— Symptoms— Physical signs of— Prognosis— Treat- ment in recent and in chronic cases, by cauterization and Sims' operation. Recto-vaginal Fistula . 885 Causes— Physical signs— Prognosis— Treatment by surgical pro- cedure. LECTURE LIV. Lacerations of the Vulva and of the Perineum — Peri- neorrhaphy 890 These lacerations are often confounded— The anatomy of the vulvar orifice— Lacerations of the fourchette— Anatomy of the perineum— Varieties of perineal laceration — Frequency of do. —Symptoms— Treatment— The primary and secondary opera- tions. LECTURE LV. The Pathology of Ovarian Tumors 905 1. Ovarian Cysts, morbid anatomy of — The ovarian cell — Symp- toms — Subjective signs in— Physical signs — 2. Dermoid Cysts of the ovary — Diagnosis— 3. Fibroid Tumors of the ovary — Laparo- tomy as a diagnostic resouree. CONTENTS. 21 LECTURE LVL PAGE. The Pathology of Ovarian Tumors — Continued .... 918 IV. Malignant Tumors op the Ovary — 1. Cysto-sarcoma; phys- ical signs and diagnosis — 2. Cysto-carcinoma — 3. Schirrhus of the ovary — 4. Colloid, or Myxoma — 5. Papilloma, Epithelioma and Cauliflower degeneration of the ovary — 6. Encephaloid of the ovary. LECTURE LVIL The Differential Diagnosis of Ovarian Dropsy ' . . . . 932 1. From ascites — 2. From encysted peritoneal dropsy — 3. From pregnancy — 4. From extra-uterine pregnancy — 5. From uterine fibroids — 6. From fibro-cystic growths — 7. From physometra — 8. From distention and prolapse of the bladder — 9. From enlarge- ment and malignant diseases of the liver and spleen — 10. From tumors which are due to menstrual retention. — 11. From renal cysts and floating kidney. LECTURE LVIII. Explorative Methods of Diagnosis 945 1. The Exploratory Incision— Mode of making — Suitable cases for — Practical value of. 2. Tapping — Not curative — As a palliative — A dangerous and un- satisfactory expedient — Has fallen into disuse — Increases the risks of ovariotomy, etc. LECTURE LIX. Ovariotomy 960 The early operation — Suitable cases for — Contra-indications for — Preparatory treatment — Asepsis and antiseptics— Surgical cleanli- ness—Assistants and instruments — Steps of the operation — Man- agement of the adhesions; do. of the haemorrhage; do. of the pedicle — The peritoneal toilet— The clamp and the objections to — Drainage — The sutures — First dressing of the wound — Putting the patient to bed. LECTURE LX. The After-Treatment 985 The importance of — Shock and reaction — Special and accidental symptons — Diet and drinks— Remedies for the nausea and vomit- 22 CONTENTS. PAGE. ing, tympanites and peritonitis— The urine, the condition of the bowels — Care of the drainage tube — Secondary haemorrhage— Re- opening the abdomen — Removal of the sutures — Contingent affections — Convalescence. The Results of Ovakiotomy 1000 Causes of the comparatively low death-rate — General consider- ations upon. LECTURE LXI. Ovariotomy by Enucleation , 1003 Miner's method of — Cases that are suitable for — Ludlam's method of enucleating an ovarian cyst — The stripping out of the lining membrane of an unilocular sac weighing thirty pounds — Appear- ance of the matrix — Absence of haemorrhage— Suppuration— Rad- ical recovery and mode of union of the divided surfaces. Ovariotomy by Partial, Enucleation 1009 1 The details of a remarkable case in which a tumor weighing eighty pounds was removed by this process — The process by which the formidable adhesions are separated — The risks of the operation — The great necessity for care in making it, and the reasons for the exemption from haemorrhage. Vaginal Ovariotomy 1013 Cases adapted for — Mode of operating — The after-treatment. LECTURE LXIL Diseases of the Uterine Appendages 1016 Class of women who are subject to — From imperfect development, obstructive and membranous dysmenorrhoea, puerperal affections, scrofula and gonorrhoeal infection — Tubal and ovarian tuberculo- sis — Forms of ovarian degeneration — Varieties of salpingitis — Diag- nosis of— Fallopian colic— Signs of— Battey, Hegar and Tait's operations for— Oophorectomy and salpingotomy. LECTURE LXIII. Fibroid Tumors of the Uterus 1032 Their relative frequency, patho ogical anatomy, number, weight, texture and varieties — 1. Sub-mucous fibroids — Symptoms— The haemorrhage, uterine deviations, the uterine souffle, tolerance of the tumor, bi-manual examination— Causes — Diagnosis from ovar- CONTENTS. 23 PAGE. ian dropsy, pregnancy, hydatids, and uterine versions — Prognosis — Treatment, medical, palliative and surgical — 2. Sub-peritoneal fibroids — Symptoms — Coincident disorders — Diagnosis — Cause and termination — Treatment, medical and surgical — Hysterectomy. LECTURE LXIV. Fibroid Tumor op the Uterus — Continued ..... 1056 Interstitial Fibroids — Symptoms — Dysmenorrhea — Menorrha- gia, abortion, sterility — Diagnosis— The tenaculum, the sound and dilatation — Treatment, medical and surgical — Trillin in monorr- hagia. Uterine Polypi 1064 Pathology and treatment of. THE DISEASES OF WOMEN PART FIRST GENEEAL PATHOLOGY AND PHYSICAL DIAGNOSIS. INTRODUCTORY LECTURE* It affords me great pleasure, in returning from a foreign vaca- tion, to find that our Annual Course of lectures has been opened promptly and properly; that the Class is already at work; that the Hospital has been repaired and is re-occupied; and that everything connected with an institution in which I have already labored for a quarter of a century is what its best friends could desire. My congratulations are necessarily late, but they are none the less hearty; and I am ready, as I am certain that you are also, for the work that is before us. The authorities of this school, for whose judgment I have the highest respect, have thought best to limit my sphere of teaching almost entirely to the department of Clinical Gynecology. To this end, as you are aware, they have appointed Professor Bailey as my assistant, and have arranged that henceforth he shall give the largest share of the Theoretical course upon the Diseases of Women. The plan is practical; it has my hearty approval; and you will be the gainers thereby. I appear before you, therefore, in the simple and single capacity of a clinical teacher, a calling and a position which is second to none in importance, and one in which, if its occupant is competent and conscientious, the greatest possible good may be done. For clinical teaching is the highest type of medical training. It may be, and it often is undertaken by professors and pupils before either party is prepared for it, or before they have obtained a cor- rect and comprehensive idea of what is included in an objective, bed-side course upon practical medicine or surgery. * Delivered at the opening of the winter session for 188-1-5. 24 INTRODUCTORY LECTURE. 25 Let us consider the object of the Women's Clinic in this college and hospital; for in taking a new start on the old road, there must be no mistake about putting the saddle on the right horse. The purposes of this clinic are so varied and so important that it may be well to study a few of them separately. I. The Proper Mode of Questioning our Patients. — In the outset I must remind you that the class of patients which will be brought before you in my clinic are in certain respects peculiar, and that your success in practicing your profession among women will depend in large measures upon your method of approaching and of questioning them when they are ill. The natural timidity of the sex; the results of the mal-education of our young women; the peculiarity of their nervous organization; the habit of suppress- ing the signs of suffering, that is so prevalent among women ; the hysterical tendency under certain conditions to exaggerate their ailments, or to antagonize and resent your opinions and enquiries ; the effects of a monthly martydom from which during middle life they are never wholly free; and the consequences of child-bearing, are so many obstacles to be overcome in the examination. Unless you respect and regard these conditions, your witness will not tes- tify to the facts in the case, and your advice as well as your repu- tation, will be thrown away T . How, then, shall we elicit the desired information? With such a list of modifying conditions, it is manifest that a stereotyped plan of putting our questions will not answer in all cases. Nor would it be prudent or proper always to begin with enquiring after the uterine or pelvic symptoms. The age, the marriage relation, the number of children, or of abortions or miscarriages, and an outline of the puerperal experience being noted, the way is clear for a direct examination. If by this time you have secured the patient's confidence, and if she is intelligent and clever, and so disposed, you may put a leading question or two and then permit her to tell her own story. Meanwhile you must listen with a calm, judicial temper; for the evidence must fall upon a mind that k capable of sifting it, and of selecting those points which are of real practical interest to the exclusion of everything else, or you will have gained nothing by the examination. If you will cultivate the temper to which I refer it will keep you from pre-judging the nature of the case in hand, and also from prescribing prematurely. Nothing is more weak and unsatisfac- tory than the trick of putting questions to an emotional witness in such a way as to make her testify to just what you want to elicit. If I should undertake to prove to you, by questions and answers only, that a hysterical woman has ovaritis, my questions might be so framed as to fashion her sensations for her, and to make her feel in imagination just as she would if she were really ill with it. And so also, if I ask such an one whether she has this or that symptom, or class of symptoms, (which I may carry in my mind 26 INTRODUCTORY LECTURE. as the picture of a drug proving), her statements may be warped by my question, which is really more of a suggestion than an enquiry. This kind of subornation of medical witnesses is, I am sorry to say, far more common than is generally supposed. It so often constitutes a species of self-deception on the part of the doc- tor, as well as of the patient, that you will need to guard against it, and more especially in your gynecological practice. The older writers used to distinguish between the signs and the symptoms of disease, and it might be well for you to bear this distinction in mind. A sign of disease was something positive and unmistakable, if not absolutely pathognomonic; while a symp- tom was inconstant, uncertain, common to functional disorders especially, and not always serious or significant. If we except the case of a small share of hysterical, fussy men, the symptoms of disease are relatively much more numerous among women than with the opposite sex; but, although the signs of special disease must vary in them, they are none the less tangible and accessible. Now these cardinal signs, as I prefer to style them, are what you want. They are to furnish the data without which you can- not make a correct diagnosis, or an intelligent prescription; and so far as it is possible or practical, your questions should be framed accordingly. The closer you keep to this rule the better it will be for all concerned. Before leaving this part of my subject I must also remind you that such a verbal examination as we have considered is not always sufficient of itself, or altogether satisfactory. My colleague, Prof. Hall, must catechize his surgical patients also, but his examina- tions do not end with asking them a few questions only. In the case of a displaced womb, or of a pelvic tumor we must supplement our queries with a physical examination that is made with the same care with which he would handle a dislocated joint or a broken leg. There are many diseases of women in which the best questions and answers that could possibly be framed would fail to give an adequate idea of the case, and in which we must have re- course to other and additional means of information before we can be satisfied either as to the nature of the ailment or the choice of a remedy. In my clinics and sub-clinics, it will be my pleasant duty to show you how to use both of these methods of examina- tions most appropriately and intelligently. II. The Study of Uterine Pathology and Diagnosis. — No branch of special pathology has had a more eventful history than that which is to engage our attention during the coming winter. Setting out with the idea, which is as old as Hippocrates, that a woman is what she is because of her uterus! her diseases have mostly been ascribed to some special lesion, functional or organic of that organ. This general conclusion was natural enough; but the most mischievous results followed the formation of sects, or parties, among which certain narrow and exclusive views obtained INTRODUCTORY LECTURE. 27 and dominated for a greater or shorter period. Not to go very far into the past, we have had those who referred nearly all the dis- eases of women to uterine engorgement (Lisfranc); or to uterine irritation (Gooch); to uterine displacements (Yelpeau, Hodge, Grailly Hewitt); to uterine induration and ulceration (Bennet);to chronic metritis (Scanzoni); and, last but not least, to lacerations of the uterine cervix (Emmet). These exclusive views were in tarn very prevalent and popular. They are already stratified in the literature of gynecology, each, excepting the last, having had its period of rise, development and decline. Each was right as to the possibility of its being a factor of disease under given condi- tions, but wrong as to the alleged scope of its influence, or its uni- versal significance with regard to treatment. Each represented a fashion in belief and practice among medical men, which has either been greatly modified or has passed away. These and other half-truths, such as Tilt's ^iew of the supreme importance of ovarian inflammation, have had their influence upon clinical gynecology, as it is described by different authors and ex- plained by living teachers. Those of you who have been in prac- tice know this very well already; and those who have not are aware that your preceptors are not a*lways in accord with your text-books concerning the ultimate causes of ill-health among women, or the best method of caring their diseases. If we could invariably find that a warped or a luxated womb was at the bottom of the difficulty, the case would be plain enough, and the cure might not be so very tedious and troublesome. If there was nothing abnormal to search for but an ulceration, or even a laceration of the cervix uteri, the lesion could be easily made out, and the treatment would follow as a matter of course. If we could reduce the whole catalogue of women's ailments to chronic metritis, or ovaritis, or hyperplasia, as Broussais brought all acute, non- sexual disorders to depend upon a form of gastritis, the system of uterine therapeutics would be very much simplified, and a stereo- typed, inflexible set of prescriptions would be all-sufficient. But narrowness is another name for ignorance. Neither of these theories can possibly cover the whole ground of uterine pathology or diagnosis, to say nothing of the treatment. You might as well try to make a drum-head of a rabbit's skin; the thing is not big enough. In sc important a department of medicine it is a great pity that our knowledge should be corrupted and our influence crippled by such dogmas. If you wish to obtain correct ideas of gynecology, either as a science or as an art, I advise you not to commit your- selves to any exclusive theory of uterine pathology, no matter who first proposed it, whose endorsement it carries, or whether it is old or new. But how shall you discriminate? How are you to know what dependence to place upon certain classes of signs and symptoms? 2S INTRODUCTORY LECTURE. And how shall you be able to discard what is worthless, and to keep only that which will be most useful? The only way to do it is through the process of clinical training and observation. If the clinics are what they should be, and if you improve upon these advantages as you should, it will be impossible for you to be unduly biased, for you will learn to balance the claims of the dif- ferent theories, and to take each at its proper valuation. Remember, therefore, that my clinics are not designed for your diversion, but for instructive illustration; and that, while they will always be aimed at the relief of suffering and the cure of dis- ease in the case of the patient who is the subject of our study, they will also enforce a lesson in the art of classifying and of identify- ing the lesion upon which that disorder depends. They will be dry and tedious enough, especially when they keep you from your din- ner, but with a basis of reading, and of reflection, and with a degree of patience and of perseverance on your part, their good fruit will surerely ripen in due time. III. The Clinical Application or the Principles of Hygiene to Gynecology — Without trespassing upon the domain of my colleague, Professor Gilman, a part of our time will be given to a practical application of the ounce-of -prevention doctrine to gyne- cology. For as the years go by the list of preventable diseases among women grows larger, and it is quite certain that the limit has not yet been reached. Considering the very important crises through which the young girl must pass, the plainest common sense would dictate that her bodily vigor should be fortified in advance, and maintained by active exercise and exposure in the open air. We cannot imagine a worse preparation for the healthy establishment of the mens- trual function; the contingencies of pregnancy, of child-birth, and child-bed; the wear and worry of maternity; and the final change which closes the drama of sexual life, than to imprison her like a nun, and to keep her as tender and as lacking in stamina as a hot- house plant, or a bit of celery. And yet this is what the busy physician the world over sees practised every day. The higher the social grade of his patients, the more certain is it tbe rule and not the exception, that the girls of the household find themselves dwarfed and crippled in the out- set by customs and habits that are suicidal to the best interests of the community. We cannot compute the harm that is done every- where, in what are called civilized countries, by repressing the natural energies, and hampering the physical life of young women at the most important period of their existence, just as the very dawn of womanhood is upon them. For it is then that they are most impressible to good or evil influences, physically as well as morally; and then that the seal of good or of ill-health is put upon them. The boys are turned out of doors, to run and romp and play, as INTRODUCTORY LECTURE. 29 well as to work; to develop and defend themselves; but the girls are considered quite to delicate and tender for any such treatment. They must be housed and coddled, and kept as much as possible from becoming robust and vigorous, hearty and wholesome, for that would be vulgar and unfashionable. The sun that ripens the peach and tints the rose, that gilds the grass on the meadow and hill-side in the morning dew, must not shine upon them, or it will ruin their complexions, and make them tawny and coarse like their big broth- ers. Their blood must be thin and watery, or th^ir hands will not be translucent. If the heart was full and bounding, and the head was furnished with the proper materials for building a brain, they might become too masculine or too intellectual, too strong and too independent. Clinically speaking this proposition will hold good, that, unless the growing girl is inured to muscular exercise and to out of door exposure, she cannot become a healthy woman. And, if it is weak and sickly, the body will clog the mind, so that the indirect result of a lack of physical training will certainly be disastrous. This very defect is often a bar to the more thorough education of women, as well as to the establishment of their health. It is a kind of criminal folly to imprison our girls in schools and seminaries, with poor and insufficient food and fresh air, no liberty and no labor, while their minds are being crammed with husks of history, or flooded with infusions from the dry roots of a dead language. It is because this folly is not limited to what is called "the bet- ter classes," but pervades society throughout, that I shall have occasion to show you during the winter, and you will have need to know, how to recognize and to remedy its effects. For you are not to suppose that the large class of women who are forced to toil, and who are subject to the worries of active life, are thereby exempted from the diseases peculiar to the sex, and from which their more fortunate sisters often suffer unnecessarily. It is the extremes of indolence and overwork, and the lack of balance between the development and the proper exercise of nerve and muscle, mind and body, that works the mischief. And what applies to the brevet woman of the better classes, applies to the girls in all the schools and shops and homes in the land. Other questions pertaining to female hygiene that will come up for our consideration, as cases present themselves in my clinic, will include the proper aliment for body and mind, bathing and cleanliness, clothing and sleep, ventilation and disinfection, and the suitable quarantine for menstruation, advanced pregnancy, lactation and puerperality. IV. To Obtain a Correct Idea of the Scope and of the Com- parative Value of Uterine Therapeutics and of Uterine Sur- gery. — There is a tradition that surgery begins where medicine ends; a rule that has long been applied to general practice, to obstetrics and to surgery proper. But the line that separates these 30 INTRODUCTORY LECTURE. two kinds of resource is so indefinite, and the faith and enthusiasm of those who would depend exclusively upon remedies, on the one hand, and on the other, of those who insist upon the necessity and sufficiency of manual means, are so pronounced as to keep up a more or less constant warfare between them. You will find that, in gynecology also, this is a serious question, for we need to be always on the alert lest we commit ourselves unreservedly, and in a partisan spirit, to the one view or the other. Something of the judicial temper will be required to determine which is most appro- priate, if one of them is to be used without the other, or when both are required. For here, as in other mooted matters, the truth may be assumed to be at some uncertain point between the two extremes. In consideration of the difficulties that lie in your path, I com- mend you. to the clinical test for the proper solution of this very important question. If you believe and promise that your reme- dies will be all powerful, the facts will not correspond; for, how- ever skillful you may become in their choice and application, our therapeutical methods, especially in gynecology, are still very im- perfect. Besides, there must be many remedies of which thus far we know little or nothing; and many conditions of disease also to which we cannot properly affiliate those that we already have and use in our daily practice. Moreover, in certain cases, there is a limit beyond which some operative procedure is necessary, just as there is in obstetrics, and in the diseases of the eye and the ear. If, however, you endorse and accept the opposite extreme, which just now is so popular, the result will not be different, excepting that, as the tools are bigger and more dangerous, you may do a great deal more harm with them. Nothing in the whole history of medicine has shed more lustre upon the art of healing than the improvement, or rather the development of uterine surgery within the last fifty years. In no single respect has America more just cause for congratulation, in all that she has done for advancing civilization, than for her original contributions to this useful department of surgery. Scores of women have gone out from this very clinic who will bless the memory of McDowell, of Sims, and Atlee, and Peaslee, and Thomas, and Emmet, and Dawson, so long as they live, and their children's children will have occasion to hold these men in everlasting remembrance. For without their help I could not have made the delicate and difficult operations which, under God's blessing, cured those poor women and set them on their way again. I know how common it is to claim all the credit in such cases for ourselves, and to leave f he inference in the minds of those to whom we minister that no one else could have done quite so well. And I also know that not one in a thousand of those who are thus benefited will ever know to whom they are indirectly indebted for whatever they have received at our hands; but the fact remains, INTRODUCTORY LECTURE. SI and we can afford to be frank and truthful. I am very fond of gynecological surgery, and proud of its achievements. The longer I live, and the larger my experience, the more I am persuaded that the women of this and of other lands have increased cause for thankfulness, not only for the growing opportunities that are afforded in our day for the development of their talents and worth, but also for the multiplication of means that will improve their health and add materially to their physical welfare and comfort. But I have never plucked out an abdominal tumor, or put a trust- ing patient in a position where there was nothing but a thin, dia- phanous membrane between her and eternity, without wishing that there was a better way, and one that was not so beset by con- tingencies of the most serious character. Among women we find that there is quite a crop of surgical cases that lie outside the realm of applied therapeutics, and in which the couditions are curable by plastic operations, and by various kinds of local and mechanical treatment The proportion between this class of cases and such as are strictly medical must be varied by circumstances, and with the march of improvement in gynecol- ogy. My clinic will not give you a correct idea in this regard, for it is largely composed of such knotty cases as have resisted the milder and more usual methods of treatment before coming to us; but it will teach you that we do not put a premium on indiscrimi- nate cutting, or operate merely for the sake of shedding blood, or of creating a sensation; and that the kind of advice given, and the value of it also, will hinge upon the correctness of our diagnosis, and the clearness and decision with which the indications are pre- sented and acted upon. If "the best physician is he who knows when to withhold his remedies," the best gynecologist is he who knows when to sheath his scapel, and when to rely upon constitu- tional and hygienic means for the cure of his patient. Between the extremes of theory and practice there is a safe and sensible mean. In gynecology the horizon of applied therapeu- tics is constantly widening, and new ground is being gained for those who, if they could, would greatly prefer to cure everything with remedies alone. But it is one thing to be captivated and over-confident, and quite another thing to be convinced from actual experience that the law of cure can possibly cover all cases, medi- cal and miscellaneous, indiscriminately, and that gynecological surgery might better be dispensed with. In my own mind, at least, there is no doubt that in the future we shall be able to accomplish more and more with our remedies ; but it is quite as probable that a conservative form of surgery will always continue to be neces- sary in the successful treatment of the diseases of women. If I can convince you clinically that, whether we prescribe our remedies, or resort to some form of surgical appliance or to oper- ative interference, in the practice of this specialty, the conserva- tive idea is the better one; and can encourage you always to culti- 32 INTRODUCTORY LECTURE. vate that idea, your gynecological training will amount to some- thing, and your professional advice will be worth having. For this idea combines strength for common objects with separate resources for special ends. Both elements in the combination are salutary, and neither should be allowed to overpower or to super- sede the other. LECTUEE I. GENERAL PATHOLOGY. THE SEVEN CRITICAL PERIODS IN THE LIFE OF WOMAN. 1. Puberty. — Childhood, Girlhood, Womanhood, Clinical history of; Comparative risks of; Not identical with nubility; Early marriage and; Delayed; Case. 2. Menstruation — Causes of Suffering in ; three steps in; Influence of diathesis upon; do. of travel; do. of the hasmor- rhagic tendency. Case.— Effect of intercurrent disease upon; do. of the cachexiae; do. of mal-treatment; the menstrual cachexia. Before we proceed to study the different diseases of women separately, we must consider some of the principles that pertain to the general subject of gynecology. A knowledge of the general pathology of those diseases will be indispensable in your practice, and, so far as it is possible, that knowledge should be acquired at the beginning of your course. For the lack of familiarity with these underlying principles, the physician is often placed at a dis- advantage, and, what is worse than all beside, the improvement and the recovery of his patients are very seriously involved. Unless you are extremely careful and resolute, there is a double temptation that will divert your minds, and keep you from devot- ing the necessary time and attention to these preliminary studies. The fact that you are permitted to enter my clinics, and to wit- ness the great variety of cases which are treated before the class, places a peculiar temptation in your way as beginners. For it may induce you to follow the example of the artist who began to paint before he had any knowledge of drawing. Add to this the propensity for prescribing, which is almost universal, and which, unless we are very cautious, is apt to be gratified in inverse ratio with our ability and experience, ani the risk that you will lose your taste for the deeper study is very great. The first elements or principles of this branch of medicine and surgery lie in the very nature of the subject, — I mean in the peculiar physiological and clinical history of the class of patients who will come under our care in the practice of this specialty. 33 34 thl diseases of women. Some one has said that " every man's life contains a novel of* at least one volume." Let me tell you that every woman's life includes a clinical history of more than one volume. For, if we study the several crises through which she must pass, is passing, or has passed, we shall find that her health and physical welfare are beset by vicissitudes that are peculiar to herself. Nor is this all. These contingencies are superadded to the risk of the more ordinary ailments to which others are liable. So that, in addition to her sexual disorders, she may have pneumonia, dysentery, typhoid fever, tuberculosis, or almost any other disease, or acci- dent that is mentioned in our works on Clinical Medicine and Surgery. Apart from all other considerations, therefore, this fact alone should suffice to elicit your sympathy and interest in the study of Gynaecology. The thought that, by close application and stiufy, and by a conscientious improvement of the advantages which it is my duly and privilege to bestow, you can in the future mitigate the sufferings and lighten the burthens that the poor women all around you are bearing, should stimulate you to put forth your best efforts in this direction. For every case that I shall show you in my clinic will have its counterpart in your experience bye-and-bye, and every ki wrinkle " that is dropped in my lecture- room will be needed to furnish your stock of expedients for sudden and serious emergencies. Since "Art is long and life is fleeting," and since we have so much to do, and so little time in which to accomplish our work, we will come at once to the subject before us which is A CLINICAL STUDY OF THE CRISES IN A WOMAN'S LIFE. The grand, distinguishing feature of woman is the fact that her physiological and medical history are included The seven crises. in the sevm cr } t j ca i periods to which she is subject. These periods are : (1.) Puberty, or the first establish- ment of the catamenia ; (2.) Menstruation, or the periodical return of the menses; (3.) Pregnancy, or the period of repro- duction; (4.) Parturition, or that of childbirth; (5.) Puerperal- ity, or the state of lying-in; (6.) Lactation, or the nursing period; and (7.) the Climacteric, or the " change of life," as it is commonl}' called. GENERAL PATHOLOGY. 35 It will be impossible for you to arrive at a correct appreciation of the subject before us without a careful study of these crises as essential factors in the diseases of women. No man, and no per- son is prepared to explain or to treat these peculiar diseases intelligently and skilfully without an adequate Necessity for the study idea f th influence whSch these periods exert ot these crises. *- upon the health and the welfare of women. For the whole subject of uterine pathology, as it is termed, lies in these cycles and what concerns them. I. Of Puberty. — The first epoch in the sexual life of woman is puberty. It consists essentially in the arrival of that period in which the ova are ripened and discharged, with the incidental sufferings and symptoms that belong to the establishment of the menstrual f unc t i on . The infancy of the girl does not differ essentially from that of the boy. There is, perhaps, a touch of softness, of delicacy, and of pliability in her organization, that are half- Childhood. l - . J . r , way distinctive ; but, in general terms they are identical. Their looks, habits, tastes and predispositions are the same. They grow and thrive upon the same food, in the same school-room, or nursery, and are full of sympathetic relations, but without the passions and propensities of after-life. They are subject to the same diseases, which are curable by the same treat- ment; and they occupy a like place in the esteem of the family, the friends, and the general community. But time works notable changes in the young girl. For it gives a more decided tone to the delicate and the almost imper- „ , ceptible shades of difference between her and Girlhood. l . her male companion. At a period varying from the tenth to the twelfth year, in this latitude, her individu- ality begins to assert itself. Her tastes and inclinations are changed, and she becomes shy and taciturn, or forward and capricious. She is timid and reserved, but sensitive, confiding, and tender-hearted. The womanly traits are soon evolved and matured, and she is no longer the non-sexual creature that she was before her emotional and physical natures were so wonder- fully developed. Henceforth her role is declared, and she must play it with all 36 THE DISEASES OF WOMEN. the risks that threaten the sex to which she belongs. The sexual life dawns amid contingencies that are more Womanhood. . numerous and more serious than you may have supposed. For, although the ovaries were perfectly formed during foetal life, and were full of ova at the birth of our subject, yet they have lain dormant until the date of puberty. And, although the womb, and the whole generative intestine were present at first as they now are, yet, until now, they never were the seat of any especial functional activity. And henceforth her diseases will be peculiar, and very different from those to which she has already been subject. This chapter is one of the most interesting in her whole Her i linical history. ,. . , . . A n . J . , t • i i n clinical history, lor it involves and includes all the rest. We must comprehend this crisis and its influence throughout the whole of her menstrual life, or very much that follows will be a puzzle and an enigma that we shall certainly fail to solve. There is a common impression that the most serious disorders which date from puberty are referable to a delay in the prompt establishment of the menstrual function. It is The comparative risks. , n . , . • i i i i • at puberty. \\q\& that, it a girl does not begin to menstru- ate before her sixteenth, eighteenth, or twen- tieth year, she will almost necessarily suffer in consequence. But I insist, that, practically considered, this is a wrong view of the case. For while the delay, if it is too tardy, is neither natural nor desirable but is sometimes decidedly harmful, still, as a rule, the risk is greater if the flow begins too early as, for example, in the tenth, the eleventh, or the twelfth year. One reason why a precocious puberty is apt arrnoTthe a saL nUbilityto be followed sooner or later by ill health, is that with parents and with physicians also, puberty and nubility are regarded as synonymous, or identical. The prevalent idea is that, since ovulation implies the possibility of conception, it also signifies the propriety of an entrance into the marriage relation. So that, even although the girl who has menstruated so early does not marry while she is still very young, the chances are that she will be placed in a wrong relation to the opposite sex, while she is a mere child in every other respect, before the generative organs are fully developed, and before her GENERAL PATHOLOGY. 37 physical maturity has arrived. Acting upon the hint that ma- ternity is possible, she is placed at a most unfortunate disadvan- tage. This is the reason why early marriages often turn out badly. The menstruation was premature, and the wedding also; and then the first pregnancy ends in a miscarriage, or in a labor that is tedious and impracticable because of the youth and immaturity of the party who is most concerned. And after this comes a chapter of consequences that are likely to be entailed upon the poor woman for life. Another reason why a premature advent of the " flow " may have its mischievous results is that, coming thus early, the young girl may be ignorant of its meaning or import, ne^°c? nCe and S6lf " ( as alas! so man y thousancls of them are), and therefore may neglect herself sadly at this par- ticular period. Knowing nothing of the consequences that may follow, she Avill be very apt to get her feet wet, to take a cold bath, or to do something to check the flow, and to compromise her health. In my clinic I shall often have occasion to refer you to this as one of the sources of menstrual disorder, and of uterine and ovarian disease in after life. If puberty is delayed by reason of constitutional or general causes, the case is serious and will need to be inquired into. There arefou?* of these causes, either of which puberty" ° f ^^ ma y retard the nrst appearance of the menses, viz., (a.) an impairment of the quality of the blood; (b.) depraved nutrition; (c.) nervous and mental exhaus- tion; and (d. ) the tuberculous or scrofulous diathesis. If the blood is impoverished, or lacking in the elements that are requisite for the healthy and vigorous performance of the bodily functions in a growing child, it is not to Impoverished blood. ° be supposed that it would contribute anything to the establishment of a new and a different function. If the girl is the subject of chlorosis, of anaemia, or of chloro-amemia, the blood may not be rich enough to stimulate the ripening of the ova, the first menstrual discharge may go by default, and the second and subsequent attempts to put this function into opera- tion may not be any more successful. In this case the general ■cause is responsible for the result. 38 THE DISEASES OF WOMEN. Or, if the nutritive process is badly performed through a lack of proper food, fresh air and exercise, caprice Depraved nutrition. . . . , __ J -, -,. or whim, or any other cause, JNature may decline and absolutely refuse to create a new demand and a new drain upon the resources of the economy until this state of things is remedied. There is no more fertile source of mischief to our young women than the abominable diet that is furnished them in many of our boarding schools and seminaries, at a time of life when they should be well-fed and nourished. For to confine our young girls to a bill of tare that would dishearten and dis- courage an anchorite, is a reproach to our boasted civilization. In the same general way it may happen that nervous and men- tal exhaustion shall interrupt the "regular course of things" with the class of subjects under consideration. Nervous exhaustion. . . . _. , . W e all know that this condition is a lertile source of mischief with many of those who have already begun to menstruate. In such cases too great a nervous strain may arrest the flow altogether for months, and sometimes for years. There are several of these cases in myelinic at this moment. So, likeAvise, when the time for this crisis, which we call puberty,, has arrived, if the girl is subjected to excessive mental w T ork or worry, if her brain fags, or her nerves " fly all to pieces," and the strain is kept up, we may reasonably expect that the initial step in this process will not be taken until the conditions are changed. The tuberculous habit often delays the first appearance of the menses, and, indeed, it often deranges this function most seriously at other times also. You should not forget to The different diatheses. . .... . ° look especially lor pectoral symptoms, a hack- ing cough, haemoptysis, night sweats, and a quick pulse, where the menses are tardy in one who is predisposed to phthisis. The scrofulous cachexia, as a rule, is accompanied by delayed men- struation ; but girls who have a curvature of the spine are apt to " flow " early and copiously. An interesting case came to our clinic a few days ago, in which the delay of the catamenial function was clue to a bronchocele : Case. — E. L , aged fifteen, has never menstruated. She is a bright, active girl, and has been closely confined in one of our city schools. Two years ago both lobes of the thyroid gland began GENERAL PATHOLOGY, 39 to develop simultaneously. This swelling has slowly increased in size until the circumference of the neck is fully From bronchocele. one _ half larger than jj. Qught to be; her gQR _ eral health is good, but her mother says that alter active exercise she is subject to slight attacks ol palpitation of the heart. There is no protrusion of the eyeballs nor any derangement of vision. She has no signs of anaemia, and there have been no symptoms that indicate the establishment of the menstrual flow in her case. It is not characteristic of her family that menstruation shall begin at a later period than usual; nor have any of her relatives ever had bronchocele. She was directed to take spongia 3, four times daily. (This case improved steadily on spongia.) Certain diseases are cured by puberty. Chlorosis, chorea, incipient phthisis, and some eruptive affections may cease by limitation when the monthly flow is fully established. It is in ignorance of this fact, that cures of these diseases are often ascribed to remedies which have been given just at that particu- lar time. What is equally remarkable is, that the phthisis and the diseases of the skin, which apparently have been cured at puberty, are apt to return at the climacteric. Among the diseases that follow the initiation of this remark- able function, hysteria is perhaps the most prominent. It is very rarely that a young girl has hysteria before puberty, or during the pre-hysteric age, and it is quite as exceptional if a woman has it after the menopause, or during the post-hysteric period of her life. In a very large proportion of cases of epilepsy among women, the disease dates from the first menstruation, or from the natural effort to bring on the flow. If to these peculiar nervous disorders we add the whole list of the diseases of menstruation, of pregnancy, and of each of the other critical periods already spoken of, you will see how impor- tant a relation this first step in the direction of womanhood bears to what are properly styled the Diseases of Women. In our search for the beginnings of uterine and ovarian disease, we shall have frequent occasion to refer back to, and to inquire after, the peculiar experiences of the patient at the very dawn of her men- strual life. And we shall often find that something in the charac- ter of the pains that she had, or in the weight in the hypogas- trium, the headache, the vertigo, the malaise and lassitude, the 40 THE DISEASES OF WOMEN. palpitations, the disgust of food, or the morbid appetite, the extreme sensitiveness, the spasmodic tendency, or the emotional uproar, will help us to clear up the diagnosis and to individualize the case. No matter if twenty or thirty years have intervened, all the obstacles that were in the way of the prompt, free, natural and almost painless establishment of this function may need to be known before we can proceed intelligently with the cure of our patient. II. Of Menstruation. — Whether we accept the prevalent theory that menstruation depends upon ovulation or not, the fact remains that the monthly molimen is characterized by states of the pelvic circulation and innervation which are easily dis- turbed and changed into the inflammatory process. The menstrual congestion which is a necessary condition of the subsequent flow, is the cause, in a large part, of the intra-pelvic pain and distress that almost always attends the Causes of suffering. „ ,. ,, . c . „. . , ,. performance of this function. The weight of the womb is increased by its temporary engorgement. Its deli- cate lining membrane begins to undergo the changes which bring about its detachment and final discharge. This "nidation," as it is technically called by Dr. Aveling, and the moulting that fol- lows is analogous to the growth and separation of the decidua in pregnancy and labor. The exfoliation of the Three steps m the pro ^ecidua menstrualis, is, in fact, beset by con- eess. . . tingencies both before, during, and after the " period." And the clinical symptoms which we have to study in menstrual disorders concern these three special stages of this process. You will often have occasion to observe that the chief complaint which the woman makes of suffering at the month, dates from two or three days to a week before the beginning of the flow. In other cases, she is in greater pain and distress after the flow has begun, and so long, indeed, as it continues. In a third series of cases, the suffering is almost entirely limited to the time when the proper discharge has ceased, or changed into a leucorrhceal flow. Very exceptionally, as in inter-menstrual dysmenorrhea, she GENERAL PATHOLOGY. 41 may suffer most at a time that is half-way between the periods. A little reflection will satisfy you of the importance of this subject. In order that a woman should be healthy during what is termed her menstrual life, excepting only while she is pregnant, or during lactation, the function of which we are speaking should be regularly and properly performed. Each of the three steps in the process should be taken promptly and they should succeed each other in a natural manner. If the nervous conditions that control the circulation are such as to drive or to divert the blood from the Anticipating symptoms. , . , , , , . . pelvis to the brain or elsewhere just when it is needed within the ovarian and uterine vessels, as a condition of menstruation, the secretion will be arrested or impaired. If the blood itself is too poor to furnish the necessary stimulus for the ripening and extrusion of the ovule, the whole function of menstruation may, for the time being, at least, go by default. If the uterus has toppled over backwards and obliterated the canal of the cervix at the internal os- uteri, the menstrual changes that are proper to the cavity of the body of the womb will be very much disturbed, or cut short in their first stage. If the neck of the womb is narrowed, or partially obliterated from any other cause, the patient will have to pass through a period of suffering which is the counterpart of the first stage of labor, and which, although it recurs every month, is as hard to bear as a veritable childbirth. Or, if we suppose that the flow has begun in a normal manner, the most serious consequences may happen through its interrup- tion. What is called an intermittent form of Accompanying symp- . , toms> menstruation, or one m which the now begins and stops alternately, is always a painful variety of menstrual disorder. There is perhaps no case of inflamma- tion of the entire lining membrane of the womb, in which men- struation is not painful from the beginning to the end of the period. The discharge is sometimes arrested by shock, as from fright, or some form of mental emotion; by falling, or by strain- ing, as in lifting something heavy; by coitus, and by getting the feet wet. And the effects are all the more serious because the mischievous influence has been applied during the flow, when there is a greatly increased susceptibility, with a diminished resist- ance on the part of the generative organs. 42 THE DISEASES OE WOMEN. Clinically speaking there is no doubt that menstrual disorders are frequently caused and perpetuated by a lack of care during the period, in some such manner as dyspepsia may be induced by causes that are brought to bear Avhile the stomach is busy with dissolving the food. And so likewise with the third act in this wonderful physio- logical process, which, to a healthy middle-aged woman, is "as inevitable as one's shadow." The rapid degen- Subsequent symptoms. . . . . , eration ol the uterine mucous membrane, the carrying away of the effete debris, and the final " parturition of the ovule," as Tyler Smith so aptly termed it, are steps that are decidedly critical. For, if a decidua is removed at every period; if this removal is accompanied by more or less peristaltic action of the uterine muscular fibre; and if it is followed by haemor- rhage, the case is one of labor in miniature, which, like the period of puerperality, has its own clinical significance. These considerations with regard to the general pathology of menstrual disorders, have their counterpart in the proper treat- ment of those disorders, whether it be medical Practical deduction. . . or surgical. Ihis, indeed, is the key to what might be styled menstrual therapeutics, and in your practical lives as physicians, whether you become specialists or not, you will have occasion to use it very often. There is another class of facts which you will need to remem- ber in this connection. The conditions that influence and modify the course, progress and termination of diseases Influence of diathesis,, i , , , . -. ,1 -, etc that are not catamenial, impress themselves upon this class of affections also. There are personal and family idiosyncrasies that may so change the clinical history of amenorrhcea, dysmenorrhcea, and menorrhagia as almost to destroy their identity. When either of these disorders occurs in a woman who is subject to scrofula, to rheumatism, to chlorosis, to syphilis, or to any serious affection of the skin, its special pathology, and its special therapeutics will be modified accordingly. Nor should you forget what I feel like insisting upon very strongly, that the diseases of which we are Influence of travel. ,. ., ■, . -, ,, . a -,, speaking are quite as decidedly influenced by external circumstances, and especially by changes of latitude, as are GENERAL PATHOLOGY. 43 asthma, tuberculosis, or intermittent fever. This fact needs to be borne in mind, because, in these days of rapid transit, and of cheap transportation, when everybody travels, sufficient atten- tion is not always paid to the climatic vicissitudes of journeying from one end of our country to the other. Some of you remember a very marked illustration of the modi- fying influence of the haeniorrhao-ic diathesis Influence of the hsem- ^ " • tit- orrnag-ic tendency. upon menstruation that we have had m our clinic. I will recall the principal facts to your mind : Case. — For some years, four of the members of one family have been coming to our out-clinic. The eldest of the three daughters consulted us for a pronounced anaemia with periodical haemoptysis, and a delay in the establishment of the monthly flow. The second one had epistaxis at puberty, which was evi- dently vicarious of menstruation, and when the uterine flow was finally established it was very irregular. The third menstruated once only at fourteen, but not again for several months, and was sickly and complaining meanwhile. And the mother, who was passing through the climacteric, not having ceased to flow at forty-nine years of age, was suffering from incipient hemiplegia. Intercurrent diseases of an acute or sub-acute type have much to do with modifying and complicating the clinical history of menstruation. During their existence, as for renf Sease° f lnterCUr " exam Ple, while a menstruating woman has typhoid fever or pneumonia, her periods are very likely to be interrupted. Sometimes she will have a sus- pension of this function, or a kind of temporary amenorrhoea that is limited by the duration of the fever, or of the inflamma- tion, whatever it may be. At other times, more especially if her general condition is adynamic, or if she is addicted to haemorrhage, the flow may be too frequent and too copious. In either event the crisis of the intercurrent disease from which her recovery dates, is often the point of departure for menstrual difficulties that she never had before. For this reason the management of acute diseases occurring in women demands especial care. The same rule has an indirect application also. Where conva- lescence from acute disease has not been thoroughly established, and the patient has drifted into a cachectic condition that may continue indefinitely, disorders of menstruation are very likely to 44 THE DISEASES OF WOMEN. ensue. The confirmed state of cancer, whether it be uterine or not, of phthisis pulmonalis, of chronic dvspep- ioufcrhexir beVar " sia > and he P atic disorders, of pelvi-peritonitis, and of pelvic cellulitis, are almost invariably complicated with one or more of these affections. If your observation accords with mine, you will learn that a considerable share of the menstrual difficulties which you will be influence of a ai-treat-called upon to cure are the sequelae of an excess ment - of local treatment, in the way of cauterization, dilatation, or incision of the cervix uteri, and the wearing of ill- assorted, ill-adjusted pessaries, that may have caused an untold amount of suffering, and had the effect to upset the menstrual function altogether. It will be my duty to teach you how to apply these resources in such a way as to make them of real service to your patients, and how to avoid the harmful conse- quences that are so often entailed upon women by their careless and indiscriminate employment. In conclusion I must remind you that chronic disorders of the function of which we have been speaking, whatever their cause or complication, may develop a menstrual The menstrual cachexia. . . ~. cachexia, which is sometimes as incurable as that of chronic aortitis, or carcinoma. This fact which has been verified by clinical experience under all the known methods of treatment, will have the effect to make us chary of promising to cure these disorders indiscriminately and invariably. LECTURE II. GENERAL PATHOLOGY— CONTINUED. 3. Pregnancy.— The physiology of; the diseases that are caused by; relation of, to uterine displacements: do. to cervicitis ; the common diseases of pregnancy ; changes of the blood in ; do. of the heart in; rheumatism in; do. nervous affections; do. metro-cere- bral disorders ; do. pulmonary, digestive, and uriuary derangements. The diseases that are cured by pregnancy; the vis medicatrix of. Diseases that co-exist with preg- nancy; ovarian and fibroid tumors, etc. III. Pregnancy. — The period of pregnancy, which begins with conception and ends with labor, is characterized by a great variety of physical changes, which, although they are natural and self- limited, as a rule, do often modify the subsequent health of women. This is why, in the case of those Avho have borne children, whether prematurely or at term, pregnancy may be considered as a critical predisponent of disease. If the uterine tissues were not developed in an extraordinary degree; if ovulation and menstruation were not The physiology of P reg- suspenc i ec i ; if the circulation and innervation n£Lncv A of the pelvic and abdominal viscera were not greatly augmented ; if the heart and the liver were unchanged in structure and not overburdened with an increase of duty ; if the demands upon the nutritive and nervous systems were not in excess of the usual needs of the economy; and if the moral and physical natures were not disturbed in so remarkable a manner during pregnancy, you may depend upon it that a large share of the diseases that are entailed upon women would have no existence. In a liberal, but not in a literal sense, all the diseases that are peculiar to women, excepting only those that belong to menstrua- tion, must be directly or indirectly related to pregnancy. The contingencies of childbirth, of the puerperal state, and of lacta- tion, therefore may be said to date from the beginning of gesta- tion. I think it will be profitable to consider this subject under the three general heads of (1) the diseases that are caused by, (2) those that are cured by, and (3) those which may co-exist with pregnancy. 45 46 THE DISEASES OF WOMEN. 1. Of the Diseases that are Caused by Pregnancy. — In this con- nection I shall not speak at length of what are commonly called the diseases of pregnancy, as for example, morning sickness, caprices of the appetite, incidental disorders of digestion and of the circulation ; but of the more chronic and permanent affections to which women are predisposed by reason of their having been preg- nant, and from which they suffer after the period of gestation has terminated. Perhaps the different varieties of uterine displacement should head this list. If we remember that the changes Uterine displacements. . . . , . „ . which take place in the uterus prior to the fourth month are almost exclusively confined to the fundus and body of the organ, we shall be able to explain the comparative frequency of flexions and versions of the womb that follow upon early abor- tion. The greater relative frequency of prolapsus as a sequel to miscarriage in the later months must be ascribed to the develop- ment of its lower segment at that period of pregnancy. Depaul and others have noted the fact that the growth of the uterus during pregnancy is not uniform upon its different sides or surfaces any more than at its two extremities. Nothing is more probable than that these one-sided conditions o?Z U grav1r u 1^? ntoften continue after delivery, more especially if that delivery was accidental or premature. When the risks of defective involution which attend upon all cases of miscarriage are added to such conditions, the source of very many cases of uterine deviation is almost positively known. So, likewise, the torsion or twisting of the uterus, which occurs in the last months of pregnancy, and which Twisting- of the womb. .,, . n z . . . , usually turns it toward the right side, may give it a lateral inclination that it will keep for a long time after the child is born. This result is facilitated by the relaxation of the round ligament on the opposite side, which gives the organs a kind of squint or divergent strabismus. You have observedthis obliquity in our puerperal wards when we have been studying the changes that occur in the womb during the first ten days of the lying-in ; and I shall often have occasion to illustrate this kind of deviation arising from the same cause, in my general clinic. Naturally enough, the statics of gestation, as well as the extra- ordinary development of tb* intra-pelvic tissues, the migration of GENERAL PATHOLOGY — CONTINUED. 47 the womb from the pelvis to the abdomen, and the stretching of all the uterine ligaments are so many factors in mefgame P n°t n s. theUter " causing and complicating the displacements of the organ, that come either in the early months of pregnancy, or that follow its close. There is another group of affections from which many, if not, indeed, most women would be exempt if they cervical inflammation became pregnant. I allude to the differ- and ulceration. ^ . ent forms of inflammation and ulceration of the uterine cervix. Those of you who have been engaged in the study of obstetrics know what is understood by the ramollissement or softening of the cervix, its change of form and structure, and its final obliteration at term. These processes, which are physiologi- cal and natural in themselves, bring about such a modification in the nutrition of the parts as renders them much more liable to dis- ease than they would otherwise have been. Clinically considered, the virgin cervix is very different from the cervix of one who has reached the sixth month of pregnancy or who has gone her full time. And there are also important differences between the cervix in the first and in subsequent pregnancies; or, technically speak- ing, between the cervix of the nulliparous and the multiparous uterus. In the treatment of corporeal cervicitis, and of endo-cervicitis, as well as of cervical induration and ulceration, I consider it very important to remember that either and all of these lesions may Effects of a by-gone have their root in the evolution and the involu- pregnancy upon the . cervix. tion of the neck of the womb, during and after pregnancy. We have good authority for the statement that epithelial cancer of the neck of the womb never occurs except with those who have borne children. The modifications that are proper to the uterine mucous mem- brane during gestation are peculiarly delicate, and of the greatest possible interest to the gyn- aecologist. These modifications include a great and growing increase of its surface, and of its vascularity; the formation, separation and final moulting of the decidua; the organization and detachment of the placenta ; the development of a new membrane to take the place of the old one; and the Changes in the endo- metrium. 48 THE DISEASES OF WOMEN. retrogressive changes that pertain to the involution of the uterus after it has been emptied of its contents. If these changes are interrupted or interfered with, the risks of inflammation are sometimes verv great, and Effects of. ,_ _ ■ _ * -, „ the consequences may last tor years m the form of ordinary chronic metritis, exfoliative metritis, menorrhagia, or an intractable uterine leucorrhoea. What we have said of cervical lesions as contingent upon preg- nancy is equally true of the common form of metritis that occurs in general practice. For, if her womb has not been developed by a contained embryo, or something like it, as, for example, in case of uterine polypi, or fibromata, it seldom happens that a woman has chronic metritis, unless, indeed, it be the result of some mis- chievous local treatment or appliance. It would not be reasonable to suppose that the peritoneum, which is the outer envelope of the uterus, should ch^el ° fPerit0neal tail t0 Participate in the changes of structure, and in the morbid risks that, without exception, are proper to all of its tissues during the period of utero-gestation. You know that this delicate serous membrane, after covering the posterior surface of the bladder, is reflected upon the anterior wall of the uterus, so that it invests about three-fourths of this organ in front ; that it passes over the fundus and descends upon the posterior face of the womb until it lines the Douglas cul-de- sac, whence it re-ascends upon the rectum. You also know that the broad ligaments are formed of duplicatures of this same mem- brane, and that the utero-sacral and the utero-vesical moorings of the womb are made of the same material, with a few muscular fibres interspersed. This is the genital peritoneum. Rouge t is authority for the fact that there is a very intimate union between the muscular parietes of the womb and its investing peritoneum, and that during pregnancy, this ton[tf s in0fmetr0 " Peri " union continues > so that the peritoneum does really participate in the hypertrophy and other textural changes that are proper to this period. Add to this, that when the uterus passes from the pelvis to the abdomen, where it may have space for its development, the ligaments are put upon the stretch, and sometimes seriously injured. These circumstances predispose many women to pelvi-peritonitis, which disease is GENERAL PATHOLOGY CONTINUED. 49 much more troublesome and common than you may have sup- posed. If my own experience in private prac- origin of pelvic pen- ti d ag a olinical teacher, may be taken as a tonitis. ' . J criterion of the facts in the case, I should say, that while pelvic cellulitis may, and does sometimes occur in those who have never conceived, pelvi-peritonitis, like the cauliflower excrescence, does not. It is true, however, that in a considera- ble proportion of cases, these two diseases are not altogether distinct. In consequence of pregnancy, the liability to inflammation of the pelvic cellular tissue is very much increased. You will find a con- firmation of this fact in our lying-in wards and in ^Origin pf pelvic cellu- the Mstory of many cases j n my dinic on Wed _ nesdays. It often happens that, because relapses of cellulitis in the non-puerperal state are so directly related to the menstrual return, the real origin of the disease, as a sequel of pregnancy, is overlooked. En passant, it may be as important to treat these cases with especial reference to their beginnings during gestation, no matter how remote it may have been, as it sometimes is to treat prolapsus uteri with reference to a defective involution of .the womb during the early puerperal period. The etiological results of the changes in the muscular tissue of the uterus during gestation will be considered iartunf c eSintheVaSCU " when we come to s P eftk of the post-partum in- volution of that organ. Having thus considered the modifications that are proper to the generative organs during pregnancy, the effects of which do not wholly disappear in after life, we must study the results of this condition upon the other organs and functions of T p h r e egra r c.y ndiSeaSeS ° f the £ elieral economy. In this regard the diseases of pregnancy, as they are commonly termed, are significant, not only during the period of utero-ges- tation, but afterward, and because of their sequelae. To facilitate this study I have arranged a table upon the black- board. It is imperfect, but it will give you a list of the more prominent disorders to which women are liable during pregnancy. The groups of diseases naturally involve the more prominent organs and functions, and are more or less serious, according to circumstances. 4 50 THE DISEASES OF WOMEN. TABLE OF THE DISEASES OE PREGNANCY. The Circulatory System. The Nervous System. The Digestive System. 1. Of the Blood: 1. Of the Mind: 1. Of the Mouth . a Plethora. a Irritability, timidity. a Stomatitis. b Anaemia. b Melancholia, vertigo. b Toothache. c Chlorosis. c Capricious inclina- c Ptyalism. d Uraemia. tions. e Hydremia. d Often entire charjge / Chloraemia. of temperament. 2. Of the Circulatory Organs : 2. Of the Sensory Nerves : 2. Of the Stomach: a The heart. a Pain: headache. a Morning sickness and b Palpitation and syn- b Neuralgia. anorexia. cope. c Over-sensitiveness. b Nausea and vomiting. c Hypertrophy, etc. d Insensibility. c Pyrosis. d Veins; varicoses. d Cardialgia. e Haematemesis. / Capricious appetite. g Catarrh of the stom- acn. 3. Of the General Circulation. 3„ Of the Motor Nerves : 3. Of the Bowels : a (Edema. a Spasms ; convulsions^ a Constipation. b Haemorrhoids. b Eclampsia. b Diarrhoea. c Haemorrhages. c Epilepsy ; chorea, etc. c Dysentery. d Varicoses. d Paralytic conditions. 4. Of the Liver: a Torpidity of, etc. b Hypertrophy of. c Acute atrophy of. If we take the circulatory system, we find that the altered char- acter of the blood, which in a considerable proportion of cases is contingent upon pregnancy, continues thro ugh changes m the blood puerpera j ifcy and lactation, so as to impair the during pregnancy 1 i J > i health of the mother more or less permanently. This is a class of causes which is very obscure, and therefore likely to be overlooked. Concerning the heart itself, there is no question that its struc- tural changes during pregnancy are often as pro- nounced in their way as are those which occur in the uterus. The most decided of these changes consists in a hypertrophy of the left ventricle, the walls of which may become increased from one-fourth to one-thirl of their thickness. Their texture is more firm and their color more bright, while the auricles Changes in the heart. GENERAL PATHOLOGY CONTINUED. 51 and thfi right ventricle retain their normal thickness. If the right ventricle is also hypertrophied, it will give rise to pulmonary congestion and haemoptysis. It the hypertrophy of the left ventricle results from the nat- ural impediment to the uterine circulation during pregnancy, it must be regarded as conservative, or compensatory, the same as if it had been caused by valvular lesions; and if the hyper-nutrition of its parietes, like that of the uterine tissues, is confined to the period of gestation, and passes off with it, the cause being with- drawn the lesion may disappear. But if anything interferes with a return of the normal conditions of the general circulation, the hypertrophy will not be removed. In this manner a single pregnancy may develop an acquired pre- disposition to cardiac diseases which subsequent pregnancies, more Changes as a predis- especially if they occur in rapid succession, will ponent of cardiac dis- be very likely to confirm. Indeed, it sometimes appears that this predisposition is ultimately changed into an exciting cause, as when it induces epistaxis, haemoptysis, metrorrhagia, or apoplexy. When this ventricular lesion exists in women who have suffered from the rheumatism that is sometimes caused by pregnancy, Ave may look for valvular complications which are Effects of the rheuma-. . tism of pregnancy. in the way of a perfect recovery. For in this case the compensating hypertrophy will not always cease by limitation, but may continue for months or years after the child is born. In the same manner and for similar reasons, the indirect conse- quences of an embarrassed circulation during pregnancy which incidental disorders of a PP ear ni dropsical, hemorrhoidal, and varicose circulation. conditions, are frequently entailed upon women. And there is no doubt that these troublesome sequelae do often affect the internal as well as external surfaces and structures. In this second column, which is devoted to the derangements of the nervous system which are incident to pregnancy, you will ob- serve that the mind, as well as the body maybe implicated. Indeed it sometimes happens that the mental disorders which accompany and which follow pregnancy are altogether the most prominent. In some cases they are most pronounced directly after conception ; in others they come about 52 THE DISEASES OF WOMEN. the period of quickening; and in others still, they develop very decidedly as term approaches. It is in the lat- Metro-cerebral disor- , i'x' 'ii.lix.li ±. ders ter class of cases especially, that the most serious conditions of mental derangement may extend beyond the period of pregnancy and result in puerperal insanity. Even where this effect does not follow directly, the less acute forms of mental disorder may come from an acquired predisposi- tion on account of pregnancy, and declare themselves long after the period of gestation has terminated. The whole subject of utero-mental pathology is intimately related to the influence which preo-nancy may have upon the subsequent health of women. As a clinical rule, the diseases of the sensory and motor nerves which occur during gestation are self-limited, Affections of the ce- uke those of diphtheria. Exceptionally, how- rebro-spinal nerves. L l J ever, they appear to be fastened upon women because of weakened and enfeebled conditions of the general sys- tem, that have been induced or perpetuated by lactation, or perhaps by a too early and copious return of the menses while she is yet nursing her child. Although, as a class, the disorders of digestion that- occur during pregnancy are very frequent and distressing, Disorders of digestion. ^ " yet they usually disappear at or betore term. The consequence is, that their usual consecutive effects are neither very lasting nor serious. The structural changes that are proper to the liver in the form of fatty deposits may continue during lactation, but, except in rare cases, they are finally disposed of without compromising the health of the subject in the future. The same is true of the incidental affections of the urinary sys- tem, the most prominent of which is the develop- Disorders of the un- ment f Brio-ht's disease, with its accompanying nary organs. rt . . 1 ./ a albuminuria, uraemia and a tendency to eclampsia- However formidable these accidents of pregnancy, they are almost always self-limited, and can therefore hardly be said to increase the predisposition to the special diseases of non pregnant women. Unless they are connected with cardiac lesions of structure or function, or of both, pulmonary disorders that Pulmonary disorders. . .,..,„ may occur at this time have no especial signifi- cance. With these exceptions they are more apt to be improved than aggravated by the development of the gravid uterus. GENERAL PATHOLOGY CONTINUED. 53 (2.) Of the Diseases that are cured by Pregnancy. — It is not unusual for a woman to date her pregnancy from the time in which she experienced a marked improvement in her ^e vis mediatrix of health> Nervous, hysterical and dyspeptic dis- pregnancy. J ./ i i orders may sometimes be suspended or disposed of in this way : but the diseases which are most likely to be ben- efited because of conception are the different forms of ovaritis, dysmenorrhea, chronic metritis and prolapsus uteri. I think that in our day it is generally conceded that the effects of pregnancy upon the development of phthisis Effects upon phthisis. , ° ,. ". . . , . „ pulmonahs, is that, although for a time it may be retarded, yet afterwards its progress will be hastened. This is especially true in case of rapid child-bearing. (3). Of the Diseases that Co-exist with Pregnancy. — This division includes carcinoma of the cervix-uteri and of the labia, intersti- tial and sub-peritoneal fibroids of the uterus, influence of pregnancy. tumors, ulceration of the os-uteri, and upon co-incident disease. ' pelvi-peritonitis. The tolerance of these com- plicating affections and foreign growths, and their reciprocal influ- ence upon pregnancy, would make a curious chapter in the clinical history of utero-gestation. The growth of a malignant disease like cancer, or of a benign tumor, like a fibroid, may be retarded while the Influence upon ovarian foetus . developino; j n u [ eY0 , But their course tumors, etc. l ^ is likely to be more rapid after term. An ova- rian cyst may cease to grow, or it may be removed during preg- nancy, as has been done by Spencer Wells and others, with no very great risk to the mother, and still less to her offspring. The uterine ulceration may disappear spontaneously as the neck of the womb is developed, or the peritonitis may become latent until the puerperal period has arrived. But either of these morbid contingencies may act as a predis- posing or an exciting cause of abortion. In short the reciprocal tendency of things when these affections co-exist with pregnancy is that the first of these two conditions must be practically arrested and disposed of, or the second must come to an end. In conclusion I ought to tell you that the mere fact that most of the diseases of pregnancy are self-limited, does not give exemp- tion from them in the non-pregnant condition. For, as a patient 54 THE DISEASES OF WOMEN. who has once had an attack of croup, of pneumonia, of enteritis, mu ,. „ or of epilepsy, is all the more likely upon The diseases of preg- l 1 J ' I v nancy may recur in theexposure to have a second attack, so a woman non-pregnant. w j lQ j^ Sll ff erec j during- pregnancy from either of the diseases named in the table on the black-board, will be ren- dered more prone to it than if she had never conceived. This remark applies with especial force to the diseases of the uterus and its appendages. Nor should you forget that, while pregnancy is a powerful pre- disponent of the diseases that are peculiar to women, menstrua- .. . tion may afterwards act as an exciting- cause Menstruation may be J o the exci ing cause for thereof, so that, practically, it is as if gestation thisxeiapsH. repeated itself every month. It is not strange, therefore, that, under these conditions, the conservative powers of Nature are so entirely overcome, and the uterine cachexia is so often developed. LECTURE III GENERAL PATHOLOGY — CONTINUED. 4. Parturition.— Effects of, on the nervous system; in primiparas ; do. multipara; traumatic lesions of. 5. Puerperality.— Diseases of ; uterine involution, results if defective; laceration of the cervix as a cause of post-puerperal diseases; the ca- chexia. 6. Lactation.— A necessary condition of uterine retraction, and a natural prophylactic of post-puerperal disease; effects of non-lactation in abortion. Case. —Why nursing is prophylactic of uterine disease ; weaning may be either harmful or salutary; effects of undue lactation. Case. 7. The Climacteric— The diseases of, are plethoric, anaemic, or nervous ; the class of affections that are caused by this crisis, those that are cured by it, and those that co-exist with. Post-climacteric affections. IV. Parturition. — In the order that we have chosen, parturi- tion, or labor, is the fourth epoch in the life of a woman. Its relation to gynaecology is peculiar and important, for it puts an end to the period of pregnancy and a limit to the diseases that pertain especially to that function, of which, indeed, it is the turning point. Labor is related to the diseases of women in two especial ways, (1) through the shock and strain to the nervous system, and (2) through the traumatism of the maternal passages. The nervous tension to which every pregnant women is subject in a greater or less degree, culminates in the act Effects on the nervous f parturitioili This is true, whether she goes system. L ' *= to term or not. For the extrusion of the ovum necessarily involves a drain of nerve force, and a shock, also, it the labor is premature, or the circumstances attending it are pecu- liar. Although our neurologists are not always careful to remem- ber it, the seeds of special forms of nervous disease are often sown in child-bed. First labors are especially obnoxious to this charge. Naturally enough, with the resistance of parts that have never been dilated or properly developed for the performance of this function, the degree of suffering will be pro- portionately increased. Here the strain is usually more prolonged and severe in its effects. Moreover, in the great majority of cases, the young wife enters upon this terrible ordeal without an ad- 55 56 THE DISEASES OF WOMEN. equate idea of what it involves or includes, except that, after passing through purgatory, she will, or may, become a mother. There is a tradition which holds that among savages women do not suffer in childbirth ; and there are those who A traditional fallacy. . • /. i ..... insist that it the women in civilized society could live in a more barbarous or " natural " manner, they also would be exempt from the contingencies of labor. But lioberton has shown that this half-truth is not worthy of credence. The fact is that, if ignorance and a lack of care when their children are born, the absence of almost all the civilizing influences of home, of fresh air, proper diet and cleanliness, could give exemp- tion from the wear and worry of bringing their children into the world, and from the diseases that may and do follow, our hospitals and dispensaries for women would be very much crippled for the means of clinical illustration. And what is true of the clinics is true of the community. But you are not to infer that, in second and subsequent labors, there is an immunity from these nervous sequelae. Effects in multiparas. _ , n , . rwery woman, whose first labor was very pain- ful and protracted, and accompanied b}^ convulsions, haemorrhage, after-pains, or even a broken breast, dreads a repetition of her former experience. And more than this, she may have such a horror of it, that through fear of becoming pregnant again, her subsequent health may be so shadowed and modified as to predis- pose her to the most intractable nervous diseases. The experienced physician would as soon think of treating valvular disease of the heart without inquiring if his patient had ever had the rheuma- tism, as of prescribing for these nervous disorders in multiparas without any reference to the lying-in as a factor in trieir produc- tion. You will observe that my invariable habit in these cases, no matter if they have had a dozen children, is to go back in my inquiries and learn all that I can of the parturient history of the patients that are brought before you. The traumatic contingencies of labor give rise to a class of surgical affections that are practically unknown in women Tffln in <\\ if* losion 5 * who have never been pregnant. Among these diseases are lacerations of the recto-vaginal septum, the vesico- vaginal septum, of the uterine cervix, and of the perineum, sub- involution of the uterus, and prolapsus of the womb, the vagina, GENERAL PATHOLOGY CONTINUED. 57 the bladder, and the rectum. Even where none of the soft parts are torn during delivery, the bruising and enormous distention of them, often results in lesions of structure and of function that have a lasting effect upon the health of women. V. Puerperality. — The puerperal state includes a period of three or more months, beginning with the close of labor. The con- dition of a woman who has just been delivered is beset with con- tingencies that may either directly or indirectly implicate her health, and perhaps imperil her life. In my special course on the puerperal diseases we have studied the various causes which in- duce disease during the lying-in, and their special diagnosis and treatment; and I need not, therefore, consider them now. It must suffice to remind you that, as a rule, (a clinical rule, to which there are exceptions,) most of the dis- limited 868 ° f ' ^ S6lf " eases ot ' tne puerperal period are self-limited, providing, of course, that they are not improp- erly treated. We have a good illustration of this fact in the case of puerperal paralysis which you have seen in our hospital wards, and which, like cases of diphtheritic paralysis, has shown a very decided disposition to get well of itself.* There is, however, one condition of puerperal convalescence which is indispensable to a perfect recovery from any and all of the diseases of childbed. That condition is the proper involution or shrinkage of the uterus after delivery. Whatever interferes with this physiological process may bring a train of consequences that shall last the patient as long as she lives. For the retrograde metamorphosis of the uterine structures after labor is quite as important as the changes that occur in the womb during gestation. A moment's reflection will convince you that the requisite invo- lution of the uterus concerns each and all of its ut C erus erDS thG Gntire various tissues ; and tbat lf H is defective, either the lining membrane of the womb, its muscular or its cellular tissue, or its peritoneal envelope, or perhaps all of them, will very likely become permanently diseased. This is the way in which the various forms of metritis are often entailed upon women. At my last clinic I showed you a case of exfolia- * De la paralysie diphtherique. Recherches cliniques sur les causes, la nature et le traitement de cette affection. Par Maingault, Paris. 1860. 58 THE DISEASES OF WOMEN. tive endo-metritis following an abortion at the fourth month, in which, you remember, that, although six months had elapsed since the accident, we found the uterus to measure four and one- half inches in depth. My own experience has taught me that an arrest of the proper involution of the puerperal uterus is a fertile iunon CtS ° f sub " inv °" source of the pelvi-peritonitis and pelvic cellu- litis that so often complicate other affections, as, for example, sub-acute and chronic ovaritis, cystitis and the differ- ent forms of uterine displacement, more especially flexions and versions of the organ. The fact that in a majority of cases sub-involution is preceded by endo-metritis, and that, especially in its Puerperal endo-metri- catarrhal d py8emic . f orms , this lesion is likely tis and sub-involution. l 7 ^ J to .extend through the Fallopian tubes to the peritoneum, illustrates the proneness to a complication of these disorders which may perpetuate itself. There is no doubt that under these circumstances the defective folding of the womb upon itself constitutes a veritable predisponent of uterine disease. You are, perhaps, aware that Dr. Emmet ascribes the occur- Laceration of the cer- rence of sub-involution of the uterus to lacera- vix a cause of. tions of the cervix. He says : * " It is believed that future observation will establish the fact that, as a rule, the involution is first stayed, and then fault}^ nutri- tion occurs as a consequence of some injury received during the progress of labor. To the occurrence of laceration of the cervix, and to the formation of cicatricial tissue in the vagina, and to the displacements of the uterus, by all ot which the circulation would be obstructed, we mubt, in some cases, attribute the continuance of an undue size of the uterus long after a reasonable time has elapsed since delivery." On the next page the same author states very emphatically that " for many years past he has met with few or no cases of sub- involution which were not due to laceration of the cervix." Without accepting this view of the etiology of defective invo- lution of the uterus in its fullest extent, there Effects of cervicaiiacer- ig no quest i n that such lacerations will often ac- ation. n i • count for the erosion, the europium, or cvers:o:i of the cervical mucous membrane, the cervical leucorrhoea, the * The Principles and Practice of Gynaecology, by Thos. Addis Emmet, M.D., 1879, p. 443, GENERAL PATHOLOGY CONTINUED. 59 cystic degeneration of the mucous follicles in the substance of the cervix, and even for the follicular disease of the throat, and of the mucous membranes generally, which we find in chronic cases of uterine disease. "We shall consider this subject in its proper place when we have a clinical case of this kind upon the table for study. Apropos of the importance of securing the proper contraction of the uterus within the first ten or twelve davs Effects of mconsider- after delivery, I must caution you against the ate counsel. . mischievous habit of allowing the lying-in woman to quit her bed within the first day or two after the birth of her child, and of leaving her without the proper support of the well- applied binder. It is nonsensical to say there is no analogy for these precautions elsewhere in nature. There is no analogy in nature for the use of a bath-sponge or a pocket handkerchief; and such arguments are silly in the last degree. Moreover, when a physician who is in general practice ad- >'edic,i experience { }[ patient to sit up and nurse the child may need to be qualified^ * t in a couple of hours after it is born, and to get up and go around her room the next day, and she does not become very ill or die in consequence, he does very wrong to conclude that his plan of treatment, or of mal-treatment, is in all respects the wisest and best. For within a very few months, or years at far- thest, the gynaecologist will be at work to repair the injuries that he should have prevented. It is another of those harmful half-truths which holds that women in the lower walks of life can get up and go to work directly after childbirth with impu- nity. Place a hundred such women on our table, one after another, pass the uterine sound very carefully, and tell me if the depth of the womb is not considerably increased. Ques- A clinical test. . . tion them c Losely and answer it the great majority of them have not had menorrhagia, prolapsus, and a uterine leu- Qorrhoea ever since the child was weaned, if not from the date of its birth. There is no doubt in my own mind that this kind of careless and improvident advice is a prominent factor in the com- parative increase of uterine affections during the last fifty years. A large share of them are post-puerperal, and avoidable. Puerperal pyaemia, which is chronic from the outset, is apt to entail a predisposition to suppurative inflammation, especially in 60 THE DISEASES OF WOMEN. scrofulous women. This fact has a clinical significance and a wider bearing among weak, delicate, scrawny The puerperal cachexia. , . .. P .. " . , . 1n and cachectic mothers than is generally supposed. Indeed, the puerperal cachexia perpetuates itself in this form in a considerable share of our cases. Pelvic abscess, suppurative peri- tonitis, pulmonary and hepatic abscesses, chronic bronchitis, and infract able forms of catarrhal inflammation, may have their root in this remote cause, and must be treated accordingly. VI. Lactation. — Apart from moral reasons why, if possible, every mother should nurse her own child, which reasons are hack- neyed enough, there is a physical argument which renders it indispensable that she should do so. For, in its largest sense, the function of lactation includes something more than the mere nourishing of the offspring. The application of the child to the breast is the most natural and necessary stimulus for the post-par turn con- The natural stimulus traction f \h e uterus. In a reflex way the for uterine retraction. # _ J frequent and habitual nursing of the infant is one of the best prophylactics of the puerperal diseases, for it is the means of emptying the womb of all debris and discharges that would putrify if they were retained. This tonic contraction is the best safeguard against septic and pyemic absorption, and also against an inflammation of the uterine tissues. Although in exceptional cases the secretion of milk may begin as early as the fifth month of pregnancy, one reason Avhy the puer- peral inflammations and fevers are to be dreaded in miscarriages is, that we cannot put the child to the breast in order to secure the proper uterine contraction. This contrac- Effects of non-lacta- ti ig the firgt gt towards the llorm al ilivolu- tion in abortion. L tion of the organ, and if it is not taken there is an arrest of diminution in size, form and weight, and it very soon becomes subject to disease. Its walls become hypertrophied, in- stead of being lessened by absorption, and its lining membrane congested and inflamed. This soon gives rise to chronic metritis, with its inevitable accompaniments of menstrual haemorrhage, pro- lapsus, and leucorrhcea. We had a case recently in our clinic that will serve as an illustration. Case. — Mrs. S., aged 26, had a miscarriage at the fourth month of her first pregnancy, five months ago, in consequence of which GENERAL PATHOLOGY CONTIMUED. 61 she was confined to her bed for six weeks. The menses were very irregular and copious, with bearing-down pains when standing or walking, with great weight in the pelvis. During the monthly flow this weight and pressure are so increased that she is obliged to keep her bed most of the time. This was her first visit to the clinic. She had been cauterized for some time for uterine ulceration. The attention of my sub-class was called to the prolapse of the uterus, the total absence of cervical laceration and of ulceration, the redness of the mucous membrane lining the cervix, the slight uterine epistaxis, and the increased depth of the womb, which measured four and a half inches. The points made were, that in this case, certainly, the defective involution could not have de- pended upon a laceration of the cervix during labor, (as Emmet insists) ; and that the metritis, menorrhagia and the prolapsus were the unavoidable sequences of the non-involution of the womb. It may interest you to know that in this case the persistent use of secale cornutum 3, three times daily for six Secale cor. in. weeks, reduced the depth of the uterus to three and a half inches, by actual measurement, and relieved her entirely of the prolapsus uteri. But there are other reasons why a proper performance of the function ot lactation, is prophylactic of uterine Why nursing is aval- disease> The fact that whi l e a WOlUail Suckles uable prophylactic. her child she does not menstruate unless she con- tinues to do so for an unreasonable length of time, is very well known. The result of this arrangement is to relieve the uterus and its appendages of the menstrual congestion, which would have a mischievous effect upon the post-partum involution that is taking- place meanwhile. The afiiux of blood to the mammary glands is therefore derivative, substitutive and salutary. Indirectly also, by delaying the return of the menses, nursing usually prevents a recurrence of conception before the normal puerperal changes in the womb are completed. For a season, and for a good reason, it holds both these functions in abeyance. Non-lactation is therefore injurious to the health of the mother by inviting a premature appearance of the ^ Weanin g maybeharm- menseSj , md ^ by increas i ng t he risks of tOO rapid child-bearing. Either of these results may predispose her to uterine disorders that will be very difficult of 62 THE DISEASES OF WOMEN. cure. And, when you consider that quite a proportion of mothers iii fashionable life are in the habit of turning away their babies on the slightest pretext, you will realize that a failure in the performance of this function is not only prejudicial to the welfare of the offspring, but also and very often to that of the parent. There are cases, however, in which it is wrong and harmful not to wean the child, as, for example, when the drain upon the mother's strength can not be borne with safety; when weaning is nec- whenthemeil ^ es have b r established, and essary. > ' return with regularity and copiously; and when another gestation has undoubtedly begun. If nursing is persisted in when there is menorrhagia, it is like burning a candle at both ends, and no one can say how long the woman's strength may hold out. If she is pregnant again, and does not put her child away from the breast, she will be very likely on account of the mammary irritation to have an abortion, to suffer an inter- ference with the development of the gravid uterus, or to ruin the health of the foetus in utero. We must guard against the effects of undue or over-lactation, for while in general we should encourage the Undue lactation. , i -i t -, ;• i mother to nurse her child, it may sometimes be necessary to caution her against continuing the practice for too long a period. The ill effects of this habit are various. It may o-ive rise to functional and organic disease of the womb, to Sub-ill VO- lution, passive menorrhagia, mental, nervous, and dyspeptic dis- orders, anaemia and dropsical conditions, recurrent epilepsy, chorea and hysteria, dimness of vision, and reflex disorders of various kinds. If these consequences were self-limited and certain to end with the taking of the child from the breast, I would not pause to speak of them in this connection. But they are more lasting and persistent, especially when the practice has been repeated with sev- eral successive children. Some of you remember a case in point, which was that of a poor woman who came to my clinic, and who, within the space of ten years, had had eight children. She had nursed four of these from twelve to fourteen months each, one of them for fifteen months, and the other three had died when they were only a few months old. So that, as her story ran, although she was only GENERAL PATHOLOGY CONTINUED. 63 thirty- live years old, and had been married but ten years, yet daring that brief period she had nursed a baby for about eight gears! VII. The Climacteric. — This is the last act in the Dhvsioloff- ical drama of a woman's sexual life. It is beset with vicissitudes that are commensurate with the importance of the function which it limits and terminates. A careful study of the influence which the " change of life,''' as it is commonly called, exerts upon the health of women is indispensable to you as students of gynae- cology. For this is indeed a " critical period.'" The disorders which are especially incident to this period have , their root in one of three conditions of the ueii- General qualities of < the climacteric disor- era! system, and for this reason may be classed as plethora, anaemia, or nervous. There is a plethora from which women suffer at this time, although thev may not have been subject to it The plethoric troubles. , » y . , .- "-, 1 . „ before, which is due to the suspension of an habitual discharge, and the stoppage of a drain that, for thirty years or more has weakened the blood and prevented a repletion of the vessels and an increase in the proportion of the red cor- puscles. This plethora predisposes them to various forms of local congestion and inflammation. But, you should remem- ber that a tendency to hyperemia in a woman at the change of life, does not necessarily increase the risk of inflammation of the uterus and its appendages as it would have done before the cessa- tion of the monthly flow. Its principal effect is to involve those organs which are not especially connected with the generative system, as for example, the brain and spinal cord, the heart and lungs and the stomach, or some part of the digestive apparatus. AVe recognize this condition of plethora in the flushed face, the headache, the vertigo, the dullness of the intellect which often amounts to a pseudo-narcotism, the anxious look, a tendency to local perspiration, and the restless, discontented, dissatisfied behavior of the patient. The pulse is usually full, but some- times it is feeble and thready, and there often is a decided tend- ency to haemorrhage. The climacteric anaemia is really a species of The anemic troubles. . chlorosis. j_ he condition is the opposite of that which we have just described. The blood is deficient in red 64 THE DISEASES OF WOMEN'. globules, the vessels are not turgid, the pulse is weak and irregu- lar, the skin is ashy, sallow, and of a waxy or dirty-white hue. The anaemic murmurs, the cardiac symptoms, the digestive derangement, and the capricious appetite of chlorosis are often present. Not unfrequently there is a dropsy of the cellular tissue, or within serous cavities, that is very difficult to cure. Sometimes this latter condition is so pronounced as to remind one of what Grauvogl styles the " hyclrogenoicl constitution." The nervous type of disease at this critical period may be hys- terical, in which case it is a prolongation of The nervous troubles. , . . , , ,.,, what was incident to menstrual hie, or it may be altogether new and peculiar to the menopause. The latter is what Raciborski styles a " nervous plethora."* This form of complication is most pronounced in those who are naturally nervous and excitable, and in those who have been compelled by circumstances to undergo a great deal of worry and to carry more than their share of mental weight and anxiety. It often happens that a woman will pass through the child-bearing period, with all of its sufferings, cares and responsibilities, in comparative health and comfort, only to break down and tc become a nervous wreck at the climacteric. Bearing these general facts in mind you will be prepared to understand and to appreciate the kind and character of the dis- eases which are liable to recur at the change of life. The pre- dominence of either of these types at this particular turn in the clinical history of woman, develops a class-bias which complicates all of the disorders to which she is liable, whether they are sexual or not. As with puberty, so with the climacteric ; there are the diseases Diseases cawed by w hich are caused by this crisis, those which are cured by it, those which co-exist with it, and those that follow it. The affections that are caused by the climacteric are of the most varied character, and, as I have just hinted, are many of them of the non-sexual order. They include menorrhagia, irregular men- struation, epithelioma, leucorrhoea, haemorrhoids, dyspepsia and the vomiting of mucus and of blood, flushings and local perspira- *Traite de la Menstruation, ses rapports avee I' Ovulation, la Feeundatior, etc., par A. Raciborski, Paris, 1868, p. 267. GENERAL PATHOLOGY CONTINUED. 65 tions, cardiac, intestinal and hepatic disorders, gnawing pains in the stomach, spinal, intercostal and abdominal neuralgia, colic, nervous irritability, hysterical narcotism, insanity, chloro-span- temia, asthma, paralysis, and .apoplexy. The change of life often cures or puts an end to chronic metri- tis, to the further growth of uterine polypi and r^jcfiQcpc CiULirpci t")V it fibroids and to the various uterine displacements, to leucorrhoea, hysteria, to a menstrual ataxia, to mammary pains, and to sufferings in the rectum and the bladder, which have de- pended for a cause upon the recurring menstrual congestion. Amenorrhoea, dysmenorrhoea, and all kinds of catamenial disorders cease by limitation when this crisis has really come. The various neoplasms of the uterus, as fibromata, polypi and cancer may co-exist with and survive the menopause. As a rule, those diseases which run their course during this period, and which continue after it, are either modified and prac- Jteezses that co-exist ticaUy disposed of by it? or they develop more rapidly when the menses have finally ceased. Ovarian cysts, and uterine and ovarian cancer are often hastened in their progress by the climacteric. And, so, likewise, are the various forms of tuberculosis, and of chronic, hepatic, renal and cardiac disease. Beside the proneness of some of the diseases of puberty to return at the climacteric, as, for example, cer- fectTonf 111 ^ 6 ^ af " tain skin and bowel affections, and phthisis, there are other disorders that are likely to follow it. Among them are chronic headache, deafness, insomnia, insanity, apoplexy, the various forms of paralysis, and the development of cancer of the uterus and of the mammary glands. LECTIJEE IV. PHYSICAL DIAGNOSIS IN GYNAECOLOGY. 1. Inspection.— The four varieties of ; abdominal do. of the external parts ; do. by the uterine speculum; do. by the forcible eversion of the rectum. 2. Mensuration.— Modes of applying. 3. Palpation, abdominal and vaginal, cases to which the for- mer is applicable; the "touch" per vaginam ; conjoined manipulation and when it is of use ; the uterine touch and the conditions requiring it. Before we begin the study of any particular affection, I think it best to direct your attention to the rational signs that belong to the diseases of women, and the proper method of eliciting them. With the addition of internal exploration, these methods are practically the same as those which are employed in the diagnosis of the diseases of the heart and lungs. This table on the black- board includes the various methods of physical exploration which may be used in the diagnosis of the diseases of women : 1. Inspection. 2. Mensuration. 3. Palpation. a Abdominal palpation. f By the vagina. By conjoined manipulation. b The " Touch:' tn * s P rac tice has become quite popular. My own opinion is that, while in rare cases it may be necessary to use these instruments conjointly, in ordinary practice we can get on quite as well, or even better, without the speculum and the tenaculum. You can learn to pass the uterine sound without the help of vision quite as soon and as adroitly as you can learn to pass the female catheter by the sense of touch alone, and without any exposure of the patient's person. And I think you should try to do so. The chief things to be done in acquiring this species of tact are to place the patient in a proper position, to ascertain the direction of the uterine curve, to manipulate carefully Points to be observed. p rather than forcibly, to have the proper mstru- ment,and not to be in too great a hurry. I have already spoken of the proper time and posture to be chosen. In order to learn the course of the uterine canal, the " touch" must precede the attempt to pass the sound. By passing the finger carefully on every side of the cervix, as high up as possible, you can get the direction of the cervical axis, and recognize any marked flexion of the PHYSICAL DIAGNOSIS — CONTINUED. 91 uterus, which is most apt to take place at a point opposite the internal os uteri, where the peritoneal coat is lacking in front. In case of the different versions the os and cervix must be located before the sound could be introduced. In ordinary cases, and with the tip of the right index finger at the external os, the sound can be passed along its palmar surface,, while being guided by the left hand, and made to enter the canal of the cervix. When it has passed an inch or so within that canal, the handle of the instru- ment should be depressed toward the posterior commissure of the vulva, and its curve turned toward the symphysis pubis. A little delicate manipulation and tact will now cause it to pass through the internal os uteri and into the uterine cavity. Sometimes, how- ever, it may be necessary to withdraw the sound and to change its shape somewhat. Or it may have failed to pass because its point was lodged in one of the lacunae which are so numerous in the cervical canal. If you use too much force it is possible for the instrument to pass not into the uterine, but into the abdominal cavity. This is especially liable to occur in case the sound slips fo2e nger fr ° m t0 ° much an( ^ P asses i nto the Douglas cul-de-sac ; and also where the tissues of the uterine cervix have been softened and somewhat disorganized as the result of chronic disease. Fatal peritonitis has sometimes resulted from this accident. If the patient is young and nervous, tell her precisely what it is that you propose to do ; that there will be no cutting, and but little pain ; that, in truth, this is only another means of extending the " touch" farther than the length of your finger will permit. Her attention should be diverted while the operation is going on. There is as much difference between two of these sounds which* to all appearance are precisely alike, as there is between two catheters. One will find its way like an intel- Choice of a sound. hgent agent, but the other almost invariably goes wrong. When you have selected a good one, let me counsel you to use it habitually and exclusively. Above all things do not be in haste. This is a delicate little operation upon the careful performance of which more may depend 1)2 THE DISEASES OF WOMEN Sims' elevator as a sound. than you perhaps imagine. At any rate you will be more likely to fail than to succeed if you are rash and pre- cipitate. It is better to take fifteen, twenty, thirty, or more minutes and do no harm, than to hurry the thing over without doing any good, or learning any- thing. If you fail altogether at one session, make another appointment with your patient and try again. You may be more successful next time. Case. — Some of you will remember a case in my clinic during the spring term, in which it was impossible to pass any form of uterine sound that we could find. Prof. , an expert gynaecologist, being present tried for a long time, and finally gave it up. One week later I resorted to an ex- pedient which I had twice tried before in sim- ilar cases, which was to use a Sims uterine re- positor as a sound, and succeeded in a very few moments. The case proved to be one of a fibrous growth in the supra- vaginal portion of the cervix anteriorly, and my theory was that only such a sound as could be bent at a very acute angle, and the elbow of which was firm, could possibly enter the womb. Here is the in- strument: Another use of this elevator as a sound is to pass it through the internal os-uteri, in order to fix the womb while the abdomen is being examined in case of fibroids and other abdominal tumors. A few years ago I fell into the habit, in my clinic, of using the sound in a particular man- ner in the diagnosis of uterine fibroids. It consisted in first passing the instrument, and afterwards, with the hand upon the abdomen, rolling the tumor and observing whether the sound moved con- sentaneously with it. This plan, which an- FlG - u - Sims ' Elevator. swered an excellent purpose at our clinicaltable, may serve you equally well when the same manipulation with the touch applied to the cervix, is not altogether satisfactory. The elevator in fibroids. The sound in fibroids. PHYSICAL DIAGNOSIS — CONTINUED. 93 Another of my " wrinkles " is to use the sound instead of the tenaculum or the volsella, to bring the uterus towards the vulva for a more careful inspection and exploration. Jtonrt.rn.fb. tea- TMg ; g d(me by fag ^ g . % carefu j ly through the internal os-uteri to the fundus and allowing it to remain in situ for the space of five or ten minutes, when, if the uterus has no unnatural attachments, the organ will descend and come readily within our reach. As an operative expedient, how- ever, this mode of bringing the uterus downwards Aviil not answer our purpose. As a modification of the sound for the purpose of extending the touch to the uterine cavitv. in case of a verv The uterine probe. " ' . J narrow or tortuous canal ot the cervix, and for the delicate recognition of inequalities of the uterine mucous sur- face, as well as of intra-uterine growths, the probe is very usef ul. There are several varieties of these probes, of which the flexible silver one, known as Sims' probe is the best. tins! Fig. 15. Sims' Silver Probe. Thomas' hard rubber probe, and his elastic probe also, are some- times of excellent service. Fig. 16. rhomas' Hard Rubber Proba. 4. Percussion. — In the application of percussion and ausculta- tion to the diagnosis of those uterine and ovarian tumors which are above the superior strait of the pelvis, it is inftumo S r i s t . i0n0fUter " vei T fortunate that they almost always come forward and lie against the abdominal walls. By so doing they push away the intestines and are directly acces- sible. This fact renders their removal, as well as their diagnosis possible, and it should always be borne in mind. Two objects may be gained by percussion when it is applied to the diagnosis of abdominal tumors : (1.) It enables us to map the outline of the tumor or tumors; and (2), by detecting fluctuation, to recognize the presence of a fluid when it exi& sin the tumors. 94 THE DISEASES OF WOMEN, In the healthy state the intestines which float within the abdo- men, and which are in contact with its parietes, The intestinal reso- nance . are so filled with g-as as to give rise to what is The uterine tumor in pregnancy. called the " intestinal resonance " on percussion. There is a condition, however, in which the area of this resonance may be diminished physiologically. When the gravid uterus rises above the superior strait, after the fourth month, its fundus inclines forward, and, in proportion as its size 'Increases with advancing pregnancy, the area ot dullness on percussion also increases. So that, in this case we have a uterine tumor which is not morbid, and the outline of which can be indicated by this mode of physical examination. In diseased states, when a tumor of any kind, whether it be solid, fluid, or composite, lies in contact with the parietes of the abdomen, similar conditions obtain, and we take advantage of this fact to indicate their topogra- phy. The area of dullness is in proportion with the extent of the tumor which lies directly against the internal surface of the abdominal walls, and which pushes the intestines away, either lat- erally, posteriorly, or upwards into the epigastric region. The area of dullness. In ascites. Fig. 17. Diagram of the ascitic outline. In ascites, when the patient is lying upon her back, and when the accumulation of the dropsical fluid is not very large, the dullness on percussion is at the sides of the abdomen and above the symphysis pubis; and the area of intestinal resonance is around the umbilicus. This condi' tion is clearly shown in the drawing: (Fig. 19.) PHYSICAL DIAGNOSIS CONTINUED. 95 If, however, the peritoneum is more fully distended, and the accumulation is very large, the characteristic resonance of ascites in the region of the umbilicus may be lacking altogether, and the whole extent of the abdomen be dull on percussion. In ovarian dropsy, no matter what the posture of the patient, if the tumor is large enough to extend beyond the umbilicus, with very few exceptions there will be dullness on percussion throughout its whole extent, and the In ovarian dropsy Fig. 18. Dullness in ovarian dropsy. Fig. 19. Dullness in ascites, etc. rounded outline of the tumor can be more easily distinguished. In this case the intestinal resonance will be found above, and at one or both sides of the cyst, as is shown in this diagram . It is very important for you to remember that it sometimes makes considerable difference whether percus- P a T tfenr StUrPOf ^ sion is a PP lied while the patient is standing, or when she is lying down. In ascites the same rule holds as in the case of hydrothorax; the line of dullness is concave when the patient is standing erect, and perpendicular, with the axis of the body when she is lying down. In ovarian -dropsy the outline of the tumor, and of the dullness also, is always convex. Here we have another illustration: (See Fig. 17.) Percussion is often useful in the detection of enlargements of 96 THE DISEASES OF WOMEN. the uterus and its appendages, from other causes ; as, for example , in uterine fibroids of a considerable size, hydatids Percussion in uterine //• 1 1 ni\ l ^ i -ii- tumors, (lalsely so-called), cysts ot the broad ligament, extra- uterine pregnancy, in tumors formed by the effusion of serum, in pelvic peritonitis and pelvic cellulitis, and by the accumulation of blood in pelvic hsema^ocele. Its practi- cal application to these forms of uterine disease will be considered at the proper time. 5. Auscultation. — Whether mediate or immediate, ausculta- tion is practised in the same general way as in the physical diagnosis of diseases of the chest. Its use in Use and range of . ° . gynaecology is, however, much more limited. A few years ago it was claimed that peculiar and distinctive vas- cular murmurs were always present in ovarian dropsy, and that the souffle which may be heard in uterine fibroids (especially at the month, when the texture is more loose and relaxed), had a certain diagnostic significance. But these theories have been abandoned, and the only real practical use of auscultation in gynae- cology in our day is limited to the detection and recognition of the foetal heart sounds in case of pregnancy. 6. Tapping. — Paracentesis of the abdomen is less in vogue than formerly, because its abuse has often been productive of mischiev- ous results. When the contained fluid is thin enough to run through an aspirator-trocar, it may sometimes be well to draw off a sample for examination; but it should not be done indiscrimi- nately. As occasion offers in my clinics, I shall teach you how to properly use this means of diagnosis. ( See Lecture LYIII. ) 7. The Exploratory Incision.— This is so valuable and impor- tant an aid to diagnosis that it is the final appeal in doubtful cases of abdominal disease of almost every description. During the course of the winter we shall probably have occasion to resort to it. (See Lecture LYIII). Part Second, THE DISEASES OF PUBERTY. LECTURE VI. CHLOKOSIS. CTilorosis. Case.— Digestive, cerebral and cardiac symptoms, scrofulous do., blood changes in,— the nervous symptoms; the pulse, the appetite, menstrual derangements, the skin ; etiology of ; diagnosis of, from jaundice and anasmia ; prognosis ; treatment, for the general and emotional causes, the cachexia, iron in, the citrate of iron and strych- nia in. Case, special indications for remedies— the diet, exercise and travel. Case. — Miss , aged 18, complains of a complete loss of appe- tite, and of headache. She is listless, and snilers greatly from palpitation of the heart, especially after exercise. At times, she has a dull, dragging pain in the cardiac region. The anaemic murmur (bruit dediable) is easily recognized. Until about a year ago she felt very well, but since that time these symptoms have been steadily increasing in severity, The skin is pale, of a green- ish-yellow tint, and almost transparent. Her lips, tongue, and alee nasi are almost colorless. The eyelids and features are slight- ly oedematous, particularly after sleeping. The teeth are decayed, the fingernails brittle. She has never menstruated, and says that her mother and her elder sister were more than 19 years old when their menstrual function was first established. In rare instances chlorosis is a congenital affection. A large proportion of cases occur in the young and unmarried. Absence or suppression of the menses is so frequent and ^Chlorosis and amenor- almost invariable an accompaniment ■ of chloro- sis, that some authorities have regarded it as identical in nature with amenorrhcea. Others are not decided as to which is cause and which effect — whether the chlorosis is the cause or the consequence of the menstrual derangement. We remark in chlorosis a decided impairment of the vegetative functions. There is always more or less of headache, anorexia, gastric derangement, dyspnoea, fluttering, pal- lgestive symptoms. p^ a ^ on? timidity, general malaise, constipation, and hypochondria. In some cases "these symptoms persist for years without proper recognition and relief. They are exceedingly ly common among young, delicate girls, especially among those who work in shops and factories, and who follow sedentary pursuits, as 7 97 98 THE DISEASES OF WOMEN. seamstresses and school-teachers. Their persistence and the accompanying ill health frequently lead physicians to decide that such patients are suffering from inflammation of the brain or its membranes, ulceration of the stomach, phthisis pulmonalis, organic disease of the heart, of the liver, or of some*6ther organ. The headache is very prone to take on the form of hemicrania, and is not unfrequently mistaken for neuralgia. Sometimes it is regularly periodical. It is always paroxysmal, Cerebral symptoms. ° . , . , and is greatly aggravated by emotional causes, over-anxiety, and too much of mental labor or worry. In rare cases it is so severe in degree as to produce delirium, spasms, and even mania. And thus it happens that the patient may suffer a temporary loss of memory, or she may decline into a state of men- tal torpor, and general insensibility. Chorea, hysteria, partial paralysis, and epilepsy, are among the possible concomitants and sequelae of this headache in chlorotic subjects. While they are really the least serious, the heart symptoms are the most alarming to the patient and her friends. Chlorotic pal- pitation, as it is termed, is due to a functional Cardiac symptoms. ~ _ change m the rhythm 01 the heart s action ; this change is of nervous origin, and has no necessary connection with organic disease of the heart. It may continue for years without inducing any structural changes, or the prolonged func- tional disorder ma} r insidiously injure the heart's texture. There is a strange relation or sympathy between the generative system of the female and the heart. One woman 1ms menstrual retention from dysmenorrhcea, and all her suf- Sympathy between gener- f er i ng r S are referred to the cardiac region. ative organs and the heart. o o Another has menorrhagia, and she complains only of similar symptoms. A third, who has chronic ulceration of the os uteri, tells the same story. In a fourth, the sole patho- logical result of an excess of sexual indulgence is disclosed in the same identical symptoms. The same may be true of amenor- rhea, prolapsus, ovaritis, and chlorosis. By physical exploration we can detect no difference in the incidental conditions of the heart. The whole precordial trouble is symptomatic, nor will the objective cardiac symptoms enable us to differentiate between them. In chlorosis the pulse is usually, but not in every case, slower CHLOROSIS. 99 and weaker than natural. It may not exceed fifty or fifty-five beats in the minute, and is sometimes as low as forty-five or forty-eight. Now and then, how- ever, you will encounter a case in which it is considerably quick- ened. As a rule, the more marked the anaemia the more frequent the pulse, providing, of course, that the impoverished condition of the blood is not the result of sudden and excessive haemorrhage. In chlorosis, as in hysteria, the pulse has this characteristic, that whatever its usual rate of frequency, no matter what the condi- tion of the patient, or the circumstances in which she may be placed, that rate is but little, if at all, changed thereb}\ The anaemic murmur, (bruit de dialled) which, in most cases of chlorosis, may be heard over the precordial region, but more dis- tinctly along the course of the great vessels, as The anaemic murmur. . . . the carotid and iemoral arteries, is a curious and suggestive symptom. Some authorities believe it to be caused by an impoverished condition of the blood, in which there is a defi- ciency in the proportion of red corpuscles. Others ascribe it to a diminution in the volume of the blood contained in the vessels. It occurs in anaemia as well as in chlorosis. There is not unfrequently a total loss of appetite. The patient may subsist for months upon an incredibly small quantity of food. In other cases the most unheard-of caprices are The appetite. . _, - likely to be indulged. She craves such outre articles as chalk, plaster, bits of clay, of coal, or of slate-pencil, cinders, sand, magnesia, grains of coffee, and vinegar. A fre- quent peculiarity of the appetite is a total disrelish for, and dislike of, every variety of animal food. One of my chlorotic patients had not tasted a mouthful of any kind of meat for more than ten years. In some the appetite is fitful. They will fast for a long time, and then eat excessively. Generally, they do not anticipate or enjoy their meals, but " go through the motion " of eating at stated periods, simply because it is expected of them in the fam- ily and in society. In consequence of this impairment of the digestive functions, a train of symptoms is sure to follow. The bowels become in- veterately constipated, or there may be alterna- Incidental symptoms. . tions ot constipation and diarrhoea. The breath is sometimes disagreeable, or even foetid. In a few cases observed 100 THE DISEASES OF WOMEN. by Marshal Hall, it had the odor of new milk. In very rare and extreme cases hsematemesis or malaena may ensue. Sometimes there is obstinate and persistent ulceration of the stomach, with intractable vomiting of ingesta. The cellular and muscular tis- sues become flabby. There is general and progressive emaciation. She becomes bed-ridden, and is believed to have passed into a hopeless decline. A species of dropsy, either general or locals may supervene. Some patients with chlorosis suffer great torture from gastralgia. In others there may be successive attacks of gastro-enteritis. Organic lesions of the liver and spleen are fre- quent concomitants of chlorosis, especially in the west and south- west, and in all malarial regions. It is unusual for this disease to exist without more or less mens- trual derangement. The most ordinary complication of this kind is with amenorrhcea. The chlorosis may set in in^roSs 1 irregularities before the menses have appeared, at puberty, and they may fail altogether. Or there may be an incidental and prolonged arrest of the flow in those who have menstruated before. In either case, the menses do not appear for months, and perhaps for years. The suppression-may date from the commencement of the chlorosis, but most frequently it follows in the train of other symptoms. The chlorosis is very apt to come on stealthily and insidiously, so much so that neither the patient nor her family remark anything wrong with her health until the disease is pretty well developed. She may have complained for a considerable period of symptoms of which I have spoken, and in addition have noticed that her catamenial discharges were less free than natural, but it is not, perhaps, until the flow has ceased alto- gether that any alarm is excited, or counsel desired in her case. It has frequently happened that the co-existence of amenorrhcea and gastric derangement has given rise to suspicions of pregnancy ; while in other cases, the arrest of the menses with troublesome chest symptoms has aroused suspicions of incipient tuberculosis. Although she is eighteen years of age, this woman has never menstruated. But in her case there is a family or hereditary idio- syncrasy which may explain this fact. Her Hereditary amenorrhcea." mother and sister were nineteen years old be- fore the menses appeared. We cannot, therefore, charge the non- appearance of the flow to the chlorosis, or vice versa. From which CHLOROSIS. 101 3^011 will infer that although they may and do frequently co-exist, these disorders have no necessary relation with each other. You will sometimes meet with chlorosis in a patient who is subject to dysmenorrhea. In such cases, the incidental hysteri- cal s}^mptoms are more pronounced and per- ^cworosisanddysmenor- s i s tent. They are very troublesome and diffi- cult of cure. The menstrual flow often be- comes so scanty as to increase the difficulty by its retention, and we may thus have a case of painful menstruation resolving itself more and more into one of entire suppression. Or the dysmenor- rhea may develop into menorrhagia, which will further compli- cate the chlorosis. Chlorosis is also incident to those states in which menstruation is physiologically suspended. It may occur Chlorosis in pregnancy, etc. . . -i -i -i i -i -i • i. during pregnancy, m child-bed, during lacta- tion, or after the grand climacteric. The peculiar discoloration of the skin, which is very marked in this case, is pathognomonic. In mild and recent attacks it is of a pale greenish tint. Hence the popular Discoloration of the skin. . name, " green sickness. lhe lips, alse nasi, the gums, and the tongue, lose their vermillion hue. The skin is sometimes of a yellowish cast. (Sauvage called chlorosis " white jaundice.") In later stages of the disease, and in very bad cases, the discoloration is more marked. The skin becomes of a waxy, dull leaden, slate-color, sallow, or dirty-white hue, and there are dark lines beneath the eyes, and at the angles of the mouth. The white of the eye has a peculiar pearly, trans- lucent appearance. The face becomes tumid, and the eyelids, especially the upper one, puffy and ceclematous. The general surface of the body appears dry, bloodless and opaque. The hands are shriveled, the nails split, brittle and broken. Patients with this disease are averse to exercise, and to society. They become listless, and sometimes pass into a state of pseudo- narcotism ; or they are low-spirited, and look The mental state. -i -i p • upon lite and the future with the most gloomy forebodings. They are disposed to melancholy. They lose interest in their studies, permit their accomplishments to grow rusty from disuse, and, in brief, are really wretched. Etiology. — The causes of chlorosis are predisposing and excit- 102 THE DISEASES OF WOMEN. ing. Among the former, the most prominent is the lymphatic temperament. It is extremely rare to meet Chlorosis and scrofulosis. . , . , - , , ~ , . „,, . with it m any other class 01 subjects. I his predisposition is strengthened by a tendency to scrofula. In these persons the blood-making function is liable to such dis- order as results in a deterioration of the quality of that fluid. Hence the relative diminution of the red corpuscles, and the pro- portionate increase in the watery part of the blood, which are almost always present in chlorosis. This predisposition is fostered by whatever hygienic influences may tend to lower the standard of health, and to vitiate the process of sanguification. These causes are usually classed as exciting ; but they are only remotely so. They include an exclusive diet of indigestible, inappropriate or unwholesome food, confinement in damp, shady, illy-ventilated apartments, deficient exercise and clothing, unrequited affection, nostalgia, ennui, chagrin, jealousy, fright, sexual excitement, and uterine and ovarian disorders. Most authors will tell you that chlorosis arises from " a disease of the blood," a phrase which is utterly destitute of meaning. It is true that in many cases the proportion of s . Biood-changes in chioro- t ^ G red globules Is deficient i but unless it be traceable to a loss of blood by haemorrhage, that is a symptom merely. In anaemia from haemorrhage of any kind, the poverty of the blood is accidental, and due to an actual loss or withdrawal of the colored corpuscles. In chlorosis, the change in the composition of the blood has been gradual, is the woik of disease that has implicated and impaired the process by which the blood itself is made. In the one case it is a chance effect ; in the other a natural and necessary consequence of diseased action. I have already explained the physiology of hyematogenesis. You are familiar with the function of the lymphatic glands and their duties in this relation. Without their Haematogenesis. aid, the blood could not be manufactured. It is a peculiar predisposition to disease in them which constitutes the chlorotic diathesis. But these glands cannot operate inde- pendently of the nervous system, any more than the liver or the pancreas. And so we must go back of them for the prime cause of the disorder. CHLOROSIS. 103 It is " begging the question"' to refer the essential pathology of chlorosis to an impoverished condition of the blood. That fluid may contain seven-tenths, or even nine-tenths roS?nd£nSf ia in chl °~ seru m, as found in Jolly's analysis of the blood of chlorotic subjects, but it will not suffice to declare that all the symptoms in this disease are due to, and depend upon, this condition alone. Nor does the relative loss of the red globules represent the disease. The special pathology and etiology of chlorosis are not to be found in the hydremia, spansemia, or the chloro-ansemia, which in most cases are attend- ant upon it. For occasional well-marked cases of this disease are certainly met with, in which there is no manifest change in the composition of the blood. Numerous reasons have been adduced for a belief in the ner- vous origin of chlorosis. Thus Eisenmann* assigns the following : "(a) In certain cases Becquerel and Roclier The nervous theory. _ •i-i-it tailed to detect any changes in the blood, (o) Chlorosis is much more frequent in females than in males, and it is a well-known fact that the nervous system predominates in the former, (c) The incipient symptoms of chlorosis, those which anticipate any change in the blood are nervous, and those nervous symptoms continue through the whole course of the disease. (cT) Chlorosis yields to those remedies which are known to act favor- ably in affections of the spinal cord, as morphia, strychnia." etc. To these we may add that many attacks occur in those who are predisposed to chlorosis, in consequence of fright, the exercise of strong mental and moral emotions, sexual excitement, masturba- tion, and the nervous tension incident to city life and society among the better classes. Dr. Clotar Miiller bases his assump- tion of the nervous origin of chlorosis on (a) " the great influence which mental emotions and certain depressions of the nervous system exert upon the origin and development of chlorosis ; and (5) the powerful curative influence of remedies acting directly upon the nervous system, and manifesting an influence corres- ponding homceopathically to the depression and general prostra- tion of vital power peculiar to this disease."! The same author says : " If I may venture to draw a conclusion from my own observations, I should assume as most probable that * Bulletin de Therapeutic, Sept. 30, 1S59. f Vide North Am. Horn. Quarterly, Vol. VII, p. 158. 104 THE DISEASES OF WOMEN. chlorosis is originally an affection of the spinal and ganglionic systems of nerves, having a character of weakness and exhaustion combined with erethism and excessive excitability." Becquerel and Roclier confirm this view : " For us, as for some other authors, chlorosis is a disease which has its beginning and its seat, its point of departure primarily, in the nervous system, giving rise consecutively to disorders of digestion, of menstruation, and of the circulation. If this definition is correct, the change in the blood in chlorosis is not a constant and capital fact, but a second- ary, incidental phenomenon, which is not absolutely indispensable to the disease."* Gabalda says emphatically, " We regard this disease as a per- fectly distinct neurosis." M. Jolly and Dr. Tilt insist that chlorosis is a neuralgic affection of the ganglionic system. Dr. H. Jones, that " in many cases, occurring among the poorer classes in London, the action of malarious influences upon the ganglionic system is the first link in the chain of causation." Upon this theory, which is so well supported by facts and by medical authority, we are able to explain the insidious and pecul- iar character of this complaint Its seat is in the nervous system. Back of all the symptoms disclosed by the solids and fluids, the cause is at work to undermine the general health. And thus it happens that in confirmed chlorosis " there appears to be not a system, an organ, a texture, or even a fluid, in the animal economy, which does not suffer." I have already said that the menstrual disorders incident to chlorosis are generally considered as the cause, and not the con- sequence thereof. The argument against this enor h rhi a 1S etr ecedes am " hypothesis is short and simple. In a majority of cases the manifest signs of chlorosis appear before there is any derangement of the monthly periods. In some instances the menstrual function escapes all implication, and the patient has chlorosis without any catamenial irregularity whatever. Now, if the non-appearance of the flow, or its suppression, or even its excess, were the cause of this disease, S ymp?omadc! :ompIications one or tne otner should always precede the pallor of the skin, and the nervous, circulatory, and digestive symptoms of chlorosis ; this affection could never * Traite de Chemie Pathologique appliquee a la Medicine Pratique. 1S64 ; p. 155. CHLOROSIS. 105 exist in one who menstruates regularly ; nor could it ever occur, as it really does, in the male subject. We therefore conclude that the menstrual complications incident to chlorosis are symp- tomatic, and not idiopathic. The real disease is the chlorosis, and not the amenorrhoea, the dysmenorrhoea, or the menorrhagia. It is said that in the West Indies many male negroes formerly sickened and died of a disease which, in all of its principle features, was identical with chlorosis. With characteristic originality, Prof. Meigs styled chlorosis an *' endangial disorder." He referred all the symptoms, but more especially the changes in the composition of the blood, to a path- ological state of the endangium, or lining membrane of the circu- latory vessels. Dr. Von Maack* holds that, in chlorosis, it is impossible for the iron of the food to be changed into haematin and fixed. And this because the saccharine function of the liver is either disordered or arrested. But this must suffice for the etiology of chlorosis. Diagnosis. — You will not be very likely to confound chlorosis with jaundice. The pearly look of the white Chlorosis and jaundice. . oi the eye in the iormer disease, and its yellow cast in the latter, will enable you to differentiate between them. I have drawn the following table, which may help you to diag- nosticate chlorosis from anaemia : CHLOROSIS. ANEMIA. 1. Is an idiopathic affection. i. Is an accident, or sequel of other dis- eases. 2. Is not caused by the loss of blood, or 2. Is frequently caused by haemorrhage, other debilitating discharges. suppuration, leucorrhcea, diarrhoea, colliquative sweats, etc. 3. May result suddenly from mental 3. Never does, causes alone. 4. The mental and nervous symptoms are 4. Not so in anaemia, especially prominent. 5. The nervous symptoms initiate the 5. The opposite occurs in anaemia, attack. 6. Fugitive neuralgic pains in the head, 6. These pains are lacking, the spine, the stomach, the chest, and especially in the side, are almost inva- riably present. 7. May be accompanied or followed by 7. These complications and sequelae are hysterical spasms, chorea, paralysis, or not incident to this affection, epilepsy. * L'Union Medicale, February, 1859. 106 THE DISEASES OF WOMEN. CHLOROSIS. ANAEMIA. 8. The skin is of a greenish, or greenish- 8. The skin is blanched, pallid, puffy, and yellow tint. doughy. 9. Hemorrhages are not very frequent. 9. Haemorrhages are very frequent. 10. Is very rare in male subjects. 10. Affects the s exes indiscriminately. 11. Rarely happens in those who are under 11. May occur at any age. twelve or over thirty years old. 12. Is limited to women of lymphatic tern- 13. May happen to women or men of any perament. temperament. 13. Is very liable to be accompanied by sup- 13. Is more likely to be accompanied by pression or retention of the menses. too frequent and copious menstrua- tion. 14. May exist and run its course without 14. Is always characterized by an impov- any perceptible change in the composi- erishment of the blood. tion of the blood. 15. The degree of change in the blood bears 15. The impoverishment of the blood is in no necessary relation to the severity of direct ratio with the degree of func- the disease. tional disorder. 16. Is most common among the better 16. Is most common among the poorer classes of society. classes. Although these symptoms are sufficiently distinctive, it some- times happens that a diagonsis between these affections is extremely difficult, if not altogether impossible. There are, doubtless exceptional cases, in which they co-exist in the same patient. [Two Cases, Nos. 6366 and 7541, were shown to the class, sitting' together, in order that their symptoms and treatment might be compared. The first of these had anaemia with vicarious menstru- ation ; and the second was a decided case of chlorosis. These cases were shown in the same way for some weeks, until they were discharged cured.] Prognosis. — In the milder forms, and under proper manage- ment, chlorosis, is curable. The chief danger is from incidental organic diseases, the most serious of which are tafdrsease fr ° miaCiden " cardiac aild pulmonary affections, myelitis, tuberculosis, dropsy, paralysis, epilepsy, and repeated haemorrhages. The disease is of a lingering, tedious nature, and patients get well or worse very slowly. But now and then one who has been ill with this disease for a lono- time dies suddenly without any premonition. For this reason, your prog- nosis should be guarded. It is a favorable sign if, under treatment, the appetite and spirits improve, and also if the menstrual irregularity is corrected with- out forcible measures. Kelapses are frequent. Treatment. — After this analysis of the disease in question, you are prepared to appreciate the difficulties in the way of its most appropriate and successful treatment. Its Protean phases and multiform complications sometimes embarrass the practitioner CIILOROMS. 107 exceedingly. The rule, however, holds, that the more carefully the remedy is chosen, providing other very necessary conditions are complied with, the more certain and satisfactory is the result. In general, you should give especial prominence to remedies which are suited to derangements of the nervous functions, or of the circulation, or of digestion, or of menstrua- s tSs medies for seneral tion - These are cardinal points in the special therapeutics of chlorosis. In most cases, the characteristic indications are discoverable in them. In one per- son the nervous symptoms may predominate ; in another, the digestive , in a third, the sexual, and so on. Or, if they are min- gled, try to learn the order of their sequence, their cause or causes, and what constitutional or accidental agency serves to perpetuate the mischief. You may often find the proper remedy by selecting one that is appropriate to the mental or emotional condition which induced the attack. Our works on materia medica teach Treatment for emotional y 0U wna t these remedies are. Most prominent cause. J J- among them is ignatia. After this, there are belladonna, hyoscyamus, coffea, opium, aconite, and some others. In selecting from this, and a much larger catalogue, the indica- tions are very similar to those which call for certain remedies in hysteria. Calcarea carbonica, sepia, sulphur, natrum muriaticum, graph- ites, ferrum, phosphorus, plumbum, and similar remedies, are often appropriate for the chlorotic cachexia, Remedies for the chio- anc [ j n c i iron i c cases may sometimes be given rotic cachexia. J o temporarily with good effect, in lieu of other medicines. The first two are especially useful in the menstrual irregularities incident to chlorosis. The same is true of cyclamen and pulsatilla. Other remedies sometimes employed are kali carb., arsenicum, lycopoclium, conium, mix vomica, china, chamomilla, helonine, and senecin. Indeed, as in hysteria, almost any remedy in the wdiole range of the materia medica may be called for. It would be a work of supererogation, as inappropriate as a pater- noster, for me to detail all the symptoms which might indicate them in this connection.* Upon the theory that chlorosis and anaemia are identical, and * For particulars see N. American Hom. Quarterly, Vol. VII, p. 152, et scq. 108 THE DISEASES OF WOMEN. that both affections are due to a deficiency of iron in the blood, iron is regarded by many physicians as a spe- Iron in chlorosis. . n , , . T . ■ , . ,.. cmc in chlorosis. It is almost as universally given in this disease as quinine in intermittent fever, or mercury in syphilis. But, for the best of reasons, it frequently fails to cure. In order to be useful, it should be prescribed upon patho- genetic indications, and in such form and quantity as to be avail- able. When there are only about thirty grains of iron in the whole mass of blood contained in the body, it surely is irrational to attempt to supply any deficiency thereof by thrusting large quantities of the crude metal, or any of its salts, into the stomach. Iron is not appropriate to those cases of chlorosis which are of nervous origin, or in which, from the onset of the disease, the nervous symptoms have been especially prominent. In anaemia proper it is more generally useful. In many cases of chlorosis there is, however a preparation of iron in which I have great confidence. This is the citrate of iron and strychnia, a salt which came into use some str^cw. ° f iron and years ago. I give it empirically in the third decimal trituration. In my experience nothing is so well adapted to control the whole train of symptoms in most cases, although it is by no means an invariable specific. It seems to combine the good qualities of iron with those which belong to the strychnia group. It will accomplish more than ferrum metal- licum, ignatia, nux, or strychnia, when given separately. I could detail several cases of this disease cured with this remedy alone. In this compound form it certainly merits 'a proving. Case. — A young girl, eighteen years old, has been ill four months. Although not obliged to keep her bed, she has to lie down many times during the day, because of severe pains in her stomach. Those pains are always in the same place, and are better after sleeping, and sometimes entirely disappear. Accompanying these pains there is sick headache and faintness, and a pain about the heart. There is difficulty in breathing, and she is obliged to sleep with her head high. She has a cough both clay and night, Avith but little expectoration. She is not rheumatic, but has had a white swelling on her right knee since she was two years old. Menstruation has been generally regular and normal since its establishment three years ago, sometimes a little too free, but more frequently scanty, and usually accompanied by severe pain. The complexion is very pale, and there are very dark circles under the CHLOROSIS. 109 eyes. The tongue is pale, and the appetite capricious. Citrate of iron and strychnia 3, four times a day. Nov. 13. She has had no pain in her stomach since she ivas here, but the palpitation and the headache still continue. China 3, in the morning and at noon, and citrate of iron at night. Nov. 20. She is very much better, the pain in the stomach has all gone, the headache is much better, there is more color to the tongue, she coughs less, but is still quite weak. Citrate of iron and strychnia four times a day, and spigelia 3, at night. Nov. 27. The patient is very much improved, with the excep- tion of the palpitation of the heart, which is aggravated by slight exercise. Spigelia 3 four times a clay. Dec. 3. She has not been so well this week. The menses came, continued three days, with no unusual symptoms. There has been no return of the stomach difficulty. The palpitation of the heart still continues. She has globus hystericus, which is -worse at night. The eyes are very sensitive to light, and she has consider- able vertigo and headache. There is no exhausting discharge. Belladonna 3, four times a day. Dec. 11. The palpitation is no better. She can sleep in the daytime but cannot at night. Her appetite is very poor; she is greatly exhausted after the least exercise, and has fainted twice after the attempt. Globus hystericus is better. Ignatia 3, four times a day. Jan. 8. She feels much better; has more color in her face. The palpitation is less; there has been no return of the gastric troubles or headache, but she is very weak, and fainted twice after a slight exertion. Spigelia 3, four times a day. Jan. 15. The patient is greatly improved. All the symptoms are better. Continue spigelia 200. Jan. 22. She is still improving. The palpitation and weak- ness, with fainting spells, have nearly disappeared. Same remedy. Jan. 29. " Feels splendid." She can walk, or go up stairs with- out the cardiac difficulty ; sleeps better at night. Continue spigelia 200, four times a day. Feb. 5. Still improving. Same remedy. Feb. 26. She is very much better. All the symptoms are relieved. Continue spigelia 200. The patient reported again in March, and the remedy was changed to ferrum metallicum 3, three times a day. In April she came again to the clinic to assure us, by her general appearance, that the treatment which she had received had restored her to health. Phosphorus is useful in chronic cases of a Phosphorus and cai- tuberculous habit> When caused by srief or carea phos. J *"> worry, or blighted love, or the loss of "fluids, calcarea phos. will often answer, especially if puberty is delayed. 110 THE DISEASES OF WOMEN. Kali carb. is adapted to cases with serious disorders of the digestive system, with thirst, a craving" for Kali carb. e J ° sugar, pumness over the eyes, constipation, and prolonged menstruation. Ignatia in nervous, hysterical girls and women, and when caused or aggravated by disappointed affection. Prof. Hoyne will tell you that calcarea carb. is " a very impor- tant remedy in bad cases, with perversions of taste; aversion to meat; longing for sour and indigestible substances; offensive breath; disposition to colds and diarrhoea; swelling and hardness of the abdomen; palpita- tion of the heart; great dyspnoea; great weakness of the spine; leucorrhoea, and coldness of the hands and feet." Dr. Holcombe calls attention to the phosphate of iron, in the first centesimal trituration, as especially adapted to chlorotic cases of lymphatic temperament and scrofulous Phosphate of iron. ,, ,. TT T constitution. He says: 1 was once treating a little child of the scrofulous diathesis, for ulceration of the cornea, conjunctivitis, and a vesicular eruption around the^eye. Sulphur, hepar sulphuris, calcarea and other polychrests had been tried in vain, when I suspended the special treatment to check a very profuse urination at night. I selected the phosphate of iron, although the acetate is generally better in such a case. To my great surprise the eye symptoms disappeared in a few days. The disease returned some months after, and was promptly cured by the same prescription. Since that time I have used it success- fully in many cachexias with degeneration of tissue." In excep- tional cases the arseniate of iron answers very well. Sepia is adapted to chlorosis with the following symptoms ; Palpitation of the heart, sudden flushings bearing down pains in the abdomen with pro- lapsus uteri and a yellowish leucorrhoea, and a premature and scanty menstruation, with a puffy, pale or yellow face. There is an acquired form of chlorosis which is the sequel to diphtheria. Dr. Gr. A. Macomber observed, that for this species of blood-degeneration, helonias was the best remedy. And, taking advantage of this clin- ical hint, we have found it of great service in chlorotic conditions CHLOROSIS. Ill following' an attack of diphtheria. It may be given alone, or in alternation with china or ferrum in one of its forms. For an interesting- paper on chlorosis arising from mental shock, I refer you to Dr. Hammond's recent report of several cases of this kind cured with arsenic and strychnia.* Much harm is sometimes done by attempting to force the men- strual flow. You should be careful to avoid this, remembering that the menses will appear as soon as the gen- menses, eral health warrants and favors it. Relieve other and more urgent symptoms, restore the physio- logical equilibrium , and this function will probably resume its accus- tomed order. There is good reason for believing that the non-ap- pearance of the menses in many cases of chlorosis is a conservative precaution, designed by nature to economize the patient's strength. An exception to the rule just specified is found in those cases of spasmodic dysmenorrhea, which are incident to chlorosis, spasmodic dysmenor- Here the most sensible and successful plan ot rhoca - treatment is to address our remedial measures to the cure of the stricture of the uterine cervix, upon which the nervous symptoms depend for a local cause. We may give bella- donna, gelsemium, caulophyllin, or some analogous remedy. The warm sitz-bath, or vaginal injections of warm water, may facilitate the flow, and relieve the suffering and the remote ner- vous symptoms at the same time. But if the spasm of the cervix is particularly obstinate, I know of nothing to compare with the careful and appropriate use of the sponge-tent. Much relief may sometimes be afforded by domestic adjuvants. In case of spinal irritation and tenderness, the back may be sponged once daily with salt and water. Friction along the spine is sometimes very useful. For the relief of local neuralgic pain, in the side and chest especially, the part may be covered with a layer of cotton batting, oiled silk or flannel. If the pain is very acute, dry heat will suffice. If it is rheumatic, the local use of hamamelis may be prescribed. The diet should be selected with great care. It should consist of digestible and nutritious articles, both animal and vegetable. If the patient has a distaste for meat, she may cultivate an appe- *Quarterly Journal of Psychological Medicine, etc., Vol. III., p. 417. 112 THE DISEASES OF WOMEN. lite for it* by beginning with salt meat, of some kind, as, for ex- ample, cod-fish, mackerel or herrings, dried beef, lean ham, and the like. Or sea-food, as oysters or other shell-fish, may be taken. Eggs or milk prepared in vari- ous ways, may tempt the appetite. Bread from unbolted Hour, animal broths, chocolate or malt liquors, may be chosen. She should not be ordered to ride or to exercise upon an empty stomach. Moderate exercise in the open air is indispensable. Riding, on horseback or otherwise, is preferable to walking or performing manual labor. And when your chlorotic pa- Exercise and travel. ...... . . tients o-o for an airing m their carriage, be sure they have the light as freely as they have the air. These hot-house productions need it as much as the pale plants that have grown in the cellar. Boating, billiards, croquet and calisthenics may be very useful. But best of all is a change of scene and surround- ings. If to these can be added the health-giving influence of cheerful society, so much the better. These hygienic means will frequently accomplish more than our best chosen remedies. Sea- bathing has its advocates, and mineral waters, especially those which are chalybeate, are strongly recommended. Whatever the cause may have been, it should be removed, and the utmost pains taken to keep the patient from under the do- minion of all perturbing influences. Marriage is sometimes salu- tary, but is of questionable utility, excepting where the attack has resulted from disappointed love. Miss will take a small powder of the citrate of iron and strychnia, 3d dec. trituration, twice daily, with out-door exercise and a generous diet. At the end of one month, the menses made their first appear- ance. She had much pain, with scanty flow. The second period was regular, the flow free enough, with little relative suffering. The headache and cardiac symptoms had entirely disappeared ; the skin became natural; the lips and cheeks had resumed their prop- er color. She took no other remedy. LECTURE VII AMENORRHEA. Amenorrhea.— Delayed menstruation— Etiology of — Symptoms of— diagnosis— prognosis and treatment— Suppressed do.— etiology. Case.— Symptoms, diagnosis and treatment. Case.— Special indications for remedies— Retention of the menses,— etiology, symptoms, diagnosis, prognosis and treatment, both medical and surgical. During menstrual life, or between the ages of fourteen and forty- five, in this country, there are only two conditions in which the non-appearance of the menses can be considered A physiological and a 1 pathological arrest of men- healthy. Ihese are chirms' pregnancy and struation. / . _ S 1 & J . lactation. Under other circumstances, 11 this function is not properly performed the woman is not well. There is, therefore, a physiological and a pathological arrest of this func- tion. I shall speak only of the latter this morning. The word Amenorrhcea is used generically. It signifies a class of affections which are characterized by an absence of the men- strual flow. It includes (1) delayed meilStriia- Definition and varieties. tion ; (2) suppression ot the now ; and (3) re- tention of the same. Let us consider these several conditions sep- arately. 1. — DELAYED MENSTRUATION. This derangement consists in the non-performance of the men- strual function, in one who has arrived at the age of puberty. It is the emansio mensium of the old authors, and Emansio mensium. : „ should not be confounded with a mere suspen- sion of the flow in one who has menstruated before ; neither with tardy menstruation in the case of women who are " irregular/' The young girl has reached the age of fifteen, or perhaps of eighteen, or twenty, but this function is not yet established. For some reason the first appearance of the catamenia is delayed. Etiology. — This irregularity is often chargeable to defective de- velopment. The epoch of puberty has not really arrived. She is yet a child. Her eye lacks expression, her manners are less sprightly than they should be, und her movements do not indicate the graceful mobility of her 8 113 114 THE DISEASES OF WOMEN. sex. Her form and features, her carriage and bodily functions, do not assume their proper proportions and characteristics. She lacks individuality. She is masculine. Her womanly traits are not matured. Her health and her fecundity are implicated by this delay, and it becomes a serious matter to study into its causes and to treat it property. For not only does her welfare concern her individual self, but also that of her relatives, of friends, and of society at large. Delayed menstruation may be due to organic causes, as for ex- ample, to congenital absence of the uterus, the ovaries, the Fal- lopian tubes, or even of the vagina. Or itmav Congenital defect. . _ ° J be caused by inflammatory adhesions which have taken place at an early age in some portion of the genera- tive intestine, or outlet. In some cases it con- madcL" 6 ' 111 ^ ° f inflam " stitutes an idiosyncrasy. In certain families the establishment of this function will in every instance be delayed until the subject is fifteen or twenty years old. Its first appearance is greatly influenced by external circumstan- ces and surroundings, education, exercise, and associations. But more frequently its delay depends upon a de- External conditions. .. .... _ praved condition of the general health. In many cases there is a developing dyscrasia, as for example, tuber- culosis, which interferes with and interrupts the coming on of the menses. Weakly, scrofulous, chlorotic girls are very liable to this form of amenorrhcea ; and in the great majority of cases of this kind you will note that the effect is likely to be taken for the cause. In all of them the gen- eral tone and strength are lowered, the digestion impaired, the blood is vitiated or impoverished, and there is atony, debility, and torpor of the various functions. Symjrtoms. — It is not unusual, in this form of amenorrhcea for the patient to complain regularly each month of the symptoms that usually attend upon the flow. She may Symptoms minus the flow. . ' ' . . have pain in the small of the back, dragging in the loins, aching across the hips, weariness of the limbs, severe and protracted headache, malaise, anorexia, and constipation. These symptoms may come and go with the regularity of the proper " period," but without the characteristic and necessary discharge. Sometimes they are followed by a vicarious hsemor- AMENORRHEA. 115 rhage from the nose, the eyes, the ears, the lungs, the stomach, or the bowels. Or the proper flow may be substituted by a vicarious leucorrhcea. Delayed menstruation is especially significant in girls who are predisposed to any form of phthisis. In them it implies a de- praved cachexia, a low state of nutrition, and Complicated with phthisis. ,.,.,. . -, . -. a great liability either to haemoptysis, or to the development of a harassing cough and hectic, which are the pre- cursors of serious disease of one or more of the respiratory or- gans. If such an one who has passed her fourteenth year with- out ever having menstruated, has a cough, or dyspnoea, habitual or frequent sore throat, hoarseness, or pain in her side, it should be regarded as' a sign of ill health, and of impending evil, and measures should be immediately taken for its relief. But, you should remember, that great harm may be done "Forcing medicines " in- j n these cases by the use of " forcing medi- cines," which are given indiscriminately, and are designed to compel the flow regardless of consequences and of the general condition upon which the disorder depends for its cause. Diagnosis. — The diagnosis is not usually difficult. As a rule (to which, however, there are occasional exceptions,) conception before menstruation is impossible. You will, consequently, have less trouble in diagnosticating this form of amenorrhcea from preg- nancy than in case of suppression or of reten- tion. In delayed menstruation from organic causes there are no changes in the physical development of the person as in puberty. The mammae are small and rudimentary, the figure is gaunt and not graceful, and, therefore, the chief pre- sumptive, as well as the positive, signs of pregnancy are lacking. There are no changes in the uterine cervix, or in the size of the womb, and there is no abdominal tumor, as in gestation. The lapse of time does not alter the case, or relieve it by limitation. The incidental diseases are different. The monthly cycle may or may not be recognized in either case. Nevertheless, since it is possible that a girl ma} r become preg- nant before ever having menstruated, or, in- deed, after her menses have been delayed for an unusual length of time, and before their final appearance, it will 116 THE DISEASES OF "WOMEN. be best for you to qualify your diagnosis. Else it may happen, after all, that the cause of the delay in the catamenia has been a very natural and common one, and that she failed to menstruate because she was enceinte. A careful physical exploration would enable you to decide as to the presence or absence of the internal generative organs. Prognosis. — The prognosis may depend upon the existence of organic defects. Of course, if the uterus were absent or only im- perfectly developed, you could not promise a radical cure of this disorder of menstruation. And so also of a congenital absence of the ovaries, the Fallopian tubes, or of the vagina. Where the amenorrhea is attributable to general ill health, or to local disease, the prognosis will be that of the dyscrasia, or of the disorder, of which in reality the absence of menstruation is but a sequence and a symptom. We must weigh the chances of recovery from scrofulosis, tuberculosis, gastro-alimentary disease, pleurisy, and morbid conditions and alterations of the blood. In other words, both with respect to the progno- An old and true maxim. ■T sis and the treatment, we must remember that our patient " is not sick because she does not menstruate, but that she does not menstruate because she is sick." Treatment. — When you are consulted in a case of this kind you should not be inveigled into prescribing at random and indiscrim- inately. For many of these cases do not need " Let well enough alone." . any medicine whatever. It the patient is well in other respects, healthy, hearty, with a good appetite, and noth- ing to complain of, except that, as her mother or friend will tell you, she " has seen nothing," it is best to recommend fresh air and plenty of it, sunshine, cheerful society of a mixed kind, travel, a change of scene and surroundings, diversion, to take her from boarding-school, and afterwards to let Nature take care of herself. If she remains well, (and she may do so for months or years,) she will be better without medicine than with it. It is time enough to prescribe your pellets and powders for her when she can make a positive complaint of suffering and ill-health. But if, on the contrary, the incipient signs of serious disease begin to crop out, you must anticipate and avert Anticipative treatment. . its lull development. 1 or by so doing you may, perhaps, ward off a threatening phthisis, or may save your pa- AMENORRHEA. 117 tient much of suffering from other diseases, and really prolong her life. The more chronic and complicated the original affection, the more difficult will be the cure, and the greater the need of perseverance on your part. 2. — SUPPRESSED MENSTRUATION. I have already said that a practical distinction should be made, and borne in mind, between suppression and retention of the menses. This distinction is based upon the fact A practical distinction. _ that menstruation, like other secretory and ex- cretory functions, includes two distinct processes, viz. : (1.) the secerning, or exhaling, of the elements of a particular fluid from the blood ; and (2) the pouring out, or escape of that product through a natural duct or outlet. Suppression of the menses concerns the former process exclusively. It relates to ovulation, and to its con- tingent secretion from the uterine mucous membrane. It is the amenorrhee radicale of Raciborski. When, after having been es- tablished and maintained for a longer or shorter period, this func- tion ceases for other reasons than because the woman has become pregnant, is nursing her child, or has passed the climacteric, (un- less there is an obstruction of the uterine cervix,) we say that she has menstrual suppression. Here is an interesting case, the notes of which have been taken by our clinical assistant. Case. — " About four weeks ago, Miss , aged 20, (late a resident of England,) applied at the College Dispensary for re- lief from the following symptoms : Cessation of the menses for the past four months, constant frontal headache, severe sacral pains, pains extending from the sacrum to the scapulae, occasional oedema of the feet and ankles, pains occasionally running down the limbs, vertigo on going into the open air, and obstinate con- stipation. At times, also, she says that she has pains from one hip to the other. There is no leucorrhoea, and no epistaxis. She states that her mother died at the age of thirty-seven years of con- sumption, and that eight of her own sisters have died at about twenty-one years of age, after a short illness, presenting the same (or nearly the same) symptoms that she has detailed to me. " As far as I can learn, there is no hereditary disease on the father's side. At the time of their decease, none of the eight 118 THE DISEASES OF WOMEN. sisters who died presented any obvious symptoms of consump- tion, but all of them seemed to drop off after suffering a short time as this patient suffers. One year ago she was cured in Bristol, England, of suppression of the menses of seven months' duration. I have prescribed for her three times without relieving anything more than the headache, and am led to believe that there must be a mechanical obstruction to menstruation (probably malposition of the uterus). Excepting a slight flush of the face, which is con- stant, this young woman presents no outward symptoms of inter- nal trouble, and were it not for her strange story, I should, per- haps, be suspicious of pregnancy. The remedy which relieved the headache was apis mellifica, but after four dsijs that had no effect." This patient had menstruated before, and could not therefore be suffering from delayed menstruation, as we have just described it. She may have retention of the flow, in conse- Hereditary tendency to q lience f g me uterine deviation, as the doctor suppression. t. suspects, but it is hardly probable that each of her eight sisters had amenorrhoea from this cause, and all at the same age. The very fact that their disease developed at this par- ticular age renders it almost certain that they were the victims of tuberculosis, inherited from the mother, and that the menstrual suppression common to them all arose from this dyscrasia as a common cause. For it is not unusual for all, or nearly all, the daughters in a family in which phthisis is hereditary, to have this disease in a fatal form, when they are twenty to twenty-three years old. And amenorrhoea (suppressio mensium) almost always accompanies it. Suppression of the menses is more common than either of the other forms of amenorrhoea. The busy practitioner has to pre- scribe for it every day. It may come on sud- Course and frequency. in ji , • ;-ii denly, or gradually and almost imperceptibly. The healthiest and most vigorous women, and especially those who are somewhat plethoric, are more likely to have it occur abruptly. Leuco-phlegmatic and fleshy women are prone to a gradual lessening and final arrest of the flow before the climac- teric has arrived. Etiology. — The causes of suppression are numerous and varied. Perhaps the most frequent is exposure to cold, A/voidable causes. . _ . as in getting the leet wet, walking, sitting or sleeping in damp clothing, improper and extreme change of dress, AMENORRHEA. 11^ as in leaving off the warm wrappings and flannels of winter, and substituting a thin party or ball dress. Taking a cold foot- or sitz- bath just before or during the flow is a very common cause of sup- pression. Emotional states often induce it. Among them are fear, fright, anxiety, mental depression, excess of mental applica- tion, the receipt of good or bad news, or solicitude for a sick friend, incompatibility in the marriage relation, the worry attend- ant upon being a witness at court, and confinement in prison. Suppression is incident to attacks of fever, and of local inflam- mation, more particularly to ovaritis, endo-metritis, pleurisy, pneumonia and enteritis, to the presence of Incident to acute disease. t • p polypi, fibroids, hydatids and moles. It is often due to change of climate. One of my patients has had it for three months at a time while visiting the Rocky Mountain region. Another, and without any harmful consequen- and r tJavei. anse ° c imate ces, every year at the White Mountains. Tak- ing a sea voyage may have the same effect. A large proportion of the female emigrants arriving in New York have this form of amenorrhcea, which may persist for months after landing. It may also arise from chlorosis, anaemia and ple- thora. It is a species of idiosyncrasy with From an idiosyncrasy. certain women, now and then to have the function of menstruation suspended for a longer or shorter time, and afterwards resumed again. The slightest forms of in- discretion at the month may suffice to arrest From trivial causes. -in m . . 1 Z, the now. Taking a drink of ice-water, eating a little ice-cream, or indigestible food, or being too much upon the feet at the time, may cause it. Hewitt has had occasion more than once to observe " that women are liable to have the menstrual discharge suspended for one or two periods after first going to reside in a house, the staircases of which are of stone and uncarpeted, their previous residence having had a wooden stair- case only.* Chronic and habitual suppression is incident to advanced stages of consumption. In some cases, however, it characterizes the disease in its incipiency, and may be one of its From chronic disease. !L first symptoms. You will be consulted for the * The Diagnosis and Treatment of Diseases of Women, by Grailly Hewitt. London, 1863, p. 44. 120 THE DISEASES OF WOMEN. relief of this symptom in young women in whom it is supposed to be the chief and perhaps the sole cause of their ill-health. On proper inquiry, you ascertain that the patient has a slight, dry, hack- ing cough, without expectoration, but Avhich is aggravated by ex- ercise. She complains of stitching, lancinating pains in the chest, and dyspnoea from the slightest exertion, more particularly on ascending the stairs. She is easily fatigued, weak, and has lost all relish for substantial food. She has become emaciated, has lost in weight, and is more pale than usual. These symptoms may have existed for a considerable time and developed insidiously, without creating any suspicion of disease of the lungs. But if you are observing, you Insidious complications. . -i -i • will note the order m which they made their appearance ; you will learn that, in the majority of cases, the pec- toral disorder has preceded the menstrual irregularity. In other words, the tubercular deposit, or the pneumonia, was idiopathic, while the amenorrhcea is secondary or symptomatic. Under these circumstances, the blood becomes deteriorated in quality, in consequence of its imperfect aeration and of impaired nutrition. All the glandular functions are im- dis^a s se ntially a glandular plicated. The ovaries, as well as the mesen- teric glands, become diseased, and, if they perform their duty at all, do so but very irregularly and imper- fectly. If the blood is too poor to furnish the proper elements for the gastric juice, for example, it may be unfit to stimulate the changes that should occur in the Graafian vesicle, and which form an indispensable part of the function of ovulation. The intimate sympathy between the lungs and the ovaries, as well as the uterus, should not be forgotten. In every case of amenorrhcea, there is more or less liability to thSr rI °" pectoral sympa " tne development of pectoral disease. In the majority, the arrest of the menses predisposes to pulmonary haemorrhage. This is the reason why hasmoptysis is more frequent among women than among men. And this also explains the more tardy convalescence of women from pneumonia, bronchitis, pleurisy, and even from pericarditis and endocarditis. In many cases the pectoral symptoms and those of scanty or suppressed menstruation alternate. Or, with each return of the month, there may be a serious struggle, so to speak, between the AMENORRHEA. 121 lungs and the uterus. Here is a case in point, to which I was called last evening : Case. — Miss , aged 20, has complained since leaving board- ing-school, two years ago, of a harrassing cough, which never troubles her at any other time excepting at the month. Its com- ing on is the precursor of menstruation, and she is satisfied that, if she were to lose record of the time in which her catamenia were due, she would certainly be notified of the same by this cough. It anticipates the flow by some six to twenty-four hours, and sub- sides as soon as the discharge comes on. The longer the delay of the menses, and the more scanty the flow, the worse the cough. Another cause of menstrual suppression was first recognized and described by the late Prof. Simpson. It consists in what he styled super-involution of the uterus following iitfr U u P s er ~ involution ° f the lakor. This abnormality depends upon a species of marasmus, or excessive absorption of the uterine tissues after delivery, whereby the organ may be reduced to one-third of its natural size, and the proper exhalation of the menstrual blood from its mucous surface is rendered impossible. It is believed that in these cases the said textures undergo a fatty metamorphosis, and finally become atrophied and shrunken, as in the senile atrophy of those women who have passed the climac- teric. Such an organic change would give rise to permanent ar- rest of the menses, and, although comparatively rare, might follow any case of labor, whether premature or at term. Sub-involution, or deficiency of absorption, following pregnancy and parturition, is, however, as I shall have occasion to tell you hereafter, much more frequently met with. It is intimately related to the clinical history of uterine obliquities. Symptoms. — The most prominent symptom is the characteristic absence of the menstrual discharge, which is itself a symptom, and not a disease per se. All the attendant s y Sms°dJranJed vascuIar signs signify that some portion of the internal generative apparatus, more particularly the uterus and the ovaries, as well as the general nervous and vascu- lar systems, are in an abnormal condition. Weakness, lassitude, aching, constant fatigue, lack of interest in family or social mat- ters, indigestion, constipation, headache, cardiac oppression, pal- pitation, breathlessness, fickleness, peevishness, fugitive neuralgic 122 THE DISEASES OF WOMEN. pains, hysterical developments of various kinds, accompany this arrest of function. Some women suffer from ovarian neu- ralgia, others from a species of uterine colic, and not a few from cramps or spasms of one or of all the voluntary muscles whenever the month comes around and they do not flow. All, except those who are really plethoric, have symptoms of asthenia, sedation, atony, debility, and general torpor of the bodily functions. They become emaciated, bloodless, almost transpa- cJxil amenorrhoeal ca " rent, and go into a decline which develops itself more or less rapidly according to the original state of their health and vitality. In brief, a species of cachexia, which soon becomes chronic, and perhaps incurable, follows ; and being- complicated with general derangement and ill health, constitutes one of the most intractable affections to which women are liable. In ex- ceptional cases, however, menstruation maybe suspended for several months, and even for years, and finally restored without any harmful consequences whatever. One of the members of our college class last year cited the case of a woman whom he had known who did not menstruate from the age of 46 to 53 — seven years. She then menstruated once, and afterwards' became preg- nant, and Avas delivered at term of a healthy living child. Diagnosis. — You will have more trouble to diagnosticate sup- pression from pregnancy than from any and all other conditions. This difficulty is increased by the fact, that in From pregnancy. . . . forming a judgment in a given case, prior to the fourth month, we are left entirely at the mercy and caprice of the patient. She may tell us that she has incurred no possible risk of becoming pregnant, when such is not the tiuth. Or, if she is anxious to become a mother, may insist that, nothing but concep- tion could have caused the arrest in her case, for she Avas never irregular before. Too exclusive a reliance upon her word may mislead and deceive us ; but in the first three months, there is lit- tle else upon which to predicate an opinion. The reflex and inci- dental symptoms, as nausea, loss of appetite, morning sickness, swelling of the breasts, are the same. Whatever changes occur in the uterine textures in consequence of impregnation begin in the body and fundus of the womb. We cannot reach or recognize them before the commencement of the twelfth or thirteenth week. Subsequent to that period, however the more unequivocal signs of AMENORRHEA. 123 pregnancy begin to develop, and the diagnosis is more easy and certain. In doubtful cases, time will help you to differentiate between a physiological sup- pression of this sort, and one which is in ever} r sense pathological. When complicated with retention, you may even have to wait until the fifth or sixth, or possibly the ninth, month before you can say with certainty whether the arrest of the menses was due to conception or to some accidental or morbific cause. In simple suppression, however, there is no permanent and con- tinuous abdominal development, no tumor, as in retention or in pregnancy. It will sometimes be difficult to decide whether the non-ap- pearance of the flow is or is not due to the " change of life." The age of the patient, and inquiries into her family From " change of life." . 1 . . history may help to settle this question. It she is past forty, the irregularity may be due to her age, although wo- men do sometimes continue to menstruate much longer. One of my patients was " regular*' until her death, which oc- curred in her sixty-second year. If the patient's mother and sis- ters ceased to menstruate as early as thirty or thirty-five, it might modify your diagnosis. Usually, if the suppression is from a morbific cause, it is preceded by a failure of the general health, and each month the patient complains of symptoms Avhich pertain most decidedly to the return of the old habit. But, when the climacteric has been reached, and the arrest of the flow is charge- able to a physiological arrest of function, the ill health, if there is any, follows the change, and the monthly exacerbation does not recur. Treatment. — You have, doubtless, drawn the proper inference with respect to the treatment for this form of amenorrhcea. Cure the original, idiopathic disease upon which this A cardinal rule. . suppression is secondary, and, in the great ma- jority of cases, if there be no organic obstacle, this particular func- tion will be reestablished. Or as Dr. William Hunter worded it in his Lectures, " With regard to the management of the menses, my opinion is, that you should pay no regard to them, but en- deavor to put her to rights in other respects. If you cure the other disorders, you cure the irregularity of the menses, 'which is the consequence and not the cause of her complaints" 124 THE DISEASES OF WOMEN. If the suppression is due to chlorosis, ovaritis, metritis, incipi- ent tuberculosis, pneumonia, pleurisy, gastritis, hepatitis, rheuma- tism, or any other abnormal condition or diseased process, the in- dication presented is to cure the primary affection, after which we may reasonably expect the secondary one to disappear. Fortu- nately we find that remedies are possessed of corresponding rela- tions to the various functions. For not only are the bodily organs linked in sympathy and susceptibility, but these sympathies and susceptibilities have their counterpart in the curative range of our remedies. The different sections of a correct and complete pathogenetic record are as intimately related as the several cantos ■of a grand old poem. If, therefore, you shall find that the remedy which is manifestly indicated for the cure of the complaint upon which the amenor- rhea is secondary, is also applicable in case of Emmenagogues. . menstrual suppression, so much the better. But, as between prescribing pulsatilla, or senecin, or any of our medi- cines as emmenagogues merely, or iron, secale cornutum, and aloes in ponderous doses with the same end in view, there is really no difference. Both methods are unphysiological and harmful. Abundant experience has satisfied me that the calcarea carbon- ica is, perhaps, the most prominent and useful remedy for the re- lief of those menstrual irregularities which are ±ions^ pec ° mp lca " incident to pectoral disease. It seems especially appropriate to complicated cases of pulmonary and uterine disorder in weakly, ill-conditioned females of a scrof- ulous diathesis, with amenorrhea, an impoverished state of the blood, and a depraved condition of the nutritive system. Pulsatilla is indicated in women with light hair and blue eyes, who are weakly, pale, and delicate, of mild and amiable disposi- tion, and who are tearful and prone to melan- For suppression alternat- -it t, • . . -,-, , -, ing with ophthalmia. enoly. it is sometimes an excellent remedy in case of menstrual suppression complicated with ophthalmia. My attention was called to this fact some years ago by my excellent friend the late Dr. Lyman Kendall, of this city, who related the following Case. — Mrs. , aged 32, had suffered frequent attacks of amenorrhea, which persisted for from three to six months at a time. The suppression came without any apparent cause, and AMENORRHEA. 125 the return of the flow did not seem to be influenced in the least by any medicine which she could take. Her general health was good. She had never been sick in bed, and suffered no ill conse- quences of the amenorrhcea, excepting an intractible and trouble- some inflammation of the eyes. Upon inquiry it was found that this inflammation came and went regularly, alternating with the amenorrhcea. When the catamenia were prompt and regular the conjunctivitis disappeared altogether ; but when they were sup- pressed, the eyes became inflamed again. There was redness and swelling in the lids, lachrymation in the open air, and irritation and pressure as from sand in the eye. Pulsatilla 6, cured both these affections promptly and permanently. Since almost any of our remedies may be indicated in special cases, I will cite the more prominent among them as they are related in a curative way to the various causes of amenorrhcea : From taking c*o/c?.---Belladonna, gelsemium, puisatilla, dulca- mara, chamomilla, caulophyllin, or macrotin, gelsemium, sepia, sulphur, rhus tox, From check of perspiration. — Cuprum, chamomilla, aconite. F) % om changes in the weather, cold and dampness. — Dulcamara, rhus tox., rhododendron, nuxmosch., puisatilla. From taking cold by getting the feet ivet.-^ Aconite, puisatilla. With leucorrhoea. and constipation. — Alumina, natrum mur., sepia, graphites, collinsonia. F'om fright . or chagrin. — Aconite, lycopodium, coffea, opium veratrum vir. Irom atony of the uterus and ovaries. — Aletris far., caulophyllin, helonias. From mental causes. — Aurum, cimicifuga, lycopodium, ignatia, veratrum alb., aconite, puisatilla. From defective nutrition. — Aletris far., natrum mur. With congestion of the head and face in plethoric women. — Glonoine, aconite, belladonna, gelsemium, sabina, sulphur, opium. With eruptions here and there, oozing out a sticky fluid. — Grap- phites. With eruptions ivhen the menses should appear. — Carbo veg. f dulcamara. With prolapsed or ante-verted uterus. — Lilium tigr., collin- sonia. 126 'J HE DISEASES OF WOMEN. With spitting and vomiting of blood at the menstrual period. — Phosphorus, belladonna. With corrosive leucorrhcea in place of the menses. — Ruta grav., silicea, sepia, arsenicum, cocculus. When the menses are suppressed immediately on their appearance, returning again to be again suppressed, intermitting menstruation. — Sabadilla. In thin married women, with forcing pjains in the uterus. — Secale cor., caulophyllin. With nervous headache and hysterical affections, with cold hands and feet. — Veratrum alb., macro tin. With painful pressing doivn as if the menses would appear. — Platina, belladonna. Chlorosis, with bloated, waxy face. — Apis mel., arsenicum, mercurius, plumbum. With pain in the ovaries just before or during menstruation. — Apis mel., Phytolacca. In young girls with a tendency to bloating of the abdomen and of the extremities. — Apocynum. With epistaxis. — Sulphur, bryonia, veratrum alb. With a frequent tendency of the blood to the head, with vertigo and buzzing in the ears. — Calcarea carb., china, ferrum. With p Kile face, blue margins around the eyes, and headache with nightly aggravations. — China, cuprum, ferrum. With cardiac palpitation and spasm. — Cuprum, lachesis, cimi- cifuga, apis mel., nux mosch., bryonia, kali carb., iodium, lilium tig., causticum, or aconite. With rheumatism or neuralgic pains in the head and face. — Gelsemium, macrotin. With indigestion. — Kali carb. for sour eructations, with fugitive shooting, abdominal pains; nux vomica, arsenicum alb., podo- phyllum nux mosch., lachesis. lor retarded or suppressed menstruation. — Dr. Holcombe* extols the value of senecin in the first decimal, or the first contesimal trituration for cases of this kind. He gives a powder every night for four months. With obstinate constipation at the month, with a discharge of *The United States Medical and Surgical Journal, Vol. VIII,, p. 44. AMENORRHEA. 127 almost clear water in lieu of the menses, and an acrid, corrosive leucorrhoea, silicea. With abdominal tympanites — Belladonna, phosphoric acid, chamomilla. With dropsy — Apis mel., for incidental anasarca, swelling of the feet, pnffiness of the cellular tissue ; helleborns, for ab- dominal dropsy, with scanty flow of dark-colored urine ; arseni- cum. Dr. G. W. Barnes* reports " invariable success with apo- cynum can. in quite a number of cases of amenorrhcea in young girls, attended with bloating of the abdomen and extremities." He also had "good success with it at least in one case of this dis- ease in which the latter symptoms were not marked." With chorea, hysteria, etc. — Belladonna, gelseminum, Pul- satilla, macrotin, hyoscyamus, coffea, ferrum cit. et strychnia (in the 3d dec. trit.), cocculus, cuprum, causticum. I am aware that these hints are more suggestive than satisfac- tory. Their chief value consists in the possibility that they may help you to decide between two or more remedies which, other- wise, might seem to be equally appropriate, and in this manner serve a good purpose. As a rule, however, in A practical hint. ,.-,'. functional amenorrhcea, * which is consequent upon different morbid states, whether they are acute or chronic, the symptoms proper to those conditions, and which would be your guide if there were no suppression, will indicate the remedy or remedies that are especially indicated. But if the suppression is idiopathic (which is comparatively rare), you will naturally seek to stimulate the functional activity of the ovaries, and of the uterine mucous mem- ber idiopathic suppres- ^^ rj^ mfty ^ accomplislied W i t h Ut the use of harsh emmenagogues. Pulsatilla, sepia, calcarea carb., podophyllin, apis mel., natrum mur., ferrum, china, phosphorus, sabina, sulphur, platina, or, among the newer reme- dies, senecin, collinsonia can., and the asclepias in., are sometimes gWen with excellent result. Dr. C. D. Williams reports some remarkable cures with xanthoxylum.f * Hale's New Remedies, 1867, p. 83. % United States Med. and Surg. Journal, October, 1871, p. 35. 128 THE DISEASES OF WOMEN. The general treatment is sometimes even more important than the special. In the temporary suppression which frequently fol- lows marriage, a single coitus, or change of cli- General treatment. . . " mate and occupation, it you are careiul not to overdo in the matter of dosing, and will take pains to correct the patient's habits, the function will regulate itself. In every case, she should take the fresh air daily. Walking, or riding in the sunshine, cheerful society, keeping the feet warm and dry, diver- sion, and a proper and nourishing diet, are useful auxiliaries to- wards a cure. They will help to restore the vital conditions which are inherent to this function, and indispensable for its proper performance. And they will also fortify the system against a degree of asthenia which is quite incompatible with ovulation. In those who are predisposed to an arrest of the menses great care should be taken at the month lest a slight indiscretion or exposure induce it. With some women all that At the month. . . _ is necessary is for them to lie down and keep tolerably quiet and passive for one or two days. In others the flow will need prompting by appropriate internal, remedies given in anticipation thereof ; by the foot or sitz-bath ; by an enema of tepid water thrown into the rectum ; or by the introduction of the sponge-tent through the uterine cervix some hours, or perhaps the night before the flow is due. In some cases the passage of the uterine sound, or probe (which, if there is no uterine deviation, is not difficult at this period), may, by irritating the os uteri, pro- duce the same effect. The habit of taking spirits, as gin or whisky, and hot drinks, herb teas and the like, should not be encouraged, for the indirect effect of such palliatives is to unhinge the nervous system and to increase the difficulty. 3. — RETENTION OF THE MENSES. In this form of menstrual irregularity there is a preternatural obstacle to the escape of the flow. Ovulation has been properly performed ; the secretion or exhalation of the menstrual blood from the uterine mucous membrane has been poured into the cavity of the womb, but there is no outlet for it. Either the canal of the uterine cervix, or the vagina, or both these portions AMENORRHEA. 129 of the generative intestine, are closed, and there is no means of escape for the periodical discharge. Etiology. — Menstrual retention may be caused by atresia of the cervix uteri, resulting from post-partum inflammation or from cauterization ; spasmodic closure of the os in- ternum ; flexures and obliquities of the womb ; the presence of polypi, or of coagula, which serve to obstruct the passage ; atresia of the vagina ; or closure of the same by an im- perfect hymen. In exceptional cases it may be due to a species of uterine inertia. Here the flow exudes passively, but the condition of the patient's general health is so low, and the uterine fibre is so irresponsive to ordinary stimuli, that the peristaltic action of the womb is not aroused as it should be. The force that is designed to unlock the internal os and to expel the menstrual product is not called into exercise. The secretion is lodged, and there is no " show." Symptoms. — In this class of cases, the menstrual molimen is more or less pronounced. The symptoms are those which accom- pany normal menstruation, always excepting The form without the flow. . no i i t» • the sanguineous now from the vulva, rams in the back and loins, around the pelvis, and down the thighs and limbs, bearing down and fullness within the pelvis, forcing pains, which are aggravated by standing or walking, headache, malaise, chills, nervous tension and perturbation, and sometimes dyspnoea, and diarrhoea or dysentery, recurring with some degree of regu- larity, may lead the patient to suppose the discharge is coining on, After a longer or shorter interval, however, these symptoms subside, and the effort to establish the flow has proved abortive. This state of things may continue for months, and even for years, to the manifest detriment of the general health. Diagnosis. — Proper retention of this flow can only occur in those who have menstruated before. For this reason, it could not be readily confounded with, or mistaken for, Delayed Menstrua- tion. The repeated efforts to expel the secretion, at each return of the monthly cycle, the kind and degree of suffering experi- enced, and the special clinical history of the case, would help you to differentiate between this form of menstrual derangement and a case of suppression, and also to diagnosticate it from " change of life," and from pregnancy. 130 THE DISEASES OF WOMEN. Prognosis. — The prognosis will vary with the cause of the dis- order, the age of the patient, and the condition of the genera] health. Other things equal, a recent case is more promising than a chronic one. If the blood has become deteriorated in quality, either from depraved nutrition or from the resorption of post- organic matters confined in the cavity of the uterus, more serious consequences are to be apprehended. Or if, in consequence of the damming up of the discharge, the ovaries have become seri- ously diseased, we would not promise a prompt and radical cure to follow the restoration of the menses. For in exceptional cases the removal of the obstacle to the menstrual discharge, whatever it may have been, fails to re-establish this very important function. Treatment. — -The prime indication is to remove the cause of the retention. Atresia of the cervix can usually be overcome by the careful and persistent employment of the uterine Surgical means. . ' sound, or probe, Friestly s or Atlee s dilators, Simpson's ebony bougies, and the sponge tent. In rare cases the hysterotome may be requisite. I could cite many cases in which these means have cured retention of the menses due to atresia of the neck of the womb, occurring as a consequence of lying-in, and of excessive cauterization. When the trouble depends upon spasm of the internal os-uteri, the same dilatation may be necessary, but it should be conjoined with such internal and hygienic treatment as is Dilatation, etc. . suited to overcome the tendency to locai and general spasms. Here you will need to counteract the hysterical bias of the patient, and to place her under conditions which favor recovery. The topical and general use of electricity promises to be of great value in this particular class of cases. If the uterus is bent, or twisted upon itself, proper means must be taken to correct and cure the deviation. The most frequent of these displacements is retro-flexion, the womb Reposition of the uterus. . -i ti i i i j? , i being curved like a retort, and the canal 01 the cervix obliterated at the point at which the body of the organ is bent upon its neck. These cases are very tedious, but if you are really skilful, you will succeed in curing a large proportion of them. Polypi and coagula are to be removed by excision, and by dilatation of the canal of the cervix. Atresia of the vagina will AMENORRHEA, 131 require a caieful dissection of its adherent mucous surfaces, after which the freshened edges must be separated and n of S !he h SliT™*' either by an oiled tampon or Sims' dilators, until they are healed. If the hymen is imperforate, it must be divided in order to discharge the contained fluid. The old plan was to make a crucial incision into this septum in such a case ; but, serious results having followed the too rapid evacuation of the fluid, modern authorities advise that the cut shall be valve- shaped instead. Fig. 20. Sims' Vaginal Dilator. If the retention is referable to uterine atony, the general health must be built up and fortified, and local excitation and stimula- tion of the womb secured by electricity, bathing, frictions along the spine, and the use of remedies suited to the especial and inci- dental symptoms, whatever they may be. LECTURE VIII. AMENORRHEA — CONTINUED. Amenorhcea, with prolapsus uteri and obstinate vomiting. Case.— Resembling perforating ulcer of 1 he stomach— reposition of the uterus, — subsequent history.— Note,— Amen- orrhoea with choreic spasms. Case,— remote disease from an arrest of the menses,— "forcing- the now,"— effect of rest and quiet,— Amenorrhea with supra-orbital neu- ralgia. Ca he fl ° w be f ° rced re ^ urn by the use 0I * emmenagogues, cathartics, hot herb teas, and the warm bath. And this under the impression that the symptoms which had their origin in the arrest of the flow could not be so promptly or effectually relieved as by its re-establishment. In many cases, where the}' were resorted to at once, and if they were not too powerful, these means were, no doubt, efficacious. Patients were cured in what was called a common-sense sort of way. But where, as in the case before you, a considerable time has intervened between the cessation of the proper menstrual flow and the making of the pre- scription, it is certainly prejudicial to the health and welfare of the patient, indeed, unphysiological, to attempt to bring it on again. Relieve the indirect symptoms by direct remedies, as speedily as possible, and trust to the natural powers to restore the function at or near the next "period." Where there is evi- dent determination of blood to the head, I can see no valid objec- tion to foot and hip baths as adjuncts to our remedies. This one thing you may bear in mind with respect to this form of amenorrhea. When some exciting cause suppressor' trouble from nas suppressed the discharge suddenly, and when, after a few hours, or days at the far- thest, the flow is not resumed, the chances of trouble at the next 142 THE DISEASES OF WOMEN. "period" will vary with the degree of congestion and inflammation of the uterus and ovaries consequent upon that suppression. If the mishap has reacted upon these organs exclusively, the mischief is likely to be perpetuated in the form of dysmenorrhea, menorrhagia, permanent retention, sterility, etc. But if, on the other hand, the brain is involved, any subsequent irregularity of menstruation will not be so apt to follow. Symptomatic disorders of the nervous system, dependent on this variety of menstrual arrest, are self- limited, and seldom interfere very seriously with the resumption of the floAV at the next and subsequent periods. The importance of this rule is shown in the treatment which it is proper to pursue under these varying circumstances. In the former case there is manifest need of treating the patient during the monthly interval, so as, if possible, to avert more serious consequences, and to secure the punctual appearance of the accustomed discharge. In the latter, the present symptoms should be relieved, and the gen- eral system regulated by attention to the diet, and by exercise in the open air, after which we may safely leave the rest to nature. I might spend the whole hour, most profitably, perhaps, in insisting upon the especial need of rest in this class of cases. When you visit such a patient, you will very Rest and quiet. J . . " .. . , likely rind her in an illy-ventilated apart- ment, surrounded by a host of anxious relatives, including one or more lovers, and neighborhood gossips enough to discourage her or drive her crazy, and to consume the oxygen to which she alone is entitled. Your first duty, in such an extremity, will be to clear the room of its unwholesome contents. If these " friends " are adhesive and pertinacious, and you cannot devise any better expe- dient, you may quietly hint that these symptoms are very pecu- liar, and may possibly develop into some contagious affection, as, for exanrple, the small-pox. This will have the effect to scatter those mischievous comforters, w T hose sympathy is a curse instead of a blessing, arid you can then forbid their return. In similar nervous states the most trivial causes may perpetuate the diffi- culty. A noisy door-bell, a talkative nurse, too much light, or sound, or stir in the room, or house, the doctor's creaky boots, and many other things may counteract the- influence of the most appropriate internal remedies. It is a very important part of your duty to recognize and remove all these obstacles to recovery. AMENORRHEA — CONTINUED. 143 The patient will take a dose of belladonna 3d, once in three hours during the day, and we shall see how promptly and satisfac- torily she will recover. AMENORRHEA WITH SUPRA-ORBITAL NEURALGIA. Case. — Mrs. K., aged 36, with light hair, blue eyes, and mild disposition, complains of a peculiar form of neuralgia associated with the return of menstruation. The menses are tardy; some- times delayed one, two, or even three days. Their appearance is in- variably preceded by a violent neuralgic pain, which is located over the left eye, along the superciliary ridge. This suffering usually begins when the flow should commence, and continues with in- creasing severity until menstruation sets in, after which it grad- ually subsides. In the interval her health is excellent. She has never had any other form ol neuralgia, but has been subject to this for ten years past. It has never been located over the right eye, or in any other than its present seat. She " expects to be sick" three or four days hence. This case is an anomalous one. It is by no means rare to hear women complain of neuralgia which is most troublesome " at the month." Sometimes it affects the head, the face, Varieties of menstrual the teeth QJ . th& earg T l iere are those who neuralgia. have occasional attacks of angina pectoris at this period. Ovarian and mammary neuralgia are frequent ac- companiments of menstruation. Incidental, shifting local pains often torment women whose courses are due but are somewhat delayed. But a circumscribed neuralgia of this sort, in this par- ticular locality, recurring with the regularity of an ague paroxysm, in immediate relation with the menses, and subsiding as soon as they have commenced, is by no means common. A strange peculiarity contingent on all these cases of menstrual neuralgia, is that the pain is more likely to be seated in the left than in the right side of the body. Treatment. — These pains are reflex. The cause that produces them is a temporary retention of the menses. Remove this cause, and the suffering is at an end. This indication Local treatment. may be met, temporarily at least, by a variety of domestic expedients. A. drink of gin, a warm sitz-bath, the application of a bag of hot salt to thehypogastrium, the operation of a carthartic or an enema, chloroform, or opium, may promote 144 THE DISEASES OF WOMEN. the menstrual flow and arrest the pain. But these expedients are only palliative and transient in their effect. They will exert no influence over the function at the next period. In anticipation of the menses the neuralgia will return again. In order to effect a radical cure thereof, we must look to the seat and character of the pain, its particular relation to the men- strual nisus, whether it comes on, or is worse Specific treatment. . . before, during, or after the flow, and to like symptoms, for especial indications for our remedies. I have never seen but one well-marked case of this kind before. It was the exact counterpart of this. I gave that woman Pulsatilla 3 The flow commenced almost immediately the neuralgia vanished; and although five years have elapsed, it has never returned. Mrs. K. will take the same remedy three times daily, until the menses ap- pear, and I prophesy that she will be free from this unwelcome neuralgia in the future. SPINAL IRRITATION, WITH AMENORRHEA, VICARIOUS VOMITING AND CONVULSIONS. I was consulted in the following case by my friend, Dr. Wm. D. Foster, of Hannibal, Mo. The notes thereof were furnished by the patient, wiio is a most estimable and intelligent person : Case. — My parents were born in Vermont, and up to within a short period before their death, were very healthy and robust. With my mother the " turn of life " came at 53. This caused a severe illness, which developed into insanity, and finally termin- ated in death from heart disease. My father lived to be 68, and died of dropsy of the heart. I was born in Cleveland, Ohio, and, when my mother died, was 14 years of age. While visiting Chi- cago the same season, I had a severe illness, of which I remember nothing, excepting that I had a very sore mouth. Previous to this illness, I had always been very well, except that when I was about seven years old I was vaccinated, and it made me very sick. I lost the use of my left arm for some time ; had swellings in the arm- pit and upon the arm, which had to be lanced. In the spring of 1862, the corner of a falling door struck me be- tween the shoulders, and left me insensible for a day or two. Upon recovery I could not see out of my right eye. It did not pain me much until I began to recover my sight, which was several months after the accident. Often since that time I have been troubled with very severe pains in that eye. At these times the pupil enlarges, and I cannot see out of it. Soon after my illness in Chicago I realized that there was some- AMENORRHEA — CONTINUED. 145 thing wrong with my spine. The physicians predicted that I would outgrow it. The pains in the back were almost constant, but were very much aggravated whenever there were signs of torpidity of the liver, which generally occurred two or three times a year. Sometimes I would be prostrated with these attacks for from two to four weeks. In 1864, 1 was troubled with the passage of gall-stones. Every few days I would suddenly be prostrated with dreadful pains in my side, which would last for several hours. These attacks de- veloped into such a derangement of the stomach that it would not retain food. The pain finally became constant, and I was seriously ill for about six weeks ; was confined to the bed, my back and head troubling me greatly. Prior to this, the worst pains in my back were between the shoulders, extending upwards to the head, and so severe as often to make me delirious for a few hours. In 1865, I had several abscesses, which were thought to have been caused by my having fallen down stairs. These abscesses are now believed to have formed in the left ovary. I had no more of them until about a year ago, but within a year have had several, all of which have been on the right instead of the left side. They have discharged through the vagina. I always had more or less headache during my " periods." For the last five years have had considerable pain in the small of my back, and in the womb itself. In the winter of 1867, I think it was, I was laid up for several weeks with lameness in the small of the back, could not move without help, and for some time there was no action of the bladder, the urine being retained. From that time until now I have suffered from scanty and irregular menstruation. The flow finally stopped entirely, and I suffered each month with pain, violent crampings, etc. I was married in 1860, at the age of 21 ; always menstruated properly until the time aforesaid, excepting about four months in the year 1859, when, for some unknown reason, my courses stopped. I did not, however, suffer much on account of it. My back always pains me somewhat, but when the different organs named are in a proper condition, I suffer no serious inconvenience from it. This statement shows, in very graphic outline, the chief points of interest in this case. But there are additional symptoms which our patient could not catalogue. For two years past, whenever the menses have been arrested, scanty, or tardy in their appearance, she has had Vicarious haematemesis. .. - "1 . vomiting of blood. This hsematemesis never comes excepting at the month, is not very copious, nor is it 146 THE DISEASES OF WOMEN. accompanied or followed by any evidences of inflammation or of other organic disease of the stomach. She is also subject to periodical attacks of severe pain in the back and head, which end in spasms, delirium, and finally in clonic spasms of the muscles of the back, with Convulsions. . opisthotonos and fearful convulsions of all the voluntary muscles. Concerning these paroxysms, which are even more painful to her friends than to herself, the Doctor says ; 6 ' I have observed that the cramps, delirium, dilatation of the right pupil, pains in the spine, etc., invariably come The causes of. J on when there is any difficulty with the liver. The menstrual approach excites the same train of symptoms. So also does any mental trouble, disappointment, or other cause of serious mental excitement. " The sensitiveness of the spine is most marked in the lower cer- vical and upper dorsal regions. The spine, however, is somewhat sensitive throughout. She frequently falls to the Prodromata. . . floor ; but, when she has any premonition, usu- ally gets to a chair or lounge, and saves herself. These spells usually follow the more severe symptoms of spinal irritation. She has never been pregnant." The patient came to this city, and was under my care for sev- eral weeks. Her case was interesting and intricate, for several theories of her disease suggested themselves. Theories concerning the jj er iH nesss might be said to have dated from nature of the disease. ° her vaccination ; or to have been caused by the traumatic injury of the spine from the falling door, and from fall- ing down stairs (spinal irritation) ; to the hepatic complication ; the menstrual irregularity and suffering ; or to the epileptiform nature of the paroxysms. But the history of the case led us to infer that these causes had acted conjointly, or rather consecu- tively, to produce so complicated a set of symptoms. My friend, the Doctor, had faithfully applied the most appro- priate remedies for the relief of the individual and collective symptoms, but without any real or lasting bene- Fideiity in the use of f]j- # j n fafa treatment he had persisted for remedies. x more than two years. The menstrual derange- ment being marked and prominent, we concluded that it must be an important factor in the case. In his letter, the Doctor said : AMENORKHOEA — CONTINUED. 147 44 The non-appearance of the menses and the scant flow have been invariably owing to the spasmodic closure of the uterine cervix. Whenever I have succeeded in passing a tent Cause of the menstrual w ithin the internal os uteri, the flow proceeded disorder. *- properly. But the introduction of that instru- ment was a proceeding in which I think there were more failures than successes. By the use of Atlee's dilator, however, I could accomplish the purpose with much greater certainty." Dilatation was therefore persevered with so as, if possible, to over- come the spasmodic closure of the cervix and to secure a free and easv flow of the menses. If this end were obtain- Failure of dilatation. *" . tit t ed, it was thought the result would be to bring relief to the nervous centers that were surcharged with blood — the patient being very fleshy and of full habit. But this means failed because of the persistent inclination to spasm of the uterine neck. For almost as soon as the tent, or Priestly* s dilator, had been re- moved, the cervix would shut so tightly that it would be next to impossible to pass the sound. We accordingly determined upon incision. The Doctor came to town and assisted me in the operation. I performed the bi- lateral section with a Simpson's hysterotome, of'the e c e?vix tionofincision but di( * not cut tlie wal1 of tlie cervix entirely through, as recommended by Sims, and prac- ticed by my friend Comstock. The hemorrhage, which was not severe, was arrested by a cervical tampon that had been saturated with the tincture of the per-chloride of iron. The patient was kept in bed for one week only, the cervix being dilated every al- ternate day with Priestly's dilator, to prevent atresia of its canal. She soon returned home, and with the occasional passage of the sound, and of the dilator (which are introduced without difficulty since the operation of incision), she menstru- Subsequent history. ates more regularly and copiously than she has done for a long time. Thus far she has had no more vomiting of blood. In other respects, also, her health is somewhat improved. The convulsive paroxysms are less frequent than they were. Their character and severity, however, are unchanged. The cer- vical and dorsal pains continue. The dilatation of the pupil and the temporary amaurosis are relatively infrequent of late, but 148 THE DISEASES OF WOMEN. when they are present they have the same characters as before. This patient is therefore still und,er treatment. Now, gentlemen, I have brought this case to your notice for the sake of illustrating three very important points, viz. : (1.) That in your daily experience as practitioners, you Practical points. it ^ will discover that the diseases ot women are often more complicated than you had supposed they could be ; (2) that Uterine Surgery, and Uterine Therapeutics are by no means perfect and infallible ; and (3) that, in this as in some other departments of our art, rapid and brilliant cures are the exception and not the rule. If clinical teachers were always faithful to their trust, and if those who report their experience in our societies and journals always told the plain, unvarnished truth, such A fallacious idea. tip i i • i • i • cardinal facts need not be mentioned m this connection. But it is not so. Students are often led to believe that nosological distinctions are real, and that diseases run an uncomplicated and unvarying course. If they have little knowl- edge of human nature and of human frailties, and especially if they have seen but little of the " practice," they are decidedly impressed with this idea. But the illusion vanishes when they are brought face to face with disease. And I have sometimes thought that they are more likely to be undeceived in this respect in treating the diseases that are peculiar to women, than in their experience with any other class of ailments. This is a case in point. It is so eas}~ to dictate and dogmatize in these matters that one might prescribe a manual operation, or an internal remedy for such a patient, and insist that either of them m S?55T c surgery and should effect a cure. But you will find that these very complicated cases are not so easily disposed of. A certain operation, or a single remedy, may need to be modified or changed repeatedly, perhaps, before the cure is effected, if indeed it ever is. The incision of the cervix uteri in this case w x as of real service. It is a great point gained to have secured the regularity and freedom of the menstrual flow, and more than all, to have put a period to the hsematemesis before any manifest organic disease of the stomach had supervened. But the operation has not cured the woman at all. And it AMENORRHEA CONTINUED. 149 would be wrong for me to report her as well again, when she is not. There are those who will tell you that this or that remedy, in a particular potency, would undoubtedly have cured her. But such an opinion is presumptuous. We can Do not claim too much. ... ttti accomplish much with our remedies. When fitly chosen they are wonderfully efficacious. Every year their curative scope is widened, and their clinical range more accu- rately defined. But, although we can accomplish more than our predecessors ever did, and with means that they deemed too insig- nificant to be of any practical use, we should not claim that our skill and success are unbounded. If we are unreasonably confi- dent we defeat our purpose and disgrace our calling. The health of woman is exposed to so many vicissitudes, and she is the victim of so many interior sources of mischief, that you will always do well to qualify your prognosis Qualify your promises. . _ . and your promises to cure her, even ol the simplest ailment. Especially should you forbear from engaging to restore her rapidly to a good state of health, in case of any disorder of menstruation or of the nervous system. I once heard a physician claim that a single dose of sepia had entirely cured one of his patients of a long-standing and serious dysmenorrhcea. It had cut short her ■suffering and relieved her like magic. This last result we were prepared to credit ; but, when he went on to say that the pre- scription had been made only a fortnight before, and that the men- strual cycle had not yet returned, every experienced person pres- ent knew just what to think of the rapid and radical cure which, in all probability, had not been effected. AMENORRHEA IN ADVANCED PHTHISIS. Case. — Miss E., aged fifteen. The menses appeared at four- teen, returned at the proper time for the following two months, and have now been suspended for ten months. About three months after the suppression she had a severe attack of haemoptysis, which continued at intervals for three weeks. She has headache all the time and chills every morning, which begin about 9 o'clock a. m. and last until 12 m. These are followed by a slight fever. There is great thirst, even during the chills. She has a cough, which is worse in the morning, and her lungs are very sore. Her father 150 THE DISEASES OF WOMEN. and mother died ol consumption. Bryonia 3, every two hours during the day, and calc. phos. (5, at night. April 28. She is not feeling much better, has chills every morn- ing, and drinks a great deal during the chill. Her throat is sore from coughing. She cannot lie in bed, but must get up and move about. Arsenicum 3 and Bryonia 3 alternately every three hours. May 4. No better; the chills continue. Her feet have bloated since her last visit, and she has profuse night-sweats, headache in the morning, and the fever lasts until night. The hectic flush is quite pronounced, and the pulse is 160. Lachnanthes 3, four times a day. May 11. She thinks she is feeling some better. Has had less headache and fewer chills, appetite is better, and she rests better. Her feet are still so cold that hot foot-baths are necessary several times during the day. Her pulse could not be counted. Lach- nanthes 3. (Exit the patient.) I have sent this poor girl to the waiting- room in order that you might hear my prognosis, and that 1 may tell her afterward the plain truth concerning the gravity of her symp- toms and our inability to do anything for her permanent cure. In such a case as this, which is really one of tuberculosis in its latest stage, the occurrence of the secondary amenorrhcea, like the sore throat, and dropsy of the feet and limbs, is of fatal signifi- cance. Her disease is positively incurable, and I shall direct that she be sent to her relatives in the country,for fresh air, good food* and home comforts, while she does live. The clinical relation of amenorrhoea to tuberculosis is not always clear and explicit, but there are certain rules which may help us to decide what that relation is in a given case. For ex- ample: If the primary lesion has developed within the thorax, the menstrual involvement may be late in making its appearance. This is the form of suppression that usually occurs in the last stages of "consumption." But if the original deposit is anywhere within the abdomen or the pelvis, in the peritoneum or the inter- nal generative organs, the interruption of the monthly flow will happen much earlier, or it may perhaps be the first and most prominent of the morbid symptoms. These facts square with the spread of the disease and the invasion of the adjacent organs,, everything depending upon the point of attack. Part Third. THE DISORDERS OF MENSTRUATION. LECTURE IX. MENSTRUAL HEADACHE. Menstrual Headache. Case.— Often overlooked— from uterine deviations. Case.— Ovula- tion and cephalalgia— diagnosis, prognosis and treatment. Case.— Menstrual retention cause of uterine displacements. Case. — Mrs. , aged 40, began to menstruate when she was only twelve years old. About that time she commenced to have periodical attacks of headache, which, she says, have always returned just before or just after the " courses." She is the mother of three children. With the exception of the time in which she was pregnant and while nursing her children, in each case, and also when, for some unknown reason, the menses were suppressed for twelve months at another time, she has never failed in twenty-eight years to have this headache every four weeks. The arrest of the catamenia took place two years ago, and afforded a complete immunity from these attacks. When the flow was first restored it was slightly irregular in its return, but the headache came on again, and since that time it has been more severe in degree than ever before. The pain is located in the temples, and across the frontal region, is aggravated by light, but not by noise. It occasionally, although very rarely, happens that a paroxysm is caused by over-fatigue and anxiety. During the attack she sometimes has slight nausea, there is occasional vomiting, weakness, a feeling of inability to stand or walk, and a very decided anorexia. She has consulted many phy- sicians, but without benefit. These few symptoms convey no very adequate idea of the suf- fering involved in the monthly martyrdom to which our patient has been subjected for more than a quarter of a qumtfy o S 3o°S. fre " century. The case is by no means a rare one. There are those who have had this painful affec- tion during their whole menstrual life. And, strange to say, it frequently happens that this particular variety of headache is 152 THE DISEASES OF WOMEN. often improperly diagnosticated and treated. I have seen patients who have been under the professional care of a number of physi- cians for this complaint, and although the monthly periodicity of their symptoms was as marked as in the case before us, no refer- ence had been made to it at all. The especial significance of the different kinds of headache that are incident to the sexual diseases of women is not as thoroughly understood by the profession as it should be. I can not hope to remedy this defect in their special pathology, but I desire to offer a few practical hints that are founded upon clinical experience. Nearly, if not quite all, these forms of cephalalgia are of reflex origin. The only prominent exception to this rule occurs in case of the impairment of the quality of the blood, as Reflex headache. . . f ,,,.,. P ,, in chlorosis, chloro-ansemia, the debility follow- ing abortion, menorrhagia, uterine leucorrhcea, or too prolonged lactation. The "menstrual headache," as it is termed, is almost always dependent upon ovarian irritation or inflammation. Hence the relation of the paroxysm to the return of the menstrual cycle. It comes regularly each month. It may either anticipate, accom- pany, or follow the discharge. The pain is most frequently located in the crown of the head, or it may be in one or both temples, in the orbital region, or even in the back of the head. It may or may not be accompanied by the " clavus hystericus." In chronic cases, it is sometimes described as " crushing, as if there were great weight upon the vertex." This is an intractable and persistent symptom, especially in women who are passing through the climacteric period. More frequently, perhaps, the pain is said to be " burning" in character, and circumscribed in extent. It is quite common for women with this kind of headache to complain of " strange " sensations in the head, or of " forge tful- ness;" or they will tell you that "half the Peculiar symptoms. • i i i it time they do not know what tney ai-e about. Sometimes, during the paroxysm, they will threaten to " go crazy," and, nolens volens, may put the threat into temporary execution. This is the form of headache with which those who are subject to difficult and delayed menstruation are most afflicted. Those who are of the hysterical or the neuralgic diathesis are par- ticularly liable to it. When it occurs as a concomitant of uterine MEXSTKUAT. HEADACHE. 153 ulceration, I think you may refer the lesion of the cervix and the headache to some primary disease in one or both of the ovaries. Attacks of headache which are incident to uterine displace- ments and to leucorrhoea, resemble what is vulgarly styled " sick headache." In this form of the disorder, the Headache from uterine displacement and leucor- paroxysms recur without regularity and with- out any special reference to menstruation. In those who are susceptible, over-fatigue, want of proper rest, or of food, or an excess of mental excitement, may induce it. Here the gastric function is prominently and principally implicated. Inci- dentally, the most curious symptoms may attend it. One of my private patients described the feeling in her head as "a sort of wriggling, as from the movement of long worms, such as are found in vinegar." It is not unusual for such persons to com- plain of a sensation " as if the head had been scalped, and the brain left exposed." I once knew a woman to be confined to her room for fifteen consecutive weeks with a spurious typhoid fever. In her case, this headache returned every fifteenth day with the regularity of an ague. Her description of the paroxysm led me to infer that there was a possible dislocation of the uterus, although it had never been suggested to my patient by her previous medical attendant. I found that the womb had settled down upon the perineum. As soon as it was restored, the periodical headache vanished and her fever did not return. If we except the expedient of setting fire to the house, nothing will place some of these patients upon their feet so speedily as to re- store the womb to its proper position, and to keep it there. There is a prevalent idea that the menstrual headache is caused by a spasm or obstruction of the uterine cervix, which has the effect to prevent a ready exit of the menstrual a( Cause of menstrual head- fl ow j n exceptional cases, this may be true; but the reverse is certainly the rule. If it were not so, labor, either in abortus or at term, and indeed, whatever would secure the free expansion of the cervix, would cure it radi- cally and entirely. But this woman's history disproves the theory of its being due, in her case at least, to a lesion or spasm of the neck of the womb. She has had three children, and now is worse than ever before. 154 THE DISEASES OF AVOMEN. Here the direct relation of the headache to the function of ovu- lation is shown, not only by the regularity of its return at the month, but also by a complete exemption from Proof of connection be- . , . . , . tween ovulation and the it during gestation and lactation. In prea- cephalalgia. & ° . . ^ & nancy, and while nursing, menstruation is physiologically suspended. When this function was arrested the headache ceased, and when it was resumed the headache returned. The same was true of the period during which, for some unknown reason, she had ameiiorrhoea. The periodical afflux of blood to the generative organs, but more especially to the ovaries, and the nervous tension and erethism connected with the monthly crisis, appear to have been sufficient to cause the headache. As soon as the vascular and nervous energies were diverted and busy elsewhere, — in the developing uterus during gestation, and in the mammary glands while nursing her infant, — the remote cause was removed, and the effect ceased. This view of the etiology of u menstrual" headache is confirmed by the history of cases in which an incidental and temporary excitement of the generative system causes an wWcTs?mu1ate°rvuia'ti i on attack independently of, and without reference to the monthly return. There are those who always have it after coitus. In some it follows the first indul- gence of the sexual act after menstruation, or Exciting causes. prolonged continence. In others, a sexual or- gasm induced by emotional influences, especially if it is ungrati- fied, may be followed by a severe attack of this peculiar form of headache. Incompatibility in the marriage relation is a frequent cause of it. It is sometimes due to a temporary arrest of the flow for a few hours, or rather to what has been styled " intermittent" menstruation. Or it may depend upon too scanty or too copious a discharge. In brief, in certain women, whatever mental or physical causes are sufficient greatly to derange the circulation and innervation of the internal generative organs are capable of inducing the "menstrual headache." Suppose we interrogate this patient a little farther, and ascer- tain if there are not other symptoms with which we should become acquainted. " Are you quite well, madam, with the exception of the head- ache ? " " No, sir, not entirely ; but the pain in my head, when MENSTRUAL HEADACHE. 155 » it does come on, is so much worse than anything else, that I make no account of the other symptoms." " What other symptoms have you?" " I have a feeling, sir, as if 'my limbs were gomg to sleep. It requires a great effort for me to keep about, and I am very sensitive to the cold air." "Do you have these symptoms now, midway between the periods?" "Yes, sir," k Tell me how you feel when the flow commences, and while it continues." "■I often have a kind of spasm in the bowels, which comes on just before the discharge begins, and then goes off again. Sometimes I become a little blind, and so long as I am sick there is more or less darkness before the eyes, so that I can not see distinctly." "Do these last symptoms disappear as soon as the flow stops?" " They do." " Show me where the pain is located/ " It is here, sir, in the left side, right over the hip. Sometimes it is in the groin, and shoots down that leg , at other times, saving your presence, it passes into my belly. And sometimes there is a throbbing in the lower part of my back-bone." "Are you quite certain that these symptoms return every time you are sick?" " I am, sir , they are as sure to come as the flow itself." Now, therefore, if there have been any doubts in your minds as to the interpretation of this case, I think they will have van- ished with the close of this examination. You kJon rch for the primary mav sometimes find it even more difficult to locate the original lesion which has given rise to a sympathetic headache, such as that of which our patient com- plains , but you should always search for it. For, depend upon it, although you may fail to remedy an obscure case, if you can explain its special pathology, its cause, course, nature, and prob- able termination, you will have almost as strong a hold upon the confidence of the patient and her friends as if you were realis- able to cure it. There is no especial difficulty in diagnosticating this from other varieties of headache. The "sick" headache affects males and females indiscriminately, and sometimes affects he?da?he? is-f '-' m ' ' sick quite young children also. It is not regularly paroxysmal. The fits have no especial relation to the menstrual cycle, but may be brought on at any time by an excess of anxiety, fatigue, or the eating of improper food. The paroxysm passes off with sleep, or is relieved by pressure, as from a handkerchief bound tightly about the head, and sometimes ends with emesis. The gastric function is chiefly deranged, and 156 THE DISEASES OE WOMEN. nausea, retching, and vomiting almost always attend it. It may occur prior to puberty, and also after the climacteric. In many women the paroxysms of this headache are more frequent during the early months of pregnancy and lactation than at other times. Those who are subject to it are apt to be wretched and hypochon- driacal. It is sometimes cured by change of climate. The " neuralgic" headache is traceable to vicissitudes of weather, unusual exposure, especially to wet and cold, prolonged mental strain, insufficient nourishment, nervous ache° m " neuralgic " head " exhaustion and perturbation of the mental faculties. Unless of a regular intermediate type, as in orbital neuralgia, or " sun" headache, it does not recur regularly, and has no especial relation to the menstrual function. It is often relieved by eating or drinking. The rheumatic dia- thesis is a strong predisponent of this variety of headache. Seam- stresses and others who live upon a light and insufficient diet, who are underfed and overworked, and who drink much of tea and coffee, are very liable to it. It is sometimes caused by decayed teeth. The pain is piercing, darting, lancinating, and erratic, sometimes present in one part of the head or the face, and again in another, now superficial, then deep-seated. The " congestive" headache, of which one sees more in the medical books and journals than in actual practice, is marked by a flushed face, redness and suffusion of the con- headaSie U congestive ' junctivse, either dilated or contracted pupils, photophobia, an intolerance of noise, and a full pulse. This form of headache is usually a concomitant of some local inflammation, and subsides without any very serious con- sequences. The " hysterical" headache differs from those of which I have spoken, in the period of its occurrence and recurrence, in the fixed limit of its location, in the fitful flow of ache° m hysterical " head " animal spirits which accompanies it, and in the marked effect that the most trifling emotional influences have to increase the suffering. It is very likely to recur at the month, more especially if the patient has dysmenor- rhea, or spinal irritation, but is not by any means confined to that particular period. Some women always have it if the menses are delayed or suppressed. In other cases it is a sequel to menor- MENSTRUAL HEADACHE. 157 rhagia. The paroxysm may be caused, and may come and go, in the same manner as the true hysterical fit. The proper " menstrual" headache returns with the regularity of an ague paroxysm every time the woman menstruates. If its habit has been to come on at the beginning of stra^headach? 116 ""^ tne mont hly crisis, this habit will be persevered in. If it has been accustomed to return at the last of the month, just as the flow has almost entirely ceased, you may expect it again at the same season. If your patient menstru- ates once in three weeks it will not fail ; if every six weeks she will not escape it. Nor does it matter if she has had an incidental attack during the inter-menstrual period. It will be all the same, whether sooner or later, whenever ovulation takes place. Preg- nancy, lactation, amenorrhoea, the climacteric, or whatever inter- rupts the menstrual function, will arrest it. When this function is restored, it will come again. The degree of suffering in the head is not always in ratio with the quantity of blood that is lost in menstruation, neither with the intra-pelvic pain and dis- tress that are experienced in getting rid of it. The quasi-hysteri- cal symptoms which sometimes attend upon attacks of this head- ache, are incidental merely, and not at all characteristic. In the majority of cases a close and careful examination reveals either sub-acute or chronic inflammation, irritation, or neuralgia of one or both of the ovaries. The prognosis will vary with the age, temperament, and sur- roundings of the patient, the nature and duration of the sexual disorder, the possibility of controlling and direct- ing her emotional states and the condition of her general health. Chronic cases are not so readily cured as those which are more recent, and therefore less complicated. The nearer the approach to the climacteric, the less promising the case. When the menses cease, however, the headache will prob- ably stop of its own accord. Frequent child-bearing, but more especially frequent abortions, render this disease more intractable than it is under opposite circumstances. Domestic infelicity is an almost insuperable obstacle to the cure of this form of headache. The periodical engorgement of the ovaries, which is contingent upon menstruation, lights up, renews, and perpetuates the lesion of those organs, whatever it may be. If we can prevent the 158 THE DISEASES OF WOMEN. monthly exacerbation of the sexual disorder, and can so regulate this function that it shall become physiological and healthy, the cure is practically accomplished. Otherwise, the disease may continue and increase until the general health gives way and fatal results follow. In those who have what has been styled the "insane neurosis," or predisposition, it may finally develop into some form of insanity. Treatment. — The first indication is to correct and control all those circumstances and habits which cause an undue afflux of blood to the internal generative organs. The Hygienic treatment. . eating 01 improper or too highly seasoned tood, the drinking of wines and liquors, too much or too little of society, all those mental and moral influences that stimulate the sexual appetite, tight lacing, running the sewing machine, and constipation, are among the avoidable causes of this disease. Horseback riding has induced it, and might therefore be preju- dicial. Exceptional cases are greatly benefited by the prohibition of sexual congress for the space of a week- before the commence- ment, and a week after the cessation of the monthly flow. One of my patients insists that she is almost certain to suffer a severe attack of headache, if the act is performed in the early part of the night, when she is weary, instead of in the early morning when she has been refreshed by sleep. If there is a deviation of the uterus from its normal position, it should be replaced. If there is any obstacle to the free exit of the menses, whether in the form of atresia, or flexion, or of strict- ure of the uterine cervix, it should be removed. The general system should be fortified against all debilitating influences what- ever. In the intra-menstrual period she should be well nourished and sent to walk or drive in the fresh air and sunshine every day. Rest at the month is an important element of cure in menstrual headache. Neither the body nor the mind should be overtaxed at this period. You should be particular in this regard, else the patient may unwittingly upset all that you have done and can do for her relief. If she is occupied as a seamstress or school-teacher, nurse, clerk, housekeeper, or what not, she should, as far as pos- sible, avoid all excess of care, confinement and toll for a few days before, during, and immediately after the catamenia. If she belongs to the higher class, she should be advised to shun all MENSTRUAL HEADACHE. 159 excitement, to forego her fashionable appointments in society, parties, balls, the church, the theatre, and the opera, whenever the crisis comes, and to take the best possible care of herself until it has passed. The extremities should be kept warm, the head cool, the skin soft and flexible, the urine free, the bowels regular, the circula- tion equable and uniform, more especially for some days before the flow is due. Such patients should be protected from exposure to stormy and cold weather. One of the worst possible things for them is to get the feet wet and chilled with snow-water. When this disease is engrafted upon a neuralgic diathesis, elec- tricity properly applied is sometimes very beneficial. In some cases relief may be obtained by having the spine m ^ C e*fem. yand and extremities thoroughly rubbed at stated intervals by one who is strong and healthy. I have known a few cases to be cured by an itinerant "magne- tizer." The remedies most serviceable in this disease are those which, oecause of their relation to the reproductive function, are most frequently indicated in menstrual derangements. Indeed, the symptoms that pertain to the lesion upon which this headache depends are often, although not always, a better guide to the choice of the remedy than the peculiar character of the headache itself. Pulsatilla, sepia, nux vomica, belladonna, ignatia, calcara carb., platina, baryta carb., lachesis, chamomilla, and apis mellifica are the chief representatives of this class of remedies. If you will compare this woman's symptoms with those proper to sepia you will recognize their marked similarity, and agree with me that she should take this in preference to any other medicine. In another week she will be " unwell," and during that short interval she had better take a dose of sepia every evening. Let her report at the end of a fortnight. One of our cleverest graduates, Dr. R. B. McCieary, has re- cently sent me the notes of a remarkable cure of this form of headache by the use of gelsemium. I will read them to you. Case. — Miss McD., aged twenty-six years, with dark hair and eyes, of a medium height, and dark complexion, has been troubled 160 THE DISEASES OF WOMEN. with headache all over the head for about six years. Occasionally she has very severe attacks, which last for several days with great prostration. She has taken various old-school remedies, but without benefit. I was called during- one of her severe at- tacks, and found her almost frantic with the pain, very nervous, and complaining of being sore all over, as if she had been pounded or bruised. She also complained of a "peculiar sensation, as if the head were full of worms crawling through the brain." I gave her gelsemium 200, a dose every three hours, which cured her as if by magic, and there has been no return of the disease since, now about " six months." MENSTRUAL RETENTION A CAUSE OF UTERUNE DISPLACEMENTS. Dr. Rigby to the contrary notwithstanding, it is undoubtedly true that many examples of uterine displacement are referable to other causes than external violence, morbid growths, and the parturient act. Among these causes there is one which has been almost entirely overlooked. I allude to an habitual delay or retention of the menses. A patient has dysmenorrhea. As a condition of functional activity, the uterine tissues are surcharged with blood, which moves sluggishly through them. The uterine th^weightofThJwomb 356 mucous membrane has shed or secreted the menstrual product into its cavity ; but this product cannot pass through the internal os uteri and the canal of the cervix. In order to empty the womb of what should escape without suffering or delay, the reflex phenomena of labor are requisite. The increase in the blood-supply, the torpidity of its circulation, and the retention of the menses within the womb, add to its volume and weight so as to drag down and displace it. Whether the dysmenorrhcea be congestive, obstructive, ovarian, spasmodic, or membranous, the consequence is a stasis of blood, and incidental suffering and disease. The proper balance between supply and waste, whether as respects structural repair or secre- tory demand, is lost. Textural changes in the inferior segment of the womb and in the cervix are almost certain to follow. The infiltration of the tissue may result in induration, hypertrophy, neoplastic growths, or unnatural adhesions. In such a case the displacement is, perhaps, active and tempor- ary. It may alternate with almost perfect health, and return with MENSTRUAL RETENTION, ETC. 161 each menstrual cycle, to be relieved by the flow. It is not unusuaL for patients to complain of symptoms mSdi placements at the tnat are ^ ue especially to prolapsus or ante ver- sion, whenever they menstruate. Many women learn from experience that much of the suffering incident to dys- menorrhcea may be relieved by raising the hips and lowering the head. One of my patients told me that for years she had derived more comfort at such times from placing her feet upon the high foot-board of her bed, and dropping the head very low, than from anything she had ever taken internally or used locally as a palliative. More frequently, however, and for reasons already specified, the luxation becomes chronic. The monthly period recurs so soon that the patient has not recovered from and^vhy^ 001116 chronic, one attack before another is precipitated upon her. It is like attempting to cure an acute gastritis while the patient continues to eat regularly and heartily of indigestible food. Nor is the mere increase of weight in the womb the sole cause of the uterine deviations which are incident to dysmenorrhcea. The more decided and powerful the expulsive utfrus Ulsive effort ° f the P ams (which are designed to force the flow), the greater the liability to displacement ; just as in labor at term the uterus descends in ratio with the strength and persistence of its contractile effort, and may even escape the vulva without first being delivered of its contents. And this is a veritable labor. There are the same contingents of structural change in the uterus, and of relative displacement of the organ, that attend upon abortion and full term delivery. The difference is one of degree, and not of kind. Amenorrhcea (suppressio mensium) sometimes results in uterine displacement. This is especially true of those cases in which certain kinds of exposure or exercise have Uterine displacements in • irom temporary suppres- arrested the now at the moment it was due. sion. If a woman sets out for a sea voyage, or a voyage by rail, the day before her menses should appear, she will be very apt to skip one period, and perhaps more. Or, if the flow comes, she may experience greater suffering than usual. If it be too scanty, or too profuse, she may be very ill. As an indi- 11 162 THE DISEASES OF WOMEN. rect consequence, she will be likely to suffer from some form of uterine flexion or dislocation. There is no question but that many cases of this kind are due to such slight and apparently trivial causes. It may be as harm- ful and injudicious for some women to leave Carelessness at the month. 1 . . home on the eve 01 menstruation as it would be for others to go to church or to a concert when in momentary expectation of childbirth. I have known a rough ride in the carriage or upon horseback, taken at this particular period, to cause a decided prolapse of the womb. And in the nature of things, there is no reason why it might not frequently happen. According to Wright, "a displacement of the uterus is just as much an absolute fact as the occurrence of a hernial protrusion," and hernia has certainly resulted from a similar cause. I do not wish to be understood as teaching that all, or even a majority of cases of uterine displacement are chargeable to men- strual obstruction or derangement. I only insist that this class of causes and their manifest consequences shall not be overlooked. The truth is that our writers and practitioners are accustomed to magnify the importance of hygiene as applied to gestation, while they make but little account of that proper to menstruation. In so far as uterine deviations are concerned, we are prone to discriminate loosely in favor of those sequelae which may follow the parturition of the embryo and foetus, and to discard all such as are consequent upon that of the menstrual product. Treatment. — If this view is correct, the inference is obvious. The cure of this kind of displacement must hinge upon the relief afforded to, and the regularity of, the men- The indication is to cure s trual process. If the dislocation, of whatever the menstrual disorder. J- variety, depends either upon dysmenorrhea, or simple retention of the menses, the first thing to be done is to remedy the catamenial disorder. To treat the case simply as a displacement, and to expect to cure it by any universal expedient whatever, whether local or internal, will be unsatisfactory and unsuccessful. Emmenagogues would only increase the difficulty.. And so also would astringents. The pessary would be of no more service in such a case than a hernial truss. Indeed, it might prove as harmful in a displacement arising from this cause as it has been beneficial in others. MENSTRUAL RETENTION, ETC. 163 This theory explains the wonderful efficacy of some of our remedies, when prescribed for the relief of uterine luxations. Through their manifest and well known rela- Modusoperandi of some ^ on j- Q ^ menstrual function, we have learned remedies tor prolapsus, etc, ' to rely upon them for the cure of those dis- placements of the womb that are consequent upon certain derangements of that function. In other words the key to their curative range and adaptability is found in their power to remove the condition upon which the disorder of place depends. From the provings alone we might never have learned what we already know empirically, logically and physiologically, of the power of certain remedies indirectly to influence the position and rela- tions of this very important organ. There is an excellent and harmless auxiliary which can be used in some of these cases to great advantage. I allude to the sponge tent, which by removing the mechanical cause of fui T a h uxma ry Se tent a " se " tne retention, may relieve the difficulty and help to cure the displacement. I am not aware that others have recommended this instrument in any form of uterine luxation. But it is a temporary, non-medicinal, unobjectionable expedient, which can be employed without risk, and in such a manner as to secure the free exit of the menstrual fluid as soon as it is poured into the uterine cavity. It certainly does not inter- fere with the action of internal remedies, nor will it, if properly applied, give rise to anj T lesion of the cervix. It promotes the painless and gradual dilatation of the internal os, obviates suffer- ing, and averts the reflex symptoms of which the patient is so apt to complain. It does not lift the womb directly, but ministers to its reposition by unloading its vessels, so that it can retract. It should be introduced from twelve to twenty-four hours in advance of the menstrual period. At this time the internal os is " off- guard," and the operation is less painful and more successful. It should be allowed to remain in for from four to eight or ten hours according to circumstances. When it is removed, the patient should keep to the bed or sofa, and not be allowed to stand upon her feet for some hours, or even, perhaps, for days. It is a singular and significant fact that cases of dysmenorrhea which merge into menorrhagia are rarely followed by uterine devi- ations of any kind. It is only when the absolute loss of blood 164 THE DISEASES OF WOMEN. causes extreme atony of all the utero-vaginal tissues that such a result is witnessed. UTERINE COLIC. Case. — Mrs. sent for me in haste, on account of her sud- den illness. She had reached home from a long journey, and in perfect health, only an hour before. After a general bath, she took a vaginal injection of cool water, and, almost immediately, felt a sharp, spasmodic pain in the region of the womb. This pain increased in severity, and, before my arrival, became almost insup- portable. It would remit, and then return with redoubled vio- lence. I found her pale, with a cool surface, an anxious, implor- ing expression of countenance, and a slight nausea. She was midway in the inter-menstrual period, and had not eaten anything unusual, or, indeed, anything whatever, for some hours. A clinical lecture without a practical lesson would resemble a sermon without a moral one. There is a point in this case which you should carry home with you. It is this, timeTinfurious . 110115 some " tnat tnere are certain conditions of the womb and other pelvic viscera in which the shock of an otherwise harmless injection thrown into the vagina may work mischief. Whatever determines the blood to these organs increases the risk of using such an expedient suddenly, and, as it were, without proper warning and delay. A woman has been at work with a sewing machine for some hours consecutively. Having finished her task, she takes a bath, and directly afterwards a vag- inal enema. Almost immediately she is seized with symptoms resembling those from which my patient suffered. Or a similar result may follow a ride on horseback, or in the carriage, a game of croquet, standing for an hour or two at an evening party, toe- long a walk, a protracted lesson at the piano, or, as in this case, a fatiguing journey, all of which acts predispose to irritable condi- tions of the uterus. Under these circumstances there is an exalted sensibility of the organ, and it may happen that a single injection of cool water brought into contact with it suddenly will act as an exciting cause of pain and disease. The same is true of cool or cold injections per vaginam before the menstrual flow has entirely ceased. And likewise also of sim- ilar injections taken immediately after coitus, with a view to pre- vent impregnation. At such periods the capillary system of the UTERINE COX.IC. 165 whole generative intestine is surcharged with blood. If we wait a little, this physiological afflux is removed, the erection of the organs subsides, and the proper vascularity is restored. But if we shock the delicate structures in the manner of which I have spoken, we must expect that, sooner or later, they will become diseased in consequence. In uterine colic the pain usually intermits. Sometimes the par- oxysm returns with almost as much regularity as the after-pains which torment multiparas, and which it is said to resemble. Or it may remit and not leave en- tirely between the more aggravated periods. The suffering is referred directly to the uterine region, although it sometimes radi- ates into the sacrum, and again into one or both groins. It is characteristic of this pain that it may be in a measure and some- times entirely relieved by pressure. The attack commences and terminates abruptly, and is not preceded or accompanied by any particular constitutional symptoms, as chill or fever. There is more or less of tympanites, which develops very rapidly and dis- appears as suddenly. There is usually considerable intestinal flat- ulence, distension and pressure. This bloating of the abdomen has all the characteristics of hysterical tympanites. Nausea is a frequent symptom in severe cases. The attack may continue for a few minutes only, or may extend through some hours, or even days. If it depends, as it sometimes does, upon uterine displacement, it may not Duration of the attack. . i t/» • ' • i subside until the organ is restored, it it is due to the presence of coagula, or other foreign bo lies in utero, it will only cease with their expulsion. In this case the pains resemble cramps, are expulsive, and labor-like. Women who are subject to dysmenorrhea are likely to have a mild form of uterine colic upon slight provocation. Such persons may be seized with it while walking in the rh^a ident t0 dysmenor " street, and be obliged to sit clown or bend them- selves almost double for a few moments, until the paroxysm passes off. Or the pain may be so severe as to cause fainting and great alarm. Emotional causes often give rise to it in hysterical persons. With this class of patients a fit of ano'er or jealousy Incident to hysteria. - . may bring on the attack at almost any time. Or it may precede menstruation and worry the patient for some 166 THE DISEASES OF WOMEN. hours or days in advance of the flow. Although usually amiable, she will become petulant, is disgusted with and distrustful of humanity in general, and of the male sex in uot Y precede menstrua - particular. Sometimes she is in a mellow or pathetic mood, or she has a fitful religious mel- ancholy, or, what is still worse, is possessed with the insane idea to work, to set her room to rights, and the plants, the birds, the books, the pictures, stoves, chairs and furniture must be squared up and cleaned up instanter. She must do an immense amount of work in a short time, and only in so doing can avoid this tor- menting species of colic and ill feeling in the uterine region. After which, when the flow sets in, she is exhausted, fitful, capri- cious, cross, tempestuous, drums on the piano by the hour, or writes explosive letters to her husband, or friends, and regulates everything with the utmost irregularity. Extraordinary fatigue of body or mind may induce it. Intel- lectual, cultivated women, are more prone to it than others. Seamstresses, young ladies in boarding-schools, Most frequent among in- actresses, and those whose minds are harassed tellectual women 7 with family cares, or who are ^victims of the social fret and friction which wear out so many valuable lives* suffer much from this painful disorder. Not unfrequently it arises from incompatibility in the marriage relation. Circumstances which develop a loathing of the sexual act, are very apt to produce it. It may originate either from im- moderate indulgence, or from being deprived of accustomed inter- course. I have known it to be caused by drinking ice-water while menstruating. Uterine colic is also incident to the neuralgic diathesis. It may alternate, or be complicated with ovarian neuralgia, hysteralgia, and even with rheumatism of the womb. In In neuralgic subjects. n women who are thus predisposed, whatever causes an irritable state of the uterus may bring on an attack of the colic. This form of the disease is very apt to seize upon nerv- ous and delicate patients during the period of pregnancy. Treatment. — Proper hygienic precautions will doubtless sug- gest themselves to your minds. You should ^Hygienic and prophyiac- warn the patient of the possible consequences of vaginal injections at improper times. And also of the ill effects of rude and violent exercise, whether of body UTERINE COLIC. 167 or mind. If she is intelligent — and your merits will commend you to this class of patients especially — explain the modus oper- andi of those very common causes of disease and suffering among women. One good, logical reason will have better and more last- ing effect upon her than any amount of scolding and fault-finding. A good prophylactic is to have the patient wear an extra layer of flannel, silk, or cotton batting over the abdomen habitually. Various palliatives have been recommended to put an end to the paroxysm. Among the more ordinary and available of these is the application of towels or flannels that have been dipped in hot water, mustard water, hot brandy and water, and the like. In some cases, a sinapism will cause the pain to vanish in a very few minutes. Bags of hot salt, or of dry bran heated thoroughly, are especially useful in case of menstrual colic, and of uterine colic following abortion. In hys- terical subjects, the ether spray may be thrown upon the hypo- gastrium. In inveterate cases, the vapor of chloroform has been injected into the vagina. Dr. Simpson advised a similar applica- tion of carbonic acid gas. When complicated, as it sometimes is, with vaginismus, I am in the habit of prescribing a vaginal injec- tion consisting of chloroform one drachm, olive oil and glycerine each two ounces. Or the same may be applied by means of a cot- ton tampon. If the attack is incident to delayed menstruation, the warm sitz-bath may afford the desired relief. In the majority of cases, belladonna or atropine answers every purpose. This is especially true if the attack has been caused by the shock from vaginal injections taken at im- Internal remedies. . proper times. Ii the case is manifestly neu- ralgic, and more particularly if it is complicated with ovarialgia, the valerianate of zinc may be indicated. Other remedies are colocynth, ignatia, caulophyllin, cocculus, chamomilla, nux vomica, pulsatilla, sabina, and secale cornutum. LECTUEE X. MENSTRUAL EPILEPSY. Menstrual epilepsy.— Case— uterine and ovarian epilepsy—from amenorrhoea. Case— intra- menstrual epilepsy, do. after dysmenorrhcea, sequelas and non-sexual causes of, prog- nosis, treatment, -Irregular Menstruation with Epileptiform Hysteria. Case.— a com- pound affection. Case.— the two distinct and distinctive stages of the fit. Case,— diagnosis, prognosis, and treatment.— Too frequent Menstruation in Incipient Phthisis. Case.— menstruation and tuberculosis, monorrhagia and do., significance of the aphonia, treatment, remedies, season and climate, mental worry. This woman is an out-patient who has been prescribed for sev- eral times already, and whose case possesses some items of clinical interest. Case. — Mrs. W., aged forty, had, seven years ago, what seemed to be an attack of sunstroke, and soon after, a fall down stairs, since which time she has had much pressure in the back part of the head and down the neck. Her headache is accompanied with a flushed face and vomiting. She sometimes becomes blind, espe- cially in the left eye, and, when the pain is very severe, there is a spasmodic jerking of the eyelids. At other times she has shoot- ing pains in the eye-balls, running from before backwards. About once in three weeks, after suffering extremely with these headaches she falls into a fit, and becomes quite unconscious for a time, frothing* at the mouth and biting- her tongue. On coining out of the paroxysm she is wild, pulls her hair, and recovers very much exhausted. Then the menses appear, but the flow is scanty and intermittent. The abdomen becomes bloated, and she has a great deal of pain in the left ovarian region. She also has occa- sional colicky pains in the bowels, and a drawing pain in the left knee. Before the fits began she was regularly " unwell " every four weeks. Belladonna 3, to be repeated every three hours. One week later, she is doing well; continue the same medicine. She is quite certain that no one in her family ever had epilepsy. Third week. The menses have appeared, but she has had only one fit, and that less severe than usual, the flow being more free. She wakens at two o'clock every morning and cannot sleep any more. Nux vom. and bell., each one dose daily. Sixth week. She has had no more fits: the courses came on slightly for one day and then stopped, but returned the third day. Belladonna and hyoscyamus alternately. 168 MENSTRUAL EPILEPSY. 1(J9 Eighth week. She is not so well, has had three fits, and was much prostrated by them. Examination with the speculum shows a large raspberry ulcer on the cervix uteri. Ehus tox. 3, every three hours, and glycerine and Hydrastis locally. Ninth week. She has been quite well until yesterday, when she had headache. Bell, morning and noon, and sulph. at night. Very few authors, and perhaps none which are accessible to you, have anything to say of Menstrual Epilepsy. Indeed, it is comparatively a rare affection, and years may elapse before you will see another marked case of this kind. The Uterine and ovarian . 7 . . . -, 7 , .-, epilepsy. epilepsia uterma and I epilepste ovarique are essen- tially the same, the disease being characterized by a return of the fit with the coming on of the menstrual period. The paroxysm is not at first purely epileptic, but epileptoid or epileptiform. It may finally develop into genuine epilepsy. There can be no question that certain diseases of the generative organs predispose to epilepsy. This is true of men and women alike. But the greater relative frequency of this disease among women is probably due to their peculiar nervous and sexual organ- ization. In them the slightest degree of irritation may be suffi- cient to cause this dreadful disease in one or another of its forms. With the return of the menstrual cycle it is not Pseudo- epilepsy. . . . -. e -. unusual lor women to experience a kind ol pseudo- epileptic seizure, which is self-limited, and passes off with the free establishment of the flow, or with its cessation. Some of these paroxysms are halt hysterical, and subside with explosive outbursts of crying, laughing or of copious diuresis. Or they may merge into a pseudo-narcotism which lasts for hours, or even for days. In other cases the convulsive attacks recur at the month with tolerable regularity, although the patient fails altogether to menstruate. This form of menstrual epilepsy, With amenorrhoea. . . , . . J , . . , , 1 . which is complicated with amenorrncea, is the most serious and difficult of cure. In fleshy women who are more than thirty or thirty-five years of age, epileptiform convulsions may co-existc with scanty menstruation, and increase in severity each month in proportion as the flow diminishes. Young women are also liable to this form of eclampsia as a contingent of too scanty menstruation. Maisonneuve records the following rare case of this kind:* * Recherches et observations sur l'epilepsie, Paris, 1863, 170 THE DISEASES OF WOMEN. Case. — Rosalie M., aged 23, of a sanguineo- bilious temperament, a strong constitution, born in Paris, of healthy parents, was quite well until her eleventh year, when the premonitory symptoms of menstruation having appeared, she was seized with epileptic fits which could not be attributed to any other cause than the diffi- culty of establishing the flow. The discharge was irregular and deficient in quantity, and each return thereof was invariably pre- ceded or followed by the epileptic seizure, which returned only at this period, sometimes before, sometimes after it, whether in the day or at night, and never tailing excepting when the courses were very free. This state of things continued despite repeated bleeding, leeching, blistering, and the taking of anti-spasm odics. The paroxysms were preceded for some days by colic in the lower abdomen and an extreme lassitude. At the moment of the inva- sion the patient experiences a feeling of suffocation, then, two or three minutes later, falls, loses her consciousness, has severe con- vulsions of the trunk and extremities, and a red face, but no frothing at the mouth. It may happen, also, that epilepsy shall depend upon uterine or ovarian irritation, or upon both these causes mtra-meustruaiepi- combinecl and yet the attacks shall return lepsy. J only in the intra-menstrual period. Here the same rule holds as in those exceptional cases of dysmenorrhcea which are characterized by uterine spasms and suffering during the interval, and when the flow is not on. All causes, therefore, which are sufficient to derange the menstrual function may predispose to these epileptiform attacks. Of 109 epi- leptics, Beau found that in 43 cases the disease had commenced between the sixth and the twelfth year, 49 from the twelfth to the sixteenth year, and only 17 be- tween the sixteenth and twentieth year. In a special monograph on the subject, M. Marrotte concludes:* (1) That epilepsy is not nnfrequently caused by derangement of menstruation ; (2) that when it does not originate from these disorders, it may be aggravated by them; and (3) That epilepsy may sometimes be developed when the menstrual function is quite normal. Spasmodic and obstructive dysme nor rhoea are not unfrequently accompanied by convulsive symptoms, that finally take on the epi- leptiform character. The sudden arrest of the After dysmenorrhcea. n , „ . , . , , , , flow, as from fright, has been known to cause this form of epilepsy. It may also occur in consequence of uterine * Revue Medico-Chirugicale, Paris, 1851. MENSTRUAL EPILEPbY. 17.1 deviations, more especially, it is said, in case of ante-flexion of the womb. The same is true of strictures of the cervical canal, whether from atresia thereof, or from its imperfect development, as in the " infantile" cervix. Other causes are emotional wear and worry, shock and alarm, hysteria, the indulgence of the de- pressing passions, masturbation, intemperance in eating and drink- ing, excess of mental labor and study, the climacteric contingen- cies, anaemia, chlorosis, rheumatic and neuralgic ovaritis, nympho- mania, the first or a forcible coitus, the repercussion of eruptions (especially about the head and neck), too prolonged lactation, and amenorrhcea. It may also arise from an insufficient development of the uterus, as in the case reported from Noeggerath's clinic* Case. — Margaret C, aged twenty-one years, native of Scotland, unmarried. Menstruation commenced at 15, and occurred three times at regular intervals of a month, then entirely disappeared, and remained absent nearly three years. Recommenced at 18, and continued a year with no nervous disturbance. Epileptic attacks then made their appearance at irregular intervals, com- mencing with muscular spasms in the right hand, the aura passing thence to the head. Nausea and intense cephalalgia continued more than an hour after the momentary attack. From the first the menses were exceedingly scanty, being a mere " show," with a great deal of dysmenorrhcea, continuing tut three days at the most. A moderately firm hymen closed the posterior two-thirds of the ostium vaginae. The uterus was a little more than the pre-puberal size, very movable, the cervix projecting into the vagina, and presenting the characteristic nipple shape. The sound entered the narrowed canal of the cervix with difficult}-, and showed the dimensions of the uterine cavity contracted in all its diame- ters. The most constant symptoms were cephalalgia of the right side, and shifting pains in the lumbar and right iliac region. To this list of causes must be added those which are common to the sexes, for women may also have epilepsy Non-sexual causes. . trom causes which are non-sexual in their char- acter. In the case before us the chain of morbid action seems to have been set in motion bv the sunstroke and the fall. Then came the headache, with pressure in the vertex and along the nape of the neck, the flushed face and the vomiting, and finally the falling fit, with unconsciousness and foaming at the mouth. And when one paroxysm had occurred there was the same tendency to a * The American Medical Times, June 4, 1864, papre 286. 172 THE DISEASES OF WOMEN. repetition of it, as in case of any other periodical affection which involves the cerebro-spinal centres. This woman's epilepsy is evidently clue to the conjoined effect of the fall and the coup-cle-soleil, either of which causes might induce it in man or woman. But the peculiarity in her case is that for some reason the type of the disease is pronounced and unvarying. The fits return at the month and at no other time, a fact which makes them contingent upon menstruation. We are perhaps safe in saying that no woman ever had a serious disorder of the menstrual function without more or less derange- ment of the nervous system. In their clinical history, ovulation and hysteria are inseparable. The nervous erethism which is incident to the menstrual crisis is almost as cer- Epileptiform hysteria. . . . „ . n ... ., ,. tain, if not as necessary a condition thereof, as is the local determination of blood to the generative intestine. The frequent recurrence of this strain upon the nervous system predisposes this class of patients to all kinds of nervous diseases. And not only do slighter causes induce more serious consequences among them than with men, but the diseases which result from these common causes are in their case peculiar and often intract- able. They take their type from this periodical function, and, whatever their real cause or character, become confounded and complicated with its disorders. In such cases epilepsy and hysteria may co-exist and defy all differentiation. The menstrual derange- ment underlies the whole difficulty, but whether it stands in the relation of cause, effect, or coincidence, it may be impossible to determine. The fact that this patient did not inherit epilepsy, and also that the menstrual difficulty did not precede the coming on of these fits is very important. An analysis of the case which failed to take these items into account would be very unsatisfactory; and a plan of treatment which re- jected them and denied their significance would almost certainly fail. If epilepsy was hereditary the prognosis would hinge upon the curability of that disorder. If these epileptiform attacks were secondary upon dysmenorrhea, or other uterine lesions, whether original or acquired, the case would be very different. Traumatic injuries of the cerebro-spinal axis are comparatively more frequent and serious in women than in men. With them MENSTRUAL EPILEPSY. 173 the slightest shock may upset and depolarize the nervous relations. The hysteroidal tendency not only increases the injurious effect of falls and blows upon the back and the head, but also complicates and perpetuates the difficulty. Hystero-epilepsy, hysterical paral- ysis and choreomania sometimes result from such accidents. The jar consequent on a fall upon either extremity of the spine may lay the foundation for protracted ill-health and complete physical disability. The sexual impressibility and excitability of which I have spoken are likely also to aggravate the effects of a severe conges- tion of the brain, as from sunstroke or any other cause. The remote consequences may be equally chronic and complicated. Indeed, in obscure cases of nervous disease among women, it is a good rule to inquire Avhether they have ever suffered from cerebral hyperemia, or from inflammation arising from this or from a similar cause. In my experience some of the most intractable cases date from an attack of cerebro-spinal meningitis, the chief remedy for. which is macrotin. Treatment. — This is one of those cases which the itinerant quack — and local ones, too, for that matter — -would promise to cure with a single prescription, and possibly with a single dose of medicine ! If I had brought this patient before you directly after the first recurrence of her period, and reported her as cured, simply because she felt a great deal better, and for once only had escaped the fits while the flow was on, I would have been guilty of a fraud upon each member of the class. If you had recorded this case in your note-books as cured, you would have written an untruth. And if it had been reported at that time in either of our medical societies or journals as a successful case, the profession would have been misled, and great mischief would have been wrought. Let me say, therefore, that no case of disease occurring in a woman, and implicating the menstrual function, either directly or indirectly, should be consid- ered as cured until at least three healthy "periods" have elapsed. And since this rule applies to a large proportion of the diseases which are peculiar to women, you should not only be chary of promising to cure them speedily, but likewise careful in claiming to have cured them at all. For in no other department of medi- cine are relapses so frequent and our therapeutic deductions so fallacious. 174 1HE DISEASES OF WOMEN. In a case of this kind the first question to decide is, which of these several factors is most significant? Is it Query. the cerebral lesion, caused by the sunstroke; the fall and the concussion which she experienced; the scanty, inter- mittent, and more or less painful menstruation, or the " rasp- berry" ulceration, the effects of which require treatment? Or, can we relieve them all by the same means and simultaneously? This poor woman's health was so good before the accident, and even now is so slightly impaired during the inter-menstrual period, as to leave but little doubt that if she had escaped the fall and the effects of extreme solar heat, she would not have had this form of epilepsy. Therefore it seems most reasonable that we should treat her with reference to this fact. Moreover, if the lesion was caused in this way, its cardinal and essential symptoms must indicate the remedy or remedies. Belladonna seemed to take hold promptly, so that the patient and her friends, as well as our clinical assist- ants, thought she would get well very soon. It covered most of the symptoms, and was also indicated as an anti- dote to the special causes of which I have spoken. But its opera- tion in such a case can not be immediate, nor its effects thorough and permanent. We may need to give it again and again, and perhaps also to change the potency from the third to a higher one. The nux vomica was given for the relief of what has been im- properly styled "a characteristic" symptom — Nux vomica. x , , 1 . 1 r i I mean the early morning wakefulness. At the third prescription she took hyoscyamus, as a remedy for the intermittent menstruation. In cases in which the flow is scanty, fitful, spasmodic, and inter- mittent, you will often find that a few doses of hyoscyamus will relieve the difficulty. But if the cause of the trouble is mechan- ical, as from uterine deviations, or from cervical obstruction caused by polypi, fibroids and the like, it will fail, as all internal medica- tion must necessarily do. I ordered the rhus tox. chiefly because of the disclosure made by the uterine speculum. You can hardly go wrong in prescribing the internal employment of rhus toxicodendron in a case of genuine raspberry ulceration of the os-uteri. But you must be certain that your differential MENSTRUAL EPILEPSY. 175 diagnosis of the ulcer is correct, or you may be disappointed with the result. I was once desired by a physician of my acquaintance to see a ' ; splendid case of raspberry ulcer of the cervix." A bi- valve speculum was introduced, the lips of the cervix uteri were separated, and what had been taken for a remarkable specimen of this particular form of ulceration, because of its color, I sup- pose, was the healthy, florid, intra-eervical mucous membrane. In this variety of ulcer the only topical application necessary may be composed of the rhus tox. or hydrastis tincture and gly- cerine. Mrs. is now taking belladonna 3, morning and noon, and one close of sulphur 6, every evening. She will continue this treat- ment until we hear from her again. {Exit the patient.) Some cases of menstrual epilepsy depend upon ovarian irrita- tion and inflammation. When this occurs in married women especially, the same remedies may be required as in a case of idio- pathic ovaritis, ovarian irritation, or neuralgia. Under these circumstances belladonna, colocynth, platina, lilium tig., alumina, calcarea carb., lachesis, mercurius sol., phosphorus, the valerinate of zinc, or some kindred remedy may be called for. In young girls and widows, marriage is exceptionally curative. Tissot cites a remarkable case of this kind : " I was consulted, three years ago, by a young man concerning the condition of his betrothed, who being otherwise in good health, was subject at the menstrual return, the flow being scant}', to vio- lent colic, which almost always threw her into convulsions. For three several times these fits had been epileptic. I ventured to promise him that, so far from aggravating her disease, marriage would probably benefit it, and the result justified my opinion. Her first confinement caused the menstrual colic to disappear, and consequently the epilepsy also. IRREGULAR MENSTRUATION WITH EPILEPTIFORM HYSTERIA. Case. — Mrs. , ag-ed forty-nine years, has been ill for more than thirty years. She was married when she was eighteen years old, and declares that she has not been well since that time. She says that her husband treated her very roughly from the first, and that in consequence the menstrual function became very painful and irregular. Within a fortnight she began to have a kind ol nervous fits or convulsions, to which she has ever since been sub- ject. These paroxysms have shown a marked tendency to recur 176 THE DISEASES OF WOMEN. at the period, but occasionally, more especially when the menstrual interval has been prolonged, they have been more frequent. Asa rule, they anticipate the flow by one or two days; sometimes they come on after it has begun, and again they follow it. She insists that for thirty years she has never passed through a period without one or more of them. There is no perceptible aura in advance of the lit, but she has a decided disposition to sleep, and often passes into the paroxysm while sleeping, whether it be during the day or the night. She becomes totally unconscious, and is oblivious to all that has passed during the lit. The only way by which she knows that she has had one is by finding that she has bitten her tongue or lips, or being told of it by those around her. She froths at the mouth, and, it she happens to be standing, falls to the floor in an insensible state. The harder the paroxysm, the more decided the discolora- tion of the face, the stertor, and the disposition to sleep after- wards. The lighter the fit the more restless and nervous she is, with jerkings and twitchings, and spasms of the voluntary muscles, and a copious flow of urine at the close of the paroxysm. She has never had any children, nor has she ever conceived. For a year past the " change of life " has caused the menses to be even more irregular than heretofore. At one time she passed three months without any flow, during which interval she was exempt from the fits. But, when the catamenia returned, although they were not more profuse or painful than usual, she had three of these paroxysms in rapid succession. She is not very much more nervous than most women of her age, and although her memory is somewhat impaired, her faculties are not badly shattered. She is very religious, and has always attended church very regularly, and yet, during all this time, she has never had but one paroxysm during the service. At intervals for more than three years, this poor woman has been coming to our clinic and some of you have seen her before. She is a martyr to the kind of abuse of which there are many vari- eties, and to which there are but too many victims. For, in all human probability, if she had been properly treated by her husband in her early married life, she would have escaped the frightful dis- ease from which she has suffered for so many years, and from which she can only be relieved by the " change of life," or by the of rave. Epileptiform hysteria, or hystero-epilepsy, as it is sometimes called, is really a compound of hysteria and A compound affection. ., T . ' . ™ . , ., ■ epilepsy. It is a curious anection, and one that has recently attracted the special attention of neurologists. Au- MENSTRUAL EPILEPSY. 177 thorities are not agreed as to which of these two disorders lies at the foundation of the difficulty, Charcot holds that hysteria is the essential disease, and uses the word epileptiform as an adjec- tive to qualify one variety of it. It is certain that in this mixed disorder these two affections may run a separate course, may mero^e or may co-exist with varying- decrees of intensity. For, O ^ ^ CD CD 1/ in one case the epileptiform quality of the fit may predominate, while in another its hysterical character will be the most promi- nent. Landouzy reports the case of a young woman who, having had epilepsy from her infancy, concealed the fact and was married in her eighteenth year. When it became known that she was subject to this frightful disease, it caused a great deal of trouble in the family, and she became hys- terical also. The paroxysms of both diseases came together, but nevertheless were distinct from each other. Her pregnancy and the birth of her first child reconciled the husband and wife, after which the hysteria disappeared, but the epilepsy remained. In epileptiform hysteria the prodroma, when there are any, and the first stage of the paroxysm, will reveal First stage of the fit. ., • ... ft , l rp / its epileptiform character. I he symptoms ot epilepsy always open the scene, and those of hysteria always fol- low in the order of sequence. This patient becomes pale at first and falls if she happens to be standing, or goes into the fit while sleeping soundly, the face thus becomes distorted and congested and she froths at the mouth, bites her tongue, is utterly oblivious to what is passing around her, and the muscles of the extremities are in a state of tonic contraction. These are evident symptoms of the epileptic seizure, and in her case they always accompany the first stage of the paroxysm. If she had epilepsy in an uncomplicated form, the fit would end with these symptoms. But in epileptiform hys- Second stage of the fit. . ,v l v <, +1 > / i teria, as the song has it, " there s more to fol- low." Directly the tonic spasms have yielded, a series of clonic spasms and slight convulsions come on; and, in a little while, the emotional symptoms of hysteria disclose themselves. Instead of stupor and indifference there is excitement and uproar, and the double paroxysm ends like a fit of common hysteria. Without extending my remarks upon this subject, I ought to 178 THE DISEASES OF WOMEN. tell you that there are two or three methods of recognizing the severity of the epileptic complicatio.11, and the to 1 ^ r s edomiDating s y m P" consequent danger from this peculiar disease. In the first place the more pronounced the epi- leptiform quality of the affection, especially if the fits are fre- quent, the higher the range ot the patient's temperature; andjoer contra, the more decided the hysterical development, the slighter the variation of her temperature. In the second place, if the disease has continued for any considerable time, the mind will become dull and shattered in proportion with the predominance of the epileptic symptoms, and more acute and excitable if the disorder is chiefly hysterical. Thirdly, in the former condition the more frequent the paroxysm the greater the danger; in the latter, the patient may have a great many of them without increasing the risk. Charcot reports the case of a woman who had nearly two hundred of these fits in twelve hours without any serious consequences. Fourthly, if the hys- terical affection is most prominent the paroxysm may always be relieved by pressure upon the ovary, as directed for the simple hysterical fit. In the absence of an hereditary tendency to epilepsy, and in view of the fact that, in all these years the epi- leptiform quality of the attacks from which our patient has suffered has not broken down her nervous system, and ruined her mentally, we conclude that her disease has been chiefly of the hysterical order. The mode of its origin, and the men- strual complication also confirm this view of the case. These, indeed, were the considerations which led me to tell the class long ago that a favorable result might be looked for with the termination of her men- strual life. If the epilepsy had been more pronounced, I would not have promised such a result. You should not forget that complicated cases of this kind may expire by limitation at the climacteric. There is a mild grade of cases in which, under careful manage- ment, this affection may be more readily and promptly disposed of. But, in forming an opinion in a given case, due allowance must be made for the degree of the epileptiform complication, the possibility of its having been inherited, the curability of the TOO FREQUENT MENSTRUATION, ETC. 179 local or functional lesion upon which the whole difficulty has been engrafted, and the duration of the disease. The negative results of treatment in this case should not, therefore, discourage you, or lead you to decide that this is necessarily an incurable complaint. Lachesis, belladonna, hyoscyamus, gelsemium, and a few other remedies given under appropriate indications, have done this woman some temporary good ; but they have had no lasting or permanent effect. For the present I will dismiss the case with the remark that, since this curious affection is compounded of t Jns e for dinal indiCa " hysteria and epilepsy in varying proportions , and since these two nervous affections are always symptomatic of some uterine or ovarian disorder, a rational and successful treatment must be based on the indica- tions that are furnished by these three factors. TOO FREQUENT MENSTRUATION IN INCIPIENT PHTHISIS. Case. — Mrs. S., aged 32, residing in an adjacent state, gives the following history of her case. She has three children, the youngest of which is four years old. She nursed the latter for a period of twenty months, her menses appearing but twice mean- while. For two years past she has menstruated as often as once in three weeks, and sometimes every two weeks. Originally, menstruation was regular, and normal in all respects. With a single exception, which occurred about four months ago, the menses have not been very profuse. Eight months ago she lost her voice, and in all this interval has not been able to speak aloud. She has no habitual cough or sore throat, but is subject to occa- sional attacks of diarrhoea, which is very debilitating, and some- times quite intractable. Has never had the aphonia before, neither was she subject to the croup, or to any anginose affection during infancy and childhood; is losing flesh rapidly; appetite capricious; perspires freely whenever she sleeps; no thirst; pulse one hundred and ten. Tuberculosis is hereditary in the family. The relation of the menstrual function to the development of hereditary tuberculosis is more significant than you may have supposed. The interval between puberty and tubercSs i0nand the a £ e of thirt y° r thirty-five represents the period at which females are most liable to be seized with symptoms of that formidable disease. After this 180 THE DISEASES OF WOMEN. period if the menses are regular, they generally escape until the great climacteric is passed. The first ten years of menstrual life show the largest proportion of cases and the highest rate of mor- tality from phthisis pulmonalis. It is not uncommon for this disease to appear in young girls at the time the catamenial func- tion is established. Retention of the menses is very often a pre- monitory symptom. We shall, doubtless, have occasion to confirm its clinical import. But it sometimes happens, that too frequent menstruation may take the place of an arrest or tardy appearance of this flow, in incipient phthisis. The case before us is one of this kind. For fifteen years, or from the age of fifteen to thirty, this poor woman menstruated regularly. Lactation was prolonged to twenty months, the menses appearing only twice before her babe was weaned. For the four months following, everything was normal in this respect. The courses then became too frequent, and have so continued until the present time. Healthy menstruation depends upon ovulation — the ripening and discharge of the ovum, which takes place every lunar month. It is possible that the physiological condition tubeTc°uTo h sif iaaad of this P ec uliar flow may be supplied in excep- tional cases of too frequent menstruation. But in young subjects, especially, clinical experience leads us to refer this remittent type of menstruation, as it has been styled by Dr. Tilt, to some severe constitutional or local disease or dyscrasia. Sometimes it is caused by uterine ulceration, which may be either benign or malignant. More frequently it is not organic, but origi- nates in the depraved and debilitated conditions of the system that are incident to phthisis pulmonalis, and to chronic diseases of various kinds. When it occurs so frequently, it loses the character of the catamenia proper, and becomes a passive haemor- rage. Under these circumstances the condition of the blood is such that it very readily escapes from the uterine mucous mem- brane, which is more than ordinarily congested. Whatever im- pairs the quality of the blood, may thus directly give rise to a too copious, as well as too frequently recurring menstrual flow. Hence it is, that instead of amenorrhoea in the early stage of phthsis, Ave sometimes meet with cases of troublesome and even dangerous menorrhagia. Indeed my own experience leads me to TOO FREQUENT MENSTRUATION, ETC. 181 conclude that uterine haemorrhage, active or passive, is more fre- quent in women under thirty-live years of age, and who are pre- disposed to tuberculosis, than our authors and practitioners have generally imagined. As a rule, however, it is more liable to occur in advanced stages of the disease than in its incipiency, and in child-bearing- women than in those who are either unmarried or sterile. In either sex indiscriminately it is not unusual for phthisis to commence with laryngitis, and consequent aphonia. But the marked sympathy existing between the womb, aphSa. CanCe ° ftlie the ovaries, and the larynx, renders this com- plication more frequent among females than with males. The loss of voice in this case is significant and seri- ous. If it were hysterical, it would not have persisted so many months. In aphonia from spinal irritation, (unless it be trau- matic), the attack comes on abruptly, continues for a few days or a week at most, and is very apt to leave as it came. Emotional causes, menstrual or sexual excitement, or bodily fatigue, may induce either of these varieties of aphonia. The loss of voice that sometimes precedes an apoplectic fit depends upon congestion of the medulla oblongata about the ganglion of the pneumogastric nerve, and is a very different affair. The obstinate aphonia, the habitual diarrhoea, the menstrual irregularity, and the frequent pulse of this patient, are objective signs, which must be interpreted as premonitory of pulmonary tuberculosis. Treatment. — The remedy for this case is calcarea phosphorica ; and you will be surprised to observe how promptly and efficiently it sometimes acts under similar conditions to those presented by this patient. It may be given in the third, the sixth, or if you please, a higher potency. My own preference is for the third decimal trituration, of which this woman Avill take two grains three times daily. Not unfrequently the bichromate of potassa, phosphorus, sodium, or spongia, will relieve the hoarseness which is incident to these cases of incipient phthisis. For this purpose they may be given incidentally, or if otherwise indicated, in lieu of the calcarea phosphorica. It is quite as important to prescribe the proper hygienic condi- tions suited to this infirmity as it is to determine the choice of the 182 THE DISEASES OF WOMEN. remedy. First and foremost this patient should, if possible, remove to a climate which is less humid than this upon the lake shore. This expedient is especially advisable at this season (February). For the weather of the late win- Season and climate. , , . , . , . ..... ter and early spring months in this vicinity is too changeable, and withal too damp, for persons who are predis- posed to laryngeal and pulmonary difficulties. She should, moreover, have a good diet, and plenty of fresh air, without fatigue. And what is still more important, she should avoid an excess of family care and worry. Any little fret or friction of the domestic machinery has a wonderful influence in keeping this class of patients always on the doctor's hands. Whether it be primary or secondary genital phthisis is of the chronic form, chronique d'emblee. It is particu- Genitai Phthisis. larly incident to puberty and the climacteric- The seat of the deposit varies, the peritoneum being most frequently attacked, and after it the Fallopian tubes, the ovaries and the uterus in the order named. The neck of the womb and the vagina are sometimes, but rarely, the seat of this disease. Tubal tuberculosis is intimately connected with the clinical history of salpingitis. If the lesion is limited to the tubes and they are removed as in Tait's operation, the local mischief must cease for a time at least. How soon, and how certainly, and in what form it will be likely to return must be decided by the subsequent history of these cases. The careful record of all cases upon which the extirpation of the tubes and the ovaries has been practised would furnish a valuable contribution to the clinical his- tory of genital phthisis. LECTURE XI. DYSMENORRHEA. Dys me no rrhaia — Definition and varieties— Obstructive Dysmenorrhea. Case. — causes, symptoms, complications, sequelae, diagnosis, prognosis and surgical treatment. Ob- structive dysmenorrhea from post-puerperal atresia. Case.— dates lrom puerperaiity.— (he result of adhesive inflammation and stenosis, a clinical lesson, a contra-indica- tionfor anaesthetics, the use of the uterine stem. Most women suffer considerably during menstruation. The kind and degree of pain experienced at the month, however, varies greatly within the limits of health, and with the ability ot the subject thereof, to bear it uncomplainingly. It is only when the pain is sufficient to make her ill, and to disable her, or to send her to bed, that we say of a woman that she has dysmenor- rhcea. But this form of menstrual disorder is not only painful ; it is also tardy, slow, scanty and irregular, and the discharge which is more or less changed in character, escapes with great difficulty. Authors have described several varieties of dysmenorrhea, but I prefer to classify them all under the three general heads of (1.) Obstructive, (2.) Neuralgic, and (3.) Membranous. There are examples of each of these varieties in our clinic to which your attention will now be called. 1. OBSTRUCTIVE DYSMENORRHEA. One of my most intelligent and amiable patients has written the following history of her case, which for the sake of the bene- fit that may accrue to others, she has consented that I may read to you: Case. — I hardly know if I was a healthy child, but I was active, impulsive and sensitive. At eleven years of age the menses ap- peared, the result, perhaps, of the grief and excitement caused by my mother's death. For about one year they returned regularly, with little pain, and then ceased, owing, I think, to wetting my feet, and improper exercise. The result was a cough, dyspepsia, and other bad svmptoms. My father emploved a physician for 183 US4 THE DISEASES OF WOMEN. me, who, after several months of medical treatment, brought on the menses again, but with much pain. At seventeen years of age I was married, after which I resided four years in Boston. During these years, in which I experienced great mental suffering also, I suffered each month, resorting to such remedies as were prescribed in a domestic way by my friends such, for example, as gin, injections of laudanum, chloroform, ete. About this time I was seized with "vomiting attacks," ii- which I would vomit a tablespoonful or more of clear green bile every ten or fifteen minutes for twelve hours, but never for a less time. As the vomiting, sometimes with purging, continued, the pain would lessen and finally disappear. The nausea and retch- ing would leave suddenly and without apparent cause, for no medicine could be kept on the stomach long enough to produce any effect. These attacks returned at intervals of three, five and eight months. I was treated for them, by physicians in Elmira, N. Y., Boston, St. Louis, and Chicago, and no one Avas able to relieve me, or to decide upon the cause of these paroxysms. During the latter half of this period of ten years, my general health was much impaired, and I suffered greatly from gastric irritability and distress. From this irritation I have never found permanent relief. After four years residence in Boston I came to Illinois, seeking no particular medical aid for some years. At length I was in- duced to try a water-cure in New-York, where I had the first vaginal examination. As a result, I was said to be suffering from "an irritation of the uterus and vagina, and nothing more." 1 remained three months under treatment, but still continued to suffer during menstruation. A few years later I was placed under the care of a noted speci- alist in this city, who toll me there was an "enlargement and retroversion" of my womb. He applied the caustic treatment for six months, and, although he declared that I " was cured" still I suffered as before, at each menstrual period. One year after this I went to another Hygienio Institution in New York. Here I was told that the " uterus was enlarged, in- durated, retroverted, and fastened down, and had entirely changed its structure, and that the change must have been going on for many years. After having been pronounced "cured" only one year before, this was rather discouraging news. I remained at this institution four months, whence I was discharged, not as cured, but better. Still I suffered with menstruation. In the winter of 1870, severe pain preceded the flow for several hours, and in addition to symptoms threatening a return of all my former clinic ulties . my bladder was much affected. At this time, and after a careful examination of my case, Dr. Ludlam decided the seat ot my difficulty to be " in the neck of the uterus," which DYSMEXOliUHCEA. 185 he found was " almost entirely closed." Under his treatment I experienced almost immediate relief, my general health improved, the bladder trouble disappeared, the gastric disorder became less annoying, and I suffered little or no pain during menstruation. Six months have now elapsed since I have finished his treatment, and the cure seems permanent. Perhaps I should add that my pain was mostly in the abdomen, and of the nature of colic. Warm applications often produced fainting fits and always had a tendency of that kind. Looseness of the bowels frequently accompanied the pains. I could only eat a, very small amount of the simplest food. Eating always increased the pain. Finally, after nearly thirty years of painful menstrua- tion, I have at last found relief ! There is one point of interest in this case that is worthy ol remark. It is that, the form of painful menstruation from which our patient suffered was the natural sequence of her nervous con- stitution. Being sensitive, impulsive and active, she almost necessarily began to menstruate at an early age; and, when the function was established, it could not continue to be regular and normal as it might have done under different circumstances. In young girls of this temperament it often happens that menstrual disorders are attributed to getting the feet wet, and other acci- dents, when the real cause of the mischief lies in the too suscep- tible nerve centres. Her early marriage, the anticipatory vomiti ng, the sudden relief of the nausea, the abdominal colic, and the diar- rhoea, all resulted from the same nervous cause, or predisposition. Although the indications for treatment drawn from the study of the patient's temperament, are apt to be overated, I am in- clined to rely upon them in cases of this kind. And I advise you to cultivate the habit of looking for this nervous constitution, because it is a significant element in various menstrual disorders. This peculiar characteristic is plainly observable even in the style of her communication, and if this report had first come to me in the form- of a letter, I think it would not have been difficult to have read her temperament " between the lines." Obstructive Dysmenorrhoea is a variety of painful menstruation winch depends upon a partial or complete closure or obstruction of the canal of the uterine cervix, whereby the menstrual flow can only escape, if at all, with great suffering and more or less irregularity. Although it is by no means a rare affection, the history of this ease proves that it may 186 THE DISEASES OF WOMEN. exist for months or years without being recognized and properly treated. The causes of this disease are various. Sometimes it depends upon the original conformation of the uterus and uterine neck, in which case, from the very first the " periods," are always characterized by unusual delay and suf- fering. More frequently, however, it is acquired at a later stage of menstrual life. It may result from a flexure of the womb, in which that organ is bent upon itself like a retort. Opposite the lesser curve, in this case, the cavity of the cervix is obliterated. Versions, prolapsus, and other deviations From uterine deviations. ' . . in the position 01 the uterus are less- likely to cause this form of dysmenorrhcea than flexions. And retro-flexion is more frequent in every form of painful menstrua- tion than ante-flexion. In certain cases the cervico-uterine orifice and canal are mechanically obstructed by the presence of a foreign body, sach as a polypus, a sub-mucous fibroid, or an old From intra-uterine growths. . " "_ coagulum, and, notwithstanding the most vio- lent efforts to expel the flow, it is partially or wholly retained within the womb. For this reason retention of the menses is often described by writers under the head of dysmenorrhcea, and vice versa. But a more frequent cause of obstructive dysmenorrhcea is a form of endo-cervicitis, in which the epithelial lining of the canal is exfoliated and lost, and, as a consequence From cervical atresia. adhesions are lormed between the opposite sides of the canal. These adhesions, whether traumatic, post- partum, or the result of a popular form of malpractice, that is of cauterization, cause an atresia which obstructs and practically closes the passage. As a rule, those women who have borne children, whether prematurely or at term, are supposed to be exempt from dysmen- orrhcea. But this form of the disease is b}^ no means a rare sequel to the abrasions and injuries consequent upon labor, as well as to the local inflammations which may occur about and within the cervix and the vagina during the puerperal state. The harsh and indiscriminate employment of escharotics foe the cure of uterine ulceration (against which I have so frequently DYSMENORRHEA. 187 cautioned you), is very mischievous in this respect. The actual cautery, or its potential substitute, the potassa From cauterization. .. .,.,,. cum calce, destroys the cervical epithelium, and there is nothing left to prevent the consequent adhesive in- flammation from sealing up the outlet. Without their epithelium these surfaces grow together, just as your fingers would if the epi- dermis that separates and protects them were removed by a burn, and the surgeon who dressed it did not know enough to keep them apart until a new cuticle had formed. From considerable ex- perience in this class of cases, I am persuaded that contraction, cica- trization, and even atresia of the cervix are frequent sequelae of the milder, as well as of the more severe and reckless cauterization to which so many of our patients have been subjected before they come into our hands. The case just cited affords a good illustra- tion of this fact. Mrs. — had already suffered from dysmenorrhea for several years. The symptoms were sufficiently marked to suggest their Own solution and significance, even to a first-course student. But, as if to render her menstruation not only difficult but impossible, she, too, must be cauterized ! The symptoms of this disease are by no means limited to the site of the obstruction. Within the pelvis, and in the back and limbs, they are similar to those which ordinarily Symptoms. . . attend upon the menstrual effort. But in this case they are greatly exaggerated. When the patient is one who has never been pregnant, the uterine cavity is so small that the menstrual exhalation from its lining membrane soon fills it, and a feeling of distention and of extreme discomfort is induced. Aching and throbbing of the uterus, with uterine tenesmus are almost always present. In those who have borne children, and who have this form of dysmenorrhea subsequently, the womb, if not really more capacious, is yet more tolerant of the retained fluid. These women therefore do not commonly suffer so severely as those who belong to the former class. In both classes, however, the presence and pressure of the blood, which has no adequate outlet, excites the peristaltic con- tractions of the uterus with a view to over- Uterine tenesmus. come the obstruction and to force the now. The case then partakes of the nature of labor. The contractions of the uterus are much less powerful, because the fully-developed 188 THE DISEASES OF WOMEN. fibres of its muscular coat are lacking. But it often happens that they are more painful than in real labor. The antagonism be- tween the body and fundus and the circular fibres about the inter- nal os uteri is very apt not only to cause intra-pelvic suffering and agony, but to develop a train of reflex symptoms such as are met with in abortion and in labor at term. Of the functions which are thus indirectly implicated and de- ranged, that of digestion suffers most frequently. Obstinate and painful vomiting is almost always present with Reflex disorders. pi n every return ot the menstrual cycle, whether it be prolonged and complete or not. It depends upon a stricture of the os internum, and comes on in the same manner that it does in rigidity of the os uteri during labor, or at the moment that the presenting part passes through the ring that is made of the enor- mously di]ated cervix. If there is ever so small a vent, and a portion only of the catamenial secretion escapes, the pain and emesis may subside. But, unless the flow comes on without any considerable delay, and pretty freely, the vomiting is likely to persist. And, what is a curious clinical fact, one that I am una- ble to explain, but which I have often observed, is that this vom- iting is almost certain to continue for about twelve hours. Our patient says that she vomited u every ten or fifteen minutes for twelve hours, but never for a less time." Some cases of obstructive dysmenorrhcea are met with in which the menstrual arrest and derangement have given rise to very complicated disorders of digestion, which many Indigestion. -, • • • -, physicians are incompetent to explain and to cure. The gastro-intestinal functions are involved just as they often are in the early months of pregnancy. Either through nervous or vascular connection between the uterus and the stom- ach, some portion of the small or large intestine, or the liver, or all these organs, the result is the various forms of indigestion, in- anition, constipation and bilious disease that so frequently arise from painful and irregular menstruation. In this, as in other varieties of dysmenorrhcea, it would be im- possible for the bladder and the rectum not to pifitton 1 and rectal c ° m " sympathize with the uterus in its prolonged effort to empty itself of its contents. Conse- quently there is, sooner or later, in almost all of these cases, more DYSMENORRHCEA. 189 or less of vesical and rectal tenesmus. This incidental suffering corresponds with that proper to the first stage of labor. Coincidently with the tenesmus of the pelvic organs there is often, and indeed usually, a train of nervous symptoms which are more or less pronounced and alarming. Head- Nervous disorder. . .... ache, restlessness, insomnia, jactitation, spasms, and even convulsions are not infrequent, ail of which, however, are relieved as soon as the flow begins, exactly as in labor when the rigid os uteri has yielded and the presenting part has passed the point of obstruction. A very painful and distressing form of spasm to which some of these patients are subject is one in which the muscles of the back part of the head, of the neck and of the superior portion of the spine are affected, resulting in opisthotonos. Painful, cramping, clonic spasms of the flexors of the fingers and toes often occur. Some women are liable to a temporary blindness at these times, and you will observe the pupil to be sometimes very much dilated and again contracted. In those who are decidedly hysterical, there may be, during the par- oxysm, an evident disparity in the size of the pupils. In true obstructive dysmenorrhcea it seldom happens that the painful and persistent effort to restore the impeded flow finally causes it to become profuse. In this respect it Menorrhagia infrequent. ,.-«,■« , , . . , , -, . , diners irom the congestive, the spasmodic, and the membranous varieties, which are all of them likely to be either accompanied or followed b}^ menorrhagia. The amount of the dis- charge is not proportioned to the severity of the pain. The flow is scanty and intermittent, and, as in the case which I have related, the inter-menstrual period is generally lengthened and irregular. If the obstruction is congenital, or has come on from any cause before marriage, these patients are sterile ; for the same mechan- ical obstacle which interfered with the men- steriiity from obstructive gt rua l exit, will prevent the ingress of the dysmenorrhcea. J- © semen into the uterine cavity, and proper fecun- dation will be impossible. If the closure of the cervico-uterine outlet takes place in consequence of cauterization, or of post- partum inflammation in one who has borne a child or children, she also may afterwards become barren from the same cause. 190 THE DISEASES OF WOMEN. If the dysmenorrhea depends upon congenital mal-formation of the cervix uteri this condition can be readily Diagnosis. . _•. recognized by the proper employment of a Sims speculum and the uterine sound, conjoined with the " touch." If it had its origin in puerperal inflammation ; if it has followed the extension of simple or specific vaginitis into the canal of the cervix ; if it depends upon some uterine ob- Physical exploration. ... _ n liquity, or the presence of a foreign growth ; or if it is the sequel of cauterization, the previous history and treat- ment of the case will facilitate the diagnosis. The simple fact that at the first attempt you fail to pass the Passing the sound. , sound into the uterine cavity should not lead you to decide the case to be one of obstructive dysmenorrhcea ; for in a healthy state of the uterine mucous membrane, and in the interval of menstruation, the internal os is in many cases so tightly closed that it requires considerable skill and experience to pass this instrument at all. But if the canal of the cervix is not absolutely impervious, a little patience and tact will enable you to succeed. You may sometimes insinuate a small Sims' probe, when a large sound, more especially a stiff one, could not be intro- duced without undue force and unnecessary suffering. I need hardly remind you that you will gain an entrance into the uterine cavity in this manner much more easily u at the month" than at any other time. You should remember that in this form of dysmenorrhcea there is not necessarily a complete and entire retention of the menses. The distinguishing characteristic of the disease The flow, and what it j s fa^ there is a mechanical impediment to the signilies. x monthly flow, which may or may not amount to a positive obstruction and arrest thereof. The failure of the prac- titioner to get a correct idea of this fact explains the proneness to blunders in the diagnosis and treatment of this affection ; for ob- structive dysmenorrhcea bears as little resemblance to endo-cervi- citis and to uterine ulceration as it does to perimetritis or to hema- tocele, and to confound them is both inexcusable and mischievous. The prognosis will vary with the cause of the disease, and also with the consequences of the menstrual irregu- larity. If the original organic defect, whenever it exists, can be remedied or compensated by surgical means, DYSMENORRHEA. 191 recovery will follow. If the acquired or accidental obstruction, whatever it is, can be removed, the result may be favorable. Something, however, will depend upon the state of health, which is secondary, and which has been induced, directly or indirectly, by the persistent derangement of the menstrual function. If the dysmenorrhea has existed for years, the patient may be so ill with symptomatic endometritis, gastritis, gastro-enteritis, ovaritis, cys- titis, chronic hepatic and digestive derangements, tuberculosis, diseases of the nervous system, or a depraved condition of the blood, as to prevent her complete recovery. And this, although the ease and regularity of the flow have both finally been estab- lished. Therefore, you should be careful how you promise to perform a radical cure of this painful affection. Treatment. — One of the most successful and satisfactory achievements of modern gynsecolog}^ consists in having supplied us with the means of cure for most cases of this Surgical treatment. disease, .brom the nature of its causes, you will infer that the treatment of obstructive dysmenorrhea must be chiefly of a surgical kind. Internal remedies are suited to the relief, and possibly the cure, of other varieties of painful menstru- ation, but they are of little or no permanent avail in this. The •cause of the suffering is physical and mechanical, just as in a case of stone in the bladder, or of biliary calculus, and although, by the use of constitutional means, Ave may mitigate the pain and other incidental symptoms, yet the cure will depend upon the removal of the cause. If the seat of the stricture is at the os externum, a slight inci- sion may suffice to open the cervical canal. If, as most frequently happens, it is at the os internum, it will be most prudent to try the virtues of dilatation, and reserve the cutting as a dernier ressort. Dilatation is equally applicable to most cases of atresia of the cavity of the neck of the organ. When the passage is very narrow you will begin with a small copper sound, or probe, which may be passed every third or fourth day until the canal is somewhat enlarged. This may be followed by the ordinary sound, small bougies, laminaria, or slippery elm tents, the use of Atlee's, Priestley's, or Nott's dilators, and finally by the sponge tent. And although (in order to take advantage of the naturtL tendency to 192 THE DISEASES OF WOMEN. expansion of the cervix), it is best to commence this treatment at the month, it must be continued during the inter-menstrual pe- riod also. As a rule, twice each week is as often as these opera- tions can be borne, and sometimes this is too frequent. As in passing the female catheter, so you will need to exercise considerable tact in the introduction of these instruments, more especially until, by repeated trials, you have Introduction of the neces-l eamec [ ^q COurse anC l curve of the Caiial ill sary instruments. each particular case. For its direction is so modified by the position of the patient, the fullness or emptiness of the bladder, the rectum, and even of the uterus itself, as well as by obliquities of the womb, that any rules which I might indicate would be of little practical service, unless you. should modify them to suit the case in hand. As a rule, the copper sound is preferable to the stiff one ordinarily employed. Sims' probe is too flexible, and might stick fast in the rugae of the cer- vix, or at the point of coarctation. If the womb is retro-flexed,, the patient must be placed in the semi-prone, and, if needs be, in the knee- elbow position, in order that the fundus and body of the organ may gravitate into their normal relations, and so that, in passing, the point of the sound may take the natural direction with reference to the axis of the superior strait. The most diffi- cult cases are those in which the cervical canal is tortuous and sinuous. You may or may not make use of the speculum to facili- tate the introduction of the sound, or of the tents. In all ordinary cases I prefer to pass them without, instead of through the specu- lum ; but perhaps you will do better with it. Much has been said of the frequent failure of dilatation of the cervical canal as a cure for this disease, and also of the injurious consequences that sometimes result from it. Failure of dilatation. . . . My own opinion, which needs a word of ex- planation, and which is based upon experimental and not upon theoretical grounds, is that, if properly employed, dilatation is more successful and less harmful than is generally supposed. I am inclined to attribute its failure in the hands of some physicians to a lack of caution on their part in the choice and application of instruments ; and also to too great haste to cure their patients, regardless of consequences. That cervicitis, cellulitis, peritonitis, spasms, convulsions, and DYSMENORRHEA. 193 even hysterical tetanus, have sometimes followed the use of the dilators and of the sponge-tents is doubtless true, but there is little question that, if the cor- rect and complete history of these cases were written, it would be found that either the tents were composed of improper material, were too large, or were pushed through the cervix uteri too forci- bly, or that they were allowed to remain for too long a time before being removed. One of my patients suffered so severely that she could not tolerate a small ebony dilator, which was passed with- out difficulty, for more than ten minutes at a time. If I had not taken the precaution to remain with her and to observe the effect, but had left her with instructions that the instrument must be kept in place for some hours, she might have been dangerously ill from this cause alone. It may seem incredible, to the more advanced members of the class especially, that any intelligent physician should be so care- less as to introduce a slippery-elm or a sea- A barbarous practice. . tangle tent at his office, and alter wards permit his patient to travel by stage or by rail for some miles to her resi- dence, before it was removed ! But this is not an infrequent occurrence, more particularly with those who practice most largely among the lower classes in such a city as this. The inju- rious effects of such a custom should be charged to the abuse and not to the proper use of the tent. Providing there is no acute inflammation of the endometrium, or of the mucous lining of the cervix uteri, no ulceration, and no extensive or deep-seated cicatrices to be broken d-£at c ion s . ions concerning up, I think that the whole or any portion of the neck of the womb may be as safely, although not so rapidly dilated, as the female urethra. In exceptional cases, where the obstruction has been relieved by dilatation, it returns after six or eio-ht months. Mischief sometimes results from a lack of care in the choice of the material of which the tent is made. The slippery-elm tents are useful and available, and answer a very Of the various tents. _ ■ ' good purpose when they are smooth and small enough to permit them to take the shape of the canal through which they are to pass. But when a larger tent is requisite, they are too stiff and straight to suit many cases. A large sea-tangle 194 THE DISEASES OF WOMEN. tent expands so slowly as to be practically useless, and to try to introduce several small ones at once, or, rather into the same cer- vix, that they may expand simultaneously, is a blundering and unsatisfactory operation. The hard rubber bougies are of various sizes, and can be bent into the desired form by heating them over a lamp, which items are much in their favor ; but they are too blunt for use in the early stages of treatment, when the passage is very narrow. If the sponge tent is an old one, it is apt to be hard and unsuitable. Moreover, when kept in contact with the cervico-uterine fluids, such a bit of sponge will more readily de- compose. Now that our sponge tents are carbolized, however, it is quite probable that some of the evil consequences attributed to the use of this instrument will be omitted in future. The rashness and injudicious haste with which dilatation has sometimes been practised, have excited a prejudice against it in the minds of many. There are physicians who Precautions in practising undertake to dilate the contracted cervix in dilatation. obstructive dysmenorrhea with the same dis- patch with which a surgeon would amputate a limb, or excise the tonsils. The whole operation must be performed at once, and the unfortunate results that may follow are almost invariably attrib- uted to the instruments used, instead of to the lack of discrimina- tion and judgment on the part of the operator. The proper plan is to " feel one's way," as the phrase is, and to take plenty of time in order to overcome the obstruction without any serious shock to the patient's system, or any risk of the diseases which I have named as contingent upon this operation. If }-ou cannot succeed in one month, it is better to take two or three, or six, if need be, and to make gradual progress towards a cure, than to be precipi- tate and finally to bring yourselves to condemn this expedient al- together. The cautious and persistent dilatation of the cervix was the only means employed in the case cited at the opening of this lecture. I have resorted to it in many other instances with equally good results. When, however, you have made a faithful trial of dilatation, and it has failed to bring the hoped-for results ; ^jndsion of the cervix r, if after having afforded temporary relief, there is a serious relapse, and you are satisfied that a radical cure is not possible by this means, incision of the DYSMENORRHEA. 195 tion of this dilator was complete and perma- Entire relief through a nen t. I saw my patient three years later, and simple operative expedient. J r j she had had no return of the difficulty. In this operation there was no cutting of the contracted cervical fibres, for, as you perceive, this instrument has no edge with which to divide them. The mere passage of the smaller sound, and then of the larger one, did not accomplish the result, for their use in the first instance did not lessen the pain and suffering in the least. There were no evidences of existing or of previous inflammation ; and if there had been, we can not suppose that so simple and transient a means could possibly dispose of them so instantane- ously almost, and so entirely. This case was evidently one of neuralgia, a pure neurosis, de- pendent upon permanent contraction of some of the circular fibres of the upper portion of the cervix uteri, unaccompanied either by inflammation or its consequences, but presenting its symptoms both during the monthly flow and also in the interval between the periods. In most cases of neuralgic dysmenorrhea, the pain and suffer- ing are limited to the monthly return. Any undue determination of blood to the uterus, or even a slight delay in a ^Sorrhffi^ neural§k ^ ie appearance of the discharge, incidental irri- tation or displacement of the organ, or ulcera- tion or inflammation thereof, may be the exciting cause of the attack. The pain may be limited to the pelvic or the ovarian regions, or it may assume the form of neuralgia located elsewhere, as in neuralgic headache, neuralgia of the face, the teeth, the eyes, the fingers, the toes, the mammae, the intercostal spaces, the stomach or bowels, or even of the heart. In such cases the suf- fering commonly subsides when the " period " has passed. But, exceptionally, as in the case of which I have spoken, where the local spasm or irritation of the cervix is perpetuated, the remote pain and suffering do not subside, but persist throughout the month. You should remember this fact, else the continuance of this form of secondary neuralgia may lead you to suppose that it has no possible connection with the uterus. In those who are predisposed to this form of dysmenorrhcea, and who are generally of a neuralgic tendency, the slightest excit- 214 THE DISEASES OF WOMEN. ing causes may induce it. One of my patients, a very observing and truthful person, who had had this disease Causes of dysmenorrhea. tor many years, remarked that when she ate very lightly, on the advent of the menses, the suffering was very much lessened. Her habit was to diet herself strictly the day before the flow came on, and to eat sparingly of light food until it ap- peared freely. A hearty meal at the beginning of the period would increase the suffering in a ten-fold degree. All those habits of mind and body, which induce prostration and perturbation of the nervous system, are likely in those who are impressionable, to bring on this form of painful menstruation. The incidental suffering, as in neuralgia, is always periodic and paroxysmal. A predisposition to this peculiar kind of nervous derangement, which implicates menstruation and involves great suffering, runs in families, and, during the first few years of their menstrual and sometimes of their married life, every daughter will be the victim of these functional derangements. Not unfre- quently the most aggravated cases of neuralgic dysmenorrhea occur in the experience of those women whose married life is an unhappy one, and who, either from a physical inaptitude for, loathing, or an # excess of venery, suffer the evil consequences of forcible, frequent or incomplete intercourse. When the flow commences, the pain usually remits. And this is true however remote its location. But sometimes the relief is more direct and positive. Only yesterday a th?de a gr° e e of pai^™ t0 lad y tolcl me tliat she always felt light of heart and buoyant immediately the flow began, al- though but a few minutes before she had been in real agony, and was peevish, irritable, and extremely sensitive to any little slight or injury. The relief sometimes re-acts in such a way as to bring on a hysterical fit of crying or weeping, or of both these together ; or it may be followed by tranquil and refreshing sleep. In very rare cases it is followed by inordinate sexual desire, amounting to temporary nymphomania. You will sometimes, but not always, find the distinctive and characteristic indications for the remedy in the remedSs tIons for internal kind, degree, location, and especial peculiarities of the pain, wherever it may be seated. These details are so varied, and so insusceptible of classification, that SPASMODIC DYSMENORRHEA. 215 you will be compelled to select from a list of remedies which are suited to the cure of every shade and form of neuralgia. Acting upon the hint that so slight a cause as the swallowing of a teaspoonful or two of cold water may cause a spasm of the uterine cervix, with scanty and painful flow, w^r™ instead ° f coM m y fri en d' Dr. M. F. Page, has sometimes given gelseminum 1, fifteen drops in half a teacupful of warm water, one teaspoonful to be taken every five minutes until relieved, then less frequently with the happiest results. In this form of dysmenor- rhcea, at or near the climacteric, he has great confidence in verat- rum viridel, five drops in the same quantity of Veratrum viride. warm water, and the same dose repeated every ten or fifteen minutes. Yet, it often happens, that what will re- lieve one case will in another case seem to be without effect, even where the symptoms are very similar. There are some cases of this disease which can be cured most promptly and satisfactorily, and without any harmful conse- quences, by the use of local means. Careful Dilatation. . .-..,., dilatation may suffice — as it did with my pa- tient — to paralyze and overcome the morbid spasm and hyperaes- thesia of the uterine cervix, upon which the whole mischief really depends. In neuralgic and spasmodic clysmenorrhcea, I think it better to perform this operation with solid than with sponge tents. Indeed, in some cases of this kind, I have remarked a singular ag- gravation of the suffering from the use of the latter, especially when introduced in advance of the flow. SPASMODIC DYSMENORRHEA. In illustration of the fact that neuralgic and spasmodic dys~ nenorrhcea are essentially the same, and that their treatment varies chiefly on account of the individual peculiarities of the patient, I now present you with the following case : Case. — Miss , age twenty-three, has been out of health for a year and a half. She first menstruated at fourteen, and experienced no unusual difficult}^ until eighteen months ago when in advance of the flow, she began to suffer unbearable pains in the stomach and over the whole abdomen and extending down the limbs. Her only means of relief is in whisky or gin, which she takes and goes to bed, and after sleeping two or three hours 216 THE DISEASES OF WOMEN. the pain ceases and does not return until the next period. The flow is regular as to time, but with it membranous shreds are expelled. She is nervous and excitable, and has slight attacks of hysteria at each period, and at these times the least touch of her clothing is oppressive to her. Ignatia 3, three times a day. Feb. 4. The flow commenced yesterday at twelve o'clock, and continued three hours without pain, after this for a few hours there was some pain, but less than ever before, and she did not take her usual preventive. The flow still continues, she has some headache which began with it and which she never had before. Continue ignatia 3. Feb, 18. She "feels well." Continue the ignatia until the flow begins, then let her take gelsemium during the period. It often happens that one may learn an important clinical lesson from domestic experience. The fact that this girl found relief from her painful disorder bv the use of gin or a^^^ ttheelnwh{sk y' settles the question as to the form of dysmenorrhcea to which she was subject. But her experience is of little use to us except in a diagnostic point of view. No amount of gin would have cured her, nor have we the exact counterpart of either of these stimulants in any of our attenuations. The essential hint derived from what she told us on her first visit, was that her dysmenorrhcea was local, spasmodic, and therefore of a purely nervous character. This temporary lesion was engrafted upon the hysterical temperament, and that was all there was of it. If she was a married woman, and had borne children, the case would have been different, for a pure spasm of the cervix which is sufficient to obstruct the flow, and which is Exceptional hint. . , . independent of uterine flexion, is very rare with those who have ever been pregnant. Under those circumstances a local examination would have been necessary before we could have decided upon the nature of the difficulty. If this patient had been placed under the influence of opiates, anti-spasmodics, or the more fashionable hypnotics, the result would have been the same as when she took the liffects of opiates etc. . , . gin, and the relief would have been transient. There is no doubt that, given in this manner, such remedies often work mischief. The hysterical excitement at the approach of the period, the hyperesthesia of the cutaneous surface, and the relief afforded by SPASMODIC DYSMENORRHEA. 217 sleep, furnish the prominent indications for the remedy that was given her. The headache that followed was not Hysterical indica- d t a medicinal aggravation, although it might tions f or ignatia. °° 7 _ o c^ have been a consequence of having taken ignatia. In cases of a true medicinal aggravation some of the original symptoms must be increased in severity; but Medicinal aggravations. ' . " here we have a new symptom altogether; a state of things which does not contra-indicate the continued use of the remedy. My own experience has led me to conclude that a proper discrimination in this regard is sometimes very important in the treatment of the diseases of women. It is not always best to stop the use of the remedy directly there are signs of its " taking hold." My recommendation for gelsemium,to be taken during the flow is based upon the observation that it is adapted to overcome any disposition on the part of the cervical fibres to contract and to cause the flow to intermit, which state of things sometimes induces a local spasm of the neck of the womb. These are cases of spasmodic dysmenorrhcea for the relief of which gelsemium is prompt and effectual. It is adapted to hysterical women who suffer severely in anticipation of the flow, and who in consequence of a delay, which is not the result of a displacement of the womb, of a polypus, or of atresia of the cervix — are kept on the verge of spasms, wakeful, restless, neuralgic and wretched. The indication is strengthened by the occurrence of occasional attacks of ovarian neuralgia, or by a morning diarrhoea, and also an hereditary tendency to rheumatism. There is quite a list of remedies that have been recommended and extolled for the cure of this form of dysmenorrhcea ; but in order to prescribe them intelligently, you will Other remedies. need to search for their special indications in any given case. The list includes, aconite, agnus cast., ammonium carb., apis mel., atropine, belladonna, cactus grand., cannabis ind., caulophyllum, coftea, collinsonia can., macrotin, hamamelis, hyoscyamus, lilium tig., moschus, natrum mur., platina, pulsatilla, thuja, veratrum alb., viburnum opulus, and xanthoxylum Dr. Jousset has often succeeded with magnesia carb. where the periods are tardy and where, owing to the pains, the flow is arrested. Dr. Richard Hughes says that " When it is rather the uterus 218 THE DISEASES OF WOMEN. which suffers neuralgic pain in the -performance of its monthly function, chamomilla and coflea are recommended; and will often (the former especially when the temper is much disturbed by the suffering) give full satisfaction. Should they not succeed, or should the general hyperesthesia calling for either be absent, I can commend to you the xanthoxylum frax. I am in the habit of giving this medicine in most cases w T here dysmenorrhea co-exists with some degree of neuralgia ; and can speak of several cures with it. If Dr. Massey's key-note for it, " prolongation of the pain down the crural nerve," is confirmed, it would seem to correspond to ovarian dysmenorrhea also." In some cases galvanism is curative, and in others, hot baths, electric baths, and Dr. Chapman's hot- water bags are all that can be desired during the' paroxysm. A few cases will be relieved by marriage and maternity, but sometimes they fail of effect, or they may increase the difficulty. In very exceptional cases, when the patient is of an hysterical diathesis, and the conditions have prevailed for a Battels operation for long time, a neurotic condition may have been developed that will not respond to the best med- ical and moral treatment that can be applied. In some of these cases the dysmenorrhcea is the exciting and relapsing cause of neurasthenia, of mental perversion and even of convulsions, in which the suffering is wearing and exasperating to the last degree. Although it sometimes fails, this neurotic condition is often cured by a resort to oophorectomy, or the removal of the ovaries and the oviducts. I shall speak of the special indications for this opera- tion at another time. LECTUEE XIII. MEMBRANOUS DYSMENORRHEA. Membranous Dysmenorrhoe a. Case— Causes, anatomical peculiarities of the Membrane, its clinical confirmation. Shape and size of the Membrane. Its expulsion practical deductions. Diagnosis from Abortion. Special Therapeutics. Other expedients. The sponge tent. I will invite your attention this morning to the following- re- markable case, which is reported by the patient herself : Case. — I was born in July, 1834, in C , Ohio. Soon after my birth an eruption made its appearance on the skin, resembling rash, occasioned, it was then thought, by the extreme heat of the season. I passed the usual diseases of children very early in life, and, with the exception of this eruption, which appeared almost every year during the summer months, and generally upon the lower parts of my limbs, I was a vigorous, active child, full of life and spirit, and in apparent perfect health. At the age of fourteen years and five months the menses made their appearance. The first discharge was plentiful, but attended with no pains or incon- venience whatever. One year after they were suppressed about three months — caused by thin shoes, wet feet, and not early acquainting my mother with the fact. I was soon set right with " Cooper's pills." I felt well during the suppression. At sixteen, while at boarding-school, my appetite grew voracious, and I ate immoderately of all kinds of food, pickles, and sweetmeats. The rash had somewhat lessened in its appearance each summer as I grew older. It was, however, upon my body one day when, just after dinner, in passing through a hall to which the outer doors were open, I met a furious gust of wind from an approaching thunder-storm. At the moment I noticed no uncomfortable sen- sation, but was shortly seized with great difficulty of respiration and extreme prostration, and in less than an hour my life seemed hopeless to those around me. This was the first attack of any- thing like illness since my babyhood. Two physicians were speedily called, who said, " the rash had suddenly struck inward." Two days before this I remember to have been very nervous, so 219 220 THE DISEASES OF WOMEN. • that I could not go to sleep on retiring, but did not know that anything ailed me. The doctors gave me tumblers full of a mixt- ure of asafcetida ; valerian was also given. I do not know what else was administered, as I was only partially conscious. My suf- fering was almost wholly from the gasping and struggles for breath. The rash never made its appearance again until I was thirty -four years old. I was left weak and sick (J think, from the effect of the dosing). It was one or two days before I could be removed home. Very soon my monthly period came on, attended with some pain. My mother told the physician, and he gave me hyoscyamus. My school days ended with my first illness. I was never able to return to school-life again. The remainder of that summer I was weak, and very nervous frequently ; had severe palpitation of the heart, and often could scarcely control my limbs and face from twitching violently, which they sometimes did in spite of me. The physicians prescribed for " nervous paroxysms," " constipation," and " general debility." I took quantities of the different preparations of iron and nervines. One medicine was to be dropped, " eighty drops every two or three hours." I knew nothing of modern glass-drop measures, and went entirely through the "dropping " ordered each time as prescribed. During the fol- lowing eighteen months dyspepsia and nervousness were my prom- inent troubles ; also obstinate constipation, occasionally having some pain at my menstrual periods, which grew somewhat irregu- lar ; but I entered into the usual duties of life, and passed for being in pretty good health. I was married at eighteen. After marriage, nothing about my menstrual periods attracted my attention for three months, when I passed over seven weeks without them. My form grew some- what fuller, and I craved certain articles of food. I took " Coop- er's pills" at m} r own instigation. When the discharge made its appearance it was attended with great pain, so that I was obliged to go to bed. I felt very sick, and a physician was called — one whom I had never seen. He gave me soothing medicine, but never said what ailed me. He attended me several months, but never inquired about anything but my constipated habit, and the nervous condition of my system. The following monthly period I was able to keep out of bed by taking spirits of camphor, which he gave me, very often through the day. During that year I had severe nervous paroxysms, violent jerking of the limbs and body, especially at night. In a few months I suffered extremely with every menstrual period the first twelve or twenty-four hours. I then went to C , to the care of the physician who had attended at my birth, and had known me all my life. He was the first who made vaginal examination. He reported a partial " retro- version of the uterus," and said I had " ovarian tumor." I went MEMBKANOUS DYSMENOKKHCEA. 221 through a long series of blisters on my spine and abdomen, purga- tives, etc. I was in his care more than a year. As I could not live in the city, I was not constantly with him. I never could myself discover the slightest soreness or enlargement in the ova- rian region, and wondered that I could find no evidence of the tumor. About this time I began suffering with what seemed to be rheumatism in my right limb, particularly when on my feet, or standing much. I rarely ever had it when warm or in a reclining posture. In a year or more I grew weary of going into C , of blister- ing and doctoring, and did without professional aid for a year or two. I did better without it than with it, as my general health was better. About this time, I once took chloroform to have a tooth extracted. It was with great difficulty that I was revived from its effects, and for sixteen hours I kept constantly sinking away. I next went to R , to a physician. He found " the uterus hardened at the neck and too low in the vagina." He first gave me a violent emetic, used electricity, had my whole body daily rubbed with No. 6, and like stimulating liniments, and put a Banning's body brace upon me. I took a great deal of macrotin, tonics, etc. His treatment, which continued several months, improved my general health more than any I had had. Yet my menstrual flow did not come right. Finally, he one day ran his fingers violently through his hair, and said "he could not see what did ail me." I went home discouraged, and again did without medical aid for two years more. Indigestion, cold feet, rheumatism, attended Vy the whole train of disorders of the nervous system, had been, ond was, my constant experience. I rarely ever had any pain in my head or spine, after the first year of my married life. A nat- urally gay temperament, a great love of fun, horseback riding (of which I was very fond), carriage driving, travel a part of every year, with never any very laborious household duties, probably kept me from becoming a bedridden invalid. On removal into the city of C I again sought professional treatment. I had then been married six years. Faithful adher- ence was made to injections of rose-leaf tea, and numerous other local remedies, and a gold pessary was introduced. Finally, after nearly two years of constant treatment, it was satisfactorily dis- covered that I had " rheumatism of the womb." I was under the care of this physician for six years, and took a great deal of medicine — I think considerable quantities of gum guaiacum in brandy. The year of 1865 I traveled in Europe, and some in our own country. I have always borne travel well, enjoyed it thoroughly, 222 THE DISEASES OF WOMEN. and fellow-travelers seldom have discovered that I was not in health. In February, 1868, I removed to Chicago. The cutting winds affected me so that in less than three weeks I dreaded to go out of doors — they seemed to search my very bones. A thirst which could not be satisfied soon set in, and, shortly, a retention of urine, with rheumatism in my whole right side. I was very sleep- less. The atmosphere seemed too cold for me to breathe, and I was obliged to cover both head and ears to get sleep at all. I found temporary relief in short, repeated visits to Cincinnati and Springfield,- Illinois. In May I had several large carbuncles, during which my indigestion and other difficulties were much relieved. About this time I frequently felt sharp pains about my heart, and sometimes a sense of dizziness, which soon left me if I laid down for five minutes. I often would catch my breath in going about in common employments, and drew long, deep sighs in ray sleep. I was nervous and wretched — and the monthly period was attended with increased suffering. In July I went to the sea shore, as had been my custom for several years, and from which I had always returned in much more comfortable health. The weather during the journey was exceedingly hot, the warmest known for years. On reaching Philadelphia by a morning train, with scarcely a dry thread upon me from perspiration, I found my body covered with rash or prickly heat, which I had not seen for eighteen years. It did not wholly disappear at once. I had passed through the catamenial period just before leaving home. We reached the sea-side, and the sea-breeze was, as usual, invigorating and refreshing to me. I bathed for one week. I was very fond of swimming, but found the exercise too severe for me, and, this time, could not practice it at all. On retiring one night I found a steady pain in my left breast. I took little notice of it, supposing it to be caused by indigestion, or pleurisy. It often awakened me during the night, but by putting my hand on the spot and warming it, I dropped to sleep. Next morning I folded a flannel several thicknesses and put over it, dressed, and ate my breakfast, as usual. Soon after breakfast I was seized with the pain most violently, and seemingly in the region of the heart. In ten minutes I was pros- trate. A mustard plaster applied increased my suffering fearfully. Dr. B., of Philadelphia, was summoned, and a young physician was present. Dr. B. at once pronounced the attack " rheumatism of the heart." The pain once suddenly went to the bladder, causing excruciating agony. A very copious discharge of urine soon followed, and the distress was again in the heart. I was relieved by aconite. In two weeks, at Dr. B.'s urgent advice, I was taken to Capon Springs, Hampshire county, Virginia. This MEMBRANOUS DYSMENORRHEA. 223 spring is celebrated for its use in " the different forms of dyspep- sia, and as a remedy in gravel its virtues are said to be unques- tionable - 1 while externally applied in the shape of cold or warm baths, its results " are proved beneficial in rheumatism and diseases of the skin." I spent three weeks here, and my heart was entirely relieved ; but, after leaving, I was again attacked, in about a week, in the city of Brooklyn. The medical attendant there never said what he thought my disease was, but " supposed my trouble proceeded from the spine." He was positive there was no disease of the heart. All the physicians said I must not return to the climate of Chicago, so I went to my relatives in the west, to R , where I was attended by a physician two months. There was a great deal of soreness to the touch about my heart, with constant, severe pain, and I could not endure a breath of outside atmos- phere, though it was only the first of October. He said I had "angina pectoris," and u h}"dro-pericardium." I had noticed I suffered more with my heart about the time the menses made their appearance — generally a few hours before, and I asked him to find whether there was not something wrong in connection with the uterus, as I had had no attention to that organ for five years. He made examination and told me I " was all right there." Suppose we recapitulate the chief points in this case, which our patient has detailed in so interesting and truthful a manner. Her first menstruation was prompt, plentiful and painless. One year later, amenorrhcea (suppressio mensium), from cold and wet feet. At sixteen inordinate appetite, the rash declining — -sudden and severe illness from repercussion of the eruption, which did not reappear for many years — inveterate and inexplicable nervous symptoms. After marriage, at eighteen, menstruation normal for three months — then seven weeks' interruption — " female pills" — illness. After this, painful menstruation each month — another physician, diagnosis of retroversion with ovarian tumor — blisters — purgatives, etc., for a year — apparent rheumatism in the right limb, worse on standing, relieved by warmth and rest in the reclining posture — was a confirmed invalid at twenty, but dis- abled only for the first few hours of the " period" — abandoned all treatment for a }~ear or two, and improved in consequence — another doctor ; diagnosis, induration of the cervix and prolapsus — emetics, electricity, friction, an abdominal harness, macrotin tonics, etc., — improvement of general health, but the menstrual 224 THE DISEASES OF WOMEN. disorder unchanged — the doctor at his wits' end — abandoned all treatment for two years more — nervous disorders continue — still another physician — two years treatment and a diagnosis of 44 rheumatism of the womb" — continue treatment four years more (six in all) — with a faithful trial of Dewees' prescription of guaiacum — 1865 in Europe- — 1868 removed to Chicago— - prairie winds in spring unfavorable — critical and salutary boils — increased cardiac trouble — rheumatism of right side — monthly symptoms worse — goes to the sea-shore in July — after a copious perspiration the eruption, which had not been seen for eighteen years, makes its appearance — cardiac paroxysms at night and next day — alternation of rheumatic pain in the heart and bladder — relief from aconite — the mineral springs improve the heart symptoms — one more doctor and another diagnosis. The additional particulars, of clinical interest, which were given me when I took charge of this case, are the following : About five months after her marriage she commenced passing membranous shreds, and since then has never escaped more than two consecutive "periods" without them. The size and firmness of the shreds vary at different times, but they are not larger, nor is the suffering relatively greater at the next period, after passing one month without them. The degree of pain and discomfort vary with the presence or absence of the membrane, and also with the amount of exercise taken at the time the flow commences. If she lies in bed for a day or so, there is little relative suffering. Although she had frequently spoken to her physicians of these membranes, only one had concerned himself about them, and he had decided, in an off-hand way, that they were the result of a miscarriage. None of them ever made any inquiry with respect to the character of these products, and until I procured this first specimen for microscopical examination, no one, except the patient and her husband, had ever seen them. Upon careful inquiry, I learned that she suffered at times,, usually some hours in advance of the flow, from a circumscribed pain in the right ovarian region. She could cover the spot with the tips of her three fingers. The pain would radiate somewhat, and extend thence along the limb. It was invariably worse in damp weather and after exercise. While the cardiac symptoms were more or less constant, they were greatly aggravated at the month. Indeed, her sufferings at this time were extreme and alarming. She had discovered that aconite 2nd would relieve this distress in a very few minutes, but disliked to take it on account of unpleasant symptoms, which MEMBRANOUS DYSMENORRHEA. 225 almost invariably followed some hours after. The chest had been most carefully wrapped in flannels. The slightest change in her clothing or exposure resulted in her taking cold and in an increase of suffering. Daily and prolonged friction, with stimulating lini- ments, had been resorted to in order to keep the blood in motion. The spine was exceedingly sensitive to pressure throughout its whole extent, for the relief of which porous plasters had been worn almost constantly for months. I found the uterus so prolapsed that, unless it was supported by a sponge, pessary or tampon, which she had worn habitually for years past, she could not stand or walk. With this deviation of the womb there was more or less of strangury, which at times annoyed her exceedingly. She has never borne any children. This case presents some striking practical facts. It illustrates that one physician, and sometimes a number of them in turn, may be deceived concerning the nature of the disease which they have been called upon to treat. It shows how the reflex and secondary phenomena dependent upon uterine disorder may mislead the practitioner ; and how apt the most experienced in our ranks are to overlook the most important symptoms, while at the same time they put great stress and emphasis upon such as are merely incidental. Membranous dysmenorrhea is a rare affection, and, when it does exist, is very apt, as in this case, to have continued for some years before being recognized. In exceptional lo^ke? _may be ° ver " cases, it occurs in young girls, but is usually met with in married women. In the majority of instances it begins soon after marriage, when it is accompanied by such slight symptoms as to be deemed of little consequence. Under these circumstances, it is usually regarded as the sequence of an early abortion. We have to confess that the special pathology of this disease is not very well known. Dewees and others have taught that it occurs most frequently in women of a rheu- Causes. . . . matic diathesis. Some authorities insist that the membranous formation, which is its chief characteristic, is always the product of conception. But this cannot be true, for it may occur in the virgin, and also in those who have for many months abstained from sexual intercourse. It is the commonly received opinion that, while in its beginning it may date from a 22 15 THE DISEASES OF WOMEN. miscarriage, the continuance of the complaint is not necessarily connected with conception. Others hold that the membranous product results from uterine inflammation. Upon this theory a recent author proposes to style the disease " endometritis epithelialis." But it is not of the exfo- liation of the epithelium merely that we are speaking. That may, and often does, occur in healthy menstruation. Oldham and Tilt refer the exfoliation of this membrane to the morbid influence exerted upon the lining membrane of the womb by disease of one or both of the ovaries. In rare instances, it may originate in syphilis. Sometimes it is related to a cutaneous eruption which has been repelled from the surface, with the appearance of which its symptoms seem to alternate. Here are two excellent specimens of the membrane which this patient has expelled with the menstrual flow. Let us examine, into its anatomical peculiarities. The old au onhem?mbrane Culiarities tnors thought it to be a kind of croupous deposit upon the uterine surface. They talked wisely, as some surgeons do in our day, of the spontaneous organ- ization of coagulable lymph into a pseudo-membrane. Dewees even suggested that these membranes might be formed from the lymph contained in the menstrual blood. If we compare this membrane with the decidua vera in the early weeks of pregnancy, we shall discover an exact correspond- ence. It is triangular, smooth within, and identical with decidua roil or]i and villous on the outer surface. If the vera. o entire cast has come away, or if we can place the shreds together properly, we shall find the three orifices cor- responding with the internal extremities of the Fallopian tubes, and the os internum of the uterine cervix. Moreover, here are numerous little openings through which the utricular glands have discharged their product. The microscope proves these mem- branes to be identical in structure. And their histological elements are precisely the same as those of the uterine mucous membrane also. It is undoubtedly true, therefore, that the decidua menstrualis, as Virchow named it, is not a new or heterologous membrane which is formed and expelled the womb at each menstrual period, but the altered lining of that cavity, which has been cast off by a species of physiological moulting. MENBRANOUS DYSMENORRHEA 227 Kow, inflammation is not a factor in the organization of the deciclua menstrualis, any more than in that of ,den n taf mmation ' s acci ~ tne decidua vera, or the outer envelop of the embryo. It is, indeed, incidental to both these processes, but it is not necessary to either of them. There is, therefore, something plausible in the theory of Old- ham, that ovarian influence has much to do with the frequent exfoliation of the uterine mucous membrane in oidham's theory of ova- ^his c i ass f subiects. In case of conception, nan influence J i - this influence undoubtedly initiates those changes which finally develop the decidua vera before the fecun- dated ovum has dropped into the uterine cavity. And do you not perceive that a slight perversion of function in the ovaries may induce a similar physiological change in the uterine textures as a contingent of menstruation? In the former case, the egg is retained throughout the period of gestation, and finally extruded at term. In the latter, it must escape, with its accompanying flow, as soon as practicable. In both, the deciduous wrapper is sooner or later expelled. This view has its confirmation in such clinical facts as the fol- lowing : When the " period " sets in, the ovaries are often found to be swollen, tender, and the seat of discom- Its clinical confirmation. _ . tort. In a majority ot cases there is considera- ble pain in one ovarian region (usually the left), which persists until after the escape of the flow, and of the shreds also. Grailly Hewitt is quite emphatic on this point and its significance :* " There is often pain in one or other ovarian region ; and it ap- pears reasonable to conclude that in some way or other this pain is connected with the formation of the membrane. The intimate functional relation between the ovaries and the uterus lends sup- port to the view that in a morbid condition of the ovary — a functional perversion, so to speak, of its influence over the uterus — we have an explanation of this abnormal occurrence." The single pathognomonic symptom of this disease is the dis- charge at the menstrual period of such a membrane as is shown you in this specimen. Sometimes, although Clinical history. . . r rarely, it comes away in the form of a sac, or complete cast of the uterine cavity, in which case it may be mis- * The Diagnosis and Treatment of Diseases of Women ; London, 1863 ; p. 479. 228 THE DISEASES OF WOMEN. taken for a mole. Usually, however, it is in shreds and pieces T which vary in size from that of your thumb nail m?mbrane and size of the to two or three square inches. These pieces, may be so regularly formed that } r ou can place them together in such a manner as to be certain from the triangu- lar shape of the mass, as well as from other characteristics, that the womb has been stripped of its lining membrane throughout. In some cases a very considerable quantity of this menstrual decidua is thrown of. It may happen that this membrane will be seen but once in the same patient. Or it may be observed each month regularly in others. Sometimes it appears at alternate an?e Sularity ° f ks appear " mon ths, and again only once in three months. In the case which I have just detailed, my patient did not for many years pass more than two consecutive "periods" without their being present. And this under every variety of climate and external circumstance. The subjective symptoms vary in different cases. Beginning usually with a delay in the appearance of the accustomed men- strual flow, the suffering is analogous to that in Its expulsion. . ..,,■. an early abortus, and in other varieties 01 dys- menorrhea. Subsequently it will be modified by the condition and susceptibility of the patient, as well as by the size of the membrane to be extruded, and the ease of dilatation of the cervi- cal canal through which it must pass. Some women suffer as severely as they would in labor at term. As I have already said, the ovarian pain is seldom lacking. One of my patients finds her suffering greatly mitigated by lying in bed for one or two days when the " period " arrives. And the patient whose case is under review has remarked that, when she ate very lightly, the men- strual suffering was very much lessened. In her experience, a hasty meal taken immediately before the catamenial flow occasions extreme suffering. Scanzoni reports that two of his patients " could always say, with perfect certainty, one or two weeks be- fore the return of the courses, whether or not they would pass membranes. Every time that this was the case they experienced for one or two weeks previously, a sharp, pinching pain in the umbilical region." The quantity of blood discharged in such cases is in excess of MEMBRANOUS DYSMENORRHEA. 229 that proper to health}' menstruation. This can be readily explained as the consequence of detaching the lining The "flow' proper „ , , „ , membrane ot the womb trom a sub-mucous sur- face which is unusually vascular. It corresponds in every way with the haemorrhage incident to abortion prior to the formation of the placenta. Sometimes the flow is profuse and alarming, but as a rule it is held in check by the contractile efforts of the womb to dislodge and expel the membrane. When this has escaped, it usually, but not always, ceases. Where some small shreds are retained, there is danger of subsequent loss of blood. In women •of an haemorrhagic diathesis, the flow may degenerate into a pass- ive haemorrhage and continue during the inter-menstrual period. In case the decidua menstrualis is not cast off, but remains until the next month, as sometimes happens, the flow may be scanty in amount at one period and copious at another. The reflex nervous symptoms which are present in this form of dysmenorrhcea vary in different persons. In some the stomach is the focal point of disorder, and a most intracta- ble vomiting results. Our patient has suffered from this symptom for nearly a fortnight at a time. In others, the greatest care is requisite to avoid severe fits of indigestion. A majority of these patients are habitually costive. If she is of a rheumatic diathesis, the cardiac s} r mptoms may be so pronounced and so clamorous as to lead to the belief that the heart is the real seat of the difficulty. It was Reflex cardiac symptoms. . . this state of things which induced my prede- cessors in the management of Mrs. 's case to form an incor- xeet diagnosis. In the frequent recurrence and severity of her paroxysms of dyspnoea, the palpitation, cardiac pain, oppression and perturbation, there were evidences of functional derangement, but of nothing more serious. The doctors must have drawn on their imagination for the physical signs of organic disease of the heart. At least, I have examined her repeatedly, and most care- fully, without being able to discover any lesion of the valves, of the pericardium, the endocardium, or of the parietes of the heart. Moreover, as soon as she was put upon the remedy which was ap- propriate for the relief of the menstrual disorder, the cardiac symptoms vanished. You should bear in mind that the remote symptomatic affections 230 THE DISEASES OF WOMEN. of the heart, and of other organs, which are dependent uport uterine disease of whatever variety, are invaria- Practical deductions. J bly aggravated at the month. Indeed, in most cases, they intermit and return as regularly as the menses them- selves. Independently, therefore, of the presence of the decidua menstrualis, this one circumstance would have led any one of you to infer that in this case the heart symptoms were reflex, and not idiopathic. It is true, however, that organic disease of the heart may finally result from such an indirect cause, when that cause i& in almost constant operation for many years. But such cases are exceptional. As in other forms of dysmenorrhoea so in this, uterine displace- ments, more especially prolapsus and retroversion, are very apt to result. In some cases the most obstinate and tio^r sequentuterineaffec ~ distressing anteversion has been caused by mem- branous dysmenorrhoea. Either and all of these deviations increase the difficulty and embarrass the treatment. Fibroids, polypi, metro-peritonitis, endo-metritis, and endo-cervic- itis, are also coincident diseases. You would diagnosticate a case of membranous dysmenorrhoea from one of abortion, by the regular return of the monthly period, by the membrane usually coming away in t . Diagnosis -from abor- s h rec ls, or if it were entire, by the sac contain- ing no rudiment of an embryo or of other mem- branes enclosed within it, and by the perforated, sieve-like appear- ance of the membrane itself. These symptoms, however, are not positive, for the patient might abort exactly at the first month ; or, because the ovum is sometimes dissolved, the sac might be empty. But it would be quite extraordinary and unprecedented for one to abort each month regularly. The only danger is from concomitant disorders. The patient might possibly die from hsemorrhage, but that would be very rare. A continuous and copious loss of blood might so undermine the general health as ultimately to endanger life. Or real organic disease of the heart, lungs or stomach, or even of the brain or spinal cord, might finally develop and destroy it. In the case of patients who are approaching the climacteric, your diagnosis should be guarded. It is very proba- ble that, could they be seen at an early date in the history of the- MEMBRANOUS DYSMENOltllHCEA. 231 disease, most cases would be curable. Sterility is an inevitable, but not always an incurable, consequence of membranous dysmen- orrhcea. Treatment. — The proper management of this disease will draw largely on your skill, your professional knowledge and experi- ence, your tact, your deliberation, and your General therapeutics. _,_ M1 , . , ,, , . patience. You will have to consider the modi- fying influences of the rheumatic diathesis, of the abortive ten- dency, the ovarian -disease, the repelled eruption, the reflex com- plications, and even of secondary disease in the uterus itself. There is no specific treatment which is suited to all cases of mem- branous dysmenorrhea alike. An exclusive idea of its therapeu- tics would certainly mislead you. Some cases of this disease are undoubtedly rheumatic, while others are not. The susceptibility of our patient to the damp, chilling prairie winds in the spring, the fugitive pains in her chest and right limb, the cardiac s}^mptoms, and the relief afforded to all these by removal to a milder and more equable climate, betray the rheumatic complica- tion. These and similar symptoms in one who was predisposed to rheumatism, would suggest such remedies as tions r rheumatic c ° mpHca acon ite, bryonia, rhus tox., nux vomica, mercu- rius and macrotin. Care should also be taken to protect the patient against the harmful influence of exposure to storms, or sudden and extreme vicissitudes of weather. She should be warmly clad, and in a measure insulated by flannel or silk wrappings. Above all things, the night air is especially inju- rious to this class of subjects. In a few women, the tendency to a periodical exfoliation of the uterine mucous membrane constitutes a species of dyscrasia. If these persons conceive, they are very likely to For the abortive dyscrasia. , -i • o ,1 -i , i abort; and 11 they do not become pregnant, they are fit subjects for the disease in question. This abortive habit is a powerful predisponent of membranous dysmenorrhcea. Most of the hints which are applicable to the prevention of threat- ened abortion are equally appropriate here. I need not pause to detail them. It may happen, in exceptional cases, that the character and his- tory of a repelled eruption will point out the proper remedy. 232 THE DISEASES OF AVOMEN. When this patient placed herself in charge of her last physician, she was put upon sulphur 30th, with prompt tiQ in .case of repelled erup- an( i evident relief of all her symptoms. This was prescribed on account of the chronic nature of her disease, and its manifest relation to the eruption which ha(l been repelled. A few doses of apis mellifica 3d were then given for the ovarian pains, the urinary trouble and the cardiac symp- toms, and she was finally ordered calcarea carbonica 12th, which she is now taking. In so far as the reflex symptoms are concerned, there are but very few of them that are distinctive, sugges- va Reflex symptoms irreie- fty^ or reliable. They are quite too sensa- tional to be trustworthy. You cannot depend upon them as indicating the suitable remedy, any more than upon a majority of similar symptoms in hysteria. The ovarian lesion and its symptoms are more significant. For, in most cases, if we can recognize and remove toms r the ovarian symp ' them, we may hope to cure the menstrual dis- order. Apis mellifica, calcarea carbonica, pla- tina, belladonna, colocynth, lachesis, thuja, kali jodatum, mercu- rius, or hamamelis, may be appropriately and successfully em- ployed. Since we understand the origin and structure of the decidua menstrualis, the stereotyped advice to employ such remedies for the cure of this disease as are given in pseudo- ^ An antiquated prescrip- membranous croup and diphtheria, would be of very doubtful service. For other reasons than those usually given, it is possible that in some cases the bichro- mate of potassa, mercurius jodatus, cantharis, ammonium caus- ticum, or even the chloride of lime, might prove serviceable. In a case of this disease, Dr. Mandl,*, however, applied the kali chlor. directly to the uterine mucous membrane, at short intervals, for the space of ten months. The effect was to interrupt the for- mation of the decidual product while he continued the applica- tion, but as soon as he desisted, it was formed and expelled as before. There is no evidence that local applications to the uterine sur- * Wiener Med. Wochenschrift, No I, 1869. MEMBRANOUS DYSMENORRHEA. 233 face have ever accomplished any more in this disease than in the case just cited. The good they do is temporary, Local applications are of anc [ even ^g j g more than counterbalanced by temporary benent. «/ the risk attending their application ; for you may take all the precautions prescribed, and yet, as a rule, they are not safe or advisable. Marriage has sometimes been prescribed as a remedy for this disease, but it is an unwarrantable expedient, and is very likely to aggravate the complaint. Conception may cure Other expedients. . . - ' _ it, provided the patient can go to term. It may be indispensable to the cure that she should live absque marito. Or we may prescribe that intercourse shall take place only at long- intervals. Very decided benefit may sometimes be derived from the em- ployment of the sponge-tent, with a view to dilate and remove any obstruction of the cervix which prevents the free escape of the menstrual blood. This would cause the womb to disgorge, unload its capillaries, relieve the hyperemia, avert an excessive hypertrophy of the mucous mem- brane, and possibly prevent its exfoliation. Moreover — and it is by no means an inconsiderable thing — this dilatation greatly mit- igates the sufferings of the patient. I applied the tent repeatedly, and with excellent effect, in the case of which I have now spoken to you at such considerable length. [One of the most interesting cases in the woman's clinic was No. 17,027. The patient came to us with psoriasis Psoriasis and memb. ... , ,-, ,. -. . ,-. -• dysmenorrhea. guttata, the eruption being on the arms and chest. For five months it had alternated with the expulsion of membranous shreds and clots. The menstrual obstruction was accompanied with labor-like pains and suffering, which continued for several days, during which time the cutaneous eruption disappeared. She first took arsenicum 3, and after- wards the 30th, with excellent effect. The irritation of the skin was relieved and cured by dulcamara 3.] LECTUEE XIV. MEMBKANOUS DYSMENORRHCE 1 — CONCLUDED. Membranous dysmenorrhea arising from repelled eruptions, from the repercussion or cutaneous eruptions; cases; sterility as a sequel ; statistics; result of treatment, etc. In July 1876 I had the honor of reading an essay upon this sub- ject before the International Homoeopathic Congress which had convened in the city of Philadelphia. The views expressed in that paper have been confirmed by my subsequent experience, and I venture to give you the substance of that report this morning. Not the least curious and wonderful of all the physiological processes known to us is the periodical development of the lining membrane of the uterus. This process of "nidation," or nest-making, is as essential a factor in menstruation as it is in generation. If it occurred only once ill a year, as in the oestruation of animals, it would still be remarkable for its delicacy, and for the peculiar contingencies with which it is beset. But, in woman, its monthly repetition multi- plies the risk of its becoming disordered, and there are compara- tively few r who pass through the whole period of menstrual life without suffering some of these consequences. Membranous dysmenorrhcea is not so well understood, nor so skillfully and successfully treated as other kinds of painful men- struation. This fact is partly due to its relative comparative infre- i n f re q UenC y # p r, compared with the spasmodic and obstructive varieties it bears about the same proportion that cases of breech presentation do to those of the cephalic extremity. Now that the shreds, or casts, thrown off in this disease are known to be caused by the exfoliation of hypertrophied mucous membrane of the uterus, and not by the exudation of lymph, and the formation of a new or croupal membrane, its morbid anatomy is very much simplified. And the fact that this product is decidual MEMBRANOUS DYSMENORRHEA. 235 and not diphtheritic, homologous and not heterologous, is destined greatly to modify its special therapeutics. But, however great the advance that has already been made, the etiology of membranous dysmenorrhoea is incomplete. For, although the felt-like shreds, or strips, which Non-inflammatory. ,.,. . ... ,, . , are moulted in this disease are recognized as portions of the menstrual, or nidal decidua, it still seems practi- cally impossible for physicians to separate in their minds the for- mation of this product from the existence of the inflammatory process. The most recent author even proposes to style it an epithelial endometritis (endometritis exfoliative).* On the one hand he declares that the sieve-like casts and pieces, consist of the hyper trophied mucous membrane which, from the rapid produc- tion of free cells, is detached and thrown off at stated periods; on the other, that the process is inflammatory and exudative, and not a mere exfoliation. Experience proves, however, that while a woman with membranous dysmenorrhoea may also have endometri- tis, she is quite as likely to have ovaritis, or even endocarditis as a coincident affection. Accepting the view of Oldham and others that the cause of this disease may frequently be found in ovarian irritation and inflam- mation ; the idea of Dewees that the rheumatic A variety of causes. ....... . . . ,. diathesis is responsible tor its existence m a. certain proportion of cases; and the more modern claim that it may be caused by uterine deviations, my experience leads me to conclude that there are some examples of this affection which are inexplicable and incurable by, or through, either or all of these different theories. In other words, these theories do not apply to all cases indiscriminately. The most intractable cases of this singular affection that have come to my knowledge have been associated in their clinical his- tory with the existence and sudden disappearance erI r p °tSn C s Utane0US of a cutaneous eruption. This eruption may, indeed, have been slight and possibly have been forgotten by the patient herself. It ma}' also vary in its character in different persons, being either papular, herpetic or vesicular, squamous, syphilitic, or erysipelatous. In one of my cases it was a " rash, like prickly heat;" in another, the patient was positive *Dr. Beig-el, in the Archiv. fur Oynakoh, Band ix. Heft I. 236 THE DISEASES OF WOMEN. that she had once had the " hives," and that her menstrual diffi- culty followed directly upon their being- " driven in." Sometimes the appearance of this eruption upon the face, hands, or body, alternates with the menstrual disorder; but more frequently, unless medicines have been taken to " drive it out," no trace of it can be found at any time. In one case of erysipelas of the legs and thighs the lesion extended to the genitals, and to the womb, and a membranous dysmenorrhcea of six years standing was the direct result. In one of my patients, who was very ill with this form of dysmenorrhcea, the repercussed eruption had not been seen for eighteen years until it blossomed out as the Case. • result of my treatment; and I have recently cured another in whose case the " salt rheum " had disappeared twelve years before, with the immediate advent of shreds and bits of membrane in the monthly discharge. The comparative frequency of cases of this kind, which have been more or less intimately associated with skin affections, precludes the possibility of their accidental relation. For, out of twelve cases of real membranous dysmen- orrhcea which I have treated within the last five years (1876), eight of them have been of this sort. In this list I do not include those milder cases which are very much more numerous, and in which there is merely an increased desquamation of the uterine epithelium in the form of diaphanous shreds, or patches. This contingent of menstruation is sometimes met with in uterine deviations, catar- rhal endometritis and menorrhagia, and is much more easily cured. Sterility is as common and constant a symptom of membranous dymenorrhcea as is the shedding of the membrane itself. And there can be no better guarantee of the cure of a case of this form of dysmenorrhcea than is fur- nished by a fruitful conception and labor at term. The clinical history of barrenness often includes the history of old skin affec- tions which, in some unaccountable way, have interfered with the function of reproduction. The remarkable effects of certain mineral waters as a cure for sterility, and for complicated disorders of the catamenial function, can best be explained by their value in some chronic cutaneous diseases which have first been repelled, and then resisted other modes of treatment. Sterility as a sequel. MEMBRANOUS DYSMENORRHEA. 237 Anatomically the epithelium is the epidermis of the mucous membrane. Clinical experience has long since demonstrated the mutual sympathy and morbid relations of these two surfaces. The occurrence of a metastasis of disease from The skin and the uter- one t ^ Qther j j • remarka- me mucous membrane. ble. Indeed it is very common, more espe- cially in cases of those membranes which, like the lining of the nose, of the throat, and of the utero-vaginal tract, arc in direct continuity with the external integument. The modern classification and description of skin affections is quite in accord with the idea that, under certain circumstances, almost any of them might be translated to the uterine mucous membrane. The moment we define eczema as " a catarrhal inflammation of the skin,"* we have declared upon its proneness to migrate from the outer to the inner surfaces of the body, and to work mischief in them. Manifestly, the internal lesion, which is due to this cause, will be intractable, if not grave in character, in ratio with the delicacy of the function involved. For the monthly Practical deductions . . . formation, enlargement, separation and repro- duction of the uterine mucous membrane, its progressive changes, its restrogressive or fatty degeneration, and the escape and cessa- tion of the flow are so many physiological steps, that such an invasion would almost certainly interrupt or modify. And it might very easily change the natural and proper exfoliation of the uterine epithelium at the month, into a morbid separation of the subjacent mucous layers, and the shedding of a thick and tough cast of the uterine cavity. That these identical consequences do sometimes follow the repercussion of an eruption, I am fully persuaded, not only because I have been able to trace the beginning of a membraneous dys- menorrhea directly to such an accident, but also because I have found it possible to cure this secondary form of the disease through a knowledge of this fact, and by using it as a key to the special therapeutics of the case. Two of my colleagues have recently consulted me concerning the best treatment for membranous dysmenorrhea, each of them having a case of the kind under his professional care. The above *A Handbook on the Theory and Practice of Medicine, by F. T. Robert, M. D., etc., p. 1018. 238 THE DISEASES OF WOMEN, theory of its exceptional origin was explained, and they were asked to inquire particularly with reference to ^ Corroborative expert- ^ ^.^j ^^ Qf ft p^oiM Qr coincident skin affection. The following evidence afterwards supplied by these gentlemen, has the merit of being fresh without having been fabricated expressly to support the theory under con- sideration. Case. — This case is reported by Prof. Gr. A. Hall, M. D., whose notes read as follows: "Mrs. M., aged thirty-five years, resides in Chicago. The menses first appeared at thirteen years of age, and were natural until her marriage at twenty-two. She has two children, the first of which was born ten months after marriage, and the other three years later, with one abortion since that time. " During her youth and up to the period of her first labor, she was troubled with the ' hives," or nettle-rash, but after the birth of the child it ceased, and she had nursing sore-mouth for weeks. This was followed by a chronic diarrhoea, which lasted for several months. The tongue has remained soft, patulous, and spongy, and is sometimes slightly ulcerated. After the diarrhoea was controlled, a small round spot, as big as a half-dollar, appeared on the inside of the left thigh. It came first before, and remained during the menstrual flow. It looked very red, and was attended with an intolerable itching, but it disappeared nearly three years ago, at the time of her miscarriage. The latter was not painful, but after a moderate flowing for twenty-four hours, the embryo and placenta were thrown off intact. Ten days later she had secondary haemorrhage which lasted for ten weeks. She was greatly reduced in strength, and has never fully recovered her health. " Four weeks after the cessation of that flow the menses were resumed, and for the first time the membranous shreds and casts, of which I send \ou a specimen, appeared. Her appetite became morbid, and she craves starch and salt. Since her miscarriage she has never had the itching spot on the inside of the thigh, or any- where else externally. The catamenia are now attended with moderate pain and flowing for three days, when the membrane is extruded, after which the pain ceases, and the flow continues for three days longer, but moderately." Case. — For the details of this case I am indebted to J. E. Mor- MEMBRANOUS DYSMENORRHEA. 239 xison, M. D., formerly of Hyde Park, Illinois. " Miss G.JVL, twenty-three years of age, began to menstruate in her twelfth .year. From her second year until puberty she had suffered from running sores, and occasionally from an eruption like bee-stings, with a fine rash over the body, but especially about the waist. For the first three years, or until she was fifteen, her skin was never healthy, nor was the menstruation either painful or too pro- fuse. " About this, time, however, the eruption would sometimes disappear from the external surface, and this change was always observed to increase the monthly pain. For the last four years, excepting only at very long intervals and temporarily, no sign of the skin affection has shown itself; but the dysmenorrhcea has become more and more pronounced. Within that time it has assumed the membranous form, and firmly organized shreds are thrown off at every return of the ' period.' Her suffering in that interval has been very severe, and thus far has resisted all medical aid." Treatment. — Concerning the curative indications which are deducible from this bit of clinical experience, we have to acknow- ledge that as yet they are neither very explicit nor complete. To have treated only eight cases of this particular kind of membrane- ous dysmenorrhoea, and to have been consulted in perhaps a dozen others by letter and otherwise, does not warrant us in dogmatizing upon its special therapeutics. The temptation to speculate upon this subject, however, is very strong, but we for- bear. For what a remedy " ought" to do, and what it really will do, are not always the same thing. Where the precise character of the eruption which has pre- ceded the menstrual lesion is unknown, we can not, perhaps, do better than to begin the treatment with the use of Sulphur. In the case already referred to, where the eruption had not been seen for eighteen years, this remedy, in the thirtieth dilu- tion, had the desired effect, and produced a marked and lasting amelioration of the uterine symptoms. But, if the nature of the eruption can be determined, either by direct inspection, when it crops out occasionally; through the description of an intelligent parent, or patient, who remembers just what it was; or, by the ferreting action of sulphur, we shall 240 THE DISEASES OF WOMEN. know better how to proceed. In this case we venture to recommend the following practical hints for trial and confirmation, or rejec- tion, as they shall prove worthy or otherwise. If the eruption is, or has been, like urticaria, give arsenicum alb., rhus tox., or urtica urens. If what is vulgarly called the " hives," apis mel. (in the third decimal trituration), belladonna, chamomilla. If it is, or was, herpetic or vesicular, cantharis, rhus tox. If squamous, or " scurfy," borax, arsenicum, mix mosch., dul- camara, silicea, sepia. If scrofulous, and otherwise unclassifiable, sulphur, calc. carb. ,, hepar sulph., mercurius. If syphilitic, thuja, nitric acid, mercurius iod., kali iod., meze- reum. If from suppressed rubeola, or if it alternates with ophthalmia, Pulsatilla; or, in the former case especially, cuprum acet. If it is erysipelatous, belladonna, cantharis, rhus tox., apis mel. Should further experience verify the importance of knowing that repelled eruptions do sometimes cause a membranous dys- menorrhoea, this limited and imperfect list of remedies will doubt- less be very much changed and enlarged. It is not improbable that there are some medicines which, although \,hey are not now sup- posed to possess any curative relation to the disease in question, may yet prove, through this general indication, to be very useful in its treatment. Among these are doubtless bromine, mercurius f bryonia, phosphorus, ustilago, and collinsonia canadensis. There are undoubtedly good grounds for confidence in the vir- tues of calcarea curb, as a remedy in this particular variety of dys- menorrhcea. It does not appear to be suited to all cases, and certainly does not deserve to be extolled as a specific ; but, when it is appropriate, its curative action is quite as marked as it often is in too frequent menstruation and in menorrhagia. I have no question that, as a uterine polychrest, it is possessed of an inti- mate and specific relation to the fatty changes which occur each month in the uterine epithelium, the physiological separation of which permits and provides for the exit of the menstrual blood from the surcharged capillaries. We have a forcible illustration of this quality of the calcarea, in its ability to discuss certain MEMBRANOUS DYSMENORRHEA. 241 morbid growths, which it resolves away through a similar meta- morphosis; but more crudely, in the power of lime to detach the pseudo-membrane in croup and diphtheria. Our Avorkers in the materia medica, and in gynaecology, should define this relation , and develop this suggestion - . The frequent indication for calcarea carb. in scrofulous and other skin affections, is suggestive of its value in the membranous dysmenorrhea, which is secondary upon these eruptions. With the few exceptions in which I have prescribed the sixth or the twelfth attenuation, I have always given the third decimal tritu- ration in these cases. If we find, in a given example, that dysmenorrhcea due to this cause is complicated with ovaritis, or rheumatism, the prescription may need to be modified. But it should not be forgotten that ovaritis itself is as likely to result from certain suppressed erup- tions as it is from the sudden metastasis of a gonorrhceal inflam- mation. In a certain ratio of cases, the best-chosen remedy that is pre- scribed on these, or similar indications, will fail to complete the cure without manual assistance of some kind. This is more especially true of the treatment of membranous dysmenorrhcea when it co-exists with retroflexion (not retroversion) of the womb. Under these circumstances the reposition of the organ, as a con- dition for the prompt and ready exit of the flow, allays and averts the tendency to a moulting of its nidal membrane. And the effect of this expedient is still more decided if a free dilatation of the cervical canal is also secured at the month. It is possible that this disease may arise as a sequel to diphtheria, when it would require to be treated accordingly. But the off- hand method of prescribing for it as though it were alwa}^s and strictly a pseudo-membranous affection, is not only unsatisfactory in theory, but unsuccessful in practice. BORAX IN MEMBRANOUS DYSMENORRHCEA. For the notes of the following case I am indebted to Dr. A. P. Throop, of New York. You will find it in the Transactions of the Homoeopathic Medical Society of the State of New York, vol. X, 1872, p. 279 : Case. — Mrs. P., aged 21 years, married fifteen months, came to 16 242 THE DISEASES OF WOMEN. me for treatment September 4, 1871. She had no children and had never suffered from miscarriages, but had been complaining for about a year of irregularity in menstruation, as follows: The menses appeared four or live days too early, and continued four- teen ckiys unattended with pain. Eight months since she noticed shreds of membrane mixed with the menstrual discharge. There wasatthis time no dysmenorrhea, but the period occurred more fre- quently, every three weeks, and sometimes lasted for sixteen days. This condition continued until the patient applied for relief from the severe clysmenorrhoea,with intense uterine tenesmus or k ' bear- ing down " pains from which she was suffering. Prescribed secale cornutum, pure tincture. The pain was not relieved at once, yet it ceased, as did also the discharge, soon after the passage of pieces of membrane of the same character, but larger than those previously passed. The discharge continued only three days after the last shred of membrane was passed. The menses again appeared on the 28th of September, with severe dysmenorrhcea, lasting seven days, at the expiration of which time a much larger, though similar membranous substance was passed. The patient, on this occasion, describes the substance as being two or three inches in length, and having "a sort of three-cornered shape." Previous to this no mention had been made of passing these unusual substances, but the history of this feature of the case was given in answer to my questions. The patient was requested to preserve this last unusual men- strual product, and, on examination, it proved to be a perfect membranous cast of the cavity of the uterus, triangular in shape, with that portion corresponding to the canal of the uterine neck a little longer than the angles corresponding with the cornea. It was ascertained to be hollow, and its external surface was studded with little villous prolongations. This membranous product, with the history and symptoms of the case, made the diagnosis easy, — membranous dysmenorrhcea. Treatment. --As suggested by Prof. Ludlam, of Chicago, pre- scribed borax 1, three times a day, till the next period. The next period occurred the 25th of October. Dysmenorrhcea much less, no cast, only shreds, less in size than for months, and the general condition better. The last prescription of borax 1, was given November 21st. In January, 1872,1 called at the patient's home, being desirous to know the sequel of the case, and ascertained that there had been no more dysmenorrhcea, as the period had not again appeared, and the patient was pregnant. As pregnancy and membranous des- quamations from the inner wall of the uterus are not compatible, the membranous dysmenorrhcea is supposed to be cured. On the 7th of August, 1872, she gave birth to a tine, healthy MEMBRANOUS DYSMENORRHEA 243 female child, and there have been no symptoms since of any uterine trouble. MEMBRANOUS DYSMENORRHEA FROM EXFOLIATIVE ENDOMETRITIS. Case. — Mrs. M., American, ret. 31, and sterile, began to men- struate when 18 years of age. Her mother did not menstruate until her eighteenth year. The first menstrual flow was very painful and profuse. One year elapsed before the second made its appearance. During this time the patient bloated frequently, and had nose-bleed, but does not remember whether this occurred at the month. During' the two following years menstruation re- turned four or five times, the periods unvariably coming while the patient was under some nervous strain. The flow at this time was very painful, but was not, and never has been, accompanied by headache. From her 18th to her 21st year, — the time of marriage, — ■ she taught school, and on her way to and from school was often exposed to stormy weather. She remembers that frequently she has sat for hours with wet feet. Two weeks after marriage the menses again appeared. At their cessation she was seized with an acute inflammation of the bladder and kidneys. This lasted four or five weeks in an acute form. The paki on voiding urine continued for more than a year. Upon recovering from this illness a leucorrhceal flow began. Up to this time her geueral health had been good, but it now began to decline. Two years later, during' a menstrual period, a falling of the womb took place. This prolapse is aggravated at the menstrual period. Some two years later the patient began treatment. A local examination was made and the case called one of anteversion. An instrument was introduced into the womb to replace the organ. This was repeated four or five times. Fail- ing to keep the uterus in place a Macintosh supporter was ad- vised. After a four weeks' trial this was abandoned on account of the inflammation caused by it. As soon as this subsided, the physician began the use of sponge- tents. About a half-dozen of these were inserted during a period of six months, on each occasion producing more or less inflammation. But one flow occurred during this time. This was profuse, and with the blood black clots were discharged, pieces of decayed flesh, and stringy substances. A diagnosis of membranous clys- menorrhoea was then made. Xo especial treatment has been taken since,— a period of six years. No change has taken place in the character of the flow. During the last three years she has had a severe cough accompanied by an expectoration of thick mucus. During stormy weather 244 THE DISEASES OF WOMEN. a sharp pain is felt in the apices of the lungs. All these pec- toral symptoms are relieved by the now, and do not again occur until six weeks or two months after the flow. Patient stopped menstruating one week ago ; feels weak ; has bearing down pains when erect, with a sensation of smarting in the womb, and an irritated feeling in the vagina; some pain on urinating; bowels constipated; arid she is troubled with haemor- rhoids. On physical examination. — The cervix is depressed and points toward the hollow of the sacrum, the womb lying transversely across the pelvis. The fundus is inclined forward (ante version). The internal os is open , the internal surface of the uterus is very sensitive, and its depth is three and one-fourth inches. There is no especial tenderness of the ovaries. In response to inquiries, the patient says rheumatism is not a family complaint, and that she has had no eruption on the skin since a child, but that there is a tendency toward consumption in the family. I have cited this case in illustration of a rare form of dysmen- orrhoea which is both membranous and inflammatory. The case is still further complicated by the uterine de- Rarity of such a ease. . , . , . , , . . , , n ... , viation, whicn very likely had something to do with causing it. For versions of the uterus which occur at or about puberty, are almost always the result of flexions ; and it is not improbable that this case may have begun Version as a factor of . . , , . . , , -. . n . , . . , -, ,. with the bending of the uterus upon itself as a sequel of her first " period," and that the long interval between it and the second, resulted partly, or wholly, from this cause. Be that as it may, the attempt to keep the organ in situ by means of an infra-uterine stem was the worst thing that could possibly have been done, for it almost necessarily Mal-treatment by the . , -. ... ,. - ,, ,. . , stem-pessary. induced an inflammation of the lining membrane of the womb, when that membrane had already been congested by the displacement. Under these circumstances the careful gynaecologist would no more think of leaving" a stem in the cervical canal than he would of placing a sponge-tent there while there was any peri- uterine inflammation. There are two or three reasons why you should be careful to differentiate this from the more ordinary forms of membranous dysmenorrhcea. In the first place the remedies that are suited to exfoliative endometritis are OVARIAN MEMBRANOUS DYSMENORRHEA. 245 not those which are most successfully used in the treatment of the common type of deciduous dysmenorrhea. They include the dif- ferent preparations of arsenicum and mere urius, the mineral acids, and baptisia. In the second place, all sorts of local treatment, including the use of sponge- tents, the resort to intra-uterine injections, the wearing of pessaries, the dilatation of the cervix ; nfflo e atroa S 10Cal0 ° ntra " b y ^ meailS ' a » d eVe11 the P ; ^g e of t!le uterine sound, or the probe, will be mischievous, and are contra-indicated in exfoliative endometritis. We may permit the use of warm sitz-baths, or hot water vaginal injections, and of enemata, to keep the bowels open, without fear of doing harm, and with the prospect of good results in some cases. This patient has now been five months under treatment. She has taken belladonna 3, during the period, and arsenicum jod., 3, during the interval. The result has been that Result of treatment. .'",„. instead ot returning every nine or ten weeks only, her periods recur every five or six weeks, and her local suf- fering, as well as her general condition, have improved in a coi- responding degree. She is very anxious to become a mother, and, if she could conceive and carry her offspring to term, it is very likely that she would be radically cured. OVARIAN MEMBRANOUS DYSMENORRHEA. Case. — Mrs. comes from a neiodiborino; State. She is twenty-six years of age, and has been married six years. She has never had any children, but has had an abortion at the sixth week. She began to menstruate at thirteen; there followed an interval of two months, and then the periods were regular until after her marriage, since which time they have varied from three weeks to three months. When she goes over two months, there is alwa} 7 s a membrane expelled, but at no other time. The periods last four and five days, and the longer the interval, the greater the pain and suffering, until the membrane is expelled, when the flow con- tinues, but without pain. There is constant pain in the left ovarian region, and on the outside of the left ankle, but none in the limbs. The infra-mammary pain is pronounced, but passes away when the flow begins, and does not come at any other time, but is greatly increased by any unusual delay in the menses. She has no leucorrhoea, no vesical trouble, and no constipation 246 THE DISEASES OF WOMEN. she sleeps best on the affected side, and has an almost constant vertex headache. On local examination, the womb was found somewhat ante- flexed, the canal of the external os was patulous, and the cervix was swollen. The introduction of the sound revealed a tortuous canal, and the depth of the womb was three and one-half inches. There was a slight corporeal cervicitis, and a little haemorrhage followed the introduction of the sound. In addition to the symptoms just given, there was a slight laceration of the cervix, which, although it happened to be of little consequence in any other way, disclosed the fact utlrL buttou " hole os that she had had an abortion, or rather, that some foreign body other than the membranes, must have been expelled from the uterine cavity. In fact she did not confess to having had an abortion until I told her that such must have been the case, when she remembered that she had had such a mishap in her early married life. You must keep a sharp look out tor this button-hcle os in making your local examinations. The theory advanced by Oldham, that ovarian inflammation is the prime factor in some cases of membranous trat 1 eT mSthe0r " illU3 " d y smeil0lThcea ' is illustrated by this patient's history. If we can cure the ovaritis, the men- strual difficulty will disappear, and there is no valid reason, at least in so far as her own health is concerned, why she may not conceive and go to term. This woman has been taking gelsemium 3, four times daily with excellent effect. All of her symptoms have improved. The menses now return every four or five weeks, and in the two last periods there has been no exfolia- tion of shreds, no labor-like pains, and almost no burning or aching- in the ovary. I am bound to tell you, however, that something of this result, and perhaps the whole of it may be due to the fact that for several months she has been living apart from her hus- band. LECTUKE XV MENORRHAGIA. Menorrhagia. Case.— Differential diagnosis in cancer; modes of examination; surgical treatment. Case.— Uterine disorders complicated with malarial fever. Case. Case. — The first case to which I will direct your attention, this morning, is one of menorrhagia. The patient, Mrs. A., is 46 years of age. Three years ago she had a miscarriage at four months, since which time she has never been quite well. " Is the flow very profuse, madam?" "O, yes, sir; it is very bad when it comes on." "Do you have it all the while, or only at particular times? " "Xo, sir; it only comes on when I have my monthly sickness." " Will excitement or fatigue produce it at any other time?" " Xo, sir." "Do you have any pain?" "Yes, sir; I am troubled with awful pressing-down pains in my hips and the small of my back." " Have you headache at these times also?" " I have a distressing headache so loug as I continue to flow." " What is the character of the flow ; is it quite natural? " " At the first it is, sir, but afterwards it is like any other bleed- ing, bating the dark clots which sometimes come away when I have those awful bearing-down pains." "Are your courses regu- lar? " " Xo, sir ; they sometimes come on every three weeks, and sometimes not so often." Menorrhagia signifies a profuse menstruation. It may or may not be painful. The flow is excessive, prolonged, hemorrhagic, and debilitating. Women who have attained Definition of. „ ° . . the age ot our patient, in other words, who are more than forty years old, but who have not passed the climac- teric period, are of all others the most liable to this disorder. In them the return of the menstrual period is prone to be irregular. Sometimes, as in this case, it is too frequent, the in- terval being less than a lunar month. Again, Variations in time. . . "r • i t . -,. this interval is so prolonged as to occasion dis- tressing symptoms, due to the suppression of an accustomed flow, or anxiety, lest conception may have interrupted the function altogether. You will frequently be consulted in similar cases. A very im- 247 248 THE DISEASES OF WOMEN. portant point is to make out a proper diagnosis. Heemorrhao-e from the uterus may result from polypi, fibroids, Differential diagnosis of . .. l j i ■> > cancer, abortion, menstrual congestion, chronic metritis, or from sub-involution of the uterus, or after delivery at full term. Uterine hemorrhage from a polypus, or cancer, may occur at any time and without premonition. It is metrorrhagia, and has no fixed period of recurrence. Menorrhagia is always and evidently connected with the function of menstruation. The attack occurs with all the regularity of the menstrual flow. The interval is as well defined as in a case of intermittent fever. It may he of two, three, or four weeks duration, but the haemorrhage is evidently determined by the accession of the catamenia. If you explore with the sound and the speculum you can detect a polypoid growth, or a cancer, if it exists, but a local examina- tion of the uterus in menorrhasfia proper, re- Modes of examination, -ni ii veals nothing especially abnormal, or pathog- nomonic, unless it be an increased depth of the organ. The mucous membrane is injected with blood, and more highly vascular than in the inter menstrual period, but this is always the case in the monthly sickness. The weight of the womb is always in- creased by the afflux of blood to it during menstruation. Excepting chronic metritis, with uterine sub-involution, the lesion that you will most frequently recognize in menorrhagia is sub-acute ovaritis. One of the ovaries is tender Complicating- lesions of. . ,, , . „, to pressure, especially at these times. I he patient cannot lie upon the affected side. She complains of lame- ness in the corresponding limb. At huch times urination is pain- ful. Strangury is a frequent and annoying symptom. The effort at stool increases the suffering, The pain extends from one ovary across the abdomen, or both ovaries maybe affected from the out- set. This pain, which is ordinarily dull and deep-seated, becomes acute like that of peritonitis, during the men- strual crisis. If you fail to detect any swelling through the abdominal parietes, the double touch may disclose a tenderness and tumefaction that will readily explain the suffering. It often happens that such symptoms date from, a miscarriage. This is very likely to occur if the foetus has From a miscarriage. . " „ : - 1 . - been carried long enough for the placental at- tachments to be well-formed. In the case before you an abortion MENORRHAGIA. 249 occurred at the fourth month. Sub-acute ovaritis is a frequent cause of abortion. In many cases the affection runs a kind of latent course and the physician fails to discover the real lesion. This patient complains of pain in the region of the right ovary, which is acute at the menstrual period, and dull or sub-acute in the interval, worse upon fatigue; of lameness in the right leg and inability to lie comfortably upon the affected side. I have found, upon making a local examination through the vagina and the abdominal parietes, that this ovary is swollen and very tender to the touch. With the instructions Local examination. , that you have already had upon the uterine sympathies you are prepared to understand how ovaritis some- times causes menorrhagia. Treatment. — For practical reasons we divide the treatment of menorrhagia into that proper during the continuance of the flow, and that appropriate to the interval. To meet the first indication very little skill is required. If the flow is passive ^Remedies during the and pamless? or nearly go? the pat ient of ail haemorrhagic diathesis, with hemorrhoids, or varicose veins, hamamelis is the appropriate remedy. It will also be indicated in case of marked ovarian irritation or inflammation, especially if the attack is sudden and its course rapid. It may be applied locally over the ovaries and indeed upon the whole abdo- men. Given internally in the first or second decimal attenuation, the t dose should be repeated at short intervals. If the flow is bright red, but passive, and accompanied by gastro-intestinal irritation, you may give ipecacuanha. China is called for when repeated floodings and leucorrhceal discharges have weakened the patient greatly. You may sometimes alternate this remedy with ipecac, with the best results. This is an old and favorite prescrip- tion. Sabina and secale cor. would be appropriate to menorrhagia when complicated with dysmenorrhea. The latter is more serviceable in post-partum haemorrhage. These comp^ a nons°. r PeCUhar remec ^ es are tne more important and reliable in examples of the kind, when the design is simply to arrest the flow. As auxiliaries, rest in the recumbent posture, quiet, the local use of hot water, and cool, acid drinks are neces- sary. 250 THE DISEASES OF WOMEN. In the constitutional treatment proper to the interval we should take into account the peculiar temperament and dyscrasia of the patient, as well as the local lesions and symp- intervai men "* toms. If there is sub-acute ovaiitis, the symp- toms may require hamamelis, sepia, platina, bell., or some similar remedy. When, as in the case before us, the menses are too frequent and profuse, and especially if the patient is of a strumous habit, with a tendency to pectoral disorder, the calcarea carb.,is_par excellence the appropriate remedy. We pre- scribe for this patient hamamelis virg., 2d decimal trituration every two hours during the flow; and calc. carb. 3d decimal trituration, morning and evening, throughout the inter-menstrual period. In the Hahnemannian Monthly for December 1870, you will find an excellent article by my friend Dr. O. P. Baer on the therapeutics of uterine haemorrhage. His remarks are so plain and practical that I will cite a few of them. He says : "I think belladonna one of our best remedies in haemorrhage from the uterus. Its sphere of action is greater than any other known remedy. I have watched its actions so constantly, for now nearly twenty-five years, have noted the symptoms relieved by it so often (many of which have never been recorded), that I have no hesitancy in terming it the king of remedies for uterine haem- orrhage. Ipecac does well in its limited sphere, of which nausea and vomiting are the chief characteristics. And mind you, this nausea must proceed from the stomach alone, and the discharge of blood be increased with every effort to vomit. This nausea does not affect the system particularly, otherwise than by inducing increased debility. Belladonna also relieves nausea, and particu- larly, when there is a wave-like feeling, or undulating sensation, or pulsating tremor all over the whole person, from head to foot; and a sick pulsation even in the fingers and toes. This symptom I have often met with, particularly in severe haemorrhages of mis- carriages, and belladonna m such cases always gives prompt relief. Ipecac would fail. I have known it to fail in just such cases. The ipecac nausea gives a weight in the stomach and no further, while belladonna gives nausea with rumbling in the whole abdomen, with great weight from above downward. Gentle pressure upon the uterus may cause nausea, and should it do so no other remedy is so promptly effectual as belladonna. Where the moving of the MENORRHAGIA, 251 hands or feet cause the same feeling' of nausea, with wave-like swimming (vertigo) of the head, bell, again, is the only reliable remedy. *.*-*•**. In the belladonna nausea theje is rarely retching, or heaving, while in ipecac there is upward heaving, raising the abdomen, bowing the back, and straining tu vomit. The action of belladonna is deeper-seated, more quiet, and more insidious. Chamomilla nausea in haemorrhage is one accompany- ing 1 fainting. A chamomilla nausea is rather lisdit, though always attended by a feeling of fainting. Belladonna has a feeling some- what similar, such as a sinking feeling, just as if the bed was going downward by undulations. Podophyllum resembles belladonna in one particular, which is, an all-over sickness, and with the general nausea, she feels perfectly indifferent and desires to be let- alone. I have seen cases where podophyllum did good work, where the patient would say, " Oh, I am so deathly sick !" " Where are you sick?" the response would be, " All over." A few doses of pod. 30, or 200, would check the whole trouble. But belladonna comes in so often as king, that I seldom need to Fig. 27. Penrose's Uterine Polypus Forceps. resort to other means. Give bell, early, and many of the worst symptoms fail to come." The surgical treatment of monorrhagia consists in the Fig. 28. Hodge's Modification of Aveling-'s Polyptrite. removal of the cause, as, for example, in extracting intra- uterine polypi and fibroids, and the removal of granulations from within the cervix. Excep- tionally, where fibroma can not be removed, the haemorrhage may be arrested by a free dilatation, or even by an The surgical treat ment. 252 THE DISEASES OF WOMEN. incision of the neck of the womb; and in the worst cases of inter- stitial and of sub-peritoneal fibroids, Battey's operation may be expedient merely with a view to the arrest of the haemorrhage. These forceps answer very well for twisting off the smaller mucous polypi located about and within the os-uteri, and which often bleed so copiously. NITRIC ACID IN MENORRHAGIA. Every practitioner of considerable experience has encountered cases of metrorrhagia supervening abortion, or that were incident to the climacteric, that have resisted all the flb ^o n. rhaRia ^^ ordinary means of arrest. The haemorrhage has continued for weeks, perhaps, in a passive and irregular manner. As a consequence, the patient has been greatly reduced and discouraged. There is a loss of appetite, headache, malaise, and a series of symptoms that are chargable to the continued drain upon her physical resources. She cannot sit upright, or stand erect, but the difficulty is increased. These cases are very annoying, perplexing, and tedious, and sometimes tax our skill to the utmost. Perhaps the various astringents have already been tried, but with- r Nitncacidasadernier out &y&{L Q ^ ^ mQre ^^ ^ familiar remedies, such as ipecacuanha, china, secale cor., sabina, crocus, hamamelis, trillin or the erechthites, may have failed in your hands. In such cases, the nitric acid will sometimes answer an excellent purpose. My habit is to give it in the second or third decimal attenuation, the dose to be repeated every one to three or four hours, according to the urgency of the symptoms. Case. — In consequence of a rough ride in the sleigh, Mrs. , aged 28, aborted at the second month. For the first few hours she had considerable pain. But the uterine contractions came on regularly, and the embryo was soon expelled. Of course, there was no well-formed placenta at this early period of pregnancy. The post-partum haemorrhage was profuse and long-continued. When the pains had ceased, the secale which she had been taking failed to have any more influence over the flow. The flow then became passive, and the discharge dark-colored and shreddy. As the result of keeping her in the horizontal posture, and upon an appropriate diet and drinks, she grew better, but soon re- MENORRHAGIA. 253 lapsed again. This was twice repeated. The usual remedies would cause the flow to cease for a little, but upon the least change of posture, the discharge commenced again. Matters went on thus for nearly four weeks, in all of which time she really had gained nothing, but lost much in strength, color and spirits. At 6 p. M. Tuesday of I prescribed nitric acid in the second decimal attenuation, twenty drops in half a glass ot water, two teaspoon- fuls to be taken each hour. On Wednesday she had had no flow since, midnight. The same medicine was directed to be repeated once in three hours. On Friday there was no return of the dis- charge, and she sat up a little. The remedy was discontinued. On bunday she came into the parlor, and afterwards recovered rapidly. I am aware that there is little in the provings of this remedy that is suggestive of its superior efficacy in this variety of haem- orrhage; and also that I am not calling vour Clinical deductions. ^ . . . ., attention to anything especially new or strange. In general terms, the nitric acid appears to be indicated in those haemorrhages from the mucous surfaces which depend upon the destruction and desquamation of their investing epithelium. Hence we find it useful in passive haemorrhages from the nose, the throat, and the respiratory, alimentary and urinary passages. The escape of blood by transudation in consequence of the removal of the protecting envelope, would occasion very different symptoms from those proper to an active and alarming haemorrhage, while in the end the result might be equally serious. The opinion that the decidua, or outer envelope of the embryo, is formed of the mucous membrane that lined the uterus before conception is now very generally received, post-menstmai Wh abortion occurs prior to the third month, hsemorrhag-e. r ' this lining is stripped off, and the cavity of the organ is left as destitute of its proper covering as is the spot where the placenta was attached, when that structure is cast off in labor at full term. If it is not exfoliated entire, the decidua may come away in shreds, in which case the attendant haemor- rhage persists for a much longer period, and is passive in charac- ter. The blood escapes slowly, and is for some nitrTclc 1 id indiCati ° nSf0rtime exposed to the action of the air before it is expelled from the uterus and vagina. The discharges resemble those of melaena. Occasionally they are quite profuse. In these symptoms, I apprehend, we have the most trustworty and practical indications for this remedy. 254 THE DISEASES OF WOMEN. In the case just cited the other remedies failed to give entire relief, because the first stage, and the active symptoms to which they were appropriate, had already passed. Then it was that the nitric acid could be used with the best results. Many cases of dysmenorrhea, more especially of the congestive and membranous varieties, merge into menorrhagia. The patient suffers extremely in the first stao-e of the men- h^morrha?e! nOrrll0eal StTU ^ ^ Vi ° d ' The fl ° W ls B ^ rted wlth g reflt difficulty and prolonged suffering, which is similar to the first stage of labor. But when the obstacle to its egress is overcome, the pain subsides and the discharge is corres- spondingly free and copious. The delay and retention of the blood in utero, and the violent efforts to force open the internal os uteri, have resulted in the partial or complete exfoliation of the endometrium, and therefore,' whenever she menstruates, it is as if the woman had had a veritable abortion. In one sense the haemorrhage is post-partum. In all important pathological re- spects, it is identical with that which supervenes upon a miscar- riage in the early months of • gestation. The detachment and disorganization of the uterine mucous membrane develops the case into one of passive haemorrhage, to the relief of which the nitric acid is frequently, but not invariably, adapted. You are already aware that, at the climacteric, many women are liable to protracted haemorrhage, which is apt to be of a pas- sive kind, not profuse, but lingering, exhaustive Hemorrhage at the nd debilitatin „ This fl 0W is Sometimes ill- climacteric. & tractable. It may or may not contain strips or shreds of what are falsely called "pseudo-membranes," but its existence often depends upon the morbid condition of the uterine mucous membrane of which I have spoken. In some of these cases the nitric acid is invaluable. Case. — Mrs. , aged 46, had been ill for five weeks with a passive haemorrhage, which dated from her last menstrual period. She was much reduced in strength, the pulse was weak and irri- table, the lips, tongue and alae nasi were very pale. She com- plained of occasional faintness, and disgust of food and drinks. The feet were cold, and she had almost complete insomnia. Her friends thought her going into a rapid decline. Motion aggra- vated the flow. Prior to the last period she had a similar attack, which continued about four weeks before the flow was arrested. MENORRHAGIA. 255 I prescribed nitric acid in the second decimal attenuation, to be taken as directed in the former case. In two hours the haemor- rage ceased. She made a rapid and complete recovery without taking any other remedy. In these cases the state of the uterine mucous membrane is very analagous to that which we meet with in apthous conditions and incipient ulcerations of the alimentary Practical conclusions. .. . . . , . , ,. mucous surfaces, as m stomatitis, typhoid lever, and in some forms of diarrhoea and dysentery. Here we have a similarity of texture, and there can be little doubt that these membranes are susceptible to disease-producing and disease-curing agents of a similar character. Possibly the sulphuric, phosphoric and muriatic acids might also be useful in some cases of uterine haemorrhage. The great benefit derived, in the treatment ot haemorrhages, from citric acid in the form of lemonade and oranges, and of tartaric acid in grapes, may not be attributable alone to their being grateful to the taste. It is not improbable that they are of service in a medicinal as well as in a dietetic way. MEXORRHCEA CERVICAL EPISTAXIS. Case. — Miss M , 19 years of age, has been an invalid for four years past. She is not confined to her room except at irreg- ular intervals, but is active and able to ride or walk, and to some extent to enjoy the society of her friends. She began to menstruate at fifteen. The first period came on with a great deal of pain and difficulty, but when the flow was finally established it continued for three weeks without cessation. After five days' intermission it commenced again, but without any considerable suffering. Again it continued until almost the end of the month, and again it returned with the regularity of the normal monthly discharge. In this manner, for four years, the flow has been almost constant. The longest interval in which she has ever been free from it, in all that time, is seven days. There is no dysmenorrhcea, the loss of blood is not excessive, but the flow is passive and painless, and continues when she is sleeping as well as during her waking hours. Sometimes under strong mental excitement, as when she is at a concert or in company, and her mind is diverted, it ceases temporarily, and afterwards returns as before. The same effect has been observed in consequence of a carriage ride and of a jour- ney by rail ; but it is of a very short duration. If the flow is arrested, she suffers no inconvenience excepting a "rush ot blood to the head," accompanied by more or less ver- tigo, headache, flushed fac% dimness of vision, and a heavy, dull feeling, with disposition to sleep. At other times her mind is clear 256 THE DISEASES OF WOMEN. and her spirits are good. And yet she feels somewhat weakened and enervated by the constant loss of blood. Her appetite is good. There is no intra-pelvic pain or distress, no haemorrhoids,, no constipation, and no urinary derangement. The only suffering noted is a feeling of aching and weariness in the region of the ovaries, more especially of the left one, at the month and after unusual exercise. During her whole menstrual life her mother was subject to a similar haemorrhage. This patient's general appearance does not indicate that she is ill. She has walked several squares to the Dispensary this morn- ing, with less fatigue than you would have supposed possible. Her color is somewhat heightened by the exercise in the open air, for her sister says that she is usually more pale than now, except- ing only when her haemorrhage has ceased and the blood rushes to her head. It is sometimes very important, in cases of this kind, to discover the relation which a passive uterine haemorrhage bears to the cata- menial function. If the flow dates from the Relation to menstruation. ■ . first establishment 01 this inaction at puberty, as in this instance, or if it habitually ceases a short time before the "period," and then recurs regularly, you may conclude that it is essentially a menstrual disorder. There A diagnostic rule. . 1 . . _ are some exceptions to this rule, as m case ol medullary carcinoma, and sub-mucous polypi, and perhaps in syphilitic endometritis also ; but, in most instances, the manner and time of its advent, and its regular periodicity afterwards (even although the period may be longer or shorter than natural), are to be taken as evidence of its connection with the process of ovulation. Nor is it difficult to explain this result. The physiological in- jection of the endometrium, which is a condition of the menstrual secretion, is relieved and removed when the healthy woman has menstruated. But, if she is not well, that extraordinary fullness of its vessels may continue, even although the menstrual flow has been discharged ; and there will remain a passive congestion of some portion of the uterine mucous membrane. This engorgement may relieve itself by a profuse and copious haemorrhage, as in menorrhagia, or even m metrorrhagia ; or it may pass away by a sort of cervical epistaxis. MENORRHAGIA. 257 01 passive flow, In which the local excess of blood oozes out and escapes more leisurely. In the former caso the critical and alarm- ing haemorrhage is sudden, and of short &i ration ; in the latter it is a mere prolongation or continuation of t le menses, without any very serious symptoms, until the month is 1 aearly or quite spent, and it is time that they should return aga u. One is acute, active, and irregular in its recurrence ; the other chronic, passive, and distinctly periodical. There is another reason why this woman's haemorrhage, although go long continued, must be classed as menstrual — a real case of menorrhoea. It is that the amount of the flow is not influenced by the exercise which she takes, or by other circumstances, more decidedly than it is in ordinary menstruation. If that haemorrhage depended upon the presence of a sub-mucous or interstitial fibroid, a polypus, ulceration, can- cerous degeneration, or venous engorgement, the quantity of blood lost would vary with her habits. Above all things, it would not be lessened by riding and active exercise. Viewing this species of haemorrhage as in a sense critical, and remembering the " habit " which has grown out of its continu- ance, with brief intervals only, for years, we Its critical nature. pi should naturally expect that the arrest of the flow would occasion more or less of suffering and disorder else- where. Hence the "rush of blood to the head," of which this woman complains whenever the flow has ceased, and which sub- sides as soon as that flow is restored. The same cause will some- times induce a violent attack of facial neuralgia, or sick headache, vomiting, delirium, hysteria, spasms, coma, or even convulsions. To show that this disease is not infrequent, and that the case before you is a typical one, I will read you some extracts from a letter received a few days ago from Dr. R. C. Sabin, of Wiscon- sin, a member of the class for 1871-72 : Case. — " My patient is now eighteen years of age. She com- menced menstruation at fifteen, and the flow has been almost con- stant ever since. The longest time in which she has been free from it is two weeks, when the interruption was caused by a jour- ney by rail. The discharge is of a bright red color, thin and watery, and has no odor. After continuing for a month or six weeks, the flow becomes stringy and thick, and then ceases for 17 258 THE DISEASES OF WOMEN. two or three days. Her health is always impaired at the time the flow stops, and there is giddiness, sudden flushes of the face, blindness, etc. These symptoms pass off as the flow returns. The urine is high-colored, and of a strong nauseous odor. " She is of scrofulous habit, short and fleshy, and. is troubled with frequent moist eruptions. The constant drain does not seem to have the least effect in reducing her weight. She was ex- tremely fleshy as a child. Her general health seems good, she goes to school, and has a gooda appetite " She has taken, at different times, sepia, pulsatilla, calcarea carb., china, hamamelis and ferrum. The latter benefits her gen- eral condition, and, temporarily, lessens the amount of the flow. Hamamelis will also check it in a few days, but then she feels wretched until the discharge comes on again." In these cases you should not fail to make a careful vaginal ex- amination before you venture an opinion concerning the nature of the disease, or the proper course of treatment Necessity of physical to i^ pursued. You may find the cervix uteri examination. i- ^ tender, swollen, congested, or in a state of are- olar hyperplasia ; or a small mucous polyp may have sufficed to perpetuate the mischief. Bi-manual examination, and the double touch, may discover such a state of ovarian irritation and inflam- mation as will account for the symptoms and give you a hint toward their relief. It is sometimes important to know whether this or other men- strual disorders have been hereditary in the patient's family. Especial inquiries should be made concerning ' the hemorrhagic diathesis, or if the patient has ever had chlorosis or ansemia. The clinical history of the case might also be modified if the woman had ever borne children, or been pregnant and suffered an abortion, and in some cases by her having nursed an infant. And so also by marriage, intemperate coitus, residence in a mountainous, a marshy, or an aguish district, by high living, and the free use of alcoholic drinks. For all these are so many avoidable causes of the disease under consideration. The fact that in this woman's history, as well as in Dr. Sabin's case, the haemorrhage has persisted for several The haemorrhage may per- years } g pr00 f that it UiaV Continue indefi- sist without manliest injury. J i- • i haemorrhage, and is the cause both ol its long continuance and of its periodical return. This is especially true if the chronic and unnatural flow dates from puberty. The reme- dies which are best adapted to the cure of this complication are belladonna, colocynth, hamamelis, lilium tig., lachesis, carbo veg., conium, veratrum vir., platina, mercurius corr., and pulsatilla. In a word, the cardinal symptoms that properly belong to the lesion of the ovaries, when the ovaritis and the haemorrhage co-exist, are a more trustworthy guide in the selection of the remedy than the quantity, or even the quality, of the sanguineous flow itself. Since it is possible that a change of climate may aid in the re- covery, one who has lived in a mountainous region may be sent to a different section ; or one who has resided Change of climate. in a low, marshy district, may be transferred to the mountains. Sometimes a cure will follow a change from the prairies to the sea-side, or vice versa, the object being to bring about an entire renovation by a change of external conditions. Or a sea-voyage, or salt-water baths, may prove very beneficial. While it is requisite that such patients as Miss should take _ . ,, . sufficient exercise, it is equally important that buitable exercise. x J x they should not overdo. Horseback riding, or running the sewing machine, skating, or dancing, for example, 262 THE DISEASES OF WOMEN. would aggravate or increase her disorder. The exercise should be more gentle and passive. I have more confidence in nitric acid, in the second decimal dilu- tion, than in any other single remedy in these Nitric acid. . J n _ J ^ cases, it is not, however, specific. She will take it four times daily, and report the result. MENORRHAGIA WITH REMITTENT FEVER. Case. — Mrs. , aged 30, has been subject to menorrhagia for three years past, for the relief of which she has had treatment by two celebrated gynaecologists, but without avail. She has taken the most powerful drugs, and been subjected to local treatment, which consisted in the topical use of astringents, such as the tincture of the chloride of iron, tannic acid, a mixture of alum and carbolic acid, and the persistent use of the tampon. She is confident that these applications have frequently been made within the uterine cavity, for her physicians have told her very plainly that such was the case. Her loss of blood at the month have been terrible, and it has often seemed as if she must die from them. She came under my care as 'a private patient six months ago. The menses had been in the habit of returning every three weeks, and continuing, with brief intervals, for from ten to fifteen days. The flow at times was copious and drenching, and she had frequent spells of fainting and exhaustion. She was pale and anaemic, cachectic and bed-ridden. I saw her first at the close of the period, and prescribed calcarea carbonica 3, a dose to be taken four times daily, and gave her no local treatment whatever. She improved from the start to such a degree, that I resolved to let well enough alone, and gave her no other remedy. When the next period arrived, which was a little later than usual, she was doing so well that the calcarea was continued. The flow lusted but six days, was much less copious and more natural in every way than it had been for years. The same remedy and the same experience was continued and repeated for four months with the effect to lengthen the interval between the periods to four weeks, and to lessen the discharge to about the normal quantity. But at the end of this time she ob- served that each period was accompanied by febrile symptoms of a more decided character than she had ever noticed before, although she was persuaded that something of this kind had often been pre- sent during the monthly molimen. h\ order to be certain of her condition during the monthly period, I instructed her to go to bed and to stay there until th's flow had ceased. Meanwhile,! visited her every day and discovered MENORRHAGIA. 263 that she was suffering from a pronounced fever of a remittent type, for which nitric acid 3, proved to be the remedy. It is not an uncommon occurrence for uterine, as well as other lesions of function and structure, to be complicated with one of the types of malarial fever. Sometimes this lesion Complicated with ma- the cause? an J ao; . lin ft fc the consequence of larial fever. ' & * the fever. In the case under review, when the calcarea had done its work, there yet remained a source of mischief which it could not counteract or remove. If the type of the menorrhagic fever is intermittent, tarantula is the remedy.* In this connection, I cannot forbear to remind you, that most uterine disorders are not so single and simple as you may have supposed, and that, consequently it is very sel- Uterine disorders not . . always easy of cure. dom that we can succeed in curing them radi- cally and entirely with one remedy, no matter how carefully it is chosen, how appropriate it may be to the more urgent symptoms of the case, nor how persistently it may be given. If there is any class of diseases in the treatment of which, the superior efficacy of our remedies can be demonstrated, it is in the different forms of uterine haemorrhage, when that haemorrhage is non-puerperal. It is sometimes astounding to see how our attenuations take hold even in the most unpromising cases. But the fact remains, that only a very few of them can be entirely cured by a single remedy. Here is another case which illustrates the tendency of men- strual hae morrhages to be complicated with the most varied and intractable disorders: MENORRHAGIA WITH RHEUMATISM. Case. — Mrs. , thirty-six years of age, dates her illness to three years ago in the old country, and attributes it to hard work. Her menstrual flow returns every three weeks, lasts for from eight to twelve days, and is very copious. She has a great deal of pain in her back, with sharp catching pains, which begin in the left, but have extended to the right side. She must lie either upon the back or upon the affected side. She has severe head- ache which is aggravated at the month. In advance of the flow all of her sufferings, including a nasty taste in the mouth, nausea and constipation, are increased to an almost unbearable extent; but as soon as the discharge begins, these symptoms are measur- ably relieved. She inherits a tendency to rheumatism. *Lectures on Clinica] Medicine by Dr. Jousset; translated by Ludlam, p. 46. 264 THE DISEASES OF WOMEN. Under the use of nux vomica 3, spigelia 3, and afterwards of colocynth, 3, the menorrhagia disappeared, and the monthly func- tion became normal ; but the rheumatism continues, and thus far has defied our treatment. [At his clinic on Nov. 3, 1880, Prof. Ludlam called attention to the fact that this patient had subsequently been very much benefited, if not almost entirely cured of the rheumatism by the persistent use of macro tin 3. He also took occasion to say that, in the case of rheumatism, or almost any other disease which is complicated with uterine affections, and more especially with menstrual disorders, the rule that we should Avithhold our remedies as soon as they have done any good, is unsatisfactory and fallacious. The reason lor this fact, for it is a fact, is that in this class of cases, especially at or about the menopause, the uterine irritation is a more or less constantly acting cause which renews the attack of rheumatism, or what not, as soon as the first effect of the remedy has passed off. Ignorance of this clinical fact, has caused many of our physicians to question the efficacy of our remedies in the treatment of chronic diseases when they are complicated with uterine affections.] LECTURE XVJ MENORRHAGIA — CONTINUED. Menorrhagia with hemiplegia; do. with Uterine Fibroid ; do. with Convulsions; suppres- sion of do. by Astringents; Vicarious Menstruation. MENORRHAGIA WITH HEMIPLEGIA. Case. — Mrs. , forty-seven years of age has been out of health for five years. She has had eleven children. During her last pregnancy, when she was about three months along, she was sud- denly taken with paralysis of the left half of her body (hemi- plegia). After the child was born, however, she recovered from it, a result which she attributes to an ex ;essive flooding. She now menstruates profusely every three weeks. At times she has numbness in the left hand and foot. She took hamamelis 3, three times a day. Five weeks later her general symptoms were very much im- proved. There was still some numbness in the left side, but she has not menstruated for six weeks. The same remedy was continued. The menstrual haemorrhage was effectually disposed of by this remedy, but she afterwards took belladonna with the best result, on account of the hemiplegia. In this case it is very probable that the approach of the climac- teric period, had as much to do with the hemiplegia, as the condi- tion of pregnancy. And the menorrhagia was tio^° mP ° UndindiCa ~ certainly contingent upon it. The proper therapeutics of the case, therefore, complicated as it was, turned upon a recognition of these facts and of these factors, and hence necessitated the use of belladonna after the hamamelis had done its work. MENORRHAGIA FROM A UTERINE FIBROID. Case. — Mrs. N., aged thirty-three, has had menorrhagia for eight years. She has never been pregnant. She first discovered the tumor about eight years ago, after having lifted and cared for a very sick sister. This tumor is sensibly increased in size with every return of the menses. The only pain that she has is with the flow, which is very copious, but of a brief duration. At one time, however, the menses were suppressed for nearly a year. [The class examined this tumor very thoroughly. Its outline #>5 266 THE DISEASES OF WOMEN. and texture could be distinctly recognized through the abdominal parietes. Prof. L. passed the sound into the uterus, and then moved the tumor with the hand upon the abdomen, so as to illus- trate the intimate connection between the two. He also said, that in this case, the menstruation had become regular and almost normal. The growth of the tumor had been arrested, and the patient's general health had greatly improved, under the use of the Trillin in the 3d decimal trituration. ] MENORRHAGIA WITH CONVULSIONS. I have had frequent occasion to extol the virtues of Nitric- Acid in a certain form of menorrhagia. Here are the notes of a case for which I am indebted to Dr. W. H. Parsons, of the Class of 1870-71 : Case. — Miss , twenty years of age, of nervo-bilious tem- perament, with dark hair and complexion, black eyes, and small in stature, had been ill for nearly four years. For the first eight years of her life she was puny and small, and, though never very ill, the skin was always of a yellowish hue, and the flesh very soft and flabby. At the eighth year she began to grow in height and breadth, and finally became very fat. She continued so until her fifteenth year, when her menses appeared. At the second month she began to have a peculiar discoloration of the skin in various parts of the body. There were dark circles about the eyes, with languor, a morbid appetite and a general chlorotic condition, and the catamenia did not return. The doctor under whose care she was placed succeeded in bring- ing on the menses, but the flow did not cease at the proper time. The discharge was muco-sanguinolent, dark and offensive, and lasted at first about a fortnight. After this it became continu- ous, and she lost the record of the month. This state of things was unchanged for several months more when the mother besought the doctor to stop the flow. Some unknown medicine was given which had the desired effect, but she went into convul- sions, and the doctor, having decided it as hopeless, relinquished the case. As soon as the effect of the drug passed off, the flow returned and the convulsions ceased. This was followed, however, by twitching of the voluntary muscles. For about six months these symptoms continued and increased in severity, and her parents abandoned all hope of her recovery. Another physician was called, who diagnosticated the case as one of menorrhagia. He proceeded to suppress the dis- MENORRHAGIA — CONTINUED. 267 charge and re-produced the convulsions. He then declared them epileptic, and treated her for epilepsy. But the girl grew weaker and more nervous, and finally he also abandoned the case, saying that " she would either outgrow it, or would ultimately die of it." At the beginning of the third year Dr. was called. He declared it to be a passive menorrhagia, and prescribed hamamelis, creasote, secale cor., pulsatilla, etc. With these remedies the flow was arrested without bringing on the convulsions, and for a time the patient seemed to improve. After this she had amenor- rhcea (suppressio mensium), for several weeks, and then for six months more alternations of suppression and continuous flow. She was finally reduced to a mere shadow, passed sleepless nights, her right side was constantly in motion, and she was anxious to die for the sake of relief. Another physician was called, the patient improved, under senecin, gelseminum, and secale cor., and the parents soon thought they could " get her along" without the doctor. So far as the discharge was concerned, she was in a somewhat improved con- dition. But generally she Avas no better. In a few months the old difficulty returned with renewed violence. I found the patient in the following condition. She is very much emaciated, and hardly able to walk ; flesh flabby, skin soft, discolored in spots, very sallow and dirty looking, hectic flush, sensitive, alternate chilliness and flushes of heat, eyes brilliant, with dark circles about them, and constantly moving from one object to another. Sometimes she sits and stares like an idiot, and acts in a very silly manner. She also complains of pains in the top and back part of her head. The pulse is quick, small and irregular ; respiration hurried ; her body is in almost constant motion, her right foot and hand are very restless, particularly at night ; starts in her sleep as from fright. She rises at six A.M., but soon returns to bed, and almost immediately falls into a deep sleep which lasts about two hours, after which she feels weary and languid. She dislikes society, is fond of seclusion, and is very despondent. Complains of pain in the dorsal region of the spine. The stomach is very irritable, with a constant feeling of " goneness," eats little, food irritates and causes pain in the stomach. Craves acids, can not eat either pastry or hearty food. Tongue is coated and of a bluish white color. The bowels are bound, the urine high colored. No pain in the uterine region. The vaginal discharge is of a muco-sanguineous nature, very dark and foetid, darker than the proper flow, with occasional clots. I stipulated that she should eat what I directed, and nothing else, that her room should be changed from a dark and curtained 2Q8 THE DISEASES OF WOMEN. dungeon to an any, pleasant one, exposed to the sunlight, and that she should continue under treatment until I pronounced her cured, whether it took a month or a year. She was to take all the apples and oranges that she could eat, to exercise lightly in the open air, and to forego her exhausting sleep in the morning. The remedy prescribed was nitric acid 3 (centesimal), four pellets three times each day. April 17, two days later, no change excepting that her stomach is less irritable, and bears food a little better. Continue the medicine. April 19, improved ; thinks the flow less ; appetite better ; but is very nervous and wakeful. Coffea 6 one dose at bed-time, and nitric acid as before. April 23. Continues to improve ; rested much better ; the discharge is very much lessened ; appetite improved ; pulse less frequent and more regular. Continue. April 26. Improving. Repeat the acid only twice per day. April 29. Flow completely stopped. Is very restless, can not lie or sit still ; starts at the least noise, seems afraid of every one, must get out of bed, looks wildly about, can not sleep. Hyos- cyamus 6 two doses at night. Nitric acid discontinued. April 30. Slept well, feels refreshed ; had the best night's rest that she has had for months. Hyoscyamus as before. May 3. Better, sleeps well, is more inclined to talk, and less nervous ; eyes less brilliant, appetite better, very little pain in the head. A slight discharge from the vagina. Nitric acid again, two doses to be taken each week. May 15. Found my patient much improved. She has passed through her menstrual period, which lasted four days and ceased spontaneously two days ago. She feels like a new creature, sleeps like a child, appetite good, stomach bears food well, no head symptoms, is cheerful and hopeful, glad to see her family and friends, her skin is almost natural, and, in brief, she appears well. Three months later (Aug. 10th), I called upon my patient and learned that she had quite recovered, and was in every respect the opposite of what she had been. The nervous symptoms^ had vanished, the menstrual irregularity had disappeared, and her health was entirely restored. This case illustrates the ill effects of " forcing the flow" at puberty. Here is a young lady of fifteen years. Nature is mak- ing an effort to establish the menstrual function. Emmenagogues at puberty. . bhe is passing through the preliminary stage or the crisis, has been sick once, and in due time all will be well. MENORRHAGIA — CONTINUED. 26^ But her incidental ill-health alarms the parents. A doctor is called, and he decides that the " change" is not progressing as it should, and that all her difficulties are due to the delay in men- struation. Thus far his opinion is well enough. But, forgetting, if he ever knew, how delicate the function of ovulation neces- sarily is, with what contingencies it is beset, and how easily its proper performance may be deranged, he prescribes something that is designed, not to prompt, but to compel the flow. The consequence is that a train of ills, which might have been avoided, is fastened upon her. The flow appears, but it is not physiological and healthy. Instead of being followed by a spontaneous return in four weeks, it does not come at all. A little more medicine, and more of tinkering with the most marvelous of all the wonderful pro- cesses of the living animal body, and, as if to revenge itself, the discharge commences and continues indefinitely, or until it is checked again by powerful astringents. Now, gentlemen, you know the mischief of the artificial induc- tion of abortion. I have shown you how ruinous it is to the health of a woman to forcibly interrupt the Remote consequences. attachments and growth of the germ. In this clinic your attention has been called to some of the sequelse of this abominable practice. But, let me tell you that, leaving the foeticide out of the question, the consequences to the woman are no more serious and lasting than those which frequently follow the taking of emmenagogues by young girls who are but just be- ginning to menstruate. The fact that with this patient the menses had already appeared should have been a sufficient guaranty that, if she were well in other respects, the flow would be regularly comm n on' ual intermissi ° ns established. And besides, as every experi- enced practitioner will attest, nothing is more common than for the " periods," after having come once or twice at puberty, to be irregular. Sometimes they skip one month, 01 two or three, or perhaps even a year, before they return again. And this without any material damage to the general health. By and by, unless the doctor or the nurse is Let them alone. ... . impertinent, ignorant or mischievous, they are resumed with very little risk, and afterwards become quite regu» 270 THE DISEASES OF WOMEN. lar. But, if you will observe carefully, I think you will find that in a very large proportion of cases of intermittent and irregular menstruation, amenorrhoea and menorrhagia, the difficulty is traceable to mal-treatment of this kind, at or about the period of puberty. In this manner it is quite possible for a single doctor, who has a passion for what he calls " demonstrative treatment," to sow the seeds of evils that fifty better men can not remedy. The relation between the nervous system and the menstrual function is also shown in this bit of clinical history. When the haemorrhage was suddenly checked the patient me^ruTwdons^ 6 na d a convulsion, and when the flow returned the convulsions ceased. Each time the dis- charge was lessened, the nervous twitchings and choreic move- ments became more manifest. And even when the convulsions were not induced by an arrest of the menses, these jerkings and twitchings were very troublesome and persistent. It really seemed as if the patient was " decreed " to have either the menstrual disorder or the convulsive affection. The problem in the treatment was how to cure the one without causing the other. You are aware that the liability to hysterical convulsions, spasms and paralysis, is limited to menstrual life. In girls, chorea, or St. Vitus' dance, subsides as pu- berty approaches, and finally disappears when the catamenial function is established. There is a form of men- strual mania that may accompany amenorrhoea, or menorrhagia, which, in many respects, resembles puerperal mania. All of which illustrates the intimate and profound relation between the menstrual function and the function of innervation. Another item that we should consider in this connection is the folly of supposing that, in certain cases of uterine haemorrhage, the disease is cured if we only stop the flow. There are cases of flooding in which if we fulfil this indication it is all that we can expect to accomplish, for in so doing we shall necessarily remove the cause of the trouble. Such cases are those in which the loss of blood depends upon the pres- ence of polypi, fibroids, hydatids, or of the A practical distinction. , . n placenta m utero, upon cauliflower excres- cence, or the more ordinary form of uterine cancer. These can MENORRHAGIA CONTINUED. 271 frequently, and indeed generally be relieved most speedily and certainly by surgical, together with medical means. But in such cases as this, where the haemorrhage depends upon a pathological condition of the uterine mucous membrane, and a morbid state of the whole menstrual function, it will not suffice to check the discharge. For, even if the patient escapes having more alarming symptoms in consequence, the disease which has caused the flow is not cured thereby. The remedy must be pos- sessed of an intimate, curative relation to the lesion that under- lies and has occasioned this particular symptom, else it will do no permanent good. The digestive derangement was a very natural and almost neces- sary consequence of the menstrual disorder. And so also was the chloro-ana?mia. Nothing could be better adapted The gastric and chior- foi th . licf than the careful attention to the otic symptoms. diet and to the surroundings of the, patient. Fresh air and sunlight, acid fruits, a cheerful room, and pleasant society, were useful auxiliaries toward the cure. Indeed, as the result proved, nothing could have been more appropriate than the treatment adopted. The nitric acid was perhaps the only remedy capable of correcting the menstrual irregularity without aggravat- ing the nervous disorder, of intercepting the convulsive paroxysms, and of curing the alimentary derangement. But alone, it was not sufficient to effect a radical cure. SUDDEN SUPPRESSION OF MENORRHAGIA BY ASTRINGENTS THE CAUSE OF SUBSEQUENT ILLNESS. Case. — Mrs. E. desires relief from attacks of what has been diagnosticated as bilious colic, from which she has suffered at frequent periods for eight months. The paroxysms almost always come on at night, immediately upon retiring. For a week past they have returned every evening. The pain is referred to the epigastric region, and is described as sharp, cutting and colicky in its nature. It also intermits, and, when most severe, there is a slight inclination to vomit. The paroxysm generally lasts about an hour, during which time she cannot lie down, but must sit, upright in the bed. After the fit she sleeps, soundly, and, with the exception of a loss of appetite for breakfast, and occasional headache, is quite well next day. It sometimes happens that un- usual excitement or fatigue Avill induce a paroxysm in the day- time. This trouble is greatly aggravated at each menstrual period. At present, the menses recur regularly every four weeks. Prior to the commencement cf these attacks she had, for some 27 z THE DISEASES OF WOMEN. months, suffered from too frequent and too profuse menstruation The flow returned every two or three weeks, and the loss of blood was sometimes extreme. To arrest the haemorrhage, her physician ordered vaginal injections of strong alum water. This expedient arrested the flow, but induced a severe attack of metritis, from which, in the hands of another physician, she barely recovered. The menstrual interval was subsequently extended to about four weeks, but the flow was still too profuse. All sorts of expedi- ents were tried to arrest it, but without effect, until the patient, becoming wearied with it, took the responsibility of resorting again to the alum injections. As soon as she did so, the exces- sive flow ceased, but in lieu of it she began to have these attacks of excruciating pain. During the eight months which have intervened she has had three other physicians, none of whom has succeeded in clearing up the diagnosis, or in curing the disease. The temptation to resort to astringents, topically and inter- nally, in case of haemorrhage, is a very strong one. This is espe- cially true in those forms of uterine haemorrhage Intra-uterine astringents. . _. which are connected with menstruation, lhe arguments against their indiscriminate employment are few and simple. In the first place, unless connected with abortion or labor at term, the excessive flow is symptomatic. In this case, to check it, and to arrest it by styptics, is not to cure the patient, but to complicate matters and make them worse instead of better. The more rational method would be to address our treatment, external or internal, or both, to the removal of the lesion, or condition upon which this flow depends. Take away the cause and the effect ceases. To strike this single symptom out of existence would be to lose time and work mischief. Again, a copious menstruation, like a free diuresis or diaphor- esis, may be critical, and in a sense salutary. It may represent a species of safety-valve which, for the welfare of crkic e a 1 ° rrhagia somedmes tne general organism, should not be too ab- ruptly closed. It is quite probable that the menstrual secretion is partly oliminative, and designed to expel certain noxious matters which would prove harmful if retained. To suppress the flow voluntarily might induce the very symptoms which are present in case of retention from diseased states, a con- sequence which it is our duty to avert. You will readily perceive that the sudden application of a solu- MENORRHAGIA — CONTINUED. 273 tion of alum to the vascular mucous membrane of the superior vagina and uterine cervix, for the arrest of the Physiological argument ' against intra-uterine as- haemorrhage, would be verv apt so to derange tringents. . .,,.,. n its capillary circulation as to cause inflamma- tion. If you desired to produce an attack of metritis, no more certain and expeditious method could be devised. It is no marvel that this poor woman suffered greatly, and almost died in conse- quence of this unwarrantable expedient. Thousands of lives have been sacrificed in this very manner. These harsh astringents are often thrown into the vagina, and sometimes even into the womb itself, for the same purpose as in this case. With utter disregard of the delicacy of the structures involved, of the danger of inflam- mation and its sequela?, of the risk of throwing the fluid through the Fallopian tubes directly into the cavity of the peritoneum, of damming up the blood upon the ovaries, of pelvic hematocele, and other consequences a hundred fold more serious than the haemorrhage itself, this practice is still sanctioned by the profes- sion. I have brought this case before you, in order to impress upon your minds some of the possible consequences that may result from such treatment ; also to show you " a more excellent way." We shall doubtless have frequent occasion to refer to the reflex relations existing between the uterine cervix and the stomach. There is much that is curious and suggestive Digestive disorders from . . ,..,,. , vaginal and uterine injec- therein. But there is a clinical hint connected uons. with the history of cases like this, the signifi- cance of which you should appreciate. A large proportion of the cases in which astringent injections of various kinds have been thrown into the vagina, and thus brought into contact with the neck of the womb, are characterized by peculiar and inveterate disorders of the stomach and bowels. Some of the worst examples of gastric indigestion that I have ever treated were chargeable to vaginal injections that had been resorted to for the cure of leucor- rhcea. In other cases, the ill effects have been observed in the production of intestinal colic, dyspepsia, and constipation. Here the irritant is applied to the superior vagina and about the cervix. Through nervous sympathy the stomach and bowels are implicated. Their functions are deranged, and more or less of actual suffering is induced. Such a train of consequences is all the more certain and characteristic, if the drug with which the 18 274 THE DISEASES OF WOMEN. injection was medicated had also a specific relation to some por- tion of the intestinal tract. And, upon reflection, you will find that a majority of the substances used in this manner have such a relation to the alimentary system especially. It is true of tannin, alum, the acetate of lead, the salts of silver, of copper, and of iron, the oil of turpentine, and many other remedies which have been used in this way. This explains the possibility that our patient first experienced her attacks of " bilious colic," falsely so-called, in consequence of the alum injections, which had been taken to suppress the haemorrhage from the womb. But there is another item which we must not pass over in silence. I allude to the fact that menorrhagia sometimes depends upon the presence of uterine polypi, ^ Menorrhagia from polypi, w hich, being very vascular, occasion the in- creased and prolonged haemorrhage at each men- strual period. And not only so, but they sometimes cause a spe- cies of menstrual colic, which greatly torments the patient. I have repeatedly had occasion to witness the most extreme suffering, sometimes gastric, again gastro-intestinal, or perhaps uterine chiefly, which was entirely due to the presence and pressure of a polypoid growth within and upon the cervix. Indeed, when I find a patient complaining of these symptoms, and learn that she has not been in the habit of taking vaginal objections, I am suspi- cious of the existence of some intra-uterine growth, which may be sufficient to account both for the menorrhagia and the spasmodic colic. And I recommend you, gentlemen, to be upon your guard in all cases of this kind. Do not trust too exclusively to objec- tive symptoms, which might mislead you, and bring down reproach upon your school and your skill. Examine the case thoroughly, and do not forget the practical hints of which I have just spoken. Treatment. — This is a case of neuralgia of the coeliac plexus, induced by the alum injections. How shall we treat it? Is it worth while trying to antidote the poison thus introduced, when so long a time has elapsed since it was taken ? Or shall we prescribe for the symptoms as we find them ? This is a point upon which doctors would assuredly disagree. My own opinion is that, if the attack were more recent in its origin, and we had a reliable anti- dote for the toxical effects of alumina, the " chemical treatment,'' as it is called, might promise good results. But, under the cir- VICARIOUS MENSTRUATION. 275 cumstances, we must base our prescription upon present indica- tions. The character of the pain, the period of its recurrence, the causes that induce it incidentally, and the aggravation at the men- strual period, are the prominent and most significant symptoms. Pulsatilla is the remedy. I recommend .that she take a dose of it every three hours during the day. If the paroxysm returns at evening, it may be repeated every twenty or thirty minutes until the attack has passed. When the symptoms are relieved, the med- icine may be given at longer intervals. I have sometimes cured this species of neuralgic colic, dependent upon maltreatment of uterine affections, by giving a few doses of atropine 3d, and again with colocynth of the same potency. There are cases of reflex disorders in other organs, as for exam- ple the stomach and bowels, the head, the heart, and the general nervous system, but more especially in the ova- intolerance of vaginal r i es t hat will not yield to the best chosen rem- injections. * «/ edies until the habit of taking vaginal injections is proscribed. This remark applies not only to injections that are harsh and decidedly irritant, but also to such as are ordinarily harmless. These cases are exceptional, and should not tempt you into an indiscriminate denial of the efficacy of such means under proper indications. It will be best for this patient not to take any kind of vaginal injection until she has recovered her health, and then only for the purpose of cleanliness. Should these means fail, it would be proper to proceed upon the hunt which I have given you concerning the possibility that there is a foreign body, a polypus, within the womb. The os should be so dilated with a sponge or other tents, that the proper exploration oan be made. This should be done slowly and carefully, in the manner which will be detailed when I come to speak of the treat- ment of uterine polypi. VICARIOUS MENSTRUATION. Case. — Sarah A., 19 years of age, unmarried, presents herself for the first time at the Clinic. " How long have you been ill?" "Four months, sir." "Of what do you complain?" "I have very frequent spells of coughing, and sometimes have the nose- bleed." " Is the cough dry or moist? " "It is dry and hard, and 276 THE DISEASES OF WOMEN. I sometimes have pain in my chest." " Do you ever raise blood? '* "No, sir." "How long have you suffered from the cough?" " Four months." " And the nose-bleed? " " For the same time, sir." " Were you subject to a cough before that time? " " Never, sir." " Have you been sick in bed with it? " " No, sir." " How often do you have your nose-bleed? " " Exactly once a month." " It comes very regular, does it? " " Yes, sir." ' ' How long does the attack last?" " I have it off and on for about three or four days." " And then it goes away and does not return at all for another month?" "It does, sir." "Is the cough worse at the same time?" " Yes, sir." "That will do; you may step into the next room for a few moments." These symptoms are suspicious and suggestive. The attention is at once drawn to the periodical nature of her complaint. The ex- perienced physician will recognize the menstrual function as the one most likely to be at fault. If with these symptoms he finds the menses have been suppressed, that there is amenorrhcea as a concomitant, the diagnosis is easily made out, for, in that case, the patient has what is termed vicarious menstruation. I have questioned this young woman, privately, and learned that for four months she has not menstruated at all. Prior to that time she reports herself as having been quite "regular." Upon further inquiry I have also satisfied myself that she is not preg- nant. This is an important point in all oases of suppression. Epistaxis may occur in plethoric persons, in the early months of pregnancy. When a flow of blood is established from some other part than the uterus, and that flow recurs with all the regularity of the cat- amenial discharge, and really supercedes it, we call it vicarious menstruation. This haemorrhage may take place from the intes- tinal or pulmonary mucous membranes, or the skin. Thus there may be critical haematemesis, or haemoptysis, epistaxis, or haem- orrhage from the eyes, ears, axillae, anus, bladder, the rectum, the ends of the fingers and toes, from thestump ol an amputated limb, or from an ulcer. Usually, however, the vicarious flow comes from a weak and vulnerable organ or surface. Thus our patient is of scrofulous habit, narrow-chested, with manifest tubercular tendencies. The respiratory mucous membrane is delicate and susceptible. The sudden suppression of an accustomed discharge from the generative intestine imperils the textural integrity of VICARIOUS MENSTRUATION. 277 this membrane. You are perhaps aware that there is a close sym- pathy of function between the internal generative organs and the lungs. Respiration and ovulation are intimately related. It fre- quently happens that the first alarming symptom of incipient phthisis will be a suppression of the menses, and consequent pectoral irritation. Now the Schneiderian membrane belongs to the respiratory sys- tem. The epis taxis and the cough, of which you have heard this woman complain, are referable to menstrual suppression. This suppression is abnormal, and consequently the remote symptoms are pathological. If it resulted from pregnancy the case would be different. Then the cause being physiological, the system would accommodate itself to the new order of things, and harm would not necessarily result. As it is, we must restore the natural flow and relieve the sup- pression, or serious consequences will certainly befall the pulmo- nary system. Treatment. — The indications are manifest. It is not important a,s in the former case, to prescribe any especial treatment for the haemorrhage. A more important work is to be accomplished. The principle function in the female economy is suspended. There is no compensating relation between the uterine and the respiratory mucous membranes, as between the skin and the kidneys, whereby the duties of the one may temporarily be imposed upon the other. This condition of things is extra physiological and hazardous, and must not be permitted to continue. The normal stimulus of functional activity in the ovaries and uterus becomes a morbid irritant when directed to the lun^s. We must restore the conditions to functional order in the generative system ; not by emmenagogues, that would compel a sanguineous flow from the uterus, but by agencies designed to harmonize the delicate sympathies now discordant. Our remedies must be directed not only to the original disease of the uterus and its appendages, but especially adapted also, to the present disordered condition of the lungs and their appendages. The pathogenesis of several of our more prominent remedies represents various shades of sympa- thetic relation between these two very important functions.* Calcarea carb., pulsatilla, calcarea phos., natrum mur., sangu- naria can., alumina, kali carb., ferrum acet., and possibly also ; 278 THE DISEASES OF WOMEN. caulophyllum, and hamamelis. I recommend yoa to devote your attention to this important therapeutical question. Many physi- cians employ these remedies unwittingly for the relief of objective symptoms dependent upon menstrual disorder, without any idea whatever of their significance. Pulsatilla is adapted to this patient's temperament and disposi- tion, as well as to the usual pectoral and uterine symptoms pre- sented in her case. We accordingly prescribe it for her in the third decimal attenuation, a dose to be taken three times daily. This should be continued at lengthened intervals throughout the inter-menstrual period. If she is not improved thereby, the calcarea phos. may be of service. Of late serious doubts have been expressed concerning the genuineness of vicarious menstruation. Dr. Robert Barnes pre- sented a paper to the British Gynecological Society last year in support of the old view that such cases did really occur, but the idea was combatted by Drs. Wilks and others. A proposal growing out of the discussion was that this "analogy of menstrua- tion" should properly be styled a vicarious hemorrhage.* *The British Gynecological Journal, 1886, pp. 151-188. Part Fourth. THE DISEASES OF PREGNANCY. LECTURE XVII. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. The Diagnosis of Pregnancy. False Conception. Case.— Excessive abdominal develop- ment in Pregnancy. Case.— The size of the abdomen as a sign and sequence of preg- nancy. Pulsatilla in mal-presentations. Case. — Mrs. , aged 39, has not menstruated within the last fourteen months. About the time the menses ceased she had a severe attack of dysentery, which continued four weeks. This was accompanied and followed by evident inflammation of the bladder, the vagina, and possibly, also the womb, from which she convalesced very slowly. Five months and a half later, she married. Her husband remained with her only two days, and then left on plea of business in a distant State. In that period only two attempts were made at coitus, in neither of which did the male organ penetrate the vagina. She suffered extreme agony in these ineffectual attempts at intercourse. During the interval, which is now eight and a half months, the husband has never returned. Four months ago she observed that the form of her abdomen began to change, becoming more and more prominent in the left inguinal and hypogastric regions. Sometimes the tumor subsides ccnsiderably, and afterwards be- comes as large as before. The only unusual sensation she has experienced was that resembling the gurgling of a liquid, which seemed to pass upwards from the left hypochondrium toward the umbilicus. The abdomen is now as large as that of one who is eight and a half months advanced in pregnancy, but the chief en- largement is upon the left side. She has had no morning sickness, no caprice of appetite, no urinary trouble, and no headache since she incurred the risk of becoming pregnant. The breasts are somewhat enlarged and tender, and the areola about the nipple is quite distinct. Physicial examination of the abdomen by auscul- tation reveals a sound resembling the placental souffle, but it is not very decided. We have failed, after several examinations, to detect the foetal heart-sounds. 280 THE DISEASES OF WOMEN. Although the whole generative function is physiological, and does not necessarily include any morbid process whatever, still its contingencies are so numerous, and the changes Its great importance. . ° which it develops within the pelvic and ab- dominal organs or so pronounced, and withal so similar to those which attend upon certain diseases, as to render the diagnosis of pregnancy a very delicate and difficult matter. It may involve the position of your patient, and others also, in society and in the church, loyalty to the marriage relation, and legitimacy of off- spring, as well as questions which are purely professional in their character, and which concern the proper treatment of the case in hand. How to decide whether a woman is or is not pregnant, is one of the lessons which you should learn most thoroughly. For nothing would so damage your reputation, as skillful practitioners, as to decide it wrongly. In many respects the case before you is a very interesting one. The menses have been suppressed tor a long period. And, al- though women sometimes reach the climacteric Suppression of the ^ f their fortieth year there fe reason to be _ menses. d 7 lieve that we should not attribute the arrest of function in her case to this cause. If there was no uterine tumor, no development of the abdomen, and none of the other signs of pregnancy were present, we might, perhaps, charge the suppression of the accustomed flow to "change of life." If she had not suffered from disease of the pelvic organs, and the sup- pression had not already existed before her marriage, the case would be different. As it is, we must remember that many other causes beside conception may interrupt the regularity of the men- strual function. Inflammation of any portion of the generative intestine, the vagina, the uterus, the Fallopian tubes, or of the ovaries, may cause an amenorrhoea which shall lead us to suppose a woman to be pregnant. So also inflammation of the bladder, the rectum, the intestines, and even of the lungs, may have the same effect, directly or indirectly. Displacements and deviations of the womb sometimes arrest the flow by obliterating the canal of the uterine cervix. The presence of polypi, fibroids, hydatids, and other tumors within that organ, may have the same mechani- cal effect. Atresia of the cervix, in consequence of the use of harsh astringent injections, or of the application of caustics, or of in- THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 281 Hammation caused by an improper or ill-adjusted pessary, or of the bungling and harmful use of instruments in abortus or in labor at term, may also cause a suppression of the menses. Therefore, while this symptom is regarded by women themselves as an almost certain sign of pregnancy, physicians look upon it as equivocal, and not by any means positive. We An uncertain sign. , ... . ,_,, . can not rely upon it m a given case, lliis woman has not menstruated for fourteen months. The period during which the arrest has continued is longer than that proper to gestation. Shall we therefore conclude that she is not pregnant, because she lias passed the ninth month without being delivered of a child? That would not be a safe or satisfactory conclusion. For, in some cases, the catamenia are arrested for weeks and even for months, and conception takes place before they have been restored. This often happens with women who become pregnant again while they are nursing their children, and before they have begun to men- struate after delivery. So our patient might have had a suppres- sion of this flow for six months or more, and then have become pregnant after her marriage, and before the menses had re-ap- peared. With respect to this symptom, therefore, there are so many irregularities, complications and exceptions that it is not to be regarded as a positive sign of pregnancy. At best, it is only cor- roborative. Taken in connection with other symptoms, it may help to settle the diagnosis, but singly and alone it is of very little consequence. An additional reason why we should not place an exclusive dependence upon it is that we are always compelled to take the patient's version of the facts in the case. If she is anxious to have children, or, for any ulterior reason, desires to have it de- cided that she is pregnant, she may claim that for a given time she has not menstruated at all, when this is not so. Or if, on the other hand, she is disposed to mislead the doctor, she may insist that her courses are regular, and normal in every respect, when in truth, they have not appeared for months. It is the habit of some physicians to prescribe marriage as a remedy for suppression of the menses, with al- Mamage as a remedy most a tota i disregard of its cause, and of the ior suppression. . , . . T . consequences of taking such advice. It is my duty to warn you against this practice. For it is altogether 28% THE DISEASES OF WOMEN. wrong. Thousands of persons have been made wretched, while few, very few, have been cured by it. In pregnancy it is not at all uncommon for the abdomen to be developed upon one side more than upon the other. Usually, however the uterine tumor inclines to the right Uterine obliquities. . 1 V ■ . ... .. . . , hypochondnum, for the alleged reason that the rectum pushes it in that direction as the womb passes above the superior strait at or about the fourth month. In this case how- ever, the tumor is at the left side, and has been from the first (left lateral obliquity). Its size and prominence, according to the patient's story, appear to vary somewhat, a fact which is easily enough explained upon the theory that there is an accompanying meteorism of the abdomen, which subsides of itself and recurs again. This would also account for the gurgling sensation, which is incidental, and not, in any sense, distinctive of preg- nancy. We need not discuss the negative value of the absence of morn- ing sickness, nausea, caprice of appetite, quickening, headache, toothache, vesical tenesmus, and other occasional symptoms of pregnancy. In many examples of gestation, they are wanting alto- gether from first to last. If she has really passed the eight mouth, ballottement would not be available. But the changes in the areola about the nipples, and in the breasts themselves, are more significant. In pregnancy, whatever changes take place in these glands affect both Changes in the breast. . ... ,„, . . ,. .. breasts alike. I his is not true of any disease to which they are subject. Consequently, when you find that both these organs are becoming larger, warmer, and softer, especially in those who have not already borne children, or been pregnant be- fore, or if there is a slight secretion of milk, it is a suspicious sign of pregnancy. More especially is this true if the nipple is more erectile, vascular, and granular on its exterior and tip than it has been, and if the circle of discoloration about it is more pronounced and decided. Here you have a good illustration of this subject. You observe the glandular follicles about the nipples are consider- ably enlarged, and that they pour out a quantity of fluid which gives the areola the appearance of having been oiled. The cellu- lar tissue beneath and within the nipple is in a state of turgescence. The discoloration about the nipple is so marked that you can see it THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 283 across the lecture-room. This looks as if our patient were really pregnant, and some authorities would decide the question upon the evidence afforded by this single symptom. But we must look a little further. If we could detect the foetal heart-sound, resembling the tick- ing of a watch beneath the pillow, we should have a positive and unmistakable sign of pregnancy. But this we The foetal heart-sound. . „ ., , , ,. ., . , , ., , have tailed to elicit. And yet it may be pres- ent. The mere fact that we fail to detect it, is no sign that a woman is not pregnant; while, if it can be heard, we know that she is enceinte. It is not safe, however, to depend upon a single examination in a case of this kind. For you may imagine that you hear it when you do not, or it may be impossible to hear it to-day, and the easiest thing in the world to note it to-morrow. The uterine souffle is so frequent an accompaniment of ob- dominal and uterine tumors, aneurism, etc , as not to afford any reliable criterion of the pregnant state. At best The uterine souffle. .. , n . . ..., , it is only a confirmatory sign, which may be classed as a probable, but not as a positive symptom of pregnancy. There is still another means of exploration that, in a case so ad- vanced as the one before us, may help to settle the diagnosis of pregnancy. If this woman really conceived eisfht and a-half months ao;o, the changes which have taken place in the uterine cervix should be quite marked and decisive. And so I find them to be. The neck of the womb is shortened and almost obliterated, soft, somewhat patulous — although she is a primipara — and in such a condition as can only attend upon gestation. This, therefore, enables us to decide that Mrs. is undoubt- edly pregnant. In reaching this conclusion, we may rely upon the changes in the breast, the discoloration of the areola, the char- acteristic softening and shortening of the cervix uteri, the abdom- inal development, and the placental souffle. All of these symp- toms are taken collectively, and within the space of a month, at least, I have no doubt but that our diagnosis will be confirmed, (Exit the patient.) Some of you may have doubted the possibility of conception without penetration of the male organ during coitus. Numerous cases are recorded in which this result has followed imperfect in- 284 THE DISEASES OF WOMEN. tercourse on account of some mechanical obstacle, as an imperfo- rate hymen, or an inveterate vaginismus, and the like. In resolv- ing such doubts you have only to remember that the essential condition of impregnation, is that the vitalizing part of the male semen shall be brought into contact with the ovum of the female somewhere within the generative tract. The discharge of that semen within the vulva may under certain circumstances and ex- ceptionally, produce the same result that would follow the com- plete act. But such cases are by no means so frequent as some have imagined. MOLAR PREGNANCY — FALSE CONCEPTION. In my obstetrical course you were told that, in forming a cor- rect diagnosis of pregnancy, an exclusive reliance upon any of its presumptive or of its probable signs would be likely to mislead you. Case. — Mrs. W , aged 42, was married eight months ago. She was at that time a widow; but had never had any children. She says that within the eight months, or since her last marriage, she has not menstruated. Prior to that, menstruation was normal in every respect. She has had no vicarious haemorrhage, or leu- corrhceal flow. When the menses ceased she began to have morning-sickness, which continued for six weeks. She had also various caprices of the appetite, with faintness before dinner, and inordinate craving tor food. There was no perceptible develop- ment of the ovum, or enlargement of the abdomen. The mamma? became swollen and sensitive. Six days ago, after walking to church, upon the icy pavement, she began to "flow." The hemorrhage from the uterus was pas- sive, irregular, and slight, until the third night, when, after having had a great deal of pain about the back and loins, with some head- ache and debility, she awakened out of sleep very much fright- ened by the escape of a fleshy mass from the uterus and vagina. The flowing soon ceased, and to-day she has ventured to walk to the Clinique. In addition to the details already given, she says that all her unpleasant and indiscribable feelings about the hips and abdomen were greatly relieved by a bandage worn tightly about those parts. This was an example of spurious pregnancy, sometimes styled false conception, pseudo-preo-nancy, quasi-g-es- Morbid anatomy. / / -, T , ,, G tation, molar gestation, and should not be con- founded with pseudo-cyesis. The product was a fleshy mole, which THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 285 the patient has preserved, and brought with her, and which we will now proceed to examine. Fortunately for us, she has kept it in water, and the examination will not be difficult. You will ob- serve that the mass is about the size of a small lemon. On cutting through its walls, we come down to the amnion, which is intact. Slitting this open, a slight flow of its proper liquor escapes. Here is the rudimentary embryo, which, although it has been eight months in utero, is not larger than it should have been at the sixth week of pregnancy. The undeveloped funis is but a mere thread, and ragged at its free extremity. Between the outer membranes, or rather within the thickened wall outside of the amnion, blood has been effused, and small coagula are seen. These appearances indicate an arrest of embryonic develop- ment. Conception probably took place as it should have done, and all went on well for a limited period. But, for Death of the embryo. 1 . . some unknown reason, the nourishing supplies that were derived from the uterine surface, and designed for the ovum, were appropriated to the abnormal, pathological growth of the chorion. The little embryo was therefore sacrificed. It died from a lack of those elements which were necessary to the devel- opment and repair of its tissues, and the hypertrophied chorion and decidua constitute this carneous or fleshy mass which is called a mole. Although women of all ages are liable to this form of spurious pregnancy, yet it is a singular fact, that those who have reached their fortieth year seem more prone to it than those who are younger. As in the case before us, it is not uncommon among women who marry a second time late in life. The formation of these moles (which are the conse- quence, not the cause, of the death of the ovum) is intimately connected with the history of abortion. Rigby says most expres- sively : " When any cause has occurred to destroy the life of the embryo, during the early weeks of pregnancy, one of two results follows, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and con- tinue to grow for some time longer, until at length they form a fleshy, fibrous mass, called a mole, or false conception." The true mole is always a product of conception. When the mass has been expelled, it is not difficult to recognize it, and to 286 THE DISEASES OF WOMEN. separate it from spurious formations which resemble it in some re- spects, by the presence of a rudimentary embryo Retention of embryo. tpt ,, , withm its cavity. li, however, the embryo died during the first month, it may have been dissolved, and we shall, therefore, fail to find it on dissection. Such a mole may be retained within the uterus for many months, or it may be cast off and expelled at or about the period at which the menses should have returned had the woman not been pregnant. It sometimes happens that the haemorrhage attendant upon labor of this kind is profuse and long-continued. Generally, however, it ceases with the delivery of the fleshy mass. Ambrose Pare cites a case in which a mole was retained in the womb for seventeen years. Among the clinical points worthy of note in the case before us, you will observe that, until her last marriage, this woman's men- struation was habitually regular and healthy. me^strua^on nancy and ^ * s important to take this fact into account, for it sometimes happens that menstrual disor- ders predispose to abnormal developments of the membranes which enclose the ovum. Membranous dysmenorrhea may indi- rectly cause this form of spurious pregnancy. Following the arrest of the catamenia there was no vicarious discharge. Morning sickness set in, and our patient was sup- posed to be pregnant. This continued for six nanc° bableslsnsofpreg " wee ks, or most probably until the death of the embryo, and was accompanied by the capricious appetite, fainting, etc., to which so many women are liable after conception. For the best of reasons there was no observable change in the abdomen. The usual development of the uterine tumor was pre- vented. There was no necessity for the womb to ascend out of the pelvis, as it would have done had gestation gone on properly. The embryo was dead, and its growth became impossible. The uterine cavity was already large enough to contain it, and hence there was no need of its further expansion. If the case had been one of hydatids (falsely so-called), the abdominal enlargement might have taken place. For these hydatigenous growths some times fill the womb, and cause it to enlarge in very much the same manner as if it contained a healthy foetus. They may also be retained even some months beyond "term" before they are THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 287 finally expelled. You should not forget that these uterine hyda- tids are really due to a defective organization of the placenta, or, more properly speaking, to a cystic degeneration of the villi of the chorion. We have no means of knowing the precise changes that took place in the breasts in this case. It is possible that the areolae may have been discolored, and the follicles about the nipples de- veloped, as in true pregnancy. These glands are liable to become swollen and sensitive from other causes, and this general symp- tom of pregnancy would therefore be very uncertain and unreli- able. At this time there is nothing peculiar in the appearance of the mammary glands. Usually, in similar cases, the series of changes proper to these organs, and which provides for the extra- uterine needs of the infant, is arrested when, from any cause, the embryo dies. Even when the mole or the hydatid mass is carried to the ninth month, or beyond, before it is extruded, there is gen- erally little or no secretion of milk. From these remarks you will infer that, although the suppres- sion of the menses, the morning sickness, and the fickleness of appetite, are to be regarded as presumptive These signs do not indi- . - . -. f « , , «ate the progress of preg- signs oi conception, and may signify that the fecundated ovum has reached the uterine cav- ity, and commenced to develop therein, still they do not afford a certain criterion of the progress of gestation. They may have marked its commencement ; but do not indicate its possible arrest or failure. This patient had the morning sickness during the first six weeks, but afterwards the only remaining symptom of pregnancy was the non-appearance of the menses. And the pro- longed arrest of this flow is to be accounted for by the presence of this foreign body, or mole, within the womb. Concerning the final cause of labor in this form of pseudo-preg- nancy, various theories have been advanced. Perhaps the most reasonable is that which refers it to the men- Cause of the delivery. - .. , , r • t '■ - t pn /» strual cycle, when the physiological afflux oi blood to the uterine, mucous membrane facilitates, if it does not actually insure, the entire separation of the decidua. At this par- ticular period the cervix uteri is also more or less relaxed, as if menstruation were coming on, and some slight exciting cause, as, for example, a fall, or sudden shock, or forcible exercise, as in 288 THE DISEASES OF WOMEN. walking on an icy pavement, may percipitate labor. Dilating pains follow or accompany the haemorrhage. In due time expul- sive contractions set in, and the womb is emptied of its contents. The suffering may be either slight or severe, its quality and degree varying with the laxity of fibre ot the uterine neck, the rapidity of the labor, the size of the mole, and the temperament of the patient. It is only in exceptional cases that the mass drops away with so little pain as this patient had. Although there are women who frequently and habitually suffer from this form of spurious pregnancy, it does not follow that one such mishap is certain to be succeeded by a second of a similar kind. Even at her age, Mrs. W. might, perhaps, pass through another pregnancy successfully. In every case of this kind it is of great importance carefully to examine the mass that has been expelled. For this purpose it should first be soaked in water for two or more hours, and then cut open so as to reveal its internal structure. EXCESSIVE ABDOMINAL DEVELOPMENT IN PREGNANCY. It sometimes happens that symptoms which are analogous to those afforded by the patient who has just left the room, depend on other causes than those already named. Only yesterday I waa consulted by letter in a case of this kind. My patient writes: Case. — I had called myself seven months advanced in pregnancy,, but many things conspire to make me think it probable that I am at least eight months along. I am exceedingly large, and from my extreme size, suffer greatly from faintness. For a fortnight I have endured severe pain in my left side, which nothing will relieve, although sitting up aggravates it. It has become almost unbear- able, wearing my life and strength away, and giving me no rest, day or night. " My little ones have always been large, weighing tenor eleven pounds, and you know I am a wee bit of a woman. But now the doctor thinks it probable that there may be two of them, which are small but amazingly strong and active, while there is evidently a great quantity of water contained in the womb. The child was in such a position as to cause much suffering and uneasiness, it being apparently across the pelvis. The doctor gave me pulsatilla, and whether it produced the effect or not, one week later it was pronounced ' all right.' " Will you be so kind as to inform me if there is anything that will relieve this pain in my side? If it should continue, would it THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 289 not be well to hasten delivery, before I am altogether worn out ? I frequently have severe and almost unbearable contractions, which cause the abdomen to feel as if turned into stone." This case presents several points of practical interest. As you will observe, it supplies additional details, and is an excellent appendix to the former one. Gestation is more advanced, and the symptoms are different. During pregnancy the size of the abdomen is relative. There is no actual scale of measurement or development for all, or even for single patients, who are successively preg- Size of the abdomen as a . . sign and sequence of preg- nant. Hence the absolute impossibility 01 nancy. judging by this sign whether a woman is in the seventh or eighth month. The abdomen is proportionally larger in short than in tall women, in multiparas than in primiparse, in those who are pregnant with twins than in case the womb con- tains but a single foetus. Its prominence varies with the laxity of the abdominal walls, the position of the uterus, the size of the foetus, and possibly its position, and with the quantity of amniotic liquor that surrounds the child or children. It may also become very large from intestinal indigestion and tympanites, abdominal dropsy, uterine or ovarian tumors, and malformation or dropsy of the foetus. Whatever their cause, these symptoms give rise to suffering and apprehension. They convert a natural process into a species of martyrdom, which, luckily, is self-limited. Diagnosis. — You will sometimes find it extremely difficult., and, indeed, quite impossible, to determine the cause or causes of these symptoms and the lesions, functional and organic, of which they are the token. A pendulous belly, with undue size of the abdom- inal tumor, occurs more frequently in spare, ill-conditioned women than in those who are short, plump, and well nourished. The mus- cles are thin and flabby, and the patient is more or less anaemic. If the extraordinary size depends on the position of the uterus, that organ will be found to incline forwards, over the pubes, or to one or the other side of the abdomen — usually to the right side. If upon the size of the child, its outline can be felt through the abdominal walls. Note should also be taken of the size and weight of former children, if the patient has ever been pregnant before. The chances are that, having always had very large child- 19 290 THE DISEASES OF WOMEX. ren, my correspondent is carrying one now, and that most of her symptoms are referable to this fact. Women who have had child- ren that weighed nine pounds and over, very rarely have twins in a subsequent pregnancy.* The position of the foetus in utero would be more apt to modify the shape than the size of the tumor. The position of the child is so frequently changed, even up to the time that labor com- mences, that a constant and uniform increase in the size of the abdomen could hardly depend on this cause. The characteristic symptoms by which you would recognize an extraordinary enlargement of the abdomen, dependent on dropsy of the amnion, are the following. It is an acute affection, the tumor is circumscribed, disproportionate, is developed rapidly, and is most likely to occur in those who have previously had, or at the time are having, dropsy elsewhere. It almost never occurs in those who are not of a dropsical diathesis. To the hand, when placed upon the abdomen, the movements of the foetus seem dis- tant and indistinct. The foetus is almost always small, feeble, and illy-developed, and generally survives its birth but a short time. The tumor may develop to such an extent as to occasion the most alarming dyspnoea and syncope, by pressing upon the diaphragm and adjacent viscera. Intestinal disorder may produce an excessive enlargement of the abdomen in pregnant women, either by causing dropsy of the peritoneum, or by the inflation of the bowels with gas. In the former case the hepatic function is almost always implicated. In the latter the intestinal glandular apparatus. The symptoms would vary, and you would not fail to recognize them. Uterine and ovarian tumors would have a history that com- menced before pregnancy. Neither mal -formation, nor hydro- cephalus, nor general anasarca of the foetus, could be diagnosti- cated with certainty prior to delivery. Twin pregnancy might be detected through the foetal heart sounds. Prognosis. — It is an exceptional case for any woman to pass through the state of pregnancy, from beginning to end, without complaining of these or analogous symptoms. And, strange to ;say, the rule appears to be that, with certain qualifications, those who are most prone to these sufferings are least liable to have * At birth this patient's child weighed eleven pounds. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 291 difficult labors, or tedious and dangerous convalescence in their lying-in. The chief danger from any of these symptoms, at what- ever period of gestation they may occur, is from abortion. If you can avert this calamity, the patient will probably do well. The greater the perturbation of the nervous system, or the more the urinary and hepatic functions are deranged, the more decidedly this unfortunate result is threatened. Dropsy of the amnion is more fatal to the child than to the mother. In all cases you should inspire your patient with courage, and with the hope that all ma}' yet be well. A lugubrious, long-faced doctor would always be an additional affliction to her, but especially under these circumstances. Treatment. — The general indication is to make the woman as comfortable as possible, to turn aside the contingencies that threaten miscarriage, and to bring her through to term as quietly and safely as we may. To this end the directions which I gave you in my remarks upon the case that preceded this are equally appropriate here. The remedies indicated will vary with the special pathology of the case, or as the phrase is, with the symptoms presented. If the enlargement is due to abdominal or to amniotic drops}', those remedies would be called for which are suited to the dropsical diathesis, and you would select from among them that one which is most appropriate to the symptoms of each individual case. I should caution you, however, against prescribing the apis mellifica in a low potency in case of dropsy of the amnion, lest it should precipitate a miscarriage. Incidental disorders of the intestinal tract suggest their own remedies, among the more prominent of which are arsenicum, chamomilla, nux vomica, mercurius, china, colocynth, belladonna, and veratrum. The pressure from a misplaced gravid uterus may sometimes be greatly relieved by a change of position on the part of the patient. Or bandages and supports, if properly adjusted, may tend to make life more tolerable, by allowing the patient to move around and to take exercise. They may also be made to add to the strength of the abdominal walls in case the child is preternaturally devel- oped, or where there are twins. I think that the induction of premature labor would not be jus- 292 THE DISEASES OF WOMEN. tifiable in a case of this kind, unless the patient were in imminent danger from suffocation by dropsy of the am- tu^ h ilbof uctionofprema " n i° n ' I can imagine, although I have never met with such an example in practice, that this expedient might be necessary as often, perhaps, as once in a thou- sand cases. Be sure you do not resort to it, gentlemen, on your patient's prescription instead of your own. Concerning the alleged power of pulsatilla to correct a mal- presentation of the foetus at any period of gestation, or in labor at term, I am wholly skeptical. Up to this date S entat'onl! ainmal " pre " (Feb., 1887) there is not a single case on record which clearly proves it to be possessed of any such properties. In every published instance the testimony is as invalid and fallacious as in that which we have just had undei' review. This patient's physician was not certain in his diagnosis. First he said she had twins, then dropsy of the amnion, and finally the (one) child was " apparently across the pelvis." Pulsatilla was given, a spontaneous change followed — as has probably hap- pened with every foetus from the time of Cain until now — and the result was accredited to the remedy that had been swallowed ! Such things may not be impossible, but they are exceedingly improbable. The Newer Signs of Pregnancy. — Hegar's new sign of preg- nancy is available as early as the sixth week. It Hegar's^sigTi of preg- consists in recognizing by the bi-manual touch, the peculiar form of the uterus, which depends upon the growth of its body without any change in the cervix before the close of the second month. This shape of the organ resembles that of "an old-fashioned fat-bellied jug." Tait's expert method is: First there is fluctuation one to the liquor amnii, and this declares its cystic nature. Tait's sign of pregnancy. If the hand is lain gently on the parietes a rhythmical contraction of the uterus by which at one time it is as hard as a cricket ball, and at another, soft as a cushion, will become perfectly evident. This alternate contrac- tion and relaxation of the pregnant uterus "is a method of diagno- sis which, when once made apparent, can never be mistaken for anything else." LECTUKE XVIII. BlLIOUS COLIC DURING PREGNANCY. Bilious colic in pregnancy; Albuminuria in ditto; the Nausea and Vomiting of do.; Vari- cose veins. We will devote the first part of this hour to the study of a case of bilious colic in a woman who is pregnant. Case. — Mrs. D , aged 30, a healthy looking woman of bil- ious temperament, with black hair and eyes, is six months ad- vanced in her third pregnancy. She complains of repeated attacks of bilious colic, which are accompanied by the usual symptoms of that disorder. Sometimes the paroxysm is very acute, and of brief duration, coming on abruptly and going off in the same manner. Again, the pain is more dull, steady, and persistent, lasting per- haps for twelve hours or more. These paroxysms are not refera- ble to errors in diet, or to excess of exposure, labor or worry, as in ordinary bilious colic, but recur without any obvious cause, sometimes waking her out of a sound sleep. She had them throughout both of her former pregnancies, but never at any other time. She carried both of her children to term. Unless they have continued for six hours or more, the attacks of pain are not followed by jaundice. Her father and two of her uncles were subject to severe fits of bilious colic. This case illustrates the peculiar relation existing between the uterus and the liver, — a subject of study which is really more important than you may have supposed. For, The vascular relation be- . • -i-i i i tween the uterus and the not only are these viscera organically related through the sympathetic and spinal nervous systems, but their vascular connections also are peculiar and sig- nificant. The portal vein receives blood from each and all of the chylo- poietic organs. Without this supply of blood from the stomach, the intestines, the spleen, the pancreas, and the mesentery, the curious and complex function of the liver could not be properly performed. But this is not all. The vaginal, hemorrhoidal, uterine, and ovarian plexuses of veins also communicate, by anastomoses, 293 294 THE DISEASES OF WOMEN. with the portal system, as well as with the inferior vena cava. A portion of the return current of blood is therefore conveyed directly from the pelvic organs to the liver, en route for the gen- eral circulation. Whether this vascular arrangement really implies such a com- pensatory relation between the hepatic and uterine functions as was insisted upon by Stahl and others, it is foreign to our present purpose to inquire. Its very existence suggests the possibility of diseased conditions which shall depend upon some derangement of the circulation in these inter-communicating vessels. One of the most marked of the anatomical changes consequent upon conception is found in the uterine veins. They become en- larged into canals and sinuses, with an increase rrv?duteru C s han§es in the °^ ca P a city which is in ratio with the nutri- tive demands of the contained embryo or foetus. Being destitute of valves, the only safeguard against a regurgita- tion and stasis of blood in them is their tortuosity, and perhaps, also, as Kollicker has shown, the temporary supply of muscular fibres to their middle coats. A woman becomes pregnant. Prior to this she may have been very healthy. She may or may not be of a bilious temperament. But within the month, and sometimes almost Bilious symptoms in early immediately, the hepatic and intestinal func- pregnancy. J 1 *■ tions are deranged. She has nausea and vom- iting, which, as in bilious affections uncomplicated with gesta- tion, are worse in the morning. The tongue is furred, the breath foul. She has no appetite for breakfast, there is disgust of water, almost invariably constipation, with bilious headache, highly-col- ored urine, and hypochondriasis. The matter vomited consists chiefly of mucus, but the paroxysm does not terminate until more or less of bile, it may be only a few drops, is ejected. These symptoms are commonly known as " bilious." That they are contingent upon pregnancy is a matter of every-day observa- tion. But that the extraordinary development ium he uterus a diverticu " of the vascular system of the uterus consequent upon conception is their indirect cause, is not so generally recognized. This functional derangement of the liver may arise from sluggishness of the venous circulation in the pel- The uterus becomes a diverticulum which receives THE DISEASES OF PREGNANCY. 295 and retains an unusual quantity of venous blood. Its weight is increased, it suffers a temporary prolapse, pressure therefrom in- creases the obstruction in the local circulation, and the parts which are even remotely related through a common vascular apparatus are almost necessarily implicated. A similar result may happen in the case of uterine deviations of whatever kind, but more especially in prolapsus, procidentia, and retroversion, in uterine scirrhus, fibroids, utSne affect g io r rf s ement ' m or P or ypi ' i n chronic metritis, dysmenorrhcea, amenorrhcea, and uterine ulceration. As haem- orrhoids and dysentery, and similar diseases in the ano-pelvic region, are very liable to be complicated with some hepatic dis- turbance, so it is with these different lesions of the womb. And since a proper supply of bile is indispensable to intestinal diges- tion, we see at a glance what a blow is aimed at nutrition when the function of the liver is thus deranged. In this list of diseases there is not one which is not usually accompanied by more or less of indigestion and inanition. Now the chief office of the liver, as an excretory organ, is to eliminate the cholesterin, which results from the destructive changes going on in the nervous substance or Cholestrsemia contingent . . . upon pregnancy and uter- neurme. 1 his post-organic product would be ine disease. m -,.-,.. poisonous if retained in the blood, and it is therefore expelled by way of the hepatic and intestinal outlet, just as urea escapes through the urinary apparatus. And, as we ob- serve that the muscular tissue, of which it was so recently an integral part, is peculiarly susceptible to the toxical effects of an excess of urea in the blood, so the nerve-centers, the brain espe- cially, are extremely sensitive to the action of cholesterin. Hence the hypochondriasis of pregnancy, and of most chronic uterine affections, which owes its origin to torpidity of the liver, and to the imperfect performance of its excretory function. And hence, also, the possibility of such suffering as that of which our patient complains. For biliary calculi consist chiefly of cholesterin, and their existence in a given case is proof positive of hepatic derange- ment. Bilious colic is therefore a contingent of pregnancy. There are those who, like Mrs. D., never have it except when they are preg- nant. Some, however, are liable to it whenever they menstruate ; 296 THE DISEASES OF WOMEN. others in consequence of excessive sexual intercourse or excite- ment , and I have known it to be caused by wearing an ill- adjusted or a misplaced pessary. Treatment. — We have proof that a knowledge of the organic relations between the uterus and the liver is practically import- ant, not only in the clinical history of similar Common influence of . . remedies on the uterus cases, but also in the known common influence of different remedies over these organs. Take, for example, nux vomica, aloes, podophyllin, and chamomilla, as they are most frequently prescribed in uterine and intra-pelvic affections generally. The symptoms which guide to the selection of any of these remedies usually pertain to the liver, or to some portion of the intestinal tract, rather than to the uterus and its appendages. There are, it is true, many exceptions to this rule, but the clini- cal fact is suggestive. In uterine lesions especially, the dial-plate upon which their characteristic symptoms may The symptoms of uterine i -i • i , i -i -i i r> disorder may be remotely be read, and which must be consulted betore located. • Ave can treat them understandmgly and success- fully, is often located where you would least suspect, it, — some- times in the liver, or in some portion of the gastro-intestinal tract ; again in the heart, the brain, or the general nervous system, and even in the eye. Hence a great variety of remedies may be requisite in uterine therapeutics, and the necessity of careful study in their employment must be apparent to you all. Before the termination of pregnancy, and while the cause is still in operation, we should be chary of promising a radical cure in a case of this kind. The disease being self-lim- This form of bilious de- {ted, its symptoms may not wholly disappear rangement self-limited. J x. J J x i until term. In exceptional cases, however, there may be but one or two attacks of the colic. During the paroxysm the indication is to afford prompt relief from the suffer- ing. Among the remedies most frequently Remedies during the fit. . employed lor this purpose are nux vomica, podophyllin, chamomilla, atropine, and chelidonium. With some practitioners the dioscorea is in excellent repute. Inhalations of ether or of chloroform may be justifiable in ex- Local palliatives. . . treme cases. In hysterical subjects, with threat- ening spasms, ignatia, belladonna, or hyoscyamus may be called THE DISEASES OF PREGNANCY. 297 for. Dry heat, in the form of hot plates wrapped in flannel, or bottles of hot water, or clothes wrung out in hot water and applied over the seat of the pain, are sometimes most grateful and bene- ficial. The warm bath is contra-indicated in case of bilious colic ■occuring in a pregnant woman. China is perhaps the best prophylactic against bilious colic. It seems to hold some specific relation to the formation and excre- tion of cholesterin. We do not know precisely what that relation is. Whether it stops the destructive metamorphosis of ne urine, and thus limits the produc- tion of cholesterin, or helps the liver to eliminate it more readily, is an unsettled question. At all events, we may avail ourselves of the clinical fact that it serves to palliate and to prevent painful attacks of this disorder. When prescribed with this intent, it should be given once or twice daily. In a case like the one before us, china will not interfere with gestation. Mrs. D. will take this remedy morning and evening. Her diet should consist of albuminous substances, and fruits. Fats, and all kinds of pastry, would be poison- Diet; mental and Q ^ T j ^ mQ { t f £ an( j ^ jj physical exercise. ^ She should have daily exercise in the open air, and be especially careful to avoid all sources of mental anxiety. ALBUMINURIA IN PREGNANCY. Case. — L. W. C , 19 years of age, primipara, weighing 180 pounds, was admitted to the hospital at the eighth month of preg- nancy. She is of full habit and is troubled with headache and " flushes." On being tested by heat and nitric acid, the urine was found to be highly albuminous. She had previously taken apocy- num can., and arsenicum alb., without any benefit. The feet and legs were enormously swollen, so that she could not walk or stand with any degree of comfort. She felt wretched, nervous and apprehensive. She took mercurius corrosivus in the 3d decimal trituration once in three hours. The proportion of albumen in the urine lessened almost immediately, and continued to decrease, so that there was a mere trace of it the day before her delivery. Although we had anticipated convulsions, her labor came on naturally, and was completed without a single untoward symptom. Her child is now three weeks old, and all the dropsical and urinary symptoms have entirely disappeared. I do not know where vou will find a case of disease which is 29S THE DISEASES OF WOMEN. the cause of greater mental strain and anxiety than such a one as this has been. To feel and realize that in all probability a woman who is approaching term will have puerperal eclampsia, and that her lite and that of her offspring depend almost entirely upon your skill, is a great load to carry. It should interest you to know how such a calamity may sometimes be averted. A pregnant woman at the eighth month may have dropsical symptoms which do not forbode any ill of this kind. But if she has decided albuminuria, with dropsv of the Signs of convulsibility. . , 1 . , . . J , . A . race and extremities, with or without amauro- sis, the probabilities are that, unless this is relieved, her delivery will be accompanied by convulsions. How to remedy this single symptom may therefore be a very important question for you to decide. Experience has led me to place great confidence in the mercu- rius corrosivus. I have prescribed it very frequently to fulfil this precise indication, audit has seldom disappointed Mercurius corrosivus. . me. lhe clerk mis furnished me notes of an- other case which occurred in the hospital some weeks ago, in which the effect of this remedy was equally satisfactory. Case. — Nancy J., aged 29, primipara, was eight and a half months advanced in her second pregnancy when she was admitted to the hospital. She reported that she had had dropsical symp- toms for two weeks already. The legs and ankles were very much swollen, the ankles being so puffy that the infiltrated integument hung over her slippers. The face and eyelids were cedematous, and she complained of much headache. On examina- tion the urine was found to be albuminous. She also had a partial amaurosis, which began and subsided with the dropsical symptoms. She took the mercurius corrosivus 3, a dose every three hours. The albumen disappeared from the urine, so that the day before her delivery no trace of it could be discovered. She passed through parturition and lying-in without any convulsions. In presenting these cases the idea which I design to convey is not that this, or any other remedy, is an absolute specific for ante-partum convulsibility. There is no real There is no Infallible . x , ' _ v . _> ' .„ . prophylactic for con- prophylactic of puerperal eclampsia. Jout if in one case in ten, you can recognize the incipient symptoms of this dreadful disease and avert it, you should know how to do it. Therefore, I recommend you not to fail to apply THE DISEASES OF PREGNANCY. 29^ the tests for albuminuria whenever any of its symptoms are present in the latter mouths of pregnancy, and not to forget that the mercurius corrosivus is in many cases an invaluable remedy for it. When Nature " flags the train" we should always take the hint.* ABDOMINAL CRAMPS AND PAINS IN PREGNANCY. Case. — Mrs. S is six and a half months advanced in her second pregnancy. For three weeks past she has complained of occasional pains and cramps in the abdomen. These sufferings are increased by exercise, slight pressure, emotional causes, and especially by the too vigorous movements of the foetus in utero. Upon examination I found the abdominal parietes somewhat attenuated, and the uterus in the position of the right lateral obli- quity. Otherwise I discovered nothing abnormal. Unless the uterus is very decidedly displaced, abdominal and sacral pains, cramps in the limbs, and like symptoms, are not very apt to worry the pregnant woman prior to cramps etc., after qmc keniiiff. After the fourth month, however, the fourth month. l ft » ' and in exceptional cases as early as the third, they may be the cause of much suffering. They depend on the changes which the uterine and abdominal structures necessarily undergo in consequence of the development of the foetus. As you would naturally suppose, these symptoms are most frequently met in primipane — those who have never borne children before. Occasionally we find a patient who always experiences them dur- ing pregnancy. As the uterus enlarges there is a gradual distention of the abdominal walls. Avery natural consequence of this distention is the production of muscular and neuralgic pains. These pains, which are sometimes general, again local — as in certain forms of hysteria — sometimes shooting and cramp-like, and again more constant, are very likely to be referred to the points of attach- ment of the various muscles which comprise the parietes of the abdomen. They may be felt in either the right or the left hypo- chondrium, in the iliac or umbilical region, and finally may settle into the permanent lumbar distress which in many cases precedes abortion. Not unfrequently, on account of its tension and * In all suspected cases it is a good rule to examine the urine occasionally, more espe- cially after the sixth month. This is a simple, and withal an important matter, for the renal complications of pregnancy and of parturition are mainly avoidable. 300 THE DISEASES OF WOMEN. extreme tenderness, when the belly has become hard and full, the skin is the seat of the difficulty. In such a case there is a neu- ralgic affection of the cutaneous nerves, which is frequently mis- taken for inflammation of the womb and its appendages. In most cases like the one before you, and whatever its seat and character, the suffering is increased by motion. Any exercise which renders it necessary for the patient to saving 1 ! increases the breathe more deeply and frequently than natural ; coughing or straining at stool ; riding or walking , turning in bed, or getting into an upright from a horizontal position ; the rolling of flatus in the bowels, or the move- ments of the foetus in utero ; may produce or aggravate it. It is usually worse when upon the feet than when sitting, and when sitting than when lying. There are, however, many exceptions to this rule. Excepting towards the end of pregnancy, say after the seventh month, it is generally worse in the day and better at night. It may be increased by mental emotions, as fright or anxiety ; and is more annoying and obstinate in those who are of sedentary habits than with the active and industrious. Lean women are more liable to it than the more robust. In rheumatic and neuralgic subjects it may depend upon vicissitudes of wind and weather for an excit- ing cause. Puny, nervous, and delicate children are more active and restless in utero, and therefore occasion more suffering of this kind, than those that are strong and vigorous. Diagnosis. — With respect to the prognosis and treatment, it is very important to be able to differentiate between the several varieties of abdominal pains to which pregnant women are subject. Among the lesions to which they are especially liable, we should separate the peritoneal from the neuralgic, the muscular from the uterine, and the ovarian from the intestinal. There is a spurious or false peritonitis, which rarely occurs except at the menstrual period, or at the time in the month which corresponds to it during gestation. It usually Spurious peritonitis. 1 1n . „ commences with a chill and local pain 01 an acute, lancinating character, in the region of one or both ovaries. The corresponding limb is flexed, and cannot be straightened without great increase of suffering. The affected part is exceed- ingly tender to the touch, and pressure, slight or severe, is insup- portable. This pain becomes gradually more diffuse. These THE DISEASES OF PREGNANCY. 301 symptoms are accompanied by more or less fever and constitu- tional disturbance. In the cutaneous neuralgia, although the diagnosis is not diffi- cult, the most unpardonable blunders are frequently made. Tar- nier's remarks upon the subject are exceedingly neurafiia Sisfromcutaneous appropriate, and I quote them :* " Having for some time made a special study of these abdom- inal, inguinal, and lumbar pains, we are convinced that very often they are due to neuralgia of the cutaneous nerves from the collateral branches of the lumbar plexus. To be assured that such is the case, it is only necessary to test carefully the sensi- bility of the skin in these regions, either by rubbing it rudely with the end of a pencil, or by raising it in the form of a fold which is to be gradually pinched between the fingers. Pressure ought also to be made all along the crest of the ilium, in the direction of the genito-crural nerve. Should we be satisfied with merely questioning the patient, or depressing the walls of the abdomen by the hand, we would incur the risk of obtaining very little information, or of suspecting the existence of deep-seated visceral pain when the skin only is affected. This mistake, which we see committed every day, would be avoided by taking the trouble to make the above-mentioned examination, and we can- not recommend it too highly. The principal parts affected by this neuralgia are the lumbar, iliac, hypogastric, and inguinal points, though the pain may appear in some other portion, of greater or less extent, of the skin of the abdomen. Sometimes confined to a circumscribed point, it occasionally invades an entire half of the abdominal walls. It very rarely affects both sides at the same time with equal intensity." If the abdominal muscles are the seat of the suffering, the pains are cramp-like, and accompanied by knotting of the fibres, which is worse upon pressure or motion. The suffer- Characteristic symptoms. . • mg between the severest paroxysms is referred to the points of origin and insertion of separate muscles. This form is most frequent in rheumatic subjects, in whom there may be a sudden metastasis to either of the larger articulations. It sometimes arises from traumatic injuries, as, for example, a blow or fall upon the abdomen. * Cazeau's Midwifery, Revised and Annotated by S. Tarnier. Phila. : 1868. p. 521. 302 THE DISEASES OF WOMEN. Metritis is a rare concomitant of gestation, but we not unfre- quently encounter a species of uterine colic that is apt to be mis- taken for one of the former affections. Hyster- Uterine colic. . . . ical women, who are highly emotional, and, I may add, exceedingly impulsive and imprudent also, are liable through some indiscretion, to attacks of this kind, and more especially about the period of quickening. So, also, are those who have been martyrs to dysmenorrhcea. The pain is referred to the uterine region and remains there. It may be intermit- tent, but it is not erratic like the muscular variety. It is prone to assume some of the characters of labor pains, and if long con- tinued or extreme in degree, may really precipitate a miscarriage. If we except their peritoneal envelope, the ovaries are singu- larly exempt from disease during pregnancy. From the date of conception their function is physiologically sus- diSasr ption from ovarian P en( ied and the condition which threatens their healthy action while menstruation continues is withdrawn. From various causes, however, their investing mem- brane may become inflamed, in which case the symptoms need not be confounded in your minds. The pain which -is referred to the ovarian region, is sharp, and sometimes intense, or pressing, throbbing, burning, and paroxysmal. It may radiate over the abdomen, or extend into the back, or down the limb of the affect- ed side. This limb is generally flexed, or if the patient tries to walk, she is lame with it. In exceptional cases pregnant women are, however, liable to a form of ovarian neuralgia. The gastro-intestinal disorders incident to pregnancy are more annoying and frequent before the fourth and after the seventh month than between these two periods. When- de? s a fncidSt e to n r a i nine*" ever tne y occur, however, they are accompa- nied by such marked digestive derangement that you will have little trouble in their differential diagnosis. Prognosis. — I recommend you in no instance to regard a case of this kind as trivial. For there is not one of them which is alto- gether exempt from the liability to abortion and its fearful conse- quences. Throughout its whole course, the state of pregnancy is beset with contingencies which it is your duty to avert. And not the least serious among them are such as may develop from symp- toms like those of which our patient complains THE DISEASES OF PREGNANCY. 303 Treatment. — This is one of those cases which we often encount- er in private practice, and which are distinguished by this pecul- iarity — they are better managed by simple domestic expedients than by the most scientific prescriptions. Yet, as I have said, we must discriminate. For example : If the pains are muscular, the part may be bathed quite fre- quently with hamamelis. Perhaps as large a proportion as one- half of all the pregnant women who complain of these symptoms may be relieved by this means alone. It is equally appropriate in ovarian irritation and inflammation. In some cases the rhus toxi- codendron answers a good purpose. I generally direct a table- spoonful of the strong tincture to be put into a teacupful of tepid or cool water, and then applied through one or more layers of flannel. If the suffering has been caused by mechanical means, or is the result of injury, the tincture of arnica may be applied in the same manner. If it is caused by undue pressure against the attenuated walls of the abdomen, you may counteract this effect by enveloping the abdomen in several layers of an elastic bandage of rubber-cloth in such a manner as to support its parietes. A bandage of linen would be too unyielding, and might indirectly induce abortion. Toward the latter end of pregnancy the feeling of extreme dis- tention and discomfort in the abdomen, will often yield to the old and simple expedient of anointing it with sweet oil. I have seen the most threatening symptoms of premature labor relieved in this manner. If the pains are cramp-like, the camphorated oil is an excellent application. If the suffering is neuralgic, you will charm it away by direct- ing that the affected part be covered with simple, dry, uncarded cotton, or cotton batting. In some cases, several layers of flannel will answer equally well. Belladonna, or atropine, internally, may hasten the cure. In the ovarian neuralgia which sometimes complicates the symp- toms, and greatly increases the suffering in these cases, I know of no remedy to compare with the valerianate of zinc. I shall have more to say in future of this contingent of pregnancy. It is very important always to regulate the exercise of the patient, and as far as possible to prevent too much of mental fric- 304 THE DISEASES OF WOMEN. tion and anxiety on her part; for, although anatomists have failed to demonstrate a nervous connection between the mother and the foetus in utero, her mental emotions do influence it greatly. It is a bad habit for those who are pregnant to take care of, and to lift and carry around, other children in the family. Although tight- lacing is popularly believed to contribute to an easy and safe labor, it is often prejudicial to the comfort and welfare of the pregnant woman, by inducing abdominal pains and cramps which may result in abortion. Internally, a variety of remedies may be indicated. Where, as in this case, the suffering is aggravated by motion, however slight, bryonia will sometimes afford almost instant relief. Nux vomica, Pulsatilla, belladonna, rhus tox., ignatia and chamomilla, are also useful under appropriate indications. The patient will take bry- onia 3d, three times daily, and report at the end of a fortnight, or of three weeks at the farthest. THE NAUSEA AND VOMITING OF PREGNANCY. The sickness and vomiting of pregnancy are sometimes very difficult to explain, and still more difficult to cure. They usually expire by limitation at or before the fourth May occur at an early, mont } 1 ^ ut mav T) e o;in or end at any time before or late period. J ° ^ delivery. The difficulty that has been experi- enced in curing it, is shown in the long list of remedies that have been recommended for it. The list of specifics for morning sick- ness includes about one half the remedies in the materia medica. In rare cases this is a fatal affection. Sometimes it terminates In abortion ; in others the death of the foetus puts a stop to it, even although its delivery may be delayed for Is sometimes fatal. , , ml , . , . , some days or weeks. I he most persistent and uncontrolable vomiting of food may threaten to destroy life through inanition, and yet the patient may If uncomplicated is continue in g 00C l fl es h. For, SO long as this not dangerous. © . disorder is not linked with a serious organic lesion of some portion of the digestive apparatus, the prognosis is favorable. You may remember that the worst cases are those which are associated with chronic and intractable disease of the liver. I THE DISEASES OF PREGNANCY — CONTINUED. 305 never like to see a patient who is suffering from excessive gastric disturbance during pregnancy, begin to show significance of a coin- . of j aimcUce especially if she has never had cident jaundice. n J » i J it before, or if there are coincident symptoms of acute yellow atrophy of the liver, or of uraemia. There are some cases of morning sickness which manifestly depend, as Rene Brian and Grraily Hewitt have shown, upon a flexion of the uterus. In these cases the gastric May depend upon disturbance is neither very severe nor long con- uterine deviations. 7 ° tinued, and yet they do sometimes result in abortion. Their diagnostic sign, apart from a local examination, is that the sickness is limited to the time of rising from the bed, a condition which is explained by the effect of gravity in bending the uterus upon itself. There are cases, however, in which the flexure of the gravid uterus does not excite emesis. In accounting for this vexatious infirmity the displacement theory is the oldest. It has also been ascribed to ulceration, inflammation, and stricture of the cervix uteri, Various causes assigned. - . . ' . . , «, to the stre tennis: ol the uterine muscular fibres CD during their development, to chlorosis, to albuminuria uraemia, and to sympathetic irritation of the pneumogastric. After the seventh month it may be due to mechanical pressure of the gravid uterus upon the stomach or the liver. The matters vomited will vary with circumstances. If the attack recurs when the stomach is empty, the egesta will consist of a viscid or slimy fluid ; if there is a great deal The matters vomited. _ . . ot retching, it may be bilious, or even bloody: if the patient has eaten heartily, the food and drinks may be rejected. Treatment. — There is no real specific for this disorder ; nor can we find in the character of the retching, the nausea, the matters rejected, the occurrence and frequency of the Lack of a specific for. ° ,. ' f . paroxysm, the degree or quality of suffering, or the disgust of food, such indications lor our remedies as will always help us to prescribe both accurately and successfully. Even where certain remedies have been extolled, there is often a doubt concerning their efficacy, because some- Questionable results. i i i • i • thing else has been given, or done, simultane- ously for the relief of the suffering. Here is a case in point, which 20 306 THE DISEASES OF WOMEN. I will quote from the JSf. E. Medical Gazette, vol. 4, page 153, to which it was contributed by my friend Dr. W H. Holcombe, of New Orleans: Case. — -I was called, two weeks ago, to a very distressing case of this kind ; and the treatment, whether strictly homoeopathic or not, was so promptly efficacious that it is worth recording. The lady was pregnant last year, and suffered horribly for seven weeks under allopathic treatment. She was only relieved by an abortion. This time she had suffered for three weeks before I was called in. She vomited about every half hour in the twenty-four, and no nourishment had been retained for more than five minutes, for a week or ten days. She was much emaciated, and greatlv prostrated from want of nourishment and sleep. She was cold, trembling, and wretchedly nervous and despairing. I ordered nux 30, and platina 30, alternately, every hour, and in- jections of beef- tea and brandy every six hours. I found her a little better the next day, but not enough so to satisfy me that I was on the right remedies. So I examined my case more thoroughly. I found two peculiar symptoms, which I regarded as key-notes. She was always greatly worse on waking from her little naps of sleep. Indeed, she declared she had rather not sleep at all than to awake with such dreadful sensations. Secondly, she referred her nausea entirely to a strange trembling, like a mass of jelly, which reached from the umbilicus to the ribs, and over the gastric and hepatic areas. I felt this tremulous motion with my hand for a long time. It was a quick sub-cutaneous quivering, almost without intermission. These symptoms belong especially to lachesis. I ordered lachesis 2000, every hour. When I went next day, I found my patient in ecstacies. She had slept half the night, had vomited only a few times, and the trembling sensations had almost disappeared. What a brilliant laurel this would be for lachesis, if lachesis alone had been used ! But, alas ! my spirit of empiri- cism had dictated an adjuvant in the shape of an injection at night, of twenty grains of the bromide of potassium, and I could not tell positively which effected the cure. Afraid to drop either, and consulting the good of my patient in preference to my own pure homoeopathicity, I continued the prescription— lachesis 2000, — during the day, and a nightly injec- tion of twenty grains of bromide of potassium. In a few days my patient was up and at the table, enjoying the pleasures of life, to the astonishment of her friends and to the glory of Homoeo- pathy. I believe the lachesis was the curative agent, — firstly, because I THE DISEASES OF PREGNANCY CONTINUED. 307 Relieve lachesis in the higher and highest dilutions to be a remedy of astonishing value; secondly, because it covered my case homceopathically ; thirdly, because, although the bromide of po- tassium is a good remedy for great nervous excitation, I have tried it several times before in the vomiting of pregnancy, and never with any decided result. Nux 30, and lachesis 30, have done more for me than any other remedies in the vomiting of pregnancy, ipecac 200, and platina 30, stand next in my confidence. Plumbum, opium, and tarantula, all high, will repay careful study in difficult cases. Nourishment by enemas of beef-tea, cream, milk-punch, etc., should be early and steadily employed. The following indications for some of our well-known remedies have a clinical confirmation : For the vomiting of a viscid mucus, especially on rising, nux vomica and cocculus. For constant, or occa- Speeial indications for . , ... .., , J ., , J# „ remedies. sional vomiting, without regard to the position of the body, and for vomiting of whatever is swal- lowed, the egesta being mixed with bile or mucus, ipecacuanha. If the mucus is milky and the patient has had, or is having, leucorrhcea, and yellow spots on the skin, sepia. For the vomiting of fluids as soon as taken, with thirst, great uneasiness and restlessness, bitterness in the mouth after eating or drinking, with pallor of the countenance, and thirst for cold brinks, arsenicum. t For the vomiting of a greenish, frothy mucus, which is some- limes relieved, temporarily, by drinking cold water, especially if there is a copious flow of saliva, cuprum metallicum. For the vomiting of bile with the food, a rancid heart-burn, and ptyalism, especially at night, mercurius. Other remedies, the special indications for which you will look to the materia medica, are, apis mel., berberis, a list of possible rem- bismuth, conium, cimicifuga, calcarea carb., edies. chamomilla, ferrum, ignatia, kali carb., kreoso- tum, natrum mur., petroleum, tartar emetic, veratrum alb., and zincum, podophyllum, and iris vers. The number and variety of these remedies implies that the so- called morning sickness of pregnancy is a self-limited disorder, because when a disease inclines to get well of itself it may easily happen that whatever has been prescribed will sometime or other get the credit of having cured it. Stretching the cervix. 308 THE DISEASES OF WOMEN. There are a few medicines and expedients that have been used empirically with advantage, amonsf which are- an^ir"^ the oxalate of cerium > apomorphia, pepsin, the eats. sulphate of soda, the arsenite of copper, gossy- pium, the bromides of soda and potassa, good old wine, cham- pagne, coffee, luke-warm gruel, and very w T eak green tea. If the uterus is displaced its careful reposition will be necessary. I shall speak of this directly. Exceptionally, if the os uteri is badly ulcerated, it may be neces- sary to treat it locally with a bland, unirritating application such as calendula, hamamelis, or hydrastis and glycerine. I have fre- quently arrested the gastric disturbance for days together by the topical use of the oleaginous collodion. The newest expedient, with which a distinguished gynaecologist has proposed to do away with morning sickness altogether, consists in the dilatation of the cervical canal. The mode of performing this little operation is to carry the index finger gently through the external os, with a rotating movement, until one-half of the first phalanx has been introduced. In the case of multiparas this is easily done; but with primiparae it will sometimes be necessary to dilate the os by^ other means before the finger can be passed. The objection to it is that there is considerable risk of inducing abortion. This plan of treatment w T as discovered by Copman, in 1875, who, for the- purpose of causing an abortion for the relief of vomiting in a case ot pregnancy, dilated the cervix with his finger, and cured the vomiting without any other result. The fact that, in very rare cases, when the life of the woman is seriously threatened, the induction cf abortion or of premature labor is sometimes necessary for the relief of The expediency of this and kindred disorders, makes it incumbent abortion. upon me to say a word or two upon this subject. There are but two indications which can render this extreme resort imperative, viz., (1) where it is morally certain that if the gastric disturbance continues the woman may die of starvation; and, (2) where there is such a coincident disease, more especially of the liver and kidneys, as makes it equally certain that she will die if the remote cause of the trouble is not removed. Concerning the first of these indications, we are learning in THE DISEASES OF PREGNANCY. 309 various ways that the human organism can withstand and survive an almost total lack of food for a considerable JL danSerfr ° m ln " Period. Perhaps there is no condition in which a woman can be placed, in which so small an amount of food will suffice, as during the first few weeks of preg- nancy, when the nutritive needs of the embryo amount to little or nothing, and her appetite and taste are so thoroughly upset. Under these circumstances you must not be surprised nor discouraged if, for what may seem an incredible time, all food whatever shall be either refused or rejected. Such patients will not be likely to die of starvation, and therefore, you had better wait and work for a favorable change, rather than resort to an expedient which in- volves a moral wrong. A mere functional disorder of the liver, the kidneys, or any of the pelvic or abdominal viscera Avould not warrant the recourse to such a terrible expedient. In case of pressure, p.la;r.e"oo r r COm ' : «Pon the liver by the gravid uterus after the seventh month, if the disease in that organ is of so serious and so threatening a nature as to imperil the life of the patient, and where the best treatment has failed to bring relief, it mav become a question whether the induction From hepatic disease. „ " . . oi premature labor is not both right and proper. For, under these circumstances the expedient concerns the saving of the child's life, as well as the cure of the mother. Where, in the later months of gestation the urinary complica- tion depends upon the same kind of pressure on the renal vessels and the ureters, vou may need to From uraemia, etc. . balance this same question most carefully and conscientiously. The mere giving of remedies, or even the hypodermic injection of apocynum to stimulate a flow of urine, so strongly Becommencled by my friend Dr. Fahnestock at our Clinical Society, will not always answer.* But, before resorting to such an expedient as the induction of prema- ture delivery, you must be certain that these conditions do really exist, and that the life of your patient is endangered by this par- ticular cause. Observe that the question is not whether you must hasten the delivery in all cases of ursemia with albuminuria occurring in *Vide The Clinique for October, 1880. 310 THE DISEASES OF WOMEN. pregnancy; but whether, when the means that are usually suffici- ent have all failed, we should try this as a last resort. This is the- question that you must settle for yourselves in each individual case with the aid of the best counsel that you can procure. In the same journal for November, 1880, you will find a report upon the treatment of nausea and vomiting in pregnancy that was read before our Society by my colleague Prof. Hawkes. This paper gives the details of several very interesting cases that were cured by mercurius, cocculus, arsenicum and lycopodium. The discussion that followed its presentation drew forth some inter- esting facts and points of a clinical kind, more especially with reference to the self-limited nature of this distressing affection, and the possibility of curing it, in exceptional cases, by the most irregular, and outlandish prescriptions. As a specimen of the latter Dr. Small cited the case of a woman who had suffered sa severely from this disorder that she was compelled to take to her bed and to stay there during the whole of gestation. She had tried, during her successive pregnancies, both schools of practice, and had been under the care of Dr. Constantine Hering, but without relief. Finally, an old woman cured her promptly with a tumbler of hard cider, which contained a teaspoonful of salt and an old rusty nail. VARICOSE VEINS. In remarking upon a case of varicose veins of the legs in a preg- nant woman, Prof. L. expressed great confidence in the value of hamamelis. He gives it internally in the third decimal dilution, and uses it locally in the form of one part of the mother tincture, or ot Pond's Extract, to three parts of tepid water, which is to be applied by cloths or compresses that are wet with the lotion. Sometimes relief is afforded by bandaging the limbs from the feet to the hips with a surgeon's roller, but the same indications are filled, and more perfectly too, by the modern elastic stocking. It is a self-limited affection, usually ending with pregnancy; but, at term, it should always be regarded as a predisponent of puerperal phlebitis. LECTUEE XIX. MORNING SICKNESS OF PREGNANCY, AND RETROVERSION. Morning' sickness of pregnancy and retroversion; Nausea and vomiting of pregnancy; Chorea during pregnancy. The first case this morning is one that illustrates the distressing affection known as " morning sickness," for which the doctors have thus far failed to find a specific. Case. — Mrs. G., aged 35, has reached the third month of her fifth pregnancy. Her first two children, a son and a daughter, were carried to term and are now living. She has aborted twice at about three and a half months, in consequence, as her physician told her of retroversion of the womb. The chief peculiarity ot the case is that the nausea and vomiting which are incident to the early months of gestation are experienced by her at night only. It commences each evening at ten, and continues, with occasional interruptions, until after midnight, and sometimes until two o'clock in the morning. She enjoys her breakfast and dinner, but has no appetite for tea. She is very confident that when she was pregnant with her two living children, the gastric symptoms came on as with most women, in the morning' and not at night. And also that, in case of the two which she lost prematurely, the nausea and vomiting occurred, as in the present instance, during the eveniug and night. For this reason she dreads an impending abortion, and is fully persuaded in her own mind that it is quite impossible for her to go to " term." This conviction is almost confirmed by the dictum of hei former physician, who declared positively that it would be out of the question for her to carry her offspring beyond the fourth month. Upon careful digital examination, I found an evident deviation or displacement of the uterus. The os uteri was nearer the sym- physis pubis than natural, and at the Douglas' cul-de-sac there was a hard, globular tumor, which yielded to steady pressure in the direction of the sacral promontory, and finally passed upwards out of reach. This little manipulation afforded her great relief. She insists that the replacement of the womb has always palliated 311 31 2 THE DISEASES OF WOMEN. the gastric distress, and sometimes stopped it entirely for days together. This is an exceptional case. It is seldom indeed that the reflex gastric symptoms in the early months of pregnancy are so pro- nounced. I have, accordingly, chosen it as in?a e Hrp?egni C nc S y mptoms the tneme for a few practical remarks. The case is a typical one, which illustrates the in- timate relationship through indirect nervous communication, between the uterus and the stomach. This peculiar sympathy is shown in various ways. I have known a patient to vomit within five or ten minutes after, and in consequence of the application of the nitrate of silver to the uterine cervix. A sudden dropping down of the womb in some cases of prolapsus produces the same effect. In many cases of tardy labor dependent upon rigidity of the os uteri, emesis removes the cause of the delay by relaxing the cervix. For it often happens that, when delivery has been delayed for some hours, the sudden relaxation of the os is announ- ced by retching, and a desire to vomit. Ulceration of the cervix may indirectly occasion the most intractable vomiting. Bennet and others are of opinion that the worst cases of " morning sick- ness" are referable to this cause. Uterine displacements are known to produce it, and it is more than possible that the slight prolapse of the womb, which is incident to the first months of gestation may help to account for this very distressing symptom. In the example before you, the retroversion, which is tempor- arily induced by more or less of exercise upon her feet during the day, and which is relieved when the patient Retroversion a possible rests at night, is evidently the chief cause of cause of morning sickness. o ' J the retching and vomiting. When the fundus and body of the uterus topple over backwards, they not only press upon the anterior sacral or sciatic plexus of nerves, which is situated at the side of the rectum, but also upon the sacral ganglia of the great sympathetic. The hypogastric plexus is also impli- cated in the displacement. The ease with which the organ can be replaced, and the manifest relief afforded, are not only useful in the matter of diagnosis, but suggestive as to the postural treat-, ment proper for our patient. For, the mere prescription of a remedy, or remedies, to be given internally for the relief of the* gastric symptoms, is but a fractional part of the physician's duty THE DISEASES OF PREGNANCY. 313 in a case of this kind. It will often happen, that by placing such a patient in a proper posture, and regulating her diet, as well as the time of eating her meals, and the amount and quality of exer- cise taken, we can accomplish more than by the most appropriate ■constitutional means. The cause of the suffering is purely local, and the treatment should be partly, if not exclusively, local also. In less than a month, if the excessive vomiting and the dis- placement do not cause abortion, this woman's womb will pass out of the pelvic basin into the abdominal Abortion a contingent of . . -, . . , , retroversion of the gravid cavity, in order that it may undergo the proper development. If we can succeed in averting the contingency of miscarriage, (which is, perhaps, doubtful,) she may go on well to term. For when the womb has escaped from the lower pelvis, its liability to dislocation will be removed, and the proneness to gastric derangement cease. Provided the retroversion is not inveterate, the gastric disorder will be self- limited. The idea has long been entertained and advocated by obstetri- cal writers that, unless a pregnant woman has " morning sickness' ' if not excessive, morn- at some period of gestation, she will be apt to Aft tTretura at mghtTn miscarry, or perhaps to have a difficult and retroversion. dangerous labor at its close. Although there are frequent exceptions to this rule, many persons passing through pregnancy from first to last without any particular derangement of the stomach, and finally doing well, it nevertheless remains true, that its presence is a more favorable sign, if it be not extreme in degree or misplaced in the period of its recurrence, than its absence. From careful observation in this respect, I am led to conclude that the habitual return of this symptom at evening, or as sometimes happens, in the middle of the night, renders it a more serious and obstinate affair than when it comes in the early part of the day, whether before or after breakfast. While it is no part of my duty or desire to reflect unkindly upon my professional brethren, I must be emphatic in warning you against perpetrating the folly and wrong ^fiorf u°ntlrrint\ v d' able which this patient's former physician commit- ted when he declared it impossible for her ever to carry another child past the fourth month. His opinion was not properly deduced from the facts of the case, and is, therefore, 314 THE DISEASES OF WOMEN. fallacious. Because this poor woman had retroversion in the early stage of two successive pregnancies, and afterwards aborted, it by no means follows that a third or a fourth attempt to com- plete the process of gestation can not prove successful. If such a verdict were as harmless as it were unjustifiable, we would pass it by without further notice. But you are witnesses to the fact that it weighs down this patient's spirits like an incubus, and dis- courages her in the outset. Such dicta are inexcusable and mis- chievous. There are few circumstances that will warrant you in telling a woman that she cannot possibly go through with preg- nancy, and give birth to a living child. Daily experience proves that even the most learned and reliable practitioners are likely to be mistaken when they pass such a sentence upon their patients. The range of physiological possibilities is a wide one, and since: Nature will do as she pleases, it will be wise in us not to assume to limit her powers in this direction. Treatment. — The first indication presented is to restore the womb to its natural position. This may usually be accomplished by a species of vaginal taxis, pressure being How to replace the womb. _ made with one or more 01 the lingers against the body of the displaced organ in the direction of the sacro- vertebral angle. In order to be most efficient and least harmful, this operation should be performed in a slow and cautious, not in a rapid and careless manner. The desired result will be facili- tated by calling gravitation to our aid. For this purpose, in most cases, it may suffice for the patient to lie upon her side, or better still, upon her abdomen. We may, however, find it best to place her in the prone position upon the knees and breast, over one or more large pillows, as recommended in the treatment of prolapse of the funis, and for the correction of presentation of the face,, side and shoulder. It may also be necessary to introduce the finger, or some other instrument, into the rectum in such a man- ner as to aid in replacing the uterus. Gariel's air-bag may be passed into the bowel behind the displaced organ, and afterwards, so inflated as to lift the fundus, and compel the womb to corre- spond as it should with the axis of the superior strait. Or you may employ this little instrument, devised by my friend, ProL Guernsey,* which is admirably fitted to fill the same indication. * Vide Guernsey's Obstetrics, etc., 1867 ; page 16. THE DISEASES OF PREGNANCY. 315 In using this instrument, Dr. Gr. recommends that after the bladder and rectum have been emptied, " the patient should be placed on the bed, near its edge, upon her knees and elbows, so that the force of gravity may assist in the reduction. The ball of Fig. 29. Dr. Guernsey's Uterine Repositor. the instrument, well lubricated, is to be brought to the anus, with the convex surface of the rod upwards, then gently pressed until within the sphincter, when the handle should be slightly elevated,, so as to bring the ball against the anterior wall of the rectum. The instrument is now to be firmly and carefully pressed up the rectum, when the ball will elevate the fundus, — care being taken to raise the handle more and more as progress up the rectum is made ; and presently the uterus will regain its normal position immediately posterior to the symphysis pubis. In all cases of uterine displacement incident to pregnancy, and whether for purposes of exploration or of treatment, you should carefullv abstain from the introduction of any The uterine sound as _ J J a means of reducing instrument whatever through the canal of the the dislocation. cervix into the uterine cavity. Such an opera- tion would be almost certain, sooner or later, to be followed by abortion. And I flatter myself that no member of this medical class would willingly commit the crime of murder, even for the sake of curing a case of prolapsus, or of retroversion of the womb ! I have known a physician, however, who, through cupidity and ignorance, found it convenient to diagnosticate many examples of the latter displacement in pregnant females, and afterwards to reduce the dislocation by means of the uterine sound — a most cruel and unwarrantable expedient. But simply to replace the oro-an in such a case Postural treatment. . r ^ . n , ™ . as the one before us is not ahvays sufficient* Unless we provide against a recurrence of the displacement, more 31.6 THE DISEASES OF WOMEN. especially when the patient assumes an upright position, the in- creased size and weight of the womb will bring- it down again. To obviate such a result, and thus indirectly to control the gastric symptoms, she should remain in the horizontal position upon the bed or sofa, and should lie either upon the side or upon the abdo- men. If she can keep off her feet altogether until such time as the uterus has ascended into the abdomen, the vomiting will be greatly relieved, and perhaps cured, and, what is still more important, the chief danger of abortion will also be averted. It is only now and then that a pessary is of real utility in the uterine deviations contingent upon pregnancy. The watch-spring pessary, covered with rubber, The pessary. . ._ " . , aviII sometimes answer a good purpose temporarily, and is less objectionable than most others. Either of the stem pessaries would be more likely to cause than to prevent a miscarriage, and moreover they are not suited to cases of retroversion. FlG . 30> watch-spring In two similar instances I have succeeded in Pessary, keeping the womb in situ by the introduction of a small sized air- pessary, to be then inflated, in the posterior and superior portion of the vagina, in such a manner as to prevent the body and fundus of the organ from falling towards the coccyx. When distended with air, this rubber bag becomes a species of cushion against which the uterus may rest without injury, and indeed it can do no possible harm to the soft parts. Nor is it half so liable as instruments that are made of more solid materials, to stimulate reflex uterine contractions, and thereby to excite an f abortion. Some practitioners prefer fig. 31. Cutter's Pes^. Hodge's lever, or Cutter's pessary in this as in other cases of retroversion. If judiciously used, it very rarely happens that the means which I have indicated Avill not serve to replace the womb and to keep it in position. A few cases are recorded in which the displacement has per- Ketroversionmay ^ted until the end of gestation. Where the persist until terra. n retroversion is inveterate, and in case of an emer- gency, it has been thought expedient sometimes to promote the evacuation of the uterine contents by rupturing the amniotic sac THE DISEASES OF PREGNANCY. 317 through the uterine cervix, or by the operation of paracentesis uteri, as first recommended by the celebrated Dr. ,Wm. Hunter. In a report upon the retroversion of the gravid uterus, read before the Obstetrical Society of London, by Dr. W. Tyler Smith*, you will find the following instructive case : " I was consulted in August 1859, by a lady, a patient of Di\ Duigan, of Gainsborough. She Avas the mother of two children,, and, in the previous May, had a miscarriage, which left her in a very weak state. She had lost blood largely, and had since been irregular at the periods. Her chief complaint was of a distressing pain at the bottom of the back, and the least attempt at walking or exertion produced faintness. On making a digital examination, the uterus was found to be retro verted, the fundus hanging upon the lower part of the rectum, and so enlarged as to make me be- lieve that pregnancy existed. She remained in town about a month; and the increase in the size of the uterus in this time con- verted the belief into certainty. There is no other condition in which the increase of the gravid uterus in the early months can be so readily estimated as in retroversion. The globular fundus is so perfectly within reach of the finger, as to render it possible to measure its increase with a precision which cannot be obtained when the uterus is in its natural position. In this case, the fundus could be lifted from the rectum, so as to afford temporary relief, but it Avould soon return to the position of retroversion. Acting on this hint, I introduced an air-pessary of considerable size which gave great relief, and enabled her to move about to an extent which had been previously impossible. With the air-pessary the uterus remained in a state of semi-retroversion. She continued to wear the instrument, with great comfort, for upwards of two months, and only left it off when quickening and the movements of the child made it certain that the uterus had risen out of the pelvis. She was delivered in April last of a living child, and carefully rested after her confinement, lying as much as possible, in the prone position. In this case, the pelvis was a large size, and it is the only instance I have seen of persistent retroversion in the gravid state, in which there was no vesical symptom what- ever. I have seen this patient twice since her delivery. The first time there was no sign of retroversion, but the second it had re- *Trans. of the Obstetrical Society of London; Vol. II.. page 297. 318 THE DISEASES OF WOMEN. turned to some extent, and I advised the use of the air-pessary again." CHOREA DURING PREGNANCY. Case. — Mrs. S., primipara, is twenty-five years old. Her menses appeared at thirteen and a half years ; but, without realiz- ing what might follow in consequence, she took a cold bath at the time and afterwards suffered from spasmodic dysmenorrhcea. At the age of sixteen she had an ulcer on the left leg, over the tibia, which began as a blister and spread extensively, finally in- volving the knee. The ulcer was healed, after two months treat- ment, by topical applications. The cicatrix has since been the seat of tingling sensations, which were aggravated by cold. For three years past this patient has not menstruated more than six or eight times in twelve months. The flow has always been painful. She is now eight months advanced in pregnancy. At the first month she began to have choreic twitchings in the left hand and arm ; afterwards the corresponding foot and leg became affected in the same way. Then there was a tingling in the left side of the face and head, and at the second month the muscles of the same side of the face began these grotesque movements. At the fifth month the choreic twitchings changed sides, the face excepted, in consequence of her being put into a cold wet-sheet pack. Since that time the voluntary muscles of the right leg and arm, and of the left side of the face have also been affected. With the dysmenorrhcea the left breast used to become swollen and very tender, but the right one always escaped. From the date of conception, however, the left breast has not been painful. Although she inherits a predisposition to rheumatism, she says she has been very careless in not protecting herself from changes of the weather. She has often worn damp clothing, and gone for many hours with wet feet. Of late she has been very nervous and sleepless, talks at night and suffers from the most frightful dreams; but the spasms are suspended during sleep. The appe- tite is good, but, since the chorea set in, the bowels have been invet- erately constipated. At evening the ankles are puffed, but in the morning they are not so. She has at times severe pains in the back and in the left side, and the spinous process of the fourth dorsal vertebra is tender to pressure. She never had the chorea while a child, nor does she know of a case in her family history. Technically speaking, this is an example of chorea gravidarum. Waiving the discussion of certain physiological questions con- nected with the subject of chorea, we shall find that its clinical his- tory is full of interest. You may have supposed that chorea was exclusively a disease of childhood, which, in the case of girls espe- THE DISEASES OF PREGNANCY. 319 daily, terminated at puberty. But here it complicates pregnancy in a woman who is twenty-five years old. In most cases of this kind, and they are not very common, you will discover that the patient has had the chorea when a child. Very likely the former attack ceased with the regular establishment of the menstrual function, for, as a rule, with young girls, it is a self-limited affair. But this woman insists that she never had anything like it before. Etiology. — Not unfrequently chorea is hereditary. I have seen it in three generations of children in the same family. Some times, by a species of atavism, it skips one generation and appears in the next following. And, even where the disease does not become fully developed, there is often a latent predisposition to it, in which certain exciting causes may precipitate an attack. Nature. — Such a predisposition is sometimes secondary upon other diseases, more especially upon rheumatism and hysteria. As long ago as the year 1821, Dr. Copland, author of the Dictionary of Practical Medicine, drew attention to the fact that chorea may be, and frequently is, a- sequel of rheumatism. In the case of children, I am confident that there are numerous exceptions to this rule, which at one time was thought to be almost universal. But with women du- ring gestation, a large proportion of those who have had chorea have also had sub-acute rheumatism. In the case before you the nervous symptoms, which have been charged to an "insanity of the muscles," and which are so pronounced while I am speaking, are engrafted upon the rheumatic diathesis. This form of chorea may spring from anaemia, or from chloro- sis. There is no doubt that the impoverished condition of our patient's blood, and the consequent lack of nu- trition of the nerve centres, has helped to pro- duce this unfortunate result. For the growth of the foetus in ntero drains the blood of its best constituents, and predisposes the mother to nervous affections of various kinds. This case is in evidence that dysmenorrhoea may develop a bias toward spasmodic affections, which shall outlive its own existence. The local spasm of the uterine neck, which caused the pain at the month, and sometimes stopped the periods altogether, worried the nervous system into this peculiar condition, which is closely akin to oonvulsibility. Hence an acquired susceptibility to such exciting causes as may bring on the attack. 320 THE DISEASES OF WOMEN. These exciting causes cannot always be ascertained. Fright is. the most common of them all. Woodman cites a case in which a pregnant woman was seized with chorea from thinking that her husband was killed; and Rom- berg and Helfft each a case in which it was caused by the shock of falling into the water. This kind of psychical shock has the same effect upon adult women who are inclined to chorea that it has upon children. I have seen a case in which chorea was induced in a young woman, who was only one month advanced in preg- nancy, by a terrible scolding which her mother gave her. Wo- men are sometimes worried into this state by the dread of havings it known that they are pregnant. The presence of the foetus in utero is an incident exciting cause of a peculiar kind. In certain very sensitive women an ovum of a fort-night or three week's development may be sufficient to excite such reflex spasms of the voluntary muscles, as you see in our pa- tient. The growing germ is a more or less constantly acting cause. If chorea begins, as it did in this woman's case, quite early in the period of gestation, it will most probably continue until its close; for while the cause remains, the effect must continue, and it will not cease until the gravid uterus has been emptied of its contents. All the reflex phenomena, connected with pregnancy, if they arc serious, are subject to this rule. Sometimes, although rarely, cho- rea is also a post-puerperal affection. As with children, it may follow the repercussion of the measles,, or of various eruptions ; and it is not improbable that this acci- dent may have been a factor in the case before us. Chorea is more common with primiparse than with those who have had children before. One attack does not, however, give exemption from another. There are those who In primiparae. . v „ .. _ . have chorea in a modified form for two or more successive pregnancies; and per contra, as with puerperal convul- sions, most women who have it at all, have it but once. In this matter very much depends upon the external circumstances, as well as upon the morbid tendencies to which the patient may have been subjected. Symptoms. — The symptoms are identical with those belonging to the same disease in children. The irregular contractions and twitchings of the voluntary muscles, which defy the will of the; THE DISJ'ASES OF PREGNANCY. 321 patient, are quite distinctive. These movements are almost al- ways unilateral, or hemic horeic, and the left side is more fre- quently affected than the right. Sometimes, however, either for an unknown reason, or in consequence of something that has been done for her relief, as with the wet-pack in this case, the lesion is shifted to the opposite side. Or the spasm may affect first one side and then the other, alternately. The more pronounced the rheumatic bias, the more likely is the disease to travel from one set of muscles to another, and finally to become general. In exceptional cases the spasms may be limited to one or both the legs, to the muscles of the abdomen, to those of the face and neck, or of the hands and finders, the larynx, Localized chorea. , , , -,. i n ,.1, "~ -,, , and the diaphragm ; and still more rarely to the heart, giving rise to what has been denominated " cardiac chorea." Whatever their location, and however severe they may be, these spasms are suspended during sleep. There is a phase of morbid action which, in some of these cases of chorea gravidarum, is both curious and suggestive. At the outset of the attack the brain is not always implicated, but after a little the cerebral symptoms show themselves and keep on in- creasing in a compound ratio until the case ends, either with abor- tion or with labor at term. This gradual and progressive impair- ment of the mental faculties is more marked in the case of wo- men than in children who have the chorea. They become irritable, peevish, capricious and unhappy; they lose their memory, grow melancholy, threaten suicide, and are full of gloomy forebodings. Not unfrequently they are subject to attacks of delirium, and may even become maniacal. Dr. Barnes (Transactions of the Obstetrical Society of London, vol. x., p. 180,) is assured of the probability that the chorea causes the mental disorders. " This it does by the repeated shocks that at first stun the nervous centres; these shocks are equivalent to concussions, they exhaust and divert the nervous force, and af- ter a time impair the nutrition of the nervous substance. This hypothesis is perfectly consistent with the clinical facts, that the cerebral disorders are progressive in proportion to the duration and severity of the chorea, and if not too far advanced, undergo Amelioration with the decline or cessation of the chorea." Although, in its nature, chorea is essentiallva convulsive affec- 322 THE DISEASES OF WOMEN. tion, you should remember that it holds no clinical relation to puerperal eclampsia, epilepsy, catalepsy, or coma. If this patient reaches term without accident, she will not be more likely than other women to have convulsions, either before or after her deliv- ery. She may reach the very acme of hysterical excitement and apprehension, but it would be quite exceptional for her to have genuine convulsions. Prognosis. — Cases of this kind usually get well, but not speed- ily, nor as the direct consequence of medical treatment. In its slighter forms the chorea may be relieved and possibly cured be- fore the termination of pregnancy. Such a result is the more likely to follow if the attack was caused by a slight shock, which has not been repeated; if it is idiopathic and not secondary upon another disease, neither upon a depraved condition of the blood, nor an enfeebled state of the general system ; if the uterus is not too irritable, or intolerant of its contents ; and if the patient has never had the chorea before. The rheumatic complications are more lasting and dangerous. Iii some of the worst cases there are cardiac lesions, which, al- though they may have been latent before, have been lashed by the choreic convulsions of the heart, into a really serious condition. A mere irritability and irregularity of the heart's action, palpitation and precordial oppression, should not discourage you; but if you recognize the systolic bruit at the apex of the heart, and above all, the physical signs of valvular endocarditis, in a rheumatic subject with chorea, the prognosis should be guarded. The anaemic murmur, which is heard along the course of the carotid and other great vessels, is not so serious a symptom. Nor in general, are the signs of hypertrophy of the heart (which is more frequent in pregnant women than is generally supposed,) necessarily g-rave in their character. The cerebral symptoms do not afford a reliable criterion of the gravity of the disease. They are the epiphenomena which are more alarming than serious. It is only when they depend upon an organic disease of the brain, or in very rare instances, upon cerebral embolism, that they are of fatal significance. As a rule they disappear after delivery. Occasionally the muscular symptoms are so severe, and the gen- eral illness is so marked, that a crisis is extemporized by the spon- THE DISEASES OF PREGNANCY. 323 taneous coming" on of labor. Xature takes this measure to get rid of the exciting cause of the trouble, and to put an end to the symp- toms. The choreic contractions may seize upon the womb in such a way, and so forcibly, as finally to bring on the proper expulsive efiort. Hence a liability in these cases to abortion and to prema- ture delivery. But, if the woman reaches the period of gestation without having had such a mishap, the chorea is finished as abruptly and as completely by the birth of the child as intermittent fever ever was by natrum murtaticum. This is a rule to which there are few exceptions. This form of chorea is sometimes fatal. Dr. Barnes has com- piled the history of fifty-six cases of chorea gravidarum, of which seven died. The post-mortem lesions were not The fatal form. . , . ., . ■ ■ ■« constant, or in any sense characteristic, rev- haps the most frequent of them was the existence of incidental, polypoid vegetations, or fibrin-beads, which had gathered upon the mitral valve of the heart. It is possible that some of these little growths may have been detached and carried with the blood into the smaller vessels, finally causing death by embolism. Treatment. — The first thing to do is to put the patient, as much as possible, beyond the reach of all those influences which tend to perturb and to derange the nervous system. For, she is, of neces- sity, very impressible to the little things Avhich are of no account in themselves, and ot which a well person would take uo notice. Her surroundings ought to suggest a calm and quiet demeanor, and everything in her daily life should be as grateful and pleasant as possible. Her diet, society, occupation, sleep and exercise, should all be tuned to this key. If it is otherwise, you need not wonder if the most fitly chosen remedies shall fail to effect. These remarks apply especially to those who have had the disease before. My own experience leads me also to place great reliance upon the kind and quality of the food that is chosen. In the majority of cases there is an evident lack of nutrition. These patients need to be ted and fortified against a debility, of which the nervous spasms, like a neuralgia, are the obvious sign. These convulsive movements often increase as pregnancy advances, because the blood becomes more and more deficient in its nourishing properties. If the drain is not stopped, or rather, if its effects are not counter- acted by a proper alimentation, the disease will grow worse instead 324 THE DISEASES OF WOMEN. of better. A mixed diet should be allowed. Let it consist of milk, eggs, game, oysters, and other sea-food, good, wholesome bread and butter, and such other healthful articles as may be avail- able, and as will suit the taste. The malt liquors are sometimes very useful in this connection ; but it is best to interdict the use of tea and coffee. For the latter we may substitute chocolate, or the alkathrepta. This part of the treatment is so important, that it should not be overlooked, even in the mildest cases. There are nervous conditions which simulate chorea, that yield readily to such remedies as belladonna, ignatia, coffea, nux vomica, agaricus, and cuprum, under appropriate indications. These states are temporary, and often depend upon avoidable causes. They are easily cured. But confirmed cases require more skillful management. The spasms are likely to be inveterate. If they are caused by fright, ignatia, opium, calcarea carbonica, or cuprum may be called for. It is said that cuprum aceticum has cured this disease when it was occasioned by seeing another person in the fit. If the chorea is traceable to suppressed eruptions , this fact pre- sents a strong indication for cuprum aceticum, calcarea carbonica causticum, or sulphur. If the original exciting cause is in the uterus, the remedies which act upon that organ in such a manner as to control its local spasms and its reflex sympathies, will surely be required. Among these are belladonna, pulsatilla, sepia, sabina, gelsemium, veratrum viride, and caulophyllin. You cannot go wrong in cases of this kind if you give either of these remedies under precisely the same indications for which you would prescribe them in threatened abortion. For if, by this means, you can avert the miscarriage, you will have found the proper medicine for the relief, if not for the cure, of the choreic symptoms. Where the symptoms have their root in the rheumatic constitu- tion, we must prescribe accordingly. Rhus toxicodendron, macro- tin, or gelsemium, may either of them be required, to correct this peculiar bias. I have the greatest confidence in the gelsem- ium, more especially because with it I have been very successful in curing the chorea when it has followed or complicated rheuma- tism in children. Excepting in confirmed organic disease of the heart, it cures most of the incidental cardiac lesions that we find in THE DISEASES OF PREGNANCY. 325 cholera, and controls the nervous and spasmodic symptoms like a charm. I prefer to give it in the second decimal dilution, taking care to watch its effects very closely. How to interpret the mental symptoms is not airy easy prob- lem. What they signify and what they indicate, is something as difficult to decide as it is in a case of hysteria. Your best plan will be to place your reliance upon such of them only, as are not incidental and illusory. At the same time, you must be careful not to underate the importance of such as, at first sight, may seem to be trivial. Fortunately, the remedies which are most likely to be required for the cure of the choreic symptoms proper, will, in general, be equally applicable for the relief of the cerebral compli- cations. In a few instances recorded, these cerebral complications have however been of such an alarming nature as to justify a resort to the induction of premature labor. But, probably because this ex- pedient has been too long deferred, these cases have very generally died. It is possible that, in consequence ot deep-seated lesions of the cerebre-spinal centres, the evacuation of the gravid uterus might fail to arrest the disease. Anaesthetics are admissible only as temporary palliatives. They are suited to the worst cases, and their use should be restricted to the later weeks of pregnancy. Sulphuric ether is safer and better than chloroform. Neither should be administered by the patient herself. A pleasant and effective compromise may sometimes be made with those who clamor for something of this kind by putting twenty drops of sulphuric ether in half a glass of water and letting them take a teaspoonful every five or ten minutes, until they are quiet. Bathing and dry rubbing, if agreeable to the patient, may also be of service. Electricity should be used, if at all, only with the greatest care, in the chorea of pregnant women. This woman will take gelsemium 3, once in four hours. [This patient was delivered with the forceps, in the hospital, in the presence of several members of the class, on the eve of January 7th, 1875. Her labor was natural. The anaesthetic, ether, acted well, and she had no sign of a convulsion. The choreic spasms abated, and in a fortnight she was discharged, cured.] LECTURE XX. ABORTION WITH MISPLACED PAINS. Abortion with misplaced pains; the ''habit" of aborting; intermittent abortion ; the sequelae of abortion. Case.— In consequence of over-exertion, Mrs, G., aged 30 r aborted at the end of the third month. She had twice before mis- carried at the same period of pregnancy. Immediately after vio- lent exercise at house-cleaning, she began to flow slightly, and to experience an occasional sharp pain in the left hypogastrium. After a restless night she awoke at 6 a. m. with an acute, lancinating headache. This pain in the head was accompanied by an extreme soreness and tenderness in the nape of the neck. The pupils were dilated to nearly the whole extent of the iris. She complained of photophobia, with a shower of sparks before the eyes, and in a species of semi-delirium declared herself in the immediate neigh- borhood of a tearful conflagration. These later symptoms would disappear in the intervals between the paroxysms -of headache. When the pain in the head returned, she would scream and shriek and beg to be held firmly, in order that no terrible accident might befall her. These paroxysms returned every ten minutes for about two hours, or until I came and relieved her with a few doses of belladonna 3d. Upon examination, the os uteri was found but slightly dilated. The pain subsided, and finally ceased. Tiie same tram ot symptoms came on the second morning at six o'clock. They were, however, less violent in degree and of shorter duration, lasting in all not more than an hour. The os uteri was a little more patulous. The passive flow continued, but there were no uterine pains whatever. The third morning she had ha-f a dozen of the same paroxyms of pain in the head. They were repeated once in five or six min- utes, and were as severe as those of the first day. In the intervals she was found to be bleeding much more freely. The stomach had become exceedingly irritable, and she vomited frequently, each effort at emesis serving so perceptibly to increase the hemorrhage that the patient remarked it herself. The head- ache passed off, but during the clay she had two pretty severe uterine pains of an expulsive character, and became really quite ill. Early next morning regular labor pains commenced and con- tinued so that in an hour and a half all was over. The head and nervous symptoms vanished as soon as the proper uterine contrac- THE DISEASES OF PREGNANCY. 327 tions began. The fifth morning the headache did not return. She made a good recovery. Perhaps a majority of cases of accidental abortion are caused by undue or unusual muscular exertion. Lifting, scrubbing, over- reaching — as in hanging a picture, carrying a Abortion from over- chM ft j- distail c e hurriedly— as when in exertion. ° J haste to reach home or to take the train, run- ning the sewing machine for consecutive hours and days, horse- back riding, or climbing steep and difficult stairs, as for example, to the cupola of the city hall, have caused the uterus to expel its contents prematurely. You will not, however, understand me to say that these causes are invariably followed by such unfortunate consequences. Far from it. In many, and probably most pregnant Remarkable tolerance th - remarkable tolerance of of exercise. fatigue and even considerable muscular effort, if it be moderately and habitually practised. There are those in whom it would be impossible to bring on abortion by any such means. But in the majority of cases such a mishap is more easily induced. This is especially true of women of sedentary habits, who ordinarily take very little exercise, whether indoors or out, but who, under peculiar temptation or provocation, exceed the bounds of prudence, and overdo and injure themselves. In the matter of taking proper exercise, as in everything they do, these subjects are fitful and capricious. In them a sudden strain, or any unusual effort, conjoined with extraordinary nervous excitement and impulse may work mischief that might have been averted. Add to this, that if the woman has aborted once or twice already, and is, therefore, predisposed to this accident, these causes are more harmful, and we have the etiology of this aborting" 11 " 1 ° f class of cases plainly before us. The habit of aborting at a particular date of pregnancy also increases the clanger from this variety of accidental causes ; for there are women who miscarry at a certain time with almost as much regularity as they menstruate when they are well. And, although this result may happen at any period of gestation, it is extremely liable to occur at the end of the third month. This clinical fact is confirmed in the case just now detailed to you. Our patient had already miscarried twice at the twelfth week, 328 THE DISEASES OF WOMEN. and now, with the arrival of the same period, over-exertion in house-cleaning caused a slight uterine flow, and pains, which resulted in the loss of the embryo. You should not fail to observe that this indiscretion and excess on her part was more mis- chievous at this particular time than it might have been at any other. Even a slight flow of blood from the gravid uterus, and espe- cially if it be accompanied by pain in either hypogastrium, or about the loins, may betoken a miscarriage. Under these circum- stances the symptoms of impending abortion do not differ, in any essential particular, from those which date the appearance of the menstrual discharge. We are naturally suspicious of them, how- ever, and solicitous concerning their interpretation and results ; for their continuance signifies an interruption in the process of intra-uterine development, and the possible sacrifice of the off- spring. But the chief peculiarity ot this case was the periodical and regularly recurring headache. This was a good example of inter- mittent abortion.* The headache took the place Intermittent abortion. _ . . ... of the uterine pains, came every morning lor three successive days, continued for a given time, and then left. The paroxysms, which were distinctly pronounced, came and went with the regularity cf labor pains. And they increased in fre- quency each day. Meanwhile, there Avas no expulsive uterine effort, or at least none of a painful or positive character. By and by the flow increased, and the stomach became implicated. Vom- iting" ensued. This was a certain sign that the os uteri had beg-un to dilate more freely and rapidly. The principle obstacle to deliv- ery, and the indirect cause of the headache, also, were removed as soon as the cervix Avas sufficiently relaxed for the escape of the contained embryo. Proper uterine contractions succeeded. The real labor Avas short and decisive. The headache vanished, haem- orrhage ceased, and our patient made a good recovery. Treatment. — There are several methods by which this case could have been brought to a successful termination. The ques- tion to decide was, which is the more safe and expedient. I might have given this Avoman a strong dose of ergot, and finished her labor abruptly, by forcing the uterus to expel its contents through *Vide U. S. Medical and Surgical Journal, vol. iv., p. 75. THE DISEASES OF PREGNANCY. 329 the slowly dilating os. Or, perhaps, a powerful cathartic Avould have produced a similar result. Or an emetic might have unlocked the cervix, with the mysterious key of reflex action. Or sitz-baths, or the colpeurynter, might have brought about the same end. Or .an old-fashioned dose of morphine, or perhaps of quinine, might Jiave arrested the headache, until such time as the gradual expan- sion of the lower segment of the womb should permit the proper pains to come on spontaneously, and terminate the delivery. But the belladonna was a more appropriate, specific, and satis- factory remedy. Not only did it relieve the headache, which, as I have said, was indirectly due to the rigidity of the uterine neck, but it also relaxed the fibres of the unyielding cervix — which is slow to yield before the fourth month — and thus removed the cause of the suffering and the delay. It was appropriate for the pain in the head, because it was specifically adapted to remedy the condition of the cervix, upon which it depended, and of which it was the consequence. It harmonized the nervous sympathies ^existing between the body of the womb and its inflexible outlet. It charmed away the impending danger to the brain, and permit- ted nature to complete the delivery with the least possible risk to the health and welfare of the patient. One of the best remedies that I have ever given in "intermit- tent abortion" is gelsemium. It seems adapted to the same general symptoms which call for belladonna, with the added complication of a paroxysmal recurrence of the symptoms that threaten to precipitate the extrusion of the ovum. The repetition of the paroxysm may have a regular type, like a fit of the ague, with a distinct interval, and may perhaps be accompanied by a discharge of mucus or of amniotic fluid. Where it is desirable to centre the scattered, or wild pains, upon the womb, and to finish the delivery, because in any event it is inevitable, caulophyllin is the remedy. THE SEQUELAE OF ABORTION. This patient was brought to the Clinic by my friend, Dr. W. W. Wilson, whose notes of the case I will read you. Case. — Mrs. , aged 39, English the mother of two children, lias always enjoyed good health until now. She has never been 330 THE DISEASES OF WOMEN. troubled with female weaknesses of any kind, and never aborted before. She became pregnant during the latter part of April, and by the advice of an old midwife, took vaginal injections of warm water twice daily, for the purpose of promoting an easy labor at term ! On the tenth of June (at the sixth week), she came by railway from Indianapolis to Chicago. The next morning after her arrival, not having any warm water convenient, she took an injection of cold water instead, and this was applied with a com- mon rectal syringe. The shock w T as such that she fainted, and in a few minutes aborted, everything coming away with a gush. A physician was called in, who arrested the flow entirely, and the next day she felt so well that she did the washing for the family. That night she was seized with cramps and great pains through her bod}^ and limbs. Another doctor came, who said that she had inflammation of the bowels, and treated her accord- ingly. Since that time she has had four other physicians in turn, one of whom treated her for neuralgia of the liver (!), another for dropsy, a third for enlargement of the womb, and the last for dyspepsia. I was called Aug. 31, and found her in great pain and distress, respiration labored, pulse 125, feverish and talking incoherently. The pains were paroxysmal, like those of labor, but were con- fined to the left ovarian region. On examination, I found the uterus and vagina normal, except that there was a-slight, whit- ish discharge from the os uteri. Ordered pulsatilla 2 ° ° every two hours, and the local use of the extract of hamamelis. Sept. 1. Much easier. The pains have almost entirely ceased. Bell. 200 . Sept. 2. Still improving, but restless and cannot sleep. Con- tinue the belladonna, but in addition to take three doses of coffea 30 between 4 and 10 p.m. Sept. 3. Husband reports his wife better. Slept well all night. Continue the same remedies. Sept. 5. Found my patient sitting up and relatively comforta- ble. Bryonia 200 every three hours, and zincum valerianicum 3 dec. a powder at night. Sept. 8. The menses came at 10 A. M. Says she is well, but very weak. China 200 every three hours. There is no single respect in which women differ more decidedly than in the readiness with which they abort. With some the slightest causes will induce a "mishap." A Causes of abortion. . , . -, . . , . -, misstep, a rough ride in a carriage, climb- ing stairs, a long walk, a severe cold, coughing, sneezing, an attack of dysentery or diarrhoea, nausea, dysuria, a severe THE DISEASES OF PREGNANCY. 331 toothache, mental anxiety, or even jumping out of bed sud- denly, have been known to cause it in those who were very susceptible. On the other hand, there are some women, who, no matter what they do, or suffer, are in no possible danger of mis- carrying. They incur every risk without the least concern, or if so wickedly disposed, m^j try every means to induce an abortion, but without effecting it. The former are often disappointed in being unable to carry their offspring to term ; but sometimes take advantage of their idiosyncrasy to put an end to intra-uterine de- velopment. The latter are often victims of their own or others' temerity in trying to interrupt the wonderful process of gestation, and thousands of them suffer the remote consequences of such conduct in the form of uterine diseases which are sometimes en- tailed upon them for life. But nature has thrown certain safeguards around pregnant wo- men which generally exempt them from harmful contingencies, and help them to pass through the ordeal of mater- Toleration of injuries n i t y w ^^ less of danger and risk than you during pregnancy. J o J would at first suppose. As pregnancy ad- vances she develops a species of toleration to processes that are new and peculiar. She even counteracts and antidotes the mis- chievous interference of doctors of every grade, and nurses of all sorts, with her prerogatives. In this woman's case, the warm water injections happily did no harm. She could bear them with impunity. But the shock of the cold water, and especially when taken so soon after the journey, caused an almost instantaneous abortion. Perhaps she might have taken this injection at another time without any ill effect ; but, the probabilities are that while the habitual use of the warm water developed a toleration for it, the cold application could not be borne at all without mischievous results. I regret to say that there are physicians who do not regard an abortion at the early period of six weeks as an affair of the least consequence. They will tell you that prior tion°ist histries ° f the Abor " to quickening the embryo is not alive, and that there is no particular necessity for min- istering to its welfare or for shielding it from harm. But let me say, that the moment the ovum escapes from the Graafian ibllicle, that moment it ceases to be a part of the maternal organ- 332 THE DISEASES OF WOMEN. ism. This is as true in case of fecundation as it is in menstruation. Arrived in the uterine cavity, the egg is no more a part of the mother than is the egg of the bird when laid in its nest to await future development, or that of the snake when dropped into the grass before being fertilized. It represents a separate organization, which, although incapable of maintaining a separate existence, is as really independent as the infant at birth, or its father at forty. Once the conditions for conception are supplied, and the vital- izing portion of the semen masculinum has impressed itself upon the ovum somewhere along the course of the The embryo is alive. generative intestine, the first step in the repro- ductive series has been taken. From this time forth, whatever imperils the integrity of that germ, implicates life ; and whoever intentionally intercepts the wonderful changes incident thereto, unless to save life, is a veritable murderer — no more and no less ! Whether prior or subsequent to the formation of the placenta, the dependence upon the mother for subsistence is substantially the same. No one familiar with the organization and function of the chorion can doubt this. The physical laws that regulate the sup- ply and waste, the nutrition and detritus of germ-life r embryonic life, and foetal life, are identical, and there is nothing in the mode of their operation which could lead us to infer that from the mo- ment of fecundation, the whole process of intra-uterine develop- ment is not of the greatest importance. It is no argument against the vitality of the smallest embryo, that direct vascular and nervous attachments between it and the endometrium have never been demonstrated. Blood-vessels have never been found in cartilages, ligaments, the epithelial tissues, and the epidermis. We may as well declare them inanimate for similar reasons. Moreover, the fact that direct means of com- munication between the mother's organism and the fecundated ovum, prior to the formation of the placenta, have not been dis- covered, is not to be received as proof of their non-existence. Reasoning by analogy, we know that the means of preserving life therein are not lacking. The fertilized human ovum is not like the seed that has been wrapped in an old mummy, and left for centuries to await the con- ditions for its development. Its growth is steady and constant, progressive, physiological and positive. The qualities it has THE DISEASES OF PBEGNAKCY. 333 derived from either parent are preserved. The predominant traits of temperament and predisposition, the idiosyncrasies and individualities that go to make up the separate being in subse- quent life, are there in esse. The hereditary features, and physi- cal bias, the mental capacity and character, which are latent and undiscoverable to us, are nevertheless epitomized in the develop- ing germ. If, prior to quickening, the mass were inanimate or dead, this could not be true ; nor would it be possible, when two or three months had elapsed, for the mother, however imagi- native, to imprint such paternal characteristics as are frequently inherited upon her offspring. The very fact that these peculiari- ties are perpetuated is proof positive of constant development and physiological change. Quickening is not a reliable criterion of the vitality of the embryo, for the obvious reasons that it does not begin at a fixed and determinate period of pregnancy ; that i Qu if h ? fe ing not the first ^ * s fr eo L uen tly lacking throughout gesta- tion ; that it may be confounded with ab- normal sensations of various kinds ; and that the force of the impulse felt by the mother may be very strong in case of a weakly infant, or vice versa. It is more than possible that foetal movements may occur for some weeks before they are recognized by the mother. Auscultation of the abdomen discloses the ex- istence of these movements before the pulsations of the foetal heart, or even the placental souffle can be heard. Not long since, a mother told me that, after its birth, a foetus of a little more than two months kicked quite violently ; and at a very early period of gestation they have been known to breathe and cry when suddenly expelled the uterus. From my frequent allusion to abortion as an indirect cause of many of the diseases of women, you already have an idea of the importance cf this subject. For the whole di^as°e rtIon as a ° ause ° f °L Uest i 011 °f its prophylaxis, the right, and wrong, and responsibility of it, must be set- tled by medical men. Nothing could be more natural than for a sudden and forcible interruption of the textural changes and sympathetic relations, peculiar to pregnancy, to result in more or less of disease and disorder. The ovaries, the mammary glands, the uterine walls, vessels and lining membrane, and the nutritive 334 THE DISEASES OF WOMEN. and nervous systems are especially apt to suffer ; and, strange to say, with certain exceptions, the earlier the period of the abor- tion, the greater the liability to these unfortunate sequelae. The list of these contingent and consecutive ailments is a long one. It includes the different forms of ovarian inflammation, ovarian dropsy, every species of menstrual disor- Sequelae of abortion. . . , . der, peri- and para-metritis, metro-peritonitis, hematocele, the formation of moles, hydatids, fibroids, and uterine polypi, uterine displacements, uterine and vaginal flstulae, subse- quent abortion, atresia of the cervix uteri, sterility, hysteria, dys- pepsia, neuralgia, leucorrhcea ; malignant diseases, as cancer, at the climacteric, and mania. Such an array of the possible consequences of abortion, whether accidental or induced, should lead you to make an especial effort to prevent it, whenever it is possible. I have placed upon the black-board a table of the causes of abortion, which you would do well to copy into your note-books, and study at your leisure : I.— Constitutional or Predisposing. III. — Reflex, or Exciting. t -Plethora, I.— Centric : -Anamia and Chlorosis, Emotional, as Fright, Anger, Grief, — The Scrofulous Diathesis, etc -> —The Menstrual Molimen, Direct blows upon the head or back, —Zymotic Diseases : Cerebro-spinal meningitis, Syphilis Cerebro-spinal effusion, Mercurialization, ■ Hysteria and Epilepsy. Variola, ■Excentric: Scarlatina, Parotidean Irritation, Diphtheria, Thoracic do. Cholera. Mammary do. Dental do. Gastric do. Rectal do. II.— Local, or Organic. Vesical and Renal Irritation, Vaginal Irritation, r.— Malformation of the Ovum. Falls . jumping, blows, etc., 2 _ " of the Membrane (moles, Functional and Organic Disease of hydatids). the Womb, 3.— Placental Abnormalities : Dltto of the Ovaries, Mal-location of, (placenta previa.) Death of the Embryo, Organic disease of, Shock from cold injections, cold Detachment of, bath > etc - Fatty degeneration of, Genital irritation (coitus), Calcareous ditto. Do - do - (instrumental). IV. — Medicinal. This class includes the various emmenagogues, or oxytoxics, which have been known to cause the uterus to empty itself of its contents, among which are tansy, (tanacetum vulgare). ergot, (secale cornutum), cotton plant (gossypium herb.), quinine, cantharis, electricity, and some others. THE DISEASES OF PREGNANCY. 335 You could not have a better illustration of the importance of this subject than the history of this case affords. It is more than possible that, until my young friend here was called to the rescue, no one had an intelligent idea of this poor woman's condition. The first doctor who came to her, and who sealed up the flow so promptly, should have impressed upon her the absolute necessity for rest and quiet. He should have insisted upon her remaining in bed, with as much care, and for as long a time as if she had just passed through labor at term. If he had taken this precau- tion, and given her no medicine whatever, she would probably have recovered without any untoward symptoms. But he did nothing of the kind, and the consequence was that she became very ill, and, worst of all, was subjected in turn to the tender mercies of several other incompetent in effects of wrong diag- doctors. One said that she had enteritis, nosis. 7 another neuralgia of the liver (!), a third hypertrophy of the womb, and a fourth dyspepsia. Their diagno- sis was wrong, and hence their treatment could not be right. She greAV worse instead of better. This brings us to the practical lesson that I wish to draw from the case before you. It concerns the difficulty of diagnosticating the diseases that may accompany or follow Difficulty of recognizing abortion. For I am confident that this pa- the sequelae of abortion. Jr tient's experience at the hands of her physi- cians is by no means an uncommon one. In truth it is very dif- ficult, and sometimes quite impossible, to decide whether this or that class of symptoms of which women complain is or is not re- ferable to abortion as a cause. The perplexity is increased by our liability to confound it with delayed or painful menstruation, menorrhagia, membranous dysmenorrhea, and by the possibility that the patient, if so disposed, may deceive us, by leading us to believe that she has miscarried when she has not, or vice versa. Add to this that in many cases the diseases of the womb and of the ovaries which follow abortion run a latent course ; or they may partake of just enough of the hysterical "mimicry " to counter- feit other diseases, as for example peritonitis, enteritis, cystitis, etc. A recent writer* has published the following table upon the * Dr. Van de Warker, in the Journal of the Gynaecological Society of Boston, vol. IV, pp. 297-8. 336 THE DISEASES OF WOMEN. differential diagnosis between spontaneous and induced abor- tion : — Accidental and Spontaneous Abor- tion, to the Third Month. 1. Ovular abortion may occur and simulate dysmenorrhcea. Later ; a gradual cli- max of symptoms, thus : loss of appe- tite, depression of spirits, pain in the loins, weight at anus or vulva, pain in breasts, followed by haemorrhage and expulsive pains in the uterus. 2. From accident ; sharp pain in the back, loins, or abdomen ; often an interval of a day or two, or more, and then pains renewed violently and bleeding. 3 Evidence of history ; habitual abor- tion, previous ill-health, or plethoric state. 4. Often a history of uterine displace- ment. 5 As a rule the pulse rarely reaches 100. 6. As a rule, there are no symptoms of inflammatory complications of the uterus or the abdominal viscera. Instrumental Abortion, to the Third Month. :. Marked constitutional disturbance from the first. Rigors, fainting or collapse, severe pain in the hypogastrium, often extending over the entire abdomen, and marked tenderness on pressure. 2. Expulsive pains before the haemorrhage Pain severe in the back, and in a line from the umbilicus to the sacrum, pain and haemorrhage occurring together. Large clots. 3. Evidence of history. Previous good health. Evidence of habitual abortion absent, or doubtful. 5. As a rule pulse from 100 to 120. As a rule there are always symptoms of inflammatory complications, and tenderness on pressure over the uterus. Os and cervix enlarged and extremely tender to the touch. Treatment. — In case of threatened abortion, it will become your duty, whenever possible, to prevent it. If, however, delivery is inevitable, you must conduct it to a safe termination for the moth- er. But your interest in the case will not end with the expulsion of the embryo, or the birth of the foetus, as the case may be, any more than the surgeon's interest in his patient should end with the operation of cutting off a leg, or stitching up a wound. Suc- cess may depend wholly upon the after-treatment. First, then, as in surgical fever following bodily injuries and surgical operations, rest is the great remedy. A woman, the lin- ing membrane of whose womb has been forcibly torn off in an early abortion, perhaps, by the use and abuse of instruments, or whose placenta has been pre- maturely detached in miscarriage, is as unfit for exercise as the man who has but just undergone an amputation of the thigh. Un- der these circumstances it is as necessary and proper that the ute- rus should repose quietly as that the stump should not be injured by the patient's hobbling around. Rest. THE DISEASES OF PREGNANCY. 337 I know there are women who ignore and disregard these pre- cautions, and who do really escape any very serious consequences. But, depend upon it, these cases are exceptional. Thousands of them suffer and die of obscure, or more obvious, uterine disease as the result of a lack of care after a miscarriage. It is no uncom- mon thing for women to leave home on a long journey directly after "getting through," or even while they are in danger of aborting on the way. And some of you know from experience what it is to have such patients come to you from a neighboring town or city directly after an " operation," looking to the murder of the little innocent, has been performed. In this case the un- known city doctor kills -the offspring, while, despite your best efforts, the ride and the excitement may cost the mother her life. The analogy between the post-partum effects of abortion and the sequelae of a severe injury, or surgical operation, suggests the use of arnica both locally and internally in these cases. The strong tincture may be diluted in the proportion of one part of the arnica to six of water, and applied by means of compresses over the hypogastrium and pudenda. If the patient flows freely, or is particularly addicted to haemorrhage, the water should be cold ; otherwise, if she prefers, it may be tepid or even warm. You can advise whatever attenuation of arnica you choose, to be taken internally at the same time. A very common, and a very useful prescription, of the stereo- type sort, is to give aconite and arnica in hourly or less frequent alternation. These remedies are wonderfully Arnica with aconite. . . . . efficacious in warding oft the incidental lever and traumatic inflammation. This prescription may serve you a good turn in case you find it impossible to visit such patients very often or regularly. It should be given as soon as the delivery and its immediate dangers are passed. Aconite is particularly in- dicated if the miscarriage was caused by fright, and has been followed by fear and dread of fatal consequences. In case of the development of quasi-inflammatory symptoms, as in the spurious peritonitis, of which I have already spoken, ovarian irritation or neuralgia, undue determi- Belladonna. . nation of blood to the pelvic viscera without haemorrhage, excessive perturbation, unrest, and nervous irritabil- 22 338 THE DISEASES OF WOMEN. ity, with more or less acute pain, local or general, I know of no remedy so useful as belladonna. Atropine in the third decimal trituration will somtimes remove these symptoms like a charm. Chamomilla, colocynth, ignatia, hyoscyamus, and other poly- chrests will be useful under appropriate indications. If the pains assume the character of genuine after-pains, camphora, caulophyl- lin, belladonna, or nux vomica, may be required. If real metri- tis, phlebitis, or cellulitis shall result, the case will become more serious, and you will need to study very closely in order to find the appropriate remedy or remedies. Do not forget to give due weight to the accidental, as well as to the emotional causes of these secondary disorders. But I need not repeat what I have already said concerning their treatment. If the abdomen is tympanitic, and exceedingly tender to the touch, order the dry, hot, bran poultice, or the application of dry heat by means of plates wrapped in flannels, Local treatment. 1 . ' _ or have the abdomen covered with cotton bat- ting, or hot flannel. If the pain is circumscribed, and limited to one or the other ovarian region, it is possible that relief may follow a change of posture. Have the patient " change sides," and learn if she cannot lie with more ease upon one than upon the other. Forbid cold drinks while she is suffering, and let all her clothing, and that of the bed, be warm and dry. The chamber should be well ventilated, but do not allow a draft of air to pass near or over the bed. Place the patient in the most favorable position for re- gaining her health. And, what is sometimes as important as anything beside, see to it that officious neighbors and nurses, (and doctors too,) do not swarm about your patient in your absence. This woman is practically cured, and I will not change the pre- scription ; for it is a good rule in medicine as well as in morals to "let well enough alone." LECTURE XXI . STOMATITIS MATERNA: NURSING SORE MOUTH. Nursing sore-mouth; its Nature, Peculiarities, Symptoms, Diagnosis, Prognosis, and Treatment. This is one of the most interesting, as well as vexatious diseases with which we are acquainted. It is interesting because of its limited history and prevalence, its peculiar pathology, its mor- tality under the old regime, and the imperfect development of its therapeutics ; vexatious, because of its multiplied forms and com- plications, and its intractable nature, if not modified and remedied by appropriate means. Nature. — Concerning the essential nature of this malady, vari- ous opinions have been, and are still, entertained by the profession at large. The 'most plausible of these, we Theories of its origin. apprehend, is that which refers its phenomena to a scorbutic cachexia. It has been convenient for the majority of medical men to attribute its origin to miasmatic influences ; to a diminution of the red corpuscles of the blood ; to scrofula ; to menstrual irregularities, antecedent to conception ; to a depraved and insufficient nourishment, and the like ; but the best writers incline to the opinion that this catalogue embraces only the crude outline of its causes and consequences, while it leaves the radical nature of the malady itself an open question. That it is of scorbutic origin is evident, from the following con- siderations : First ; its causes are such as tend to derangements of nutrition and assimilation. Second ; it is invariably accompanied by anaemia. Third ; except in degree of violence, many of its symptoms are identical with those of the scurvy. Fourth ; the same dietetic regulations are requisite to cure the one as the other. Both demand a pabulum largely composed of vegetables, and of vegetable acids especially. 340 THE DISEASES OF WOMEN. Fifth ; they are alike mortal under treatment by excessive and improper medication, as by mercurials, quinine, etc. ; and this fatality is induced by an identical process of disintegration of the tissues, in which their elements are forced to remain, without elimination, as abnormal constituents of the blood. Sixth , those remedies which are most valuable in stomatitis materna, are also such as are most successfully employed against scorbutus. Peculiarities. — The stomatitis materna has the following characteristics: It is peculiar to females, and always to women during the term of utero-gestation, or at some iaaL?ion d t0 gestation and period of lactation. A few writers, indeed, claim to have witnessed examples of this disease in males ; but as a rule, one would as readily anticipate attacks of "morning sickness," among the latter sex (rare cases of which do indeed occur), as of this particular variety of stomatitis ; and in what follows, we are therefore to declare, and to keep in view the essential characteristics aforenamed. Symptoms. — These may be properly classed into local and general. The local symptoms of the stomatitis materna are not subject to a regular order of development, but vary with each particular example of the disease. Their more usual approach, however, is as follows : The patient calls attention to a burning or scalding sensation in the mouth, which sensation is greatly aggravated by the taking of warm, or even of cold drinks, and by efforts to masticate her food. Upon inspection, the physician remarks a fiery, red appear- ance of the mouth, which redness is found to exist in patches, or diffused more or less continuously over the whole buccal surface. Sometimes this eruption is isolated, presenting the appearance of ulcerated tubercula of the size of a pea, more or less. Again the aforesaid patches attain the diameter of a quarter of a doilar, when they may degenerate into ragged and indolent ulcers, thus constituting the worst examples of the disease which are to be met with, and which frequently spring from chronic neglect, or from that still more deplorable cause — a dyscrasia induced by drugs that have been ignorantly prescribed for their removal. With this local inflammation, whether it be diffused or isolated, THE DISEASES OF PREGNANCY. 341 deep-seated or superficial, there are other symptoms which are equally characteristic. Among these there will Incidental symptoms. in'i -11 -n Pvi o be round a marked pallor 01 the s-uriace, resembling chlorosis ; a sad and dejected expression of the coun- tenance ; soft, flabby muscles, while the rotundity of the form remains as in health ; anorexia, pyrosis, and other disorders of digestion ; a profuse flow of saliva ; the tongue is red and smooth ; cutting and colicky pains from the simplest ingesta ; alternations of constipation and diarrhoea ; strangury, with strong and scalding urine, which is acid to test paper ; palpitation, especially trouble- some at night ; the secretions are generally normal, the skin soft, but without any sensible perspiration ; and, if during lactation, a decided sympathy between the child and its parent, whereby it is discovered to have inherited thus early, some of her more imme- diate and palpable frailties. Chronic cases are likely to be accompanied by a diarrhoea which is chargeable to an extension of the specific inflammation to the middle and inferior portions of the alimentary mucous membrane. This symptom is frequently a very perplexing one, as well on account of the increased emaciation and debility which it occa- sions in every case, as because of its intractable nature, as shown in its alternating with the mouth symptoms, being better when they are worse, and vice versa. In these examples, it is not unusual to discover that all the mucous membranes lining the different interior surfaces of the body partake of this inflammation. Thus the inner coats of the larynx, the trachea, and of the lungs, of the pharynx, oesophagus, and of the whole alimentary tract, as well as of the vagina and urethra, are sometimes found to be separately or universally involved. Hence result great disturbances of function, nutrition, etc. ; for the destruction of the epithelial scales which marks the invasion of this disease upon local surfaces, interferes very materially with the healthy condition and requirements of those organs which are indirectly but more seriously implicated. The foregoing symptoms are liable to so frequent modification, both in the order of their succession and in their severity, that authors have fancifully described some three to five distinct varie- ties of the nursing sore-mouth, for which classification, practically speaking, there would appear to be no real necessity. We shall, however, consider a few of them separately. 342 THE DISEASES OF WOMEN. Of the buccal symptoms : These are the primary and more palpable symptoms of the stomatitis materna. There is very little question, however, but that these local A constitutional disease. phenomena are symptomatic of a more pro- found disturbance of the general organism ; and that, properly speaking, we are to regard them as the certain evidence of some such original disorder. Examples are not wanting in which this disease is believed to have pursued a latent course in the system, during which interval, for a greater or less period of time prior to the development of these symptoms, it has sapped the strength and impaired the functional processes of the economy. Indeed there is every reason to believe that those cases of digestive and assimilative disorder, incident to utero-gestation, which distress and harass the patient exceedingly while carrying the foetus, and which, subsequent to her confinement, will not unfrequently result in a manifestation of the above local symp- toms, are to be referred solely to the existence of a latent stoma- titis from the beginning. These examples are perhaps as infre- quent as they are invincible, but in the practical experience of those physicians whose opinions are of value, the remark will hold good that it is only through a close and careful study that we may come to appreciate the worth of this class of symptoms, as affording us an index at once to their pathology and treatment. The peculiar characters which such symptoms present are found to vary with the severity and duration of the complaint. In very mild cases the eruption assumes more of an erythematous appear- ance, being diffused in patches over the sides of the tongue and of the cheeks. Or it may consist of common vesicles, resembling the aphthae adultorum of some writers, which vesicles ultimately degenerate into more or less troublesome centers of infection, each showing at its base a hardened and whitish colored ring. These indurations terminate either by cicatrization or ulceration. To this form of the complaint the name of follicular stomatitis has been given, for the reason that the peculiar eruption finds its more frequent seat in the mucous follicles of the mouth. In bad cases, when these vesicles burst, they develop into ulcers, which are either superficial or deep-seated. If the system has been very much depraved, and the vitality runs low* The local ulceration. , ., , -■ r these ulcers may be very numerous and ot large size. You will find them located on the sides or upon the THE DISEASES OF PREGNANCY. 343 upper surface of the tongue, upon its fraenum, on the fraenum of the lower lip, on the gums, the cheeks, or the roof of the mouth, and even in the throat and fauces. They are painful in propor- tion to the extent of the raw surface which is exposed, and to the depth of the ulceration. In exceptional instances the,;e ulcera- tions have dipped down to the bone beneath. It is not unusual for these characteristic lesions to disappeaz suddenly, leaving the patient in apparent health. After a brief interval, however, they reappear, and may thus lesion rcious nature ° f the keep coming and going for weeks, or even for months. In the most serious cases this sudden metastasis increases the danger, by implicating other and more vital organs. Symptoms of gastric or alimentary disorder almost always accompany those peculiar to this variety of sore-mouth. They may precede, follow or alternate with the buccal Incidental gastric disorder. symptoms, but are rarely altogether absent. I have seldom treated a case of this form of stomatitis, during either pregnancy or lactation, which was not accompanied by- epigastric uneasiness, anorexia, or pyrosis. Instances in which this disease runs its course without a more or less decided implication of the stomach and bowels are believed to be very rare. In this respect the stomatitis materna resembles the aphthae of infants which, as you are aware, is almost invariably accom- panied by intestinal derangement, more especially indigestion and diarrhoea. The concurrent digestive disorder in this variety of sore-mouth has been attributed to various causes, among which are the imper- fect mastication of food ; an improper and dera a n u geme°nt. the digestive unwholesome diet ; the actual transfer, or the continuation, of the local lesion to the gastric •and enteric mucous membrane ; to a depraved nutrition from other causes, and to glandular disease either in the intestine or the mesentery, or both. Among the numerous contingencies of pregnancy and parturi- . . , tion there are few which are more troublesome Diarrhoea. than an inveterate diarrhoea. This is especially true in patients of a scrofulous or tuberculous diathesis. And it 344 THE DISEASES OF WOMEN. is this class of subjects which is most liable to be seized with it after labor. When complicated with stomatitis the diarrhoea may either anticipate or follow the symptoms already enumerated. More frequently, however, it alternates with them — a fact which implies a metastasis of the peculiar disorder from the oral to the intestinal mucous membrane. Disordered digestion and assimilation are, therefore, almost cer- tain to exist in well-marked cases of stomatitis materna. Not unfrequently they are the source of well-grounded apprehension, and, if ever so slight, they will occasion you no little anxiety. You should bear in mind, however, that the coincident diarrhoea is but a symptom, and that its essential pathology is the same as that of the buccal erythema, eruption, and ulceration. Beside local suffering in the mouth, the patient may complain also of a troublesome strangury, with smarting or scalding sensa- tions during, or immediately after urinating. toSs nal and vesical symp " Occasionally these symptoms precede those already enumerated. Sooner or later they are almost certain to be present, and when they are not mentioned voluntarily, you will learn, upon inquiry, that they really exist. The urine is most commonly acid in its reaction — a symptom reputed by some authorities to be pathognomonic of this variety of stomatitis. Its specific gravity will vary from 1024 to 1030. For the most part, the general symptoms are such as imply a debility which may be extreme. If the disease has existed for any considerable time, the patient is usually anaemic. She is pallid and exhausted, and the face ap- pears puffy and bloated. Her complexion is less waxy and clear than in chlorosis, but has a sallow and cadaverous shade in it, which is not common in other diseases. These symptoms are likely to be accompanied by an irritative fever which may remit regularly and finally develop into a real nectic. It is said that primiparae are more liable than multiparae to this form of stomatitis. With certain women it appears to be constitutional, and always recurs during pregnancy or lying-in. irie milk furnished by the breast may be either deficient or ex- cessive in quantity. Not unfrequently it is of such quality as to poison the child and render it sickly and short-lived. Wherever it may be located, authorities are not agreed as to THE DISEASES OF PREGNANCY. 345 whether the anaemia in this disease is the cause or the conse- quence of the local inflammation and ulcera- tion. The simple fact that it is limited to the periods of gestation and lactation, when the blood is being drained of certain elements for the support of the young, and that, as a rule, it ceases as soon as the child is born, or weaned, suggests that the anaemia must have preceded the local lesion. And such is the case. The woman may have been in ill-health for a con- siderable time before the sore mouth commenced. This primary impairment of the quality of the blood explains the greater lia- bility of young, scrofulous, weakly and sickly persons, as well as of those whose systems have been reduced by frequent child- bearing, to the disease under consideration. It also affords a reason for the more general prevalence and malignity of this dis- ease in miasmatic districts, and in those localities and seasons in which there is a scarcity of fruits and vegetables, and where, as a •consequence, the stomatitis degenerates into a species of " land scurvy.*' We can not otherwise explain the migratory character of the disease, its tendency to invade the pharynx, the oesophagus, and the gastro-intestinal tract, the respiratory apparatus, the nasal passage, the Eustachian tube, and even the genito-urinary outlet. In the order of its occurrence therefore, the anaemia is doubtless the first visible sign of the impaired nutrition upon which the stomatitis really depends, and without which it can not exist. This form of stomatitis may commence in the early, the middle, or the latter months of gestation, and persist to term or even later. Or it may date from delivery, from the first Onset of the disease. month oi nursing, or perhaps later and continue for an indefinite period. In very rare cases it exists in the form of pruritus of the vulva during pregnancy, and after child-birth develops into stomatitis proper. Diagnosis. — The diagnosis is not difficult. The sex of the subject and the peculiar circumstances in which she is found — either pregnant, or in one or another of the stages of recovery from her confinement,— with the local symptoms already detailed, will enable you to diagnosticate it readily. It It may be latent. . is only when this disease is obscure and runs a latent course, being limited to the gastric, alimentary, or urinary 346 THE DISEASES OF WOMEN. mucous membranes, that you would be likely to overlook it, or fail to distinguish it from other similar and serious affections. Prognosis. — The prognosis will vary with the original strength of the patient's constitution ; her age, habits and surroundings; the co-existence of tuberculosis of the lungs, or Qualifying circumstances. . . ot the mesenteric glands; the period ot the commencement, and the duration of the disorder ; the type and persistence of the accompanying fever ; the seat, nature and ex- tent of the local lesion ; the ansemia and the emaciation. If, prior to becoming pregnant, the patient was robust and healthy, and had no cachexy, either hereditary or acquired, the probabilities are in favor of her recovery. This result is the more certain if she is young, of good habits, and lives in a healthy neighborhood. A tendency to phthisis in any of its forms is always a grave complication. If the stomatitis commences in the early months of gestation, it can seldom be cured before delivery, and other things equal, the longer its duration prior to labor the greater the danger. In rare cases it results in abortion, after which it ceases spontaneously. If the accompanying fever is either typhoid or hectic in its type and character, you will need to qualify your prognosis. And so also if the disease has become chronic, with deep-seated ulcera- tion in the intestines, the stomach, or the larynx and trachea. The occurrence of passive, or repeated, or excessive haemorrhage from the mucous surface implies great danger. The more the blood is impoverished and vitiated, and the greater the emaciation and the muscular and nervous exhaustion, the fewer the chances of a speedy and certain recovery. It is sometimes quite impos- sible to eradicate this disease in the case of women who have had it in several successive pregnancies. Although recovery fre- quently follows the weaning of the child, yet even this expedient sometimes fails. The danger is increased by excessive or pro- longed medication. Treatment. — The first thing to be clone is to select a suitable diet. This consists of a proper admixture of vegetable and animal food, for you will observe that in many cases the patient has lived almost exclusively upon meat. In frontier settlements, people sometimes eat little or nothing excepting bread and bacon. In such communities the THE DISEASES OF PREGNANCY. 347 women suffer from an aggravated form of the nursing sore-mouth T which is closely allied to scorbutus, and which may sometimes be cured by merely regulating the diet. Even in towns and cities similar cases are not infrequent. The taking of solids is usually so painful that food must be given either in the semi-solid or fluid form. If, however, she can eat it, rare roast beef or mutton, or broiled meats which are juicy and nutritious, may be prescribed with good effect. She may also have milk, eggs, oysters, game, plain custards, animal jellies, cracked wheat, oatmeal, or, if she prefers,' a little codfish with cream. Salt food may be permitted as an appetizer, but should be used sparingly. Potatoes, carrots, tomatoes, baked apples, and other fruits and vegetables, if fresh and fully ripe, are not only permissible but indispensable. Cures have been effected by allowing the patient to drink freely of butter-milk. Other acidulated drinks are almost specific. Lemonade, orange- ade, and jelly -water, are most available. They may be taken either warm or cold, as the patient prefers, and Acidulated drinks. . are not contra-indicated m most cases of indi- gestion and diarrhoea. Nor will they antidote the proper reme- dies. The best criterion, in their selection, is to consult 'the patient's preference, or craving, if she has any. Rule for choosing them. . . ° The same is true with respect to the diet. As a rule, you may let her have whatever she longs for in the way of food or drink, providing it is not wholly indigestible or absolutely poisonous. The malt liquors and cod-liver oil have also been added to the bill of fare. The expedients devised to check this disease, and to hold it in abeyance, and which are sometimes successful, thfs x d p ise d i e se. ts forarresting are the induction of premature labor, the wean- ing of the child, and a change of climate. The induction of premature labor is justifiable only in those extreme cases of stomatitis in which it is morally certain that the patient must die unless pregnancy is terminated Premature labor. ± ° J and the womb emptied of its contents. Fortu- nately such an extremity is almost never reached prior to the seventh month of pregnancy, after which the child is viable. In a resort to this expedient under such circumstances there is no warrant for the performance of criminal abortion, which implies and includes the intentional sacrifice of the foetus. 348 THE DISEASES OF WOMEN. Because taking the child from the breast of the mother who has stomatitis will sometimes be of immediate and lasting benefit ,„ . , to her, physicians have inferred that weaning Weaning the child. i i was the best remedy. The custom with some is to prescribe it indiscriminately. So soon as they discover the slightest inflammation and exfoliation of the oral mucous mem- brane, further nursing is prohibited. But weaning will not always mitigate or arrest this disease. Nor is it necessary to resort to this expedient in a majority of the cases that come under our care. Unless it is manifest that the mother is pretty nearly bankrupt in strength and nutritive resource, that she is drawing her life away to keep her child alive, that she is so anaemic and emaciated as to be totally unfit both on her own and the infant's account to nurse it any longer, we prefer not to interrupt this very important func- tion. A change of climate, especially if the patient leaves a mias- matic district, will sometimes cause the symptoms of this disease to disappear promptly and permanently. In Change of climate. ri r A J £ J exceptional cases a removal ot a tew miles only will work almost as marked a change in her feelings as it does in certain cases of asthma and of intermittent fever. This expe- dient is particularly applicable if the stomatitis is complicated with chronic bowel affections. Railway travel is indicated if there is an inveterate diarrhoea, and residence in an equable cli- mate for those mothers who are consumptive. Hysterical sub- jects, with the nursing sore-mouth, may sometimes be sent away from home with the greatest relief to themselves and all con- cerned. The medical treatment of this disorder is constitutional and local. Gf internal remedies, the various acids are in the best repute. The nitric acid has been given in the The medical treatment, 1 . . . , , lower and higher potencies, under almost every variety of indications, and often empirically, with good results. The sulphuric and muriatic acids are equally useful. I remember a case in which two prominent physicians had treated a lady for stomatitis materna for two whole months. She grew worse and worse. Finally they told her that she must wean her infant, and that after doing so she could not recover her health under at least one year. I made her but THE DISEASES OF PREGNANCY. 349 three visits, ordered a nutritious diet, and prescribed sulphuric acid in the third decimal dilution to be taken four times daily. She continued the remedy for the space of a fortnight. A radical cure followed, without weaning the child, or the employment of any local application whatever. My practice is to put twenty-five drops of the second or third attenuation of either of these acids in half a glass of water, of which two teaspoonfuls are to be taken once in from three to six hours. Arsenicum is generally suitable for cases of this form of stoma- titis which are to be met with in malarious districts. If there is burning in the mouth, with frequent desire for Arsenicum album. -i-i-ii • r> i i • 1 i cold drinks ; 11 the water which the patient drinks habitually is stagnant or impregnated with decomposing matter of various kinds ; if there is great prostration of strength, anorexia, with chronic disorder of digestion and painless diarrhoea ; if the system has been poisoned with quinine in large doses, or if the accorapairying symptoms are analogous to those of typhoid fever, it may prove of excellent service. The same indications will call for natrum muriaticum. Dr. Murch was in the habit in these cases of alternating the arsenicum with small doses of Bel- locq's charcoal. If the disease is complicated with glandular dis- ease of a scrofulous or syphilitic character, the arsenicum jodatum might be preferable. Dr. D. T. Brown* has witnessed the best effects from preceding the employment of arsenicum with a few doses of carbo vegetabilis. Dr. W, C. Barker extols the use of " arsenicum 6th in alternation with sulphur 6th, repeated once in four hours, in those cases of nursing sore-mouth which are char- acterized by a very slight and almost imperceptible odor of the breath, with considerable prostration of the general strength." Dr. I. S. P. Lord vouches for the superior efficacy of arsenicum and natrum muriaticum in the 30th, in preference to other attenu- ations. The form of this disease to which mercurius is best adapted is that in which the ulceration of the tissues is very marked. The ulcers are corroding, the breath offensive, the Mercurius. ° 7 secretion of saliva profuse, in short, the symp- toms are those of the stomatitis ulcerosa of the old writers. If * Vide Transactions of American Institute of Horn., for i860, p. 78. 350 THE DISEASES OF WOMEN. there is no syphilitic taint, the mercurius corrosivus is preferable, otherwise the mercurius joclatus, or even the mercurius solubilis, may be selected. Where disorders of digestion in pregnant or lying-in women are due to a latent stomatitis, and particularly in patients who are predisposed to scrofula or phthisis, the calcarea Calcarea carbonica. . . carbonica may be 01 excellent service, I he symptoms which indicate it are dryness of the mouth and tongue, with a sense of roughness and stinging ; a dry, bitter, sour, or metallic taste ; great aversion to boiled food and to meats in par- ticular ; inclination to salt diet, or to such indigestible articles as pickles, dirt, chalk, slate-pencils, etc. ; nausea, with acid eructa- tions ; vomiting of ingesta ; profuse colliquative diarrhoea, with undigested stools ; a sudden metastasis of the eruption from the mouth to the alimentary mucous membrane ; and acidity of the urine, with burning in the urethra during micturition. There are some examples of this disease which it would be very difficult, if not indeed impossible, to cure without this remedy. Dr. Helmuth reports* that ammonium carbonicum cured a case of long standing in which there Was great prostration, hollow cough, and burning in the tongue — the whole Ammonium carb. , n . . -. . /> n n . rl . -. i buccal cavity being filled with vesicles and ulcerated depressions, and the tongue swollen, stiff, and very sen- sitive to cold air and drinks. He also cites the case of a young lady cured by the use of baryta carbonica, for which remedy the chief Baryta carbonica. .,.,. ,-, iij i ij_ indication was the absolute and complete anorexia. " In an emaciated female who had suffered severely from the disease, and had been troubled for a long period Natrum muriaticum. ' , ... -i with ague, natrum munaticum and arsenicum, in repeated doses of the 6th attenuation, effected a cure in twenty- one days." In the report to the American Institute, from which I have already quoted, my friend, Dr. N. F. Prentice, says: "Formerly I had a great deal of trouble in the treatment of this disease, and of sore, mouth in children, but during the last three or four years I have used the veronica *U. S. Journal of Horn., Vol. I, p. 413- THE DISEASES OF PREGNANCY. 351 (empirically it is true, for I have but a very few provings of it,) almost exclusively, and with universal success. I have been in the habit of giving it internally in the first decimal attenuation, and of applying it locally to the mouth in the proportion of ten to thirty drops in two fluid-ounces of soft water. When they are indicated, I use other remedies in alternation with veronica." Dr. J. Davies has succeeded in some obstinate cases by the application of a trituration of the rhus toxicodendron, and an internal use of the attenuations of the same Rhus toxicodendron. . . _ ' remedy. He triturates the berries ot this plant with saccharum lactis, in the proportion of one berry to ten grains of the sugar, and applies the powder, moistened, through the medium of a thin linen cloth. Other remedies which are sometimes serviceable are belladonna, causticum, china, nux vomica, sulphur, hepar sulphuris, ferrum and staphisagria. Topical applications of various kinds are grateful and beneficial. The most common and harmless consist of lotions, washes and gar- gles, composed of borax, or borax and honey, The local treatment. sage and borax, a mixture 01 equal parts ot borax and sugar in a pulverized state, tincture of myrrh, an infu- sion of the golden seal, or of cayenne pepper, butternut oil, or glycerine. Some physicians recommend the chlorate of potassa to be dissolved in glycerine and applied locally. Others prefer a very weak solution of the carbolic acid. And yet others are in the habit of prescribing the topical use of hydrastin in water, or glycerine, or both. In cases where the buccal and faucial mucous membrane is badly ulcerated and the breath is fetid and offensive, a drachm of the mother tincture of baptisia may be added to four fluid-ounces of water and applied locally. Or Bretonneau's mixt- ure of one part of hydrochloric acid and three parts of honey may be used instead. Dr. Barker has the greatest confidence in fre- quent rinsings of the mouth with simple cold water. There are those who, in exceptional cases, think it necessary to touch the ulcers with a pencil of the nitrate of silver. I prefer calendula, or hydrastin. Tannin and other astringents are harsh and revul- sive, and may do more harm than good. All of these therapeutical resources, however, are of secondary importance compared with the good effects of an appropriate diet, 352 THE DISEASES OF WOMEN. a good climate, the stoppage of any nutritive drain, and the cura- tive influence of fresh air and the sunlight. No remedy in any attenuation, and no local means of any kind will be likely to suc- ceed if the general conditions are not supplied ; and therefore our first duty, even before choosing the remedy, is to see that they are furnished. In the milder cases they are all that is necessary, and we can save our medicines for those who really need them. And, let me tell you in this connection, that there is more of reputation, as well as of good sense and satisfaction, in curing some of our patients by means that are within the reach of every- body, than there is in the use of those which are more scientific and fanciful. " The best physician is he who knows w r hen to with- hold his remedies." THE RENAL FUNCTION AND THE GRAVID UTERUS. The clinical significance of renal inadequacy, of renal embar- rassment and of renal inflammation in a pregnant woman who has passed the fifth month is very great. For whatever we may say of uterine displacements as a source of mischief, those which occur while the organ lies above the brim of the pelvis are often beset with the most serious consequences to the mother and the child. It is then that the body of the gravid uterus should lie obliquely, and whatever forces it into line with the long axis of the body, and forces it downward as when primiparse resort to tight lacing, will cause the kidneys to be functionally or organic- ally diseased through pressure upon the abdominal vessels. Albu- minuria, dropsy, a temporary form of Bright' s disease, uraamia, puerperal convulsions, mania and paralysis not unfrequently result from this cause. Part Fifth. THE POST-PUERPERAL DISEASES. LECTURE XXII. SUB-INVOLUTION OF THE UTERUS. Sub-involution of the uterus. Case.— Sub-involution with recurrent abortion. Case.— Sub-involution and chronic metritis of eighteen years' duration. Case.— Sub-involu- tion, chronic metritis, menorrhagia, and prolapsus. Case. Under the head of post-puerperal diseases I shall include those affections only which, while they do not come under our care dur- ing the lying-in period, are yet necessarily related to labor. Being a sequence of delivery, whether at term or prematurely, they are sometimes styled post-part um affections. Their common and cardinal peculiarity is that they depend upon lesions within and about the post-gravid uterus, and are therefore limited to those who have been pregnant. Such of them, however, as require surgical treatment will be considered further on. In our obstetrical and puerperal clinics you are being taught at the bed-side whatever pertains to the clinical history of labor and of child-bed disorders. My own special course on the puerperal affections will acquaint you with the most interesting and practical part of this very important subject, while it excuses me from their consideration in my general course upon the diseases of women. Manifestly the list of post-partum lesions should include the remote sequelae of abortion, of miscarriage and of premature deliv- ery, as well as of labor at term. For a post-abortum laceration of the cervix uteri does not differ in any essential particular from one that has occurred at the ninth month. Post-partum cellulitis and sub-involution of the uterus are the same in both cases, and we shall never know how to treat them intelligently until we take their common and invariable cause into account. 21 :*53 354 THE DISEASES OF WOMEN. It is especially incumbent upon us to consider this and kindred questions very carefully ; for we, of all others, should discriminate between those diseases which are idiopathic and such as are sympto- matic, or between the primary and the secondary affections that we are expected to cure. When a mother consults us for the relief of an intra-pelvie disorder, we should, if possible, satisfy ourselves whether the lesion that we find does not date from her delivery, no matter how long since her baby was born, or from some mishap or neglect which interfered at that time with her puerperal convalescence. This subject is so very important, and concerns the welfare and comfort of so large a class of our patients, that I must beg you to give it your especial attention just now, while the opportunities for its clinical study are so abundant and so easy of access. SUB-INVOLUTION OF THE UTERUS. Case. — Mrs. S , aged 37, has not been been well since her last confinement, which was six years ago. After the birth of the child, the labor being rapid and very painful, but quite natural, she Avas taken with uterine haemorrhage, which was very active and copious at first, but finally became passive. This haemorrhage did not and would not yield to remedies. The doctors could not cure it, and it ceased only when she had weaned the child. Sub- sequently her menstruation was resumed, but it was too profuse and long continued. Sometimes she continues to flow for three w r eeks, constantly, and has only one week's interval before the period comes around again. But the discharge always lasts a fortnight. She has no pain or soreness, but complains of dragging sensations in the uterine, ovarian and sacral regions. After the third attack of menorrhagia she began to have dropsi- cal symptoms. Her face, hands and feet, and finally the whole general integument, became puffy and cedematous. Then she had palpitation of the heart, and dyspnoea after slight exertion, as in walking up stairs. Sometimes she would waken out of sleep with impending suffocation, and in order to breathe freely would be compelled to jump out of the bed, and to walk about her room. This was accompanied by violent beating of the heart, and a sen- sation as if she had been struck upon the head. She is positive that the urine has always been normal in quantity and quality. She has had six physicians, five of whom have treated her for " disease of the heart." The other one said she had "ulceration of the womb," and applied caustics to the cervix uteri (or there- abouts), twice each week, for several consecutive weeks. SUB-INVOLUTION OF THE UTERUS. 355 This bit of clinical history is significant and suggestive. But it Is incomplete. The fact that this woman's ill-health dates from her last labor, and that the most prominent and urgent symptoms relate to the menstrual return, are pretty certain indications that something is wronof with the womb. It cannot be ulceration of the cervix, merely, for unless it be cancerous such an ulceration is never accompanied by so severe a haemorrhage. And if it were cancerous it would not have begun so directly after delivery, neither would it be apt to return with the regularity of the men- strual cycle. I have passed the sound into the uterine cavity, and find, by actual measurement, that its depth is five inches. The instrument entered without difficulty, and passed to the The depth of the f undus of the onran without the least obstruc- uterus. o tion. My first impression on finding the uterine cavity of such an increased size, was that its enlargement was probably due to the presence either of a sub-mucous, or of an interstitial fibroid. But, failing to find any evidence of such a tumor, and satisfying myself that the increased development of the organ was uniform on all sides, and that its cavity did not contain any abnormal growth, I decided the case to be one of subinvo- lution of the womb. To the " touch" the cervix feels swollen and enlarged; and on examination through the abdominal parietes, by conjoined man- ipulation, in this manner, an oblong tumor is Negative symptoms. ,.-... A ,, , r™ i found rising above the pubes. Ihus examined, between the two hands, the mobility of the tumor is consentane- ous with that of the womb. AVe exclude the possibility of a sub- peritoneal fibroid in this case, for the simple reason that, in chronic cases especially, extra-uterine growths are not necessarily, and, indeed, are almost never, accompanied by menorrhagia. Nor does the commencement of their growth date so directly and positively from the lying-in. • Etiology. — Defective puerperal involution and resorption of the womb is more common than is generally supposed, and as a cause „ of ill-health is therefore very likely to be over- Various causes. -ii-i-r^ „ .- looked. It often follows abortion, more especi- ally when it occurs after the fifth month. In women of lax fibre it is sometimes caused by a too early " getting up " after delivery 356 THE DISEASES OF WOMEN. at term. Those mothers who do not nurse their children at first are very subject to it, although in a limited and circumscribed form. It is sometimes a sequel of twin-delivery, and also of an ex- cessive accumulation of the amniotic fluid. Rapid labors, especially if they are not followed by after-pains, are more likely to be fol- lowed by defective involution of the uterus than those which are tardy and difficult ; and I have remarked the same sequel from the use of chloroform in labor. The latest generalization in gynaecology ascribes almost every case of sub-involution to a laceration of the cervix during or in consequence of labor. I shall refer to this subject when I come to speak of cervical lacerations and their surgical treatment. In the present connection it must suffice to say that, in my judgment, Dr. Emmets' view is too sweeping and exclusive. This interruption is what physiologists style the " retrogressive metamorphosis" of the uterine tissues after delivery, and is intimate- ly associated with the clinical history of uterine displacements. We cannot reasonably suppose that the extraordinary growth of these tissues, which has been ofoino: on for months, will be resolved awav and removed in a few days after the womb has been emptied of its contents. The re- trogressive changes are not always so rapid, and more time may be required for the organ to resume its proper size, weight, form, and relations. Hence the necessity for post-partum rest in the horizontal posture, and for the avoidance of all such causes as might derange this very delicate and wonderful process. Haemorrhage after delivery bears so important a relation to the contraction ot the womb that its occurrence and persistence in this case leads us to suppose that, following the Hgemorrhage etc, , ^ J . i , • » ,, . . ' labor, the involution ot this organ was incom- plete. And the uterine tissues must have remained in this relaxed state. The subsequent development of menorrhagia, with too frequent as well as too copious menstruation, confirms this view. So also do the dragging sensations, which she has experienced so constantly in the intra-pelvic and sacral regions, and the abnormal depth of the uterus But how shall we explain the cardiac complication, and why did it follow the third instead of the first attack of menorrhagia? Manifestly, because of the excessive and continued loss of blood, SUB-INVOLUTION OF THE UTERUS. ?57 -or of the anaemia which resulted from the haemorrhage. If the heart symptoms had been dependent upon organic change, they would probably have disclosed themselves at an earlier period in the history of the case. In real cardiac disease we do not require to bleed the patient for diagnostic purposes. Functional derange- ment of the heart's action is a frequent accompaniment and conse- quence of anaemia and chlorosis, of an impoverished condition of the blood from whatever cause, and of chronic uterine and ovarian diseases which implicate the nervous system especially. Aud although the long-continued operation of these general and local causes may finally set up a real organic disease of the heart, yet such a result does not always lollow. I have made a careful phy- sical examination of this woman's heart, but failed to rind any evidence of a structural lesion. And we may reasonably infer that, if she has nothing of the kind now. after having been treated for " disease of the heart" by rive doctors in succession, she will prob- ably be exempt from it in the future. Treatment. — I am glad of the opportunity to show you this •case, for it is a typical one, and its treatment involves certain questions which cannot be regarded as settled. Practical dedu:tions. , , . . . , ^ _ h\ the first place, this kind ot post-puerperal lesion underlies so many other uterine affections, that in many cases it is impossible to explain their nature or to treat them in- telligently, without reference to what Simpson very properly styled a sub-involution of the uterus. And secondly, a practical application of our knowledge ol the relation of certain remedies to this particular lesion would not only enable us the more promptly to cure the original disease, but likewise also, whatever might =come of it, or be complicated with it. Here the defective involution of the uterus is the prime cause of ili-health. That cause is still at work. Manifestly, the first indication is, if possible to remove it. But how The prime indication. f , shall it be done.-' Is there any known remedy for this relaxation of the uterine muscular fibre? There are well- known remedies which affect this organ, just as there are those which decidedly and certainly allect other hollow muscular organs, as, for instance, the heart, the stomach and the bladder. These include secale cor., sabina, china, and ipecacuanha. Ergotism in women is always accompanied by a determination 358 THE DISEASES OF WOMEN. of blood to the internal generative organs, and if the uterine muscular fibre is at all developed, as during ac^o7ergo°t giCal pregnancy, labor, or lying-in, by expulsive con- tractions of the womb. Under the latter condi- tions, ergot excites the peristaltic movements of that organ with the same certainty that opium congests the brain, and that verat- rum viride lessens the force and frequency of the pulse. Its power to facilitate delivery at term, and to arrest post-partum haemor- rhage is established. This power depends upon an intimate physiological relation or affinity between the fully developed muscular fibre of the uterus and the spurred rye. But you should remember that the similarity of the womb with the other hollow viscera is exceptional, and by no means constant. Within the limits of health there is no condition in which the muscular coat of the heart, the stomach, or the bladder is wanting. Yet in the non-gravid uterus, and more especially in those who have never been pregnant, this coat has no real, but only a rudi- mentary existence; and in those women who have conceived, and even carried their children to term, the normal involution of the oro-an after labor has restored it as nearly as possible to its ante- muscular state. So, therefore, we say, that there is a period in the history of most women, which is characterized by an extraordinary evolution of the uterine muscular fibre, and that the various disease-producing contingencies which beset its orowth and decline have their thera- peutical counterpart in remedies of which secale is the type. The ero-ot is believed to act both through the nervous and the vascular systems. It supplies such a variety of motor force to the atonic uterine fibre as will stimulate its contraction, and at the same time secure a sort of specific or physiological torsion of the capillaries. This makes it the remedy for those haemorrhages which depend upon a lack of uterine contractility ; and there seems but little reason to doubt that if our patient had taken it directly after her delivery, the womb would have been closed, the haemor- rhage controlled, and the retrogressive metamorphosis of the tissues established. But, instead of such a complex and very desira- able result, the womb remained flaccid, and did not fold upon itself; the blood ceased flowing temporarily, when there was little more to lose, but commenced ao-ain with the recurrence of the SUB-INVOLUTION OF THE UTERUS. 359 monthly crisis; and the organ is larger and deeper to-day than it should have been an hour after the birth of the child. Here, then, is the chief point in this case. The symptoms given followed her last confinement, six years ago, and with every men- strual return since that time, there being a similar engorgement of the uterus, and the same relaxed condition of its walls, she has passed through a similar experience. In so far ss the loss of blood is concerned, and if it were possible, she might as well have borne twelve children each year. And can you see any reason why this drain should not impair the quality of her blood, and develop dropsical and cardiac symptoms? The only marvel is that she is still alive. We must treat this defective involution of the uterus, with re- current haemorrhage, as we would treat the same train of symp- toms, minus the cedema and the dyspncea, if she Indications for secale. ... .-; . , . . , ..„ n were still m the lying-m chamber. I he first indication is to secure the proper uterine contraction. The object of this is three-fold viz.: to stop the excessive now, to stimulate the absorption of the redundant muscular structure, and to relieve her of the pain, and soreness, and dragging sensation to which she has been a martyr. This indication is plain and practical. The secale cor. may, perhaps, be all the remedy required. I have treated several such cases successfully with it alone. My prefer- ence is for the second or third dilutions. Sometimes I give one and sometimes the other. It is possible, in chronic cases like this, that the medium and higher potencies might be as useful ; I cannot say. Of this one thing, however, you may be assured, that in all such cases, whether they are directly or indirectly dependent upon a defect, interruption, or irregularity in the organic changes proper to the womb during pregnancy or parturition, you will do well to seek for therapeutical indications in the history of that abnor- mality, whether it be of ante-par 'turn oy post-par turn origin. And, if the other incidental indications correspond with these, which are cardinal, so much the better. But let me warn you not to be misled by the occasional pathological contingencies of the case merely. There is a wide and essential difference between a case of men- orrhagia which depends upon a defective involution of the womb, 360 THE DISEASES OF WOMEN. whether it be chronic or acute, and one of excessive menstruation, caused by uterine polypi, fibroids, cancer, cauliflower excresence, ovarian disease, chronic metritis, or an impoverished condition of the blood. This case is typical of a certain kind ot monorrhagia, and I am speaking only of this particular variety. The reason why our best practitk ners give comparatively few remedies, is that they learn to classify their cases in this practical way, and to group their remedies accordingly. When such a classification is impos- sible, they are compelled to proceed on the old sui generis plan. But in our day, when the means of forming a proper differential diagnosis are so multiplied and so accurate, these exceptions must be very rare. That the secale not only causes the parietes of the womb to contract, but also has the specific effect to stimulate the absorption of an excess of its tissue, is shown in the recent experiment in Avhich its active principle, ergotine, has been injected sub-cutane- ously for the cure and removal of uterine fibroids. Those of you who have ever given china in haemorrhage after delivery, whether in abortion or at term, are aware of its virtues. For the relief of a familiar train of symptoms of Indications for china. . . . , , . . ,. , this kind, and which are referable to relaxation and lack of tonicity in the uterine muscular fibre, even secale is not a more efficient remedy. The power of cinchona to produce a decided effect upon the muscular coat of the womb, is also shown in those cases ot tardy labor, in which a few doses of quinine have caused the most powerful expulsive pains, emptied the uterus, and induced its cannon-ball contraction as a security against flooding. And so, likewise, of sabina, ustilago, trillin, and ipecacuanha, which are so often and so unwittingly prescribed for the relief and removal of this identical condition. Doubt- remed"es! 0nSf0r0ther less ' tbese remedies, and perhaps many others, have a curative relation, not only to acute and recent, but also to chronic and complicated cases of sub-involution of the uterus. I wish you might bear this fact in mind. It is very important for this class of patients to abstain from walk- ing and from standing for a long time. With the approach of the monthly period, and until the flow has entirely ceased, they should keep the recumbent, or, better still, the horizontal posture. SUB-INVOLUTION OF THE UTERUS, ETC. 361 For, no matter how appropriate the remedy that is chosen, an opposite course would induce a hypostatic congestion, and subse- quent haemorrhage, with uterine prolapse or procidentia, and a perpetuation of the puerperal hypertrophy. This woman will take a dose of secale cor. 3d decimal dilution, three times each day. SUB-INVOLUTION AND RECURRENT ABORTION. Case. — Mrs. V , aged twenty-two, has been married fifteen months. In that time she has had three miscarriages ; the hrst at four months, the second at three and one-half months, and the third at three months. Prior to* this experience she was always well ; she used to weigh two hundred and five pounds, now her weight is one hundred and forty-eight pounds. The first abortion was caused by a fall upon her back. She kept around for a Aveek after the tall, had no pain or especial inconvenience, and at the end of a week miscarried without pain. The now lasted about three days ; she remained in bed for nine days, and then got up, but, as she did not feel very well, she took to her bed again and kept it for four days more. Then she felt well and returned to her duties. The second abortion was caused by stooping and lifting a wash- tub. This was done in the morning. She began to flow at once, and at nine in the evening the foetus was discharged. She had no real pain, but kept her bed three days. The third came on after putting up the clothes line, and hanging some heavy wet clothes upon it. This time she was in her bed for nine days. The last abortion occurred six weeks ago. She had no physician in either case. Last week, or five weeks after the third " mishap," she had her menses, the flow continuing for six days. At' that time she had more pain than usual with the discharge. This, she says, was the first and only time that she has menstruated since her marriage. This case affords an excellent illustration of the natural history of abortion, (1,) because the patient is intelligent and honest enough to o'ive an account of her experience ; A rare case. i « n t ttt and (2,) because she did not have a doctor, either before, during, or after her "mishap." For once, therefore, we have a case of the kind in which the patient is frank enough to tell the whole truth, and at the same time, is free from the mis- chievous effects of professional interference. Although this woman has been married only a little more than a year, she has already had three abortions ; one at the fourth month, 362 THE DISEASES OF AVOMEN. another at three and one-half months, and a third at three months. Her case is one of recurrent abortion. ^Frequency of abor- j t doeg ^ fuUy iUustrate wlmt lms been gtyled the "habit" of aborting, else it would almost invariably have occurred at the same period of pregnancy, and, having: begun at the fourth month would have continued to recur at very nearly the same date. When abortion occurs repeatedly, it may assume a regular type, in which case it most frequently happens at the month. Or, as in intermittent fevei% the type may change, and Types of abortion. . . ,,-, ; it may anticipate, or come earlier, as it has done in this instance. Sometimes the type is retarding, and a woman who began by aborting at the fourth month, will end by miscarry- ing at the sixth, or at the seventh month. And, whether the- subsequent "mishaps" are earlier or later than the first, there is a curious tendency to respect the regularity of the monthly cycle, and, if they do not occur at the month, to happen half way between the periods. You will observe that each time this woman has aborted since the first attack, her pregnancy has been shortened just two weeks. My own observation leads me to conclude that the more removed the date of miscarriage from the time in the month at which men- struation would have occurred, the less the probability that a diseased state of the ovaries has had anything to do with causing the trouble. Exceptionally, ho wever, as in inter-menstrual dysmen- orrhea, the ovarian influence may be most pronounced in the middle of the month, and hence abortion, or miscarriage, from ovarian disease might occur at that time also. It is morally certain that, when this woman aborted at the fourth month, it was not in consequence of metritis ; because she had no pain from first to last, neither after the fall, nor yet Peculiar cause of . . * -i i with the expulsion 01 the embryo. And what was true of the first case, was true of the others also. Her singu- lar exemption from suffering is also due, in no small measure, to the rest in bed which she took after each of the abortions, and to keeping off her feet, as if she had been delivered at term . For there is no such prophylactic of post-puerperal metritis as rest in the horizontal posture after the womb has been emptied of its con- tents, whether prematurely or not. SUB-INVOLUTION OF THE UTERUS, ETC. 363 The treatment of abortion, and of its sequelae is sometimes very difficult because of the impossibility of knowing what has caused it. But ill this case, or rather in each of the Treatment. . cases under review, the exciting cause was traumatic; first our patient fell upon her back ; the next time she stooped and lifted a wash-tub, and the third time she strained her- self with the arms raised above the head. The etiology in this case is, therefore, very plain, and it sometimes happens that a disease is already half-cured when you know what has caused it. It may, perhaps, appear strange to some of you that so slight an accident should produce such serious results, especially in a healthv-lookino-, vigorous woman like our Peculiar susceptibility. * patient. But it only proves that she was sus- ceptible to the action of this class of causes, which, in Avomen who are differently constituted, might have had no such effect. There are those who can undergo almost any kind of physical exercise or fatigue without the risk of abortion. Some women work hard throughout their pregnancy, and others travel and inc*ir the greatest risks by sea and land without any mischievous results. But there are those in whom a misstep, a tit of coughing, or strain- ing at stool, may be sufficient to arrest the development of the ovum, and to bring about its expulsion. But what shall we prescribe for this poor woman? Is my duty discharged to her and to you when I have ordered a few powders, and told her to come again? A moment's reflection assures me that, under the present conditions, she would probably abort as often as she conceived. Her predisposition to abortion is partly original, and partly acquired. If we suppose that her fall was severe enough to have caused a perfectly healthy woman to mis- carry, we cannot think, other things equal, that the slighter shocks should afterwards have had such serious consequences. There must have been something in her clinical history to predispose her to a repetition of the accident. And that something which is at the bottom of the difficulty, is what we want to cover with our prescription. In fifteen months she has had her menses but once. Three times rest. 6 imP ° r aDCe ° ni ^hat iuteival, in consequence of a fruitful conception, the womb has begun and continued to develop until it was suddenly and forcibly emptied of its con- 364 THE DISEASES OF WOMEN. tents. Having the good sense to go into a puerperal quarantine, she dodged the contingencies of haemorrhage, and of active inflam- mation. But, before the uterus could possibly have recovered itself, before its involution was half finished, before menstruation was resumed, gestation had begun again. And this process has been repeated twice already. The first rational indication is to provide against such an experi- ence in future. For nature would continue to resent such a disregard of her laws. The womb must rest, and recover its tone, as well as its size and form. We must take care that she menstruates regularly. And she should be very cautions about becoming pregnant again under six months or a year, when with proper care meanwhile, she might be able to reach her term without any acci- dent. She will take calcarea phos. 3d trituration, twice daily for one week, and then arnica 3, one dose every alternate night. [One year later this woman became the happy mother of a healthy and vigorous child.] SUB-INVOLUTION AND CHRONIC METRITIS OF EIGHTEEN YEARS DURATION. Case. — Mrs. Z.— , aged forty- three, is the mother of three children, the youngest of which is eighteen years old. She has had no mis- carriages. She has not been well during the long interval, but has suffered from articularrheumatism,menorrhagiaand prolapsus. She has had much local treatment by esc haro tics, for an alleged uterine ulceration. There is great weight within the pelvis, especially in advance of the monthly flow, at which time she is compelled to keep to the bed or couch. The menses are very copious, and are accompanied by a great deal of pain. She did not nurse her last child. Her last labor was very prolonged, and finally was instrumental. It sometimes happens that the post-pa rtum involution of the uterus is interrupted even when the patient has suckled her child. If the menses return prematurely, and recur Causation. •%■,-, i . i frequently, the flow will be menorrnagic and the conditions will be very similar to those in which the puer- peral involution is interfered with by endo-metritis. This is the condition which predisposes to chronic metritis as a coincident affection. The lack of the pioper tonic contraction of the uterus SUB-INVOLUTION OF THE UTERUS, ETC. 365 favors the sub-involution, and the menstrual congestion precipi- tates the metritis. An intimate knowledge of the special pathology of sub-involu- tion is essential to its proper treatment. The best evidence of this fact is found in the method of treating it indis- Not always the result crimiuate iy as j t it were always the result of an of inflammation. f ' J inflammation. You should bear in mind the clinical rule that, unless a woman has suffered from some form of metritis in child-bed, or unless it is the consequence of too early menstruation after her delivery, she is not likely to have sub-in vo- lution and metritis at the same time. The case before us is, however, an exceptional one. We can- not learn her puerperal history, neither can we estimate the mis- chief that has been done in her case by cauteri- Physical si°*DS. zation. The menorrhagia and the pain at the month, as well as the inflamed condition of the cervix, which you observe in the field of the speculum, are so many evidences of metritis. The depth of the uterus, which, as you see is five inches, discloses the condition of defective involution that has existed for eighteen years. There is also a laceration of the cervix which must have occurred at the time of her delivery. It is a question whether Emmets' operation should properly be the first step in the cure; or if we should try to fulfill the physi- ological indication of securing the contraction of the uterus as a means of putting an end to the menorrhagia, the xnetritis and the prolapsus. For the present she will take the secale cornutum 2, four times a day. SUB-INVOLUTION, CHRONIC METRITIS, MENORRHAGIA, AND PROLAPSUS. Case. — Mrs. S., aged twenty-six, had a miscarriage at the fourth month of her first pregnancy, five months ago, in consequence of which she was confined to her bed for six weeks. The menses were very irregular and copious, with bearing-down pains when standing or walking, with great weight in the pelvis. During- the monthly flow, this weight and pressure are so increased, that she is obliged to keep her bed most of the time. This was her first visit to the clinic. She had been cauterized for some time for uterine ulceration. I have had this case placed upon the table in order to show you that sub-involution does not always depend upon a laceration of 366 THE DISEASES OF WOMEN. the cervix uteri. The depth of the womb is four and one-half a practical lesson. inches, and the uterine epistaxis and the pro- lapsus are the natural and necessary conse- quence of its non-involution. It yas about as stupid to cauterize the wcmb in this case as it would have been to have put the tinc- ture of iodine into its cavity, or to have propped it up with a pessary. [This patient continued to report every week at the Clinic. She was examined locally from time to time, but no topical appli- cations of any kind were made. She took nothing but the secale, and improved from the first. In ten weeks the uterus measured only three inches, and the metritis, the menorrhagia and the pro- lapsus having disappeared, she was discharged cured.] SUB-INVOLUTION AND RETRO-DISPLACEMENT OF THE WOMB. These two lesions not unf requently coexist, both of them dating from child-birth. Sometimes a deep laceration of the uterine cervix will account for them, but the condition is quite as likely to depend upon a torn perineum. In such a case it may be difficult to decide what course to pursue in the treatment. My preference would be to stitch up the cervix and then to put the - patient upon the proper internal and local treatment, as already advised, and finally to repair the perineum. The success of this consecutive treatment, which is partly medical and partly surgical, will depend upon the persevering use of the former, and the greatest possible care in the performance of the latter. LECTUKE XXIII. PELVI-PERITONITIS. Ftlvi-Peritonitis.— Clinical history of, Case.— varieties,— Symptoms, the pain and its special characteristics,— the tympanitis, the facial expression, the temperature and pulse, the decubitus, the nausea and vomiting-, the effect upon the menses, the chill and thirst, the stage of effusion, the fixity of the uterus, the peritoneal tumor, the reflex disorders. —Causes. Case.— Prognosis— Treatment both local and general. Cases. Clinical History . — Although pelvi-peritonitis is much the more frequent with those who have borne children, or who have suffered from a miscarriage, it is not necessarily a post-puerperal affection. Seventy-five per cent of the cases are consecutive upon labor, and twenty- five arise from sources which are non-puerperal. Compared with inflammation of the uterus proper, it is relatively about as frequent as pleurisy when compared with pneumonia. Indeed, if the truth were known, I have no doubt that there are more cases of pelvi-peritonitis than there are of pleurisy. And yet some of your preceptors may tell you that they have never seen a case of it. Case. — Mrs. , came to me from Alabama. Her clinical his- tory was as follows: She was twenty-two years old, and had been married eight months. Three months after marriage she had an abortion at the second month, which was induced by fright on a railway train. She had labor pains for twelve hours before the ovum was extruded, and was confined to her bed for three weeks afterward, during which time she seems to have had a sharp attack of metro-peritonitis. From that time she has had a great deal of pain in the right half of the pelvis. This pain was diffuse and not localized, or of a burning character, as in ovaritis. It is however, very much aggravated at the period, when she is compelled to go to bed and stay there until the flow has ceased. At first the monthly discharge begins with- out pain, and geneially without her knowledge, but in a period varying from half an hour to two hours, the suffering begins and does not cease entirely until the flow stops. The character of the flow is natural. These intra-pelvic pains are very much aggravated by riding in a 368 1HE DISEASES OF WOMEN. rough carriage, on horseback, or over a rough road; by coughing, or rapid breathing from any cause ; by constipation and unusual retention of the urine ; by coitus, the introduction of the specu- lum, and of the uterine sound; and also by the occurrence of a storm. Local examination reveals a pouching downwards of the right lateral cul-de-sac, with great tenderness and an inclination of the body of the uterus towards the left side. The tenderness extends forward to the region of the bladder and is so marked that, after being introduced, 1he most careful separation of the blades of a Cusco speculum causes an unbearable pain, especially in the right half ot the pelvis. The passage of the sound, which was also very painful, showed that there was no uterine deviation, except in the direction already indicated. Varieties. — Authors have recognized many varieties of pelvic peritonitis. Thus they speak of the common, the benign, the chronic, the suppurative, the menstrual, the recurrent, the hemor- rhagic, the tuberculous, and the cancerous forms of this disease. But these divisions are unnecessary, except as they serve to qualify the cause, the course, and the complications of this form of peri- tonitis. Symptoms. — There are several stages in this disease, and the symptoms vary in each of them. Thus we have the stages ot con- gestion, effusion, adhesion, resolution, and of Different stages of. c . ™ ,, suppuration, Iney are not all present m every case, for if the trouble is arrested with adhesion, that will be the end of it, unless there is a relapse ; and so also with the other modes of termination. Many cases, however, pass into the chronic form and develop a sort of cachexia that is really incurable. The first, or the congestive stage is accompanied by pain which is usually, but not always, preceded by a chill. The pain is sharp, darting and lancinating in character, like that of ordinary peritonitis. Exceptionally it comes on without any prodroma; and still more rarely the pain is lack- ing altogether. The pain is located at the base of the abdomen, low down over the superior strait, but it usually inclines toward one hip more than the other. Its grand characteristic is that it is ^special characteristic aggravated by mo tion, by pressure, by increased rapidity of respiration, by standing, and by the effort to urinate, or to evacuate the bowels. On account of this PELVI-PEF1TCXITIS. 369 pain there is a marked and decided intolerance of the touch, whether it is applied by the vagina, the rectum, or in the com- bined form. In some cases this intra-pelvic pain is so decidedly increased by the touch and by pressure, that we cannot use the speculum to any advantage, or even, perhaps, succeed in passing it at all. This is especially true in case of tne pelvic peritonitis which is contingent upon cancerous infiltration about the neck of the uterus and the vagina. In the second stage, the pain is less acute and agonizing, and, According to the site and extent of the effusion, takes on a drag- ging, forcing character, with a feeling as if the womb would be expelled, and with more or less tenesmus of the bladder and the rectum. Another symptom which is seldom lacking is abdominal tym- panitis. This may be local or general , and it may come on abruptly ac the onset of the disease. The cause of the meteorism, the colicky pains, and of the disposi- tion to vomit also, in this disease, is the adhesion of folds of the intestine to parts that are naturally free from such an attachment. Half the women who have tympanitis, menstrual colic and vomit- ing at the " month," are really ill with pelvi-peritonitis, although perhaps in so mild a form that it has not been recognized. In acute cases the face is pale and anxious, but in chronic cases it may have the dull earthy hue of coprremia. When it follows abortion, especially if there has been a, great The facial expression. ■,.'■,«,""•-.■• ... . deal oi haemorrhage, you will sometimes recog- nize the puerperal tint of M. Bordon. In pelvi-peritonitis, unless it be in the puerperal form, the temperature is not usually very high. It ranges from 101° to 103°, rarely reaching 104°. But the pulse has The temperature and .., ... the pulse. the characteristic trequency oi peritonitis, al- though it is not so small and filiform as it is in diffuse peritonitis. The dorsal decubitus is the usual one, and the limbs are drawn up, in order to relax the abdominal parietes, as in puerperal peri- tonitis. In the chronic form of the disease, The posture taken. however, this posture may be assumed only at the monthly period, or after exercise, as in riding or walking. Sometimes the patient finds great relief from having the hips raised.- u 370 THE DISEASES OF WOMEN. In very acute attacks, and in the menstrual and the recurrent forms of the disease, there is apt to be more or less vomiting. Obstinate vomiting at the month is more likely Nausea and vomiting 1 . . f\ ■ to be due to this than to any other cause ; and you should not forget that it may sometimes be relieved almost instantaneously by lifting a prolapsed womb into its proper posi- tion. The vomiting is more frequent in pelvic peritonitis than it is in pelvic cellulitis. The menstrual flow is sometimes diminished, sometimes suppres- sed, and at other times is very much increased in quantity. When this form of peritonitis occurs in those who have mens^ UPOn ^ never bsei1 P re g* liant > ^ is ] ike ty to induce either amenorrhcea or dysmenorrhea ; but as a post- puerperal affection, in the great majority of cases at least, it is accompanied by menorrhagia and sometimes by metrorrhagia. Unless there are septic or pysemic complications, or extensive suppuration with relapses, the initiatory chill does not repeat itself. There may, however, be inordinate thirst, with or without tolerance of cold water, and a less of appetite. When the local congestion has continued for a period varying from a few hours to several days, it is relieved by the effusion of serum, as in pleurisy or synovitis. When this The stage of effusion. . J . . J - , , J T n has taken place the local symptoms, as revealed by the "touch," are entirely changed. Now three things are to- be especially noted; (1) the diminution of the Three points to be ob- _ ,. served in local exam- local pam on pressure, (z) the fixation ot the uterus, and (3) the presence of a tumor at some portion of the roof of the vagina. Tins diagram will odve you an idea of the formation of the lateral pouches made by the dipping of the peritoneum at the sides of the uterus. The retro-uterine depression is more capacious, and comes lower down, especially upon the left side. The more extensive the circum-uterine inflammation, and the more prolonged the first stage of the attack, the greater the liability of the uterus to become anchored by adhesions. If uSrus fiXlty ° f ^ the case is complicated with cellulitis, or with tuberculous or cancerous infiltration, you may find the uterus quite immovable. Fixity of this organ is very apt PELVl-PERITONITIS . 371 to follow in case of pelvi-peritonitis that has been caused by a mis- chievous use of the sponge-tent?, the hysterotome, caustics, and The peritoneal tumor. Fig. 32. The Utero-lateral Peritoneum. even the wearing of an illy adjusted pessary. It sometimes creeps on insidiously as a sequel to endo-metritis, membranous dysmen- orrhea, and partial or complete stenosis of the cervix uteri. When the effusion has taken place, the fluid drops into the most dependent portion of the peritoneal cavity. Hence the swelling formed by the accumulation will naturally be found at the roof of the vagina, and as a rule, either laterally or posteriorly. The most frequent seat of this tumor is at the Douglas pouch, which, if the quantity of fluid is large and limited to that vicinity, will be so inverted as to pro- trude behind the cervix. If this inversion and protrusion of the roof of the vagina takes place on all sides it will throw a kind of collar about the cervix which is peculiar and cannot be mistaken. Sometimes it is of limited extent and may occupy one side of the pelvis only. Even when the effusion is very extensive the tumor that is formed does not very often rise above the superior strait. And, because the peritoneum does not extend below the level of the posterior lip of the cervix, it does not drop very far down- wards, or reach the vulva as may happen in pelvic cellulitis. To the touch, the feel of the tumor is hard, irregular and im- movable. In the relapsing form of the disease it is almost always painful on pressure. Like the tumor of pelvic hematocele, the 372 THE DISEASES OF WOMEN. firmness of its texture is more pronounced the older it is, or at least, until suppuration has taken place and an abscess has formed. If the attack terminates by adhesion, or by resolution, this tumor may disappear altogether. Such a result may happen spontane- ously, even when the tumor is as large as an orange, or the foetal head. This is the class of tumors which are sometimes mistaken for ovarian tumors, and which are reported in the journals as cured by all sorts of remedies. In the chronic form of pelvi-peritonitis menstrual relapses are the rule and not the exception. It seems that, the more the uterus and its appendages are bound clown bv the false Menstrual relapses in. ', membranes which have resulted from previous inflammation, the more intolerant it is of the monthly nisus. For this reason the worst cases of dysmenorrhcea, which develop into menorrhagia and drag a patient down, are dependent upon this variety of peri-uterine inflammation. The bands which fasten the uterus to the Fallopian tubes and the ovaries, the bladder, and the rectum sometimes interfere very decidedly with their functions. The extension Reflex, digestive, and f th j nflanimation to the per itoneal coat of the other disorders. . ■ •. . intestines may result in more or less of strangu- lation and agglutination and thus interfere very materially with the nutritive function. From these causes, chronic pelvic peri- tonitis is almost always accompanied by a series of reflex disorders, such as spinal irritation, headache, hysteria, and paralysis. There is a form of pelvi-peritonitis which results from Menor- rhagia, and which, besides being accompanied by sterility, is very difficult of cure. It is very likely to occur in the Gonorrhoea! pelvi- j ^ f th ho haye been dissipated ill peritonitis. / their early years, or who, because of absence from home and other circumstances, are led to the practice of wrong habits. These cases originate in a gonorrheal ovaritis, and are as unmanagable, if you fail to recognize the taint, as some cases of crusta lactea are from a similar cause. Causes.- — Much of the confusion of medical writers concerning pelvic peritonitis is attributable to the fact that A source of confusion. „ ' , , .-, , e , , , most of them, and the best of them, have insisted that it was always consecutive upon metritis. Bernutz, whose excellent clinics I attended in Paris, is the leader of this PtLVI-PERlTONITIS. 373 party. *Jousset and others, however, recognize a variety of causes which may or may not be connected with any form of metritis, whether puerperal or non-puerperal. These causes include abortion, an extension of endometritis through the oviduct to the peritoneum, as sometimes happens in the lying-in, salpingitis, ovaritis, metritis, gonorrhoea, pelvic- haematocele, uterine and ovarian tumors, the extension of entero- peritonitis, cystitis, recHHs, uterine deviations, coitus and the use of injections during menstruation ; and the traumatic effects of operations about and within the cervix uteri, more especially cau- terization, the passage of sponge-tents, forcible dilatation, incision, and amputation of the same, the resort to intra-uterine injections, mid the wearing of mal-adjusted pessaries. I have long been satisfied that a large share of the non-puerperal cases of pelvic peritonitis especially, are of a rheumatic nature. Some of the worst examples that I have ever From rheumatism. . .. seen, belonged to this clans, and have occurred in women who have never been pregnant, and in whom there was an evident translation of the rheumatic lesion from other serous membranes to the peritoneum. Here are the notes of a case of this kind which was sent to me by Dr. C. C. Brace, of Boulder Colorado, and which is still under my treatment. Case. — Mrs. , aged thirty-eight years, was married fourteen years ago, but has never been pregnant. She has been ill for four years. She was first taken violently with spinal meningitis, and this illness continued from December until April. As soon as the back was better she began to have very severe pains within the pelvis. In a little while the spinal suffering was entirely substi- tuted by the pelvic pain and distress. Five years before, she had been operated upon for vaginismus; but now a similar spas- modic condition of the vagina came on again, ar>d the operation was repeated in the month of July. About the first of October she began to sit up again, but, in a fortnight became worse and complained of very severe intra-pelvic pain and distress. She had paroxysms of this suffering which occurred at the month, and at other times also in consequence of the least fatigue or worry. After the second operation she returned to Nebraska in January, where she remained two months on a visit ; but while there the old pain in the back and neck returned. The consequence was that she was obliged to return to Colorado. There she was confined to her bed for eight months, during which time the spinal symptoms ♦Lectures on Clinical Medicine, translated by Ludlam, Chic-go, ] age 268. 374 THE DISEASES OF WOMEN. almost entirely disappeared and the pelvic suffering came back again. Added to this she began to have spells of intractable vomiting from prolapse of the uterus, to which she has now been subject for two years, and which my friend Dr. B., and myself also, have frequently relieved by repositiug the womb. The menses return regularly every four weeks, being sometimes a day or two in advance. The flow continues four days, is normal in quality, and has never been very copious. The local symptoms are those of an unmistakable pelvic peritonitis. Other accidental causes have been assigned for this form of peri- tonitis. A case is reported in the British Medical Journal, in which the attack was induced in a young girl, by swinging. My friend Dr. W. A. Sheppard, of Dundee, 111., called me in consultation a few months ago to a woman who had had a severe attack of pelvi- peritonitis with a sudden ante version of the uterus, that was caused by her being swung over and over several times in a ham- mock. Diagnosis. — Pelvic peritonitis is much more likely to be mis- taken for pelvic cellulitis than for anything else. But, since I have not yet spoken of pelvic cellulitis, it will " be best to defer my remarks upon the differential diagnosis of these two affections, until the next Lecture. In pelvic hematocele the recent tumor is soft and yields to pressure; but as it grows older it becomes more firm and unyield- ing. On the contrary the tumor in pelvi-peri- Jrompelvieha B mato- tonitis ^ j^ at first) and become s soft and fluctuating when pus has formed in it. As a rule the haematomatous tumor is much the larger of the two. The constitutional symptoms are very different. Peritonitis often attends upon hematocele either as a cause or as a complication. We shall speak of pachy-peritonitis and its resulting haemorrhage at another time. The diagnosis of pelvic peritonitis from parenchymatous metritis is very clearly given by Gkierin:* " In both these affections the invasion of the disease may be announced by a From parenchy- chill; both are accompanied by acute pain, and matous metritis. * J \ m we may find in the case of metritis a tumor which, reaching above the pubis, may lead us to believe that it is due to *Lecons cliniques sur les maladies des organes genitaux internes de la femme, par Alphonse Guerin, etc., Paris, 1878, page 366. PELVI-PEUITOMTIS. 375 pelvi-peritoiiitis. But the vaginal touch will soon dissipate our doubts on that question, hi metritis we shall recognize that the tumor is movable, whilst in peritonitis it is fixed by adhesions as firmly as it it were nailed. In this form of peritonitis the culs-de- sac are filled by the tumor, while in metritis they are free. In metritis the cervix uteri is larger than normal, its lips are thick and everted. The os uteri is not changed either in its volume or its consistency in pelviperitonitis." Jousset differentiates between pelvic peritonitis and abscess of the iliac fossa as follows : *" In abscesses in the iliac fossa 1 , if they are superficial, the tumor is not perceptible by iiiIc°fossa. SCeSS ° fthe the vagina, but extends directly towards the horizontal ramus of the pubis. When they are deep-seated and profound, there is retraction of the thigh upon the pelvis, through irritation of the psoas muscle ; very often oedema of the labia majora, and a cleep-seated swelling in the external portion of the iliac fossa, which afterwards is felt in the lateral walls of the vagina, and towards the horizontal ramus of the os- pubis." Prognosis. — The simple adhesive form of this disease may run its course and terminate favorably in a month or six weeks ; but more serious cases will require more time and vJSety! adhe8iVe care - In both > an(i ilia11 forms of pelviperi- tonitis there is a marked tendency to relapse, and the slightest imprudence, exposure or over-exertion may pre- cipitate a fresh attack. This peculiarity is so pronounced, that an experienced gynaecologist will be very careful in promising to cure this affection, or in claiming that he has ever succeeded in doing SO. When the adhesions are very extensive they complicate the case and protract the cure, by binding the uterus and its appendages and the intestines in unnatural positions, so as greatly to increase their tendency to disease, and to increase the suffering of the pa- tient also. For this reason the most tedious cases are sometimes characterized by an absence of the tumor. This is especially true in such as are non-puerperal, as the gonorrhceal and the rheumatic. Do the best we can, some of these cases will continue for years without any permanent improvement. * Op. citat. p. 275. 376 THE DISEASES OF WOMEN. In attacks of pelvi-peritonitis which are secondary upon puer^ peral metritis, salpingitis, and ovaritis, as well as in those which follow a prolonged course of local treatment by seoondrryTo r r ms raland escharotics, and the harmful expedients of uterine surgery, the result will vary with the duration and severity of the previous disease, or of the treatment to which she has been subjected, and her remaining constitutional Fig. 33. Peritoneal Adhesion of the Tubes and Ovaries to the Uterus. vigor and vitality. If the primary disease has been protracted, if she is of a scrofulous habit, if her strength has been exhausted by nursing, or impaired by her inability to eat well and to digest her food, if she has had menorrhagia, or repeated abortions, the ten- dency of the tumor to develop into an abscess will be very much increased. Pelvi-peritonitis is comparatively frequent in delicate women who are predisposed to tuberculosis. Thiscom- jects! UberCUl ° USSUb " Potion, or the possibility of it, should lead you to qualify your prognosis. Treatment. — The treatment is local and general. The uterus the folds of the peritoneum, that a moment's reflection will convince you of the importance of rest for the patient when that membrane is in- flamed. If a woman cannot wink without changing the position of the womb in its relation to other organs, or without tightening and stretching its ligaments ; and if these is so m The importance of rest. PELVI-PER1TON1TIS. 377 means of support are composed most largely of peritoneum, it is evident that bodily rest is indispensable to the cure of pelvi-peri- tonitis. No advice is more harmful in these cases than to insist that the poor victim must get up and go about, must exercise vigorously, and walk or ride, perhaps on horseback, or travel about as if she were well. Certain modes of exercise are very injurious, as for example, running a sewing machine, sitting for hours at a piano, or standing all the day long in a store, or all the night at a party. When these habits are resumed after an attack of peritonitis, no matter how slight it may have been, we cannot expept that the inflamed surfaces will ever be restored to their ante-movbum state. A mode of exercise including the proper postural treatment for some of these cases has recently been suggested by Dr. Van de War- ker.* This mode consists in placing the patient in a hammock. Dr. W. says: " I have used the hammock several times, and have never failed to observe more or less relief as an apparent result. If we examine the matter we shall perceive good reason for such a result. The position of a patient in a hammock is one peculiarly adapted to relieve tension upon intra-pelvic indurations or adhesions; from head to heels, the patient is in a perfect bow, the pelvis elevated. The natural effect is, first, to relieve tension, or stretch ; second, to lessen hyperemia of the pelvic vessels by the elevation of the hips. All this, of course, relieves pain. " But we have a further effect not so easy to explain. A pecu- liar sedative effect seems to be due to the motion. We all know how seductive and soothing is the sense of langour that steals over the senses, while gently oscillating in a hammock. There is no doubt but the Lotus-like tendency has its force doubled in the case of a woman whose power of nervous resistance is weakened by disease, or put upon a severe tension by pain." The local expedients that may be of service consist in the use of hip baths of warm water, or vaginal injections of the same, the topical application of the bran poultice and other emollients, and the painting of the lower portion of the abdominal integument with Latour's oleaginous collodion. If the womb is out of place it should be carefully reposited, but Transactions of the American Gynaecological Society. Vol. 3, 1878, page 342. 378 THE DISEASES OF WOMEN. pessaries of all kinds are harmful, and cannot be borne. There la scarcely a week that passes in which I am not obliged to remove a pessary that is persecuting- some poor woman in this way. In very exceptional cases, however, an instrument with a perineal support may not only be tolerated, but of real service. All those which put the vagina upon the stretch, are mischievous, even in the milder forms of pelvi-peritonitis. Of late, excepting in local peritonitis with pelvic hsematocele, we never find it necessary to resort to opiates in these cases. There is an expedient which has the double merit of relieving pain and of being of direct benefit in curing the inflammation, and that expedient consists in the use of very warm or hot water, in the form of a vaginal irrigation. It is always available, and will assuage the pain as promptly and more efficiently than morphine. Its use can be repeated as often as necessary without any harmful results; nor does it in the least interfere with the action of the appropriate A substitute for opium. Fig. 34. Lord's Hot-water vaginal douche. internal remedies. Moreover, it is quite as useful in pelvic cellu- litis and in hematocele as in pelvi-peritonitis; and, since these affections may merge, or are apt to be mistaken for each other, this surely is an advantage. PELVI-PERITONITIS. 379 To apply these injections (first recommended by Emmet), the patient should lie upon her hack with the hips raised. She should be undressed and go regularly to bed. Then Mode of applying the , . m i d . ftlshione d English bed-pan beneath hot-water injections. * , the hips, or bring them to the edge of the bed, and so arrange the rubber cloth beneath them that the water may flow into a basin or bucket upon the floor. The stream can be thrown by a syphon of plain rubber tubing, or by a syringe with a constant current. See Figs. 36 and 37. The temperature of the water, of which from two quarts to two gallons may be used at one time, may be gradually increased from U£T to 1(JS°. The operation may be repeated as often as necessary without any bad effects. Where there is much induration a tampon of cotton that has been saturated with the mixture of aconite, hamamelis, calendula, conium or chloroform, and In a general way this remedy is pine. & J J useful to abort the congestive stage of pelvic peritonitis. If you are certain that it is indicated and relief does not follow its employment, you will sometimes do well to substi- tute a few small powders of atropine 3. If tardy menstruation is the cause of the conges- tion, you may drop the belladonna and substitute gelsemium. Bryonia should not be forgotten or overlooked in this connection. What Baehr says of it (Science of Therapeutics, translated by *A Manual of Pharmacodynamics. By Richard Hughes, L. R. C. P. Ed. Third Edition 1876, page 315. PELV1-PERITONITIS. 381 Hempel, Vol. I, p. 515) is certainly true. "Hartman's assertion that peritonitis cannot be cured without acon- ite, seems to us more applicable to bryonia. It comes into play at the most decisive period in the development of the disease, namely when Ave desire to remove the effused fluid as soon as possible .... In comparing the second stage of peritonitis with the pathogenesis of bryonia, we shall find that, in the majority of cases, this remedy is indicated by its physiological effects upon the healthy. It is almost certain that, under the in- fluence of bryonia, the exudation is reabsorbed without caus- ing any further derangement; hence, that no suppuration will take place. But the medicine should be used consistently ; we cannot expect to obtain results in a day that can only be obtained in from ten days to a fortnight." Apis mellifica is indispensable if pelvic cellulitis complicates the case, and if we desire to abort the tendency to all forms of pelvic abscess. If the effusion is lodged in the meshes Apis mellifica. . . ..,' . n-- ot the areolar tissue, the apis will do all tliat is claimed for bryonia when the serum has been poured out as a con- sequence of peritonitis. But it needs to be given in a low form, and frequently repeated. For the best of clinical reasons I have great confidence in the internal administration of terebinth in puerperal peritonitis; and likewise also in post-puerperal pelvic peritonitis. Terebinth. . . . In its effects upon the urinary organs it is closely related to cantharis, being also possessed of a wonderful influence upon the serous membranes. It is adapted to the relief of such typhoid and haercorrhagic states as are met with in typhlitis and dysentery ; and is useful in peri-cystitis also. In the form of pelvic peritonitis which is more or less complicated with cellulitis, occur- ing in weak and adynamic conditions of the system, more especially if there is pachy-peritonitis with hematocele, it is one of our very best remedies. I generally prescribe it in the second decimal trituration. When the attack arises from a metastasis of rheumatic inflam- mation directly to the peritoneum, it has sometimes been unwit- tingly cured by brvonia, belladonna, rhus tox., The salicylate of soda. . a ... , " , ,. ^. ,. , , T hamamelis, colocynth, and macrotm. Oi late 1 have given the first, and sometimes the second decimal trituration 382 THE DISEASES OF WOMEN. of the salicylate of soda in some of these cases with very decided benefit. It is indicated for the relief of the intra-pelvic pain and distress, especially when it is of a neuralgic or rheumatic character; but the more acute the case, and the more decided the diminution in the quantity of the urine secreted, and the absolute increase in the proportion of uric acid contained in the urine, the better the indication. There are three general indications for the use of macrotin in this disease, (l)the possible rheumatic character of the lesion; (2) the disposition to implicate the spinal muscles and ligaments indirectly, and (3) the nervous, and mental symptoms. This remedy has been extolled in a loose way as a kind of specific for rheumatic metritis, and for uterine neu- ralgia. These alleged cures, however, are lacking in the essential • elements of diagnosis, and, considering' the Do. in rheumatic per- . . . n , . .. .,. itonitis. greater re rati ve frequency of pelvi-pentonitis, it is more than possible that the results obtained by macrotin should rather be credited to its curative influence upon rheumatic peritonitis. It is not always easy to distinguish spinal irritation from a pain- ful condition of the spinal muscles that is very generally known as myalgia; but, it is necessary to do so, in or- Do. in peritonitis with . . spinal myalgia. der to obtain a clear indication lor macrotin in pelvi-peritonitis. For this remedy is not called for in the former case, while it certainly is in the latter. This indi- cation is confirmed by the occurrence of other reflex rheumatic pains, as for example, pleurodynia, intercostal rheumatism, the infra-mammary pain, and the pains which in chronic cases are located in the left side. I cannot give you a better illustration of the power of macro- tin to control the mental symptoms that sometimes accompany this disease than to cite the principal details of do for the mental a case wn ich I have already published in Jous- symptoms in. _ . set's Clinical Medicine. This is one of a num- ber of similar cases in which this remedy has benefited my patients and brought me no little reputation. Case. — Mrs. . came to me from Baltimore in 1876. She had been ill for four years, or since the birth of her last and only living child. Her condition was really deplorable. The menses PELVI-PERITONITIS. 3S3 were regular, but scanty; there was much intra-pelvic pain and dis- tress, spinal myalgia, and sleeplessness with a complete loss of appetite. Mentally she was on the ' versre of insanity; nothing von earth interested her; her lovely boy, her sister, her friends, society, and the church were all very distasteful. She could not read or think with any diversion or satisfaction, and she became emaciated and wretched. She had treatment from both and from all schools of medical practice; had worn pessaries, and had passed through the purga- tory of leeching and blistering, starvation and hydropathy, but without being benefitted in the least. Locally there was an exten- sive abrasion of the cervix uteri to which I applied the oleagin- ous collodion. She was of a rheumatic diathesis, which, with the character of the pelvic and spinal suffering, and of the mental symptoms, indicated macrotin. She took this remedy, and this only, in the third decimal trituration. In a short time she began to improve, and in a few weeks was quite well again. Three years have now passed (1880) and there has been no return of the old trouble. She has gained in flesh, is rosy and hearty, and the centre of attraction for a large circle of friends. [At his sub-clinic on Friday October 15th, 1880, Prof. Ludlam showed the class three cases of pelvi-peritonitis which were in some respects remarkable. In the first of these, Case. the patient, aged 35 years, the mother of five children, the youngest of which was five years old, complained of severe pelvic pains which she has had since her last labor. Her puerperal history was very indefinite. The pain is limited to the right half of the pelvis and to the region of the umbilicus, but disappears from both localities upon her lying down. In search- ing for the cause of this relief by the change of posture, it was explained as follows : "When she is standing the uterus is prolapsed and drags upon its peritoneal supports, or in other words, upon the so-called uterine ligaments, consequently the inflamed mem- brane is put upon the stretch. But, when she lies upon her back, as was demonstrated to the class, the womb recedes of itself and its ligaments are relaxed. Besides, when she stands erect, sits, or walks about, there is a hernial protrusion at the umbilicus, which causes the pain in that locality. When she lies upon her back, the hernia being a small one disappears of itself, and the pain along with it. In the second case, there, was a clinical history of partial steno- sis of the cervix uteri and consequent dysmenorrhcea, for which 384 THE DISEASES OF WOMEN. the patient had been treated surgically by incision three year& Cage before. After this operation she had suffered from an attack of peri-uterine inflammation from which she has never entirely recovered. For two years she has had a form of menstrual peritonitis. Of late, however, her symptoms have changed and she now complains of a burning pain in the vagina with great tenderness, which prevents the in- troduction of the speculum. On visual inspection the vagina was found to be the seat of a diffuse and very violent inflamma- tion of a non-specific character. The peculiarity of this consisted in the fact, that the vaginitis was consecutive upon the pelvic peritonitis, and that she had never had it before. In the third case there was an evident complication of pelvic cellulitis and a laceration of the cervix with the pelvic peritonitis. The patient also had rheumatism of the left Case. ankle-joint. The case had been under careful observation for some weeks, and there was no doubt about the diagnosis. The form of the laceration, which was shown to the class, is very well illustrated in the accompanying figure. Fig, 35. Bifid laceration of the cervix. Prof. L. said that the chief obstacle to the cure in this case was that, while the circum-uterine inflammation, more especially the peritonitis continued, an operation for the laceration of the cervix was contra-indicated.] LECTUKE XXIV. PELVIC CELLULITIS. — PELVIC ABSCESS. Pelvic cellulitis. Case.— The congestive stage— the stage of effusion— ditto of resolution- ditto of suppuration. Causes. Coincident diseases. Diagnosis. Sequelae. Of late years the physiology and pathology of the pelvic areolar tissue has attained a great and merited degree of importance. The whole theory of uterine displacements and of uterine inflam- mation is concerned in its clinical history. From the day in which Dr. Priestly's researches and dissections were published (1854), until Dr. Emmett's book was issued last year (1879), uterine pathology has undergone a complete revolution, and what was vaguely styled the " loose cellular tissue" has received such con- sideration as has not been bestowed upon any other tissue within the pelvis. I shall therefore, take especial pains to give you as correct an idea as possible of the subject of pelvic cellulitis, ot which you have already seen a number of cases in my clinic. The subject is a difficult one, more especially because the struc- ture involved is outside of the generative intestine, and is therefore, only indirectly accessible ; because this same areolar tissue is greatly modified by pregnancy, is more likely than almost any other structure to be injured during labor, and also because it has a puer- peral history Avith sequelae that are very peculiar and persistent. Another characteristic which complicates the study, and the treatment of pelvic cellulitis is the tendency to the formation of abscesses. PELVIC CELLULITIS. — PERI-METFJTIS. — PELVIC ABSCESS. Case. — Mrs. S , set, 30, was delivered by forceps of a dead child twelve weeks ago. Following this her physician said that she had puerperal fever. When she entered the hospital she complained of acute pain in the right iliac region, Which was ag- gravated by touch and motion. There was a tumor (for which she had been blistered) in the right iliac fossa, which was of 25 385 386 THE DISEASES OF WOMEN. irregular outline, and could be very plainly felt above the brim of the pelvis. The corresponding limb was retracted. She could not lie upon that side. She had diarrhoea, with black, shiny stools. She complained of cramps in the uterine region on going to stool. Burning during micturition. Emaciation. Pulse 85, and weak. Tongue coated. Yesterday she commenced to have a pretty free discharge of pus from the uterus, and her symptoms are already somewhat relieved. Until then the vagina was hot, dry and very sensitive. The tumor could be recognized by the " touch," located at the right side of the cervix uteri in the roof of the vagina. Synonyms. — This disease has received several names which only serve to confuse the mind. Thus, among its synonyms are pelvic cellulitis, peri-uterine cellulitis, perimetritis, parametritis, pelvic abscess, intra-pelvic abscess, abscess of the uterus, inflamma- tion and abscess of the broad ligaments. The term peri-uterine cellulitis, proposed by Dr. Thomas, as locating the lesion more definitely, and implying that this is one of the sequelae of uterine disease or accident, is perhaps least objectionable. You are aware that the pelvis is lined with a fascia which is re- flected over the muscles contained within it, and over the pelvic organs also, and which serves 'to shield, to The pelvic cellular tissue. • strengthen and to separate them. .Now be- tween the layers of this pelvic fascia, when they come into con- tact with each other, and also between the fascia and the organ which it covers or separates from another organ, there is inter- posed a quantity of loose cellular tissue. This tissue is particu- larly abundant between the folds of the broad ligaments, about the abdominal portion of the uterine cervix, between the uterus and the bladder, about the urethra, in the recto-vaginal septum, and in the recto-sacral space. There is considerable discrepancy among authors concerning the presence of this areolar tissue between the peritoneum and the Uterus itself, a majority insisting that there is so little of it there as scarcely to be worth mentioning. Hence there are those physicians who insist that peri-uterine cel- lulitis proper is a kind of mythical disorder — one of the refine- ments of uterine diagnosis. But I apprehend that there is no real conflict between the au- thority of the anatomist on this point, and the experience of the gynaecologist, when he finds that attacks of inflammation are PELVIC CELLULITIS. 387 sometimes seated in the areolar tissue about the uterus. For this form of the disease is especially incident to the An important suggestion. a i i i ,i puerperal state. And when we remember the changes that take place in the other uterine textures in conse- quence of conception, I can see no reason to doubt that there is, during pregnancy, a corresponding growth and development of its cellular tissue also. Authors have not, in so far as I am aware, said anything on this subject. Nevertheless it may be true that this particular tissue, like the muscular coat of the womb, is pro- duced and then removed to answer certain very important physi- ological ends ; and that this consecutive development and decline constitute a predisposing cause of cellulitis as one of the con- tingents of labor, whether premature or at term. At any rate, I give you the hint as one that contains something practical. Peri-uterine cellulitis, therefore, is an inflammation of the con- nective tissue about the uterus and within the pelvis. As I have said, when it is not traumatic, it rarely occurs Frequency of. . except as a sequel or contingent ot lymg-m. Gestation and labor are, therefore, its most powerful predispo- nents. The disease is less frequent than puerperal peritonitis and phlebitis, but is probably more common than many practi- tioners have supposed. (Exit the 'patient.) Authors divide this disease into three, but I shall specify four stages. The first is that of congestion, the second of effusion, the third of absorption or resolution, and the fourth Its four stages. . _ ot suppuration. I add the stage oi resolution, because I believe that appropriate treatment will sometimes en- able us to cure our patients without allowing the disease to pass on to the suppurative stage. The First or Congestive Stage. — The congestion may set in ab- ruptly a few hours after delivery, or it may be delayed until some days or even Aveeks have passed, and then may come on insidiously. The symptoms are such as mark the onset of inflammatory fever. There is a more or less decided chill, which may or may not be repeated. If the chill is lacking, it will be substituted by rigors, which are sometimes painful and persistent in ratio with the exhausted and debilitated, condition of the patient. The febrile re-action is very decided. The heat of the skin is often intense, the pulse full, strong and 388 THE DISEASES OF WOMEN. rapid, or, in weak subjects, quick, frequent and irritable. The tongue is furred, and not unfrequently there is nausea with dispo- sition to emesis. These symptoms are accompanied, or followed almost immedi- ately, hy intra-pelvic pain and distress. The location of this pain varies with the seat of the inflammation. If Intra-pelvic pain. . ' -, \. the cellular tissue between the broad ligaments is attacked, the pain will be referred to the corresponding side of the pelvis, in which it will be deep-seated and very severe. If the same tissue surrounding the uterine neck is the seat of the lesion, the suffering will be in the upper part of the vagina, and contact with this organ, even by the exercise of the most delicate " touch," will be insupportable. If the peritoneum is also inflamed, the pain will be acute and lancinating in character. Most of the pain experienced, however, is ascribed to the pressure of the effused fluid (which has escaped into this tissue) against the neighboring organs. In many cases the bladder, and in others the rectum, are thus mechanically pressed upon, giving rise to strangury and tenesmus, which are not relieved by the usual remedies. Very often, more especially after the tumor caused by the effused serum has been formed, the pain is described as throbbing and paroxys- mal. It is usually not diffuse, but local and circumscribed in its extent. In acute cases the congestive stage is limited to a few hours. The Second or Stage of Effusion. — As in peritonitis or pleu- risy, the period of effusion generally follows in pretty rapid suc- cession. The serum escapes from the capilla- Formation of the tumor. ... - , pi i r> l ries into the meshes of the areolar tissue, infil- trates it, and solidifies as if it were out of the body, or just as it does in the pulmonary air-cells when it causes a hepatized state of the lung in pneumonia. The resulting tumor varies in it'< shape and size according to circumstances. If the space between the fasciae is limited and of a particular shape, the " swelling ,f cannot be larger, and must be of the same configuration. It grows rapidly until it has attained its maximum size, becoming more and more firm and dense, or perhaps softer, in its structure. If the patient is in a weak, adynamic state, however, the clot will not be firm, and the tumor will remain flaccid, or become softer,. in some such manner as it does in pelvic heematocele. In many PELVIC CELLULITIS. 389 examples the tumor is exquisitely tender to the touch, but again it is not so. In the majority of cases of peri-uterine cellulitis, the tumefac- tion is situated in the lateral portion of the pelvis. You may find it in one or the other of the iliac regions. And Location of. . . _ its presence is best made out by means ot the bi-manual exploration. The index finger of the right hand being introduced into the vagina for the purpose of examining the os and cervix uteri, as well as the cul-de-sac of Douglas, the iliac region is examined at the same time through the abdominal pari- etes with the other hand. Between the two the size, shape and consistence of the tumor, whether it be above the pelvic brim or below it, can be pretty accurately determined. If there are any remaining doubts, the finger may be introduced into the rectum, and so much of the posterior and lateral walls of the womb as are within reach may also be examined. As a rule the uterus is fixed, or but sliqiitlv movable. One of the first symptoms indicative of this effusion is a local heat, swelling and tenderness of the vagina, which is apt to be felt at one side of the canal, and limited to one Symptoms. . . spot. Later the vaginal wall covering the tumor becomes thickened and indurated. It may, or may not, remain sensitive. If the tumor develops in either iliac fossa, the corresponding limb will usually, but not always, be flexed. This retraction of the thigh relieves the pain by relaxing the muscles in the imme- diate vicinity of the tumor. It is involuntary, and more or less complaint will be made when the leg is distended. In jmerperal women the milk and lochia are usually suppressed. This complicates the case, and implicates the nervous system more especiallv. Delirium, insomnia, unrest, spasms, Incidental symptoms. l . convulsions, and even mama have followed irom this cause. In rarer cases there is retention of urine, and still more rarely an almost total suppression thereof. Vomiting is a frequent accompaniment of pelvic cellulitis, possibly, as Dr. Att- hill suggests, because of the endo-metritis which generally co- exists. This stage of effusion, with its resulting tumor, may continue unchanged for a variable period ranging from one week to a 390 THE DISEASES OF WOMENo month. There is no fixed limit to its duration. Sometimes, in con^ sequence of a relapse, the congestion is again established, and the resulting effusion follow- ing, there is an increased pouring out of serum and a marked and sudden growth of the tumor. Again the inflammation being pas- sive, the tumor becomes insensibly larger. Or it may develop in the right iliac fossa, and when some considerable time has elapsed, commence to grow and finally attain a marked development in the left one. Successive tumors of this kind occurring in the same locality, are by no means rare. The Third Stage, or that of Resolution. — The stage of absorp- tion, or of resolution, is that in which the tumor- may remain for some time at a stand-still, and finally pass away without ending in suppuration. As you will infer, if for any reason, as for example because of a depraved cachexia, great debility from previous illness, inanition or excessive medication, the patients' vitality is very much reduced, the reso- lution of the swelling would be impossible, and suppuration would almost inevitably follow. Under the circumstances, therefore, in which we are likely to find these patients, this third stage of the disease will frequently be lacking altogether. But when her strength has previously been good, her gestation and labor have been accomplished without too great a draught upon her nutritive and nervous resources ; res C o?;'t d ion? nsthatprom ° te when she has been well nursed and properly fed, medicated and otherwise cared for; and above all when there is no prevalent epidemic erysipelas, or puer- peral disorder, we may observe the tumor gradually and quietly resolving itself away under appropriate treatment. If the swell- ing consists of effused serum, and not of coagulable lymph, it may be more readily absorbed. The Fourth, or Suppurative Stage. — If left to itself, however, or mal-treated, and in a majority of cases almost inevitably, the tendency of this disease is to terminate in suppu- Symptoms of. . „ . ration. With the commencement 01 this pro- cess the symptoms vary as in the case of abscesses located else- where. If the pain and tenderness have subsided, they are very- apt to return. The tumor may become extremely sensitive again, and motion, or the pressure upon the tumor caused by an attempt PFXVIC CELLULITIS. . 391 to stand upon the feet, to urinate, or while at stool, may occasion extreme suffering. The limb cannot be extended. The patient's body is flexed in the bed. A species of hectic Accompanying hectic. lever, 01 a remittent type, sets in. there are rigors alternating with great heat, and evening exacerbations of fever, which sometimes mislead the physician. When she sleeps there is a profuse and exhausting perspiration, as in the worst cases of phthisis. The face and skin are pale. The countenance assumes the expression which surgeons recognize as characterizing that pus has been formed somewhere in the body, and is awaiting its discharge. The pulse continues rapid, although it has lost in strength. There is anorexia and great debility, with or without diarrhoea. Even although the tumor may have been firm and like fibro- cartilage, or almost like scirrhus, to the touch, it now begins to soften. This softening may be recognized either Seat of the fluctuation. ,,-,.-, P , , . , by abdominal or vaginal palpation, or by both combined. It may occur gradually, or develop itself more rapidly. The weaker the patient the less the resistance to this process, and the more speedy the resulting fluctuation. This fluctuation is in most cases observable at the upper part of the vagina at one side of, or directly behind the cervix uteri, in the posterior cul-de-sac. " From some peculiar arrangement of the layers of the pelvic fas- ciae, when pus is formed in the course of a pelvic cellulitis, occur- ring in the upper half of the true cavity of the pelvis — and this, you must remember, is the most frequent seat of the disease — it has a tendency always to point in this direction and to find an exit for itself, either at the lower base of the broad ligaments, or in the posterior cul-de-sac of the vault of the vagina ; and it is at these spots, where the fascial layer seems to be unusually thin and weak, that the feeling of fluctuation is ordinarily first detected."* Now this fluctuation may be due to the presence of effused liquor sanguinis, or of pus. But if the disease has persisted, as in the case before us, for a considerable time, gnosis of the presence and been attended by the inflammatory fever, followed by the hectic, the copious perspiration after sleeping, and the frequent, irritable pulse, you may be rea- sonably assured of the presence of pus in the tumor. ^Clinical Lectures on the Diseases of Women, by Sir J. Y. Simpson. D. Appleton & Co., New York, 1872, page 72. 392 THE DISEASES OF WOMEN. Concerning the means of escape for the pus, when it has been formed, it is important to remember that it may extemporize an outlet for itself through the bladder, the uterus, Its varied means of escape. . . the vagina, or the rectum, It it iorms at the superior strait, it may gravitate, and, running down along the course of the muscles, may pass beneath the pelvic fasciae, and escape with the femoral vessels, so as to point near the groin. Sometimes it passes backwards through the great ischiatic fora- men, and forms an abscess in the region of the hip ; or it may even point at the great trochanter of the thigh bone. In rare instances it perforates both the uterus and the bladder, and leaves a fistula between them. Still more rarely, perhaps, it discharges into the cavity of the peritoneum. In seventy cases of puerperal pelvic cellulitis, Dr. McClintock, of Dublin,* found that thirty- seven ended with suppuration and the discharge of pus. Of these twenty-four were opened externally, or burst, of which twenty were discharged from the iliac region, two above the pubis, one in the inguinal region, and one beside the anus. Six others found an outlet through the vagina, five through the anus, and two burst into the bladder. With respect to the essential nature of this disorder, I have long held and taught the idea set forth by Virchow, that, in reality, it is a species of erysipelas. Its clinical history, cenuHti 1 s t . ialnatureofpelvic its epidemic prevalence, and its special thera- peutics, correspond with those . of erysipelas, more closely than with any other disorder. It is quite probable that many cases of this disease have been mistaken for puerperal peritonitis, and that the propagation of this latter malady by cer- tain fomites is really to be explained upon the siplifs. ^ 1 ^ 11 ^ 10 ^" theory of the inoculability of the erysipelatous poison as in the case of phlegmonous erysipelas. Causes. — I have already reminded you that pelvic cellulitis is one of the contingencies of lying-in. It may follow in conse- quence of injuries sustained in natural unassist- ed labor. One of its most frequent causes is the traumatic injury of the cervix uteri by pressure of the pre- senting part, especially of the head, during delivery. In abortion * Clinical Memoirs on the Diseases of Women. PELVIC CELLULITIS. 393 it may follow a similar injury to the neck of the womb. For this reason it is comparatively frequent where abortion has been in- duced by means that are almost necessarily harmful. Women have sometimes brought it on themselves in this way. Puerpesul cellulitis is one of the sequelae of instrumental deliv- ery, more especially when the resort to the forceps and other in- struments has been unwarrantably delayed, A sequel to dystocia. when they have been ignorantly or carelessly used, and when the patient has not received the proper attention and nursing after their employment. These causes are more effi- cient in proportion with the debilitated and depraved condition of the patient's system, and also with her proneness to scrofulosis, phthisis, and even to certain acute diseases, as, for example, pneu- monia and erysipelas. The non-puerperal cellulitis may result from the forcible intro- duction, or the prolonged retention, of the sound and the sponge or other tents. The wearing of intra- su4er y ntingentofuterine uterine pessaries, even the best of them, is very apt to induce it. Incision of the cervix uteri, whether for the cure of obstructive dysmen- orrhcea, for the removal or arrest of development of fibroids, or even for the arrest of uterine haemorrhage, is not an in- frequent cause. It has followed amputation of the cervix, ovariotomy, the ligation of polypi, the excision of haemorr- hoidal tumors, the operation for vesico- and recto-vaginal fistulae, and also that for ruptured perineum. It has also resulted from the use of very severe escharotics, as the potassa cum calce ; the wearing of vaginal pessaries for a long time without removal ; excessive and too forcible coitus ; and the extension of corporeal metritis and ovaritis to the areolar tissue about the uterus, and between the layers of the broad ligaments. Coincident Diseases. — Peri-uterine cellulitis rarely runs its whole course without being more or less complicated with other diseases. This is true, indeed, of most of the ailments for which you will be called upon to prescribe. The lines that separate pneumonia from pleurisy, or rheumatism from neuralgia, for ex- ample, are much more distinct and clear in the books than you will find them to be at the bedside. So you will most frequently observe that this form of cellulitis is more or less confounded with 394 THE DISEASES OF WOMEN. pelvi-peritonitis, ovaritis, and endometritis, in which case its clini- cal history and symptoms will be modified accordingly. Diagnosis. — This fact complicates its diagnosis. If you are not more skillful than your predecessors, you will sometimes be puz- zled to differentiate between pelvic peritonitis, Sometimes very difficult. \ • ■ -i i • r»i n • pelvic neemotocele, uterine fibroids and pelvic cellulitis. Let me beg your earnest attention therefore, while I tell you how you may know them apart. The pelvic areolar tissue being between the layers of the broad ligaments, and beneath the outer coat of the uterus, both of which structures are composed of reflections of peri- From pelvi-peritonitis. . toneum, it may be supposed that in case 01 in- flammation of either of them, the symptoms must necessarily be very distinct, not to say pathognomonic, in order to be recognized. As a rule, the pain in the first stage, prior to effusion, is less acute in cellulitis than in pelvi-peritonitis. In the former, if the exu- dation of the liquor sanguinis is copious, the suffering is increased by it ; while in the latter, as in pleurisy or synovitis, the effusion is followed by a mitigation, if not by an entire remission of pain ; which may return, but which, from that time forward, is less, acute and altogether changed in its character. In most cases of cellulitis the tenderness, pain and local heat are referred to and commence in the iliac fossse. The same is true of puerperal ovaritis, in which the peritoneal investment of the ovary becomes inflamed during lying-in. But in the former the pain does not change its location, nor does it incline to become diffused over the abdomen, both of which symptoms are proper to ovaritis occurring in puerperal women. I have copied Dr. Thomas' table, giving the differential signs, between peri-uterine cellulitis and pelvi-peritonitis, upon the blackboard :* PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 1. Tumor easily reached, generally found I. Tumor, if discoverable, very high, only to one side of the uterus, and may be in vaginal cul-de-sac, does not extend felt above the pelvic brim ; above the superior strait ; 2. Tendency to suppuration ; 2. Suppuration less common ; 3. Abdominal tenderness chiefly over one 3. Abdominal tenderness excessive above iliac fossa ; brim of the pelvis ; * A Practical Treatise on the Diseases of Women. By T. Gaillard Thomas, M.D., ~tc. Third edition, 1872, page 461. PELVIC CELLULITIS. 395 PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 4. Tumefaction generally noticed later- 4. Generally noticed near or upon the ally in the pelvis ; median line ; 5. Tendency to monthly relapses not 5. Tendency to relapse every month marked ; very marked ; 6. Retraction of thigh not rare ; 6. Retraction of thigh rarely occurs ■ 7. Pain severe and steady ; 7. Pain excessive and often paroxysmal ; 8. Facies not much altered ; 8. Facies very anxious ; 9. Nausea and vomiting not excessive ; 9. Nausea and vomiting often excessive ; 10. Does not necessarily displace the 10. Displaces the uterus as a rule ; uterus ; 11. Uterus fixed to a limited extent ; 11. Uterus immovable on all sides. The statement of some of these signs needs to be qualified. If r for example, the inflammation in cellulitis was always limited to the broad ligament on either side, the tumor could invariably be reached without difficulty by downward pressure in the corre- sponding iliac fossa. But the fact is that it has no such constant seat. It may happen that the connective tissue surrounding the inferior segment of the womb, or about the cervix uteri, shall be inflamed, while that which separates the layers of the broad liga- ment escapes altogether. In this case we should fail to find the tumor at the superior strait, but might detect it per vaginam or by the rectum. In exceptional instances of pelvic cellulitis, it is impossible to locate the tumor at all. Peritonitis is more directly related to disorders of menstruation, and to the return of the monthly cycle, than cellulitis. The com- mencement and brief continuance of the peritoneal pain in the median line, and the absence of a marked tendency to suppura- tion, will generally enable you to separate this disease from pelvic cellulitis. Owing; to the extension of the inflammation in this form of peritonitis, the induration, if there is any, is not always located in the median line, as the pain was at the beginning of the attack. When gonorrhoea! , or, indeed, ordinary inflammation, ex- tends from the uterine cavity through the Fallopian tubes, and invades the abdomen and the pelvis, it is more likely to give rise to peritonitis than to cellulitis. You should not forget that, while pelvi-peritonitis is quite a common affection with non-puerperal women, pelvic cellulitis almost never occurs excepting among those who have recently been confined. It must be acknowledged, however, that the lines which sepa- 396 THE DISEASES OF WOMEN. rate these two diseases are not always distinct. For, whether \t be due to the fact that the textures involved They may co-exist. . are contiguous, and that these lesions frequently co-exist, or that our present means of differentiation are imper- fect, it remains that they may be combined without our knowing it, and that we are liable occasionally to mistake one for the other. Although pelvic cellulitis and pelvic hematocele are both of them most frequent after delivery, yet the conditions of the patient's general system upon which they are From pelvic hematocele. too rrn i • prone to occur are very different. Ihus, pelvic hematocele takes place in consequence of a weak, adynamic state in which the blood has become of bad quality by extreme losses, as in uterine hemorrhage, or from the rupture of one or more small vessels during labor. It is also incident to the hemorrhagic diathesis. Neither of these conditions pertain to the etiology of pelvic cellulitis. In pelvic hematocele the formation of the tumor is not pre- ceded by local congestion, and symptoms proper to the first stage of an acute inflammation, as in cellulitis. It comes on suddenly, and is accompanied by signs of prostration, sinking, and collapse. The tumor in hematocele varies in its consistence, but is never hard and ligneous to the feel, like that of cellulitis. The more impoverished the blood, the softer the tumor. In cellulitis, the tendency toward suppuration causes the swelling to become softer as it grows older. The opposite change occurs in the hemato- matous tumor, which gradually becomes harder than it was orig- inally. Uterine fibroids come on insidiously and grow very slowly. Un- til they occasion trouble mechanically they are neither sensitive nor do they cause pain in the womb or the adja- From uterine fibroids. . . . cent parts. If sub-mucous, or interstitial, they are characterized by the frequent occurrence of metrorrhagia, and inter-periodic hemorrhage, which is not a contingent of cellulitis. The tumor, in case of fibroid, is firm and not oedematous to the feel, and there is no tendency in it toward suppuration. Fibroids do not render the uterus immovable, as the tumor in cellulitis -often does. In case, however, that you can not otherwise decide as to the nature of the pelvic tumor, you may pass the exploring-needle into PELVIC CELLULITIS. 397 it from its vaginal surface. If you bring away a drop or two oX pus upon the instrument, it is a positive sign of abscess ; if blood only, and that of a dark, purplish color, it may be a case of hem- atocele ; and if no specimen of any kind of abnormal product is obtained, the negative symptom will satisfy you that it is probably a case of uterine fibroid. This is an excellent means of diagnosis and may really be a great blessing in your hands. For the safety of your patient, as well as of your own reputation, will depend upon your skill in diagnosis. Sequelae. — The most common sequel of this form of cellulitis is pelvic abscess. It often happens that the evacuation of the tumor a single time will not suffice. In many cases Relapsing abscess. . these abscesses continue to discharge lor months and even for years. The accompanying symptoms vary with the location of the tumor and its means of outlet. Incredible quan- tities of pus are poured out, and the patient's strength and vitality are so undermined that her health may be ruined thereby. Another result of this disease, which is frequently entailed upon those who have had it, is sterility. It is not unusual for a woman to lose her first-born in consequence of a difficult labor, to have cellulitis in child-bed, and to recover her health in every respect, except that in future she remains barren. In this case the cellular inflammation has caused the function of reproduction to be suspended. This fre- quently happens as an indirect result of criminal abortion. Menstruation is sometimes most seriously implicated, either because of ovarian complications, with cellulitis, Menstrual disorders. . or from some partial or complete obstruction or the Fallopian tube or of the cervix uteri. Other sequelae include certain uterine displacements, and the vesico- or recto-vaginal fistulas which are sometimes caused by sloughing of the septa between the bladder, or the bowels and the vagina. Prognosis. — The prognosis should be cautiously made. If it is possible to secure the resolution of the tumor, and to prevent seri- ous relapses, the patient will probably recover.. concurfenrdlease ditior and Mucn w ^ depend, however, upon the general strength and vitality. If these shall be very much reduced, the case is less promising. So also with the 398 THE DISEASES OF WOMEN. chronic and incurable disorders of digestion with which it may be complicated. But you should not despair of curing even the worst attack, provided the patient is not already moribund, and you can supply certain physiological requisites for her recovery. If the disease is epidemic, the prospects are less favorable. If it occurs in the winter or spring months, during stormy and in- clement weather, when erysipelas, diphtheria, The epidemic tendency. . .. 1 _ . 1 scarlatina, or dysentery, and kindred diseases are prevalent, it subtracts so much from the chances of recovery. Those cases which arise from traumatic injury are generally more grave than such as are referable to more ordinary causes. If the disease invades other organs, as when the pus that has formed finds an outlet through the uterus or the bladder, it may prove fatal through the serious complications that follow. If the abscess discharges into the cavity of the abdomen; the patient will be -very apt to die suddenly. The janitor's bell, which is as inevitable as one's shadow, has overtaken us. I will speak of the treatment of pelvic cellulitis at my next lecture. LECTURE XXV PELVIC CELLULITIS. (CONTINUED.) Pelvic cellulitis, continued ; Prognosis. Case; the Sequelae and Treatment. Case. Case. — Mrs. , is married, and the mother of two chiU dren, both of whom are dead. She had an abortion at the thrid month, now six months ago, and has not been well since. For many years she has been subject to leucorrhcea, and while an inmate of St. Luke's Hospital, in New York, she says she had blisters applied to the region ot the ovaries for the cure of that infirmity. The menses are copious, returning every three weeks, and continuing for from four to six days. A local examination in the sub-class room revealed great tender- ness in the ovarian and pubic regions, the cervix was somewhat swollen, and about the os uteri it was highly inflamed. In the left lateral cul-de-sac, the finger detected a placque of inflamed areolar tissue which has been the seat of an extensive infiltration, and which has doubtless existed for a long time. There was no lacera- tion of the cervix uteri. Next to the differential diagnosis of this disease, its prognosis is the most difficult and imperfect. In a given case the result will vary with the cause, the complicating lesions, Qualifying conditions, " ° the condition 01 the menstrual function, the treatment to which the patient has formerly been subjected, her puerperal experience, and the clyscrasia upon which the cellulitis has been engrafted. 1. The cause. — Cases which date from the lying-in, and which have developed from injuries received during labor, are very tedi- ous and difficult of cure. Puerperal traumatism Traumatic causes. . „ . , . . is a fertile source of pyemic relapsing pelvic abscess, especially if the mother has failed to nurse her infant, is of the scrofulous or tuberculous habit, or has not been properly cared for in child-bed. Other forms of peri-uterine traumatism resulting from surgical operations about and within the cervix uteri, the wearing of ill- adjusted pessaries, inveterate constipation, the pressure of uterine 399 400 THE DISEASES OF WOMEN. fibroids, stone in the bladder, and sexual abuse, are followed by forms of cellulitis which are severe and dangerous in proportion with the acuteness of the attack, the nature and more or less con- stant action of the exciting cause, and the physical ability of the patient to survive the effects. In miasmatic districts, and in tropical climates, where bilious disorders abound, there are cases of pelvic cellulitis that depend indirectly upon a derangement of the portal In paludal districts. . . l , . . circulation. VV nile the hemorrhoidal and the ovarian veins are gorged with blood from this cause, a cure of the concurrent cellulitis is not to be expected. Some of these cases will get well merely from a change of climate. Certain epidemic causes affecting women in child-bed, leave their impress upon this form of post-puerperal inflammation. If a woman has had either erysipelas or scarlatina,, In epidemics. peritonitis or phlebitis, septicemia or pyaemia during the lying-in, an inflammation of the pelvic areolar tissue that may be engrafted upon her, will partake of its characteristics, and the prognosis will vary accordingly. 2. The complicating lesions. — The most important of these are pelvic peritonitis, hematocele, hemorrhoids, uterine fibroids, ovaritis, cystitis, urethritis, vaginitis, laceration and ulceration of the cervix uteri, ulceration of the rectum, chronic metritis and uremia. Peritonitis holds about the same relation to cellulitis that pleurisy does to pneumonia. Either may precede the other in the order of its coming, but they often and indeed With peritonitis. , , . A ° T . lT: , usually co-exist. In a serious case, therefore, this fact should be borne in mind, for without it a careful prog- nosis would be impossible. The suppurative form of peritonitis, especially if it is of pyemic origin, is a serious and dangerous com- plication of pelvic cellulitis. If, however, it sets in, in the puer- peral state, when more than a fortnight has elapsed since the birth of the child, it is likely to run a tedious course and finally to terminate in /eoovery. Tubercular peritonitis is a complication that is necessarily of a fatal character. If the peritonitis is ovarian, the lesion will be apt to develop into an abscess, that may discharge itself through the Fallopian tube, or the rectum, or possibility through the abdominal parietes, or PELVIO CELLULITIS. 401 there will almost certainly be a resulting disorder of menstruation of an intractable kind. The complication of peritonitis with cellulitis is less likely to be rapidly fatal than to become chronic, and is exceedingly trouble- some on account of the persisting lesion of Anew version of an structure or of f imct ion, in either or all of the old fact. ' m ' pelvic organs. This is the root and the founda- tion of the uterine cachexia. It is as true now as it was fifteen years ago, when Bernutz, in speaking of pelvic peritonitis, insisted that " the future knowledge of uterine pathology is as certainly subordinate to an acquaintance with this affection as pulmonary pathology is to a complete knowledge of inflammation of the thoracic serkms membrane." Dr. Emmet's recent observations confirm this remarkable exhibition of clinical foresight. For Bernutz really suggested what Emmet has just now developed. When pelvic cellulitis, or peri-uterine inflammation of the cel- lular tissue co-exists with laceration of the cervix, the cure will be difficult. For an operation for the radical cure of the lacera- tion of the cervix is contra-indicated while the cellulitis remains; and the cellulitis is not likely to be cured while fhe laceration remains. 3. The condition of the menstrual function. — Whether we con- sider the menstrual function as eliminative or not, there is a causa- tive relation between the arrest of the menses, Menstrual disorders n < • i ;i vj. r ^i and cellulitis. as we ^ as cer tam changes in the quality of the discharge, and the occurrence of a severe type of pelvic cellulitis. Experience teaches that, when the monthly derangement precedes the local cellulitis, the case is amenable to treatment directed against the first cause of the attack, but not otherwise. If the disease began with the resumption of the menses at the close of lactation, i't will be very apt to develop into abscess of the broad ligament, and to be rebellious in its character. So also, if it follows the abrupt and premature weaning of the child from any cause, and the consequent reflux of the blood towards the pelvic viscera. I am satisfied that the resumption of the inhibited process of ovulation is a very important factor and complication of this disease in those who have borne children. In a certain proportion 402 THE DISEASES OF WOMEN. of cases of pelvic cellulitis we cannot foretell the result without weighing these conditions very carefully. Pelvic cellulitis is sometimes complicated with an intractable menorrhagia. There is no doubt that in many cases of so-called chronic metritis accompanied by copious men- luiitis. "^ 1 ^ aad Cel " struation, the lesion is really one of peri-uterine cellulitis. In this class of cases the prognosis will hinge upon our ability to control and to cure the excessive flow. But we must not forget that these conditions predispose our patients to pelvic hamiatocele, and also to concurrent peri- tonitis, under which circumstances the danger is very much in- creased. 4. The treatment to which the patient has formerly been sub- jected. — A very considerable proportion of the cases of pelvic cellu- litis that come to us for advice, have already been ment. ChieVCUS treat " cauterized or maltreated in one way or another. Sometimes we know what escharotics have been employed, and sometimes not. Occasionally the patient is able to give an intelligent account of operations that have been made upon the cervix uteri, and of expedients that have been resorted to for the dilatation of its canal, to change its direction, or to correct some special form of uterine deviations. But oftener she is in the dark about the whole business, and we are left to conjecture what may have been done, frcm the traces of mischief that remain behind. If we know what the peculiar practice of her former physician is, or is very likely to have been, we shall have the key to the case, or at least to its complications. This informa- A clinical hint. #11 n . ^ tion will come to us from various sources, ror example* in my own practice, having cases that come from all quarters, I have found it necessary to know, through all the books and journals that I can get, just what form of practice is most popular with each and all of our uterine specialists. So that, when a patient comes to me from a prominent gynaecologist in New York, or Philadelphia, or San Francisco, or from some of my neighbors nearer home, my knowledge of their writings, of the work they do, and of their way of doing it, is useful in putting me on my guard, both as to the prognosis and the treatment of pelvic cellulitis and its complications. For these post-gynaecological lesions are not always of a trifling or a transient character ; and PELVIC CELLULITIS. 403 if we promise to cure the cases upon which ^hey are secondary, as we might reasonably do if they were idiopathic, we shall often fail. If we remember that there is not a single method of surgical treatment for uterine affections, from the adjustment of a pessary to the operation for laceration of the cervix, which is not capable of causing pelvic cellulitis, or peritonitis, or both of these affec- tions, and that most frequently they are resorted to by physicians, and often by specialists, in an indiscriminate manner, we shall not be, likely to forget that the prognosis will depend upon what has been done for these cases before they came into our hands. 5. Her puerperal experience. — The form of pelvic cellulitis which results in abscess of the broad ligament, is often of an insid- ious kind, and may continue for months or years without being suspected or discovered. It is usually the result of pyaemia, and may be complicated with lacerations of the soft parts, that have healed spontaneously, or others that remain, and which can be found upon a very careful inspection. When Post-puerperal lesions. , uiir^-i these traumatic lacerations have healed of them- selves and disappeared altogether, and when the patient is unable to give any detailed information concerning her lying-in, it is very difficult to make a careful and reliable prognosis. This is a clinical fact which can be verified in our daily experience, and which fur- nishes an argument for the necessity of a better knowledge of the puerperal diseases. When abscess of the broad ligament (which depends upon an inflammation of the cellular tissue between the layers of that liga- ment), becomes chronic, and relapses frequently, broad\gament° f the ^ * s a ^ mos t always complicated with some seri- ous disorder of the menstrual function. Not infrequently the latter furnishes the best criterion of the gravity of the disease, and also the best guide to its treatment. In very exceptional cases this form of abscess, with its periodical discharge, is vicarious of menstruation. There is a class of cases of pelvic cellulitis that occur in women who have borne their children rapidly, who have had but very indifferent attention during their lying-in, and who suffer from it because the parts that are chiefly concerned, more especially the cellular tissue, have not recovered from the effects of one pregnancy before they are precipitated into 404 THE DISEASES OF WOMEN. those of another. Under these circumstances, the patient's general strength is so reduced, and the vitality of the intra-pelvic tissues has become so low that the prognosis, in so far, at least, as a radi- cal cure is concerned, will need to be qualified. For this state of things borders upon the uterine cachexia, and is not always cur- able. Another form of post-puerperal cellulitis is at the bottom of certain chronic affections of the bladder and urethra. The lesion is a legacy of the puerperal state. It is peri- With vesical lesions. . \ . cystic, and very intractable. In some cases, it has been caused by the use of an unclean catheter during the lyino-- in; in others, by a careless neglect in allowing the urine to accumulate inordinately, in cases of peritonitis or endo-metritis when, after having urinated naturally for some days, the patient loses the power to do so. The prognosis in these cases is very unpromising and the greatest care and patience are necessary in order to bring about a favorable result. One reason for this lies in the fact that the local cellulitis in the vicinity of the bladder and of the urethra is almost certain to be complicated with a local peritonitis. 6. The dyscrasia upon ivhich the cellulitis has been engrafted, — In those women who bear children, and who are of a scrofulous diathesis, there is a great proneness to inflam- mation of the areolar tissue, and a corresponding exemption from the forms of glandular inflammation to which other scrofulous persons are subject. This is shown in the history of puerperal mammitis, in which, in the great majority of cases, the disease is seated in the inter-lobular, and not in the glandular tissue. With this peculiar predisposition to cellulitis as a post- puerperal inheritance of this class of subjects, we find the same tendency to suppuration and abscess as in scrofulosis. The prognosis in pelvic cellulitis, in the case of those who are decidedly scrofulous, will, therefore vary with our ability to recognize and to overcome the effects of this complication. It is only by the greatest care that we can prevent the extension of the disease, its frequent relapse, and the recurrence of abscesses, which drain the patient's strength and drag her into an incurable cachexia, or even into tuberculosis. The cancerous diathesis develops a form of pelvic cellulitis, in PLLVIC CELLULITIS. 405 which the lesion that is outside of the uterus, almost always follows the development of that within its body or cervix, so that a recog- nition of the cancer through the speculum, or by the touch, will enable us to decide upon the danger and sig- nificance of the accompanying 1 cell ulitis. When this order of succession is reversed, the fixation of the uterus, and the signs of the cancerous cachexia will clear up the case. We must not forget, however, that the anchorage of the uterus is as com- mon a result of a benign as of a malignant cellulitis. M. Louis, estimates that in at lea-st one-twentieth of all those who are the subjects of tuberculosis, the lesion is located in the generative organs. There is no doubt that the With tuberculosis. . n , m r • , i proportion ol women who sutler from genital phthisis, as compared with those who have the disease in some other form, is still larger. Those who die of pelvic peritonitis and of pelvic cellulitis in their chronic form, are almost always the victims of tuberculosis. So little has been said of this diathesis as a complication of pel- vic cellulitis, that the subject deserves especial mention in this con- nection. We are not warranted in promising a radical cure of this disease in women who are predisposed to phthisis, especially if they have borne many children, or if they have been treated for a con- siderable time by caustics and the local appliances of the old Bennet school. Even when tuberculosis does not develop within the pelvic cavity, the existence of chronic cellulitis may indirectly excite the forma- tion of tubercles in the lungs. We may anticipate this result in hereditary phthisis, more particularly if the disease had threatened to develop itself at puberty, and been suspended for a time, either by the establishment of menstruation or the occurrence of preg- nancy. In this case the prognosis of cellulitis, at or about the climacteric, would be almost necessarily of a serious character. Case. — At the request of my friend Dr. W. H. Woodbury, of this city, I recently saw a caso of pelvic cellulitis which was quite peculiar. The patient was attacked with cellular inflammation during her lying-in ; she was ill for a number of weeks when an abscess formed and discharged itself through the rectum. This discharge continued at short intervals, but, meanwhile, the lesion extended above the superior strait and reached half-way to the umbilicus, where it suppurated and a deep-seated abscess resulted. 406 THE DISEASES OF WOMEN. A surgeon was called who made two unsuccessful attempts to open this abscess. On a third trial he brought away the pus, but left a wound in the intestine through which for three years past small quantities of faecal matter have been discharged. This unfortunate condition had been entailed upon the patient before she came into Dr. Woodbury's hands, and our consultation concerned the prognosis and the propriety of operating for the relief of the post-surgical lesion of the intestine. We concluded however that an operation was not advisable until the inflamed and suppurating areolar tissue about the wound had first been healed. The prognosis turned upon the patient's vigor, her ability to withstand the effects of the prolonged drain, and to overcome the tendency to induration and suppuration. The per- severing use of remedies, and the skilful and sensible adjustment of her surroundings may finally cure her, and fit her for t'he pro- proposed operation. Before I speak ot the treatment of pelvic cellulitis, the clerk ot my clinic will read you the notes of a private case which are given in the patient's own words, and which will serve to show the erratic course of the disease as well as the difficulty ot its diagnosis. The patient has entirely recovere I her health. Case. — I am twenty-eight years old, and was confined two years ago with my first and only child. ' I had enjoyed- perfect health during pregnancy, excepting a soreness of one of my breasts, which was occasioned by my own imprudence. My labor began at seven o'clock in the evening, and lasted until one o'clock the next morning, when I was delivered of a dead child. I was under the care of a midwife who gave me some powders, a little wine, and free draughts of cinnamon tea, in order to hasten the pains, which she thought were too slow. From ten p.m. to one o'clock a.m., I had one continued pain, and was finally delivered in the standing posture. The child which, two hours before its birth had been alive, was a very large one. For some days after delivery I lost a great deal of clotted and very offensive blood. I had pains low in the sides and groins almost immediately, and, five days afterwards was taken with a very severe chill, which was followed by a burning fever. The milk disappeared twenly-four hours later. The flow became yel- lowish and watery, instead of bloody. A physician was called, who decided that" I had puerperal fever. He prescribed medi- cines to control the fever, and ordered vaginal injections of water containing carbolic acid. At first [ seemed to improve, but in a few clays the pain in the sides returned. The doctor examined me internally (with a speculum), and said that I had ulcers on the neck of the womb. He burned them twice a week for about PELVIC CELLULITIS. 407 six weeks with the nitrate of silver, but, before they were cured, I was taken one morning with severe cramps in the bowels, which lasted the whole day, and were followed by chills and fever. These cramps came every two or three days, and were very pain- ful. The doctor ordered paregoric, and afterwards laudanum. In the middle of the following May I was compelled to change my residence. My ride in the carriage was a very painful one, and in a few days I was worse than ever. I began to have a severe and steady pain in the left side of the bowels, low down (iliac region), and the doctor, after another examination, declared me to be threatened with an ovarian tumor and hardening of the left ligament. A greenish ointment was applied over the whole side of the abdomen, and the swelling gradually disappeared, but the ligament (Poupart's) has always remained hard. I took at that time a great deal of iron, and of the iodide of potash, con- tinuing it until my stomach could support it no longer. In the summer a diarrhoea, with straining, and a pain which continued after each passage, set in. This lasted for many months and left my bowels in a very weak state. I, however, improved gradually, and finally the doctor ordered me to go out of doors. Walking was difficult and painful. In August, while in the open air, I caught a severe cold, and became very sick again, with cramps in the stomach and bowels, vomiting and diarrhoea, with dreadful straining. Another physician was called in counsel, and I was said to be in great danger. They said I had a commencing peritonitis, with great swelling of the womb and general inflam- mation. The end of September came before I was able to be up again, but the diarrhoea and pains continued, and made me so weak and wretched that, in the following January, I resolved to try Homoe- opathy, and accordingly sent for Dr. S****. Within a month the diarrhoea and pain ceased entirely, my appetite returned, and I gained flesh and strength. I felt so much better, indeed, that I accepted a proposition to go to Europe. But toward the middle of March, I began to feel considerable pain in the right side (iliac region), which, until that time, had been well. These pains soon became so severe that I lost all rest. Nothing unnatural could be seen or felt in that locality. The pains were of a tearing char- acter, and extended from the right hip through the groin to the knee. All the pains which I had suffered before were as nothing compared with these. For six weeks I never slept without taking the hydrate of chloral, a very little of which sufficed. Dr. S. though^ my suffering was due to neuralgia, and, believ- ing that the sea-air would most probably cure me, advised me not to abandon the idea of going abroad. Consequently, although I had noticed two small lumps in my left groin, as they were not 408 THE DISEASES OF WOMEN. painful, I paid no attention to them, and left Chicago for New York in the latter end of May. The journey proved very hurtful, the lumps increased in size, and I was compelled to take to my bed almost immediately after my arrival in New York. The first of June Dr. F***** came to see me, and after a thor- ough examination told me that I had no sign of ever having had an ovarian tumor, that the glands were swollen, that my sickness would be tedious, but that, with proper care, he thought I would recover. He did not wush to frighten me by saying that I already had one or more abscesses. The first of these abscesses was opened by the doctor on the eighth day of June, and the second a week later. Even after they were discharged, moving in the bed was very difficult, and walk- ing quite impossible. The flow of pus continued profusely for about a month, and, having given up the proposed voyage, I was not well enough to return to Chicago until the twelfth day of July. Dr. F. feared lest the journey by rail might determine an- other abscess, but it did not seem to do as much harm as it had done before. Arrived at home, I placed myself under the care of Dr. R. Ludlam, and although I still suffered severely at times, I was able to get up and to sit in an arm-chair before the fire. Walking was still difficult, and I abstained from it. The Great Fire came early in October, my house was burned up, and it was expected that it would prostrate me entirely ; but in this we were agreeably disap- pointed, fori never felt so well as for about six months after- wards. One abscess (orifice) closed entirely, and the other almost ceased to discharge. At the end of March I began to experience a return of the old pains in the left side, which were attributed to my having walked too far in making an excursion down town. I had chills and fever, and the doctor feared that another abscess would form. Three weeks later an abscess pointed just beneath the scar formed by the first one. It was lanced, and discharged, but less freely than before. In all other respects, excepting this local trouble, I am well. In addition to the symptoms which this patient has detailed so intelligently, others were elicited on physical examination. While this last abscess was forming, the "touch" revealed a swelling of about the size of a pullet's egg in the left vaginal cul-de-sac. This tumor was somewhat soft and. very sensitive, so that when I pressed upon it my patient felt inclined to faint. The left border of the uterus and of the cervix were tumefied and puffy, or oedematous. The PELVIC CELLULITIS. 409 Douglas' cul-de-sac felt thickened, indurated, and less supple than natural, giving the impression that (probably at the time she experienced the severe tenesmus of the bowel) there had been a retro-uterine tumor also. The vagina was hot and dry. Conjoined manipulation, with pressure in the left iliac fossa, could not be borne. The peri-rectal tissue was also indurated. The bladder and urethra appeared to have escaped implication. Abdominal palpation was not painful. The uterus was forced to the opposite, or right side of the pelvis (right latero-version), a displacement which might explain the prolonged and severe attack of neuralgia from which she had suffered more than a year before. I must not omit a reference to the fact that in this case the two first abscesses discharged above, and the last one below Poupart's ligament. She is taking calcarea carbonica 3 , morning, noon and night. Treatment. — -It has been said that practically it is not a very serious matter to be able to form a correct diagnosis between pelvic cellulitis and the diseases which so inferences based on cor- c i ose iy resemble it. But, gentlemen, I am of rect diagnosis. J 7 o a very different opinion. For, suppose a physi- cian should tell you that it was of very little consequence to him whether his patient had the pleurisy or the erysipelas, and that the treatment was substantially the same, no matter what the name of the disease, what would you say of him, and what would be the measure of your trust in him as a skillful and successful practitioner? And if we expect him to discriminate between pleurisy and erysipelas, why should he not also, when it is pos- sible, separate peritonitis from erysipelas ? In other words, if there is a difference in the morbid anatomy of inflammation which varies with its seat in particular tissues, and if these dif- ferences are always characteristic of the disease in question, why should they not modify the treatment accordingly ? Since the symptoms, course, and mode of termination of the diseases are really so unlike, is there any good reason why an inflammation of a serous membrane should be treated as if it were identical with an inflammation of the cellular tissue ? I think not. I know that it is possible, and that there is a strong temptation so to refine and to rarify the symptoms by which diseases are 410 THE DISEASES OF WOMEN. differentiated as to leave no particular meaning in them, and to exclude a more practical idea of disease and its Pathological deductions. . treatment. But this is the other extreme. We must, and will always have, a theory of the disease which we undertake to cure. And, good or bad, true or false, that theory stands in our minds as a chart of its special pathology. Other things equal, the clearer and more correct our views on the sub- ject, the fuller will be the measure of our success and usefulness; for the physician who knows as definitely and accurately as possi- ble what it is that he wishes to cure, will usually exercise the greatest care in the choice of the means which he employs to that end. Now our clinical knowledge of the nature, peculiarities, com- plications, and tendencies of cellulitis enables us, not only to treat the symptoms that are present in the earlier stages of the disease, but to forecast and avert such as might and would otherwise fol- low. When we are called to a patient like either of those of whom I have spoken, and whose case is the groundwork of these remarks, we must cast about to see if we can not terminate the inflammation, or at least avoid some of its more serious con- sequences. And what are the consequences that we wish, if possible, to turn aside ? They are (1) to prevent the exudation of the liquor sanguinis, or serum, into the meshes of the General indications. . . n «, xr , . p . . - mtra-pelvic areolar tissue ; (z) it it has been already poured out, to promote its absorption and removal, and (3) to prevent suppuration, or abscess. These general indica- tions, therefore, correspond with, and concern the three last stages of pelvic cellulitis, viz. : effusion, resolution and suppuration. If we consider these enquiries in the order named, you will per- haps be able to obtain the best idea of the special therapeutics of pelvic cellulitis. It is as reasonable to suppose To prevent effusion. ... i • i i i _c that we nave remedies which are capable ot acting in such a manner upon the congested cellular tissue as to prevent effusion therein, as that we have those which are known to produce a similar effect in the first stage of serous inflamma- tions. There is no reason why, if we begin in season, many cases of threatened cellulitis should not be prevented from progressing beyond the stage of congestion. We ought to be able to cut short PELVIC CELLULITIS. 411 this disease as we sometimes do pleurisy, peritonitis, synovitis, and pneumonia. Of course, if the patient is peculiarly susceptible, and the interna* conditions, as well as the external circumstances, con- spire to produce it ; and more than all, if we are not called in the incipient stage, or what is equivalent, do not know what dis- ease we are prescribing for, the chances are that effusion will not, or can not be prevented. But our duty is plain. If there are remedies that are capable of removing and relieving the accumu- lation and stagnation of red and white corpuscles in the vessels of this same connective tissue, and of thus averting the conse- quences that might follow, we should be prepared to prescribe them intelligently. The well-known effects of aconite in allaying the fever, in equalizing the circulation, in promoting a critical perspiration, or diuresis, and putting an end to threatened local inflammation, renders it very useful in this stage of the disease. The disease being consecutive to parturition, and allied as it is in most cases to surgical fever, the earlier this remedy is used the better. My own preference is to give it in the second or third decimal attenuation, and, under these particular circumstan- ces, to repeat the dose as often as every fifteen or twenty to thirty minutes. If the patient suffered extremely during labor, if labor was very prolonged, or if it was completed by instrumental aid, arnica may be used both topically and inter- Arnica. . ,.-.,.. nally. Ihere is no valid objection against alter- nating aconite and arnica for the relief of these symptoms. The arnica should, however, be given at longer intervals than the aconite, and, if you prefer it, in a higher potency. Belladonna has a specific relation to cellulitis, especially if it is of an erysipelatous type or character. In the outset of the attack it may even be preferable to Belladonna. . . . . aconite, providing there is not a very high degree of fever, and the nervous symptoms predominate. Given early and rapidly, it may suffice to avert the inflammation, par- ticularly in the case of nervous and delicate women, with arrest of the lochia, meteorism of the abdomen, throbbing headache, delirium and photophobia. Many experienced and reliable prac- 412 THE DISEASES OF WOMEN. titioners prescribe aconite and belladonna in alternation for the relief of these symptoms, and are of opinion that, thus given, they do most excellent service. Whether or not the same prompt and desirable results could, in this instance, be obtained by the reme- dies given singly, my experience will not enable me to decide. Nor will the experience of any single practitioner settle this ques- tion for you. There is another remedy which I believe to be of incalculable service in the incipient stage of puerperal cellulitis, as indeed it is in puerperal peritonitis also. That remedy is the veratrum viride. Those of you who were present at the meeting of the Chicago Academy of Medicine, held last month (February, 1872), will remember the excellent report of Dr. W. H. Burt, of this city, on the physiological and toxical effects of this poison.* Its wonderful power to control and regu- late the vascular movements, to equalize the circulation, and, as it were, to stamp out a local congestion that would almost inevit- ably result in inflammation, is being recognized by physicians of all schools. My experience, as stated before the Academy during the dis- cussion on Dr. Burt's paper, has satisfied me that this remedy holds some specific relation to the female generative system. Precisely what that relation is, I can not say. But it appears to be especially adapted to the relief and removal of puerperal inflammation. For many years I have been in the habit of pre- scribing it whenever, in a lying-in woman, the first symptoms of pelvic, or peritoneal congestion show themselves ; and, when my directions have been faithfully followed, the result has been most happy. It restores the milk and lochia, when these have been suddenly suppressed, quiets the nervous perturbation, relieves the tympanites and the tenesmus, whether vesical or rectal, and frequently cuts short the attack. When called in season, I have seldom failed to set aside a threatened cellulitis by the same means. My custom is to give it in the second or third decimal dilution. In an urgent case, the dose should be repeated every twenty minutes or half hour, for four or five times successively, and afterwards less frequently. You will find the particulars of some very interesting cases of * See the U. S. Med. and Surgical Journal, Vol. VII, page 268. PELVIC CELLULITIS. 413 erysipelas cured by the local and general use of the veratrum viride in Prof. Hale's work on Materia Medica.* In addition to the faithful employment of one or more of these internal remedies, it may serve a good purpose, and can do no possible harm, to resort to the local use of dry heat by means of hot flannels, or of a dinner plate that has been immersed in hot water, wrapped in flannel and then placed directly over the seat of the pain. Sometimes great good can be effected by applications of towels or cloths wrung out of hot water, and frequently repeated. But best of all is the simple, old-fashioned bran poultice that I have so fre- quently recommended you not to forget in cases of threatened puerperal inflammation of whatever variety. For the stage of effusion, which in many, and perhaps in a majority of cases (as you will be called to them in private prac- tice), can not be averted, a different class of For the stage of effusion. . . remedies are certain to be indicated. Promi- nent among them are apis mellifica, arsenicum alb., bryonia, rhus toxicodendron, digitalis, cantharis, mercurius sol., stibium, helle- borus niger, colchicum and sulphur, which may be given accord- ing to the particular symptoms, or group of symptoms that are present. Concerning the use of the apis mel., which is an invaluable remedy at this stage of the complaint, I am of the opinion that man}^ physicians have failed with it because Apis mel. . the preparation which they have given has not been trustworthy. In 1868, my friend, Dr. J. D. Craig, of Xiles, Mich., sent me a trituration of the remedy which he had prepared and prescribed with excellent effect. His method was to extract the sting of the honey-bee, and its poison-bag also, with a pair of forceps, and then to triturate these with the saccharum lactis in the proportion of two grains of the sugar to one sting. This he called the first trituration, from which others could be made in the usual manner. I have prescribed this preparation in the second stage of cellulitis, and in dropsical disease, with good effect, and can therefore recommend it to you. But, if you desire to facilitate resolution, and to counteract the * The Horn. Mat. Medica of the New Remedies, by E. M. Hale, M.D., etc., second edition, 1S67, page 1053. 414 THE DISEASES OF WOMEN. tendency to suppuration (which indications are identical), it is indispensable for you to put your patient upon a good diet. If the digestion is impaired, and food can not be taken, or tolerated, that disorder should be corrected as speedily as possible. And, when it is remedied, you must see to it that your patient is not starved into the very condition that you wish to avoid. For in most cases of this kind, the quantity of serum effused, the size of the tumor, and the risk of abscess bear a proper relation to the impaired quality of the blood, and to the too rapid destruction of tissue that is going on in the sys- tem. And, unless the patient's strength is fortified against it, you will learn when it is too late, that either a passive, but very extensive, infiltration of serum has taken place, or that pus has already been formed and is seeking an outlet. Under these circumstances, therefore, do not permit the febrile condition to mislead you. If such a result were desirable, a rigid diet would be the very best means of inducing Caution. . . a hectic lever and its attendant symptoms. Jb or the weaker your patient, the greater the liability to fever and to the non-removal of the tumor, excepting through the process of suppuration. In puerperal women, especially, whose strength has been taxed during gestation, and who have survived the mar- tyrdom of labor, there is a strong predisposition to the diathese de suppuration of Trousseau. If you persist in keeping them upon an insufficient aliment, the best chosen remedies will not help you out of the difficulty. Indeed this is one of those condi- tions in which good food may be worth more than medicine. I firmly believe that the patient who was before you at my last lecture, would have died during her first week in the hospital if she had not been properly nourished. Nor do I know of anything that is more beneficial in some of these cases than certain preparations of alcohol. There is no danger of exciting inflammation or fever by Stimulants. . the proper use of the best brandy, or whiskey. Stimulation will be well borne, and may bridge over the chasm. The alcohol acts most beneficially if mixed with some nutrient, as for example, with milk, the whites of eggs, or beef tea. Two or three table-spoonfuls of milk punch may be given every one to four hours, according to circumstances, and continued until the PELVIC CELLULITIS. 415 crisis has passed. Wine will not suffice. The malt liquors will .answer a better purpose farther on. Certain external means may conduce to the same end. I have great confidence in the bran poultice already recommended. It may be applied day and night for an indefinite period. Where the induration, or rather, the tumor is above the brim of the pelvis, an excellent expedient, designed to facilitate its resolution, is the local application of the camphorated oil, which consists, as you know, of gum camphor dissolved in olive oil. The inflamed region should be thoroughly anointed with it, and then covered with a thick layer of cotton batting. If the pain is very acute, and more especially if it is ovarian, one part of the tincture of hamamelis may be added to four parts of hot water, and applied topically by means of a com- press. If the cellulitis is of traumatic origin, arnica may be used in the same way. A blister would de-vitalize the tissues and do positive harm, and so also would the tincture of iodine. Abso- lute rest is indispensable to the cure. The best general rule for the treatment of the suppurative stage is to avert it if you can, but to promote the discharge of pus if you must. If you find that an abscess really is To promote suppuration. forming, no matter where the fluctuation may first be observed, give the patient hepar sulphuris, calcarea carb., mercurius sol., sulphur, or such other remedies as the symptoms may require. Or, if the discharge has already been too copious and long continued, silicea may be prescribed with a view to its arrest. Emollients of linseed meal, slippery elm, or bread and milk, hot fomentations and the hip-bath will sometimes afford relief to the pain and hasten the formation and discharge of pus. Or you may apply warm water per vaginam by means of a syphon, so as to facilitate the same process internally. If the abscess points externally (and it is most desirable that it should do so), it may and should be lanced so soon as it is ready to discharge. Wait until the integument cov- How to open the abscess. . ermg the tumor has softened and become thin ; and be careful to make the puncture as low down as possible in order not to open the cavity of the peritoneum. It is safest to cut close to Poupart's ligament, more especially from the middle por- 416 THE DISEASES OF WOMEN. tion of the ligament outwards, in order to shun the sheath of the? the femoral vessels. Some authorities recommend to make a val- vular incision in opening" these abscesses, in order to avoid the possible in- troduction of the air into the abdominal cavity. Unless there is a very decided fluctuation of the tumor along some por- ion of the vaginal wall or roof, or you are posi- tive concerning the pres- ence of pus therein — from having brought it away fig. 36. The vaginal douche, with the exploring needle — you will not be warranted in opening it per vaginam. For there is danger in such a case of wounding some of the pelvic viscera. But when there is a point of fluctuation, you may puncture very carefully and evacuate it as you would if it were^ ( a more accessible hematoma. It is safer, as in hematocele, to lance such an abscess through the vaginal sep- tum, than from the rectal side of the tumor, because of the greater number of small vessels that are supplied to the latter. Whenever it is possible the sac should be entirely emptied, else a fistula may form and remain. Fig. 37. A vaginal syphon. In suitable cases the abdomen may be opened, the abcess emptied, its margins stitched into the incision, Laparotomy and drain- j xi ji j j j • j mi_ ■ ' • age in. and the wound closed and drained. This is a severe and hazardous remedy, and should not be resorted to without all the precautions and skill that are necessary in the worst cases of abdominal surgery. The contra-indications for the employment of this measure, preceded as it should be by a careful exploratory incision, will be considered farther on. LECTURE XXVI, TEL VIC HEMATOCELE. Pelvic fcasmatocele, clinical history; etiology. Case.— symptoms; diagnosis. Case.— prog- nosis. Case.— treatment, palliative, (Case,) medical and surgical. Cases. Definition and clinical history. — An hematocele is a tumor composed of blood that has been effused, and which has become more or less solid. A pelvic hematocele is a Definition and vane- bl d tumor that has been formed within the ties of. pelvis, and which, both from its origin and loca- tion is connected with the internal generative organs. Various qualifying terms have been applied to these tumors, as for example, they are called peri-uterine, because they are outside of the wonib, but in its immediate vicinity; retro-uterine when they are in the Douglas' space; vesico-uterine when they are located anteriorly, between the uterus and the bladder; intra-peritoneal when the blood of which they are composed has been poured into the peri- toneal sac ; and extra-peritoneal when it has been emptied into the cellular tissue. The intra-peritoneal variety has also been styled the true and the encysted hematocele, in distinction from the false, the pseudo, the non-encysted and extra-peritoneal hematocele. Some writers call the latter a thrombus. By drawing a parallel between the recto-vaginal fold of the peritoneum, in women, and the tunica vaginalis testis in men, Bernutz concludes and insists that true hematocele can only take place within the peritoneum. But these qualifying terms only serve to indicate the accidental location and anatomical relations of the tumor. Xeither of them is sufficiently comprehensive to include the whole subject, nor do they represent so many varieties of the same affection. For this reason we prefer the general term pelvic hematocele. Let me observe in the outset, that a hematocele is not a disease per se, but a contingent of certain intra-pelvic disorders, as for example, of amenorrhcea from cervical occlusion, menorrhagia and 417 i 418 THE DISEASES OF WOMEN. metrorrhagia, abortion, extra uterine pregnancy, and pachy-peri- Not a disease per M toi ^is. It is always either a secondary, or an accidental affection, but it is none the less im- portant on that account. Indeed, it is a very serious condition, and therefore I am anxious that you should have a clear and prac- tical idea of its pathology and treatment. The clinical history of pelvic-hematocele is consequently varied. Its advent, its course, its complications and its final result wiL 1 depend upon the nature and severity of the Its clinical history is v ilu • ' • i • 1 «.l • n not constant. disease or the injury upon which it is secondary. It Avill also be modified, in a manner at least, by the general constitution of the patient, by the hemorrhagic diathesis, and by the slowness or the rapidity with which the effu- sion and the extravasation of the blood has taken place. Etiology, — The causes of pelvic hematocele are predisposing and exciting. In many cases a plethoric condition of the system, with a tendency to a profuse and prolonged menstrua- Predisposing- causes. . „ tion precedes the attack. A copious now of the menses predisposes to hematocele when that flow is intermittent and very irregular. Sometimes those women who tor some cause are anaemic, or in a state of chloro-anemia, are Catamenial disorders. ,.,,..,«, A . r , liable to the formation of these peri-uterme tumors. This is especially true in case the condition of the blood has induced an attack of amenorrhcea. Briefly, whatever consti- tutional or local causes is capable ot arresting or deranging the catamenial function may incline the patient to this affection. Marriage seems to have no influence in the production of this disease, at least in so far as the proper marital relation is con- cerned. Hematocele may and does arise, however, from sexual excess, and also from abortion, from extra-uterine gestation, and even from labor at term, but this can- not be properly charged to the marriage relation as a predisponant of hematocele. Ao;e has its influence, for we find that attacks of this disease are comparatively more frequent among those whose sexual vigor is most pronounced, and at a period of life when it Age and sexual vigor. . is most active. Inis period extends from twenty to thirty-five years of age. Women of an hemorrhagic diathesis are more prone than others PELVIC HEMATOCELE. 419 to this accident; for this state includes a weak and varicose con- dition of the veins, not only in the lower ex- The hemorrhagic tr emities and in the external parts, but also of diathesis. A the internal organs and surlaces. Clinically there is very little difference between a varicose condition of the hemorrhoidal veins and that of the utero-ovarian vessels. And, when either of them is ruptured there will be an escape of blood from the anus, or an extravasation of it within the pelvis, accord- ing to the location of the lesion. The blood itself may become so depraved in quality as a result of the zymotic diseases, like scarlatina, v r ariola, diphtheria, malig- nant jaundice, or purpura, as to incur the risk of its effusion or transudation from the free sur- face of the inflamed peritoneum. For in this class of cases we may have a hemorrhagic peritonitis as well as a hemorrhagic pleurisy. Pelvic peritonitis may predispose to pelvic hematocele by reason of the adhesions and false membranes which have been formed during its course. These sequele are not directly, Pachy-peritonitis. ., n . , _ or necessarily, of a serious character: but, as Virchow and Bernutz have shown, there is a possibility that the delicate vessels which ramify upon these neo-membranes may be ruptured, and a haemorrhage result. This is what is understood by pachy-pelvi-peritonitis as a preclisponant of hematocele. Those of you who are interested in the study of this peculiar sub- ject will find the remarkable monograph by Bernutz in the Ar- chives de locologie, des Maladies des Femmes, etc., for March, April and May, 1880. The exciting causes include various traumatic injuries, as for example, blows upon the abdomen, falls upon the buttocks, the effects of jumping and of beino; thrown from a The excitin" causes. *"" carriage, and rough riding on horseback, especi-* ally when these are applied during the menstrual epoch. Voisin reports several cases that were due to the indulgence of coitus during menstruation, and other writers have attributed it to a violent shock or fright during sexual intercourse. It may some- times be caused by lifting, by straining at stool, by over fatigue, intense mental emotions, or by too early exercise after an abortion. Nonas reports two cases in which it was caused by the use of cold 420 THE DISEASES OF WOMEN. injections during menstruation ; and others have known it to arise from the application of cold sponges and compresses to the vulva during* the monthly flow. Whatever is capable of arresting this periodical discharge very abruptly may precipitate this form of internal haemorrhage. The resort to vaginal and intra-uterine injections for the relief of men- orrhagia, or to stop the flow after an abortion, may have the effect to turn the tide the other way, and to cause an accumulation of blood within the peritoneal or the cellular tissue of the pelvis. The same is true of the use of the sponge tent for plugging the cervix uteri, and of the tampon, when the uterus may fill with blood and force an outlet through the Fallopian tubes into the peritoneal cavity. It has been suggested that the menstrual blood, after having- been retained in utero for a greater or less length of time, might- be very poisonous when brought into contact with the peritoneum. Pure, healthy blood, it is said would not induce peritonitis ; but, if the blood was depraved, either in the general circulation, or when it came into the peritoneal cavity from some special source, it would be very likely to cause septic infection, as well as a serious inflammation. There are exceptional cases in which hsematocele evidently results from a partial or complete stenosis of sJno^s? erVlCal the cervix uteri * We have hacl one of these under our observation for three.years past. The facts were as follows : Case. — Mrs. , aged twenty-eight, a slender, delicate woman who had been married for six years, but without offspring, and with no history of an abortion, consulted us for the relief of a very severe headache to which she had been subject much of the time since her first menstruation at the fifteenth year. Of late, the headache had become decidedly menstrual, anticipating the flow r some twelve or twenty-four hours, and being always somewdiat relieved by it. But the monthly discharge was so scanty and escaped with such a stillicidium, that she felt satisfied that the retention must have something to do with her suffering. She had long been subject to haemorrhoids. I gave her remedies for some time, but without effect, and finally obtained permission to make a careful internal examination of the uterine cervix. She would not consent to this until she had satis- fied herself that quite recently, indeed at her last period, she had PELVIC HEMATOCELE. 421 felt something quite wrong and unusual within the pelvis. I felt the conical cervix crowded forward towards the symphysis pubis by a retro-uterine tumor, that was of irregular form and doughy to the touch. Around its outline the tissues were very tender. Unfor- tunately, I could not know how long this state of things had •existed. The tumor was bi-lobular, with a kind of sulcus between the lobes that could easily be felt by the rectal touch. This sulcus, indeed, corresponded in shape, size and direction with the rectum itself. She had had a great deal of sacral pain, and of dragging in the hips and the loins, but the bowels were regular. The sacral distress was usually very severe at the month. There was an almost complete stenosis of the uterine cervix, and only the smallest sound could be passed through the internal os uteri. With the absence of the signs of pelvic cellulitis, and of an uterine fibroid, the case was diagnosticated as one of menstrual hematocele, due to a reflux of blood from the uterine cavity. A careful dilatation of the uterine canal was begun and continued throughout the inter-menstrual period. "When the month came around, the flow was much more free, and she had very little head- ache. The strictest quarantine and rest were enjoined for a week during the period, and then the careful dilatation of the cervix was resumed. In three months the menstrual trouble and the headache had vanished, and, by a free coffee-ground discharge from the rectum, the tumor had almost entirely passed away also. For the last two years she has been quite well. The intra-peritoneal haemorrhage in hematocele has been attrib- uted to various sources. Thus, Bernutz ascribes it to menorrhagia with a regurgitant flow of the menses through the rh S a g u J ceot ' thehfemor - oviduct:^ Xelaton, to the rupture of a Graafian follicle, and the gravitation of blood into the retro-uterine pouch : Virchow, to the rupture of the newly-formed vessels in the false membranes that have resulted from a local peritonitis: Peuch, Bichat and Devalz, to a rupture of the utero- ■ovarian vascular plexus; Tilt and G-enouville insist that it comes from the ovary; Trousseau and Tardieu, to a sanguineous exhal- ation from the peritoneum; Tyler Smith, to an ovarian or Fallo- pian menstruation, which is vicarious in character; and Gallard to the escape or dropping of the ovum into the peritoneal cavity, or in other words, to the detachment of the ovum in extra-uterine gestation. Other causes that have been noted are a rupture of the Fallopian tube and of the ovary, the detachment of the fecundated ovum in 422 THE DISEASES OF WOMEN. tubal pregnancy, and the sudden arrest of the lochia after confine- ment. Symptoms. — As a rule, the more sudden the attack and the greater the loss of blood, the more likely is the tumor to be of the non-encysted variety. For a slower and more scanty extravasa- tion within the peritoneum is almost certain to excite an adhesive peritonitis, in consequence of which, the walls of the haematic cyst are formed. So that, while the immediate danger corresponds with the suddenness of the attack and the profuse escape of blood, in the former case, in the latter, the pain and local suffering are the most pronounced. The symptoms are local and general. The pathognomonic sign is found in the presence of a tumor which is located at some por- tion of the roof of the vagina. The physical characters of this tumor, when it is large enough to extend above the pubis, or into the iliac region, are dullness on percussion, irregularity of outline, tenderness on pressure, partial Local gymptoms. Fig. 38. Clover-leaf form of hematocele,, or complete fixity, and elasticity with a sense of fluctuation which soon gives place to an unequal density, (like the tumor of pelvic cellulitis.) When this tumor rises above the superior strait, it may take the clover-leaf form, as seen in this drawing. The signs per vaginam are the recognition of the base and inferior outline of the tumor; the dislocation of the cervix, forwards, back wads, or laterally, PELVIC HEMATOCELE. 423 by the pressure of this foreign body; great tenderness on pres- sure in one or all of the culs-de-sac; and immobility ol the tumor and of the uterus. The largest tumors are almost always intra-peritoneal, and are naturally retro-uterine. The smallest are at the anterior cul-de- sac, because the vesico-uterine pouch, except in advanced preg- nancy, is too shallow to contain a large quantity of blood. The more prolonged the stage of fluctuation in the tumor, the greater the certainty that its outline is not limited by tumo 1 ?^ SiZG ° f thG a cyst-wall, and the greater the probability that the effused blood is impoverished and lacking in fibrine. The conjoined manipulation and the rectal touch are very useful in detecting these haematomata. Voisin's* description of the mode of formation of these tumors is very graphic : " When blood escapes ^rom the ovaries, the tubes, or the uterus, it tails naturally behind the broad ligaments ihe?um°o f r. f0rmati0n0f illto the retro-uterine peritoneal space, limited before by the broad ligaments and uterus, behind by the rectum and lateral folds of the peritoneum, — on all sides by serous membrane. Above, the cul-de-sac is open, and commu- nicates largely with the rest ol the abdominal cavity. In some rare cases the blood is carried in part into the vesico-uterine space, but in a very small proportion compared with the mass extrava- sated behind the uterus. Hardly have some drops of blood pene- trated into the serous cavity than it inflames. This inflammation results in speedily establishing adhesions between all the pelvic organs, or rather between their peritoneal covering's. The coils of intestine are pushed upwards by the extravasated fluid, or rise upward by their own lightness. The collection of blood encysts rapidly, thanks to the energy of the inflammation of the serous membranes and the formation of cellular adhesions. The sides of the tumor are then limited, before by the broad ligaments, behind by the rectum and peritoneum, below by the recto-uterine cul-de sac, above, by the coils of intestines which, by their adhesions to the fundus uteri, the broad ligaments, the ovaries, the tubes, the round ligaments, and the peritoneum which covers the lateral parts of the pelvis, forms for the cyst a sort of resisting roof." The uterus may or may not be moved independently of the tumor. Not unfrequently it is in a state ol subinvolution. If the retro-uterine tumor is large and dense, the cervix may be pushed *Del' Hematocele Retro-Uterine, Paris, 1860. 424 THE DISEASES OF WOMEN. Fixation of the uterus. behind or above the pubis, and the rectum obliterated. If the ante-uterine tumor is large enough, the fundus and body of the womb may be retrovertecl. If the effusion has taken place on all sides oithe uterus, that organ may be fixed as in a mould or cast when the tumor begins to harden. Ketro-uterine haematomata may distend the Douglas cul-de-sac until it reaches the floor of the pelvis, or by pressure may induce an infiltration of the recto-vaginal septum. It is very rare to have more than one of these haematic tumors in the same patient. (See Figs. 39 and 40.) In some cases these tumors diminish in size from time to time. If we can prevent a repetition of the flow, especially in menor- rhagia, they will shrink as they become more solid, until finally they are removed by absorp- tion, cr by their suppuration and discharge through one of the pelvic outlets. This fact may be confirmed by means of a care- ful bi-manual examination repeated now and then. Changes in the tumor. Fig. 39. Intra and extra-peritoneal hsematocele. If the haemorrhage happens to occur when the rectum is loaded with faeces, the tumor may be moulded into such a form as after- PELVIC HEMATOCELE. 425 Form of the tumor exceptionally. wards to exempt the patient from rectal tenesmus, which usually is one of the most distressing symptoms in retro- uterine hematocele. And strangury may also be lacking as a symptom if, during the solidifi- cation and encystment of the tumor, the patient has invariably Jain upon her back. Pelvic hematocele is so often related to menstrual disorders lhat the first symptoms are generally connected with amenorrhoea, menorrhao-ia or dvsmenoiThcea. If a copious General symptoms. ° " menstral now is suddenly arrested, and a hema- tocele results, its onset will be very abrupt; but if the menstrual flow escapes very sloAvly, drop by drop, the tumor may develop gradually, and the general symptoms will come on imperceptibly. In the former case the sudden shock as well as the loss of blood, may induce fainting and prostration. In both conditions, when the hematic tumor is formed, the external flow ceases. Fig. 40. Intra-peiitoneal haeimito; e'.e. The larger the' size of the tumor, the greater the amount of blood eftused, and the more sudden the attack, unless in very exceptional cases, the less marked are the sio-ns to ^ s coincidentperi - of a coincident peritonitis. And hence, at the very beginning, the pain is not always a criterion of the gravity of the case. If the attack has come on slowly, or 426 THE DISEASES OF WOMEN. the extravasated blood has been poured into the connective tissue, or into the peritoneal sac, when those parts are already inflamed, the suffering w 7 ill be very severe. Large accumulations give rise to great suffering, how- ever, when they have existed for a little time. The pain, which is perhaps more agonizing than even a woman is called upon to endure, under other circumstances, is located about and within the pelvis and the lower abdomen. Sometimes it is paroxysmal, and partakes of the character of labor pains ; again it is confined to the sacral region, and is referred to the rectum, where it causes an insufferable tenesmus. In some cases there is a distressing strangury, and in others an absolute inability to stand. But this pain, wherever located is excrutiating in char- acter, lancinating, expulsive, or neuralgic, with a feeling as if the intra-pelvic tissues were being torn and lacerated. If the attack has been very abrupt and severe, there will be loss of blood and such a shock to the nervous system as to induce syncope and collapse, with coldness and pallor Other symptoms. _ . _ . . , , . . , . ol the surface, pinched features, hiccough and vomiting, and an almost imperceptible pulse. These symptoms bear a pretty constant relation to the amount of^ blood that is effused, and may be so overwhelming as not to be followed by reac- tion. Their suddenness and gravity are like those which are due to perforation of the bowel in typhoid fever. A very remarkable case of this kind was reported to the Clinical Society of our Hospi- tal last year by Dr. E. F. Baker, of Davenport. In milder cases the suffering is mitigated after a few hours y but, in consequence of increased effusion or of an extension of the peritoneal inflammation, it is likely to return. ^ mid and relapsing Exceptionally there is a relapse at each return- ing menstrual period. When the effusion is gradual and is limited to the pelvic cellular tissue, the suffering may be comparatively slight; indeed, there is reason to believe that, through the good results of menstrual quarantine, many of these cases pass without recognition. The remaining general symptoms are those of pelvi-peritonitis ; and they are modified as the case passes through the different stages of resolution, suppuration, and discharge. The digestive disorders, more especially the bilious vomiting and loss of appe- PELVIC HEMATOCELE. 427 tite, are limited to the first stage of the affection, but, for mechan- ical reasons, dysentery, or a dysenteric diarrhoea, symptoms in the . ]ikel t b ; developed. The fever varies ac- later stages. _ J l cording to circumstances. If the pain and the peritonitis are marked, the temperature and the pulse will be increased; but, if the haemorrhage has been great and sudden, the temperature will be low and the pulse feeble. When the duration of the disease is prolonged, a marked and persistent anaemia is developed. The color of the skin resembles that of chlorosis, and because of occasional or periodical relapses of the disease, it may become permanent. The coincident peritonitis may increase or continue until it becomes suppurative, and an abscess may form about the haematic cyst. The accompanying symptoms will include the signs of the suppurative form in addition to those of haematocele. Diagnosis. — In a differential way it is more difficult to distin- guish between a pelvic abscess, or pelvic cellulitis and pelvic haematocele, than between haematomata and any iius r .° m PGlViC CeUU " other class of P elvic tumors. ll1 m y lectures on pelvic cellulitis, I have already given you the signs by which we separate these two diseases. This is a very import- ant subject and one that merits your careful attention. The great Nelaton, mistaking a pelvic abscess for a pelvic haematocele, punc- tured the tumor through the posterior wall of the vagina, and discharged an immense quantity of pus instead of blood. Nor is it always easy to avoid confounding this disease with uterine fibroids. The chief points to remember are that in haema- tocele the tumor forms and orows rapidly ; that From uterine fibroids. ' . t i its formation is accompanied by grave constitu- tional symptoms; that the tumor is regular in its outline, and soft to the touch, growing more dense as time goes on ; that its presence causes the most intense suffering which may continue, or repeat itself; and that, if it is retro-uterine, it displaces the uterus upwards and forwards as no other pelvic tumor is likely to do. The very opposite is true in the case of uterine fibroids, for they are of slow and gradual growth, without any special or dangerous constitutional symptoms; the tumor is more or less irregular in outline, and hard from the first; its presence is tolerated without severe pain, and it does not displace the womb in any particular direction. 428 THE DISEASES OF WOMEN. Although these differential symptoms may appear very plain and quite sufficient, great care is requisite in deciding between these two affections. For the celebrated Malgaigne, of Paris, and the no less distinguished Stoltz, of Strasbourg, each mistook a pelvic hematocele for a uterine fibroid. The former did not dis- cover his error until (in 1850) he had made an incision into the os uteri with the intention of enucleating the tumor; and Stoltz, was so confident of his diagnosis, that he made his patients' case the subject of several lectures upon fibrous tumors of the uterus. In the latter case the existence ol the hematocele was not dis- covered until 1he autopsy was made. Bernutz and Goupil could not decide, in a case at the Hotel Dieu, whether it was an haematic tumor or a uterine fibroid; and several cases are on record in which a larg-e haematocele was mistaken for an ovarian cyst. Indeed, in one case, recorded in ^ jjg Mr- aM _ M j ig^» the Transactions of 'the Lon- /^^ - ■ -£jp don Obstetrical /Society, the H % ~~"~jk /^^^l °P era ti° n tor ovariotomy ^Ara: |lif Jjf was actually begun under «l ^ P ' r ^ ^ig^r a misapprehension of this If we except the very rare cases of ovarian tumor in which there is a haemorrhage within the cyst, there should be no danger ot mistaking a case of pelvic hematocele From ovarian dropsy. P ™ . . . . tor one ot ovarian dropsy. I lie history ot the case, including the mode of formation of the tumor, the incidental suffering, the constitutional symptoms, the menstrual or puer- peral complications, and finally, the tapping of the tumor will enable us to decide between them. Extra-uterine gestation is always accompanied by some of the signs of pregnancy ; the tumor is of slow growth,andis generally painless. If the vascular attachments of the ovum are not From extra-uterine brok th . RO raye constitutional Symp- pregnancy. ' o j l toms ; but if they are ruptured, we shall have symptoms of pelvic haematocele superadded to those of extra-uterine pregnancy. Case. — In a very remarkable case of this kind to which I was called in consultation in December 1879, by my friend Dr. Thomas Fig. 41, The aspirator. PELVIC HEMATOCELE. 429 Fig. 42. Drawing- of an hematic tumor resulting from a rupture of the sac containing TorWvZVeZlZrT 11 ^ T , MS tUm ° r W3S Sh ° Wn t0 ^CoUe^e and HospS TcZ Rnw«I t V S ltS removaL The f acts as illustrated were also confirmed by Drs ope"S n LUngren ' Parmellee ' and ° thers ' who were P-sent and who assSted ta the PELVIC HEMATOCELE. 431 Bowsey, of Toledo, Ohio, the pregnancy was ovarian, and the sac and its attachments had been ruptured at the eighth week, with a resulting hematocele of the right broad ligament. Even at so early a period, Dr. Rowsey had very skilfully recognized the case as one of extra-uterine gestation, and when the rupture took place and his patient was in great peril, I was sent for to decide upon the exp3cliency of an operation for the removal of the tumor. We determined upon gastrotomy, and found the right broad ligament to be the seat of an haematic tumor larger than my fist, at the upper and inner angle of which the dark blood was oozing into the peritoneal cavity. The sac upon the right ovary had been ruptured and was filled with soft blood-clots, and the embryo with its rudimentary cord was immersed in fibrinous clots, and fluid blood. The whole mass ;was carefully removed by the ecra- seur, taking the broad ligament along with it. The patient re- acted well, but for some unknown reason, since a post-mortem was not held, she died on the third day. (See Fig. 42.) The diagnosis of retro-uterine hematocele from retroversion of the uterus is made out quite readily. The signs revealed by the conjoined manipulation ; the possibility of lift- From retro-version - tfa tmnor the ab sence of the agonizing of the uterus. fa ' . fa - fa peritoneal pain, and of the vomiting and the collapse of hematocele ; and the confirmation of the displacement by the passage ot the uterine sound or probe, enable us to detect the uterine deviation with a good degree of certa'nty. In doubtful cases, and as a last resort, the exploring needle or the aspirator may be called into requisition to settle the diagnosis. But these instruments should be used with the «3SS!!»*"««« ta8t care, and not indiscriminately. They are most decidedly contra-indicated if the tumor is very large, and if its contents do not solidify. If the tumor is very hard they reveal nothing ; and even when it is soft the fluid may be t^o thick to run through the canula of so small a trocar. If upon the withdrawal of the instrument a few drops of pus are brought away we shall know that the case is one of abscess with or without an hematocele. I have already shown you the aspirator. (See Fig. 41.) The needle, or the trocar, after being carbolized, should be passed on the vaginal side of the tumor. Prognosis. — If the effusion is slight and the tumor is circum- scribed ; if the accompanying peritonitis is local and adhesive ; if the general condition of the patient is good, and the attack does 432 THE DISEASES OF WOMEN. not repeat itself too often, a gradual recovery is the rule. This result is likely to happen in the extra-peritoneal, or cellular variety, more especially if the collection of blood is not so large as to break through into the peritoneal cavity. The latter form of the haematic tumor is, however, very likely to terminate in abscess. But if the patient is of an hemorrhagic diathesis, and the loss of blood is sudden and large : if the shock and collapse at the onset of the attack were pronounced and the reaction intense; if the tumor continues soft and flabby, the pulse weak and feeble and the appetite poor; if the anaemia continues, and the chlorotic hue does not give place to the florid complexion; if the attack was menstrual, and there is a probability of a relapse at the next or subsequent periods; if the rupture was tubal, ovarian, uterine,, or the consequence of an extra-uterine pregnancy ; if the case is complicated with diffuse peritonitis, more especially if it is puer- peral ; or if there is a concurrent suppuration, or a consequent cachexia, the prognosis is generally unfavorable. Even in chronic cases where these haematomata empty their contents into the rectum there is danger that the haemorrhage may be renewed and become so excessive as to be beyond control. I ought, however, to say that of late, unless they are over-whelm- ingly fatal in the first stage, cases of pelvic haematocele are more readily controlled than in former times. This result depends upon our having a more correct idea of their special pathology than was possible twenty years ago. And, consequently, upon our know- ing enough to avoid the added dangers of a mischievous interfer- ence with what we do not understand. Treatment. — The treatment is palliative, medical and surgical. Absolute rest, to be enjoined, not only because it gives compara- tive exemption from pain, but also because it is Palliative treatment. . . n , the best means of preventing an increased enu- sion of blood, or a relapse. The patient will choose the position which is most easy, and she should be permitted to keep it. It may be necessary to insist that she shall remain in bed through two or more consecutive menstrual periods. And not only should she be kept quiet, but the bowels should be at rest, and not wor- ried by cathartics, or even by enemata. I have known a case in which a relapse of an haematocele was induced by strangury. For PELVIC H2EMATOUELE. 433 a lono- time after an attack of this disease sexual intercourse should be strictly forbidden. In serious cases it becomes a question whether our dislike of opiates should notyield to our desire to relieve the terrible suffer- ing that is incident to the haematic tumor. If we had a remedy or remedies exactly suited to all the symptoms in the case, and if the ill effects of the narcotic were not more than counter- balanced by the rest that it brings, and the consequent exemption from an increased extravasation of blood, I would advise you never to resort to morphine in this class of cases. You may get along without it if you can, but, the tact is that in very bad cases you will be forced to give it, although under protest. Other means of assuaging the pain and of preventing an increased effusion ot blood are to resort to hot water injections per-rectum, or per-vaginam. You may add two tablespoonfuls of the mother tincture of hamamelis to a pint of very warm water, and throw it into the rectum or the vagina. Or compresses wet with the same solution may be applied over the pubis and the vulva with good effect. Some authors prefer cold instead of warm applications and injections. In this case cold water, and even ice water may be thrown into the rectum as a means of arresting the haemor- rhage ; and the same may be applied locally to the lower portion of the abdomen and to the pubic region. For the immediate relief of the collapse such stimulants as whisky or brandy, milk punch, or egg-nog, with inhalations of camphor, or ammonia may be servicable. If at the same time the pain is very severe, a few whiffs of the nitrite of amyl may bring relief and the much needed repose. The medical The medical treat- treatment, as stated by Jousset, is included in three principal indications, viz., (1) to limit and overcome the serous inflammation, (2) to favor the absorption of the effused blood, and (3) to prevent a repetition of the haemor- rhage. The first of these indications is to be met by the remedies of which I have spoken in my lecture on pelvi-peritonitis. They are aconite, belladonna, colocynth, rhus tox., and terebinth, to which may be added china, ipecacuanha, secale cor., arsenicum, thlaspi bursae, hamamelis and digitalis. Here are the notes of an interesting case to which I was called in consultation some weeks ago by my friend Dr. E. Gr. H. Miessler, of this city. 431: THE DISEASES OF WOMEN. Case. — Mrs. G., aged 33 years, of bilious temperament and of a weak constitution, enjoyed good health until she was married, which was ten years ago. From a continued exposure to wet and cold (her lot was to assist her husband in a butcher shop) she contracted rheumatism, which not only caused her very severe pain at times, but made her lame and wretched. At the end of the second year of her married life she gave birth to a premature child, which labor occurred in the eighth month. From want of proper care and assistance this accident gave rise to some severe pelvic trouble, which resulted in sterility from obstructive dysmen- orrhcea and general debility. About the middle ot September I was called to relieve her if possible of her pain and lameness as she was not able to move about. All of her symptoms were of a rheumatic character, for which I found bryonia 3, was well indi- cated. The pains were worse on motion, and better at rest, with thirst for cold drinks, and constipation. Sept. 19 was called again. The following statement was given by the patient herself. She felt greatly relieved from her pain and lameness — was able to move about and do her work. On a cold rainy day, and while menstruating, she did her washing and took cold. Her chief complaints were severe excruciating pains in the left ovary, and in the back, across the kidneys. Pulsatilla and belladonna 3 were given in alternation, and hot bran- poultices were ordered to be applied locally. There was but slight fever. The next day the ovarian pains were somewhat relieved, but the pain in the back was more severe. It was not a constant pain, but paroxysmal, and seemingly aggravated by flatulency. There was nausea and vomiting, with a yellow-coated tongue, loss of appetite, thirst, restlessness and headache, tenes- mus, ccnstipation of the bowels. A vaginal examination revealed some swelling along the posterior wall of the vagina, which was very sensitive to the touch, the pain being made very much worse by straining at stool. Nux vomica and lycopodium 3, to be given alternately, and also an injection of warm soap-suds, but all in vain. Sept. 20. No better, but rather worse. Pulse 120 — tempera- ture 102° — more swelling, and all the symptoms aggravated. Sept. 21. There is an aggravation of all the symptoms. Pulse being 120, temperature 102°, the tumor being larger and more painful. The same treatment was continued. Sept. 22. The patient having had a very restless night despaired of her recovery, and expressed a desire to have another physician called in consultation, to which I willingly consented, and Dr. R. Ludlam was sent for. He made a careful examination and approved my diagnosis, that it was a genuine case of retro- uterine hematocele. It was thought best to hasten suppuration by injecting water as hot as it could be borne, and to give hepar PELVIC HEMATOCELE. 435 sulph. internally. The hot water injections, which were to last from ten to fifteen minutes at a time, and to be repeated several times during the day, gave great relief. On account of the great pain, caused by the flatulence, and the fearful tenesmus, lycopodium, nux vomica, and mere. sol. were successively given. After two days more of suffering, a very offensive matter of a dark brown color escaped by the rectum, which gave decided relief. Then for a day the discharge was very profuse. It gradually lessened in quantity, but lasted about five days. As the tumor discharged its contents, all the morbid symptoms disappeared, and the patient made a good recovery. The surgical treatment consists in discharging the contents of the tumor either by incision or by tapping. The former method is proper and expedient only when the tumor The surgical treat- j m ^ ^j, accessible> The latter is the merit. J common method of discharging the cyst. In our day these tumors can be tapped with the aspirator much more safely than was possible with the old-fashioned trocar. But still the operation is not devoid of danger, and is strongly contra- indicated in certain conditions. Thus it would Contra-indicationsfor not b gafe Qr expedient while the e ffused blood tapping. ... continues in the fluid state, without being encysted, nor while the size of the tumor continues gradually to diminish and the patients condition to improve, nor if the source of the haemorrhage, being catamenial and dysmenorrhceal or obstructive, still remains to reproduce the difficulty. Most authori- ties have regarded it as an " extreme resource." But, if the tumor has existed for a long time, and shows little or no disposition to be absorbed or to disappear ; if the original cause of the haemorrhage in such cases is no ^indications for tap- longer - n operation . if there is a very large accumulation, which is not too recent, but which causes great pain and pressure, with forcing pains like those of labor; if there are rigors and signs of suppurative fever; if the symptoms are those of septic infection, or typhoid in character, with a hyperthermic condition, there should be no delay in evacu- ating the tumor. I am opposed to putting it off very long, for when properly used it gives great relief and expedites the cure. Some authorities, remembering that Nature most frequently discharges these tumors spontaneously through the rectum, insist that they should be tapped from the rectal side. But this is not 436 THE DISEASES OF AVOMEN. important. We select the most dependent part of the pouch, anc£ discharge it with a large-sized aspirator trocar. Fig. 43. The aspirator. A safer resource in the hands of an experienced gynecologist is to open the abdomen, empty out the accumula- Laparotomy, washing . • . • i i i • i m and drainage in. tion, tie any bleeding vessel, remove the ovary,, or the wounded tube, if necessary, wash out the abdominal cavity and close the wound with careful drainage. LECTURE XXVII. CERVICAL METRITIS. -Acute Cervical Metritis ; Chronic Cervical Metritis ; Corporeal cervicitis and scanty menstruation. Of late the subject of the inflammation of the uterine cervix has attracted more attention than ever before. Its diagnosis and treatment are very far from being perfect, but the case that I shall show you upon the table, and my remarks upon this form of inflam- mation in my general clinic will give you a practical idea of this very important subject. For, as there will be no lack of these cases in your private practice, wherever you are located, it is my duty to familiarize you with the different forms of cervical metritis. ACUTE CERVICAL METRITIS. Case. — Mrs. , aged 35, the mother of three children, the youngest of which is six years old, relates the following story: Eight days ago, at the proper time, the menses made their appear- ance without any unusual symptoms. On the same morning she commenced a five days' job of work upon the sewing machine. At the close of the first days' labor the flow ceased for some hours, and then, after a foot-bath and a night's rest, it returned. On the third day there was another intermission in the menstrual discharge, and on the fourth clay it ceased entirely — two days sooner than usual. She now complains of headache, with slight vertigo, the face is flushed, the pupils are somewhat dilated, noise worries her, and she cannot bear the light. There are cutting, darting pains in the upper portion of the thighs and across the hips. These pains are Avorse on motion and while standing upon the feet. She also has a burning, bearing-down pain, within the pelvis, some stran- guary , and great discomfort. She is very nervous and apprehensive. The " touch" reveals the os uteri patulous, the cervix swollen, hot, dry, and exquisitely tender. She cannot bear the least pres- sure upon it. The womb lies very low in the pelvis, so much so that when she stands upon her feet it rests upon the perineum. Examination with the speculum shows the tumefied and tender 437 438 THE DISEASES OF WOMEN. cervix to be congested and more than twice as large as natnral T but there are no signs of abrasion, neither of ulceration. The epithelium covering its vaginal portion is intact, and there is no- unnatural discharge from the external os uteri. This is a case of acute inflammation of the neck of the womb. Writers describe two varieties of cervicitis — one in which the substance, or parenchyma of the uterine cervix is the seat of the inflammation (cervical metric tis), or areolar hyperplasia (Thomas); another in which the inflammation is limited to the mucous membrane that covers the vaginal portion and lines its canal (cervical endo-metritis). These diseases are so frequent and troublesome that you will need to study their clinical history most carefully. Cervical metritis is very rare in those women who have not given birth tcf one or more children, either prematurely or at term. Indeed the most powerful predisponent of this Rare in nulliparae. , . . disease is found in the changes which are inci- dent to the uterine cervix during the middle and later months of gestation. The virgin cervix is firm and fibrous, almost cartilag- inous in texture. Its vascularity is not at all pronounced, its dil- atability is scarcely sufficient to permit the ready exit of the menses. But the modifications which it undergoes during preg- nancy change the consistence of its tissues, not temporarily, but, in a sense, permanently. The contraction and involution which follow delivery do not restore the unyielding nature which is proper to the virginal cervix, and thenceforth we find it liable to diseases from which it was exempt before. One of the most frequent of these affections is acute cervical metritis. And all of its exciting causes produce a more decided and damaging effect if they are applied at or predisponent 1117 cyde a about the time of the menstrual return. It is. possible that this woman might not have expe- rienced any ill consequences from the same kind of exercise had it been taken at another time. But, she " did not think,' ' — a very common infirmity with patients as well as with their physicians — and therefore, she set to work the very day the flow began, intend- ing to persevere with it during the " period." Much has been said and written of the sewing-machine as a cause of uterine disease. I apprehend that it is the abuse, instead CERVICAL METRITIS. 439 of the proper use, of the machine that works the mischief in those who run it. The trouble is that, with most utfSnl n disTa a s C e h s mes and housekeepers, it offers such a ready and expe- ditious means of doing the family sewing that they are tempted to postpone this labor until it has accumulated for weeks, and perhaps even for months. Then they go to work for days and nights consecutively, in order to despatch it, and to " get it out of the way." The instrument itself may be as inno- cent as the piano. It is this habit of playing upon it, or rather of working with it, continuously for hours and days together, that does the harm. If the same work were properly distributed, as our wives and daughters " practice " upon the piano — not as a business, but as a recreation and diversion, the result would doubtless be very different. In the case of those women, how- ever, who are obliged to sit at the sewing-machine from morning until night each day in the week, in order to obtain a livelihood, it is almost impossible for them to escape certain functional and organic diseases of the womb. Whatever tends to wound, bruise, or irritate the neck of this organ may, in those who are predisposed to it, give rise to cervi- cal metritis. Too violent exercise, as horseback mSritis S ° f acute cervical riding, or riding in a rough carriage or car , misplaced, or badly -fitting pessaries ,' too forci- ble and excessive coitus ; prolapsus, and the various flexions of the uterus , standing for too long a time upon the feet, as in the case of female clerks in our shops and stores, and of ladies at fashionable parties ; a sudden arrest of the menstrual flow ; and the extension of the inflammation in cervical endo-metritis from the lining membrane of the uterine cervix to its parenchymatous structure, are among the more common exciting causes of this disease. You will readily understand how it is possible for either of these causes to develop this form of metritis by converting the physio- logical injection of its structures, which is nec- res^i°ts e ° f operation and essary to their nutrition and also to the men- strual function, into a pathological congestion thereof. A local arrest of the circulation, a temporary sluggish- ness, or stasis of blood in its loose, connective, dilatable tissue, represents the first step in the inflammatory process. What the 440 THE DISEASES OF WOMEN. result of this engorgement will be we can not say beforehand. If the cause is not removed and the case properly treated, the cervix may become the seat of chronic inflammation, hypertrophy, indu- ration, and possibly of scirrhous deposit. Acute cervical metritis is more likely to be confounded with cer- vical endo-metritis than with any other disease. In the former, the neck of the womb is swollen and tender, Differential diagnosis. not only to a light touch, but also to pressure upon it from within the vagina, and through the rectum ; there is no abrasion and no ulceration, no appearance of hypertrophied villi (so often mistaken for granular ulceration) and no leucor- rhceal discharge. The constitutional symptoms are such as attend upon the more severe forms of local congestion and inflammation in other parts of the body. There is almost always pain in the head, photophobia, a flushed face, and such nervous symptoms as those of which this patient complains. Fortunately the organic changes in the cervix, which are the sequelae of acute cervical metritis, develop so slowly that prompt and proper treatment may prevent the disease from becoming chronic, In most cases, how- ever, these changes take place insidiously and in a latent manner, so that the acute stage will have passed before the physician is consulted. Doubtless the frequent return of the menses serves to perpetuate the liability of the neck of the womb, which has once been inflamed, to repeated attacks, that may finally end in estab- lishing the chronic form of the disease in it. In those women in whom the cervix is unusually long, as well as in those who are of a relaxed fibre, cervical metritis is very apt to become chronic and intractable. The same is true if the disease occurs in women of a decidedly bilious temperament, and who may be suffering from old hepatic disorders. Chronic affections of the rectum, as pro- lapsus and hemorrhoids, sometimes retard or prevent the cure of a case of cervical metritis. Treatment. — The increased suffering which this woman experi- ences when she is upon her feet, suggests that she should not be allowed to walk about. The horizontal posture Postural treatment. .-, P . . is the first thing you should prescribe lor simi- lar cases. You can not expect to cure them readily if the posi- tion of the patient's body facilitates and necessitates a determi- CERVICAL METRITIS. 4.41 nation of blood to the inflamed part. Especially should these patients be counseled to keep to the bed or sofa during the men- strual period, and for some days thereafter. They should also avoid all those emotional influences which might, directly or indi- rectly, excite the sexual system. The bladder should be emptied regularly, and the bowels not permitted to become torpid and in- active, or otherwise the intra-pelvic circulation might be so deranged as to prevent the best chosen remedies from having their desired effect. If, in a given case, there is reason to believe that any of the causes already named has occasioned the attack, that cause must be removed. And you should act promptly. Remove the cause. T _ . . .. Learn the source of the mischiet and remove it as soon as possible, else the most proper and appropriate time for curing the case, or at least for preventing it from developing into the chronic form of the disease, will have passed before you have accomplished anything. As the result of an abundant experience, I am persuaded that in these cases of engorgement of the cervix uteri, with incipient inflammation of its deeper-seated tissues, " pre- •cure revention be " er than mention is better than cure." Hygiene should go hand in hand with Therapeutics. It would not be sufficient to give this woman belladonna, or any other rem- edy, and dismiss her without specific instructions concerning her habits of life, of exercise, and exposure. It is just here that our knowledge of special physiology and of special pathology will render us the most important aid. It may fail to suggest the rem- edy for the symptoms complained of, but it will not fail to suggest what, in such a case as this, is vastly more important. It might involve a species of suicide for this patient to persist in running the sewing machine. She should not ride or walk very far or frequently. A journey from Chicago to New York, before her symptoms are relieved and the next menstrual period safely passed, might render her an invalid for months or even for years. And so also of croquet, of ironing, sweeping, or prolonged standing upon the feet, whether for pleasure at a party, or for profit in a store or in school. Any menstrual irregularity should be remedied. Sexual congress should l>e prohibited. Pessaries and every species of artificial support, 442 THE DISEASES OF WOMEN. whether within the vagina or around the body, are positively and decidedly mischievous in this class of cases. The same is true of the use of cold and astringent injections thrown into the vagina, and of most of the lotions and ointments that are applied in case of haemorrhoids. If you can properly attribute the attack to traumatic injury, there will be no harm in prescribing a vaginal injection, consisting of the tincture of arnica, glycerine, and tepid Local measures. i i i ■ r • i • ^ water, in case she has nsemorrnoids, with venous discoloration of the vagina, or a varicose condition of the veins of the lower extremities, it is best to substitute •hamamelis, for the arnica. Simple glycerine and water, one part of the former to five of the latter, will sometimes allay the burning heat and pain within the pelvis. I have occasionally witnessed the best, effects from Dr. Sims' method of applying pure glycerine directly^ to and about the cervix by means of a cotton or sponge tampon which is saturated with it. In one of my cases it certainly brought away half a teacupful of serum with which the swollen and pen- dulous cervix had previously been engorged. It may be possible by some such simple and harmless expedient to prevent what might otherwise develop into chronic cervical metritis. The internal treatment should be regulated by the obvious, symptoms peculiar to the individual case for the cure of which you. are consulted. This woman will take of bella- donna 3d, a dose every three hours. When her symptoms are somewhat improved, it may be repeated once in six hours. Let her come again next week. In some of these cases, whether complicated with other forms; of pelvic inflammation or not, and where tho The hot rectal douche. - .11 , i n i suffering is very acute, the hot rectal douche recommended by Dr. Chad wick, of Boston, is an excellent means of relief. The water used may be as hot as the hand can bear, and before it is thrown into the rectum, the finger should be passed into the vagina with its palmer surface toward the cocyx. As soon as you begin to feel the lower pouch filling up, you should, wait a little, but without withdrawing the nozzle of the syringe. In this way from one to four pints of water may be injected with- out exciting an immediate action of the bowels. The patient CORPOREAL CERVICITIS, ETC. 443 should keep quiet for half an hour, and it is possible that the water may not pass away again for an hour or two. CHRONIC CORPOREAL CERVICITIS. CHRONIC CERVICAL METRITIS. Case. — Mrs. Emma H. , aged 26, Irish, is of sanguine temperament, has had three children and two miscarriages, the last of which she induced herself six months ago. The menses have always been profuse, and accompanied with great pain. At present she complains of pain in the left hypogastric region which, at times, extends to the pit of the stomach. She also says she has pains through the womb. The bowels are habitually costive. The appetite is poor. Micturition is difficult, and the urine carries a heavy deposit of urates. She also has leucorrhcea, which is both cervical and vaginal. . . Physical examination shows the uterus to be three and a half inches in length. The cervix is engorged, thickened and swollen in the direction of its circumference. Its diameter measures nearly two inches. It is ■ smooth and firm to the touch. The introduction of the sound, although not at all difficult, occasioned great pain. There is nothing discoverable about the neck of the bladder or the urethra to account for the painful micturition. She was first placed on belladonna 3 once in two hours. The cotton tampon saturated with pure glycerine, was to be intro- duced every evening and worn through the night.. This treat- ment, local and general, promptly relieved the engorgement and tumefaction of the uterine cervix, and her general condition was very much improved. Since that time, however, she has treated herself and our clinical assistants, to a series of hysterical mani- festations, of which the following is a list : 1st. Gastralgia, which continued at intervals for three days. 2d. Retention of urine — which she passed easily enough when left to herself — lasted one week. 3d. Paralysis of the right arm for three days, and 4th. Pseudo-pleuritic pains that continued for twenty-four hours. Our patient was brought into this institution from a neighbor- ing hospital where, she says, her case was decided by the phy- sician to be one of uterine cancer. I do not credit her story, and yet it may be a true one. For excepting what the doctors some- times say of each other, no kind of testimony is so unworthy of trust as that which patients bring us concerning the views of other physicians, and the treatment to which they have already been subjected. 444 THE DISEASES OF WOMEN. Symptoms — This is a case of chronic cervicitis, or of cervical hyperplasia. For some reason, most probably on account of the abortions which she has suffered, such inter- Mechanical symptoms. . . - . . stitial changes have taken place within the uterine neck as to result in its enlargement and hypertrophy. Its measurements are very much increased, so that, within the pelvis it acts like a foreign body, or a tumor, causing suffering in other organs, and making the patient wretched. It presses against the urethra in such a manner as to give great pain on passing water ; upon the rectum so as to cause the bowels to be obstinately bound ; and is sufficient to maintain a constant leu- corrhoeal flow. •Other symptoms which usually attend upon this affection are pelvic and sacral pains ; prolapse of the womb, which is dragged toward the vulva by the increased weight of Direct and reflex symptoms. . its lower segment; dyspeptic troubles, as vomiting, loss of appetite, gastralgia, loathing of food and caprices of appetite ; and inability to walk without great effort, pain and fatigue. The incidental nervous disorders are more prominent than characteristic. Hysterical symptoms are an almost certain outgrowth of this particular lesion. Reflex ovarian irritation is also very common, and pains in the left hypogastrium, such as this woman complains of, are almost always present. Menstrual disorders are frequent. Some of these patients have amenorrhcea. In many cases there is unusual pam and difficulty in the commencement of the "period," which Menstrual disorders. . • i i • i i p i is occasioned by a partial closure 01 the cervico- uterine canal. But when that obstacle is overcome, the cervix being so very much engorged, the flow becomes excessive and perhaps long-continued. It often arises from excessive or impro- per exercise or travel at the month. The neck of the womb is so tender to the touch that sexual intercourse is intolerable. In some cases of insuperable aversion to the act, which you will meet with in private practice, you will find that this condition of the cervix exists, Many patients with this form of cervicitis complain of burning pain within the pelvis. This pain is usually aggravated by exercise, as in standing, riding or walking. With CORPOREAL CERVICITIS, ETC. 445 the swollen cervix against the vaginal walls sometimes occasions extensive ulceration of its investing mucous membrane. Nature and Cause. — This disease consists essentially in a hypertrophy of the cellular tissue of the uterine cervix. And this hypertrophy, or hyperplasia, as Dr. Thomas prefers to style it, almost never occurs excepting in those who have been pregnant. It is a post-puer- peral affair. It may follow delivery at term, but is more likely to result from an arrest of development consequent upon abortion. In many cases it supervenes the artificial induction of miscar- riage, the traumatic injury sustained seeming to add to the risk of its resulting as a sequel. It may be either the cause or the consequence of dysmenor- rhcea. In " bilious climates" it is indirectly connected with hepatic disease. In this class of cases the From bilious complication. . i -i • i uterus acts as a diverticulum tor the blood which should circulate more actively through the portal system. The connective tissue of the cervix becomes engorged, and an exces- sive development of the uterine neck is the consequence. The cause acts and re-acts. You will be on the alert for this condi- tion of things among multiparas in malarious districts. Diagnosis. — A few symptoms, carefully considered, will gener- ally enable us to differentiate between this disease and cancer of the uterine neck, which is usually of the scir- From uterine cancer. . rnous variety. I am pretty confident that, in this case, the swelling of the cervix is not due to scirrhous de- posit, because it is smooth and regular in outline and feels like a fibrous tissue. If it were cancerous, the outline would be irregu- lar, nodulated, and bosselated, and it would feel hard and carti- laginous. Cervical metritis is almost always a sequel to preg- nancy and to labor. It bears no especial relation to the climacteric. Cervical cancer is not at all infrequent in nulliparae, and is most common at the "change of life." In the former, no matter how much the organ is swollen or displaced, it is mobile. In the latter, it may be fixed and immovable. In cervical metritis there is no evidence of a particular cachexy, while in cervical cancer such a dyscrasia is, sooner or later, manifest. In cervicitis there is no tendency to deep-seated ulceration, with destruction of 446 THE DISEASES OF WOMEN. tissue and haemorrhage ; in cancer, such a tendency is very marked. But, even with the greatest care, it is not always possible to distinguish between these two diseases, more especially in the non-ulcerated state of uterine cancer. I have A new diagnostic test. . several times resorted to an expedient that has helped me to settle the diagnosis between them. You will do no harm by trying it. It is simply to use the cotton tampon satu- rated with pure glycerine, just as it was employed in this case. If the enlargement is due to plain, uncomplicated cervicitis, the depletion by means of the glycerine will soon lessen the size of the uterine cervix very perceptibly. If, however, the swollen state of the cervix arises from cancerous infiltiation, or from an interstitial fibroid, the glycerine will not sensibly diminish its bulk. If this simple test had been applied in the case before us, my unknown predecessor would not have decided this to be a case of uterine cancer ; for now the cervix is nearly normal both in size and texture. • The increased depth of the womb, the liability to haemorrhage, to endometritis, to uterine displacements, and to coincident peri- tonitis, which belong to chronic corporeal me- mS?t!s nosis from corporeal tritis, and not to corporeal cervicitis, will serve to separate these two diseases. In some cases they succeed each other, and again they co-exist. Prognosis. — This disease may continue indefinitely. Its course and termination will depend upon the nature and severity of the disorders with which it is complicated. It may decline at the climacteric, or possibly develop into a more serious form of or- ganic disease. In a reflex manner it may cause the gravest lesions of the heart, the lungs, or of the nervous centers. Frequent abortions render it more chronic and intractable. If the patient is ill in other respects and incapacitated from exercise, the cure is more doubtful. Treatment. — It is quite as important to prescribe the proper posture for this class of patients as it is in case of acute cervical metritis. Keep them in a horizontal or reclin- ing posture, and off their feet,, at the month especially. Shopping, visiting, party-going are as injurious as a CORPOREAL CERVICITIS) ETC. 447 journey by rail, or an excursion on horseback. Such a patient should let her sewing-machine rest, and her servants take care of themselves. If there is obstructive dysmenorrhoea, remove the cause and relieve the consequent engorgement of the cervix. If she has intermenstrual dysmenorrhoea, cure it. If the flow is too scanty, try and prompt it to be more free. If the rectum is paralyzed, or the bowels are badly consti- pated, she may be relieved when these conditions are set aside. She should be especially careful not to do anything before, during •or directly after the flow that can by any possibility complicate the case and increase the cervical hypertrophy. If there are " bilious " symptoms remember that they are likely to afford the most prominent and cardinal indications for £he rem- edy or remedies. Podophyllin, mercurius, chamomilla, bryonia, tiux vomica, china, natrum mur., nitric or nitro-muriatic acid, or some similar remedy, may be specifically called for. Other remedies that I have found especially useful are bella- donna, lachesis and apis mellifioa. Some of the Bell., lach. and apis. best cures that 1 have ever made have been performed with these three remedies in this class of cases. Locally the same treatment as already recommended for the acute form of this disease is equally suited to the chronic vari- ety. The cotton tampon saturated with glyc- Local adjuvants. \ r . iDj erme can do no possible harm, will not interfere with the action of internal remedies, and may do a positive good. After the first application it can be prepared, introduced and re- moved by the nurse or the patient herself. I generally recom- mend that it shall be used two or three times per week, according to circumstances. CORPOREAL CERVICITIS AND SCANTY MENSTRUATION. Case. — Mrs , has a urinary trouble, which is aggravated about the time of the flow, the menses are regular but scanty. The trouble began two years after the birth of her child, which w r as about six years ago ; she has never had a miscarriage ; she is obliged to pass the urine often, it is painful and scanty, and there is a thick sediment; sometimes there is but little pain, but it will be increased if her feet are cold ; there is some strangury, but no involuntary flow ; riding in the cars increases the urinary difficulty. 448 THE DISEASES OF WOMEN. On local examination, the os was found much swollen and of a purplish hue, with a well defined vesicle on the anterior lip which was filled with serum. The cervix was elongated, red, and of sugar-loaf form, but there was no abrasion or ulceration, and no leucorrhcea. There is no flexion or sub-involution of the uterus. Tartar emetic 3, three times a day. This woman first presented herself at our general clinic. She has since submitted to a careful local examination in the sub- clinic, and »her case is now a clear one. She has corporeal cervicitis,, the principal enlargement of the cervix being at its upper portion. Those of you who saw it in the field of the speculum will remem- ber how it looked. You will also recall my remark'that, since she had not had menorrhagia, but really suffered from scanty and diffi- cult menstruation, it was impossible for her to have either chronic metritis,* or sub-involution of the womb. And you remember that when I introduced the sound it passed to the depth of two and a half inches only, which fact confirmed my statement. But, how can corporeal cervicitis occasion a scanty flow of the menses? Manifestly by narrowing the cervical canal and thus partially obliterating its outlet. And the pres- sure of this same tumefied cervix upon the neck of the bladder causes the strangury. The fact that this latter symptom did not depend upon any form of uterine deviation was demonstrated to you by the direction which the point of the sound took when it entered the womb, and which it afterwards kept. The rational treatment for scanty men- struation in this particular case consists in the adoption of measures for the cure of the concentric hypertrophy of the cervix. The indications are not changed because, in this particular instance, the lesion is chiefly limited to the upper, or the abdominal portion of the neck of the womb. Hot water irrigation (See Fig. 44,) rest in the re- cumbent posture, especially at the month ; keeping the bowels regular, and the bladder from becoming distended ; the avoidance of excessive sexual excitement, tight lacing, or too prolonged Query. Treatment. Fig. 44. Hall's Syringe. CORPOREAL CERVICITIS, ETC. 449 standi 112:, and the passage of the sound, or the trial of slight and careful dilatation of the cervical canal almost directly in advance of the flow, are measures. Tartar emetic. Fig. 45. Peaslee's uterine stems. This latter indication can be met by the passage of the sound or of graduated bougies in the form of Peaslee's dilators. Clinical experience teaches that in this kind of a case, the indi- cations are peculiar. The symptoms detailed by this woman are as real as those of pneumonia or of rheumatism, but they depend upon a mechanical cause, and will persist while that cause con- tinues to be applied. The structural lesion furnishes the chief indications for the treatment, because, without this lesion, there would be no symptoms that were sufficiently distinctive to tell us what the trouble was, neither what the remedy should be. I pre- scribed tartar emetic being fully satisfied of its power to reduce the hyperplasia in this benign and localized form of uterine inflammation. It may not be suffi- cient of itself to cure the case, but it will give us a start in the right direction, and you should not forget that the first step towards a cure, like the beginnings of disease, is often the most important part of it. During the past summer (1880) I had at one time six cases of this disease under treatment in my sub-clinic. These cases were carefully examined from week to week in the presence of the class. All local treatment whatever was withheld, and the most careful observations were made and noted in each and every case. They took no other remedy than tartar emetic, and the effect was so perceptible that every member of the class, as well as a number of physicians who were present from time to time, was satisfied with the result. 33 450 THE DISEASES OF WOMEN. Where this inflammation is benign, and the infiltration of the cervix with serum that is loosely organized, constitutes the whole of the local difficulty, the case is in some sort the counterpart of the hepatized lung in pneumonia. This was what Spiegelberg recognized when he recommended the sponge tent as a means of diagnosticating simple corporeal cervicitis from cancerous infiltra- tion of the cervix, and this was my idea in advising the internal use of tartar emetic tor the resolution of the hypertrophied cervix, when it was traceable to a non-specific inflammation. I have now been in the habit of using it in similar cases for more than ten years, and although it is not always curative, it seldom fails to be of essential service, especially in conjunction with the topical use of glycerine, or of hot-water irrigation. There is a clinical distinction between uterine hyperplasia, whether it be of the cervix or of the body of the uten ?ub?mvo r iSdon! and womb or both, and uterine sub-involution. The former, especially, if it is limited to the cervix, is almost always accompanied by painful and scanty menstruation ; while the flow in sub-involution is always excessive, and, unless it is accompanied by endo-metritis, is rarely painful. In exceptional cases there is no doubt that these two conditions coexist. When you are in doubt, there can be no impropriety in prescribing secale cornutum in the second or third decimal attenuation, and carefully observing the effect that is produced upon the size and texture of the cervix as well as the depth of the womb. LECTURE XXVIII. CHRONIC CERVICAL ENDOMETRITIS, OR ENDO-CERVICITIS. — UTER- INE LEUOORRHGEA. Endo-cervicitis; its cause, symptoms, diagnosis, prognosis, and local and general treat- ment.— Case. Inflammation of the mucous membrane lining the uterine cervix is especially interesting because of its clinical relation to what is commonly known as uterine leucorrhcea. This patient came under our care six weeks ago. She is now almost well, and I present her as an illustration of the importance, nay, the absolute neces- sity, of a correct diagnosis as a condition of cure in some of these cases, and for the purpose of showing you that the simplest reme- dies are sometimes the most efficacious. Her clinical history, as recorded on her admission, is as follows : — Case. — Mrs. , 28 years of age, the mother of two chil- dren, has been an invalid for two years past. Her ill health dates from her last accouchement, which was normal in all respects. She, however, "got up" very slowly, and was weakly during lactation. She still nurses her child, which is a big, hearty boy ; and being obliged to take the entire care of him, she holds and carries him most of the time. She has not menstruated since her confinement. She complains of aching in the loins, a dragging sensation about the hips, which extends to the thighs, and bearing down pains and pressure within the pelvis, u as if everything would be forced from her." This latter symptom is worse when she rises to her feet from the chair or couch. She also has a leucorrhceal dis- charge, which is thick, creamy, and sometimes more watery and copious. The freer this flow the greater her debility and prostra- tion, and the more severe and distressing the pain in the back. Upon arising in the morning this discharge is often so profuse as to cause her to be faint, to destroy her appetite, and to incapaci- tate her for her household duties. She finds it impossible to stand more than a few minutes at a time, and can not walk but a short distance without being very much fatigued. She enjoys a short ride, providing the carriage is easy and the road is not rough. At times she has a burning pain which, she thinks, is in the 451 452 THE DISEASES OF WOMEN. mouth of the womb. Intercourse is almost intolerable. The bowels are badly constipated ; the appetite poor and capricious, with more or less of nausea and loathing of food, especially in the morning. Her eyes are so weak that she can not read or sew more than five or ten minutes at a time without pain, indistinct vision, and lachrymation. The touch reveals a tumefaction and tenderness of the cervix uteri. The womb lies very low in the pelvis. The external os uteri is patulous, and its lining membrane everted. A thick, albu- minous mucus was taken directly from the can'al of the cervix and subjected to microscopical examination. There is no visible ulcera- tion, although she has been treated by three physicians for that disease. The neighboring organs appear to be healthy. I have already spoken of cervical metritis, or inflammation of the parenchyma of the uterine cervix. The case before us is one in which the lesion is limited to the mucous membrane that lines its canal. It is styled cervical endo-metritis, or endo-cervi- citis, to distinguish it from corporeal endo-metritis, internal metri- tis, or inflammation of the proper uterine mucous membrane, which is found within the cavity of the womb. For while you would naturally suppose that these two affections would often co- exist, the fact is that they are almost as distinct and as little related to each other as are bronchitis and bona fide pneumonia. Those of you who are not practically familiar with this disease may be disposed to question whether such a limited extent of in- flammation could really induce very serious or Extent of the cervical persistent svmptoms and ill health. The ute- mucous membrane. J- o -T rine cervix is only one and a quarter to one and a half inches in length. But the mucous membrane that lines its cavity presents a very considerable surface. Its rugae, or plicated folds, are numerous ; it is reflected over the arbor vitas uterinus, and dips down into each of the little glands within the cervix, of which, according to Dr. Tyler Smith, there are as many as from two to three thousand. In an ordinary case of endo-cer- vicitis, therefore, a larger extent of mucous membrane is inflamed than you would at first have supposed possible. And not only is this lesion an extensive one. The necessary implication of the glandular apparatus develops a disorder of se- cretion which depletes from the patient's general A glandular lesion. , , , r. strength, complicates the case, adds to the sut- CEVRICAL ENDOMETRITIS, ETC. 453 fering and retards the cure. Every well-marked example of endo- cervicitis is accompanied by a more or less copious and intractable leucorrhcea. And, although it does not come from the cavity of the womb, this discharge is commonly regarded as uterine. Hence, a majority of writers treat of this cervical leucorrhcea, which is a contingent and consequence of inflammation within the cavity of the cervix, and exterior to the os internum, as uterine catarrh. As applied to this disorder the term is a misnomer, and calculated to mislead. For there is as great a difference notTSl iTtlrlh.^ 1S between the character of the now in true ute- rine catarrh, and in proper cervical leucorrhcea, as there is between the rusty sputa of pneumonia and the mucoso- Duriform secretion which is stained with blood in bronchitis. Labor, whether in abortion or at term, is indirectly one of the most powerful predisponents of cervical endo-metritis. The changes which the womb undergoes after deliv- ery, and which are designed, through the process of involution, to restore it as nearly as possible to its original size and form, may occur so imperfectly, or so irregularly, as to leave that organ in a very unnatural state. In this condition of sub- involution, its various tissues, including the A sequel of labor. . . mucous membrane withm the cervix, are prone to become inflamed. It is for this reason, as in the case before you, that endo-cervicitis often dates from delivery. When a pa- tient tells you that, since the birth of her last child, she has suf- fered from symptoms which are the counterpart of those of which Mrs. complained, you will have a strong presumptive sign of her disorder. A careful examination locally will either confirm or disprove your suspicions. The scrofulous cachexia also predisposes to this form of uterine inflammation. It could not be otherwise, when Scrofulosis. so important a part of the secretory apparatus is implicated. The same is true of the return of the menstrual D r# Tyler Smith observed that flow. © «/ the clearness or the opacity, as well as the vis- cidity of the discharge, its creamy, soapy, gelatinous or ropy appear- * The Pathology and Treatment of Leucorrhoea, by W. Tyler Smith, M. D M etc., Philadelphia, 1855, page 64. CERVICAL ENDOMETRITIS, ETC. 457 ance, and indeed all of its physical characters depend upon the alka- linity or the acidity of the secretion with which it is mingled. The acid mucus secreted in the vagina changes the quality of the leu- corrhceal fluid poured out from the cervix uteri, as decidedly as it does that of the blood which escapes from the same channel in ordinary menstruation. I think it very important for you to remember this fact. You will not understand me to say 7 that all cases of this form of leucorrhcea depend npon cervicitis. By no means. There are other causes, such as obliquities of the uterus, Cervical leucorrhcea from ^[ 1Q p resenCe f foreign OTOWtllS, ulceration of ■other causes. ± o o the os uteri, granular degeneration, ovaritis and kindred affections even more remote, and which operate in a reflex way, that sometimes originate and perpetuate this discharge by stimulating an undue activity of the glands within the cervix. For the present I must defer their consideration. The dragging sensations about and within the pelvis are not always so marked and severe in this form of cervical inflammation as they are in cervical metritis. For in endo- Pelvic pains and suffering. ...... -, n , , . cervicitis the neck ot the womb is not neces- sarily so tumefied and tender ; and we find that the contingent distress and pain in the sacral and lumbar regions vary with the quantity and quality of the leucorrhceal flow, rather than with the size of the cervix. Something depends, however, upon the state of the patient's strength, the duration of the disease, her ability to withstand suffering, or her tendency to exag- gerate and overstate the kind and degree of her pain. She is very apt to complain of bearing down sensations, symptoms of prolapse, forcing of the pelvic viscera towards the vulva, and not infrequently of rectal aching and tenesmus whenever she stands upon her feet. Under these circumstances there is an aggravation of the symptoms from motion, pressure, coughing, or sitting down. These patients frequently complain also of burning sensations, which are located either within the vagina, at the; mouth of the womb, or in the ovarian region. Sometimes Burning sensations. . -i • i -\ -, the cervix is so displaced and tender that inter- course is very painful. More rarely, however, the unnatural con- dition of the parts causes an increased sexual desire, which the 458 THE DISEASES OF WOMEN. patient feels must be gratified, even though it be at the cost of subsequent suffering. Straining at stool, or in urination, may cause a flow of mucus from the cervix, and even from the vagina. The bowels are almost always constipated, although in some cases there is an alternation of constipation and diarrhoea. The bladder is more or less implicated, and cystitis, vesical tenesmus, dysuria and retention are by no means infrequent. Either as a cause or a consequence of the local lesion, the digestion is impaired, the nervous system undermined, and the general health borne down. Among the lower Constitutional effects. orders especially, such patients are very wretched. They are martyrs to vice, ignorance and self-depend- ence, to their children and families, to their own improvidence, and not unfrequently to the incompetency of their doctors. A considerable proportion of cases of endo-cervicitis are char- acterized by impaired vision, or rather by weakness of the eyes and inability to use them. This is true not Weakness of the eyes. . . alone 01 inflammation ot the cervical mucous membrane, but of other diseases of the uterine neck, and perhaps of the ovaries also. For there is an inexplicable sympathy be- tween the inferior segment of the womb and the eyes. I have treated a case of incipient amaurosis which was entirely and promptly relieved by the removal of a small mucous polypus that was found hanging from the external os uteri. Women have in almost numberless instances complained to me of pain, aching and weakness of the eyes immediately after the application of even the mildest lotions directly to the cervix. It is not at all unusual for this symptom to follow copulation temporarily, and in case of immoderate indulgence of the sexual appetite, to become chronic and perhaps incurable. The patient before you had these symptoms in a marked degree, and just in proportion as the ute- rine irritation and inflammation have been relieved in her case,, has the weakness of vision and its attendant symptoms improved. My friend Prof. Yilas, the oculist, informs me, however, that such symptomatic derangements of vision are apt to remain after the primary trouble with the uterus has been cured. Upon making an examination with the speculum in a case of endo-cervicitis, if the woman has ever been pregnant, you will almost certainly find the cervix uteri somewhat swollen, the os CEKVICAL ENDOMETRITIS, ETC. 45 9 patulous, and, if the leucorrhceal flow has been copious or long continued, the mucous lining of the canal ol s P ?culum ation whh the the cervix everted. In the virgin, however, and in those who have never conceived, as well as in very mild and recent cases, the tumefaction, the relaxed and open os uteri, and the hernia of the cervical mucous membrane may be lacking, and yet other equally reliable signs may lead you to diagnosticate the case as one of cervical endo-metritis. In other words, the inflammation in this case is limited to the cervical canal, bounded above by the internal os, and below by the exter- nal os uteri. I am convinced that endo-cervicitis is much more common among young unmarried women than it is generally sup- posed to be. In the latter class the vaginal portion of the cervix is rarely inflamed. Its investing membrane is not congested, neither is it hot, dry, or especially tender. But in confirmed cases, occurring in women who have borne children, you will observe that the mucous membrane about and within the os uteri is in a state of hyperemia and of evident inflammation. The nearer the men- strual period the more these parts will be congested, and the more open and dilatable the os tineas. In considering the diagnosis of this disease we are led to remark that the most mischievous results have followed the confounding of inflammation with ulceration and induration of the neck of the womb. Dr. Bennett, for example, believes them to be consecutive and inseparable, and, therefore, treats of them as synonymous, if not absolutely identi- cal. Errors in diagnosis, confused ideas of disease, and the careless use of medical terms, are necessarily followed by harmful conse- quences. For they always reflect the treatment that will be adopted. If I were to teach you that inflammation, induration and ulceration are essentially one and the same disorder, my indi- vidual error as a teacher would react against the welfare of your patients and of the community, through you, because it would set you upon the wrong track in therapeutics. Remember, therefore, that the discharge from the uterine cervix of such products as I have described does not Ulceration is incidental. . imply that there is necessarily any ulceration thereof. Take a pair of speculum forceps, such as I hold in my hand, 460 . THE DISEASES OF WOMEN. ■wrap a bit of cotton about them in this manner, and pass them through the speculum as far as the os uteii. Let them approach the cervix very cautiously. Then turn them over and over, thus, very gently, and you will wind up and remove A practical hint. ,. . . n . the stringy mucus just as if it were a spider s web. If this little manipulation is carefully performed, the free surface of the mucous membrane will be left exposed, and you will see at a glance whether you have a case of simple inflamma- tion or of ulceration to deal with. But if you undertake to remove the mucus from the diseased part without this precaution, and mop it away roughly, the delicate vascular surface, more especially the hypertrophied villi will be wounded, and the part so bathed in blood that you can get no very definite idea of the lesion. For the same reason it is best to be careful in the introduction of the speculum, more especially the quadri-valve and cylindrical varie- ties, lest you injure the cervix and fail in your object. Now a simple abrasion of the os-uteri may be, and most fre- quently is, merely incidental to the endo-cervicitis. The leucor- rhceal discharge does not come from the denuded ceraJd s^face. rom an u ~ surface, but is derived from within the canal of the cervix. If, however, the ulceration is deep- seated, and granular in character, and especially if the granula- tions are exuberant, and the patient is scrofulous, a large quantity of pus may be secreted from the surface of the sore. You will be able to diagnosticate endo-cervicitis from cervical metritis, by the absence of febrile action, and of local tenderness, which almost invariably accompany the latter ; ^Diagnosis from cervical by the existence of a i eu corrhcea, of congestion of the mucous membrane about and within the cervix, the open state of the os-uteri, the eversion instead of the retraction of its lining membrane, and by its relation to the scrof- ulous and catarrhal dyscrasise. Although these diseases are some- times found to coexist, yet such a complication is not frequent. The prognosis should be guarded. If you promise to cure suet cases in a given length of time you may be sadly disappointed ; ' for they are by nature chronic and tedious. And Prognosis. . . there are so many causes which,, directly and indirectly, modify the vascularity of the part that is inflamed, and derange and damage its glandular function, that your best inten- CERVICAL ENDOMETRITIS, ETC. 461 tions will be thwarted and your best prescriptions often rendered of no effect. Sometimes the sexual instinct and appetite of his patient is a sworn enemy of the physician, that overrules and overcomes his determination to cure her of this disease. Whether spontaneously aroused, or purposely stimulated, or whether it be gratified or repressed, the effect is to antidote and to counteract his efforts, to complicate the case, and to postpone the cure. The return of the monthly crisis multiplies the contingencies with which this disease is beset. So also the central and depend- ent position of the womb, and more especially of its neck, and its relation to other organs, both near and remote, all of which tend not only to render the attack persistent and almost perpetual, but to bring on relapses when it has apparently been cured. Treatment. — Nothing is more common than for young physi- cians to claim that a few doses of this or that remedy have sufficed to cure a case of cervical leucorrhoea. And this Of speedy cures. 1 . 1 independently of sexual excitement, the monthly exacerbation, and all the drawbacks which are but so many obsta- cles in the way of their superiors in age and experience. The fact is, their remedies may have been properly chosen, and most appropriate to the case in hand, but in the nature of things it is ascribing too much to them to insist that they are competent to cure such cases so promptly and decidedly. Merely to change the character or the quantity of the flow, or altogether to arrest it, is not to perform a radical cure. For relapses are the rule and not the exception. The doctor may plume himself on his skill in its treatment, and declare his patient well again, but the next day, the next week, or the next month, some exciting cause which is contingent upon her organization, or her position in the family, or in society, may upset all that he supposed he had accomplished, and consequently she is "as bad as ever again." Most of the exciting causes of enclo-cervicitis are avoidable. It will be necessary to remove your patient from under their influ- ence. You will see to it that there shall be no Remove the cause. sudden interruption or derangement of men- struation ; that her clothing is suitable and sufficient ; that her feet are warmJy clad and dry ; that her skirts are suspended from the shoulders ; that there are no ligatures about her body or her limbs , that she is not the victim of excessive sexual indulgence (espe- 462 THE DISEASES OF WOMEN. cially at or near the month), of uterine displacements, constipa- tion, dysmenorrhea, dysuria, ovaritis, blennorrhagia, rough riding, wearisome exercise, or the wearing of an abominable (not abdomi- nal) supporter or pessary. Both with reference to the prophylaxis and the cure of this complaint, an inherent tendency to scrofulous and catarrhal in- flammation should receive your early and con- The need of nourishment. , J stant attention. If your experience shall cor- respond with my own, you will find that the prime indication with this class of subjects is to have them sufficiently nourished, to bring their assimilative functions and their blood up to the healthy standard. In other words, you must not only stop the drain, whatever it may be, which is exhausting their vitality, but also supply them with such available nutriment as shall more than compensate the waste that has been going on. It may be quite as difficult to select the proper diet, and to arrange all its details to suit each individual case, as it is to select the remedy, but, in my judgment, it is quite as requisite to the cure of the disorder. Milk in some form, bread and milk, cream, beef, mutton, oys- ters, fish, fowl, game, soups and broths of different kinds, if not too greasy, the whites of eggs, and malt liquors, may supply this need. Cod liver oil has bene- fited some of these cases amazingly. In others the digestion has been improved and the general strength fortified by the use of the acid phosphates. Brandy and whisky are usually interdicted, but sometimes a mild native wine, or the extract of malt, may be allowed. Condiments and coffee are often injurious, while acid drinks are not only grateful but useful also. Some of these patients will never get well while they remain within doors. Others need a change of scenery and surround- ings, and they must travel. And yet another Travel and exercise. . class must be kept in a passive state. But how to fill these indications without harmful consequences is the ques- tion for you to decide. When you have regulated all these inci- dental matters, which I assure you are much less trivial in their bearings than they seem in their recital, the case will be more than " half cured," and you will be prepared to study its special therapeutics. CERVICAL ENDOMETRITIS, ETC. 463 Excepting for the purpose of cleanliness, vaginal injections are of little avail in this disorder. For unless the mucous membrane that covers the vaginal portion of the cervix is Vaginal injections. . -i-ii i also inflamed, or ulcerated, they do not reach the diseased part. And yet you will find that a majority of those who have already been under treatment for this disease have been in the habit of taking medicated injections of various kinds. With a view to clear the vagina of the unnatural discharges which come from the neck of the womb, to prevent their decom- position, and also, in case the endo-cervicitis is specific, to pre- vent the inoculation of the adjacent parts with the poisonous flow, we may prescribe injections of Castile suds, or of glycerine and tepid water. A better means of relief, however, consists in the direct appli- cation of pure glycerine to the inflamed cervix. This substance has the power of causing a free discharge of ceHne topical use ° f gly ~ serum from its engorged capillaries, and thus of removing an incidental cause which not unfre- quently serves of itself to perpetuate the disease. The determi- nation of blood to the dependent cervix, and its stasis therein, is a prime cause of the excessive and abnormal secretion from the cervical glands. If we relieve this local embarrassment of the circulation, it is like extracting a splinter from the flesh in a case of irritative fever. Moreover, the expedient is simple, available and harmless. It neither interferes with the use of internal remedies nor antidotes them. It has no injurious effect upon menstruation, nor does it entail any reflex or remote consequences upon other organs, which may or may not be implicated. During the past six weeks this patient has had no other treatment. We have not given her a grain or a drop of medicine, and yet she is almost well. A good method of applying the glycerine is to make a firm tampon of cotton, tie a thread about the middle of it to facilitate its removal, saturate it thoroughly with pure How to apply it. , . . 7 • j? glycerine, and introduce it into the vagina alter the patient has retired for the night. It should be pushed up against the cervix and left there until morning, when it can be withdrawn. The removal of this tampon will be followed by a more or less copious discharge of a thin serum, which is the pro- 464 THE DISEASES OF WOMEN. duct of the " insalivation," as it has been termed. This little operation may be repeated, according to circumstances, from one to three times each week during the inter-menstrual period. Another, and a more direct means of applying this substance is to take such an instrument as this, which is a flat uterine probe, armed with a bit of cotton-wool or soft sponge, Another method. . . . . . saturate it with the glycerine, introduce it into the cavity of the cervix and pass it as far as the internal os uterL Turn it about gently, and after . a few seconds it may be with- drawn, freshly charged with glycerine, and again introduced. Fortunately the open state of the external os, in almost all of these cases, facilitates and even suggests a resort to this topical means of relief. The patient should remain for a time upon her couch, and should not go to ride or to walk for several hours after the application. In very rare cases the glycerine is poisonous to the mucous membrane, and can not be used in the manner direct- ed. You should always be careful to select the best quality of glycerine for internal use. If the discharge is either purulent or puriform, the tincture of calendula may be added to the glycerine, in the proportion of one drachm to two ounces each of glycerine and Calendula, hydrastis, etc. -,...,,'■, 1 -i • -i i -n r\ i distilled water, and applied locally. Or the hydrastis, hamamelis, arnica, or baptisia, may be used in the same way. In exceptional cases, occurring in strumous subjects, and which are very chronic and intractable, one drachm of the tinct- ure of iodine may be mixed with two ounces of glycerine, and applied with a camel's hair pencil to the canal of the cervix. I have sometimes used the oleaginous collodion with the best pos- sible results. Although, as I have already said, in endo-cervicitis the inter- nal os uteri is in most instances closed, yet because it might pos- sibly be agape, or readily forced open, it is not Intra-cervical injections. ... , . ■■ safe to resort to injections thrown into the cer- vix, lest the fluid pass into the womb, and even into the abdo- minal cavity. No matter what the variety or the degree of the uterine dis- placement in this disease, every species of me- Pessaries. . i-i -i t l j_i chanical support is more likely to do harm than good. The only pessary that I ever employ in these cases is the CERVICAL ENDOMETRITIS, ETC. 465 saturated tampon, of which I have just spoken, which some of my patients wear whenever they are upon their feet. Exceptionally the perineal strap or pad is palliative, and will permit of moder- ate locomotion and of riding out into the fresh air. But the or- dinary supports, and especially the stem-pessaries, are absolutely harmful in the treatment of those uterine deviations which are in- cident to this form of endometritis. In very tedious cases compression of the inflamed mucous membrane exerts a salutary influence, not only in lessening the copiousness of the flow, but in curing t4ie lesion upon which it depends. For this pur- pose the carbolized sponge tent may be introduced from time to time, and left in situ for some hours. Or the other varieties of tent may be preferred. Simpson's ebony bougies sometimes answer equally well. Medicated bougies and suppositories are not of any especial value in endo-cervicitis. Compression would, however, be harmful, excepting in chronic cases of this disease, and should always be used with caution. Concerning the employment of caustics in the management of this disease, they certainly are no better indicated than they would be in nasal catarrh, influenza, catarrhal Escharotics. i i -i • • i^t ophthalmia, or a " cold m the head. It would be just as reasonable, and equally efficacious, to apply the nitrate of silver, or chromic acid indiscriminately, in the one case as in the other. Physicians succeed in curing bronchial, renal and in- testinal catarrh without the topical use of alum, the acetate of lead, or even of carbolic acid, and why should they claim that a similar inflammation of the mucous membrane within the uter- ine cervix is not, and can not also be responsive to milder means of cure ? Theoretically, the adherents of the Bennet school are certainly wrong in their deductions ; practically, I believe, they are working more mischief (unwittingly, to be sure) than any equal number of physicians, of whatever denomination, the world over. For what excuse can there be for converting a case of simple endo-cervicitis into one of open ulceration of the os uteri, in order to cure it ? And how shall the intelligent phy- siologist excuse himself to his own conscience for sealing a dis- charge from the neck of the womb, regardless of the consequences that may be entailed upon his patient ? so 466 THE DISEASES OF WOMEN. I have long been of the opinion that, in the selection of the constitutional remedies for this form of leucorrhoea especially, the physical characters of the flow, as it is ordi- A fallacious practice. , . . narily obtained, nave been considered more im- portant and suggestive than the facts of the case will warrant. The usual mode of noting the peculiarities of the discharge which comes from the cervical canal is fallacious. An albuminous secre- tion, which is alkaline in its reaction, is subject to contact, suc- cussion, retention and admixture with an acid mucus in the vagina, which changes its properties in many respects, if it does not alter it entirely, after which the product is recommended to be taken as a criterion of the actual lesion, and a guide in the choice of the remedy. Under these circumstances, nothing is more natural than that the flow should become white, watery, milky, opaque, cheesy, curdy , yellowish, brownish, flesh-colored, or even greenish. And, since the conditions which give rise to the varying qualities of the ieucorrhceal flow (in endo-cervicitis, or uterine catarrh), are purely accidental, and contingent upon the passage of that flow through the vagina, I feel like insisting that they are not to be depended upon as therapeutical data. Take a parallel case. Suppose that, in nasal catarrh, the dis- charge were first subjected to the action of the vaginal mucus, or to any other acid mixture, and afterwards submitted to you as representing the proper pathological product itself, what kind of an Idea would you form of the disease in question ? And sup- pose, farther, that a physician should insist that, after such manip- ulation, the color and other characters of the discharge would indicate the remedy, what would you think of him ? Now, I propose, that in order to obtain a correct idea of the secretion which is poured out by the cervical glands in uterine leucorrhoea, we should not trust to the patient's Rule for examination of • ■ _c j i j.j *j_i 1 the flow in cervical leu- version oi the matter, neither to our own exam- ination of the flow, when it has been mingled with the vaginal mucus, but that, in order to examine it properly, we should take the discharge directly from the cervix uteri itself, as well for curative as for diagnostic reasons. Then, as in nasal catarrh, we would have the original product unchanged, and what- ever we could learn from it that would help us to differentiate be- tween remedies would be much more satisfactory and trustworthy CEKVICAL ENDOMETRITIS, ETC. 467 in every respect. And I do not know why a leucorrhceal secretion should not be thus carefully inspected from time to time, as we examine the sputa in pneumonia, or the urine in a case of Bright's disease. Moreover, it should be done in the same manner in mak- ing our provings. I apprehend that the varying qualities of a natural secretion, as, for example, the menstrual blood, the urine, or the perspira- tion, as these fluids are influenced by disease, abnormal dLXrS and afford a much better criterion of the structural and functional conditions of the organ or organs involved, than do the physical properties of products which, like the sputa, diarrhceic discharges, and the cervico-leucorrhceal flow, are in themselves morbid. If this is true, they also supply us with a better guide in the selection of our remedies. The physical properties of the flow in cervical leucorrhcea are many of them too fickle and varying to be possessed of the prac- tical significance which has been ascribed to them. The leucor- rhcea itself is but a symptom, and to divide and subdivide it, is perplexing to one's patience, and sometimes too transcendental to be of real use. If cures have been effected (and they undoubt- edly have), when remedies for cervical leucorrhcea have been pre- scribed on these shadowy indications, the result must be attributed to the fact that they were accidentally suited to the relief of the more cardinal and essential conditions underlying those symptoms. We may, therefore, depend upon them only when we can not do better. In vaginal leucorrhcea, however, the thickness, thinness, tenuity, color and peculiar character of the discharge, are more distinctive and significant. If it has acrid or corrosive properties, we should give this clinical fact its proper interpretation. For, excepting in case of malignant disease of the womb, as in medullary cancer, cauliflower excrescence, and the like, this kind of flow never comes from the cervix uteri. Where both these varieties of leu- corrhcea co-exist, as they sometimes do, you will generally succeed in curing the vaginal form first, and that which depends upon enclo-cervicitis afterwards. If you can trace the origin of an attack of cervical endo-metri- tis to " taking cold," or to an epidemic influenza, no matter what length of time has elapsed since the disease set in, you will do well 468 THE DISEASES OF WOMEN. to prescribe the remedy or remedies that would have been suited to the primary disorder. Whatever remedy Practical hints. i- J J would have cured the "cold," the influenza, or the catarrhal fever, upon which the endo-cervicitis is secondary, may suffice to cure its remote effects and to help your patient out of her difficulty. Due notice must also be taken of the catarrhal dyscrasia, as it might be termed, and of the scrofulous and the syphilitic dia- theses. So, likewise, of a predisposition to biliary derangements, whether it be chargeable to inherent peculiarities, or to the acci- dental circumstances of climate, season, an improper diet, or mal- medication. In this climate the consideration and study of these utero-hepatic complications are indispensable. But above all, you will look for the most prominent and trustworthy indications for your remedies in those symptoms which are connected with and depend upon certain coincident derangements of ovulation, men- struation, and of the digestive, the respiratory, the circulatory and the nervous systems, and also of the bladder and the rectum. If you will adhere closely to this method of selecting the remedy in this class of cases, it will enable you to distinguish the true symp- toms from these which are only incidental, and perhaps fallacious. Thus, if the prominent symptoms complained of are referable to ovarian irritation, inflammation, or derangement, they might indicate belladonna, atropine, apis mel., colo- For reflex ovarian disease. . . . cynth, phosphorus, alumina, platina, enma, hamamelis, pulsatilla, zincum val., lachesis, caulophyllin, lilium tig., conium, podophyllin, bufo, or some kindred remedy. Or, if some menstrual embarrassment or difficulty gives a par- ticular stamj), or character, to the symptoms, it may be indispens- able for you to study the pathogenesis, and the f F mens°truatfon. t dlsor ers published experience of the profession with bovista, secale cor., sabina, alumina, ferrum acet., calcarea carb., lilium tig., baryta carb., sepia, pulsatilla, am- monium carb., phosphoric acid, senecin, cocculus, helonin, can- tharis, or xanthoxylum. For the digestive complieations the more For utero- dierestive com- -i • • -\ ••i-i plications. common remedies are nux vomica, cham omnia, arsenicum alb., mercurius, graphites, lycopod- ium, colocynth, veratrum alb., aloes, opium, sepia, carbo veg., CERVICAL ENDOMETRITIS, ETC. 4(39 t3ollinsoiiia can., china, sulphur, hydrastis can., the citrate of iron and strychnia, kreasotum, plumbum, pulsatilla, alumina, natrum mur., podophyllin, aesculus hip., nitric acid, and mix moschata. For those which implicate respiration: phosphorus, bryonia, sanguinaria, calcarea phos., calcarea carb., sili- spkawrTa^mcnt?. 1 and re " cea, lycopodium, stannum, tartar emetic, lache- sis, hyoscyamus, drosera or dulcamara. For symptoms connected with the local and general circulation: veratrum vir., bryonia alb., stannum, apis mel., of\ n he C dTc C ufa e don dls ° rders digitalis, cactus grand., aconite, gelseminum, veratrum alb., naja trip., or belladonna. For the nervous symptoms, especially in those who are liable to Hysteria, almost any remedy in the Materia Medica might be re- quired. Most likely, however, you will find ne^ous te c r o mp^ca[ion 1 s and what you want under the head of hyoscyamus, ignatia, coffea, moschus, caulophyllin, lilium tig., belladonna, atropine, cocculus, gelseminum, cimicifuga, caus- ticum, chamomilla, agaricus muse, sulphuric ether, senecio, taran- tula(?), Scutellaria, or cypripedium. If the vesical symptoms are the more painful and prominent, you should consult the class of remedies most frequently and com- monly employed in the treatment of diseases ' of the bladder and urethra. This class includes cantharis, cannabis sat., dulcamara, belladonna, apis mellifica, mer- curius, lryoscyamus, camphora, ferrum, chimaphila umb., and the •eupatoreum purpureum. When the rectal troubles predominate, we have aloes, podo- phyllin, mix vomica, sulphur, hamamelis, col- tom°s! euter °- recta symp " linsonia can., and the sesculus hippocasta- num. Do not understand me as recommending that these remedies shall be given consecutively, or without discrimination. In classi- fying them my object has not been to supersede the necessity for their differential study and adaptation, but to indicate the variety of s}miptoms which, in the treatment of this vexatious disorder, do really afford the most trustworthy guides in the selection of our means of cure. For almost every one of them has some especial relation to diseases of the uterine cervix. 470 THE DISEASES OF WOMEN. CERVICAL ENDO-METRITIS. Case. — This woman is 30 years of age, she had one child which is now eight years old, and has had no miscarriage during that time. The ninth day after her confinement she got up, but was obliged to again take her bed, because of prolapsus of the womb. Previous to the birth of her child she had some spinal trouble, which was much aggravated after confinement, and her physicians diagnosed an abscess on the back over the right hip — for which the hot iron was used and this was kept open for one year, for three years fol- lowing she was confined to her bed. She now complains of con- stant back-ache, and bearing down pain for a week previous to the flow, which is irregular, but scanty, lasting but one or at most, two days, and is followed by sick-headache. The left leg gets numb if she lies on that side, and is worse in damp weather. On local examination, we find the uterus prolapsed, lying but one inch within the vulva, also a partial laceration of the perineum, the os is large, patulous, and is button-hole shaped, The cervix is swollen, red, and very tender, she has no leucorrhcea. The sound passes without obstruction, and there is no subinvolution. Tartar emetic 3, three times a day. The points in this case are the non-increase in the depth of the womb ; the scanty menstruation ; the enlargement of the body of the cervix as a complication ; the expulsive uterine pains in advance of the flow ; the prolapsus uteri ; and the numbness of the left leg. Each and all of these symptoms are referable to the hyperplasia of the neck of the womb and to the rent in the perineum. If the laceration ol the cervix played an important part in this case there must have been subinvolution with chronic metritis, and possibly cellulitis, and menorrhagia. ART OIXTH. THE DISEASES OF LACTATION. LECTURE XXIX. ABSCESS OF THE MAMMARY GLAND. Burrowing- abscess of the mammary gland with a sinus— on weaning a child, and the subsequent treatment of the mammary glands— Galactorrhcea— Excoriated nipples. Although the diseases of lactation belong more properly to the Puerperal department of the Hospital, in which I shall speak of them at the bed-side, there are some of the more common of these affections that will come into our general clinic. Prominent among them are such as are due to over lactation, non-lactation, lactation which is co-incident with menstruation, sub-acute and chronic abscess of the mammary gland, and excoriated nipples. It happens that we can show you a number, of such cases this morning. The first on the list is one of burrowing abscess of the mammary gland with a sinus. This is a very unfortunate condi- tio;., and one that will draw upon your patience in a peculiar manner. You will, therefore, observe its symptoms carefully. Case. — Mrs. -, aged 28, has two children, the youngest of which is three months old. She complains of a " gathered breast," which began to trouble her seven weeks ago, or when the babe was five weeks old. She first noticed what appeared to be a small "cat-boil" on the right breast, which was not very painful and did not in the least interfere with nursing. It, however, contin- ued gradually to increase in size, and to become more tender. Three weeks ago her physician advised that it should be poulticed and afterwards freely lanced. The former part of the prescrip- tion was tried, but she would not consent to its being opened. As a consequence, the abscess broke at the end of another week, and although it seemed but a small affair, discharged a large quantity of healthy pus. The orifice through which this fluid escaped has 472 THE DISEASES OF WOMEN. continued to enlarge until it is now about the size of the nail of my index ringer, and, only yesterday, she was startled by discov- ering that whenever the child nurses, or she swallows anything, and sometimes when she moves the right arm, the milk escapes quite freely from it. Two days since, another " boil " made its appearance at the lower and outer margin of the same breast, and now, you see the hardened, smooth, glossy and convex outline of the surface at that point, as the redness, and also the pain of which she complains, indicate that the suppurative process is still going on. She is weak and feeble, with slight hectic, unrest, anorexia, and is withal very much discouraged. Unless it be located in the loose cellular tissue about the nipple, the mammary abscess which points like a boil is apt to be a serious and deep-seated one. This is especially true if the local and con- stitutional symptoms indicate that the gland has been inflamed for a considerable time. Under these circumstances, pus may form and collect at the base of the breast, or in the areolar structure that separates the lobules, long before there is any external sign preparatory to its escape. The size of the abscess proper is, there- fore, no criterion of its extent or gravity. Boils situated about the margin of the breast, and especially at its lower border, not unfrequently give vent to the contents of a burrowing abscess which may have existed for some weeks, and committed great havoc with the gland itself. There may be only one of these, but usually there are two or more which ripen successively. We occasionally meet with superficial abscesses that only involve the integument covering the gland, but these are not necessarily, or indeed frequently, seen in nursing women. They occur in young girls, in consequence of tight lacing, the wearing of hard and un- yielding pads over the breasts, or of bruising those organs in some accidental way, and scarcely deserve the name of abscess. The form of milk abscesses of which this is an excellent illus- tration, is peculiar to depraved conditions of system which consti- tute a species of cachexia. They are very prone to become sinu- ous, and the canals which are formed may be either superficial or deep-seated, running through or beneath the gland in every direc- tion. Multiple abscesses may communicate in this manner. Unless relieved by proper means, these sinuses may even become fistulous. It has happened that the entire mammary gland has been destroyed and discharged through these openings. ABSCESS OF THE MAMMARY GLAND. 473 In the case under review, the extravasation and escape of milk is caused by a rupture of one or more of the proper lactiferous ducts, whieh are compressed during suckling, deglutition, and also when the arm is moved. It is hardly necessary to remind you that these symptoms require immediate relief, else they may persist and increase in severity until they destroy the patient's life. Treatment. — I have more confidence in phosphorus and silicea than in any other remedies for sinuous and fistulous abscesses of the mammary gland. It is best to give them separately. Perhaps you will succeed more frequently with the former than with the latter. They should be given in the sixth, or a higher potency, and the dose repeated every three to six hours. It has been claimed that the local application of the tincture of phoshorus in tepid or , i the indiscriminate weaning children early, and, indeed, that many of them of infants. . -.. prefer not to nurse their babies at all. lnese most unnatural and baneful practices are, unfortunately, becom- ing more frequent. In all our cities and towns — and in these days of railways and telegraphs there are no more country villages — the custom of rearing children at second-hand, or by proxy, is becoming more and more popular and prevalent. The most silly- pretexts are preferred by people in fashionable life for denying the little infant the mother's breast. One such mother will decline to ruin her bodily form and figure by nursing her own child, another considers it vulgar, a third is too much of an invalid herself, while a fourth is unwilling to sacrifice the pleasures of the table, of the toilet, or of gay and fashionable society, of late hours, or of some favorite form of dissipation, for the cares and crosses of maternity. Among women of the great middle class of society there is a grow- ing aversion to what is both natural and necessary for the welfare of their delicate offspring. For the most trivial, and even shame- ful reasons, too many little innocents are thus denied their most appropriate aliment. The consequence is that a large share of American mothers never experience those reflex influences that would tend to soften and sweeten their own natures ; and that thousands of children are poisoned by all sorts of artificial substi- tutes for healthy human milk. Another class of mothers place a premium on the luxury of nurs- ing their own children. They are never quite ready and willing to wean them. If your future observation accords with my own, you will have reason to conclude that, with many members of this 476 THE DISEASES OF WOMEN. class, the pleasure derived from the performance of this very natu- ral function constitutes the chief enjoyment of their married life. Not unfrequently, however, there is another reason for the re- solve on the part of these women to prolong the period of lactation. As a rule, menstruation is suspended until the iact 1 It e ion Ctsoftooprolonsedcnud is ta ken from the breast. This they all know as well as we do. They are also aware that, while the nursing woman does not menstruate, she is not very likely to conceive again. Hence many mothers voluntarily continue to suckle their children beyond the proper time, in the hope that they may thus avoid too rapid an increase in the family. But since there are many exceptions to the rule that a nursing woman may not become pregnant, and more especially because the health of the child, and of the mother also, may be injured thereby, it will become your manifest duty, in some cases, to insist that this practice shall be relinquished. As a rule, if both the patient and her child are well, the little one should not be weaned before it is about a year old. After this period the mother's milk becomes deficient in iZ he pr ° per dme f ° r wear '~ casem > — a physiological reason why lactation should not be prolonged. In deciding upon the most proper time for taking the children from the breast, something depends upon circumstances. If, for example, the little thing has cut its teeth freely and early, and manifests a disposition for a mixed diet, being ready and eager to eat almost anything that is offered, there will be little risk in weaning it. It will, however, be more safe for the child to cease nursing in cool or cold weather, as in the fall or winter, than in the late spring or early summer months. If a severe epidemic, more especially any alimentary disorder, such as cholera infantum or dysentery, is prevalent among young children, you should counsel the mother to wait until the epidemic has subsided before she puts her child away. The almost utter impossibility, in our larger cities, at certain sea- sons, of procuring good, healthy cow's milk for the infant, may afford another valid reason for prolonging lactation even beyond the twelfth month. Statistics prove that after the ninth month, weaning is more apt to be followed by mammary abscess than at any period between the second and ninth months. In the case in which we have just been consulted, the child's age ABSCESS OF THE MAMMARY GLAND. 477 is favorable, it has its complement of teeth, eats well, and is thrifty in every regard ; the season (November) is propitious ; and there is no disease which at this time is especially prevalent among infants and young children. We therefore advise that this woman's babe be weaned. Treatment. — And now the question is fairly before us ; what course is most proper for the mother ? In her case there is a man- ifest predisposition to a profuse and prolonged secretion of milk. Ordinarily the quantity of milk secreted is in proportion to the frequency with which the breast is drawn, or emptied ; the more it is nursed, the greater the yield. But in this case a profuse flow is furnished by the gland, although none of the product is forci- bly withdrawn. Here there is a danger lest the milk may accu- mulate and give rise to inflammation, and, ultimately, to mammary abscess. Hence we must, if possible, institute measures that will avert such a calamity. For it is a species of martyrdom for any woman to suffer from an abscess or abscesses of the mammary gland, and we should use our best endeavors to spare her such an infliction. Where, as in this instance, the flow of milk is very profuse, and especially if the child is several months old, I think the wiser course is to wean it gradually — say to nurse Prophylactic treatment. , , it only at night for a time, and to feed it dur- ing the day. This plan will prevent the accumulation of a very large quantity of milk in the breasts, and also allow the general organism to accommodate itself to the new condition of things, points which are in some cases most significant. If the mother stops nursing abruptly, there will be greater risk of local trouble, and of a general derangement of her health, than if the change is less sudden and extreme. This rule, which has its exceptions, is also applicable in case it becomes necessary to wean the child at a very early age. In gen- eral, however, it is thought advisable to put the infant away from the breast at once, as less troublesome than gradual weaning. Afterward, if the ducts become obstructed, and the glands dis- tended, hard and painful, a resort is to be had to some artificial means of emptying them, and of averting farther trouble. Medicines which are believed to have the power of lessening the quantity of milk secreted are termed Anti- Antigalactics. , galactics. They are used both internally and externally. Of those which are adapted to internal use the more 478 THE DISEASES OF WOMEN. prominent are belladonna, bryonia, calcarea carbonica, and phos- phorus. Besides these, other remedies are suited to lessen a redun- dancy of this flow, when it is attended by peculiar symptoms, all of which are lacking in this case. For, Mrs. Z. is not ill at the present time, and the most diligent search might fail to disclose a single symptom of an abnormal condition. Our treatment must, therefore, be prophylactic. It should be designed so to diminish the quantity of this secretion as to insure the breasts against local disease or injury, and the general system from all contingent dis- orders. To fill this indication I have more confidence in the cal- carea carbonica than in any other remedy. I prefer it in the third decimal trituration. Your future experience may cause you to decide in favor of some other form or potency of this remedy. This is a matter which cannot be settled for yon in the lecture-room. In general, the younger the child the greater the danger of mammary abscess from weaning it. There are, however, excep- tions to this rule also, in which it is almost or The age of the child a .. criterion of the danger of quite impossible to take the child from the mammary abscess. breast at any period without incurring the risk of this accident. When a physician tells you that he has always been able to avoid such a result in his practice, you may safely conclude that he has been unusually fortunate, or that his obser- vation has been limited. Local adjuvants are not only admissible, but, in certain cases, necessary also. Most practitioners prefer camphor for this pur- pose. Cloths may be wet ivith the common Local applications. . tincture and applied directly to the breast. Or it may be anointed with a mixture of camphor and sweet oil ^— the camphorated oil of the shops. A saturated solution of cam- phor in glycerine makes a more pleasant and equally useful prep- aration, which may be kept constantly applied over the gland by means of flannel compresses. Several of my medical friends assure me that they have derived the most satisfactory results from the topical employment of cold water, as a preventive against mammitis and mammary abscess in cases of this kind. I have no experience therewith. They recom- mend to apply a wet compress directly over the gland, and to pro- tect the clothing by a dry one outside. This is to be renewed from time to time, the water being at the temperature of ordinary ABSCESS OF THE MAMMARY GLAND. 479 well or hydrant water. They claim that the faithful use of this simple means will spare much subsequent trouble to all concerned. Another method consists in covering the breast with one or more layers of flannel, and then applying a bladder which is partly rilled with broken ice. Persistent rigors and chilliness, however, contra-indicate the use of cold applications of all kinds. A stimulating lotion may also be made of black pepper QPiper nigrum}, by permitting it to stand for a considerable time in good hrandy. The pepper should, however, be in the grain and not ground, or pulverized, otherwise, by insinuating itself into the del- icate skin, especially in the region of the areola, it might occasion much suffering. This lotion may be applied in the same manner as recommended for the glycerole of camphor. In inflammatory cases in which the pain and throbbing of the gland are severe, or if the pains are neuralgic, the application of the belladonna plaster will sometimes afford the greatest possible relief. It may serve not only to abort the suppurative process, but also to put a stop to the further secretion of milk. This expedient seems especially adapted to those cases in which it is advisable, directly after labor, to institute measures for the preven- tion of a free flow of the lacteal product. Dr. Marley recommends to smear the breast with the extract of belladonna.* He has em- ployed this treatment .for the prevention of mammary abscess with almost uniform success in 44 cases, in which a prompt arrest of the lacteal secretion was necessary. When the breasts are large and flabby, the extra weight may be relieved by a broad handkerchief, a net-work supporter, or by strips of adhesive plaster properly applied. i)r^st a s nsofsupP ° rtforthe These plaster-strips are sometimes used to secure uniform compression of the glands, and thereby diminish their secretion. The bandage of Seutin has been •extolled for the same purpose. Our patient should abstain from soups and all kinds of liquid food, and satisfy her appetite chiefly with solids. It would not be best for her to drink largely of any fluid The proper diet. J whatever, more especially of water or malt liquors. She will take a dose of the calcarea carbonica every night, and apply the camphorated oil externally. * Ti-ansactions of the Obs. Society of London. Vol. I., p. 31. 480 THE DISEASES OF WOMEN. EXCORIATED NIPPLES. The next case on the list this morning is one which has come as an inheritance from the puerperal state, and which will have its counterpart to your experience as general practitioners. It will afford you a good illustration of a class of cases which some wise physicians and nurses consider to be always preventable, but which will happen now and then in spite of the greatest care and precaution. It is a case of excoriated nipples, and, when we con- sider the delicate organization of the part involved, its peculiar function, its liability to traumatic injury, its exposure to the action of the mucus from the mouth of the infant, and to the heat and suction that are applied, the marvel is that such lesions are not more frequent. Cases of this kind are sometimes very difficult of cure either because the patients general condition favors their becomings chronic and intractable, because there is some trouble of the gland behind them, and of which they are the outlet, or because of the necessity of putting the babe to the breast often enough to empty it and nourish the child. Case.— Mrs. G.'s third child is but four weeks old. This babe is a fat hearty boy, while the mother is slender but of general good health. She reports having passed through her lying-in without any serious illness. She has, however, suiferecl extremely from sore or excoriated nipples. This trouble 'began immediately after the appearance of the milk, on the third day after delivery, and has continued until the present time. She says that she could "get on very well, but that each time after nursing, the nipple is left raw and bleeding;" and that " when the little fellow lets go his hold, it almost takes her life." She had a similar ex- perience with each of her former children, from which, despite all the means employed, she did not recover until they were weaned., at the agfe of three months. This is by no means a trivial case. In private practice you may encounter forty of them for every one like that upon which my brave colleague, the professor of surgery, has just performed a capital operation. And, unless you know how to treat them, each one may give you forty times as much trouble. Although the nipple may be accidently torn off by the child, you will not ABSCESS OF THE MAMMARY GLAND. 481 he permitted to dispose of this troublesome member by ampu- tation. Sore nipples are more frequent in primiparse than in multiparas. There are those, however, who, like our patient, suffer from them with each successive pregnancy. The affection ^iost frequent in primi- SO metimes begins during the later months of gestation, but usually not until the child has been " put to the breast" a few times. If the skin covering the nipple is very tender, thin and delicate, the first Local and general causes. . , . . . attempts at nursing may increase its sensitive- ness or strip off the epidermis in some places. The more vigorous and voracious the child the greater the danger in this respect. In women with light complexions, and light or red hair, the cuticle is very delicately organized, and easily removed. There is a popular idea that, because they are stronger and more rough in their little manners, boys are more apt than girls to wound the nipple while nursing. There is little doubt but that this painful affection is sometimes due to the removal of the sebaceous matter from about the nipple by the mouth of the infant. In other cases the nipple is bruised by the gums. Or it may arise from a lack of cleanliness, or from not drying the nipple so carefully as should be done after nursing. Sometimes it may spring from a depraved or cachectic condition of the general system, chargeable to original organization or to the drainage which is consequent upon gestation. Again, it may be caused by an aphthous condition of the child's mouth, whereby it has been inoculated with a poison- ous principle. In exceptional cases the child may be syphilitic, and the erosion of the nipple will be found to present some specific peculiarities. The first symptom complained of is a burning or scalding of the nipple when the child takes hold of it, or upon its removal from the breast. This sensation may be accom- panied or followed by pain which is more or less acute. Sometimes the nipple, and again the whole breast, feels as if bruised. Or they may be the seat of acute, lancinating or stinging pains. In some instances the mother can scarcely persuade herself that her nipple has not really been torn off by the child. The torture of nursing the infant is sometimes very great. A fissure or chap in the skin, which is scarcely visible to 482 THE DISEASES OF WOMEN. the naked eye, may be sufficient to cause the most extreme and exquisite suffering. Women of the utmost courage and fortitude are not unfrequently brought to tears by this experience. Occa- sionally the weak and irresolute, more especially those who desire an excuse for weaning the child, refuse to nurse it after a few trials. Upon careful examination we may, perhaps, find that a consid- erable portion of the nipple has really been denuded of its invest- ing cuticle. This excoriation is generally most The excoriation. ° marked at the tree extremity and apex of the organ. It may arise from the warmth and moisture of the child's mouth, which seem as it were, to blister it and to separate the scarf skin from the delicate derm beneath. These abrasions may be either superficial or otherwise, according to the length of time that has passed since they commenced, and the lack of cleanliness or of proper treatment. They sometimes develop into broad ulcers, which are exceedingly vascular and irritable. They are slow to heal, because the reparative material thrown out is apt to be washed away or removed by the child before it is fully organized. Not unfrequently the fissures will be found to consist of long, narrow, linear ulcers, which are deep-seated and intractable, and which bleed easily. These ulcers may dip down The ulceration. . .- . into the nipple perpendicularly from its summit, or they may take a transverse direction, and finally cut off one- third, one-half, or the whole of the organ. They are exceedingly painful, particularly when exposed to the air, and in case the lips of the fissure, or hair-like ulcer, separate from each other. They may even become fistulous. The symptoms are aggravated by each attempt at nursing. The discharge from the abraded surface, or from the fissure, soon dries upon the nipple and forms a scab, beneath which pus is sometimes collected in considerable quantity. The injury done to the nipple by the nursing process may cause it to bleed so freely as to sicken the child and induce vomiting. In exceptional cases this affection may begin Avith an herpetic eruption about the nipple. The little vesicles are broken, and the almost constant irritation of nursing causes them to develop into ulcers, which finally coalesce and give rise to symp- toms such as I have already detailed. At other times it is the ABSCESS OF THE MAMMARY GLAND. 483 -outgrowth of a species of scorbutic cachexia, and accompanies the nursing sore mouth. Perhaps the most serious consequence of excoriated nipples is the danger of mammary abscess, which may result in any case from a lack of determination, or from neglect sorlnTppfe? abscess from on tne P art °f tne P at ient an d nurse, to have the breasts well and frequently drawn. The milk accumulates, the gland becomes painful, indurated and inflamed from over-distention of its ducts. The suppurative process is soon established, and constitutional and local symptoms of a grave character follow. It is in this manner that the worst examples of mammitis and mammary abscess may be indirectly referable to an erosion or ulceration of the nipple. If the patient is addicted to the wearing of tight dresses, this unfortunate result is all the more likely to follow. Treatment. — As prevention is better than cure, so we may save trouble by the use of expedients which are designed to prevent the possibility of the nipples becoming sore. Prophylactics. - .. _. . . lney may be " hardened by applications oi a weak lotion of the tincture of arnica, of alcohol and water, of brandy and water, of a linen cloth constantly wet with rum, by a wash consisting of equal parts of the tincture of myrrh and rose water, by bathing them in port wine, in green tea, or in a mixture of three parts of green tea with one of brandy. Or you may direct the use of a cerate of white wax and butter in' equal pro- portions. In the case of primiparse, simple prophylactics of this kind are especially serviceable in the later months of pregnancy. Care should be taken that the clothing over the breasts is not too warm and tightly fitting. It should be light and thin, esx^ecially during the last month of gestation. These precautionary meas- ures are also suited to those who have suffered from sore nipples on previous occasions, and in whom, if possible, it is most desira- ble to avert such a calamity in the future. Here, as everywhere else in the practice of your profession, you will find great need of discrimination. For although these and other expedients are useful and harmless, when Need of discrimination. .,.,..« properly applied, they may work mischief if wrongly used. And while too much blame is frequently laid at the door of monthly nurses, it is still true that they do a great 484 THE DISEASES OF WOMEN. deal of harm by resorting to traditional specifics of whose real properties and powers they are ignorant. An eminent author says: "Most nurses, indeed, possess a cata- Watch the nurse. . logue of nostrums — never-iailmg cures — for chapped or ulcerated nipples ; and I think many of the most dis- tressing cases of the kind we meet with are occasioned by these busy characters taking the management on themselves , and, as is usual with the ignorant, relying implicitly on the virtue of their favored specific alone, without attending to the necessity either of protecting the nipple, or of duly evacuating the breast." If there is simple abrasion of the nipple, it may suffice to have it carefully cleansed and then dried \ r *02 THE DISEASES OF WOMEN. In many cases the} 7 are too frequent, as well as too profuse, for a season, and afterwards are more tard}^ and abnormal in this, respect. In a considerable proportion of cases the amount of the flow lessens gradually, so that it may finally come away drop by drop, or until there is nothing of it left. But as the Haemorrhage. change approaches, many women find them- selves flowing more freely than ever before. Indeed, the tend- ency of the catamenial discharge to develop into a haemorrhage is often observed. Out of 500 women at the change of life, Tilt observed that 208 had haemorrhages of various kinds. Of these, IS 8 had either a single terminal flooding, or successive floodings.* Other forms of haemorrhage, which are in a sense vicarious of the monthly flow at the climacteric, are haemorrhoids, entorrhagia, epistaxis, haemoptysis, cerebral haemorrhage and apoplexy, hsem- atemesis, haematuria, bursting of varicose veins, bleeding from the ear, and cutaneous ecchymosis. In plethoric women these losses of blood are in a sense critical, and although they are often dan- gerous in themselves, yet as a kind of safety-valve, they are sometimes salutary. The sudden arrest of the accustomed flow, when the change comes on abruptly, and more especially in those who are in good health, is often the occasion of alarm with such Simulates pregnancy. persons lest the} r be pregnant. I his suspicion finds apparent confirmation in the coincident gastric derange- ments that not unfrequently ensue. There is something resem- bling morning sickness, caprices of appetite, a sense of fullness and discomfort, and pelvic bearing-down and aching which women recognize as very similar to, if not identical with the symptoms of early pregnancy. You will certainly be consulted in cases of this kind, and in making a diagnosis should not forget that some women cease to menstruate as early as the twenty-fifth year. Sometimes the most violent, and again the most persistent and intractable indigestion, colic, diarrhoea, haemor- Alimentary symptoms. . . rhoids, dysentery or constipation, come with the first symptom of the menstrual decline. In many cases, these *The Change of Life in Health and Disease. By Edward John Tilt, M.D., etc., London, 1867, page 65. THE CLIMACTERIC PERIOD. 5(Jo attacks are self-limited, and subside of themselves when the crisis has finally passed. In a few they supplement the catamenial flow, and may pass into the chronic form. The circulation is very irregular, as is shown by flushes of heat in the face and elsewhere, local congestions to the head, giddi- ness, blushing and discoloration of the skin, Disorders of the drcuia- coldness, tingling and numbness of the ex- Iion. ° ° tremities, sudden outbreaks of perspiration, chilliness, rigors, and active haemorrhages. The nervous symptoms and sequelae of the climacteric are marked and sometimes very troublesome. In degree they vary from the slight mental perturbations, vulgarly Nervous symptoms. -i t i n i ?, styled " the fidgets, to the most profound con- vulsions and paralysis. Headache, vertigo, nervous irritability, pseudo-narcotism, self-absorption, insomnia, jactitation, palpita- tion, dyspnoea, horrible dreams, fainting, erethism, depression, debility, twitchings, spasms, mania, and full-fledged hysteria are by no means uncommon at this period. Either of these affections may precede, accompany or follow the cessation of the menses. In many cases the disorder is ephemeral ; but in others it becomes seated and confirmed. Spasmodic affections are very apt to con- tinue, and to take on a regular periodical type, which is most difficult of cure. The ganglionic nervous system is always impli- cated. There is a form of epilepsy which is not unusual at this period. I have seen several cases of the kind that were • in no way connected with the hereditary form of this disease. Only yesterday I was consulted by my friend, Dr. W. R. McLaren, for the relief of the following Case. — Mrs. , aged fort} T -five, is now passing through the grand climacteric. The menses recur every four to six months. They are quite profuse. About every seven weeks she has the epileptic seizure. There is no very strong muscular contraction or rigidity. The face is pale, and during the paroxysm there is stertorous breathing, with foaming at the mouth. The fit, during which she is quite oblivious to everything external, lasts about four minutes. After it she sleeps for three-fourths of an hour. The change of life commenced with her one year ago, at which time she first began to have the epileptic paroxysms. Epilepsy is 504 THE DISEASES OF WOMEN. not hereditary in her family, although her mother also had fits at the change of life. Disorders of the nerves of special sense are not infrequent. Deafness, blindness, aphonia, loss of the sense of taste or of smell, and of tactile sensibility in various portions of seSes° rdersofthespecIal the- skin, are among the more common of these affections. These complications are most apt to occur in weakly, nervous, debilitated women in whom, for some reason, the climacteric is very much prolonged or exhaustive. The respiratory system comes in for its share of the contingent ailments. Those women especially who are predisposed to pecto- ral complaints, who inherit this bias, and who sy Sem asesoftherespiratory have suffered some of the consequences of incipient organic disease of the lungs at or before puberty, are most likely to have something of the kind at the climacteric change. Perhaps the first thing noticed is a more or less copious spitting of blood, or a nervous, irritating cough, which by and by settles into a confirmed habit, and is accom- panied by free expectoration. In some cases these symptoms develop into a rapid decline, and the patient may not live more than a very few weeks. In others they subside of themselves when the first cause is removed, and the menstrual crisis is safely over. In not a few instances the boasted cures of phthisis pul- monalis are really to be ascribed to the fact that such cases as these are self-limited, and frequently get well of themselves. But, as you would suppose, it is the generative function and the sexual organs which are most seriously disordered in conse- quence of the final cessation of the menses. Disorders of the genera- xhus Dr. Tilt* found that of 500 women at the tive system. change of life, 463 suffered from uterine affec- tions. Among these contingent disorders are uterine cancer and catarrh, cervical inflammation and hypertrophy, uterine ulcera- tion, haemorrhage, hysteralgia, leucorrhcea, displacements, tumors, hydatids, polypi, and fibroids. Either or all of these diseases are more serious if the patient has already suffered from them. Other complications are ovaritis, ovarian induration, atrophy and paralysis, the development of cystic tumors, and of ovarian *Op. citat., p. 82. THE CLIMACTERIC PERIOD. 505 abscess, and hematocele. And still another disease of the generative system, properly speaking, is cancer of the breast, the development of which appears in many cases to be hastened by the permanent arrest of the menstrual secretion. Women sometimes suffer from a species of rheumatism and others from neuralgia which worries them exceedingly, and may perhaps wear away their remaining strength very Rheumatism and neuralgia. . rv» • • rapidly. Again these affections are combined, and either or both of them may be located within the pelvis. The arrival of the critical period may act as an exciting cause, and really occasion an attack of rheumatism in one who not only has never had it before, but who was thought to be free from any pre- disposition to it. I could cite you many cases of this kind, but it must suffice merely to call your attention to the fact itself. Prognosis. — Where serious diseases occur at the climacteric, or follow it almost immediately, you will be puzzled in your prog- nosis. Eminent authorities are of opinion that The general health the f^g ovarian activity is commensurate with the best criterion. «/ constitutional vigor ; and that, as a rule, life is longest in those women in whom puberty is retarded and the menstrual function most prolonged. Therefore, it will be a safe criterion upon Avhich to base an opinion if we say that the patient's previous health (especially in so far as ovulation is con- cerned) has been good or ill, habitually. If she has been weakly and sickly, and suffered from menstrual derangements, such as dysmenorrhea, menorrhagia, and amenorrhcea, or her nutritive resources have been sapped and drained by a chronic leucorrhcea, or diarrhoea, or mal-medication, or starvation, whether mental, moral or physical, the case is not of the most hopeful kind. The same is true of the bad effects of scrofulosis, and of too rapid child-bearing, as tending to undermine the general health and vigor, and to leave the patient a more easy prey to the contingen- cies that beset the menopause. We are therefore compelled to make due allowance for previous ill health, and to qualify our prognosis ; for it is a crisis through which the woman must pass, and whether she will survive it or not, will depend very largely upon the stock of strength that she has in reserve to be°in with. 50 J THE DISEASES OF WOMEN. Critical catamenial haemorrhages are dangerous, not because, as the ancients believed, that certain poisonous matters from the menses are retained in the blood-current, and Cause of the danger. i -i -i • • it i need to be eliminated, but because ol an over- whelming afflux of blood to a delicate tissue or organ, which mav soon result in disorganization and death. If the cessation of the periodical flow shall re-act upon the lungs, and light up the tuberculous diathesis, it will not be safe to promise to cure the patient. And so, also, The tuberculous diathesis. pi-txi ot the alimentary disorders, ot which 1 have spoken ; for, although some of these utero-intestinal affections subside of themselves, when the menses are entirely disposed of,, still in many other cases they only run a more rapid and fatal course. Treatment. — The critical period, therefore, is beset with so many dangers that its treatment becomes a very important mat- ter. The first thing to be done is so to regulate Hygienic rules. the habits and surroundings 01 the patient as to protect her against these dangers. The state of her mind, the amount and variety of her physical exercise, and her food, must be prescribed and regulated according to the rules of hygiene and of good, sound common sense. Nothing wears upon a woman who has reached the turn of life like a want of sleep, of rest, and of freedom from the petty cares and annoyances which she could once overcome by her own strength of will. She should be encouraged and stimulated by cheerful society,, and pleasant intercourse with a few friends. Her thoughts should not be introverted. She should not be permit- ted to brood over such reflections as will make her nervous and wretched, but should become interested in the- welfare and happiness of others ; for this is the line of thought that henceforth must engage her attention. Especially should you guard against the development of any disease to which she is predisposed. If she is liable to hsemor- rhagic attacks from plethora, let her diet be Guard against hereditary p i a i n an d unstimulating, her habits as active as predispositions. -L © ' possible within the limits of prudence, and give her such remedies (according to their specific indications) as aco- nite, belladonna, veratrum vir., gelseminum, bryonia, or ipecacu- THE CLIMACTERIC PERIOD. 507 anha. If, however, the haemorrhage is passive, and the result of an anaemic or vitiated habit, you may consult For the haemorrhage. . .-.,. the merits ot nitric acid, china, arsenicum alb., secale cor., sabina, crocus, trillium, erechthites, pulsatilla, ferrum met., and carbo vegetabilis. Cool acidulated drinks ought always. to be preferred in this class of cases. Tea and coffee should be interdicted, and so, also, should very active or violent exercise. Next to this tendency to haemorrhage, which is always alarm- ing and frequently dangerous, especially at this time of life, the possibility that the patient may pass almost hthLis he tendency t0 insidiously into a decline from tuberculosis in some of its forms, renders it necessary to antidote this predisposition whenever it exists. For this pur- pose certain precautionary measures are requisite. A limited amount of exposure is not necessarily harmful, but care should be taken that these patients incur no risks in this regard. They should not be suffered to take cold, to get the feet wet, to go out in a storm, to wear insufficient clothing, no matter how fashion- able, or to talk or to sing too much and too long at one time. They should keep in from the night air especially, and not be permitted to sit in the open air, as many women are in the habit of doing. Such a patient should not be removed from her old home into a new house, for example, in which the walls are not dry. In brief, without being fussy, she should take unusual care of her health at this period, for a slight indiscretion, or an otherwise trifling cold might act as an exciting cause for the development of a latent disease that would soon carry her off. The remedies to be thought of in this connection are calcarea carb., calcarea phos., sanguinaria, phosphorus, stannum, mercurius jod., kali jod., kali brom., kali carb., hepar sulph., lachesis, sepia, lycopodium, nitric acid, ignatia, bryonia and silicea. The greatest possible care should be taken to recognize and to remedy the first symptoms of tuberculosis in a woman who is passing the critical period ; for if this is done there is little doubt that much trouble and suffering may be spared, and her life prolonged. The symptoms of coincident digestive disorders may be treated upon specific indications, always giving pref- For the digestive disorders. L r J ° ° L erence, however, when possible, to those reme- dies that have a curative relation to the generative, as well as 50o THE DISEASES OF WOMEN. to the alimentary function. Nux vomica, colocynth, arsenicum alb., mercurius, pulsatilla, natrum mur., bryonia, calcarea carb., cocculus, veratrum alb. and veratrum vir., chamomilla, sulphur and belladonna belong to this class. The diet should be regulated with the greatest care. The wonderful influence of aconite over most of the derange- ments of the circulation at the climacteric, has long been known. It is an invaluable and almost indispensable ciSiadon disorders ° f the remedy. Other available remedies of this sort are veratrum viride, gelseminum, and bella- donna. They are not only indicated physiologically and patho- gen etically in many cases, but the indication includes their special relation to disorders of the sexual system, more particularly to such as depend upon certain crises in the uterine and ovarian circulation. For the " flushes" and flashes of sudden heat, which constitute the most troublesome symptoms in milder cases, Dr. Madden recommends lachesis, either in the sixth or twelfth dilu- tion ; Dr. John F. Gray, sanguinaria ; and Dr. Trinks, sulphuric acid. You will find the indications for these and other remedies in Dr. Richard Hughes' excellent work on Therapeutics.* The nervous epiphenomena demaucl such remedies under almost the same identical indications, as would be prescribed for them if they were incident to the more com- For the nervous symptoms. mon menstrual disorders, as tor example, dys- menorrhea, amenorrhea or menorrhagia. Belladonna, ignatia, hyoscyamus, coffea, chamomilla, moschus, pulsatilla, caulophyl- lin, macrotin and senecin, are most freely indicated. And so likewise of diseases of the generative organs that are incident to the critical period. The rules which I have so fre- quently repeated with reference to their medi- For the disorders of the ca j anc j surgical management should be carried generative system. © o out in practice with even more than ordinary •care and skill. Whatever can possibly interfere with the structural changes which result in the atrophy of the ovaries and the uterus, as a part of the critical process, should be removed. For these structural changes, brought about through fatty meta- morphosis, really pertain to the period through which the patient * A Manual of Therapeutics, by Richard Hughes, L.R.C.P. Ed., etc., etc., N. Y. 1869, page 455. THE CLIMACTERIC PERIOD. 501) is passing, quite as decidedly as the cessation of the flow itself. Since it might therefore interrupt this retrograde metamorphosis of the tissues if inflammation were established in them, you should see to it that such a contingency is averted ; or if it has already be^un, to cure it and remove its consequences as speedily as possible. For the rheumatic and neuralgic complication, macrotin, rhus tox., atropine, the valerinate of zinc, mercurius, For rheumatism and L J neuralgia. and similar remedies will be required. THE COMPARATIVE FREQUENCY OF VARIOUS DISEASES AT THE CLIMACTERIC. At a late meeting of the Clinical Society Dr. B. L. Reynolds presented a table of fifty cases drawn from my clinic, illustrating the date of the menopause and showing the relative frequency of the diseases that accompany and follow it. Of these fifty cases, it will be observed that the age at which menstruation ceased, was below forty in two cases ; between forty and forty-five, in fitteen cases ; between forty- five and fifty, in twenty cases : between fifty and fifty-five, in thirteen cases. In one instance, the change of life occurred at fifty-six and in another at fifty-five. Of the diseases from which the patients were suffering when they came to the clinic,, and which were post-climrcteric, there Avere seven cases of dyspepsia, six of apoplexy, Relative frequency fiye of rl ieumatism, four of procidentia of the of disease. L uterus, three of headache, two of anasarca, two of gastritis, two of epithelioma of the cervix, two of prolapsus uteri, and one each of asthma, epistaxis, bronchocele, Bright's disease, dyspnoea, papular eruption, incipient paralysis, hemiplegia, hemorrhoids, haemoptysis, spinal irritation, tuberculosis, uterine epistaxis, metrorrhagia, ovarian dropsy, uterine fibroid, and chronic vaginitis. Although this table might have included many more cases, it serves to illustrate the relative frequency of diseases that occur at this particular period, and will give a good idea of what I shall be privileged to show you in this department of my clinic. Dyspepsia, rheumatism, etc., are as certainly modified by the menopause as they would be by puerperality if they occurred after child-birth. 510 THE DISEASES OF WOMEN. •aov Tj<-rt | iO ^<)O^Tti'^iO'5ti-^LOr^'<^Ttirt*TtiTjHrtl'^irtiTt 1 ' •asvo 'OK aov SxtftftfPn p- p- = p .5 ,rH s os y, >>© & >> u c *s .= >> a W^H^^PhOPhP^PPPhPPhP^ X>CS^Oi05i0003 t*l>^XGOXX30MXQOGOX»XCOO0XXtX)X0Ot-Nt' asvo Ir« CO.P CO C3 CD-g P r— i -h o; 9? P-~ P o3 T3. CD ,P a >. • >.co CD .22 CD CD c re-Ox's ^.'C P O CD +=> CD a- CD ® -P o'p-0£ O ^ ° m CD S -- o3 O CD ^ g 5 P jEl'P P-^> Cy — V4/ ^ kj^ ^ •*< r* gfiiij: +j Q-4-> P- > P* 1- 1*1 -* O T^ r^ ri ..— I 03 c s >>cd CO > '5 CD fH O ;i 0.5 p 'S.h co a>» ^■eoce C5MiOCBQOaiN3:iOXOqeO'i'C»«NHXMXiC»eOHOt' i-H 1— 1— iMCMrOCO'rf^riTfiiO'CiiOiOCDOI^^'CN^COTtiiOiOcO cr)COCOiX>COCOCOCOCOCDCDCC>CDCC>CDCDCOt^GOI>.'t^L^t^l^l^ therefore, you are not to conclude that such a patient is certain to fall a victim to one of the forms of uterine cancer. This kind of a dis- charge, in this class of cases, is self-limited and not malieriant. But bearing in mind that cancer of the womb is more frequent after the climacteric, you should be careful in promising an exemp- tion from that terrible disease while the discharge continues to be corrosive in character. It is for the relief of this kind of a discharge, in connection with the menses at the menopause, that I prefer the use of nitric acid, and sometimes of kreosotum, either of which acrid flow. ° r * may be given in the third or the sixth dilution. When the menses are scanty with flushings of the face and vertigo, sanguinaria 3, is often an excellent remedy. For the throbbing pulsations, and local determinations of blood 520 THE DISEASES OF WOMEN. to the head and to the spine, which threaten to end in paralysis, glonoine is a better remedy than lachesis. POST-CLIMACTEEIC NEUROSIS. Case. — Mrs. , German, aged sixty, midwife, has been an invalid tor eight years past. Her menses ceased without any other ill effect than that, when they stopped, she became subject to dis- tention of the stomach and abdomen, with shooting, stabbing pains that came mostly at night and forced her to cry so loud that her neighbors could hear her. The seat of these pains, here and there over the abdomen, sometimes became swollen and tender to the touch. For months at a time she has not been entirely free from this local hyperesthesia. The bloating of the stomach is sometimes accompanied by a burning pain at the epigastrium. This patient has been prescribed for by many physicians, but without relief. Last year she made a voyage to Germany ex- pressly to consult certain eminent practitioners, but derived no benefit from their prescriptions. Through the advice of a neigh- bor, she came here three weeks ago, and I recognized the relation existing between her symptoms and the menopause. For it may happen that the remote consequences of this important " change" shall be entailed upon a woman for many years after the flow has ceased. My first prescription was the citrate of iron and strychnia in the 3d decimal trituration; but it did her no good. At the next visit she took atropine in the same potency, to be repeated every three hours. You have heard her story and can believe her when she says that for eight years she has not been so free from suffering as since she has taken that remedy. We will continue it, but repeat it only thrice daily. CLIMACTERIC RHEUMATISM. Case. — This patient is forty-five years old, married, and has had several children. She now complains of pains in her shoulders and chest, which she thinks were caused by taking cold about a year ago. At that time, an abscess formed in her left breast, which was lanced and discharged freely. She was not nursing at the time. Her menstruation was established at eighteen, and still continues. For six months previous to the flow, she had been afflicted with blindness, which came in paroxysms in the afternoon, and continued until the next morning. The flow now lasts a week, and is copious, causing great exhaustion. There is a cold BILIOUS COLIC AT THE CLIMACTERIC. 521 sensation extending from the knees down to the feet, which are always cold. Silicea 3, four times a day. May 12. Is feeling' much better; has some pains across her shoulders, but is gaining strength. Silicea 3. May 19. The patient was improving until, beinsc unfortunately exposed to the rain, she took a severe cold, and the old pains in the neck and shoulders have returned. The menses are also delayed. Rhus tox. 3.* June 2. The pain in the shoulders has disappeared, but there is still some in the region of the stomach and liver, which she thinks is aggravated upon taking a deep inspiration. The menses have not yet appeared. Rhus tox. 3. [The record shows that this patient afterward suffered from muscular rheumatism in other parts of the body, but chiefly in the fleshy parts of the arms, for which she took macrotin with the best effect. The menses came less frequently, and finally ceased alto- gether, after which the rheumatism soon disappeared.] Rheumatism at the climacteric is quite as much of an outlaw as it is under other and very different conditions. This case was cured by macrotin 3, under indications which have come to be regarded as reliable. A little while ago, you remember, we cured another case with nux vomica 3, when, along with the rheumatic pain in the right arm, there was formication, or a feeling as if ants were crawling beneath the skin. Other cases have been cured with gelsemium, cactus, lachesis, aconite, and sanguinaria. BILIOUS COLIC AT THE CLIMACTERIC. Case. — Mrs. T. aged 52, ceased to menstruate four years ago. For two years before the change came she had been subject to what her physician said Avere attacks of bilious colic that were due to the passage of gall-stones. After the flow stopped these attacks of the colic became less severe, but they still continued to recur at intervals of from three to ten days, when she applied to this clinic six weeks ago. She has been forced to be very careful in her diet, and has observed that when the lit ccmes on, if she lies down and keeps very quiet it is less severe and passes oft* more quickly. She says that her mother died of cancer of the stomach. Concerning the cause of the difficulty she is firmly persuaded that it was due to fright. The circumstances were that, while she was menstruating, word was brought to her that her child was dead. He Avas soon brought home from school in a horrible fit, after Avhich he was ill for a long time and she nursed him. When this happened she had already had some wa ruing of the approach 522 THE DISEASES OF WOMEN. of the climacteric ; and after this fright and worry she not only had the attacks of colic, but she became very irregular and suffered more than usual at the month. For the first fortnight she took china 3, three times daily, with the effect to lessen the severity of the paroxysms, but they still continued to return as before. She was then put upon chamomilla 3, and improved in every way. In a little while she observed that a single dose of this remedy would snuff out a paroxysm, and soon they ceased coming altogether. If the change of life always came at a certain age, and if its advent could influence the health of women for a certain period only, before its arrival, we should be better able cifmrcterif 0118 ^ 1116 t0 estimate its effects in a clinical way, and also to prescribe for them intelligently. But when a woman has been out of health for two years in anticipation of this epoch, and when during that period she has been exposed to an exciting cause that would certainly have made her ill at any other time, the morbid conditions are so complicated that it is very difficult to solve them. If we add to this, as in the case under review, a manifest predisposition to a disease, or a dyscrasia like that of cancer, we shall be very chary of promising to cure the patient, or even to make her comfortable for any considerable length of time. You have witnessed the remarkable effect of chamomilla in this case, and the delight with which our patient A qualified prognosis. c ascribed the result to the remedy; but I must warn you not to conclude that her disease is radically cured. PROLAPSUS UTERI WITH DROPSY, DATING FROM THE CLIMACTERIC PERIOD. Case. — Mrs. , aged 52, has had four children, the youngest of which is now fifteen years old. She has had but one abortion, and that occurred prior to the birth of her last child. Her men- struation was first established at the age of twelve years, and it ceased at forty, that is to say twelve years ago. She says that her mother met with her " change " at the same age. The first symptom of ill health that this woman remarked in her own case, was a bloated feeling in the abdomen, which was sometimes quite full and distended, and again would subside to almost its natural size. This enlargement, she says, was uniform in its development,, and not limited to any particular portion of the abdomen. There has been no tenderness on pressure, and no soreness. The swell- PROLAPSUS AT HIE CLIMACTERIC. 52S ing is notably increased by exercise, and is accompanied by bloat- ing and pufnness of the limbs, the feet, and the face. The bowels are habitually constipated, and if she fails to take a laxative pill, she has a great deal of straining at stool, and finally passes only dry, hard scybala. By reason of this urging at stool, she is quite positive that the womb is sometimes very much pro- lapsed, so much so, indeed, as to threaten protrusion from the vulva. She is also certain that at these times she has felt it lying between the labia majora. When she lies with the head low and the hips raised, the " tumor" disappears. The Dispensary Physician, has made a careful vaginal examination of this case, and diagnosticates it as one of confirmed prolapsus uteri. The swell- ing of the integument is evidently dropsical, as is proved by its " pitting" under the pressure of my finger. The urine is scanty and high colored ; the appetite capricious. Uterine displacements are so frequently related, either directly or indirectly, to abortion and to labor at term, that it will be well Parturition a cause of for you, in every case, to inquire whether the uterine deviations, and atient has rece ntlv passed through the process the climacteric period -»■ - • *■ o i predisposes thereto. of parturition. This woman's last labor occurred fifteen years ago, and the probability that the uterine deviation dates from that event is very much lessened by the fact that it was not noticed until three years later. The prolapsus came on with the "change," or the advent of the grand climacteric, which, in her case, occurred at the early age of forty years. It is, therefore, possible for the uterus to become displaced at the end of the child- bearing period, and from other causes than a defect in its proper involution, or folding upon itself, after labor. Now the most obvious reason why she, at her time of life, has a prolapsus so decided, and which is only remotely, if at all, related Dropsy at the ciimac- to pregnancy, is the co-existence of dropsy, to teric, and constipation, which many women are liable at the climacteric. causes of prolapsus. The .^^ ftnd general anasarca are indicative of a weakened and relaxed fibre, which strongly predisposes to uterine displacements. Add to this the direct pressure imposed upon the womb, also the semi-paralyzed condition of the rectum, and of the perineum (which has lost its resiliency), and the dis- placement downwards, even to the extent of procidentia, is readily explained. The only support that the uterus has from below, is from the contractile wall of the vagina, which rests like a column upon the perineum ; and the chief muscles of the latter are con- 524 THE DISEASES OF WOMEN. nected with the rectum and the anus. In the constipation which is incident to chronic cases of this kind, the tone and elasticity of these tissues is partially or wholly lost. The straining at stool may therefore not only serve to perpetuate the luxation, but also to change its degree, and even its variety. It may convert a case of retroflexion into one of retroversion, or of .simple prolapsus into procidentia. This relaxed or weakened condition of the muscular floor of the pelvis is, as I have already said, much more likely to follow upon the heels of labor, either premature or at term; but it also occurs in those who, like this patient, have borne numerous children, and Avho become subsequently afflicted with protracted and debilitating disease. Treatment. — The relief afforded by the horizontal position, with the hips elevated, is significant. Many cases of prolapsus need but little beside appropriate postural treatment. It Postural treatment, fe } ng that th displaced uterilS Will and the perineal pad. *■ l l gravitate into its proper position, if the patient can keep off her feet. But it is not always possible, nor would it be best, for women with this infirmity to go to bed and remain there. Those of the poorer classes must work, and they ail need exercise. And thus it may become necessary to supply a means of support which shall supplement the relaxed muscular fibre of the vagina and of the perineum. It is in just such examples of prolapsus as this, occurring in women somewhat advanced in life, who are ill in other respects, and constitutionally weak, and withal obliged to walk and to work daily, that I am accustomed to recom- mend the wearing of the perineal pad, as a means of temporary relief. It will accomplish more, and is more available in most instances, than any other form of supporter. In conjunction with the proper internal remedies, its effect is to tone up the parts which afford the natural support for the uterus, and at the same time to allow the patient to move about with impunity. I shall speak, in a subsequent lecture, of the proper indications for pes- saries, and the value of them in this and other forms of uterine displacement, as they occur under different circumstances. It is important that this patient should re- an^ y r?mea 3 ieT CaUti0nS ' f rani fr° m a U violent exercise, more especially from lilting heavy weights, and from scrub- bing, sweeping and ironing. She should not permit herself to POST-CLIMACTERIC ANASARCA. 525 strain at stool, neither sit in a constrained position for any con- siderable time. Her food should consist largely of albuminous matters, designed to improve the quality of the blood; and of vegetable substances, particularly of such as are somewhat laxa- tive, as fruits, and bread made of unbolted flour. The remedies that are most prominently indicated for this particular case are mix vomica and apis mellifica. And, since neither of them will cover the two sets of syrup. Internal remedies. . toms which are present, 1 recommend them to be given in alternation, the former at evening, and the latter in the morning and at noon of each day. The mix vomica is espe- cially indicated on account of the constipation, the straining at stool, the passage of scybala, and the threatened escape of the uterus from the pelvic cavity. There are the best possible patho- gentic and physiological reasons for its employment, although in chronic cases like this, I think it should not be given more than cnce or twice daily, hi similar cases, lycopodium, or sepia, will sometimes prove of the greatest utility. The manifest relation between the commencement of the drop- sical symptoms, and the arrest or cessation of the menstrual function furnishes us with a characteristic indication for the apis mellifica. In using this remedy, my own preference is for the second or third decimal triturations. POST-CLIMACTERIC . ANASARCA. Cose. — Mrs. , is 66 years old. She is married, has borne sixteen living children, and has had two miscarriages. Ten of the sixteen children died before they were one year old. She has been constantly ill for six or seven years. The menses apparently ceased at the age of fifty-two, but were intermittent and irreg- ular during the three following years. She had always flowed copiously at the month, and suffered much from exhaustion. There is now a general anasarca. The urine is scant; there is pain in the kidneys, and her limbs " burn like fire." There are also varicose veins of the lower extremities. She has some vertigo, but the appetite and the sleep are good. Hamamelis 3. May 26. She thinks there is some improvement, but the urine is still scant; her limbs burn, and the veins are still swollen. Hamamelis 3. June 2. She is feeling very much better; her limbs are less troublesome ; the quantity of urine has increased, and with that all 52G THE DISEASES OF WOMEN. the symptoms are improved. Continue the hamamelis 3, three times a day. The two prominent factors in this case were such as often co- exist, viz. (1) a tardy venous circulation, and (2) anaemia. m . . . . Both these conditions are incident to the haemor- The haemorrha -i i with the suddenness of a rupture ot the bag of waters. She could not have had an abscess without previous local pain and suffering, and general constitutional symptoms, of which she makes no mention. Constipation is the rule in similar cases, and a woman at 45, who has had eight children, can hardly have escaped haemor- rhoids. Concerning the latter I have questioned her carefully, and find that they are not inveterate. This prurigenous eruption is always accompanied by a loss of rest and sleep, constant irritation and distress. It is very apt to become chronic. The heat of the parts, and Symptoms. . . the torment sometimes occasioned by walking, sitting, intercourse, and physical exercise of every kind, are almost insupportable. If the characteristic peculiarities of the eruption have not been destroyed by the scratching and rubbing of the parts to which the poor victim is compelled to resort, the papulse resemble those of prurigo when it is seated on other parts of the body, as, for example, the neck, shoulders, back and outer surfaces of the extremities. So much of The eruption. n it as is located upon the cutaneous surface ot the labia, the perineum, and even about the anus, may be color- less and invisible, but if the parts have been wounded by fric- tion, you may perhaps find little black scabs scattered here and there. Sometimes, as in this case, there are occasional vesicles and wheals, which are readily discharged. On the mucous side of the raphe and within the vagina, how- ever, the color of the eruption differs from that of the surface upon which the papulae are located. This is especially true in VULVOVAGINITIS. 541 the case of elderly women in whom there is no diffuse vaginitis, and whose vaginal mucous membrane has not The color of. . _ recently been discolored either by pregnancy or menstruation. But, in younger persons, in whom the opposite condition of this membrane prevails, there would be very little difference in hue between them. The causes of this peculiar affection are really unknown. It has been ascribed to various infractions of the rules of hygiene, such as the eating of unwholesome food, and the lack of proper clothing, cleanliness and exercise, to sexual excesses, to the change of life, and to the non- elimination by the proper emunctories of certain impurities from the blood. It may alternate with chronic skin disease. There is a form of granular vaginitis from which pregnant women sometimes suffer that should not be confounded with this. In it the eruption, or rather the pin-head pim- va5nuE° sIs fr ° m granular pies, consists of myriads of little granulations which give rise to pain, heat, and sometimes to considerable discharge. It is self-limited, is not accompanied by vulvar prurigo, and terminates with deliver}^. Prurigenous vulvitis, of which this is an example, can be dis- tinguished from the follicular variety by the fact that in the latter the lesion is limited to the follicles which are From follicular vulvitis. . . , . , found upon the vulva, and just withm the ostium vaginse. These follicles become inflamed and finally dis- charge a purulent or muco-purulent secretion which, in many cases, may be seen exuding from the mouths of the separate folli- cles. But these diseases often co-exist. Follicular vulvitis is also incident to gestation, and may occur as a contingent or sequel of the eruptive fevers, and of diphtheria. More frequently, how- ever, it is due to a very depraved and vitiated habit. Sometimes it is a sequel of gonorrheal inflammation. This form of vulvo-vaginitis not being purulent as it would be if the eruption were eczematous, or herpetic, or if the inflamma- tion were more diffuse and deep-seated, the The leucorrhoea. amount of the leucorrhceal discharge is not m proportion with the local suffering. Mrs. T. has but little flow of this kind. Where, however, the eruption and the inflammation extend within the cervix uteri, and possibly into the uterine cav- 542 THE DISEASES OF WOMEN. ity, as there is good reason for believing that they sometimes do, the quantity of mucus and of pus secreted may be very large. In middle-aged and more vigorous subjects the presence of these little papulge (as in case of other vegetative growths within the vulva), may excite a very troublesome leucorrhoea. If the dis- charge that is poured out is thin and serous in character, it is very apt to dry upon the parts and then to crack and break into little scales which cause an intolerable pruritus. Some of these patients will tell you that they have no leucorrhoea, when in fact they are deceived and the discharge is disposed of in this way. In rare instances the eruption invades the urethra and occasions a very persistent and troublesome form of urethritis. The entire exemption of our patient from urinary troubles, such as strangury and the like, affords an indirect proof that she has not suffered from any variety of uterine devia- ceming uterine displace- tion. For this reason I felt almost confident merits. . that her womb was in situ before passing the sound. You remember that the attachments between the neck of the uterus and the bladder are such that it is next to impossi- ble to displace the former without pressing upon, or changing the position of, the latter. And when a woman tells you that she is not subject to, and has not suffered from, vesical troubles of any kind, you may be reasonably assured that her womb is where it should be. But you are not to conclude that because she has strangury, dysuria, etc., therefore her womb is displaced ; for these symptoms may arise from other and very different causes. The prognosis is generally favorable, but the time required for the cure will vary according to circumstances. Such cases recover more readily in winter than in summer, in cool Prognosis. . . . than m warm climates, and in young than m old patients. Scrofulous persons, and those who are predisposed to aphthous conditions, or to chronic cutaneous eruptions of what- ever kind, get well very slowly. The syphilitic taint may retard the cure. If it follows the climacteric very closely, or co-exists, as in the case before us, with rheumatism, we shall not be war- ranted in promising very speedy and permanent relief. Treatment. — As affording direct relief, and being capable of making life tolerable, the topical treatment is very important. The proper palliatives have already been mentioned when speak- INFANTILE LEUCORRHCEA. 543 ing of pruritus of the vulva. Cleanliness, frequent bathing with cool or tepid water, and the application of a Topical treatment. , .. , , , , , bland demulcent, as bran-water, glycerine, almond oil with or without chloroform, or of the muriate of Irydrastin with glycerine, will answer an excellent purpose. Cloths or compresses anointed or saturated with one of these may be applied to the vulva ; or the cotton tampon may be the vehicle for introducing the same into the vagina. The diet should be plain and unstimulating, the exercise mod- erate, and coitus positively forbidden. The internal remedies should be suited more especially to the character of the eruption, the patient's peculiar clyscrasia, and the relation of the disease to child-bearing and Constitutional treatment. . , . the climacteric. Among the remedies that may be required in different cases are rhus tox., sepia, sulphur, arseni- cum, calcarea carb., conium, hydrastis, croton tig., carbo veg., mercurius, natrum mur., kali carb., creasotum, thuja and the mineral acids. Taking the peculiar eruption, and the incidental rheumatic symptoms as a guide, I shall select the rhus tox. as the remedy for this patient. She will take of the 3d attenuation a dose every three hours. This frequent repetition is justified in her case by the severity of her rheumatism. She will also have the glycerine and hydrastin applied locally morning and evening. INFANTILE LEUCORRHCEA. There is a form of vulvo-vaginitis to which little girls are liable, and of which I may speak in this connection. The mucous mem- brane reflected over the vulva becomes so in- flamed, heated and irritated, that the child has no rest, but is constantly tempted to relieve itself by rubbing the parts, which only increases the trouble and extends the inflamma- tion. Sometimes the first symptom complained of is pain on passing water, which also creates a sense of scalding and itching. This is accompanied by dryness, redness, and heat of the inflamed surfaces. Soon, however, the parts become moist from the exu- 544 THE DISEASES OF WOMEN. dation of a thin, colorless mucus which, as the case progresses,, becomes of a thick and creamy consistence. The amount and quality of the leucorrhceal discharge varies with the constitutional taint, as well as with the duration of the disease. In scrofulous children, more espe- cially if they have been allowed improper food and have not been kept in a cleanly, healthful condition, the leu- corrhceal flow may be either very copious, or perhaps ichorous and corrosive. In bad cases of this kind there is not only inflamma- tion, but ulceration also of the vaginal mucous membrane. When these patches of ulceration are present, they may be seen by stretching the labia apart. More rarely they are found in the upper portion of the vagina. The causes of this form of vaginitis in children are numerous. Sometimes the urine has such acrid properties as by its flow over the vaginal surface to induce this disease. Simple catarrhal urethritis may develop into vulvo- vaginitis. Or it may arise idiopathically from exposure to cold, or a sudden check of perspiration. Sometimes it takes the form of an epidemic, and prevails in winter along with a more or less severe influenza. I have known it to alternate with a severe and troublesome coryza. It may attack several children in the same family or neighborhood. Irritation of the rectum, and sometimes of the colon, may induce it. In some instances it is due to the presence of worms that have escaped at the anus, and crawled within the vaginal orifice, where, by their presence, they excite a great degree of itching and irritation. And sometimes there is no doubt that it has been caused by a mischievous rub- bing and irritation of the parts by nurses and servants who have had the children in charge. The proper treatment for cases of infantile leucorrhcea is first* if possible, to remove the cause. It is very important to avoid exposure to cold and wet, and to order a proper and digestible diet. Cleanliness, bathing and drying the parts carefully afterwards, either with a very soft towel, or better still, with an application of finely pulverized starch, or lycopodium powder, as in case of infants to prevent intertrigo, are very useful. If the complaint is related to influenza, the internal remedies INFANTILE LEUCOURHCEA. 545 will be the same as are suited to the epidemic catarrhal inflamma- tion, no matter where it is located. If it occurs in scrofulous children, the remedies which suggest them- Local and general. selves, and which are most useful, are calcarea carb., hepar sulph., and mercurius. A majority of cases may be cured with pulsatilla, or calcarea carb. If the passage of the urine occasions great suffering, give can- tharis, and have cloths that have been dipped in warm water applied over the vulva. If there is ulceration, or aphthous in- flammation, add hyclrastin or calendula to the water. If ascaricles have created the mischief, order lard to be smeared about the anus, or a decoction of garlic, or an injection of olive oil to be thrown into the bowel, and give the child teucrium. It is important that children who have this affection should not be allowed to sleep in the same bed, or to be washed with the same towels as those who are healthv. For Isolation. . " « although the disease is not always easy 01 com- munication, yet it might happen that it would spread through a whole family of little ones, and occasion much suffering and anxi- ety. It is a pleasure to be able to assure the mother or nurse that, with proper time and care, this disease may be readily and certainly cured. 35 LECTURE XXXIV. VASCULAR TUMOR OF THE MEATUS URINARIUS. Vascular tumor of the meatus. Non-specific urethritis. Causes. Symptoms; posture, quality of the urine. Diagnosis; from cystitis; from gonorrhoea. Treatment; rest, diet and drinks, general indications and local treatment. Urethral fever, and fissure of the urethra. Case.— Pathology of. Treatment; sitz-baths in, treatment for the vesical and renal complications, and for urethral lacerations. The refined and cultivated physician is sometimes at a loss to know when it is best to propose, and to insist upon the necessity for a physical examination of the female generative organs. He will not pander to the vulgar habit of resorting to this measure almost indiscriminately ; while, for the sake of his patient's wel- fare, as well as of his own reputation as a skillful diagnostician and practitioner, he must not postpone it too long, neither neg- lect it entirely. So important is this matter that a physician's reputation is sometimes made or ruined by the rumor that he is in the habit of using the speculum on the slightest pretext, or that he is opposed to its employment altogether. I am led to these reflections in consequence of the examination which I have just made of a case in the ante-room. This case had been attended by two physicians, one of whom pretended to have made a proper " examination" of the patient, while she refused to allow the other to do so. Both were wrong in their conclusions, and, consequently, neither of them did the patient any good. Case. — Mrs. T , 30 years of age, the mother of two child- ren, the youngest of which is four years old, has been in poor health for twelve months. One year ago she got her feet wet while menstruating. She has not been well since. Prior to that date her menstruation had always been regular ; but since that sudden check of the flow, the periods have returned every three weeks. There is no pain, but from time to time the flow is becoming more scanty. Soon after the taking cold she began to have trouble in passing water. The inclination to urinate was very frequent, and some- times quite irresistible. It was aggravated by being much upon the feet. Anxiety of mind, sudden good or bad news, and excite- VASCULAR TUMOR OF THE MEATUS. 547 ment of any kind would induce a paroxysm. At first, but only for a short time, the urine was copious and colorless, but for many months it has been perfectly natural in quantity and quality. The only exception to this rule is that it has, once or twice, been d very little bloody. The only real pain experienced is after the flow of urine, or rather, while the last drops are running away. This induces a burning, stinging pain, which is peculiar, and " very dreadful," to her. Walking is painful, and, for some reason which she can not explain, intercourse occasions the most excruciating suffering. The first physician who treated her for this difficulty made an examination with the speculum, and after analyzing all the symp- toms that were gathered, pronounced her to be suffering from " disease of the kidneys." After some months of treatment with no especial reference either to the menstrual or the urethral diffi- culties, she changed her physician for one of more intelligence and experience. Her second physician prescribed for her for a time, and then requested permission to make an examination with the speculum. But it was denied, and he continued to treat her for " disease of the womb." The physical examination just made discloses a vascular tumor which is nearly the size of my thumb-nail, at and within the mouth of the urethra. It is very tender to the touch, and of a cherry-red color. The urethra around and beyond it is tumefied and evidently somewhat inflamed. The womb is in situ, and the os uteri has a healthy appearance. These vascular tumors, which are not at all infrequent, are very troublesome and often give rise to much suffering. They are located just at the mouth of the urethra, Nature and location. -,.,.. -i i • and within its canal, being attached thereto by a pedicle, like a polypus. They consist of a hypertrophy of the mucous papilla?, and are very vascular. Sometimes the tumor is lobulated ; more rarely there are two instead of one. The pedicle may be so slender as to break very readily when you seize the growth with a pair of small forceps ; or it may be firm and un- yielding. The symptoms accompan}dng such a case have already been detailed in this report. Painful and frequent micturition, espe- cially after exercise upon the feet ; pain upon Symptoms. . . walking, intolerance of coitus, and the most peculiar and exquisite suffering with the passage of the last drops of urine, are almost pathognomonic. These symptoms may con- 548 THE DISEASES OF WOMEN. tinue until the patient is Tery weak and irritable. But the diag- nosis can not be made with certainty except by a physical examination of the parts involved. Indeed this examination must be visual, for unless you see the tumor, you can not be certain of its existence. The question recurs upon the necessity for such an examina- tion. This woman, who lives within a stone's throw of the hospital, has suffered for twelve months when «^inSio y n for physical sne m ight have been relieved in as many minutes. But two things were in the way of her getting well so speedily. The first was the ignorance of the doctor who examined her with a uterine speculum, and reported that she had " disease of the kidneys." How thifcas a e cles t0 recovery in this instrument could aid in the diagnosis • of renal disease, and what particular affection of the kidneys she was thought to have, I do not know. The second obstacle was her own shrinking sensitiveness, which would not permit the other physician (who was compet- ent) to do as he thought best. And so she has failed to obtain the hoped-for relief. How shall you act in similar cases ? The best rule that I can suggest is that you wait a reasonable length of time, providing the symptoms are not very urgent. Give the to^hysicXxpiofation 5 ^ appropriate remedies meanwhile, and place the patient under such hygienic regulations as will favor her recovery. But if the symptoms do not yield as they should, or if they show a decided tendency to relapse, the infer- ence will be that there is a local cause which perpetuates the mischief, and prevents a radical cure by internal means, alone. Under such circumstances a few sensible and cogent reasons addressed to the patient, will satisfy her of the necessity of a local examination, and obtain her consent thereto. You can explain the case by saying that the persistence of the symptoms and their liability to return when they have been relieved, leads you to conclude that they do not afford a reliable criterion of the nature of her disease. And, above all things, assure her before- hand that you will on no account proceed to operative interfer- ence, until the case is fully understood by both parties. This plan is as appropriate in a case in which the symptoms VASCULAR TUMOR OF THE MEATUS URIXACIUS. 549 are connected with urination, where the quality of the urine is unaltered, as it is in cases of chronic and invet- Especially requisite . * ,. „ , ,, in diseases ot the erate uterine disease. I or you may be morally certain when you have given eantharis, mer- eurius, aconite, apis mel., cannabis, hyoscyamus, and kindred remedies, under appropriate indications, and relief has not fol- lowed, that the case needs a local examination, and perhaps topical treatment also. Treatment. — Excision is the remedy. You may seize the growth with a pair of delicate forceps, and snip it oif with a pair of sharp scissors, or the bistoury. Or ligation, or as- tringents and cauterization may answer; but they are more slow and painful. The stump, or point of attach- ment may be touched with the per-chloride of iron, or with a stick of the nitrate of silver, in case of haemorrhage. In order to prevent the subsequent growth of the tumor it may be necessary to repeat the application of the caustic after a few days. I have recently treated a case in which I had occasion to modify the usual means of excising these growths surgically, and the success of the experiment encourages me to a new mode of. recom mend it to the class. But I will first operating. give you the brief history of the patient's symp- toms and sufferings : Case. — Mrs. , aged 30, the mother of three children, the youngest of which was two years old, consulted me for the relief of urinary symptoms from which she said she had been suffering for a twelve month. Her physician had treated her constantly for nine months for uterine prolapsus. She had had applications of some sort made to the womb through a speculum, had worn a pessary, taken sitz baths, and tried electricity, both wet and dry, but without any relief. Local examination, by a direct inspection of the meatus urinarius, revealed a vascular tumor which evidently had blocked the passage and caused all the mischief. The uterus was not displaced, there was noleucorrhceal or menstrual trouble, and in fact no other lesion. It may seem to you that such a blunder in diagnosis would be inexcusable, but I assure you that the facts are as stated, and that the physician is a neighbor of mine who will feel very badly over it, if he ever learns how the case has turned out. My mode of operating was to seize the growth slowly but firmly with this pair of Pean's artery forceps. 550 THE DISEASES OF WOMEN. When the blood had been thoroughly pressed out of the growth T a pin was passed behind the forceps transversely and its point cut off. After that, the forceps being* still attached, the elastic liga- Fig. 48. Pean's artery forceps. ture was applied beyond the pin, and the forceps removed. The pin kept the ligature just where I wanted it, no blood was lost, and the growth soon sloughed off. In a few cases, where the growth was so attached upon all sides of the meatus that it would have been very difficult to remove the whole of it without an extensive dissection, I have had good results from the local application of a strong solution of alum in carbolic acid. This does not cause very much pain, is always available, and may be repeated as often as is necessary. If the tumor is of the nature of the urethral haemorrhoids, blue, varicose and very vascular, care must be taken in its removal lest the loss of blood be considerable and troublesome. To avoid such a result, a needle may be passed and a ligature tightened so as to include the growth without cutting it off. If the tumor is very large, a needle armed with a double ligature may be passed and the threads tied both ways. . When the tumor is remote from the meatus, or high in the canal, it is a less easy matter to sieze it and to remove it satisfac- torily. In this case the easiest method is to sieze it with some form of a polypus forceps or snare, such as are used for removing polypi trom the nose or Irom the ear, and thus remove it. In case of cancerous growths within and around the meatus, I am satisfied that instrumental interference should be avoided. The after-treatment consists in keeping her in the horizontal posture for twenty-four hours or more, in order to avoid consecu- tive inflammation. If there are any signs of urethritis, it should then be treated as if the case was an idiopathic one. NOX-SPECIFJC URETHRITIS. 551 XON-SPECIFIC URETHRITIS. Affections of the urinary organs in women are very trying to all concerned, not only because they are often difficult of cure, but also because of the suspicion and the fear on the part of the patient that they may be of a specific nature. It is for this latter reason especially that urethral difficulties are often permitted to continue for mouths, and perhaps for years, before the physician is consulted. From this delay the complications that ensue may not only undermine the physical health, but possibly the domestic happiness of the patient. Case. — Mrs. -, aged 28, has been ill for fourteen weeks. She is the mother of two children, the youngest of which is one year old. The babe was weaned at six months, since which time she has menstruated regularly. On the eve of the regular " period " she was seized with a strong desire to urinate, but, being " down tGwn on a shopping expedition," she could not conveniently re- spond. Although suffering great pain in consequence, micturition was deferred for more than an hour, during which interval she rode home, a long distance, in the street-car. But the simple evacuation of the bladder did not end her sufferings. For she still felt an almost irresistible call to urination, which has tor- mented her at intervals of from ten minutes to an hour ever since. The flow has never been involuntary. If she lies quietly upon her back, the irritation subsides, but the moment she turns upon either side the dysuria comes on again. Although in a less marked degree, standing and sitting produce the same result. She cannot sit in a chair five minutes without the most disagreeable sensations and throbbing, which are referred to the meatus and the course of the urethra. She says the pain is most acute and burning during the floAv. This pain is described as always of a burning character. The urine is sometimes cloudy, with a ropy sediment, but usually quite natural in appearance. It has never been bloody or highly discolored. The quantity voided in twenty-four hours is neither excessive nor deficient. Two years ago she had a similar attack, which continued for three weeks and appeared to subside of itself. Although her at- tention had not been called to the fact before, she now remembers that it followed a similar imprudence. She is quite positive that it bore no relation to the birth of her first child. This patient has already been under the care of several physicians, at whose pre- scription she has taken buchu, copaiba, oil of turpentine, and the usual drugs, including the extract of belladonna in large doses. 552 THE DISEASES OF WOMEN. She has also made use of sitz-baths, suppositories, herb teas, etc., etc., but with only the most temporary relief. The uterus is prolapsed the moment she assumes the upright position, whether in standing or sitting. With this exception, the womb is normal in every respect. The vagina is not inflamed, neither is it especially sensitive, except along the course of the urethra. Pressure on that canal from above downwards causes the same pain of which she complains when passing water. It also forces the escape of a muco-purulent fluid from the meatus urinarius. The orifice of the urethra is more highly colored and tumefied than the surrounding mucous membrane. It is a singular fact that most writers upon the diseases of women have said little or nothing of this painful affection. We cannot attribute this oversight to its infrequenc}^ for, in the female subject, urethritis is much more common than stone in the bladder or cystitis, both of which diseases have received a due share of attention at the hands of the gynaecologist. Nor is it an insignifi- cant complaint. For whatever occasions such suffering as our patient has experienced, has a claim upon us for relief. Urethritis may be acute, sub-acute, or chronic. The two latter are the more frequent. It may arise from taking cold, more espec- ially during the menstrual period, getting the feet and limbs wet, sitting in wet skirts at church, or in the concert room ; from the extension of the inflam- mation in case of vaginitis along the mucous membrane of the urethra, or from the irritation of pruritus in the same canal ; vas- cular tumors of the meatus ; polypus of the urethra ; from acrid- ity of the urine; the contact of leucorrhceal discharges, or of vitiated semen ; from the pressure of a dislocated womb ; uterine, ovarian, hernial, or pelvic tumors ; cancer ; misplaced or illy- adjusted pessaries ; horseback riding ; mechanical injury during labor, or the induction of abortion by those who are ignorant of anatomy ; too forcible or too frequent coitus, especially at the month ; also from masturbation, gonorrhoea, syphilitic ulceration, urinary calculus, and indirectly from neglect to respond to the promptings of nature when the bladder should be emptied. A spurious form of this disease is sometimes met with in hysterical women. In the sub-acute variety the attack may recur with each menstrual period. The most prominent symptoms are burning and smarting or NON-SPECIFIC URETHRITIS. 553 scalding along the course of the urethra, with frequent desire to urinate. In many cases this burming sensation Symptoms. . . . is continuous, being aggravated by the now ot urine. In others it commences when the patient is half, or, per- haps, wholly through with the act of micturition, and continues for some moments after the discharge is completed. The burning and the urging to urinate are increased by motion. Hence, if the patient persists in walking about, or sitting up, these symptoms Are aggravated. For this reason, she is generally better at night. She may find it possible to lie in a particular position, and in that only, with a relative degree of comfort. Thus, while our patient is easy upon her back, she cannot turn Posture chosen. . . . . . irom it upon either side without increasing the difficulty. Sometimes the erect position is intolerable. It is par- ticularly so if the case is complicated with prolapse of the womb, or uterine or other intra-pelvic tumors. The vesical tenesmus is very apt to be increased by the same cause. Usually, the character of the urine is not changed in any par- ticular, except that it is mixed with mucus. The blennorrhagic discharge may be quite profuse or scanty, ac- Character of the urine. t i i cording to the duration and gravity oi the attack. It varies, also, with the individual constitution, scrofulous persons being more apt to have a copious flow of mucus than others. The mucus is mixed with the urine when it is voided, but afterwards separates and settles as a cloudy, ropy material. It is never bloody. In very nervous women, after a paroxysm of strangury, there may occasionally be an abundant flow of pale, limpid urine, such as frequently follows a hysterical fit. When you visit such patients and inquire in general terms con- cerning their ailments, you will most likely be told that the}- have disease of the kidneys. For, however intelli- A domestic fallacy. gent in other matters, most women suppose that anything wrong with urination implies that the kidneys, and not the bladder or urethra, or both, are at fault. A diligent inquiry into the especial symptoms will enable you to discriminate between urethritis and nephritis, for example, and you should not, there- fore, be satisfied to prescribe upon the patient's diagnosis. Cases of this kind might, perhaps, be confounded with stone in the bladder. The pain at the close of, and after urination, the 504 THE DISEASES OF W031EN. increased suffering and strangury from moving around during the day, and the frequent, scanty, interrupted flow Diagnosis— from stone. . . oi urine, are common to both arrections. But where the symptoms depend upon urinary calculus, we shall find them modified and supplemented by others which are lacking in urethritis. The pain caused by the contraction of the bladder upon the stone is sometimes acute, but generally of an aching character. And although it may extend along the course of the urethra, it is not accompanied by the burning sensation of which Mrs. complains. In stone, the urine is more or less bloody ; its chemical reaction varies with the kind of deposit ; the micro- scope detects an excess of some of its earthy constituents, and by "sounding" the bladder we recognize the presence of a foreign body contained within it. Cystitis is accompanied by more or less marked constitutional symptoms, as chill, fever, anorexia, and rapid loss of strength. The pain, which is referred to the pubic region, From cystitis. is in the first stage acute, lancinating, and ex- treme in degree when the bladder begins to contract. It is increased by motion, by pressure, and is worse at night during the febrile exacerbation. It may be of a burning character, but is more apt to implicate the rectum than the urethra. There is also a feeling of distension of the bladder. In advanced stages the abdomen becomes tender and tumefied, and in its further develop- ment the affection differs entirely from urethritis. It is extremely difficult, and sometimes quite impossible, to determine whether a given case of urethritis is or is not compli- cated with gonorrhoea. If the inflammation is From gonorrhoea. . _ ' . tit specific, the attack is more likely to be accom- panied by marked constitutional symptoms, by more intense suf- fering when the urine is passed, by a more copious discharge of mucus, and, what is still more characteristic, the more acute symp- toms subside spontaneously in from two to four days. But the particular history of the case, and especially the habits of the patient and of her husband, will help you to settle the question as between a benign and a specific inflammation in the urethra. Let me recommend, however, that, whenever it is possible, you shall give all parties concerned the benefit of a doubt, and pro- ceed to the* relief of the symptoms which are actually present. NON-SPECIFIC URETHRITIS. 555 Treatment. — Perhaps no better opportunity will offer in which to say a word concerning the length of time required for this and similar diseases to recover under proper treat - Rapid cures exceptional. . ment. In some of our books and journals you will find it reported that a single dose has cured such a patient almost instantly. The inference is that if we prescribe carefully and accurateky, the relief will be certain and speedy. The truth it often quite the reverse. Such a case as this, one in which a poor woman has been ill with marked and decided local inflamma- tion for many weeks, must, in the nature of things, convalesce slowly. And so is it with the majority of diseases that the physi- cian is required to treat. The ill effects of motion are so manifest in urethritis that the first condition prescribed should be rest in the recumbent position. The patient may be allowed to lie on the back, P oSdon in the recumbent or upon either side, as she prefers, but should not be permitted to stand, sit, or walk about. Riding would be equally injurious. She should as much as possi- ble refrain from doing anything which would increase the pain or the frequency of urination. For this reason, it is best to pre- scribe sexual abstinence also. The diet should consist of plain, wholesome food, which is freed from condiments and easily digested. All kinds of wines and liquors are poisonous. Tea may be allowed The diet and drinks. . L . r J in moderation. Ihe meals should be taken regularly. Vegetables are better than meats for these patients. If she eats an excess of sugar her sufferings may be greatly increased in consequence. Diluent drinks, as rice water, gum arabic, an infusion of flaxseed or of slippery elm, may mitigate the suffering by rendering the urine less stimulating and acrid. If the case is at all obstinate or chronic, a careful examination should be made of the meatus urinarius, the urethra, and adjoin- , . ing organs. If there is a vascular tumor at the General indications. . orifice, or a polypus in the canal, remove it by the scissors, ligature, or caustic, as you think best. If the uterus is displaced, correct the deviation and cure the remaining symp- toms with appropriate internal remedies. If the inflammation is a sequel of vaginitis, or of pruritus of the vulva, treat it as you would have treated the idiopathic affection. And so likewise if it 556 THE DISEASES OF WOMEN. For gonorrhoeal urethritis. is incident to leucorrhoea or any form of menstrual derangement. In gonorrhoeal urethritis, especially if there is considerable inflammation and heat in the vagina also, I know of no remedy so well adapted to the relief of acute symp- toms as atropine 3. Besides this we have aconite, cantharis, cannabis sativa, and mercu- rius, which may be given under appropriate indications. Simple, uncomplicated cases may require cantharis, cannabis, conium, belladonna, mix vomica, calcarea carbonica, hepar sul- phuris, or mercurius corrosivus. Mrs. will take a dose of cantharis 3d once in three hours. The local treatment is simple, and sometimes very useful. I have many times relieved the suffering and hastened the cure by thoroughly anointing the urethra with cosmo- line, or vaseline as a vehicle for hydrastin. To apply it you may wrap a long and slender dressing forcep tightly with cotton, smear it with the cosmolineand, passing it carefully along the urethra allow it to remain there for the space of five or ten minutes. Or, medicated injections containing glycerine, warm water, and the same remedy that is being given internally 'may be ap- plied through such a syringe as this. (Fig. 49.) Local treatment. Fig. 49. The uterine and urethral syringe. In case the attack of urethritis is complicated with inflamma- tion and induration of the cellular tissue about the passage, or if it is gonorrhoeal and relapsing, the hot water douche is of exceeding value. Water as hot as the patient can bear it may be thrown through a catheter like this. {Fig. 50.) The urethral douche. Fig. 50. Skene's reflux catheter. You should not forget, however, that in the healthy state, or when it is not dilated, the female urethra will not hold more than from eight to twelve drops of liquid at one time. URETHRAL FEVER. 557 URETHRAL FEVER, AND FISSURE OF THE URETHRA. Case.— Mrs. aged 33, has never had a child or a miscar- riage. One year ago, when living in Michigan, she was ill with bilious fever, which continued four or five weeks. At this time the kidneys were somewhat involved and she began to have nerv- ous chills, which came regularly twice a day lor a while, gradu- ally increasing to four or five in number daily. The chills continued in this way some weeks, but since coming to Chicago she finds that they are decreasing in number and severity, so that now she has but two daily, at 10 a. m. and at 3 p. m. Some- times she can prevent them by moving about. She says she does not feel cold, but there is a chilly trembling sensation all over her body, her eyes run and she feels as if she had taken cold. There is no sweat following the chill, although there is sometimes fever. She sleeps well and is never awakened by a chill. The menses are regular, but of too long duration and are too copious. She has some headache during the chilly stage, and her feet and limbs feel numb. The urine is sometimes scanty and sometimes copious, and the bowels are habitually constipated. She has never had haemorrhoids, and can lie upon either side. Ignatia 3 four times a day. Oct. 27. She has had two chills in the forenoon and one in the afternoon, lasting from half an hour to an hour. At the onset her head becomes dizzy, and there is a desire to yawn, and the feet become cold. She says that of late, during the menses she has pain in the back and down the outside of the limbs, and also in the left breast, but none in the pelvis. The eyes are very sen- sitive to light during the chill, (there is a marked nystagmus.) Gelsemium 3. .Nov. 3. She is not much better and has considerable pain in the region of the sacrum. There is a drawing pain in the muscles of the neck, extending up into the head. Macrotin 3. Nov. 10. Although the chills still continue she is in some respects better, but there is a feeling of heat on the top of the head and her feet are very cold. Sulphur 30. Nov. 24. She still has three chills every day. There is no fever, but she feels dull and stupid after the chill. About 3 or 4 a. M, during the past week, she has been awakened with a sensa- tion of coldness between the shoulders, and she cannot get warm. She now tells us that about one year ago she had an attack of inflammation of the urethra, and was ill some time, and she has pain now when passing the urine. Some days she must void it every half hour, and must get up quite often at night to urinate. She has observed that the urine is sometimes clear and again it is clouded. These symptoms are not aggravated at the menstrual period. Thlaspi bursa 3. 558 'IHE DISEASES OF WOMEN. Dec. 1. The chills still continue. Straining to urinate, as she sometimes must, will induce one. To-day she has a flushed face and some fever. Her appetite is good, but she has not been able to eat salt food for some time, because it always aggravates the urinary difficulty. She has not been obliged to get u«p at night as often, but during the day she must urinate four or five times. She has had treatment for urethritis. Thlaspi bursa 3. Dec. 3. Local examination before the sub-class revealed swel- ling and tenderness along the course of the urethra. The meatus was protruded, very reel, and sensitive. Pressure along the urethra, from the neck of the bladder forward caused considerable pain, but did not bring away any discharge. There was a slight coincident vaginitis. This affection, which for the lack of a better name is called ure- thral fever is compounded of a nervous predisposition, a miasmatic exposure or experience, and a local non-specific Pathology of. . * ! ' l inflammation ot the urethral mucous membrane. It is the outgrowth of a peculiar cachexia, which the experienced gynaecologist should be able to recognize at a glance. The case before you illustrates the necessity of a local examina- tion before an accurate diagnosis can be reached, or an intelligent prescription can be made. It also shows that the adaptation of the remedy to the epi-phenomena is not always easy or successful ; and that a slight local inflammation which is remotely located may be sufficient to perpetuate some of the symptoms of a mias- matic fever, and finally to develop a cachexia that is almost as enigmatical as hysteria or hypochondria. In prescribing for urethral fever you should proceed in the same manner as in a case of menorrhagic fever, giving the first, and the most prominent heed to the local symptoms. Some of these cases can be cured by the regular practice of drawing off the urine with the catheter. In others relief will come with allowing. a Sims' catheter to remain in situ. & When these cannot be borne it may be well to order the warm hip-bath, which can be continued for several minutes and repeated four or five times daily. It is not a bad rule to advise that such a bath shall be taken as often as the chill returns, or in anticipation of it. For this chill is a kind of outlaw, or a spurious affair at the best, and you may sometimes dispose of it by an expedient that will divert the patient's attention. In cases which are complicated URETHRAL FEVER. 559 with pelvic peritonitis the good effects of the sitz-bath will be enhanced by taking a vaginal or a rectal injection of hot water at the same time. Nor should you forget that the condition of the urine as revealed by chemical examination, and by the microscope, may afford the most important therapeutical indications. In For the vesical and e h case WQ should look for the pre sence renal complication. J L of mucus, pus, epithelium, blood cells, alkalinity, and the absence of urea, and when either of them is found, be very careful to interpret its clinical meaning correctly. Cases of urethral fever sometimes depend upon a laceration of the mucous membrane about and within the meatus, which lacera- tions are likely to develop into linear ulcers uSnra? erati0nSOf ^ that are vei T painful and difficult of cure. In the puerperal state especially, they may cause a high degree of fever and give you much trouble. Local applica- tions made directly to the wound will give the greatest relief. Nitric acid 2, hydrastis 2, or, if there is suppuration, calendula, may be mixed with glycerine and used in this way. Dr. Shears, our house physician, has recently cured a very interesting case by the application of the oleaginous collodion. When this lesion has become chronic, the best thing to do is to resort to the local appli- cation of iodoform (which, when mixed in equal parts with the oil of sweet almonds, has no bad odor). This can be used in emulsion with the oil, or by means of a slender gelatinous sup- FlG - 5L Duncan's suppository, pository, which can be passed into the urethra and allowed to dissolve. (Fig 51.) I have given you the details of this case until the present, just as they were recorded by Mr. Dow, our clinical clerk, and they will serve to show you that one of your teachers at least, cannot treat these cases properly without a little time and thought, and without an analysis of the symptoms and conditions that are pre- sented. This patient should have had mercnnus cerrosivus 6 t a month a«"o. LECTUKE XXXY. CYSTOCELE. — HERNIA OF THE BLADDER. — VAGINAL CYSTOCELE. VESICOCELE. Cystocele. Symptoms. Case.— Varieties of; treatment, mechanical, and surgical. On dila- tation as a means of diagnosis in diseases of the bladder and of the urethra. Vesical inspection and palpation. The catheterization of the ureters. Hysterical ischuria. Case. Case. — Mrs. H., aged 39, married, is the mother of two children, the eldest of which is five and the youngest is three years. About six months ago she began to have a discharge from the vagina, with severe bearing down pains. At first she thought she had falling of the womb, but now she thinks the bladder comes down, because when the swelling is the largest so as to protrude a little from the vulva, she has to push it back before she can urinate. There is considerable soreness of the parts, and not much pain on urinating, but the urine contains a considerable quantity of red sand and mucous sediment. The menses are regular, but just before the period there is increased inflammation and tenderness about the bladder especially. When the tumor protrudes it obstructs the vagina so that it is possible only to pass the nozzle of the syringe, the tumor is very sensitive, and the pain does not cease upon lying down, its protrusion is produced by over exertion, after which it remains for two or three days and then may disap- pear of itself. She is very nervous and restless, and does not sleep well. Dec. 3. A local examination in the presence of the sub-class showed vaginitis with swelling and deformity of the urethra. The p?«rts are very sensitive. A female catheter was introduced and its point passed downward toward the hollow of the sacrum. The touch showed that the bladder and the uterus were both pro- lapsed. On lifting the bladder to its normal position the catheter pointed in the right direction, behind the symphysis pubis. There are three cases of vaginal cystocele now in our clinic, which shows that the affection is not a very rare one. This is not a very bad case, but in most respects it is typical. It shows the union of prolapse of the bladder with prolapse of the uterus, and of the vagina. It shows concur- rent vaginitis, the inability of the patient to urinate until she has 56J CYSTOCELE. 561 reposited the tumor, and the liability of the urine to undergo alkaline decomposition when it is retained in the pouch that is formed by the prolapse of the bladder. It also shows the absolute sign of cystocele as revealed by the passage of the catheter. There are four varieties of vesical hernia, viz., the inguinal, the crural, the perineal, and the vaginal. The two former occur very rarely, and only in men ; the two latter varieties of cysto- -. j womeu _ Perineal cystocele is sometimes cele. J J contingent upon pregnancy, and disappears after delivery. Boyer ascribes it to the pressure of the uterus and of the foetus upon one side ot the pelvis more than the other. Vaginal cystocele is most common with those who have borne a number of children, but it may happen in young girls, and in those who have been married without becoming cyttoceie! ^^ mothers. The pathognomonic signs of this affec- tion are the formation of a tumor at the anterior and upper portion of the vulva, which is largest when the patient stands erect; which disappears or is easily reduced when she lies down; which is covered with transverse wrinkles when the blad- der is empty, and smooth when it is full, which interferes with urination until it has been reposited, and in which the urine may accumulate until it has become ammoiiiacal, or even until calculi have been formed therein, and the change^ in the direction of the urethra, so that when the catheter is passed the axis of the blad- der is entirely changed. Whether this form of hernia of the bladder depends upon the prolapse of the uterus and of the vagina, or if it has preceded it, cannot always be known ; nor is it of very great practical im- portance to speculate upon it. It is enough to know that the clinical indications are identical, and that the cure of the case requires that both and all of these parts should be reposited, and kept where they belong. The treatment is either mechan- Treatment. ical or surgicaL With a view of supporting these parts, various pessaries have been devised, of FlG - 52 - Skene's pessary for cystocele. which Dr. Skene's is in more general use than any other. 36 562 THE DISEASES OF WOMEN. My friend Mr. George E. Halsey, of Halsey Brothers, pharma- ceutists in this city, has devised a modification of the Shannon supporter, which is very simple Case. and at the same time very useful in cystocele. If ^ou ever have a case of this kind, I recommend you not to forget this instrument. A lady sixty years of age had had cysto- cele for twelve years, during which time she had used various expedients to keep the bladder in position. She then began to wear Halsey's pessary for prolapsus of the bladder, and she told me only a few days ago that she has now worn it for two years with entire relief, and I know that she is a truthful witness. In the American Journal of Obstet- rics for July, 1880, you will find an illustrated description of Gehru ug's ante-version pessary as adapted to the treatment of cystocele and procidentia uteri. The paper gives the details ot eight case^ of cystocele that have been cured by it in the hands of different physicians. Here is the instrument, which requires to be intro- duced with about the same manipulation as a Hodges pessary. Various surgical operations have been practised for the radical cure of vesicocele which, en passant, are Operations f or cysto- equa ] ly applicable ill recto- cele and rectocele. *■ J L L cele. Huguier's method consisted in dilating the urethra with the sponge- tent, so as to permit the introduction of the index finger of the left hand into the fig. 54. Genrung's ante- bladder. The anterior wall of the vagina version pessary, was then seized with the Museux forceps and dragged down Fig. 53. Halsey's pessary for cys tocele. CYSTOCELE. 563 wards and forwards so as to separate it as far as possible from the corresponding- walls of the bladder, after which several long pins were passed so as to cross each other be- neath the vaginal fold, and through the cel- lular tissue which separates the vaginal and vesical walls. Care was taken not to pierce the bladder, by means of the finger which Avas retained within it, after which a wire loop was thrown about and below the pins, and the vaginal fold was tight- ened. The final step consisted in applying the ecraseur so as to remove the redunclent tissue. The same operation, but with the finger in the rectum as a guide lor the pins, was made for recto- eel e. Jobert (de Lamballe) removed several longitudinal bands of the mucous membrane from the anterior wall of the vagina and stitched the incisions together, taking the pre- caution to leave a flexible catheter in situ in order to prevent the contractions of the bladder while the healing process was going on. Yidal (de Cassis) advised to form a cica- trix by means of applying a number of serra-fines, which may Vidal's oppration. . ., , . be allowed to remain until the parts of the vaginal mucous membrane included have sloughed away. FlG . 55 serre-fines. The operation which I prefer, both for cystocele and rectocele, is that first practised by Professor Stoltz, of Nancy, Stoltz's operation. \_ . \. . ' . J ' h ranee. Here is a diagram which will give you a better idea of it than a mere verbal description. Fig. 56. Colporrhaphy, or elytrorrhaphy, is an operation designed to narrow the vagina so as to prevent the prolapse J ° P cy r stoc?ief or of the bladder, the uterus or the rectum, or of all of these organs at the same time. Of the various methods designed for the cure of cystocele, that of Stoltz is the best. It consists in denuding the vaginal surface of the tumor in a circular form and in passing the suture along the mar- gin of the wound, so that it may be closed like a big hole in a stocking. The patient is placed in the lithotomy position, and the paring must be done very cautiously lest the bladder be injured; and for the same reason the needle must not be passed too deeply into the 564 THE DISEASES OF WOMEN. tissues. The suture is run in as a seamstress "gathers" the linen on her needle. It should be of strong, but fine and pure silk that has been carbolized or of the colored silk- worm gut. The most im- portant part of the after treatment is to prevent such an accumu- lation of urine as would have a mischievous effect upon the proper healing of the wound. After the second day vaginal injections of calendula, glycerine and warm water may be given once or twice a day. The suture may be removed at the eighth or ninth day. Colporrhaphy for rectocele. R#*3 C Fig. 56. Stolz's Method. Most cases of rectocele are accompanied by perineal laceration, and can be disposed of by the operation of colpo- perineorrhaphy. This result is secured by carry- ing the line of freshening well up over the sum- mit, and by passing the suture so as to draw that summit into the perineal wound, which will shorten the posterior vaginal wall, make the perineum firm, and furnish a means of support for the prolapsed or retro-verted uterus. If, however, the rectocele is a large one, forming a tumor that is forced out of the vulva, two operations will be necessary. First, a colporrhaphy should be made in order to dispose of the redundant vaginal tissue, and to narrow that passage ; and afterwards, if there are no reasons to the contrary, it may be followed by perineorr- haphy. The operation is similar to the one just described, except that the form of the freshened surface may vary according to cir- cumstances, and that the sutures may be crossed transversely. DILATATION OF THE URETHRA, ETC. 565 Because of the strain upon the wound and the probability that *-*, ^ the sutures will need to be left in place for a fortnight or more, they should be of silver "mat ^ wire. Fig. 57 c Stoltz's method, the wound closed. Case. — Mrs. , aged 62, was sent to the hospital by Dr. Thomas Gillespie, of Keno- sha, Wis., for relief from what proved to be a rectocele. The tumor was as big as a very large orange, and protruded from the vulva. She had suffered from carrying it for about twelve years, and always supposed that it was the uterus. The operation was made before the class and consisted in freshning a large oval surface on the vaginal side, and carefully closing the wound with silver sutures, of which there were twenty in all. The bowels were kept soluble ; the wound was washed, after the second day, with a mixture of calendula, glycerine and warm water and the diet was restricted to fluids and light soups. At the end of three weeks ten of the sutures were removed, at the end of four weeks, the last ten were carefully taken. The result was perfect in every particular; the tumor had disappeared, the cicatrix had healed completely, and the bowels were regular and moved with- out pain or soreness of any kind. I am satisfied that a very important step of this oper- ation is to carry the sutures across the freshened sur- face of the wound, so that they shall always be ex- posed at the mesian line, a precaution which brings the two flat surfaces to- gether when the wound is closed, and which prevents an undue strain upon the edges of the wound. Fig. 58 Fig. 58. The Sutures in situ. ON DILATATION OF THE URETHRA AS A MEANS OF DIAGNOSIS IN DISEASES OF THE BLADDER AND URETHRA IN WOMEN. Some of you are already familiar with the fact that the female urethra may be so dilated as to admit of the introduction of the index finger. You have seen me perform this operation by means of the dressing forceps, Atlee's uterine dilator, and the sponge- 566 THE DISEASES OF WOMEN. tent. Of late this expedient has been quite frequently resorted to for the removal of stone from the bladder without cutting. Here is a sponge-tent that I wish you to examine carefully. Ten minutes ago it was removed from the urethra of one of my lady patients, and it presents some appearances sptn^e-Teirt 56 f0r the Wn feh it is quite probable you have never before observed. Its base is as large as a silver dol- lar. It is of unusual length, and is composed of the best sponge. Excepting only at its smaller extremity, it is as clean as if it had just been washed. There is not a shred of mucus or a drop of blood upon it anywhere else. At its tip, however, you will see a quantity of pus which is slightly streaked with blood. My patient has been ill for some weeks with a violent, non- specific urethritis. Under the appropriate treatment, which I have already detailed to you the inflammation of Case. the urethra was entirely cured. But there re- mained a frequent desire to urinate, inability to retain the urine for more than an hour at a time (unless she was riding in her car- riage), an occasional deposit of a creamy-looking matter in the bottom of the vessel, and more or less of vesical tenesmus. Some of the symptoms resembling those of stone in the bladder, and all of them failing to respond to the usual remedies, I determined to dilate the urethra for the purpose of further exploration. This was first clone by means of the instruments named, and afterwards by the introduction of a series of long sponge-tents at intervals of three days. Each time that I have removed the tent it ha& presented the appearance so well shown in this specimen. The use of the tent in this case enables me to locate the seat of the ulceration very definitely. I know by the appearance of the sponge that the urethra is in a healthy state, and that the pus which has been discharged with the urine came from some portion of the bladder. Having stretched the vesical sphincter with the dilator, so that the urine escaped freely, and afterwards intro- duced the tent to the same distance, by actual measurement, I am confident that its tip was applied to and within the neck of the bladder. The thick, creamy pus, which has been brought away by the sponge, was not sufficiently fluid to have run clown from the cavity of the bladder, but was evidently taken up by it directly from the diseased surface at its neck. The distal extremity of DILATATION OF THE URETHRA, ETC. 567 this sponge looks exactly as if it had been applied to a suppurat- ing ulcer on the integument. I am, therefore, justified in feeling as confident in the diagnosis of ulceration of the neck of the bladder in this case, as if I had seen the ulcer. Indeed this means of exploration has certain ad- vantages over the endoscope as applied to diseases of the urinary passages in the female subject. It is more simple and available. It does not require an especial and expensive instrument. It furnishes a sample of the discharge, and dilates the urethra so as greatly to facilitate the local application of remedies, if it shall be deemed desirable. There is no harm in dilating the temale urethra quite rapidly. For this reason, and because it lessens the duration of suffering, we choose a freshly-made tent, one that will soften and expand very readily. The patient should be placed upon the back, with the hips brought to the edge of the bed. The feet may be put each in a chair at the side of the bed, as if you were intending to apply the obstetric for- ceps. Then take Atlee's uterine dilator, or the long dressing for- ceps, have them well oiled, or anointed with glycerine, or with soap from the dressing-table, introduce them carefully into the urethra, and separate the blades so as to stretch the passage from right to left, and from above downwards. Upon the removal of the instrument the tent can be pushed in carefully and steadily, until it has reached the neck of the bladder. Hold it there for a few moments until it begins to soften, else, being pointed and somewhat conoidal, it may be forced out by a sort of peristaltic spasm of the adjacent muscles. Ynu may leave it within the urethra for from half an hour to one or two hours, but not longer. For it will soften and dilate much more rapidly than if it were in the canal of the uterine cervix ; and besides, an early removal will give you a better idea of the condition of the neck of the bladder than if it were allowed to remain for any considerable time. It need not be carbolized. If the passage is very narrow, or has been inflamed, it is better to begin with a small-sized tent, and afterwards to use larger ones. The sponge is certainly preferable to the sea-tangle, or slippery elm and other material, because it is less hard and irri- tating when first introduced, and because it does not need to be 568 THE DISEASES OF WOMEN. retained so long in the urethra. The bladder should be emptied before beginning the operation. I have used the tent also in very obstinate inflammation of the urethra, and have thus been enabled to recognize, locate, and treat, an ulceration of its mucous membrane The tent in urethritis. ^^ movQ direct J y Jmd successfully than Icoulcl otherwise have done. The topical employment of remedies to the inflamed urethra might easily be secured by means of medicated tents and bougies. In dilating the urethra for the purpose of bringing medicated substances and injections in contact with the neck of the bladder, and with the upper portion of that canal, it is best to stretch it only at its inner extremity, by means of one of the instruments named. This leaves it funnel- shaped, and, while the patient lies upon her back with the hips raised, secures the retention and contact of the substances injected. An ordinary hard-rubber intra-uterine syringe will answer a bet- ter purpose than a more complicated one for throwing these injec- tions into the female urethra, and even into the bladder, when it is necessary. Or you may use a Nott's hard rubber syringe, with the straight pipe, being careful not to apply too much force. Fig. 59. Nott's hard rubber syringe. Vesical Inspection and Palpation. — Dilatation of the urethra has also been practised for the purpose of examining the interior of the bladder by the eye and the touch. The late Dr. Grustav Simon devised vesical speculse, of various sizes, the largest being about an inch in diameter, which could be passed through the 'urethra so as to expose the lining membrane of the bladder. The patient being anaesthetized, a small incision is made on either side of the meatus, the urethra is stretched as already described, and DILATATION OF THE URETHRA, ETC. 569 the speculum is passed slowly and carefully. Only five to tea minutes are required to dilate the urethra in this way. A better instrument, however, is Dr. Skenes', endoscope, which can be applied more easily, which you can find in the instrument shops, and which can be used with the sunlight or with a strong- artificial light by the aid of a concave mirror. Object of intra- vesical inspection. Fig. 60. Skene's urethral endoscope. The practical value of this inspection of the interior of the bladder, realized in certain cases of cystitis, of chronic ulceration, and of foreign growths with- in the oro-an. For visual inspection of the urethra only, you may use a cylin- drical speculum like this. (Fig. 61); or, if you want to look jus within the meatus, a common ear-spec- ulum will sometimes answer the pur- pose. Vesical palpation is not difficult es- pecially after dilatation of the urethra FlG - 6l - Urethral speculum, with the endoscope, or such an instrument as Hunter's uterine dilator. When passing the index finger into the urethra, the second finger should also pass along the vagina so as to include the vesico- vaginal septum between them. The object of paction! intra " VeSiCal the touch as applied to the inner surface of the bladder is to recognize the hypertrophy of the organ in chronic cystitis, the presence of vegetative growths and 570 THE DISEASES OF WOMEX. of foreign bodies within it, for the diagnosis of defects in the vesico-vaginal septum when the vagina is closed, and for the detec- Fig. 62. Hunter's uterine dilator. tion of fissures at the neck of the bladder and in the urethra. It is also employed in the vesico-uterine touch of Noeggerath* and for 6BK TrZ Fig. 63. h BW., Posterior wall of bladder ; B Gr., Fundus; Tr. L, Trigonum Lieu- taudii: fob, Opening of the ureters; aaa, Ligamentum interuretericum. (The distance be- tween the vesical opening of the urethra and the ligamentum interuretericum is too great as here represented.) the detection of the probe in catheterization of the ureters. Here is a diagram that will give you an idea of Simons' method of sounding the ureter, by passing the instrument along the finger to and within the orifice of that tube. Concerning the danger of digital palpation, and dilatation of these parts, Dr. Simon says : *See Page 83. HYSTERICAL ISCllURIA. 571 ** Within two years and a half, the time I have been practising- digital palpation of the bladder, over sixty cases came under observation in the Heidelberg clinique. Generally, palpation was carried out by us repeatedly in one sitting and by several of our medical brethren, who happened to be in our clinique at the time, yet, as I stated above, no serious consequence was ever witnessed. By so great a number of palpations of the bladder, every scruple which might have been brought forward against it ought now to be put aside, and this method of exploration, which was formerly only permitted in some rare cases and by specialists, should become the common property of every medical man.'' In my judo-men t, and as the result of experience, this statement needs to be qualified. For it is possible to expand the urethra to such a degree as to rupture its walls; and Em- met and others have known dilatation to be fol- lowed by incontinence. It is always important to remember that the calibre of this canal may vary in different persons, at different ages, and under diseased conditions. My own experience leads me to conclude that the touch is of more value than the sight, in intra-vesical diagnosis. When I eome to speak ol cystitis, the question of forming- an artificial fistula between the bladder and the vagina (kolpocystot- omy) for the purpose of diagnosis and for drainage will be con- sidered. HYSTERICAL ISCHURIA. I shall not detain you with any extended remarks upon the sub- ject of retention and suppression of the urine. There are several varieties of ischuria which take their name from the local seat and cause of the disorder. Thus we have the calculous ischuria, in which the disorder depends upon the presence of stone, either in the pelvis of the kidney, the ureter, the bladder, or the urethra; and the renal, the vesical, the ureteric* and the urethral, which are due to disease or obstruction in either of the parts just mentioned. All of these affections are as likely to occur in women as in men. But there is one form of ischuria, or of anuria, \ Ttericai may be which is almost entirely limited to women, and which is known as the hysterical ischuria. There are two reasons why this affection is called hysterical (1), because 572 THE DISEASES OF WOMEN. it occurs in hysterical subjects, and is, therefore, of a nervous ori- gin; and (2) because it may attach itself to local lesions, more especially of the genito-urinary system, with which it has no necessary connection. Among nervous women it is not rare to meet with cases in which, apart from such mechanical causes as uteriue displacement, sub-involution, pelvic tumors, and the like, there is a great deal of disturbance of the renal function. There may be a deo-ree of suppression, with scanty urination, or perhaps, under strono- mental excitement, a total arrest of the function. You would be surprised to hear a patient say that she had not passed a drop ot water for two, three, or four clays and nights ; and possibly alarmed, if on percussion in the region of the bladder, you should fail to find any evidence of its distention, or on passing the catheter, you could not obtain more than a spoonful or two of urine. In this connection your knowledge of physiology will serve you a good purpose. You know that a sudden and complete arrest of the secretion of urine is a much more serious .eaTfons i0 in giCalCOmPli " affair > thai1 itS S radual a » d l™^ Suppression. And you also know that in the latter case there maybe an elimination of urea and other urinary elements from the gastro-enteric mucous membrane, which is compensatory. This explains the intractable vomiting or the diarrhoea which so often accompany hysterical ischuria. The fact that, in this affection, urea has been found in the matters vomited, and its proportion actually weighed from day to day, shows the clinical and necessary eonnection betAveen them. There is an essential difference between this form of ischuria and the suppression, with uraemia, which is incident to malignant jaundice ; between it and the uraemia with sepsis in certain puer- peral cases ; and between it and the urinaemia that is incident to ulceration of the bladder. In simple cases of hysterical retention of the urine the attack may be sudden and self-limited. This is the form iimLT PleCaSeSiSSelf " whichoften accompanies the hysterical parox- ysm, and which usually ends with a copious flow of clear, limpid urine. Such attacks are due to a temporary con- dition in which the renal sympathies are unhinged, and they sub- side when the cause is removed ; or, if they continue, may be cured HYSTERICAL ISCHURIA. 573 by mental shock, by electricity, and by such traditional remedies and expedients as are useful in other forms of hysteria. If, however, this affection is associated with the graver forms of paralysis, and of renal or hepatic disease, the case is more serious, and we shall need to qualify our prognosis . The secondary form But, even in this secondary form the ischuria may sometimes be relieved by a few inhalations of chloroform, or of ether, by the passage of the catheter, as was advised by Dr. Wm. Hunter ; or by a peremptory refusal to use that instrument any longer, as in the following case, for the notes of which, I am indebted to our house physician, Dr. G. F. Shears: Case. — Miss A., aged 21 years, of a very nervous temperament was suffering with Bright's disease and from very painful men- struation. The act of urination was quite painful and often per- formed with difficulty. During one of my visits, the patient complained of great fullness in the bladder and of inability to pass the urine, although several efforts had been made. I used the catheter and left orders to be called if the urine was not passed in five or six hours. Promptly at the expiration of the six hours I was informed that she was in great pain and still un- able to urinate. The catheter was a^ain used, being passed with difficulty on account of the sensitive condition of the parts. Every remedy which seemed appropriate to this condition was tried, but without avail. The catheter was the only real means of relief, and, although its passage caused the most exquisite pain the patient begged for its use and it was applied four times a clay for ten clays before I determined that there was no real need of it. For some da} T s my suspicions had been aroused as I noticed- the varying character of the urine which was sometimes dark and scanty, sometimes nearly normal in appearance, and again as clear as the clearest spring water. Still I hesitated to act upon my suspicions. There was certainly a lesion of the uiinaiy apparatus and it appeared incredible that anyone would undergo the pain the patient seemed to suffer during the introduction of the instru- ment unless it was to relieve greater pain. At length being firmly impressed with the idea that the demand was hysterical, I determined to no longer use the catheter. At my next visit I succeeded in making the patient feel that the use of the catheter was very disagreeable to me, and that I considered it entirely unnecessary. These insinuations immediately brought tears and protestations against the injustice of my decision. I how- ever persisted in my idea, and told her that whatever it had done in the past it would not be necessary to use it again. My words were prophetic, tor although the case remained in my hands some .574 THE DISEASES OF WOMEN. four months longer, during which time the same symptoms were often present, the catheter was never again necessary. You are not to suppose that all of these cases are to be cured so promptly by the same, or by any other means. The best effects are often derived from fitly-chosen remedies, among which are apis mel., mere, cor., causticum, belladonna, hyoscyamus, and mix vomica. The most important clinical indications for these remedies will generally be found in the lesions of function or of structure upon which the ischuria is engrafted ; and you will therefore give due prominence to the coincident symptoms of cystitis, urethritis, nephritis, Bright's disease, and especially of neuralgia, hysteria, and spinal irritation. LECTURE XXXYI. CYSTITIS. ■Cystitis. Causes. Symptoms. Diagnosis. Prognosis. Treatment, local, general, surgi- cal, and dietetic,— washing out the bladder,— remedies for— cystotomy, mode of per- forming, the after-treatment. Objections to, results of, the artificial eversion of the bladder, drainage.— i he milk diet in,— the Clysmic spring water in. The irritable bladder. Cave.— causes of, hysteria as a factor in, three points In the diagnosis of, treat- ment.— Stone in the bladder— diagnosis and treatment of. While all of the tissues of the female bladder may be the seat of inflammation, the mucous membrane is more prone to it than any other. It is the sub-aeute and chronic forms of mucous cystitis which are commonly known as catarrh of the bladder. Acute cys- titis is rarely an idiopathic affection ; and we do not very often meet with it unless in the puerperal state. Causes. — Cystitis may arise from exposure to cold and wet; from a direct extension of vaginitis and urethritis to the bladder ; from cliptheritis, from an excess of local treatment in uterine and urinary affections; from over-distention of the bladder; from the sudden arrest of leucorrhoeal and gonorrheal discharges; from prolonged retention and decomposition of the urine ; from falls and blows upon the pelvic region, and from the traumatism of natural or instrumental delivery; from the presence and pressure of abdominal tumors, or of the displaced uterus ; from foreign bodies that have been introduced into the bladder; from stone in the bladder, from polypus of the urethra, or from urethral calculus, carcinoma, or from haemorrhoids, as well as from ulcers, fissures, and foreign bodies in the rectum. Symptoms. — The symptoms which are most prominent, and which are always present in this disease, whatever its form or va- riety, are pain in the region of the bladder, vesical tenesmus, or strangury, and a frequent desire to urinate. The degree of the suffering varies with the acuteness and the severity of the attack. Most patients complain sorely of a feeling as if the bladder had not been quite emptied, and that they must continue to strain to accomplish it. They may even sit upon the vessel hours at a time. 555 576 THE DISEASES OF WOMEN. In the milder and more chronic cases the pain and tenesmus are very much aggravated by standing, riding, or walking about; while sitting or lying down may afford comparative ease. If, however, the constitutional symptoms are very marked, there may be a nightly aggravation which interferes with rest in the recum- bent posture. The urine is hot and highly colored, and in a little while be- comes alkaline in its reaction. At first it is cloudy, but soon con- tains mucus and blood; then it becomes more thick and glairy, and finally deposits a viscid, ropy, or purulent sediment. Its passage is often accompanied by pains which radiate along the ureters to- wards the kidneys, along the urethra down the lower extremities, toward the spine, the sacrum, or the perineum. If there is any considerable uterine disease or deviation, all the symptoms will be worse during the menstrual period. In chronic cases especially, the constitutional symptoms are such as indicate impoverishment of the blood from anaemia, and poison- Fig. 64. Ashton's fenestrated speculum. ing of it by the absorption of the urine, or of some of its elements from the ulcerated surface of the bladder. Urinaemia from this cause may be rapidly fatal, and is always accompanied by violent fever, vomiting, prostration, and collapse. Diagnosis. — Here, as elsewhere in the case of women, you should not depend exclusively upon the subjective signs in making the diagnosis. The symptoms I have just indicated are good enough so far as they go, but they are not sufficient. Nor w r ill the chem- ical reaction of the urine, or its microscopical examination settle the question, for these modes of enquiry are better suited to the diagnosis of renal than of vesical disorders. It is as impossible to make a careful and reliable diagnosis of cystitis. 577 cystitis in women, without a physical examination by palpation, percussion, by the touch through the finger and the sound, as well as by the speculum , as it is in uterine disorders. And these means of differentiation are to be applied to the bladder in the same way that we apply them to the uterus and its appendages. The best speculum is Skene's endoscope (Fig. 60) although the local ex- amination of the meatus (Fig. 64) and the urethra from the vag- inal side may sometimes be advantageously made by an instru- ment like this, which is Ashton's fenestrated anal speculum. (See page 576.) I have sometimes used an intra-uterine speculum for the pur- pose of dilating the urethra and of inspecting its inner surface. Fig. 65. Intra-uterine speculum. The use ot the speculum or endoscope in these cases is some- times very important, for it may happen that an intractable cys- titis shall depend upon a fissure at the neck of the bladder, which could not be recognized except by actual visual inspection. Prognosis. — The prognosis depends upon the patient's general constitution, the curability of the complicating disorders, the grav- ity of the toxical symptoms, and the kind and duration of the treat- ment to which the patient has already been subjected. Treatment. — The treatment is local, general, surgical and die- tetic. In the acute form, local applications of hot water by means The local treatment, of compresses to the pubic region, poultices of flax-seed or of oat-meal, or warm sitz-baths are of the greatest service. Sometimes the hot- water irrigation of the vag-ina will mitigate the suffering and relieve the congestion. If the case is complicated with prolapse of the bladder, with dys- menorrhcea, or with pelvic congestion from any cause, the patient should be advised to lie with the hips elevated, and the shoulders depressed. In cystocele with cystitis, the bladder should be repos- ited and kept in place in order to prevent the decomposition of the urine. In case of stone, the foreign body should be removed. 37 578 THE DISEASES OF WOMEtf. In chronic cases with copious discharges of mucus and pus, great relief may be obtained and a source of der. washing out the Mad- infection removed, by washing out the bladder once or twice daily with warm water. This may be done by means of a closely fitting syringe and a double- Fig. 66. Burns' reflux catheter and adjuster. current catheter, of which there are several on my desk. (See Figs. 66 and 67). A more convenient instrument for flushing the bladder, and for .Fig. 67. Nott's double-current catheter. medicating its inner surface afterwards, is such an one as this ? which was designed for intra-uterine purposes. Fig. 68. Molesworth's double canula and bulb syringe. Having cleansed the bladder it becomes a question whether you should medicate it topically. In cases with ulceration and the free secretion of a muco-purulent fluid, with Topical medication of the ^.j^ j haye certain l y ha d R00( ] effects from the local use of calendula. In rheumatic and hsemorrhoidal subjects you may substitute the hamamelis for calendula; while, if the trouble is of traumatic origin, arnica is The medical treat merit. CYSTITIS. 57fc best. Ill all cases, however, only a few drops of the strong tinc- ture should be added to the injection. The internal or general treatment, is sometimes very difficult and tedious. In the acute form, cantharis is more appropriate than any other single remedy. It is adapted to burning and tenesmus with violent pains in the bladder, the passage of scalding urine which issues drop by drop and is scanty, turbid, and sanguineous. When these symptoms are accompanied by prolapse of the uterus and of the rectum, with pains alonsf the ureters and in Cantharis the kidneys, with aggravation upon standing and relief from sitting, its effect is sometimes very prompt. The indication for cantharis is strengthened if the attack is due to a translation of gonorrhceal vaginitis or urethritis. And so like- wise of sub-acute cystitis which has resulted in atony of the blad- der with retention of urine. There is another indication for cantharis which it will be worth your while to remember, which is that it is adapted to cystitis occurring in those who are subject to erysipelas, more especially of the face and of the external genitals. It is just as true in the case of vulvar erysipelas, with vesical irritation, occurring in lit- tle girls, as it is with women. Belladonna is called for when the region ol the bladder is very sensitive to the touch, with shooting pains in the loins, and paralysis of the neck of the blad- der, with involuntary discharges of urine. It is especially adapted to those nervous and delicate subjects who cannot sleep, and who greatly exaggerate their suffering. In very acute cases, and especially if they are of gonorrhceal origin, a few powders of atropine 3, at hourly intervals will bring relief, and, if given early, will abort the attack. In chronic cases, cannabis sativa, chimaphilla, mercurius sol., copaiva, terebinth, hydrastis, causticum, pulsa- Other remedies. tilla, phosphoric acid, conium, dulcamara, lyco- podium, kali carb., and sulphur, have their special indications, for which I must refer you to the Materia Medica. Clinical indications. _-_ 1 „ ..,,..,. I he re are, however, a tew practical clinical in- dications which you may carry with you. For rheumatic cystitis, aconite. 580 THE DISEASES OF WOMEN. For milky urine with a tendency to rapid decomposition, phos- phoric acid. For inflammation with paralysis of the bladder, hyoscyamus, causticum, carbo veg. s plumbum, or sulphur. For chronic cases complicated with peri-cystitis, colocynth and terebinth. For inflammation of the neck of the bladder especially, digitalis and elaterium. For catarrhal cystitis with a deposit resembling the white of an egg that is slightly cooked, dulcamara. For burning, pressure, and tenesmus, nux vomica, arsenicum, cantharis, or aconite. For intractable tenesmus, tarentula. For sub-acute cases induced by dampness and taking cold, dulca- mara. For chronic catarrhal cases, especially in old people, carbo veg., or cocculus. For cystitis arising from cantharides and other drugs, apis mel- lifica, or camphora. The surgical treatment consists in devising a means for the thorough and constant evacuation of the blad- Surgical treatment. l & der. There are two methods of filling this in- dication; (lj by the operation of cystotomy, and (2) by drainage through a self-retaining" catheter. The operation of cystotomy, or kolpocystotomy, is practiced by opening the bas-fond of the bladder and creat- ing a vesico-vaginal fistula, which establishes a continuous drainage of the organ. It consists in passing a grooved staff into the triangular space, the apex of which is at the com- mencement of the urethra and its base at a line drawn trans- versely from the orifice of one ureter to the other. While this is held firmly, the perineum being retracted with a Sims' speculum, and the patient anesthetized, an incision is made with a bistoury along the median line and in the groove of the staff. The edges of the wound are then seized with the forceps, everted, and about one-fourth of an inch of tissue on either side is snipped off with the scissors. The haemorrhage, which is not troublesome, if we have kept to the median line, may be controlled by torsion, by Pean's forceps, or by sef re-fines. CYSTITIS. 581 In lieu of the incision, Dr. Pallen has proposed to make the opening with the thermo-cautery, which obviates the risk of venous haemorrhage, and prevents the premature contraction and closure of the fistula. The subsequent local treatment consists in washing out the bladder daily, and thoroughly, with starchy and demulcent fluids, such as flax-seed water, etc. When tne cystitis The after-treatment. . _ . . „ . . . -i-i't is cured, the artificial opening may be closed as in ordinary cases of vesico-vaginal fistula. The chief objections to this vesico-vaginal section are that the operation is not devoid of danger from consecutive cellulitis, for although in most cases at the point of the incision C yst^ e omy GStOVaffinal thevG ^ no cellular tissue between the vesical and the vaginal wall, still it may happen that there shall be, and that this tissue will become infiltrated and in- flamed in consequence of the wound, whether it is made by the knife or the cautery; that the relief from the pain of cystitis is substituted by a distressing infirmity which involves constant dribbling and escape of the urine as fast as it is poured into the bladder, and that the proportion of radical cures of cystitis in this way does not warrant a frequent resort to it. At the Woman's Hospital of New York, where the best operators, skilled nurses, and constant care were had, the following results were obtained : Cystotomy was performed for the relief of cystitis in seventeen cases, of which four were cured, and thirteen improved." * Simon practised a modification of vaginal cystotomy which was designed to invert the bladder and so to expose its internal surface that its lesions could be observed, and that tumors f T t h vflfH? aleversi0n which were beyond reach through the urethra of the bladder. J " could be easily removed. This plan consisted in making a T-shaped incision through the anterior vaginal wall , after which, and by means of tenacuke, the bladder could be turned inside out. The tumor being removed, and the exploration finished, the wound could be readily sewed up again. Where cases resist the ordinary treatment, or in conjunction with it, some sort of self-retaining catheter may be applied for * Diseases of the bladder and urethra in women, by Alex. J. C, Skene, M, D., etc., 1878, page 205. 582 THE DISEASES OF WOMEN\ the purpose of keeping up a constant drainage of the inflamed organ. A bit of rubber tubing may be passed catheter.^ by ° so as to co ^ itself and be retained within the bladder, which, when it chokes with mucus can be cleansed by a syringe; or Holt's or Skene's self-retaining catheter may be left in situ for the same purpose. But you should not forget that, Fig. 69. Skene's self -retaining catheter, although the urine has free exit through the catheter, the bladder maybe partly filled meanwhile. So that, as Dr. Matthews Duncan says, " in order to insure that the evacuation is complete, you have to squeeze it out through the catheter, as the sportsman does with rabbits he has shot." There is no doubt in my own mind that, in cystitis, the regula- tion of the patient's diet is quite as important as it is in Bright's disease, or even in diabetes. I could cite several c Otitis 111111 dietlQ cases in my own experience in which this part of the treatment has clone more good than my remedies. I am confident that one of my patients, who had had cystitis for four years, owes her life to the milk diet; and that several others have been promptly and permanently benefitted by it. I began to use it in this class of cases five years ago (1875). and am fully prepared to recommend the plan adopted in England by Dr. George Johnson, who gives the following directions : " The milk may be taken cold or tepid, and not more than a pint at a time, lest a large mass of curd, difficult of digestion, form and collect in the stomach. Some adults will take as much as a gallon in the twenty-four hours. With some persons the milk is found to agree better after it has been boiled, and then taken either cold or tepid. If the milk be rich in cream, and it the cream disagree causing heartburn, headache, diarrhoea, or the symp- toms of dyspepsia, the cream may be partially removed by skim- ming. Constipation, which is one of the most frequent and troublesome results of an exclusively milk diet, is to some extent obviated by the cream in the unskimmed milk. When the vesical irritation and catarrh have passed awa} T , solid food may be com- bined with the milk, and a gradual return made to the ordinary diet." In some cases I have found that skim-milk, butter-milk, or koumyss answer very well. Another valuable, if not indispensable auxilliary in the treat- CYSTITIS. 583 ment of sub-acute and chronic cystitis especially, is the use of appropriate mineral waters, the best of which, water S ySmlCSPrlDg J think, is the "Clysmic" spring water. My attention was first called to its value in conse- quence of its remarkable effect in the cure of one of my best per- sonal friends. The notes of her case, are as follows : Case. — Mrs. , aged 26, the mother of three children, had suffered for four years from what was diagnosticated to be " ca- tarrh of the bladder," " inflammation of the neck of the bladder," and "the first stage of Bright's disease with malarial fever in its worst form." So many different opinions as to the nature of the disease were given by Drs. Alonzo Clark, George E. Belcher, and several other distinguished and competent physicians of New York City. Both schools of treatment were faithfully and 'skil- fully tried, but without avail. The catheter was used for many weeks; then an injection of morphine, and twice each week an application of iron was made to the interior of the bladder, which was continued for six months. It became impossible for her to walk, for the slightest exertion caused an untold agony with local spasms that required the use of seven grain suppositories of opium before they would yield. The pain that was caused by the desire to urinate was beyond description. When her weight had been reduced from 172 to 112 pounds, and it seemed impossible that she should recover, a final consulta- tion, of physicians was held and it was decided to wash out the bladder and inject a solution of the nitrate of silver. The prog- nosis given was that she must die, or be bed-ridden for the balance of her life. Before beginning the use of the caustic injections she began to drink the "Clysmic" water. In a very little while the painful symptoms subsided, and in a few weeks she had entirely recovered her health. More than two years have now elapsed, and there has been no return of the difficulty. This kind of spring water seems especially adapted to those cases of urinary disorder in women, which are catarrhal in character, and which are compounded with miasmatic and dyspeptic derange- ments. For this reason it has a wide range of application in paludal districts, and with those patients who have developed a kind of urinary cachexia, which does not respond to ordinary remedies, and which, except for its use are exceedingly difficult of cure. 584 THE DISEASES OF WOMEN. THE IRRITABLE BLADDER. A bout fifty years ago the celebrated Dr. Kobert Gooch first recognized what he afterwards described as the 'irritable uterus.' In our day, with improved methods of physical examination, we identify most of the symptoms of that peculiar affection as belong- ing in reality to what is called the irritable bladder. Here is a case of this very common and intractable disorder. Case. — Mrs. , aged 22, has been married four years, but has had no children and no miscarriages. Her menstruation is nor- mal in the quantity and character of the flow, and also in the regu- larity of its recurrence; but for a week before her period, and durinff it until the flow has ceased, she suffers a marked ag-o-rava- tion other urinary symptoms. These symptoms consist chiefly of a desire to urinate, and of dysuria. She must void her urine at intervals of from ten to thirty minutes; the periods varying with exercise while upon her feet, with the return of the catamenia, with loss of sleep, and with mental worry. The more frequent the discharge the more cloudy the urine. She has been for eleven months past in the care of a gynaecologist of this city who has cauterized the cervix uteri every week. A local examination revealed a condition of the os and cervix uteri that was normal except for the effects of the cauterization. The sound showed that the uterus was slightly anti -flexed. The bladder, as felt at the anterior cul-de-sac, and by conjoined manipulation was not hypertrophied or especially sensitive. The urethra and the meatus were normal. A second local examination, which was made two days in ad- vance of the monthly flow, disclosed the same conditions, except that the forward flexure of the uterus was somewhat increased. The treatment consisted in repositing the uterus, and enjoining a strict monthly quarantine, with rest upon the back, beginning four days before the flow, and continuing until it had ceased. The womb was replaced four times in all by 1he sound; she took no medicine, and in two months was entirely relieved. This case illustrates the fact that ante-flexion of the uterus may provoke an irritation of the bladder. Other deviations of the uterus may have the same effect. And so like- Causes of. J wise may an excessive use of the speculum, of caustics, or of the catheter, too frequent coitus, prolapse of the vagina, vaginitis, urethretis, nephritis, stone in the bladder, can- cer, haemorrhoids, hVsure in ano, a lack of cleanliness, errors in diet, and the abuse of diuretics. STONE IN THE BLADDER. 585 Other causes are oxaluria, or the deposit of the oxalate of lime in the urine; and uric and phosphatic deposits, which earthy mat- ters are direct sources of irritation to the vesical mucous membrane. This affection is very common in gouty subjects. In a considerable share of cases this disorder is a hysterical neu- rosis. When it is so there is very likely to be either an incouti- Hysteria as a fac- neiice or a retention of the urine at times, and tor in. other syptoms of hysteria also will be present. For the irritable bladder is not a disease per se, but a symptom, or condition, which must depend either upon a local or a general cause. By exclusion, if you know what these causes are, you will be able to differentiate between them, and to settle upon the proper one. The healthy bladder is not tender. If, upon passing the vesical sound, and pressing lightly while the instrument is within, much r™. ■ •*'.'.. pain is felt, it is a case of inflammation and not Three points in the L diasnosis of. one of simple irritation of the organ. If the -depth of the bladder, when measured from the meatus to the fundus, is more than five inches, the probabilities are that we have a case ot irritable bladder. Moreover, if the bladder is always irritated and excited to contraction by the presence of the urine, whether that fluid is cloudy or limpid, the case is of nerv- ous origin, and the irritability depends upon vesical hyperses thesia. If we know the cause and can unravel the complications, the treatment of the irritable bladder is not difficult. Manifestly no Treatment single remedy or expedient is sufficient for all cases. Apis mellifica, mercurius, hyoscyamus, belladonna, lycopodium, ignatia, nux vomica, ferrum, and thlaspi bursa, have each been extolled, and are useful under appropriate indications. When the gouty and lithic acid diatheses are present, lithia carb. is an excellent remedy. For irritating urinary deposits nitric, or the nitro-muriatic acid, with plenty of fresh water, or the "Clysmic" spring water for drink. STONE IN THE BLADDER AND IN THE URETHRA. In the treatment of vesical diseases you will often suspect the presence of calculi, and it is therefore important that you should know something of this subject. For, while stone in the blad- 586 " THE DISEASES OF WOMEN. der is much less frequent with women than with men, it is an Relative frequency affection that sometimes gives us a great deal of, in women. of trouble. The short and dilatable urethra in women not only favors the escape of such small foreign bodies as by incrustation would otherwise become larger and more trouble- some, but it also facilitates their surgical removal per vias natu- rales. In addition to the ordinary causes of stone in the bladder, which are applicable to men and women alike, this affection is rendered Causes more frequent in those women who have under- gone the operation for vesico-vaginalhstula, and in those who are suffering from cystocele. The symptoms are those which I have just enumerated when speaking of cystitis, viz. : pain, dysuria, vesical tenesmus, increased Symptoms upon standing or walking, and the presence in the urine of mucus, pus, and blood, the morbid products varying with the duration and severity of the accompa- nying inflammation. Physical examination by the passage of the sound, by the con- joined use of the sound in the bladder and the finger in the vagina, or by the passage of the index linger directly into the bladder, i& not difficult, but is very decisive. The calculus that escapes de- tection in this way must be encysted, but even in that case it may be found by first distending the bladder with warm water, and then making the examination. In some cases the urethral specu- lum may be of service by bringing the foreign body directly into view. (Fig. 61.) When the calculus has been forced into the urethra it is readily recognized by the touch, applied to the vagi- nal surface of that canal, and also by the introduction of the sound. If the calculus has lodged in the ureter, or even in the pelvis of the kidney, its presence may be detected by Simon's method of catheterizing those tubes, as I have already explained. (Fig. 62.) The prognosis depends upon our ability to remove the foreign body with certainty and safety; upon the curability of the co-ex- isting inflammation and ulceration ; and upon Prognosis. ° m 3 *■ the tendency of the disease to relapse. The indications for treatment are few and simple. If the calcu- lus is already in the urethra we have only to dilate the passage, to seize the stone with a pair of forceps, to give it a slight rotary STONE IN THE BLADDER, ETC. 587 motion, and to extract it. If it is still in the bladder, and we are satisfied that its diameter does not exceed an Treatment. inch? the urethra s i 10U id b e dilated, and it should be carefully seized with the forceps, so as not to include the vesical wall, and then delivered slowly through that canal. When the stone is too large to be extracted through the urethra, one of two methods for its removal may be adopted : (1) Lithotripsy and it may be crushed by the lithotriptor, and the vaginal cystotomy, bladder carefully washed of the fragments, or (2) the operation of vaginal cystotomy, which I have already des- cribed, and which opens the way for its removal through an incision in the vesico-vaginal septum, may be made. If the first of these is determined upon, care must be taken not to wound the inner surface of the bladder, and not to permit any of the fragments to remain as the nucleus for a new formation ; and if the second is necessary, the wound will need to be sewed up, as in vesico-vagi- nal fistula. The possibility of vaginal cystotomy in women does away with the necessity for the resort to the perineal section, which has been the usual mode of operation in men. In case of vesical calculus occurring in a patient with occlusion of the vagina, disease of the uterine cervix, anchorage of the supra-pubic litnot- uterus, or intra-pelvic tumors of such a nature as omy - to interfere with a resort to vaginal cystotomy, we should have a resource in supra-pubic lithotomy. This opera- tion which has been so skilfully and successfully practised by my good friend Prof. Helmuth, of New York, * is quite as available in women as in men; but it should be restricted to those cases in which the vaginal incision is impracticable. Sometimes these calculi are voided spontaneously; sometimes their passage may be facilitated by the resort to warm sitz-baths, spontaneons dis- ot by irrigation of the vagina or the rectum with charge of. } lot wa t er ; and sometimes they are forced through the urethra by straining while the patient is in an unnatural posi- tion, as in bending very far forward, or while lying down. A little while ago this specimen was given me by a private patient who had passed it voluntarily. Her history is as follows : Case. — Mrs. , seventy-three years of age had been subject to * The American Observer, Nov. 1880, page 532. 588 THE DISEASES OF WOSIEN. attacks of renal colic. They seemed to be induced by fatigue, she had had them for two years, and they were relieved by the usual remedies. In the last but one of these paroxysms, the suffering was located in the left ureter exclusively, and the relief, when it came, was sudden and complete. She then passed five weeks with greater ease and comfort than she had known in the two years. At the end of that time, after several severe fits of straining to urinate, she succeeded in passing this calculus. It is one inch in length, and moulded into the form of a cylinder. Its weight is thirty-six and one-half grains. SARCOMATOUS GROWTHS WITHIN THE BLADDER. The occurrence of these and of papillary growths within the bladder are rare. The following is the most remarkable case of the kind that I have seen: Case. — Mrs. , age 37, has for several years suffered from a burning during urination, and a spasm of the neck of the bladder after passing the first few drops of water. The urine is strong with a heavy sediment. A year ago it became bloody and now the loss of blood is sometimes frightful. When the bladder is irrigated small bits of flesh and clots sometimes come away. There is a stinging as of fine needles in the bladder, with a sense of retrac- tion in that organ on drinking cold water. Straining to force the flow of urine fails of effect, but a deep inspiration causes it to flow freely. There is a monthly aggravation with tympanitis and invet- erate insomnia. Failing to detect a stone, and confident of some local cause for the hemorrhage, I dilated the urethra, and, on passing the index finger into the bladder, discovered a growth as large as a lemon. This was removed without accident and was found to be sarcoma- tous. Seven months later the old symptoms had returned and the bladder was found to be studded with small friable growths which were removed with the curette. In six months more a third crop was taken for the relief of symptoms that were worse in every way. She developed a wretched cachexia, became exhausted and emaci- ated, and in a few months died. The use of the curette within the diseased bladder is a danger- ous expedient, and, although it is somewhat painful, should be done without an anaesthetic, lest the bladder might be perforated. LECTURE XXXVII. UTEKINE DEVIATIONS AND DISPLACEMENTS. Uterine Deviations and Displacements. General considerations upon. The natural position and mobility of the uterus. The uterine ligaments and the cellular tissue as a means of support. The etiology of uterine displacements. The predisposing, and avoidable causes of. The intrinsic and extrinsic and the accidental ditto. The symptoms of. The diagnosis of. The treatment. The scope and value of internal remedies exclusively— the necessity for reliable indications of all kinds. The cardinal symptoms in the choice of a remedy. Case.— The use and abuse of pessaries. Reasons for objections to them. Harmful varieties of. Contra-indications for. Indications for. Not incompatable with our remedies. Abdominal belts and supporters. Arguments pro and con. Dr. Hodge's experience with them. No single subject in the realm of gynaecolgy has attracted so much attention as the question of uterine displacements and their relation to uterine pathology. There has been, tio G n S neraiCOnSidera " and sti11 is ' a class of Physicians who regard disorders of place as the essential and funda- mental element in uterine pathology, and who refer all, or nearly all, the diseases of women to this single cause. The great leaders in this party were, the late Dr. Hodge, of Philadelphia, and Dr. Grailly Hewitt, of London. But, as with the theories of so many others, their exclusive views have been modified, and uterine deviations are now taking their proper place among the causes, effects, and complications of pelvic disorders. Before we proceed to the study of the separate displacements, I must speak of the normal position of the uterus, and of its range of mobility within the limits of health. For, rZt-m^T'Z™* having heard so much of uterine deviations and mobility of the uterus. *= of their evil consequences, you may have fancied that the uterus is held in a fixed position, like the articulating surfaces of a joint. The fact is that the womb is more movable, and in a healthy way, than any other organ in the body, not even excepting the eye. In a qualified sense it is never at home. In foetal life and until puberty, it is an abdominal toJ^&T ^**" ^g* 11 '' du ™£ the menstrual life it belongs within the pelvis ; in the early months of preg- nancy it lies below the superior strait; in the latter half above it; 590 THE DISEASES OF WOMEN. in puerperality it is first an abdominal, and then pelvic again. These changes of place are physiological and necessary. ■ But more than this, it is so mobile as to be constantly changing its position, although in a slighter degree. Talking, breathing, swallowing, coughing, sneezing, moving an arm or even a finder, standing, walking, lying down, the effort at stool and at urination, the monthly engorgement of the uterus, and many other such slight causes may move it in different directions and alter its position with reference to the fixed parts of the lower pelvis. So that, there A clinical rule. Fig. 70. Normal position of the womb. 1. Kectum. 2. Uterus. 3. Bladder. 4. Vagina. are slight and self-limited forms of uterine deviation which are ol no consequence in a clinical point of view, except in establishing the rule that uterine displace- ments are important and mischievous only when they are -permanent , and when they create or complicate disease by their effects upon the uterus and upon other organs within the pelvis. This diagram (Fig. 70) will give you a correct idea of the normal position of the uterus as it lies between the bladder in front and the rectum behind. Observe that even with the bladder distended, its axis inclines forward at an obtuse angle with the axis of the vagina; and that its fundus and body are raised above the bladder in such a way as greatly to be influenced by its vary- ing form. This fact, together with the intimate union existing UTERINE DEVIATIONS AND DISPLACEMENTS. 591 between the lower segment of the uterus and that of the bladder, shows why one of these organs cannot be displaced without in- volving the other. The uterus is sustained by folds of the peritoneum with inter- lacing fibres and areolar cellular tissue. The utero-vesical lio-a- ments in front of the womb, the utero-sacral The uterine iiga- Wments behind it, and the broad ligaments on ments. ... . . . either side of it, are the moorings by which it is attached. Below, its only support is derived from the vaginal column, which rests upon the perineum. Etiology. — The causes of uterine displacement are predisposing -and exciting. Among the former the most prominent is preg- nancy, which, by increasing the size and weight Predisposing causes. „ < ? „ , °. oi the uterus; by changing its iorm and its vascularity as well as its relation to other organs; by straining its ligaments and demoralizing its means of support; by debilitating the general strength and tone of the nervous and muscular sys- tems; and by the traumatism that is incident to delivery, is a more potent factor of these difficulties than any other. Menstruation is also a powerful predisponant of uterine displacer ments.* The monthly congestion of the ovaries and their append- ages, the risks of interruption to the flow, the sudden diversion of the blood to other parts of the body, and the pelvic engorgement that attends upon an imperfect or incomplete performance of this function, supply the conditions for disorders of place which are unknown before puberty and after the climacteric. Obstinate and habitual constipation, paralysis of the rectum, and a round and capacious pelvic brim should also be classed among the predis- ponents of uterine displacements. Another class of predisposing causes are avoidable, and must be charged to the usages of modern society. The habit of tight lacing, the wearing of heavy skirts and dresses which are Avoidable causes. „ . , ,, , not properly suspended from the shoulders, and of high heeled shoes, which change the relation of the organs within the pelvis and place the centre of gravity where it does not belong, are all of them, in a greater or less degree mischievous. Skating, dancing, riding on horseback, without regard to the menstrual period, and especially the new method of cultivating *See pages 132 and 160. 582 THE DISEASES OF WOMEN. the voice, which is called the " abdominal method" and which develops the diaphragmatic, at the expense of the thoracic respira- tion, are fruitful sources of uterine displacement. The exciting causes of this class of troubles are of three kinds, (1) the intrinsic, or those which lie within the uterus itself; (2) the extrinsic, or those which are within the pelvis and abdomen but outside the uterus ; and (3) the accidental, or such as result from some mechanical vio- lence. The most frequent of the intrinsic causes of uterine displace- ments of all kinds are puerperal subinvolution, pregnancy, chronic metritis, menorrhagia, interstitial and intra- The intrinsic causes. . - ^ . i i • -ii-i,-i uterine growths, as fibroids, polypi and hydatids ; hypertrophy of the cervix ; and chronic corporeal cervicitis. The study of these causes is indispensable to their careful and successful treatment. I would no more think of trying to cure a chronic case of prolapsus without first measuring the depth of the uterus with a graduated sound like this, (Fig. 71) than I would of giving Fig. 71. Jenks' elastic graduated sound. a diagnosis of whooping cough without looking at the frsenuni linguae. When you have no graduated one, an ordinary sound will answer the purpose. Each and all of the affeetions named are characterized by an increased depth of the uterus, when we meas- ure from the os to the fundus of the organ. For this reason, the sound is as important in a case of prolapsus or of procidentia, as it is in versions and flexions of the womb, although in a very different way. The extrinsic causes are the inclination or bias which the uterus has received during pregnancy; the pressure of extra-uterine fibroids, of ovarian, abdominal, and pelvic tu- The extrinsic causes. ^^ ^ Qf ^ abdominal viscera ; t he lesions of place that have been entailed from pelvi-peritonitis, pelvic cellulitis, and pelvic hematocele ; ascites, chronic cystitis, cysto- cele and stone in the bladder; rectocele, haemorrhoids, prolapse UTERINE DEVIATIONS AND DISPLACEMENTS. 593 of the bowel and of the vagina, and laceration of the perineum. The kind and degree of displacement induced by this class of causes varies with circumstances and with the tolerance which the uterus has for them. The accidental causes are chiefly mechanical, and include the mischievous effects of falls, blows, and injuries from jumping, or straining the body severely. The extreme The accidental causes. or spasmodic action of the diaphragm in coug- hing, convulsions, in running, or rapid breathing from any other cause, may also put the womb out of place. Here we have a veritable dislocation, which is the result of applied force, the same as in luxations of the elbow or shoulder from an accident. Symptoms. — The symptoms are direct or pelvic, and remote or reflex. The direct symptoms are recogniz- able by one or another of the modes of physical ex- ploration of which I have already spoken. (Lectures IV and V.) They vary with the kind and degree of the displacement, and will therefore be treated of when we come to speak of the several varieties of this general disorder. The remote symptoms are of two kinds (1) those which arise from a derangement of the intra-pelvic circulation, and (2) those which depend upon disorders of the nervous system, both ganglionic and cerebro- spinal. The former class of causes accounts for most of the troubles with the liver, the kidneys, and the digestive organs which either as cause or effect, usu- ally attend upon uterine displacements. The nervous causes implicate the more distant functions and or- gans, and indirectly give rise to the hysterical symp- toms which are so common in these disorders of place, FlG as well as in uterine affections generally. Diagnosis. — The diagnosis will be considered when we come to speak of the different varieties of displacement to which the uterus is subject. At present it must suffice to say that a careful and reliable diagnosis in this class of affections is absolutely impossible without a physical examination. 72. Gid- den's uterine sound. 594 THE DISEASES OF WOMEN, Treatment. — The general therapeutics of uterine displacements involves several important questions: (1) the significance and clinical value of the subjective symptoms in the General therapeu- ch ice f th reaiedv or rem edies to be em- tics of. " ' ployed; (2) the possibility of curing these displacements with internal remedies only; and (3) the use and abuse of the mechanical treatment by pessaries of various kinds. Concerning the two first of these inquiries, it has always seemed to me that, in a given case, if the subjective symptoms are common . , to two or more kinds of uterine deviations ; if The scope and value ' of internal remedies they are not to be depended upon exclusively, exclusively. even in the simplest cases, in making a diagnosis ; if the misplaced womb may cause such derangement of the circu- lation and of innervation as will persist until the organ is reposited and kept in situ ; if the lesions of the uterus and of its appendages, which cause and complicate these displacements, are of so varied a character ; and if the hysterical epi-phenomena are most prom- inent and least significant, we ought not to rely wholly upon the complaints of the patient in our selection of the remedy. You may depend upon it that the cures which have been claimed for internal treatment based upon such indications merely, are faulty and fallacious. The idea is not that the symptoms of which the patient complains in these cases are of no value, neither that remedies The necessity for re- which are g iven u P on pathogenetic indications liable indications of an are always inefficient. For these subjective symptoms have their value, which varies in dif- ferent cases; and medicines that are given in this way are some- times, but not certainly, or even usually, curative. Both are too slender to be relied upon exclusively. Both need to be re-enforced ; the symptoms, by a careful physical and objective examination, and by physiological reasoning; and the indications, by a knowledge of the intrinsic, the extrinsic, and the accidental causes of the dis- placement, by clinical experience, and by physiological reasoning also. Hence I have said that the reports of cases in which it has been claimed that deviations and displacements of the womb are easily cured by the affiliated remed}^ are faulty, because they have not told the whole story ; and fallacious , because they may mislead you into supposing that such a result is the rule and not the excep- tion. UTERINE DEVIATIONS AND DISPLACEMENTS. 595 That our internal remedies may, and do sometimes work won- ders in this way, even in this class of cases, there is no doubt, in my own mind at least, for I have tested them very thoroughly. But I should lose faith in my own clinical convictions, if they had no better foundation than the improved state of feeling, and the mere say-so of my patients. In an old play, I think it is the Octoroon, there is a scene in which a poor fellow is on trial for his life for having murdered a man in an out-of-the-way place. The evidence is all in, and the case is about to be closed with the result of liberating the prisoner, when a travelling daguerreotypist rushes into court with a pic- ture that he had incidentally taken of the scene of the murder, including, of course, the portraits of the prisoner and of his victim. When all other evidence had failed, the guilty man was convicted by this proof and by the plea of this providential witness who in referring to his camera-obscura, said "the apparatus can't lie!" In all semi-surgical affections like those under consideration, the subjective sensations partake of the nature of circumstantial evi- dence. Without more direct and positive proof we shall first fail to convict the patient of having a real displacement, and after- wards to convince a competent professional jury that we have really cured one. But, when the evidence that the uterine sound can furnish is brought into court, we shall have the facts in the case, for " the apparatus can't lie." Bear in mind, therefore, that the symptoms upon which you are to rely for the choice of your remedies in this class of cases are the cardinal signs that are coupled with some struc- tom h s eCardinalSymP " tural or functional disorder of the generative intestine, the bladder, or the rectum, or of the peritoneum, or the cellular tissue within the pelvis. If either of these lesions is post-puerperal, or if it is especially connected with menstruation, the symptoms will have a peculiar significance. You will have an ample illustration of this mode of prescribing in my clinic, but let me quote a case which several of the sub- classes have seen upon my table : Case. — Prolapsus from sub-involution. Mrs. T , aged 28, married, has had but one child which is now two years old, and no miscarriages. Her labor lasted only half an hour, her lying-in was tedious, but so far as we can learn, she had no especial illness. Her health has, however, been wretched from that time until the 596 THE DISEASES OF WOMEN. present. She nursed the baby for fourteen months. The menses; returned when the child was nine months old, and have come regularly and copiously every three to four weeks since that time. She complains sorely of bearing down pains, and dragging in the hips and loins, which almost entirely prevents her from being upon her feet. At times there is so much downward pressure that she feels as if all the pelvic organs would be forced out. Her appetite is gone, and she is generally in a very forlorn condition. Local examination by the touch, found the uterus considerably prolapsed, tumefied, and tender. In the field of the speculum, the os uteri was found to be lacerated in a linear direction, and the anterior lip discolored and badly swollen. The sound passed readily and showed that the depth of the uterus was four and one-half inches. She took secale cornutum 2, three times a day for two weeks; and then secale 3, as often for another fortnight. She received no local treatment whatever, and took no other remedy. At the end of one month the uterus was measured again in the presence of the sub-class, and its depth was found to have been reduced to three and one-half inches. Meanwhile her general health and spirits had improved in a corresponding degree. The dilapidated, dragging sensations had almost entirely disappeared, the pressure was gone, and the appetite had returned. She had passed through another menstrual period, but instead-of continu- ing copiously for five or six days, as heretofore, it lasted only three days and was of moderate quantity. Secale 3, was continued as before. I will not repeat what has already been said concerning subinvo- lution of the uterus, but will remind you that, in the case just cited, the cause of the prolapsus, as well as of the menorrhagia, was recog- nized by physical exploration. The curative indications were partly physiological, and partly clinical. If the secale would finish the work of uterine involution, which for some unknown reason had been interrupted during the lying-in, it was exactly what was needed to put an end to the prolapsus. That it did so, even after an interval of two years from her lying-in, was evident to all the pupils and several physicians who saw the case with me. " It runs without saying" that the laceration of the cervix was not an obstacle to the cure of the subinvolution. The opposition to the use of pessaries is not The opposition to pes- f there have alwa g been thoge who were saries an old story. . . . so prejudiced against them that they could not be persuaded to employ them. This is one of those questions, which like the propriety of tying the funis, of putting on the UTERINE DEVIATIONS AND DISPLACEMENTS. 597 The causes of mis- chief from pessaries. "binder, or of giving quinine tor intermittent fever, blooms peren- nially in our medical societies. Nor is it likely to be settled until physicians have learned to discriminate between cases of displace- ment that are primary and those which are secondary. This is the .first step towards the correction of extreme views on both sides; for where both parties hold to a half-truth neither has the benefit of the whole truth. A pessary is a crutch, or a prop, that is used under protest, and for the most part temporarily. If it is of the proper kind, and is properly applied, in suitable cases only, it is an undoubted means of relief. The mischief that is sometimes done by them arises from the notion that they are always necessary ; from a preference for one pattern for all cases indiscriminately; from their not being fitted appropriately ; from their being introduced or worn without regard to the month; and from a lack of cleanliness, which is often consequent upon wearing them. Certain varieties are especially harmful. If the ring pessary (Fig. 30) is too large it will stretch and paralyze the vaginal muscular fibre, and practically destroy the means of uterine Fig. 73. Mcintosh's pessary, support from below the organ. If the cervix is capped with a cup that is either too large or too small, its protecting epithelium will soon be destroyed, and abrasion and ulceration will fol- low. All kinds of stem-sup- ports are likely to induce cellu- litis, or peritonitis which may Fig. 74. Curved stem pessaries. result fatallv. (Tii?. 74.) When pessaries have been worn long enough to have been forgot- ten, and have decomposed or broken within the vagina, they have given rise to ulceration and to fistulas. A case of this kind was reported to our National Society a few years ago by my friend Dr. S. S. Lungren, of Toledo, in which he found the fragments of a fiflass tumbler that had been introduced bottom side up to sustain 598 THE DISEASES OF WOMEX, the uterus. Similar cases are on record in our medical works,, and, although it may seem strange to you that a woman should have forgotten the introduction of such an instrument, you may perhaps stumble upon such things in your own exper- ience. A case is recorded in the Ohio Medical and Surgical Journal for 1852, in which a wooden pessary was removed after it had been forty-one years in the vagina. The contra-indications for pessaries are numerous and important. They are cer- tain to be harmful if Contra-indications t j . sub-involution for. of the uterus, chronic metritis, corporeal cervicitis, endo-cervi- citis, in vaginitis, and in all kinds of circum-uterine inflammation, as pelvic cel- lulitis, and pelvic peritonitis with or with- out hematocele. penary!"' McIntosh ' s uterine They are more especially indicated in displacements with vaginal relaxation and prolapse, procidentia, with cystocele and rectocele oc- curring in wo- Indications for. ' p men of a very lax fibre, with muscular atony, who have borne their children rap- idly, and who are compelled to be upon their feet most of the time. In some cases of uterine displace- ment that occur in the early months of pregnancy, and in scir- rhus of the cervix and lower segment of the ! womb, pessaries are of great temporary benefit. The same is true when, as in old fio. 16. Coxeter stem pessary, ladies, we are not warranted in operating for the radical cure of these displacements. Case. UTERINE DEVIATIONS AND DISPLACEMNTS. 599 Briefly, I think it is wrong to abuse these instruments, or to insist upon dispensing with them altogether, until we have some- thing better to fill their place and to answer ^Argument for their ^©ir purpose. If you discard them entirely, and refuse to apply them under any condition, a certain share of your patients will be compelled to consult those who will use them for their relief. And, after all, since they do not interfere with the action of fitly-chosen remedies, we may resort to them as to any other form of surgical dressing, as for example, to a truss in hernia, or to splints and bandages in other dislocations. Closely related to the last of the three questions that we have answered is that of resorting to external, or abdominal supports for the relief of certain forms of uterine displace- ^Abdominal suppor- ments> There are twQ sid(?s tQ tMs quest i on a l so . The objections urged against these belts, binders or corsets, as a class are that, when snngly applied they weaken Fig. 77. Mathieu's abdominal supporter. the abdominal muscles by their steady pressure; that they force the intestines downwards upon the displaced uterus and thus increase the difficulty ; that they interfere with the freedom of action of the diaphragm, and so embarrass respiration; and that, sooner than with any other form 600 THE DISEASES OF WOMEN. Advantages of. of support, a woman becomes a slave to them, and must continue to wear them indefinitely. The advantages of this form of support are their cheapness, the ease of their application by the patients themselves; the possibility of wearing them and the relief afforded by them in some cases of peri-uterine inflammation ; their adaptation to cases in which from over-distention and rapid child- bearing the abdominal parietes are so lax as to permit the weight of the intestines to fall upon the uterus; and the tact that, when properly arranged, they afford a better perineal support than any form of pes- sary can possibly do. fig. 78. But these instruments are not adapted to all cases indiscriminately; nor is any one pattern always suited to the same variety of displacement in different persons. One woman will feel more comfort- able, and derive greater benefit from a simple elastic belt which she can fit for herself, while another will need a more complicated binder with elastic straps and adjustable pads, which can be shifted like those upon a truss. Here are three kinds of belts which in many cases will answer a good purpose. (Figs. 78, 79 and 80.) Other forms of this binder are more or less popular in different parts of the country. You will find a dozen or more of them on my desk, and can examine them, or try them on if you like, at the close of my lecture. Twenty years ago one who had had more experience than any other physician in America, in the treatment of uterine displace- ments wrote as follows: " From what has been said, the conclusion may fairly be made, that external supports are at least but palliative as regards some symptoms of displacement, and that they have no tendency to restore the organ to its prope 1 * position; but, on the contrary, that the whole tendency of the abdominal brace is to aggravate the pressure on the uterus, and increase its deviations. Hence Fjg. 79. UTERINE DEVIATIONS AND DISPLACEMENTS. 601 such supporters should be enumerated among the causes, original or aggravating, of uterine displacements, and not among the remedies. This view is confirmed by the constant experience of the author. Few patients, for some years, have come under his care in which these bandages have not been used for a longer or shorter time ; yet, in all cases, the displacement was found still existing, and in some to a great degree." * Fig. 80 a. Shannon Self Adjusting Supporter. Fig. 80 b. Shannon Elastic Supporter. It is well to remember that women with downward displacements of the womb are really suffering from a hernia of that organ, and like one with an inguinal or a femoral hernia, are in need of some kind of a mechanical support. For those women who are obliged to be upon their feet a great deal under these circumstances, one of the two forms of the Shannon supporter often answers a very good purpose. ( See Fig. 80. ) *On Diseases peculiar to women, including displacements of the uterus. By Hugh L. Hodge, M. D., etc., 1860, page 299. LECTURE XXXVIII. PROLAPSUS UTERI AND PROCIDENTIA. Pseudo-prolapse of the uterus. Prolapsus uteri, with superficial ulceration of the cer- vix. Prolapsus uteri with right latero- version. Prolapsus with anterior inclination of the fundus uteri. Procidentia uteri. Procidentia uteri from pertussis. Case. — At five p. m., of June 4, 1866, I was summoned in haste to visit Mrs. , who, the husband wrote me, was "almost dead with prolapse of the womb." In his note he requested me to bring the necessary instruments for replacing that organ. The patient, aged 52, had been ill one week, under the care of two physicians who had diagnosticated the case as one ot prolapsus uteri, and who, I was told, had several times restored the womb to its normal position. These operations had caused her great pain, and she had a mortal dread lest 1 should think it necessary to repeat them. The day previous, the doctor had succeeded in introducing a Hodge's lever pessary, which, after a little, dropped out of itself. Although she had taken opiates freely and fre- quently, she had not slept for two days and nights. There was retching and bilious vomiting, and, although she had taken cathar- tics, the bowels had not been opened for four days. There was much ineffectual tenesmus, and with each effort at stool she com- plained of feeling as if the uterus and neighboring organs would be expelled from the body. She was exceedingly nervous, and at intervals of five to fifteen minutes suffered acute pains across the inferior portion of the abdomen. These pains were aggravated by motion and by any considerable degree of mental excitement. She described them a. short, sharp, spasmodic, cutting and col- icky in nature. She was greatly depressed in spirits — "must have relief or she should die." I enjoined rest, as first and most important. Belladonna 3d, and nux vomica 3d, were to be taken in hourly alternation until the symptoms improved, after which they were to be repeated every two hours. If she slept, she was not to be awakened or disturbed. If the bowels did not move before daylight, they might give her an enema of tepid water. I made no examination per vaginam. June 5, 5 :30 p. m. — Patient better. After taking the first dose of the belladonna she slept for some minutes, and had but one more spasm of the pain. The remedies were repeated only at 602 PROLAPSUS UTERI AND PROCIDENTIA. 605 long intervals, for she slept quietly during the greater part of the night. At daylight, not having had a stool, the enema was ad- ministered with good effect, although the passage was very pain- ful, and she was much exhausted in consequence. The tenesmus and vomiting were relieved, and she declared herself well. Con- tinued the same remedies once in four hours. The " touch" re- vealed the uterus in situ. The husband and family were delighted with the promptness of the relief afforded. Two days later this patient was able to attend to her household duties. Nothing is more common than a temporary prolapse ot the womb. Some women have it at each menstrual period; others after any extraordinary fatigue, as in walking prolapse. 11070 ' merine or ridin g '> some from [L fit of meiltal anxiety or of coughing; others after a stool; and others again after coitus. When induced by these causes it is a sell- limited affection, and may pass away with rest in the recumbent posture. This is a very different thing* from a chronic and invet- erate prolapse, and requires very different treatment. If my predecessors had recognized this fact, this patient would have improved before I came ; for in that case they would have for- borne to do anything mischievous. A correct knowledge of special pathology on the part of the physician is sometimes an excellent safeguard for the patient. One of two ill results may follow a wrong diagnosis in cases of this kind. Either the slight and temporary displacement may be converted into a permanent one, with all its Consequences of in- - . -it-it /» correct diagnosis. consequent suffering and disorder, by reason or a harsh and inappropriate treatment; or it may happen that harmless and inefficient means may get the credit of holding some specific curative relation to uterine deviations of whatever kind. Nothing could be more cruel, harmful and unnecessary, than to resort to manual treatment in such a case as laUo n n neCeS ' arymaniPU " this ' hl the Sta # e in wMch l f0Ulld it: - Wh y explore and worry such a sensitive womb with the sound? Probing will not relieve these acute symptoms, and a pessary would be about as useful as a fracture box in inflamma- tory rheumatism. Opiates might deaden the sensibilities, but they are possessed €04 THE DISEASES OF WOMEN. of no curative relation to the symptoms detailed, and would indi- rectly unhinge the nervous sympathies more Harmful medicat,on. ° , . . , , , and more. 11 the cathartics operated at all, the effect would be, by increasing the peristaltic action of the in- testines, to increase the uterine displacement and to render it more permanent. There is no question, in my own mind at least, that very many examples of confirmed prolapsus have been en- tailed upon our patients by such inappropriate and inexcusable treatment at the hands of those who have preceded us. On the other hand, the fact that such cases may get well of themselves, providing we do nothing to interfere therewith, is too frequently lost sight of by our physicians. and P quackishclim3? Evei ^ khld ° f vemed Y haS thus been £ iven aAld extolled as a specific for uterine deviations. You will find the most incredible stories of cures with this or that dilution detailed in our books and journals. Perhaps a single dose has worked the most marvelous results, the womb being replaced, according to the report, almost as soon as the medicine was swallowed, no allowance being made for the tend- ency to a spontaneous reduction of the dislocation, the self-lim- ited nature of the attack, or the good effect of rest in the proper position. When carefully chosen, it is reasonable to suppose that our remedies are capable, in many instances, of curing what might otherwise develop into a troublesome case of what remedies may llter i ne p ro lapse. We may sometimes avert do in prolapsus. L l J such a consequence of neglect, or of ill-treat- ment, in much the same manner as we prevent a case of pulmon- ary congestion from resulting in pneumonia. It is possible, by this means, to spare our patients much suffering, and frequently to turn aside what would otherwise be a real calamity. I cannot claim that belladonna is a specific for any form of uterine luxa- tion, but I may insist that it was adapted to the relief of the peculiar incidental symptoms of which this patient complained. Nux vomica will not go to work like an intelligent agent to re- store the fallen womb to its proper position, but it holds a spe- cific, pathogenetic relation to the incidental symptoms in many cases of the kind. And so of podophyllin, sepia, calcarea carb., and many other remedies. W^e must select the remedy according PROLAPSUS UTERI WITH ULCERATION. (505 to the symptoms that are present, just as in a case oi incipient pneumonia, or pleurisy. In this stage, the proper treatment is medical, and not surgical. Whether you should alternate remedies, as it seemed best for me to do in this case, your own observation must help you to de- cide. It would be very wrong to claim that dits kerriati0n0lreme cures have D0t been effected in this manner, and equally at variance with truth, to assert that careful study and close observation do not lead a majority of practitioners more and more to prefer the single remedy. PROLAPSUS UTERI, WITH SUPERFICIAL ULCERATION OF THE CERVIX. Case. — Mrs. , aged twenty-four, began to menstruate at twelve, from which period she dates her illness. The catamenia are irregular, sometimes appearing once in three weeks, again in four, and, occasionally, with an interval of five weeks. The only particular suffering experienced at the period is a dull, aching pain about and in front of the left hip, and a dragging pain across the loins. The flow usually continues three days, and is normal in quantity and quality. During the inter-menstrual period she complains of a bearing down sensation within the pelvis. There is great weakness of the back in the lumbar and sacral regions. Standing for any length of time, or walking a short distance, fatigues her exceed- ingly. When weary, she is subject to a peculiar sensation in the lumbar region, "as if a considerable portion of the backbone, perhaps six inches long had been removed." This is soon followed by a faint feeling, and sometimes by actual syncope. At other times, and especially if she is in a room in which there are many other persons, as in a church, or in a concert hall, there is a sense of impending suffocation. Sometimes the unnatural feeling along the spine recurs without any apparent cause or premonition. Then follows an irresistible propensity "to drop down upon the knees." At such times the lower limbs feel numb, insensible, and semi-paralyzed, but the knees are especially weak and powerless. Another symptom which she has remarked is a sense of coldness on the top of the head, which, whenever she swallows either cold or warm drinks, is curiously changed into a sensation as of "crawl- ing" under the scalp. So marked is this symptom that she has insensibly acquired the habit of placing her hand on that part of the head for its relief, whenever she nuts a cup or glass to her lips. For some years past (she does not know how long) she has had leucorrhcea. The discharge is habitually more profuse immediately before, but ceases during menstruation. In character she de- scribes it as "catarrhal," creamy, bland and unirritating. 60() THE DISEASES OF WOMEN. The touch reveals the uterus prolapsed, the neck of the womb tender and tumefied. When she stands, the anterior lip of the cervix rests upon tiie posterior vaginal wall, directly over the perineum. Upon examination with the speculum, a large, irreg- ular, suppurating ulcer was found to extend within the external os uteri, and over a considerable portion of the anterior lip of the cervix. Uterine deviations not unirequently date from puberty. They are the more likely to follow if menstruation begins at a very early uterine luxations or a very late age. With this patient the flow may begin at puberty. fi rs t appeared when she was but twelve years old. Under these circumstances it must have required more than ordinary effort on the part of the ovaries and the generative intes- tine to establish this very important function. The ripening, transit, and parturition of the ovum in such subjects resembles labor, and so far as disorders of place are concerned, the conse- quences to the uterus are of a similar character to those which are contingent upon that process in older women. In the case before you, the afflux of blood to the internal generative organs, the increased weight of the womb, the requisite dilatation and relax- ation of the uterine cervix and of the vagina, the contractile effort of the womb to expel its contents, supplied the identical conditions which predispose to uterine displacements following abortion or labor at term. Irregular menstruation may be a cause or a consequence of uter- ine deviations. In one form or another they are very apt to co- exist. It is unusual to meet with a chronic case Irregular menstru- ation a cause of prc-iay- of prolapsus, or of retro-version, in which the menses are not more or less irregular as to the time and method of their recurrence. This state of things is undoubtedly due to a derangement in the local, intra-pelvic circu- lation. The uterus has become the seat of venous engorgement. Its increased weight has borne it down upon the structures that were designed to sustain it, until they have given way, and it has become displaced. For if the uterine ligaments are not fortified against this increase of weight in the womb, an undue or unus- ual determination of blood to this organ, or sluggishness in its circulation, weakens these supports, and renders them more liable to yield. PROLAPSUS UTERI WITH ULCERATION. 607 Hence, also, the frequent complications of uterine displacements with chronic disorders of digestion. The connection between the uterine luxations venous systems of the uterus and the liver, •and digestive disorders, explained in my remarks upon another case is significant. There are few examples of prolapsus which are not accompanied by haemorrhoids, prolapse of the rectum, or by a more or less obstinate constipation. Lumbar and sacral pains are incident to most cases of prolapsus, and of uterine ulceration also. But the kind and degree of these Lumbar and sacrai pains are modified according to circumstances. P ains - As a rule, they are more acute and tormenting in nervous, hysterical, and delicate women than in those who are of a different temperament and organization. Among the more robust and energetic there is sometimes a remarkable tolerance ol uterine displacements, which may exist for years with little com- plaint of pain in the loins, or of especial suffering of any kind. But these cases are exceptional. In prolapsus, the pains in the lumbar and sacral regions are brought on or increased by standing, riding or walking, and some- times by bending forwards and then rising suddenly to an upright position. The back feels very weak, and perhaps as though it were actually broken in two. The more chronic the case, the greater the suffering, more especially if at the same time the patient has leucorrhcea, irregular menstruation, or ulceration of the uterine cervix. For, independently of the falling of the womb, these several diseases are almost always accompanied by similar symptoms. This poor woman has them all, and it is by no means strange that such an array of symptoms should present themselves. The dropping down of the uterus, and its direct pressure upon the anterior sacral nerves, and also upon the utero-cervical ganglia, Proiapus and par- °f tne sympathetic, is sufficient to account for -aiysis the sudden, partial, and temporary paraplegia, or powerlessness in the lower limbs. She falls upon the knees irresistibly. There is numbness and semi-paralysis, which are self-limited. The nervous currents between the spinal center and these parts are interrupted , and the consequence is manifest. Rest, with change from the upright to the horizontal position, causes the Avomb to lift itself, as the French would say, and the normal nervous circulation returns. 608 THE DISEASES OF WOMEN. The same physiological reasons explain the peculiar sensation "as if a portion of the spine had been removed," the fain tness, the Hysterical compii- syncope, and the eccentric symptoms which are cations, referred to the top of the head. Through the frequent recurrence of this displacement, the nervous system has acquired a predisposition to hysterical complications. On this theory, the increase of suffering from swallowing cold or warm drinks, which act produces a "crawling" sensation beneath the scalp, as well as the sense of suffocation when in a room full of people, are by no means inexplicable. The relief afforded by pressure upon the top of the head, proves that the peculiar sensa- tion felt in that region is purely nervous. Let me remind you, however, that these symptoms are none the less real because we style them "nervous," and because it is only The reality of k * ner- through our knowledge of the reflex nervous vous' symptoms. system that we are competent to explain their existence. In truth, this woman has suffered more from these peculiar sensations in the head than from pains in the loins, or in the left iliac region, the temporary paralysis, or from any and all of her other symptoms. For, although the element of exaggera- tion enters largely into the hysterical constitution; we cannot doubt that persons with this temperament are possessed of an increased susceptibility to pain and disease, and that they do really suffer more than others under similar external circumstances. But this case has other complications. Some authors will tell you that prolapsus, leucorrhoea, and uterine ulceration, like a symptoms versus cough or a diarrhoea, are not to be considered as disease, so may separate disorders, but as symptoms: merely. And in the main their view is correct ; but symptoms, like quarrels, do not come wichout cause. When it is possible* we muse find out their source, in order to be able to explain their significance and to cure them. There may have been an order of sequence in the coming on of these symptoms, which it is most desirable and necessary for the physician to know. Our patient has a chronic prolapse of the womb, which in all . probability owes its origin to causes already Leucorrhoea and ul- l J < » J ceration from proiap- named. Following this displacement, and con- sus * sequent upon it, she also has leucorrhcea and uterine ulceration. Which of these two contingent affections came PROLAPSUS UTERI WITH ULCERATION. 609 first, we do not know. Nothing is more common than a leucor- rhceal flow of a catarrhal nature accompanying the slighter and more temporary degrees of uterine prolapse. Here the discharge depends on glandular derangement without structural lesion. There need be, and generally is, in these cases, no ulceration what- ever. But if the uterine deviation is persistent, and especially if the uterus lies low upon the perineum, its friction against the poste- rior vaginal wall is pretty certain, sooner or Ulceration from , . . , . „ .. abrasion. later, to cause an abrasion ot its investing epi_ thelium. This mechanical cause may induce and perpetuate a superficial ulceration of the neck of the womb, or of the vagina, or of both of these parts together. As the deeper seated textures become involved in the lesion, a more or less copi- ous discharge is poured out, and in future the leucorrhcea will either depend entirely on, or be greatly modified by the existing ulceration. The belief is very general that, directly or indirectly, all cases of uterine ulceration originate in the inflammatory process. But I apprehend this view is not correct. Inflam- ulceration sans ma tion always imperils the proper nutrition of inflammation. . . . . the organ or tissue in which it is seated. Its chief danger lies in this very fact. But there are many disorders of nutrition, and some of them of a most serious character, which certainly are not in any manner dependent upon the inflammatory process. It is probable that a large proportion of cases of uterine ulcer- ation commence with simple abrasion of the mucous surface. The wearing of an ill-adjusted pessary, or of one ADrasion° f uterme w T hich is made of improper material, the careless employment of the female syringe ; the abuse of sexual intercourse; horseback riding; mechanical injury of the os uteri during delivery ; the use of harmful injections thrown into the vagina, especially after coitus or during menstruation; the contact of corrosive discharges from the uterine cervix, and of vitiated semen, as well as friction from the various uterine dis- placements, may be sufficient to produce it. Superficial ulceration of the os following abrasion of its epithe- lium differs from other varieties of uterine ulceration. It consists 39 610 THE DISEASES OF WOMEN. essentially in defective reparation of its investing membrane, and Nature of ulceration not in a destructive metamorphosis of the un- from abrasion. derlying textures. Treatment. — The medical management of such cases as this is especially vexatious. We must begin rightly or we shall fail. Any attempt to cure the leucorrhcea without ^ Therapeutical reflec- ^cogmzmg or relieving the ulceration of the os uteri, or to remedy this lesion without doing anything for the displacement of the womb, would reflect upon our skill and experience. And so also if we were to elevate some of the incidental, irrelevant, hysterical symptoms of which our patient complains, to the dignity of characteristic symptoms, when they do not deserve such distinction, and afterwards busy our- selves with curing them. It is a rule in therapeutics that the symptoms of a complicated, chronic case of disease should be made to disappear in an order which is the reverse of that in which they came Rule Reducible from __ the j t fi t d SQ b fe t th starting the order of symptoms. ' « point. But when applied to the treatment of uterine affections, this rule has many exceptions. The most stupid blunders have sometimes been perpetrated through ignor- ance of this fact. The first indication is to keep this woman as quiet as possible. She need not lie in bed all the time, but she should assume the recumbent position either upon the side or the Postural treatment. * ; . , , back. And, if necessary, she should persevere in this tor some weeks, or even for months. For you will not cure these cases so promptly as some enthusiasts would lead you to believe possible. Walking, standing, and sitting aggravate her sufferings. She must therefore, keep quiet. Her shopping and her church-going must be done by proxy. She is no more able to run a sewing machine than she is to run with a fire engine. And, if she were my pri- Dressinsthe hair, etc. Jr . . , vate patient, I should forbid her dressing her own hair — which is really one of the most tiresome and injurious kinds of exercise for a woman who is suffering" from uterine dis- cs ease. Her clothing should be worn loosely about the waist. No matter what the kind and degree of the uterine displace- ment, if the os uteri is abraded or ulcerated, it is wrong to apply PROLAPSUS UTERI WITH ULCERATION. 611 any pessary whatever; lor, by direct pressure upon, and contact with, the denuded surface, these instruments contra-indications n W ork serious mischief. Under such circum- for the pessary. J stances, they have been known to increase the sufferings, to extend the lesion of the cervix, to multiply the reflex symptoms, and to augment the leucorrhceal flow. Keeping- the patient in the proper position is a harmless and efficient substitute for these appliances in all cases of this partiuclar kind. (Exit the patient.) Another requisite for this woman's recovery, of which I have forborne to speak in her presence, is the prohibition of sexual con- gress. Otherwise it is next to impossible to Prohibition of sexual e f ^ ^^ jj sepamtion from congress. t L her husband will insure against the undue determination of blood to the internal generative organs, which is consequent upon the sexual act, and will thereby remove one of the principal causes that serve to perpetuate the abnormal con- dition and position of the womb. If we overlook or ignore this item, a cause which may counterbalance all our efforts at cure, will be constantly at work, and we may fail in consequence. I do not doubt that much of the boasted efficacy of escharotics in uterine ulceration should really be attributed to the interrup- tion of sexual intercourse, which they necessitate. I can conceive that frequently the caustic might be less harmful than coitus. „ , ,. „ And so, also, of similar cures which are ascribed Modus operandi of ' ' caustics, etc., in cer- to the use of cold water in the various hydro- tam cases. pathic establishments. Without saying a word against this system of treatment, it is quite probable that the ben- efit derived in many ol these cases is due as much to the enforced absence of the patient from the bed and board of her husband, as to the bath and remedies that are prescribed. For the cure of a simple, suppurating ulcer of the os uteri, I know of nothing so beneficial locally as the calendula. To a drachm of the strong tincture of calendula add Calendula topically. , two ounces each ot glycerine and distilled water. Of this mixture a tablespoonful may be put into a teacupful of tepid water for an injection per vaginam. This injection, which should be retained as long as possible, may be repeated once or twice daily. The calendula not only heals the abraded surface 612 THE DISEASES OF WOMEN. most kindly, but it also relieves the swelling and tenderness of the cervix, which are so marked in the case under review. In not a few instances it may suffice to arrest the leucorrhceal flow. Or a mixture of glycerine and water in equal parts may be applied by means of cotton tampon. If you think best, there is no valid objection to adding a few drops of en?s herl ° Cal eXPedi " the gratis to this preparation. I have some- times melted simple cerate and applied it directly to the denuded cervix, through the speculum, by means of a camel's hair pencil. Injections of sugar and water are wonderfully efficacious in healing these simple abrasions of the utero-vaofinal mucous membrane. The preparation of collodion with castor oil, recently extolled by M. Latour, in his method of treating diseases by isolation, has been of great service to some of my private patients, in whose cases it was applied to the os uteri, in the manner as- recommended for the simple cerate. The internal remedies most appropriate for the case under con- sideration are nux vomica and calcarea carbonica. I need not detail their respective indications. If you will study the symp- toms carefully, excluding those which are merely sensational and incidental, you will not fail to endorse my prescription. They should be given, for a limited period, night and morning — the nux at night and the calcarea in the morning. Let her report at the end of a week. PROLAPSUS UTERI WITH RIGHT LATERO-VERSION. Case. — Mrs. — complains of a series of symptoms, from which she says she has suffered for more than a year past. She is mar- ried, but has never borne any children, neither has she ever had a miscarriage. She has dragging pain in the hips and loins, and sometimes there is strangury, with obstinate constipation. The bowels move at long intervals spontaneously, but with much effort and tenesmus, which at times are ineffectual. The stools are in- variable dry, hard, and scybalous. When straining at stool, she sometimes " feels as if everything would be forced from her." All the unpleasant symptoms are increased during and tor some time after the menstrual period. At times she experiences severe cramping pains in the right thigh, which come on suddenly after prolonged exercise upon her feet, or after standing for a consider- able time. The only means of relief that she has found trom the latter paroxysms is obtained by lying down immediately upon the PROLAPSUS UTERI AVITH RIGHT L AT ERO- VERSION. 613 left or opposite side of the body. By keeping quiet in this posi- tion for a little while, the cramp-like pain subsides and soon leaves entirely. She has not been able to lie with any degree of com- fort upon her right side since her ill-health began. And if she rolls upon that side while sleeping, the cramps in the right thigh will awaken her at once. She has , an almost constant headache in the region of the temples. During and after the menses, how- ever, it is apt to be located in the occipital region. The now is too profuse. It continues a whole week, instead of four days as heretofore. It is also too frequent, returning as often as every three weeks at the farthest. You have doubtless observed the relative frequency of consti- pation as an attendant upon the diseases of women. One of its most common causes is a paralysis of the rec- constipation from t j j^ exam j ne a this patient per vagi- rectal paralysis. l . & nam, and found the uterus prolapsed, and at the same time lying obliquely from right to left across the vagina. The most plausible theory of this displacement is that the descent and pressure of the womb against the bowel caused it to become paralyzed. The accumulation of faecal matter in the rectum forced the fundus of the uterus toward the right acetabulum, and lateio-version was the natural and necessary consequence. Whether the constipation really preceded or followed the pro- lapsus, it would be impossible to say. Latero-version of the uterus always depends upon pressure applied to the side of its body or fundus. It is incident to the history of fibroids, ovarian tumors, and to tumors within the broad ligaments. When due to either of these diseases the organ may be ,n^ at r°.r^n,T displaced either toward the right or the left an over-loaded rectum. 1 _ o side of the pelvis. When, however, it depends upon the pressure of a tumor caused by impacted faeces contained within the rectum, the fundus will, as in the case before us, always be thrown toward the right acetabulum and the cervix toward the tuberosity of the left ischium. The diagnosis may be con- firmed by the introduction of the uterine sound or probe. The incidental symptoms are interesting and significant. The cramping pains of which Mrs. complains are referable to pressure of the corpus uteri upon the anterior The cramping pains. , - A branches ot the sacral nerves, W hen sue lies upon the right side, the womb falls upon those nerves, or is 614 THE DISEASES OF WOMEN. pressed by the distended rectum against them. When she turns upon the left side, it drops away, and the cramp ceases. When she walks too far, or is upon her feet for too long a time, the womb is more decidedly prolapsed. The nearer its approach to the perineum the more direct and positive the pressure of the rectum toward the right side of the pelvis. Straining at stool only increases the difficulty, and it is no marvel that she feels as if all the pelvic organs would be forced through the vulva. These cramp-like pains are very similar to those which may attend upon an advanced stage of labor. In presentations of the vertex especially, when rotation occurs suddenly and the head passes rapidly through the inferior pelvic strait, direct pressure upon the sacral nerves often causes the patient to cry out that her " legs are cramping." And so also in cases in which the womb is retroverted suddenly, as from a fall or other impulse, one or both the lower extremities may be violently cramped and even paralyzed. In this poor woman's case there is no dropsy of the feet and ankles, and the veins are not varicose, because the pressure is not applied to the vessels going to the lower extremi- ties. Those vessels emerge from the superior pelvis beneath Poupart's ligament, and are, therefore, not liable to be pressed upon by the uterus, excepting in its gravid state, after the fourth month. One of two causes may be sufficient to account for the implica- tion of the bladder in this case. The strangury might be caused by the displacement of the uterine cervix, or The vesical symptoms. ,, , by pressure of the uterus against the neck of the bladder and the urethra. The uterine cervix is so joined with the inferior portion of the bladder that it cannot be very decid- edly displaced without dragging upon that organ, and give rise to more or less of irritation, inflammation, and vesical tenesmus. Hence it sometimes happens that the most prominent and per- sistent symptoms of uterine luxation are referred almost exclu- sively to the bladder. And, because they suppose that all de- rangements of the urinary function are due to renal disorder, patients not imfrequently consult their physician for the cure of disease of the kidneys, when they are really sufFering from some form of displacement of the womb. Such slight degrees of prolapsus, as are incident to the men- PROLAPSUS WITH RIGHT LATEKO-VERSIOX. 615 strual period and to the early weeks of pregnancy, are sometimes the cause of frequent and painful micturition. These sufferings are, however, relieved spontaneously — by the escape of the menses and the subsidence of the monthly hyperemia in the one case, and by the final ascent of the uterus above the superior strait in tfie other. In chronic prolapsus all these symptoms are made to Vanish, at least temporarily, by lifting the womb into its proper position. This case illustrates the possibility of uterine displacements disconnected with abortion or with labor at term. The frequent return of menstruation, and the excess of the flow, indicate a primary disorder of this very important function. Treatment. — There are two reasons why this woman is not well. The first is, that her rectum is paralyzed ; Leading indications. *■ u the second, that she menstruates too freely and frequently. All the symptoms that have the least significance may be referred to one of these two causes. This is the most common form of constipation in females. If the muscular coat of the rectum has lost its tonicity through neglect of the patient to attend to the calls of To remedy the con- n;l t U re, or to go to stool regularly everyday, stipation. ' c c J J J ' ' this bad habit should be corrected. Enemata containing olive oil, or castor oil, may be given for temporary relief, with the view of softening and removing the impacted faeces. Laxative food is of more service in constipation depend- ing upon causes which affect the upper portion of the intestine. Some of these patients with paralysis of the rectum might eat brown-bread, oatmeal, figs, prunes, or baked apples until dooms- day without the least benefit. If the uterus is prolapsed, or so displaced as to press directly against the rectum, that pressure must be removed, or the con- stipation can not be cured. And since these causes act and react, the uterine deviation may depend upon Empty the rectum- th j k f ^flfe™ in the rec tum, the pres- restore the uterus. J ' l ence of faecal matter within the gut, or upon straining at stool. Pessaries are contra-indicated in case of uterine displacement with profuse and too frequent menstrua- tion. The most ordinary remedies for this variety of constipation, 616 Tin: diseases or women. with its incidental uterine displacement, are alumina, mix vom- ica, natrum mur., plumbum, opium, belladonna, sulphur, zincum and lycopodium. Among those which are in best repute for the cure of too fre- quent and copious menstruation you will find calcarea carb., china, phosphoric acid, cantharis, zincum met., spongia, sulphur, kreosotum, and magnesia carbonica. This patient will take mix vomica 3d at night, and calcarea carb. 3d in the morning, one dose of each daily. She must keep off her feet as much as possible, particularly at the catamenjal season. PROLAPSUS WITH ANTERIOR INCLINATION OF THE FUNDUS UTERI. Case. — Mrs. S , aged 27 years, has never been pregnant. She has had prolapsus and has worn a ring pessary for a year past. Local examination discloses a downward displacement, with a slight inclination of the fundus of the uterus towards the bladder. The menses are regular, but the prolapsus is much ivorse during the flow. The bowels are constipated and relaxed alternately, but she has no haemorrhoids. Nux vomica 3, three times daily. This case proves the possible inefficiency of the ring pessary, but it does not argue that vaginal supports are never necessary or useful. If the ring had been removed in advance of the menstrual period, and replaced after it, some good miofht have resulted. But, awkward as it is, I think a Hodge's pessary (Fig. 83) would have done better. For some of these cases the dumb-bell pessary known as Trask's (Fig. 81), or the hard-rubber pessary de- vised by Dr. Fraser (Fig. 84) will keep the organ in place. Zwanke's butterfly pessary, which is very popular in Germany, is sometimes very useful in these cases. As a rule, Hornby's instrument, which is cheap, durable, easily adjusted, with a spring-stem, and a per- ineal support, is the one that I prefer. PROCIDENTIA UTERI. Case. — Mrs. , aged forty-seven, who comes before the sub- clinic to-day has suffered from procidentia uteri for nineteen years, and since the birth of her first child. She has since that time, given birth to five children and had one miscarriage. The menses PROCIDENTIA UTERI. 617 congestion its the same ceased two years ago, and she now complains of a feeling of great weakness, especially in her limbs, while the womb is dislocated, and asks that something may be done for her # A fortnight ago I showed you a patient who had suffered from procidentia of the uterus, for sixteen years. You will remember that in her case, the tumor was very large, and that she told us it had been carried externally lor a num- ber of years without being" replaced. The sur- pig.82. zwanke's pessary. face of the tumor was excoriated in large patches, and the cervix was swollen and discolored almost beyond recognition. The tumor was the form and size of an ego-- plant, and, from venous lower portion had very much color. (Fig, 88.) In the case which is now on the table, although the tumor is not so lar^e, the fig. 83. Bodge's pessary, extrusion of the womb at the vulva is equally manifest. The pear-shaped outline of the organ is pre- served, there are no excoriations, the two lips of the cervix are recognizable, you can see the patulous os, and the parts are not so discolored as in the former case. The exemption from some of these lesions is easily explained, for this tumor can be readily reposited. The Avomb must have returned into the pelvis, else she could not have become pregnant so often after its exit. The diagnosis of procidentia uteri is not difficult. We know it from inversion of the uterus and from fibroids and other tumors that might be extruded, by the form cf the tumor, by our ability to recognize the lips of the cervix and the os uteri at it? lower portion, and by the possibility of pass fig. 85. Hornby's pessary. j U g the uterine sound into it. Observe that I introduce the sound through the os uteri quite readily and pass- its point directly to the fundus. I now withdraw it and show you the depth of the womb, which is exactly four inches. Fig. 8-t. Fraser's pessary. "Diagnosis. 618 THE DISEASES OF WOMEN. Case. Hornby's pessary. There is very little doubt that this displacement of the uterus followed childbirth, and that the escape of the organ from the pelvis was facilitated by its defective involution. Ten years ago I gave the class a lecture on procidentia, illustrated by a cadaver brought to the table, from the dissecting room. All the appearances indicated that the poor woman had died directly after la- bor. The uterus was not in- verted, as it might have been from an improper delivery of the placenta, but it had been ex- pelled ill a perpendicular direc- tion with the cervix looking downward. I passed the sound and showed the class that its depth was seven inches, careful examination of its textures satis- fied us that it was the puerperal uterus which had thus been extruded. The case was a very remarkable one. Treatment. — There are three methods of treating these cases The first is to reduce the dislocation and afterwards to keep the parts in apposition, as the surgeons would ^W; say, by the adjustment of a pessary which would keep the womb where it belongs. We shall try this plan first and if it fails, must afterwards resort to one of the others. The second method consists in remov- ing a portion of the vaginal mucous mem- brane, (Fig. 87) as in the operation for cysto- cele, and bringing the edges together by suture in such a way as to narrow the , , . Fig. 87. Incisions and sutures vagina and prevent the extrusion of the in Eiytrorrhaphy. womb. This is styled eiytrorrhaphy, and in making it, I prefer Thomas' operation which I have already described under the head Episio-perineor- 01 CyStOCeie. rnaphy. The third, consists in freshening the edges of the labia and bringing them together by suture so as to close Eiytrorrhaphy. PROCIDENTIA FROM Pi-.lITl "SSIS. (jld the vulvar orifice, excepting only a small opening which is left for the discharge of the urine. This operation is termed q)isio- 2) er in eo rrh ajpliy. PROCIDENTIA UTERI FROM PERTUSSIS. Case. — At the eighth month of pregnancy, Mrs. , aged 32, was seized with a violent attack of whooping cough. The par- oxysms ot coughing were so frequent and severe as to threaten premature labor; but by careful management she was finally brought to term without any serious mishap. After delivery she got up well, the violence of the cough gradually abating until, at the end of two months, it had almost entirely ceased. With the exception of a slight cough, and an habitual constipation (which she always has while nursing), she felt herself well. At the end of the third month, and while taking her usual afternoon drive, she took cold, and the consequence was, a recurrence of the whooping cough. The fits returned with their former severity, and she "felt as if she should cough herself to pieces." The second evening after the return of these trying symptoms, while at stool, and during a paroxysm of the cough, she suddenly felt something escape the vulva. I was summoned, and arrived shortly. The womb had been forced entirely out of the pelvis, and was lying between the thighs. It was easily reduced by appropriate taxis and the proper treatment was instituted. She made a good recovery. Pertussis is a rare contingent of pregnancy. This case is, therefore, somewhat extraordinary. I have cited it in order to Anta°-oni«m of th- ma ke a few clinical points particularly clear to diaphragm and peri- your minds. It illustrates the antagonism of the diaphragm and the perineum, the former of which, you remember, is the muscular floor of the thorax, and the latter of the abdomen, or, more properly, of the pelvis. In consequence ot gestation, and after delivery, the lateral and in- terior supports of the womb are not always sufficient to retain it in situ. The ligaments have been stretched and off duty for so long a time that they are lacking in tone and strength. The vaginal and muscular column resting on the perineum has been so relaxed and distended as to yield it but little support from below. This state of things predisposes to downward displacements of the womb after delivery. If the patient is upon her feet too ^arly and too frequently, if the womb folds upon itself very 620 THE DISEASES OF WOMEN. slowly, and its involution is imperfectly accomplished, such mis- haps are more likely to follow. Constipation in some lying-in women, and diarrhoea in others, are predisponents of prolapsus and procidentia uteri. Among the exciting causes of these particular displacements in lying-in women, and in those who have recently been delivered, a violent cough is, perhaps, the most serious. Coujrh a cause of u i i • 1 • i ±. uterin. displacement. Hence > we may have prolapsus in a slight or extreme degree as a concomitant of pneumonia, pleurisy, bronchitis, or whooping cough. The pectoral lesion Fig. 88. Procidentia of the uterus. proper has nothing to do with causing the displacement. The cough alone is responsible for it. It acts through the spasmodic and forcible contractions of the diaphragm, which it necessarily induces. And the more violent the couodrinof fit, the greater the danger of this unfortunate result. During the fit of whooping cough the convulsive action of the diaphragm is sometimes prolonged and painful. In children it is very apt to be followed by retching and vomit- Labor a predisponent. . , , . . . -T • , i * i nig, and sometimes by severe and intractable tenesmus of the bowel. In the case of my patient, who had just been straining at stool, its effect was to overcome the slight re- sistance offered by the sphincter vaginae and the perineal muscles, and to empty the pelvis of the womb itself. Of course, this PROCIDENTIA FROM PERTUSSIS. 621 accident would be much more likely to happen at the second or third month after confinement than after the vagina and peii- neum, as well as the uterine ligaments, had recovered their ton- icity, and were better able to sustain the womb, and to retain it in its proper place. Treatment. — The treatment proper for a case of this kind is preventive, postural, and remedial. The occurrence of a severe cough during gestation, and espe- cially towards its close, should cause you to take especial pains to prevent such a sequel to the labor as happened in this case. After delivery the patient should be kept in the horizontal position for a longer period than usual. The binder should be snugly and firmly applied, and she should not be allowed to stand upon her feet until three or four weeks have elapsed. She should be cautioned against straining at stool, or in urinating, and counseled to suppress the desire to cough as much as possible. Where the womb has really been expelled, the first thing to be done is, of course, to replace it. This may be easily accomplished in recent cases. Place the patient on her back, raise the hips and lower the head. Then, hav- ing anointed the hand, grasp the tumor firmly, and insinuate it gently within the vulva, passing it first in the direction of the vaginal axis, and afterwards in that of the pelvic axis proper. When in situ, apply a perineal bandage and pad, which should be worn for some weeks, even after the patient has left her bed. There is no more natural and effectual support, in a case of proci- dentia than this. You can extemporize such a support out of the simplest materials. The most appropriate and efficient remedies should be given for the cough, and every precaution taken to prevent a relapse. This is especially important in case of whooping cough, the effects of the paroxysm being so disastrous and prejudicial to permanent recovery. Cure the cough, and its indirect consequences will cease. Stop the convulsive action of the diaphragm, and the uterine displacement may not return. LECTUKE XXXIX. FLEXIONS AND VERSIONS OF THE UTERUS. Uteiine Flexions. General remarks upon. Retro-flexion. The touch and the sound in the diagnosis of. Case.— Re-position of the organ. Stem pessaries. Ante-flexion. Com- parative frequency of. Causes, diagnosis, and treatment. Case.— Latero- flexion. Causes. Case.— Symptoms. Contingent affections. Postural treatment. Uterine Versions. General remarks upon. Varieties. Retro-version. Clinical history of. Ante-v rsion, causes, symptoms, and treatment. Latei'o-version, the rarity of. In- version, the clinical history and modern surgical treatment of. General Remarks. — In order that you may have a clear idea of the nature of uteiine flexions, two facts should be borne in mind : (1) that, in this kind of displacement the shape Two peculiarities of. " ., . 1 , .. .: . of the uterus is always changed, and (2) that the flexure occurs at the junction of the neck with the body of the organ. Properly speaking, therefore, these deviations are char- acterized by a change, or curve in the axis of the womb, which is bent like a chemist's retort. You know that the uterine cervix is so fixed by its vaginal attachment as to be comparatively secure, while the body of the uterus has a greater latitude of motion. It is The anatomical ^[s arrangement which permits a bending or predisponent of. " l rt twisting of the organ backwards, forwards, or laterally, while its neck is in situ, or very nearly so. These flexions are facilitated by the peculiar disposition of the peritoneum, which is lacking at, and below the point where the neck and body of Ihe womb are joined anteriorly. Indeed, this might be called the anatomical predisponent of uterine flexions of whatever kind. Varieties. — There are three kinds of uterine flexion, (1) retro- flexion, (2) ante-flexion, and (3) right or left later o-flexion. RETRO-FLEXION OF THE UTERUS. We have already considered the relations of retro-flexion to obstructive dysmenorrhea, (page 202), but something remains to be said upon this subject. This form of flexion is more common 622 KETROFLEXION OF THE UTERUS. 623 than either of the others, and two causes, in addition to those already named, combine to make it so, viz. the effect of over-distension of the bladder, and of rectal paralysis, with or without obstinate con- stipation. This cut gives a good idea of the relations of the retro- flexed uterus. (Fig. 89.) The bladder and the rectum in. The touch. Fig. 89. lietiY.-tiexion of the uterus. The diagnosis of this particular deviation is not difficult. The subjective symptoms are not peculiar except that, as in other forms of flexion, they are most pronounced at the month, and that they usually subside when the flow has stopped. If the flexion is acute, the ordinary vaginal touch may indicate both the direction and degree of the displacement. Madame Bovin proposed that in these cases the finger should be passed along the side of the cervix, instead of before it, or behind it, and the idea is a very good one. In the case of virgins, retro-flexion may be recognized by the rec- tal touch. But since there are so many retro-uterine tumors that resemble the form of a retro-flexed uterus, we must appeal to the uterine sound as a means of settling the diagnosis. I The uterine sound. . ° a . have had this patient placed upon the table in order to demonstrate the application and utility of the sound in similar cases. For this purpose I prefer a Sims' sound to Simpsons, the latter being too large and unyielding. 624 THE DISEASES OF WOMEN. Case. — Mrs. , aged 25 years, has been married two years, but has had no miscarriage. Before her marriage she had scanty menstruation, with bearing down pain in the hips and loins, and inveterate headache. The bowels were constipated, and all her symptoms were aggravated at the month, as well as by stand- ing and walking about. There are no vesical symptoms, but after fatigue she has fits of nausea that are accompanied by increased headache. Observe that the touch finds the cervix in its proper position, or nearly so. This is the rule in all cases of uterine flexion which are not extreme or complicated. But when I pass the sound the direction of its point and of its curve afford a good idea of the direction and degree of the displacement. When what we may call the pelvic curve of the instrument looks downwards and back- wards; when the point of the sound has turned towards the hollow of the sacrum ; and when the sides of the handle are reversed, as Fig. 90. Ludlam's Repositor. you see them externally, we know that the body of the uterus is displaced posteriorly. By careful manipulation I have now suc- ceeded in lifting it to its proper position, but as soon as I let go of the sound the uterus falls back again, and the sound is reversed along with it. This you can all see for yourselves. There are several modes of repositing the retro-flexed uterus, one of which is to raise it to its proper place by means of the sound. Another is to use some form of elevator which is especially de- signed for the purpose. I prefer my own uterine repositor (Fig. 90); but Sims' (Fig. 14); or Noeggeraths' eleva- o Reposition of the tor (Fig> 91 ^ may answer equally well. Great care should be used in their application, advan- tage being taken of the prone position, in order to facilitate the reposition of the organ. The next indication is to keep the uterus in situ. In simple cases it will suffice to lift the fundus into place once or twice RETRO-FLLXION OF THE UTERUS. 625 per week, to replace it a few hours in advance of the monthly flow, and to keep the patient lying- on the abdomen Keeping it in place. ., . • i i i T i • • + • until the period has passed. Ihis is a trying expedient, but it may answer the purpose, and enable us to avoid the wearing- of instruments. 'Fig. 91. Noeggerath's uterine elevator. The best pessaries for uterine flexion are the straight, split, or curved stems, which have fie^on^ 68 iQ retr °" beei1 in vo S ue sillce the <%* of old Dr. Macintosh. In some cases the plain hard-rubber stem will be r Fig. 93. Hard rubber sufficient (Fig-. 92.) At first it maybe too stem - straight to pass the internal os, in which case it may be bent to the required curve by holding it over the flame of a lamp. The principal objection to this stem is that it is apt to drop out, and hence, I prefer Chambers' stem pessary, (Fig. 93), which can be readily introduced and which expands in such a way as not to be easily displaced. Fig. 93. Chamber's stem pessary. When the case has almost developed into one of retro-version, and the cervix is thrown forwards, if there is no circum-uterine inflammation (which is a bar to the use of intra-uterine stems ot all kinds), Cutter's stem pessary will answer a good purpose. But it should be used very cau- tiously. (Fig. 94.) The modus operandi of these st2ms is by passing The retro-uterine through the Canal tampon. & Ot the Cervix, the fig. 94. Cutter's stem pessary. internal os, beyond and the point of flexion, to keep the uterus 40 626 THE DISEASES OF WOMEN in its own proper axis. Sometimes we have good results from pushing a cotton tampon, which has been anointed with carbol- ized cosmoline, into the Douglas' space, where it may be worn for some hours or days ; or a little pad of oakum, or of carbolized tow, may be placed behind the uterus in a similar manner. ANTE-FLEXION OF THE UTERUS. In estimating the relative frequency of this form of uterine devi- "FiG. 95. Ante-flexion of the uterus. ation, we should not forget that before puberty the normal posi- tion of the uterus is one in which it is curved Comparative fre- verv decidedlv forwards ; neither should we lose quency of. : ; d sight of the fact that this position of the organ may continue during menstrual life, without being in reality abnormal. It is only when the womb has toppled over toward the symphysis pubis and caused a train of symptoms, more especially connected with Urination or menstruation, that the flexion requires treatment. The causes of anteflexion are chiefly local ; as chronic disease of the bladder, with freqnent urination and strangury; stone in the bladder ; interstitial tumors in the anterior wall of the uterus; tight-lacing, and the ordinary causes of uterine displacements. The diagnosis is not difficult. The inability to retain the urine without suffering, while the patient is upon her feet, and the relief afforded by lying upon the back, arc invariable symptoms. But you are not to mistake this for Causes. Diagnosis. ANTE-FLEXION OF THE UTERUS. 627 a daily aggravation, since it is the patient's posture and the con- sequent change in the relation of the pelvic viscera that produces Fig. 96. Silver uterine probe. the symptoms. It she slept in the day and walked about at night, the order of things would be reversed, but the clinical significance of the symptoms would remain the same. The combined touch, the bladder having been first emptied, is sometimes sufficient to settle the diagnosis ; but the introduction of a silver probe like this (Fig. 96) or of the uter- The touch and the - ne soun( j w {\\ |) 6 m0 re thorough and satisfactory. Here, as in retro-flexion, the direction of the point of the instrument, and the forward and downward inclina- tion of its curve, toward the bladder and over it, will also indi- cate the kind and degree of the displacement. It is not always easy to pass the sound in these cases, and you may have to exercise a little tact in introducing it. I have some- times succeeded by directing my patient to lie How to pass the U p n her back for some hours, in order that the sound in extreme A . it cases. urine might accumulate, and that the distention of the bladder, together with the effects of grav- ity, might carry the fundus of the uterus toward the rectum, and so straighten its axis that the sound would pass quite readily. The urine can then be drawn with a catheter, and the displacement identified. In very rare cases the canal of the cervix may be so blocked or deformed by the presence of a small fibroid opposite the internal os uteri and in front of the cervix, that the or- a soTnd. reP ° Slt0r aS dinary sound will not pass within the uterus. Such a case was sent to our clinic by Dr. Mul- holland, of Indiana, last summer (1880). I have already referred to this case (page 92), in which you remember I made use of a Case Sims' repositor, and passed it readily in place of the sound. There is an advantage in using this instrument as a sound, for when it has been passed, we are ready to lift the organ into place (Fig. 14). 628 THE DISEASES OF WOMEN. The treatment of ante-flexion of the uterus is decidedly influen- ced by the disabilities of the patient, and by the kind and degree of exercise that she is forced to take. If she can lie upon the back and thus relieve the bladder of pressure upon its fundus, the uterine walls may recover their tone, the organ may lose the habit of careening forwards, and the blad- der may become tolerant ot its own proper contents. In the milder cases, where the symptoms are worse at the mouthly period and almost wholly disappear in the interval, a menstrual quaran- tine, with keeping the patient constantly upon her back until the flow has ceased will sometimes be sufficient for the cure. This is especially true if we are careful also to select such remedies as are suited for the regulation of the catamenial discharge and for the relief of other incidental symptoms. When a mechanical support is necessary, in order that the uterus may preserve its own axis, the various stem-pessaries that have alreadv been advised in retro-flexion are equallv Stem pessaries in. •/ *■ useful. They may be worn in most cases with impunity, but should not be used if there is endo-metritis, pelvic- peritonitis, or pelvic cellulitis. LATERO-FLEXION OF THE UTERUS. Case, — Mrs. , aged 51, of nervo-bilious temperament, war admitted to the hospital one month ago. She has been suffering more or less for ten years with uterine difficulties. At forty years of age she was treated locally for ulceration of the os uteri, and cured. She has had three children, the last of which is sixteen years old. She passed the climacteric eight months ago without accident, and attributes her present troubles to having to ascend and descend thiee flights of stairs at her boarding place last winter. She complains of pain in the back and a sense of dragging down in the pelvis, profuse vaginal leucorrhoea, and a burning pain in the right inguinal region. The last symptom, however, is not constant. She cannot lie upon her left side. The right leg is at times numb and almost paralyzed. The bowels are tolerably reg- ular, the appetite is not very good, the urine is normal. Physical examination reveals a right latero-flexion of the womb, the body of the organ being apparently adherent to the right wall of the pelvic cavity. This deviation of the uterus was corrected by means of the sound, which, together with a few doses of nux vomica 3d, promptly relieved the paralytic feeling in the right limb. The patient was ordered to lie on the left or opposite side LATERO-FLEXION OF THE UTERUS. 629 :and upon the back exclusively. Subsequently she took the citrate of iron and strychnine in the third decimal trituration, a dose every three hours. Cases of latero-flexion are comparatively rare. Nonat met with it in but one out of three hundred and thirty-nine examples of uterine displacement. As in other flexions of ^Relative frequency the Qrgan the cervix ig buf . slightly, if at all dis- placed, while the body is more or less curved upon its neck. The pain and distress are usually referred to one side or the other of the pelvis. The womb inclines more frequently to the right than to the left side, probably because in a majority of cases it has taken that direction during pregnancy. In some of these cases it is possible that the involution of the womb after delivery may be less complete in the right or dependent part of the organ, and that, consequently, its increased weight may cause it to topple over in that direction. Occasionally it is said to follow as a sequel of chronic metritis, and aiso of constipation with paralysis and a stuffed condition of the rectum. It may occur in a woman who, being confined to her couch, persists in lying day and night, always upon one side of the body. Or it may be displaced laterally by direct pressure from uterine and ovarian tumors, peri-uterine deposits and pelvic abscess. The symptoms are not distinctive. Most patients complain of burning pains in the iliac or the inguinal regions, which pains are severe and protracted, and exte id more or less Symptoms. . • . . into the corresponding hip and thigh in propor- tion as the nerves are pressed upon mechanically, and the free distribution of the nervous currents is interfered with. Inability to lie on the opposite or sound side is suggestive, although not by any means pathognomonic of this particular variety of uterine deviation. It is only by the introduction of the sound that we can be quite positive in our diagnosis. If, after being passed as far as the internal os uteri, the point shall enter the organ Physical signs. r . n and then travel towards the right or left acetab- ulum, the concavity of the instrument looking to the correspond- ing limb of the patient, it is safe to conclude that she has a lateral deviation of the womb. If the direction of the sound is changed 630 THE DISEASES OF WOMEN. when she turns over and lies for a little on the opposite side, the displacement is not a very serious affair. I have now passed the sound to the fundus uteri. You will ob- serve that the roughened surface of the handle, which corresponds Passing the sound. to tlie ti P of tne instrument, and its anterior curve, looks toward the right thigh of the patient. And although, as I have told you, the sound is of little use as a means of repositing the organ, still, in these cases of lateral displacement, and with proper precautions, it may be of service in this way. While she is lying upon the opposite side therefore, so that gravity may assist us, we gradually turn the sound, and the uterus along with it, until its pelvic curve or concavity looks to- wards the symphysis pubis. Now the organ is in situ, and the sound has served the double purpose of acquainting us with the precise Repositing the or- r r , ? & .* gan. nature of the displacement, and ot furnishing us with a means for its reduction. The treatment of such a case as this is very simple. The first indication, after having put the organ in place again, is to select a proper posture for the patient. Manifestly Postural treatment. s } ie snou |(j ]i e on the opposite side, in order to keep the womb from gravitating into its unnatural position. This woman had right latero-flexion, in which the fundus uteri had toppled over against the right side of the pelvis. She must there- fore lie upon her left side, if she wants to get well of this diffi- culty. There will be no harm in her turning upon the back occa- sionally, but she should not permit herself to lie upon the right side for months to come. This will be a difficult prescription to take. For the first few days especially, it will require some moral courage to carry out Need of courage. tnese instructions faithfully. She will proba- bly have pain in both hips, aching and unrest, in consequence. She may lose her appetite, pass sleepless nights, and, altogether, feel worse for a time than when she came to the hospital. But ultimately her sufferings will be relieved, and she will be Had of her is more certain to be present than any other subjective symptom. Hysterical symptoms of every kind and description may depend upon this local cause, and may disappear when it has been removed. The effect of retro-version in the production of morning-sickness during pregnancy has already been considered. (Lecture XIX.) The vaginal touch finds the uterus lower down than natural, for confirmed cases of version are almost always complicated with more or less of prolapsus. By the finder, the Diagnosis. *• 1 ' * i i ipi outline oi the body and neck ot the womb can be readily felt. The rectal touch is often essential to a correct diagnosis, for in no other way can the nature of this retro-uterine tumor be so thoroughly known. When this form of touch is combined with the skilful use of the sound we shall have something to depend upon as a means of diagnosis. The conjoined touch, through the vagina and the abdominal parietes, may also be used to advantage, especially if the walls of the abdomen are not too thick. But sounding the uterus in these transverse positions is not always an easy matter, and hence its reposition by internal means is sometimes very difficult. The directions that reduction* m ° 6 ° f are usuaii y given for performing this operation, in a bad case of retro-version, are fast becoming as antiquated as the old time details of the mode of reducing a hip-joint dislocation. For the effects of atmospheric pressure and of gravitation are now taken advantage of as an aid, and indeed 634 THE DISEASES OF WOMEN. they are often sufficient to lift the organ into place. The expedient of applying atmospheric pressure within the vagina for this pur- pose, is another result that rightfully dates from the discovery ot the Sims' speculum, by the use ot which, with the patient in the knee-chest position, it is best applied. The mode of applying pneumatic vaginal pressure, with gravi- tation, to the reduction of retro-displacements has been carefully and skilfully elaborated by Dr. Henry F. Camp- m^d. 0aPPlythiS bell > of Augusta, G-a.* The posture chosen is the same that was adopted by Deventer in 1701, in the treatment of prolapse of the funis. The patient is placed upon her knees with the chest thrown forward upon the bed or couch, the hips being raised at an angle of about forty-five degrees. This is what is known as the genu-pectoral, or semi-prone position. The vagina is then expanded, by the introduction of the speculum, the best of which is a Sims', which lifts the peri- neum and allows the air to fill the passage. The combined effect of gravitation in removing the superincumbent weight ot the intestines, and of the steady pressure of the atmosphere, is to raise the fundus and to replace the organ. In most cases this will be sufficient, but exceptionally you may need to apply direct pressure by the finger, or possibly to seize the os with a tenaculum like this, and bring it into position. (Fig. 98.) Fig. 98. Uterine tenaculum. Dr. Campbell recommends a domestic application of this expe- dient which consists in the frequent resort to this position, and the separation of the labia with the patients P a«ent beVSedb ** own nil g ers > or h J the passage of a small tube. Patients, he says, can be taught to do this at their own homes. In the reduction of these dislocations Dr. Guernsey's uterine elevator may sometimes be applied through the rectum. (Fig. 99.). It is especially adapted to retro-version occurring in virgins and during pregnancy. In some cases direct pressure maybe applied to the fundus uteri *Trans. of the American Gynaecological Society, Vol. 1, p. 198. RETRO-VERSION OF THE UTERUS, 635 and the organ lifted forward by Armstrongs' fenestrated elevator, which is a very simple and useful instrument. (Fig. 100.) Fig. 99. Guernsey's uterine elevator. In retro-displacements that have been neglected, or mal-treated Fig. 109. Armstrong's uterine repositor. under the theory that their reposition was very difficult if not im- possible, because of peritoneal adhesions, there may be so much tenderness and tumefaction as to necessitate some treatment before reducing the dislocation. The best expedient that I have ever found in Preparatory treat ment. 4^ Fig. 101. Ftowe's retroversion elevator. cases of this kind is the frequent and persistent use of hot- water vaginal irrigation. When the swelling is largely in the depressed fundus, I have sometimes directed that the water should be thrown into the rectum through a double-current sound such as you have seen in use in our puerperal wards. In either case the patient should be placed in the prone or the semi-prone position. 631) THE DISEASES OF WOMEN. Eig. 102. Woodward's retroversion pessary. Ill a day or two the effects of mal-position, and the strangulation of the womb will have passed away, after which the organ may be reposited as we have already di- rected. The next thing to be done after getting the organ into position is to keep it there. If the mere re- moval of the weight of the intes- tines from above the uterus was all that was necessary, and it may be in recent cases, the wearing of an abdominal supporter would be suffi- cient. But, in chronic and confirmed retro-version the external belt supplies only one of the conditions that are ne- cessary for retaining the or^an in situ. n . \„ ■*■. , , Fig. 103. Woodward^ pessary for bometnmg more will need to be done retroversion. in order that the body and fundus of the uterus may also be lifted from their unnatural position. This end is secured by the constant dilatation of the vagina which provides for the admission of air, as in the mode of reposition which has just been described. Such a dilatation is maintained by the Fig. 104. Graily Hewitt's re- various p e S S a r i e S troversion pessarv. +i ± i i that have been used for retro-version, the most popular of which owe their reputation to the fact that they keep the vagina on the stretch, instead of to the crutch-like form that has been given them. In one way or another they are all modified from the old ring pessary which was designed to ex- pand the vagina. Hodge's lever pessary Fig. 83.) illustrates the idea exaclly, and the same principle is applied to both of Woodward's pessaries (Figs. 102 and 103) Graily Hewitt's (Fig. 104) and Thomas' ^If'J* ™ 5 ' retr °" vcr - {Fig. 105) retro-version pessaries unite the double principle of RETRO-VERSION OF THE UTERUS. 637 leverage and vaginal distension, and are therefore profitable in many cases. Sometimes we may succeed in keeping the organ in position by placing a tampon or other instrument in the posterior cul-de-sac. For this purpose a Buttle's pessary (Fig. 106) may answer, especially if there is a coincident prolapsus. Thomas' modi- fication of Cutter's pessary for retro- version (Fig. 107) puts a crutch behind the organ and keeps it forward. In a few cases, however, I have found that • ^^^^L otters' original pes- ^^^^^ g sary for retro-version fig.iob. Buttle's pessary. ^t^^^ 6 (Fig. 26) could be worn when Thomas' modifica- ^^^^^P tion of it could not. Concerning the medical treatment, if the trou- ble began in the rectum, and its chief symp- tom are dependent upon rectal paralysis, chronis constipation, or haemorrhoids, collinsonia can. in the second or the third dilution is often an invaluable remedy. It will not cor- rect the retro-displacement, but it will do away with many of Internal remedies. Fig. 107. Thomas' Cutter's pessary. the most troublesome rectal symptoms that are connected with it. Other remedies that may be especially indicated are nux 638 THE DISEASES OF WOMEN. vomica, podophyllin, alumina, aloes, hamamelis, calcarea car- bonica. The treatment proper for retro-version during pregnancy has already been given in Lecture XIX. ANTE-VEESION OF THE UTERUS. This drawing (Fig. 108) will give you a good idea of the relative position of the uterus when its fundus is thrown forward upon the bladder, and its cervix upwards against the rectum, the axis of the organ being across the pelvis. Fig. 108. Ante-version of the uterus. 1. the rectum. 2. do. lying- upon the uterus. 3, The fundus uteri. 4. the bladder 5. the urethra. 6. the vagina. Observe that the bladder is almost inverted, that the rectum is partially obliterated, and that the vagina is put upon the stretch. When the uterus is also prolapsed, its fundus may press the ure- thra firmly against the pubis. The greater the degree of this transverse displacement, the greater the acquired deformity of each and all of these pelvic viscera. Consequently the functional derangement of the bladder, and of the rectum especially, will vary in a corresponding ratio. They will also become chronic if the duration is permanent. Ante-version is less frequently met with than ante-flexion. The chief complaint is of symptoms that resemble those of cystitis, for which, indeed, it is often mistaken. Naturally enough the vesical symptoms are worse when the patient is standing or walking, and sometimes there is such an absolute inability to walk, or to stand, that those who hav e ANTE-VERSION OF THE UTERUS. 639 ante-version become bed-ridden. Owing to the partial oblitera- tion of the bladder, its capacity is so diminished that only a small quantity of urine can be retained within it, and this causes a very frequent and painful urination. The rectal symptoms are not always present. In bad cases the cervix may retreat so far into the hollow ot the sacrum as to obstruct the passage ot faecal matter and occasion tenesmus, and diarrhceic or dysenteric symptoms. If there is any difference be- tween ante- version and retro-version in so far as these peculiar symptoms are concerned, it is that, while in the former, lying on the back mitigates the tenesmus, or the constipation, it is not so in retro-version. Courty says: "With several patients who had retro-version it has seemed tome that, whether applied with the hand, temporarily, or constantly with the abdominal belt, pressure upon the hypogastrium tended to increase instead of to lessen the suffering; while the contrary was the rule in ante- version." * Beside the subjective symptoms, the physical signs are also important and essential to a correct diagnosis. The touch applied along the sides of the uterus, the remoteness of Physical signs of. . , . , . . . . the cervix, its being carried in the direction of what the old doctor called the "premonitory" of the sacrum, will help us to decide the question. If to this we add the conjoined palpation, through the vagina and around ^i^^B^fc|^. the symphysis pubis, the case may almost al- i4^^^^^-'-'-' : "^^^pk ways be clearly made out. Even the rec- BF ^^llk fll tal touch has a negative value when the Ilk llL Jm fundus uteri cannot be found posteriorly. ^^(l&SlgB fpP^ When the sound or the probe can be passed, the direction of its point and curve will be V e*s?onTessary ChCOek ' S ante " almost if not quite as distinctive as in ante-flexion; and the -effect of the dorsal decubitus with the hips raised will assist in the differentiation. The reposition of the organ is facilitated by keeping the patient on her back and thus permitting the bladder to displacement. * the become filled, after which the hips may be raised so high as to bring gravity to our aid. At the same time the air may be admitted into the vagina by lifting its *Traite Pratique des Maladies de l'Uterus. des Ovaries et des Trompeo, par A. Courty. Prolessor, etc., deuxienne Edition, Paris 1872. page 863. m. 640 THE DISEASES OF WOMEN, anterior wall with a Sims' speculum, or with the depressor. With this exception the directions that I have given you for the correction of retro-displacements apply also to this form of version. There is a form of Cutter's fenestrated pessary which is suited to ante-version. Beside that, there are modifications of the ring, and of Hodge's pessary, which are suited to these Means of support. o l J ' cases, more especially because they serve the pur- pose of separating the vaginal walls so as to secure the admission of air. Among them are Hitchcock's (Fig. 109), and Kinlock's (Fig. 110), ante-ver- sion pessaries. Abdominal supporters are more useful n ante-version than in retro-version. The Fig. 110. Kinlock's ante-ver- , , .. , sion pessary. dorsal position, at least for a portion of the time, is almost indispensable for the cure of these cases, some of which are very much benefitted by cultivating Best and remedies the haMt oj . Naming the urine for a few hours at a time. The incidental symptoms may re- quire to be relieved by internal remedies such as cantharis, bell- adonna, mercurius, hyoscyamus, digitalis, nux vomica, and tere- binth. LATERO- VERSION OF THE UTERUS. This form of uterine version which is exceedingly rare is almost always due to a fall upon one hip or the other, to lesions that have been acquired during the lying-in, or to the pres- Peculiarities of. ' . °. ence of tumors or of dropsical and other accu- mulations which force the womb out of place. This version is also characterized by a transverse position of the uterus, but, instead of lying across the pelvis in an anteroposterior direction, the fundus is at one acetabulum and the cervix at the other. The subjective symptoms are not characteristic. The chief com- plaint is of neuralgic pains which are persistent, which radiate through the pelvis and the abdomen, and which toms bJeCtiVe SymP " are likej y t0 affect the sacral nerves in their distribution to the lower extremities. The ves- ical and rectal symptoms are incidental and not constant. The physical diagnosis is practised in the same manner as for LATERO-VERSION OF THE UTERUS. 641 Treatment. other forms of version. The touch, conjoined manipulation, pal- pation by the rectum, and the use of the sound Physical signs. are the means at our command. The treatment does not differ essentially from that of the other varieties of version. The uterus is to be restored to its proper position by a similar means. There are no in- struments which are of practical use in this form of latero-displacement, and we are obliged to depend upon the postural treatment rather than upon pessaries or supports of any kind. An essential part of the treatment consists in recognizing and removing the cause of the difficulty. If it is traumatic the inter- nal use of arnica, hypericum, or rhus tox. may be required. If it is post-puerperal there may be lesions of the pelvic, serous or cell- ular tissue that will need to be treated. If it depends upon the presence of tumors in the broad ligament, the ovary, the bladder, the rectum, or even the bony pelvis, these tumors will require special treatment before the version itself can be cured. INyERSION OF THE UTERUS. In this form of displacement the uterus is partially or wholly turned inside out. In the slighter degree the fundus is dimpled, Fig. 111. Inversion of the uterus. indented, or depressed toward the cervix. The inversion may be complete even before the tumor is expelled from the vagina. This condition is shown in the diagram. (Fio-. HI.) 642 THE DISEASES OF WOMEN. In the chronic iorm, apart from the puerperal state, the inverted organ is more apt to be extruded from the vulva. The predisposing causes of inversion are childbirth, and the development and distension of the uterus by contained tumors and fluids. The exciting causes are traction on the placenta or the umbilical cord; rapid labors; rigidity of the uterine cervix with a laxity of the muscular fibres of the body and fundus; the artificial extraction of the child in case of uterine inertia, and the dragging effect of fibrous growths and polypi when they are attached to the fundal zone of the uterus. When inversion follows labor it may happen immediately, even before the placenta has been detached, or it may occur as late as the tenth day. Although the gynaecologist does not always see these cases in the acute stage, yet 75 per cent of them date from delivery; and 20 per cent are due to the traction of intra-uterine fibroids and sessile polypi. The symptoms vary with the stage and the more or less recent occurrence of the accident. If it has happened very recently they will be more alarming and dangerous on account of the haemorrhage, the shock, and the accom- panying depression and collapse. In chronic cases,, the patient complains of uneasiness and distress, with a feeling of pelvic strangulation that arises from the presence of the tumor. The same cause may L produce a tenesmus of the rectum and of the blad- der, with sacral and lumbar pains, all of which are very much increased by standing or walking. Another symptom is the occurrence of a haemorrhage from the surface of the tumor, which is periodical, and menstrual in char- acter. This haemorrhage is prevented from being very copious, at least in chronic cases, by the contraction of the cervix, which acts as a tourniquet upon the tumor. The tumor is a globular mass, that is more or less soft and flabby to the touch, abraided from exposure, which causes a muco- purulent leucorrhoea, and is largest at its lower extremity. Its size varies with the complete- ness of the inversion, and with the nearness to the lying-in period. For the inverted uterus may be carried outside of the body for twenty years or more. The tolerance of this unnatural condition is greatest after the menopause. In very rare cases there is a spontaneous reduction of the displacement. INVERSION OF THE UTERUS. 643 In a recent case, where the placenta is still adherent, the diag- nosis will be plain enough. But when months or years have elapsed since the inversion took place, great care will be required. You would know such a case from one of procidentia, by failure to lind the os-uteri, and one or both lips of the cervix at the lower end of the tumor ; and by the inability to pass the sound, as you have seen me do it, in procidentia. The diagnosis of partial inversion from a case of sub-mucous fibroid, is sometimes very difficult. Tlie sound in utero gives precisely the same indications, and the diagnosis aST a sub " mucous must therefore be made by the conjoined manipu- lation. By this means we may recognize the rotundity of the uterus in the case of a fibroid, and the dimpled, or invaginated fundus if there is a partial inversion of the uterus. You may remember also that while the uterine surface of a tumor is sensitive, you may pinch, or push a needle into a polypus or a iibroid without causing pain. The most absolute test for inversion is the same that is applied in the case of absence of the uterus, id est the passage of the sound into the bladder, with its point looking back- Thf* cruoifil tpst "for wards, and of the finger, or a large bougie into the rectum. If these two meet readily, the inference is that the womb is absent, the same as if it were congenitally lacking. The greatest care should be exercised in the diagnosis for it has happened that the inverted womb has been amputated, under the supposition that it was a polypus or a fibroid. The prognosis varies with the acuteness of the case, the possi- bility of the immediate reduction of the tumor, the degree of the haemorrhage and the anaemia, the severity of the shock, the lax and diseased condition of the uterine parietes, the sloughing and the risks that attend upon all forcible attempts at re-inversion. When the displacement has become chronic and developed a cachexia with a low vitality of the tissues and an impoverished state of the blood, it will not be safe to promise a cure, even although we may succeed in reposit- ing the womb. The treatment for this form of clisp lacement is beset with pecu- liar difficulties. The first indication is to reduce, or to re-invert 644 THE DISEASES OF WOMEN. the organ by forcing- its body and fundus through the constricted cervix. If the tumor is lar^e from ag-e or expo- Treatment. ox sure, and the utero-cervical orifice is narrow, as. it almost always is, this operation m;\y be impracticable. For it is this orifice, which Mauriceau compared to the neck of a phial, that interferes with the ready replacement of the womb, and the constriction of which it is sometimes quite impossible to overcome. In recent cases of inversion occurring in obstetric practice, the parts are in such a condition that prompt and immediate action m acute cases. will generally be successful. If the placenta remains attached, strip it off carefully, and then apply steady pressure with the tumor in one hand, while the other hand is placed for counter-pressure above the symphysis pubis. Be careful, however, to begin the inversion about the neck of the organ before you indent the fundus. You will find some very interesting and instructive cases of this kind reported by Dr. L. M. Pratt/ol Albany, *; Dr. A. K, Thomas, of Philadelphia, t; Dr. Mary Safford Blake, J; and Dr. C. G. Higbee, of St. Paul, Miun., I. When inversion follows abortion, which is very rare, and of very doubtful diagnosis, the reduction is usually spontaneous. . But in confirmed cases of inversion that have After abortion. . .. „ . . existed for months or years, nature is not dis- posed to aid the re-inversion. Taxis and vaginal pressure are the principal means for reducing the dislocation, and since a too forcible manipulation by the hand may result in a laceration of the soft parts, espec- Manual treatment . " . . ially it it is continued for a long time, elastic pressure by a rubber pessary may be alternated with it. But before the attempt is made to replace the organ the bowel and the bladder should first be emptied. If the uterus is still within the vagina, it may be well to apply hot- water injections as a pre- paratory means. Anaesthesia is necessary for the relief of pain and for the relaxation of the soft parts, more especially of the cervical ring. A gradual replacement is safer than a rapid one, and the manual *. Trans, of the New York. Horn, Med. Society, New Series. Vol. 1, p 353. +. Trans, of the American Institute of Homoeopathy, Twenty-fifth session, 1862, p. 36& *. Do, do. do. do. for 1873, page 503. §. The United States Med. and Surg-. Journal. Vol. IV. p. 216. INVERSION OF THE UTERUS. 645 method, with proper precautions, is better than the instrumental one. In the attempt at reduction by the hand, two indications must be kept in mind; (1) to dilate the contracted ring of the cervix by counter-pressure through the abdominal parietes, and (2) by steady and continuous pressure to force the inverted fundus through it. In Dr. Tait's method the first of these indications is met by the introduction ol the index finger of the left hand into the bladder, aud the index of the other hand re^almerhod! 68100 ' int ° the rectum « Then the fill g ers approach each other and are in position to stretch the cer- vical ring, while both thumbs are made to press the fundus upwards and towards the cervix. The possible success of this method is shown by the fact that Dr. T. reduced a case of inversion of forty years standing, in the space of half an hour. Once begun the reduction was finished by pushing up the fundus with a tallow candle that was Avrapped in a rag. The external os was closed by a silver suture, which was removed on the third day, and the patient recovered without a bad symptom* Courty's method consists in first drawing the uterus outside of the vulva, if it is not already there, in passing the index and medius of the rio-ht hand into the rectum, and above method 7 S rectal the uterus, and then by curving the fingers for- ward using them to dilate the cervical orifice. The body of the organ is then seized by the left hand, pushed into the vagina and moved in different directions so as to facilitate its re-inversion, the thumb and the index being pressed upon the pedicle of the tumor. It would be well to try this plan before dilating the urethra and operating through the bladder, as prac- tised by Dr. Tait. Dr. Watt's method is really the same as Cour- ty's Another means of manual reduction is known as Noeggerath's, which consists in the usual counter-pressure over the pubis, and in direct pressure upon the cornua of the uterus thod. ° with the finger and thumb until the indentation has begun, first in one corner, and then in the other, after which the center of the fundus is depressed, and the re- Inversion is completed. If the patient is a thin person the coun- *The Cincinnati Lancet and Observer lor Marcn 1878. 646 THE DISEASES OF WOMEN ter-pressure, according to Dr. Thomas, may be made to reach the cervical ring through the abdominal parietes. But you are not to suppose that the trouble is over when a por- tion or even the whole of the body of the uterus has passed through the internal os ; for it may be quite as difficult to finish the replacement as it has been to carry it thus far. Unless the operation has been a very rapid one, the anaesthetic will need to be withdrawn, and for the present, at least, it may be necessary to relinquish any further attempt at 1 eduction. In this case Dr. Emmet advises to stitch the os uteri with a ent EmmetS expedi " silver suture as a temporary expedient. If it is possible, however, the re-inversion should be completed at once by pushing up the fundus with a stick of hard Fig. 112. Mode of re-inversion in Dr. Ellis' case. rubber or ol wood, or even with a tallow candle if you can find one. Drs. Sims and Barnes have advised that, where Sim's and Barnes' tn e cervical orifice will not yield and the reduc- method. . . ... tion isotheiwise impracticable, an incision may be made upon each side of the cervix. This expedient is seldom necessary. Vaginal elastic pressure in aid of the re-inversion may be steadily and constantly applied by means of air pessaries, and, water bags, or by cups that are mounted upon a stem. These may be kept in place by a T bandage. A very interesting case of inversion wa& INVERSION OF THU UTERUS. 647 reported to one of our journals some years ago, by Dr. E. R. Ellis, of Detroit. The case was of eight months duration, and in reducing it utero-vaginal pressure was continued at intervals for the space of nineteen days, by this instrument. (Fig. 112.) The mode of applying vaginal pressure that ismost popular just now is known as that of Dr. J. P. White, of Buffalo. It is sim- ple, rapid, efficacious, and quite safe, if properly Dr. White's method. -, ' , ,, ., -. 1 ' , used. A glance at the repositor, and at the accompanying cut, will explain its modus operandi. (Fig 113) Precautions. Fig. 113» White's repositor for inversion. In all cases in which an attempt is made at immediate instrumen- tal reduction the eifort, if unsuccessful at first, should not be con- tinued for more than one or two hours, other- wise fatal peritonitis or cellulitis may result. Nor should it be repeated in less than thirty-six to forty-eight hours afterwards. Several fatal cases are recorded in which this rule was not followed. Where judicious taxis and elastic pressure have failed and it becomes a question whether the uterus should be amputated, Prof. Thomas' method of opening the cervical ring so as to reposit the organs should be carefully considered. This method, which is one of the Dr. Thomas' meth od. 648 THE DISEASES OF WOMEN. boldest achievements of American surgery, consists "in abdominal section over the cervical ring, dilatation with a steel instrument, made like a glove-stretcher, and reposition of the inverted uterus by any one of the methods mentioned, by the hand in the vagina." Amputation has been practised as a dernier ressort, but it is a very dangerous one, from risk of haemorrhage. Perhaps the safest method is that of Courty, who surrounds the neck of Amputation. 1 the organ with a rubber ligature, that may be tightened on the second day, and which secures a complete repara- tion of the womb in a fortnight or less. When the knife or the ecraseur are used, the tumor should first be Heated for two or three days. The galvano-cautery is objectionable on account of the danger from secondary haemorrhage. SURGICAL OPERATIONS FOR RETRO-DISPLACEMENTS. Alexander's operation consists in making an incision of from one and a half to three inches along the inguinal Alexander's operation, canal, down upon the external abdominal ring, freeing the round ligaments and drawing them out through the wound. The fundus uteri is then lifted forward into position, a "run" is taken in the ligaments after which they are cut off and stitched into the wound by the sutures that close the incision. Drainage, keeping the uterus in situ by a galvanic stem, and rest, are requisites to success. The author insists that the difficulty of finding these ligaments can only be avoided by experiments on the cadaver. Hysterorrhaphy, which was first practised by Kceberle in 1869,* is being perfected in its technique and promises Hysterorrhaphy. excellent results in unconquerable cases of re- troflexion and of prolapsus. Its steps include laparotomy, the reposition of the uterus, the removal of one or both ovaries (if necessary), and in so stitching the womb as that its fundus shall lie against and become adherent to the abdominal parietes. * Archives de Tocologie, etc., Paris, 1877, page 548. LECTURE XL. ULCERATION OF THE WOMB. General observations on uterine ulceration. Varieties of. Simple ulcer of the uterine cervix. Aphthous ulceration of the os and cervix uteri. Irritable ulcer of the uter- ine cervix. Diphtheritic ulceration of the os uteri. Post-partum ulceration of the womb. General observations. — The subject of uterine ulceration has acquired a new interest of late. A few years ago ulceration, with or without induration of the cervix, was gen- influence of modern « thought to be the essential and funda- views on ulceration. J » mental lesion in most of the diseases of women. For thirty years, indeed, this idea domiuated, and the practice was to rely upon local treatment, exclusively. But, now that w r e can differentiate more closely, we know that ulceration of the cervix uteri is really infrequent, and that the appliances of the Bennet school of gynaecologists were often brought to bear upon a lesion which had no existence until it was induced by the treatment. It is pleasant to think that such a result has been brought about by clinical, painstaking, study and experience; and that henceforth the poor women are to be spared the suffering and the harm that have been unwittingly and unnecessarily inflicted upon the sex for a whole generation. Uterine ulceration may be a local or a constitutional disease. The forms of this ulceration that are purely local are abrasion with simple and irritable ulceration. The V«iriG"ti.6S constitutional varieties include the aphthous, the scrofulous, the varicose, the diphtheritic, the syphilitic, and the cancerous form. The special pathology of each and all of them is very important not only in a diagnostic, but also in a curative point of view. We shall consider some of them separ- ately, reserving to a future occasion what we have to say of can- cerous ulceration. 650 THE DISEASES OF WOMEN. SIMPLE ULCER OF THE UTERINE CERVIX. Case. — Mrs. T •, aged 28, mother of one child, has been ill for six months. She complains of weakness and debility, which incapacitate her for her daily duties. There is a great deal of pain in the sacral region, dragging in the loins, and bearing-down sensations when she is upon her feet for any considerable time. Internally she feels a sense of swelling and fullness within the vagina, and of burning at its upper portion. At times there is quite a free leucorrhceal flow, which is of a bland unirritating character. Examination with the speculum reveals a simple ulcer of the size of my thumb nail, situated chiefly on the posterior lip of the os uteri, and extending within the orifice. The subjective symptoms of this, as of most other varieties of uterine ulceration, are not peculiar. The patient may complain of pain in the sacrum, the hips, the thighs, Subjective symptoms. " . . the coccyx, the symphysis pubis, the hypogas- tric, or the ovarian regions. There is a sense of weight and fullness, of weakness and bearing-down in the region of the womb. She has, perhaps, great lassitude, with an almost insuperable dislike of mental and physical exertion. Leucor- rhcea and painful menstruation are frequent and trouble- some concomitants. In some cases, as in this one, there is a sense of tumefaction, and of local heat in the parts affected. This symptom is especially tormenting after the menstrual dis- charge has ceased, and also after coitus. Not nnfrequently there is an aversion to sexual congress, and when complicated with vaginitis, the act is likely to be followed by a bloody discharge. The reflex hysterical symptoms are numerous and varied. Such patients are prone to be hypochondriacal, and sometimes exhibit strong tendencies towards insanity. The objective local symptoms revealed by the "touch" and the uterine speculum are peculiar, and we must rely upon them as diagnostic. The ulcer, the shape of which Objective local symptoms. . . is irregularly circular, may occupy one or both lips of the cervix, although the posterior lip is its most frequent seat. For this latter reason the slightly curved speculum is sometimes preferable in making an examination. The lesion sometimes extends within the os and along the cervical canal. On removing: the accumulated secretion from the SIMPLE ULCER OF THE UTE*RINE CERVIX. Qjl orifice with a pair of long dressing-forceps and a bit of charpie or cotton, and expanding the bi-valve speculum, if you use it, the ulcer is freely exposed. There is necessity for care in all these manipulations of the cervix, on account of the extreme delicacy of the structure implicated. This ulcer within the os and the canal of the cervix is sometimes the last and most difficult part to heal. Indeed it often happens that such cases are dismissed as 'cured, when only the mucous membrane exterior to the orifice has been healed. The simple ulcer is superficial, not excavated, and its margins may be irregular, wavy or stellated. In some cases its borders are slightly raised and cord-like to the " touch." Appearance of. . . The color is usually scarlet, evincing a re- markable degree of vascularity. Sometimes however, it is of a dark or dusky-red hue, resembling erysipelas. This blush may ex- tend beyond the border of the ulcer itself. The more protracted the case, the darker and more livid the complexion of the ulcer. The surface is almost always covered with a muco-purulent secre- tion, which must be wiped off carefully. In an acute case the part looks as if a corresponding extent of its investing epithelium had been stripped off. Sometimes there is a simple erosion, which Kennedy has compared to excoriations of the glans penis, and to aphthous ulcers in stomatitis. The cervix is swollen, congested and sensitive. When the lesion has existed for a considerable time, it has a suppurating surface, and it becomes the source of an intractable and exhausting leucor- rhcea. At this stage the simple ulcer may degenerate into the fungous, or granular variety, of which we shall have more to say hereafter. The most common causes are painful, forcible and too frequent intercourse ; coitus during or directly after menstruation, while the uter o-vaginal mucous membrane is very vas- Causes. , . . . cular and sensitive to mechanical injury ; dis- proportion in length between the male organ and the vagina ; the injudicious use of astringent and harmful injections per vaginam ; cold ; insufficient clothing of the inferior extremities ; vaginitis ; and friction of the parts from walking when the uterus is prolapsed upon the perineum, are among the more frequent causes of simple ulceration of the os and cervix uteri. Tyler 652 THE DISEASES OF WOMEN. Smith is of opinion that the corrosive properties of the leucorrhoeal discharge may occasion this form of ulceration, when brought into contact with the surface. This form of uterine ulceration is especially apt to occur soon after marriage ; or it may be caused by too prolorgecl nursing. According to eminent authorities, among whom are Churchill, Bennett and Whitehead, it may result in abortion and sterility. The treatment proper for this variety of ulceration is consti- stitutional and local. The internal remedies most frequently indi- cated are, arsenicum alb., arsenicum jod., nitric Treat7nent. acid, belladonna, arnica, ignatia, aurum mur., mix vomica, sepia, and sulphur. Incidental complications, of course, require intercurrent and appropriate remedies. The local treatment should be as soothing as possible. The principal indication in most cases is to prevent the contact of the vaginal mucus and of the leucorrhoeal discharge, Topical treatment. and so to protect the denuded surface from the influence of atmospheric air as to facilitate the reproduction of the proper epithelial tissue. If the ulceration is of traumatic origin, you may prescribe vaginal injections of dilute arnica with glycerine- If the leucorrhoea is purulent, or muco-purulent, it may be better to substitute calendula for the arnica. Other topical expedients are injections of an infusion of flax-seed, or of dilute glycerine, which does not become rancid ; the direct application to the ulcer of a watery solution of gum tragacanth, or of a solution of loaf- sugar ; painting the ulcer with collodion, or with glyceroles of iodine, hydrastin or aloes. Latour's oleaginous collodion is prefer- able to the ordinary collodion, because it does not cause pain by its shrinking. This last preparation has other merits which commend it as an external application in abrasion and in superficial ulceration of the cervix. It is flexible and water-proof, like a thin layer, or pellicle of india-rubber, and hence it protects the surface that it covers from contact with the uterine and vaginal secretions. Be- fore applying it with the cotton brush the surface of the ulcer should be dried very carefully. The coating that forms will re- main for from two to five days. Here is the formula for its prep- aration : APHTHOUS ULCERATION OF THE CERVIX UTERI. 653 -R Ether sulph., grammes 400. ' Alcohol, " 100. Gun-cotton, 35. Ol. Uicini, 35. Mix the three first ingredients thoroughly, and when dissolved, add the castor oil. APHTHOUS ULCERATION OF THE OS AND CERVIX UTERI. Before showing you an interesting case of apthous ulceration of the uterine cervix, I must remind you that this is really and most decidedly, a constitutional affection; and that it is not marked by any subjective symptoms which are peculiar or valuable, in so far as the differential diagnosis and the treatment are concerned. Without a local inspection of the lesion, its recognition would be as impossible as it would be to identify the eruption of scarlatina without seeing it ; nor could we know what we have cured, if we are successful, without a careful visual examination ot the cervix to begin with. For this is a local affection of constitutional ori- gin. Case. — Mrs. S , forty years of age, the mother of four children, has been ill for eighteen months past. She is pale, and has the worn look of one whose strength has been exhausted either by a drain of the vital fluids, or from inanition. She has a slight leucorrhcea, but the discharge bears no relation to the month, and from her description appears to be exclusively vaginal. There is at times much burning in the vagina, and at the neck of the womb. This is aggravated by standing a long time, or by riding. It is also apt to be worse in the evening. Sometimes there is strangury, but it is of brief duration and not very severe. There is not a great deal of inter-pelvic pain and distress. Her appetite is poor and capricious. Her food k * does not appear to do her any good." Her nervous system is shattered. She cannot sleep, is exceedingly anxious about her children, and, in short, hl nothing goes right any more." On examination the vagina is found to be considerably inflamed, hot and dry, and the anterior lip of the uterine cervix to be the seat of an aphthous ulcer, which is twice the size of the thumb nail. The only treatment she has had was a four months' course of bi-weekly cauterizations, from which her health became so bad that she was obliged to stop taking them. This form of uterine ulceration begins with a slight vesicular. or herpetic eruption, which is located upon the cervix. The vesicles, which are as delicate as those of vari- The eruptive stage. . _ 1 , cella, soon burst, the epithelium becomes de- tached, and small curd-like spots appear. With a pencil-brush these spots can be easily removed, and the denuded surface re- mains a bona fide ulcer. If a number of these vesicles coalesce, 654 THE DISEASES OF WOMEN. they finally develop into an extensive patch of ulceration. Some- times the ulcers are small, yellow and of regular outline ; again they are much larger, with an inflamed base and an irregular ragged outline. Now and then the serum discharged from the vesicles is so acrid and excoriating as to inoculate the neighboring surfaces. The chief characteristics of the aphthous ulcer, however, are its shallowness, its being preceded and accompanied usually by the herpetic eruption on the cervix uteri, and the repeated attempts and failures to reproduce the proper investing epithelium. The surface of this ulcer, as seen through the speculum, is half concealed beneath an abnormal in- vestiture, which is constantly being exfoliated and reproduced. In this respect it resembles the aphthous ulcer of stomatitis, and like it, is an evidence of a depraved state of nutrition, a kind of scorbutic cachexia. The diagnosis is very important, for it has very much to do with the treatment and conduct of the case. The only forms of uterine ulceration with which this is liable to be confounded are the diphtheritic and the syphi- litic. From the diphtheritic ulcer it may be known by the deli- cate and imperfectly organized structure of the membrane that covers the ulcer, which in respect of its color and thickness, is very different from the wash-leather deposit in diphtheria. The attendant constitutional symptoms are much more grave in diph- theria than in an ordinary case of aphthous ulceration. The syphilitic ulcer is of a dark, red hue, and never bright or yellow, and the general constitutional symptoms are wholly dif- ferent from those which are incident to the aphthous form of uterine ulceration. The principal causes of this disease are defective nutrition, an impoverished state of the blood, chlorosis, tabes mesenterica, chronic gastritis or gastro- enteritis, and the exhausting processes of gestation and lactation. The treatment is very simple, and if properly chosen, very suc- cessful. Much depends upon the correct diagnosis of the difficulty. Such cases are sometimes cured unwittingly, and neither the doctor nor the patient knows what has been done. More frequently, however, they are made APHTHOUS ULCERATION OF CERVIX UTERI. 655 worse by the treatment adopted. This result may often be as- cribed to the fact that physicians do not always discriminate as to the particular variety of ulceration with which they have to deal, and that the means chosen are inappropriate, too harsh, and there- fore harmful. It is not at all unusual for the simplest cases of this kind to run along for months, and finally, for them to be nearly or quite sacrificed upon the altar of a promiscuous cauterization. Let me tell you, gentlemen, that in the whole range of our art, I do not know of any temptation to compare with that which sometimes prompts and permits the physician to diagnosticate and to pretend to cure the most serious uterine diseases when they have no real existence. Patients not unfrequently declare them- selves ill with some particular " weakness," and, whether they are mistaken or not, will insist upon being treated therefor, either -at our hands or by another. The fashion is to gratify them, and to put a premium upon every kind of local expedient especially. Thousands of women have thus been cauterized for uterine ulceration which, before the application of the escharotic, had no existence. Multitudes of them have done Reprehensible practice. , . penance by wearing pessaries, and supporters of every description for luxations of the womb that could not be found, except in their own imagination, or in that of the physician. They have been bed-ridden and abused until the weakness of the sex has become a by-word and a reproach, mainly because the doctors have been too anxious to " make out a case ;" and after- wards, because they have seen fit to persecute them with the most harmful appliances. The doctor who treats a broken leg or a case of small-pox must be skilled in diagnosis, and measurably honest. His selfishness may prompt him to make his patients as many visits as possible, and to extort a fabulous fee for his services ; but, concerning the nature of the accident, or of the ailment in question, there is little relative opportunity for him to deceive the sufferer or the friends. But when he is consulted in the case of a woman who is supposed to be ill with a sexual infirmity, the conditions are changed. He makes his diagnosis in the dark, as it were, and who shall dis- prove it ? His professional opinion is not open to criticism, nor his skill to a healthful competition. And hence the peculiar temptation, in this department of our calling, to those members 656 THE DISEASES OF WOMEN. of the profession who have a bias towards dishonesty, and who seize upon every opportunity to make the most out of a class of eases which are often obscure, intricate and tedious at the best. Bennett and a host of lesser lights have decreed the uterine cervix to be the center of pathological interest in woman. Too many physicians make it the focus of pecuniary interest, and therefore punish it through personal cupidity and a lack of con- science, as well as of knowledge. Here is a poor woman whose local disease is the sign and seal of a constitutional cachexy. She is ill from her head to her feet. Her whole organism is deranged. A few little A constitutional and not • i , i i J j 1 iri merely a local disease. vesicles were 'developed upon the neck ol her womb. Their investing tunic was raptured, and an aphthous ulcer was the consequence. That ulceration has perpetuated itself, because the general condition from which it came has not been cured. A moment's reflection will satisfy you that cauterization is contra-indicated. For even if its effect were locally beneficial, and not injurious, it could do no good in a gen- eral way. The cause would remain, and the consequence would repeat itself. A more skillful, and successful method of cure in these cases* is to set about correcting the vitiated condition of the system, precisely as you would in a case of stomatitis 'leiuh™^ the general materna. You may order a diet consisting chiefly of the nitrogenous principles. Beef, in the. form of steak or broths, oyster-soup, the whites of eggs, and milk, are preferable. To correct the strumous habit, the vegeta- ble acids are also necessary. Baked apples, peaches, grapes, oranges, or lemonade, are almost always grateful, and, I believe, useful in such cases. Where patients have foresworn tea and coffee, I have sometimes prescribed that they should resume their use, with a view to arrest the too rapid metamorphosis of tissue which is going on. For the first or vesicular stage of this disorder, and in old cases where a new crop of vesicles appear from time For the vesicular stage. ,. , - . , • ,• to time, cantharis, rhus tox., or aurum muriati* cum, are usually sufficient. APHTHOUS ULCERATION OF THE CERVIX UTERI. 657 If there is also an aphthous condition of the mouth and of the alimentary mucous membrane, you may find it tion° r the aphthous condi " necessary to prescribe arsenicum alb., hyclrastin, mix vomica, belladonna, mercurius jod., or the nitric or sulphuric acid. Locally, I think it a good plan, in this form of uterine ulcera- tion especially, to use the same remedy that is administered inter- nally. It can be applied with water, or glycer- Local treatment. . t • i me, or both these substances as a vehicle. A very simple and available injection consists of adding a table- spoonful of glycerine to as much castile suds as will be needed for one application. In addition to the medicines already named, the coptis trifolia, borax, kali bichromatum, and of late years, the carbolic acid in weak solution, deserve to be mentioned in this connection. If the suppuration is very considerable, as it some- times is, calendula injections may be used with advantage. Where there is chronic vaginitis, with profuse leucorrhcea, and desquama- tion of the vaginal epithelium, whatever variety of injection is chosen, may be brought in contact with the entire mucous mem- brane of that canal through such an instrument as this, which is a cylindrical speculum, that is perforated with numerous holes of the size of a large shot. For the herpetic form of this disease, Leadam recommends the injection of a weak solution of the thuja oc, to be repeated two or three times daily. The objection to the topical use of astringents, as for example, tannic acid, alum, and the acetate of lead, in cases of this kind is that they do not possess any especial and spe- ^Objections to astringents, cificaUy curative relatk)n t O the disease itself ; and also that they are extremely liable to cause such a modification of the circulation as shall tend to involve the menstrual function, and thereby to complicate the case. We will give Mrs. S arsenicum alb. 3, a dose three times daily. Her diet will consist of bread and milk with beef, potatoes and tomatoes, for dinner. Once each day she will drink a glass of good fresh lemonade ; and she will not let the day pass without going to walk or ride a lit- tle in the open air. She will also use the injection of castile suds and giyceriDe every night and morning.* *In four weeks this patient was well. She took no other remedies. 42 £58 THE DISEASES OF WOMEN. IRRITABLE ULCER OF THE UTERINE CERVIX. This form of ulceration is most frequently of local origin. It is is often chargable to maceration of the cervix i n the utero-vagv inal discharges, to the wearing of ill-adjusted pessaries, and to an excess of local treatment. For, much as they are imposed upon and persecuted, the cervical structures do sometimes resent such treatment, and take on an irritable state which is characterized by an excess of vascularity and sometimes by exuberant granula- tions. When this condition becomes chronic, there will be trou- ble elsewhere. Case. — Mrs. B , aged 40, has been ill for two months past. All her sufferings are referred to the epigastric region. She is subject to cramp-like pains in the pit of the stomach, which are sometimes so severe as to threaten her life. These paroxysms bear no relation to her meals, are not influenced by the variety or quality of her food, nor are they assuaged or aggravated in any manner by eating. They are quite as apt to return during the night as in the day. She has slight nausea, but no vomiting ; is very thirsty, and the bowels are costive. The tongue is pale but not coated, the lips are blanched, the oral mucous membrane looks as if it would readily become ulcerated, as in stomatitis materna. She is the mother of four children, the youngest of which is three years old. Has never had stomatitis. Has always menstruated regularly, but, for some months past, has observed that the flow is less free than formerly. She has no pelvic pain or distress of any kind, but is at times annoyed with a copious leucorrhcea, which she describes as purulent and very weakening. The discharge is increased by prolonged exercise, as by washing, or by walking a considerable distance. She has been treated for the gastric diffi- culty for some weeks past, but without the slightest relief. No physiological fact is more certain and more significant than the reflex relation which connects the uterus and the stomach. This relation is especially marked between Reflex relations of uterus $ie u terine cervix and the stomach. This poor and stomach. -L woman is the victim of utero-gastric irritation which is so decided as to make her wretched and to cause her a great deal of pain. But the pain and suffering are located exclusively in the epigastrium. From the mere symptoms which she has given us one would not be led to suspect any uterine com- plication. Even the leucorrhoea would not necessarily be due to IKRITABLE ULCER OF THE UTERINE CERVIX. 65i) ulceration. It might be catarrhal, and, at her age, critical in character, more especially as the quantity of the menstrual flow \s gradually diminishing. • In treating this class of cases in private practice it is not always advisable or necessary to subject the patient to an examination with the speculum. The better plan is to n eIe h s3ar P y e . culumnotalways remember these reflex relations, and to try if possible to cure the patient without placing a premium on the indiscriminate use of this means of diagnosis. But where the disease of the stomach, the heart, or any of the more important viscera does not yield to well-chosen remedies, you will be justified in proposing to search for the remote cause within the pelvis. And not unfrequently you will discover a latent and unsuspected lesion of some kind which will be quite sufficient to account, not alone for the peculiar nature of the individual symp- toms, but also for their persistency in not yielding to treatment. That there may be very extensive and serious disease of the pelvic organs, without a corresponding degree of suffering, indeed with- out the patient or her physician having sus- be T iatent terine lesi ° n may pected anything of the kind, is a fact beyond question. It is altogether probable that the ulcer which some members of the class saw in this case, in the ante-room just now, has existed from the commencement of this woman's illness. I have seen examples of the kind in which a similar lesion must have continued for months, and even for years, without being recognized. Such an oversight is quite as inexcusable as it would be to treat a patient's throat or lungs for months together without ever having made a physical examination of the parts affected. The surface of these uterine ulcers, in all such as are benign and not malignant, or specific in character, is usually covered either with pus, or with a bland, somewhat gelatinous iv?muc Va . lofthepr ° tect " mucus, resembling the white of an egg. These coatings are protective, and should be removed very cautiously, else the free surface of the ulcer may be wounded, and its appearance very much changed. If you will take a bit of cotton wool, or of soft sponge in the grasp of the forceps, pass the instrument carefully through the speculum, and when it approaches the cervix uteri, give it one or two. turns upon 660 THE DISEASES OF WOMEN. its own axis, very gently and cautiously, you can wind the mucus about it in such a manner as to remove it from the surface of the ulcer without injuring it in the least. But if you mop it off roughly, your examination may be of little practical advantage, at least in so far as the differential diagnosis of uterine ulceration is concerned. The irritable ulcer is irregular in outline, and varies in its depth. It looks as if it had been cut out with a " punch," the base thereof being considerably depressed Appearance of the ulcer. ,,-,,■,■,«,■, , below the level 01 the mucous membrane covering the uterine cervix. This mucous membrane is some- times red, inflamed, and even cedematous, but again, as in this case, it is almost as colorless as cartilage. The bottom of the ulcer is of a dark red cranberry hue. Sometimes its vessels are so surcharged with venous blood as to cause it to be almost black in color. The granulations are very vascular, and bleed upon the slightest touch. Such patients sometimes complain of a slight flow of blood after exercise and after coitus. This ulcer implies a low grade of vitality. As in the case of irritable ulcers located on the shin, examples of which you have seen in the surgical clinic, it depends upon a morbid state of the general constitution, and a depraved habit of a sign of depraved vi- the patient. The digestive system is almost always deranged. The patient is badly nourish- ed. The mucous membranes elsewhere are not healthy, but pale, easily inflamed, and readily become ulcerated. This poor woman's lips and alse nasi confirm this view. They have a pearly, exsanguine look, and her tongue has the ragged appear- ance of one which has been badly ulcerated. The gums are not healthy, and there is every reason to suppose that the lining membrane of her stomach has participated to some extent in this tendency to inflammation and ulceration. Hence her indigestion, inanition, general ill-health, and uterine ulceration, which, with its consequent leucorrhcea, are increased sources of weakness and disease. But you must not suppose that this variety of ulceration is limited to the poorer classes of society. Indeed, Not limited to the poor. ,, .. » ,'. ,. the most marked examples ot this disease are sometimes met with among those who have " lived too well," IRRITABLE ULCER OF THE UTERINE CERVIX. 661 bs the phrase is. These persons have brought on indigestion, and a depraved state of the nutritive function by eating irregu- larly and immoderately, by drinking too much wine and spirits. and developing an irritable, nervous temperament that has predisposed to this species of cachexia. It sometimes follows excessive loss of blood, as in haemorrhage from abortion, and may be due to too prolonged lactation. Treatment. — When there is reason to believe that uterine ulceration proceeds from, or is perpetuated by some digestive derangement, it is of the first importance to .DSTetc. he indigestIon ~ correct that disorder, whatever it may be. For this purpose the diet should be carefully prescribed, such aliment being chosen as can be most readily •digested and assimilated. Albuminous articles are preferable. Lean meats, milk, the white of eggs, oysters and fish in their season, good bread, rice and farinaceous food, afford a sufficient variety. Fruits will furnish the vegetable acid, which is some- times an excellent antidote to this cachexia. In case of indi- gestion, peaches, apples, pears and cherries should be cooked before eating them. This is especially true if they must be procured from the market. It is also desirable in this class of cases to husband the re- sources of the patient's system as much as possible, by closing any drain which may be exhausting her little stock of strength. Haemorrhage, too excessive or prolonged lactation, diarrhoea, leucorrhoea, night sweats, copious expectoration, or diuresis, may need to be remedied before you prescribe for the ulceration itself. Fresh air, sunlight, diversion of the mind, and the cultivation of a good morale, are as requisite here as elsewhere. The class of remedies most frequently indicated are arsenicum -alb., nitric, muriatic or sulphuric acids, sulphur, rhus toxicoden- dron, baptisia tinctoria, hydrastin, and arseni- Internal remedies. , . cum jod. Incidental remedies may be given for incidental symptoms, but we can not be very far wrong in prescribing the first of these for Mrs. B. She will take a dose of arsenicum alb. 6th, morning and evening, and report on our next clinic day. But it is not sufficient merely to regulate the diet, the exercise, 662 THE DISEASES OF WOMEN. and the hygienic condition and surroundings of this class of patients. Some kind of local treatment is Local treatment. ■ called tor, and may, it properly selected and applied, assist in the cure. Although, as I have already said, Nature extemporizes a coating for the ulcerated cervix uteri, still that coating is not always sufficiently protective to prevent the contact of the atmosphere and of acrid discharges, which may serve to interrupt the healing process. And although it is in a measure protective, that mucus is not properly, or in any sense curative. Therefore we find it advisable and necessary to substitute this natural covering by a better one, one that shall serve to keep the part protected against harmful influences, and which is, at the same time, possessed of healing properties. You may sometimes apply the baptisia, calendula, hydrastin, or, if you prefer, the same remedy which you have ordered to be taken in- ternally. Simple glycerine will sometimes be sufficient. When either of these substances are given by injection, the vagina should first be syringed out thoroughly, in order to remove foreign matters, mucus, etc. After taking such an injection, the patient should lie upon the back, with the hips elevated, and without moving the body or shoulders for a considerable time. These injections may be repeated twice or thrice daily, according to cir- cumstances. Where the leucorrhceal discharge is purulent and copious, as in this case, I prefer the calendula with glycerine. In this case the near approach of the climacteric may interfere somewhat with a prompt and radical cure of the ulceration. For, although all forms of uterine ulceration heal more slowly and less certainly at the change of life, you will find the irritable ulcer especially liable to become chronic, or, if healed up, to break out again. I have long been satisfied that a special source of mischief in these cases, and one reason why they resist our remedies and re- lapse, is to be found in the condition of the rectum which permits the absorption into the pelvic circulation of certain fsecal matters. This induces the form of blood-poisoning that has been described by Dr. Barnes under the head of copramio, which has the effect to interrupt the healing process in cases of irritable nicer especi- ally. To overcome this condition we must correct the habit of constipation, and, if necessary, have the rectum cleansed every day. DIFHTHERITIC ULCERATION OF THE OS UTERI. 663 DIPHTHERITIC ULCERATION OF THE OS UTERI. In this variety of uterine ulceration the constitutional symp- toms correspond with those which are present in diphtheria, affect- ing other portions of mucous membrane, as for Constitutional symptoms. , . example, the nasal and respiratory passages. There is the same evidence of blood-poisoning, the same prostra- tion and attendant phenomena, and the same sequelae that occur when the throat is the seat of the abnormal deposit. Examination per vaginam reveals an ulcer upon one or both lips of the cervix, which is covered, or nearly so, with a heterol- ogous deposit. This deposit or pseudo-mem- Physical symptoms. ' . . brane is a ioreign growth, which, m due time, exfoliates. In some cases instead of one or two large-sized ulcers, there are a number of small, whitish, shining patches, which vary in size from that of a split pea to half a hazel-nut. These patches may, or may not, coalesce. To the " touch' ' they impart a rough or dry sensation that is quite peculiar, and very different from the feel of other ulcers. The pseudo-membrane which covers the diphtheritic ulcer, or patch, is at first very adherent, and cannot be detached without more or less injury and consequent haemorrhage. The pseudo-membrane. ft i--ii t n • • Atter a little while, however, the friction of the parts during the motion of the body, as in walking or sitting upright, or a careless introduction of the finger, or of the specu- lum, may separate them. Their removal leo.ves a raw, bleeding, painful, intractable, suppurating ulcer, which may, or may not, extemporize another wash-leather covering for itself. According to Becquerel, in the order of their coming, the formation of these false membranes precedes the development of the ulcer, or diph- theritic chancre. It is only while something of the covering remains that these ulcers can be diagnosticated with absolute cer- tainty. As a rule the larger the surface of the diphtheritic ulcer, the more superficial it is ; and per contra, the and h he d dSc h hrr f 4 he uker ' sm aller its dimensions, the greater its depth. The deeper the ulcer, the more profuse the discharge. Sometimes the flow therefrom is acrid and corrosive, and as in HGl: THE DISEASES OF WOMEN. nasal diphtheria especially, it destroys, or perhaps inoculates the adjacent tissues. This discharge is always fetid, and, when it is obtained directly from the ulcerated surface, emits the peculiar diphtheritic odor. True diphtheria may be produced in other per- sons by inoculation with this virus. Diphtheritic ulceration of the os uteri is rarely an idiopathic affection. The throat and other parts are generally first attacked, and afterwards the vulva, vagina and neck of the A secondary disease. . ,.,.., womb. As m syphilitic ulceration, the superior vagina and cervix are less frequently the seat of the lesion than are the inferior vagina and the vulva. It has been remarked that, as in other forms of diphtheria, this species of uterine ulceration is especially liable to occur during the epidemic prevalence of va- dola, rubeola and erysipelas. Many obscure affections of the gen- erative system have undoubtedly resulted from prolonged exposure to diphtheria, and the fatigue of nursing those who were ill with that disease. In these cases the utero-vaginal mucous membrane has probably been the seat of diphtheritic inflammation and ulcer- ation, where nothing of the kind was suspected. If the diphtheritic ulceration of the os and cervix uteri takes place during pregnancy, it is very likely to cause abortion ; if during the lying-in state, it may invade the uterine cavity, in which case pseudo-membranous patches have been found at post mortem lining the uterus itself. Dr. Tilt reports a case in which he claims that a patient had a diphtheritic ulcer of the os uteri from leech-bites. But, in order to produce a generic ulcer of this kind, it is Cause. , . n necessary that the specific cause should be at work. For this specific agency, whatever it may be, is just as requisite in this case as it is in diphtheritic angina or conjunctivitis. The only cases of diphtheritic ulceration of the os uteri and the vagina which I have seen have occurred in the persons of those women who, from watching and taking care of those who were ill with diphtheria, became predisposed to this form of the complaint and took it in this way. It is possible, and even probable, that some previous disorder of the generative system, in each of these cases, may have caused the lesion to locate itself upon the uterus rather than in the throat. During the prevalence of an epidemic POST-PARTUM ULCERATION OF THE WOMB. 6G5 of diphtheria you should examine this class of patients very care- fully with the speculum. The treatment need not differ essentially from that proper foi other forms of diphtheria. If any one remedy deserves more prominent mention than another, it is cantharis. And this not only because of its frequent indi- cation in the treatment of other varieties of diphtheria, but also on account of its special curative relation to the cervix uteri. Mercurius jod., kali bich., kali brom., phytolacca, nitric acid, jodium and hepar sulphuris may be of great service under their especial indications. Locally, injections of the tincture of hydrastis, or calendula, or of any of the aforenamed remedies, diluted with water, or glycer- ine, or both, are sometimes very serviceable. If the discharge is very fetid and offensive, the chlorate of potash, in the proportion of half a drachm to four fluid-ounces of distilled water, and used in the same manner, an- swers a good purpose as an antiseptic. And so also does a weak solution of carbolic acid, of kreosote, or of the permanganate of potash. The objection to the potash salt is on account of its color. My friend, Dr. W. H. Holcombe, has made use of the kali bichromicum, in the strength of half a grain of the crude drug dissolved in a tumbler of water, " as an injection for ulcerated os uteri, and even for leucorrhcea, with sfood effect." This may also be used for the relief of diphtheritic ulceration and of vaginal diphtheritis. Since this form of uterine ulceration is inoculable, like the syphilitic variety, it is important to exercise the proper care in the use of instruments, napkins, etc., lest we carry the disease to other patients who may hap- pen to be under treatment for various uterine affections. There is also the same need for isolation in diphtheritic ulceration of the womb as in diphtheritic sore throat. POST-PARTUM ULCERATION OF THE WOMB. Although ulceration of the womb is not usually classed among the sequelae of labor, there is little doubt but that it sometimes occurs in this connection. Case. — Mrs. , aged 28, has an infant five months old. She nurses the child, which is thrifty, and lives exclusively upon the 6Q6 THE DISEASES OF WOMEN. breast. The mother is not well. She has not menstruated since her confinement. She complains of aching in the loins, weariness on very slight exertion, pain in the left iliac region, with inability to lie upon her left side, malaise, anorexia, frequent headache, occasional strangury, and a leucorrhcea which at times weakens her very much and increases the old pain in the back. These symptoms began during her lying-in, and have continued until now. An examination with a speculum discloses a simple suppurating ulcer within and around the external os uteri. When uterine ulceration occurs in women who have but recently been confined, it is very apt to be overlooked. The patient may have escaped the perils of childbirth, but for Likely to be overlooked. some unknown reason she has a lingering con- valescence. At first there may have been a considerable degree of puerperal inflammation, and following this a state of things analogous to what Trousseau styles " colliquative suppuration/' Lactation, is, perhaps, normal, and the other functions are intact, but she is extremely weak and reduced, and rallies but slowly. A month or two may have passed before she is able to make an excursion to the dining-room, or the parlor, and three, or even six months before she can take a drive. Meanwhile she has lost her accustomed elasticity, and life is become a burden. She drags around, impelled by circumstances, and the probabilities are that her ill health will be charged to some other cause than the ulceration, which dates from the birth of her child. In such a case the lesion of the os is undoubtedly a result of the inflammatory process. After delivery the uterine tissues readily become inflamed. This inflammation is tic£ sequd ° f inflamma " often, but not always, of such a low grade and type as to develop into ulceration. And once the ulcerative metamorphosis is begun, it is likely to be overlooked and perpetuated. It is altogether probable that pressure upon the cervix, and traumatic injuries thereof during the labor, may indirectly occasion such symptoms as those of which our patient complains. If there were anything distinctive in these symptoms, they would be more easily and generally recognized. But, in a given case, we cannot know positively that a lesion of the cervix exists without ocular examination. Here the speculum is as requisite a F0ST-PARTU3I ULCERATION OF THE WOMB. 667 means of diagnosis as if the disease were idiopathic, and did not follow parturition. There are two general causes for this species of uterine ulcera- tion, or, rather, for ulceration of the cervix, occurring in women at this particular period. The first is the drain bbUi paired quaUty ° f th ° u P on the mother's blood during gestation ; and the second, a similar drain through the mam- mary glands while she is nursing. By impairing the quality of the blood, and thus lowering the grade of vitality, these causes increase the risk of post-partum inflammation. And in such depraved states of the system there is but a short step from inflammation to ulceration of the uterine neck. The same remark applies to ulceration as a sequel of abortion, more especially after the fourth month. Treatment. — The hint which I have just given 3^011 concerning the relation between the depraved and impoverished condition of the blood and the symptoms complained of, is Weaning the child . . 01 great practical significance. Acting upon it, you would prescribe the proper hygienic regulations. If you are satisfied that there is too much of waste and expense to the mother's organism in the quantity of milk that she furnishes, it is better to feed the child with something else than to bankrupt the mother's strength in this manner. Weaning is a last resort. It is not necessary, except in extreme cases, and where the quality of the milk is such that the child is finally poisoned by it. The diet should be as nourishing as possible. Allow milk, lean meats, eggs, game, fruits, and good bread and butter, instead of the sick-room teas, slops and kindred abomina- Thediet. . ' L tions. Fresh air and sunlight should also be ingredients in the prescription. But let me caution 3-ou to re- member that walking may be very harmful, in case of uterine ulceration, and for this reason, the womb beinGr Walking. . ' ' ° pendulous when the patient walks, the denuded cervix is brought into contact with different portions of the vagi- nal mucous membrane. Friction irritates it, and excites the local circulation to such a degree as greatly to increase the suffering, and to extend the lesion. Moreover, the blood gravitates into the pelvic organs, and the consequent congestion more than counterbalances the good effect of the out-door air and exercise. ()QS THE DISEASES OF WOMEN. Riding is less objectionable, but I have observed that many patients with uterine ulceration complain seriously of the street-cars, the stopping and starting, as well as the roughness of which, worry them more than riding in the stages on the avenue, or in a private conveyance, if it be carefully driven. You would not send such patients to ride in a rough country wagon, neither upon horseback. Compared with ordinary cases of uterine ulceration, the post- partum variety may be more easily and promptly cured. The explanation of this fact is to be found in the ex- andwhy° mparatively easyi emption of the menstrual return, which so much retards the cure under different circumstances. Here is no periodical determination of blood to the womb. In lieu thereof we have a physiological afflux of blood to the mam- mary glands, which is really derivative in its influence upon the intra-pelvic organs. For this reason, the proper treatment should not be deferred, else the menses will re-appear, and the cure be very much delayed in consequence. It sometimes happens that the too early return of the menses in one who is nursing is an evidence of debility and of waning strength. It may signify that the mother's force tadon nstruati ° ndurInglac " and vitality are fast ebbing away. Much will depend upon a proper interpretation of the symptoms in such a case, and upon the line of treatment which you adopt. There are those who insist upon the necessity of cauterization in every form of uterine ulceration. They cannot divest them- selves of the idea that such lesions are removed indiscriminate and exciu- f rom ^he sphere of influence of internal reme- sive local treatment. I dies. They argue, and with some show of rea- son, that there is a lack of responsiveness on the. part of the tis- sues w^hich compose the uterine cervix to the best selected consti- tutional treatment. Some even go so far as to insist that no such ulcer can be healed except by topical applications, among the best of which are the various escharotics. But many physicians are in the habit of treating ulceration of the mucous membrane and of the integument by means of internal remedies exclusively. The various forms of stomatitis, ulcerated sore throat, chronic laryngitis, and bronchitis, typhoid fever, POST-PARTUxM ULCERATION OF THE WOMB. 669 chronic enteritis, typhlitis and dysentery, yield to this method of medication. If in any of the three former affections they consent to apply the caustic, it is an exceptional case ; while, in the latter, it would be altogether impracticable to do so. A large proportion of cases of external ulcer need nothing more topically than to be protected from the irritating influence of the atmosphere by some bland and harmless appli- Only specific ulceration . ' needs specific local treat- cation. In some cases we may facilitate the healing process in them by the local use of the same remedy that is given internally ; but, excepting in specific ulcers, not one in a thousand of them needs cauterization. So in ulceration of the os uteri — when there is no specific reason, either in the nature of the lesion, or in its cause and symptoms, why some specific remedy, as for example the nitrate of silver, or iodine, or what not, should be applied locally, your good sense and judgment would dictate their prohibition. It has been argued in advocacy of the indiscriminate local treat- ment of uterine induration and ulceration, that a spontaneous cure thereof was impossible, because of the frequent Arguments pro and con. . return and concomitants ot the menstrual now, the dependent position of the uterus, and the evil consequences of sexual excitement. But it does not follow that, because these cases do not get well of themselves, therefore they all need to be cauterized. It is bad practice to prescribe at wholesale. In the case before you the menstrual aggravation is not present. The peculiar position of the womb does not so strongly predispose to its vascular derangement, or to the perpetua- Interdiction of coitus. . n 1 tion ot a chronic lesion unless the woman men- struates, or its tissues are undergoing the changes which are proper to gestation. In serious cases of ulceration of the womb, the worst consequences may follow a frequent repetition of the sexual act. Such a patient should live apart from her husband. A large share of the benefit attributed to the local treatment of uterine ulceration by caustics of all kinds should really be ascribed to the necessary interruption of the marital intercourse, which is thus rendered impossible. The same is true, but in a qualified sense, of the advantage claimed for change of air, etc., by those who leave their homes and husbands behind them, to seek for treatment elsewhere. 670 THE DISEASES OF WOMEN. You will not understand me as objecting to every variety of local application in simple ulceration of the os uteri. Such an ex- treme view would be as untenable as that which Allowable local treatment. -. holds that such means, and only such, are abso- lutely requisite and curative. There is no valid objection to the topical employment of diluted glycerine, with or without the cal- endula, of sweet oil, or of the oleaginous collodion in the case of this poor woman. Either of these substances will be grateful to the diseased part, will serve to protect it from the injurious effects produced by contact of the vaginal mucus and the leucorrhceal discharge, and will also stimulate the reparative process whereby the lesion can be healed. The calendula is especially useful where the purulent or muco-purulent flow, as in this case, is very con- siderable. It may be used as a vaginal injection morning and evening. The internal remedies that may be required will vary with the symptoms presented in each individual case. Chief among them are calendula, calcarea carb, arsenicum, sepia and sulphur. LECTURE XLI. LEUCORRHOEA WITH CHRONIC OVARITIS. General remarks on leucorrhoea. Leucorrhoea with chronic' ovaritis. Chronic leucor- rhoea and the scrofulous dyscrasia. Irritable uterus or hysteralgia. Although leucorrhoea is a symptom and not a disease per se, we are so often called upon to prescribe for it that it may be expedient to consider it briefly in the two cases which I shall show you this morning. Both of them are secondary and symptomatic, and in this light they are typical. The first is dependent upon chronic ovaritis, and the second upon a very different cause. Leucorrhoea may also be a critical and therefore a salutary affection, and for this reason it is not always best to seal it, whether by local or general means. If a flow of this kind follows the menstrual period it may be prophylactic of ovarian and uterine inflammation. Cases of laceration and of sub-involution of the uterus are almost as certain to be accompanied by leucorrhoea as they are by menor- rhagia and prolapsus. Case. — Mrs. , aged thirty, was married seven years ago, but has had no children, and has never suffered a miscarriage. She has had leucorrhoea for the last ten years. The discharge is of a yellowish white color, sometimes thick and creamy, and again thin, copious, and quite fluid. After having been upon her feet for a long time, the flow becomes more profuse. She is certain that the quantity discharged frequently amounts to three or four ounces in a day. When the matter which is most liquid escapes, she feels most exhausted. She complains, at such times especially, of a sense of weariness, and of dragging pains in the loins and hips. For a lono; time, she remarked the leucorrhceal discharge was most profuse either immediately before, or directly after, her menstrual "returns;" but tor some time past she could discern no especial increase at this or any other period of the month. She menstruates regularly every four weeks, but the proper flow is gradually lessening in quantity, so that at present she is "sick" but two days instead of three, or three and a half, as hereto- fore. The only suffering experienced during menstruation is a severe, burning pain, which is located just within the anterior 671 672 THE DISEASES OF WOMEN superior spinous process of the left ilium and above the groin, or in other words, in the region of the left ovary. This pain, which is sometimes very severe, always extends down the corresponding- thigh to the knee. She has never had it upon the right side. She is quite confident that she has not menstruated a single time, dur- ing the last ten or twelve years, without experiencing this peculiar, burning, cramp-like, neuralgic pain. When the catamenia cease,. it immediately declines, and she has never had it in the inter-men- strual period. Riding and walking increase its severity. Examination by the speculum discloses a scrofulous suppurat- ing ulcer at the os externum, extending into the canal of the cervix. The mucous membrane, investing the vaginal portion of the uterine neck, is considerably swollen and congested. The left ovarian region is exceedingly sensitive to external and internal palpation. She has been treated by four physicians, three of whom cauterized the cervix severely, but without any benefit to the patient. Indeed, she steadily continued to grow worse, and, as you see, her general health is now very much impaired. A chief point of interest in this case is the lesion of the left ovary and its consequences. For, the local symptoms which occur so regularly, are so characteristic and so constant Burning pain in ovaritis. ovulation sometimes a that we are iorced to conclude that the ovarian constant cause of ovaritis. m . disease is the primary one. There is, indeed, something quite distinctive about this " burning " pain in the inguinal region, which extends down the limb of the same side. When it comes on with the return of the catamenia, and ceases during the inter-menstrual period, you may be certain that the cor- responding ovary is inflamed. This inflammation may exist for years, with a brief, sub-acute and self-limited attack each month. The cause of this fresh and painful recurrence of inflammation is the physiological afflux of blood to the organ ; without this afflux the proper function of the ovary can not be performed, any more than the gastric juice can be secreted if the delicate capillaries of the gastric mucous membrane are not injected with blood. It is the periodical repletion of the vessels of an inflamed ovary that gives rise to the peculiar, burning, cramp-like, neuralgic pains of which our patient has just made complaint, and that has literally been the thorn in her side for these many years. The reflex relations of the ovaries are numerous, varied, and Reflex relations of the important. They are in sympathy with the ovary " lungs, the mammary glands, the uterine mucous membrane, the nerve centers of animal life, and especially with LEUCORRHCEA AVITH CHRONIC OVARITIS. 67o the uterine cervix and its secretory apparatus. The neck of the uterus is not more intimately associated with the womb itself, of which it is the natural outlet, than it is with the ovaries. These little organs, although remotely located, have really as much to do with the active dilatation of the os uteri, and the escape of the menstrual flow through it, as they have with its first formation in the uterine cavity. They not only serve as time-keepers for the menstrual organism, but they also open the gateway of the generative intestine for the escape of its periodical discharge. This peculiar sympathetic function is exceedingly liable to derangement. In a state of health, both of the ovaries and of the cervix, it is intact. But suppose that either of Sympathy between the uterine cervix and the these parts becomes the seat oi serious and pro- ovaries. -I -i . . . tractea disease — nothing is more certain than the consequent, although indirect, implication of the other. It would be almost, or quite impossible for our patient to have had this form of sub-acute ovaritis for so long a period without the cervical leucorrhcea also. Protracted and persistent leucorrhceal discharges, whether from the uterus or the vagina, or both to- gether, are always indicative of structural disease somewhere. The lesions which produce them may b idiopathic or secondary. They may depend upon causes which are purely local, upon those which are constitutional, or upon such as are reflex. In the case before us there is little doubt that the ulceration depends on the inflammation of the left ovary, which is the fount and origin of the disorder for the relief and cure of which we have been consulted. The gradual diminution of the menses is significant and sug- gestive. When ovaritis is accompanied by uterine ulceration, which is not cancerous or phagedenic, there is Leucorrhcea may substi- a l m ost alwavs a tendency in the menstrual tute menstruation. J J secretion to become more and more scanty. Under these circumstances, the leucorrhcea sometimes substitutes menstruation, when it is termed " vicarious." This result is more likely to follow the inflammation of both ovaries than of one. In catarrhal leucorrhcea, without ulceration of the cervix, and uterine and vaginal ca- whether it comes from the uterus or the vagina, tarrh from ovaritis. ^q discharge is usually increased either before or directly after the catamenial flow. Here the ovarian sympa- 43 674 THE DISEASES OF WOMEN. thy spends, itself- in giving rise to an extraordinary secretion of mucus, and menstruation is more apt to be profuse than scanty. Some of the worst forms of menorrhagia, or excessive menstru- ation, are engrafted upon this kind of leucorrhcea, which may also arise from ovarian irritation and inflammation. Sterility is a natural and almost necessary consequence of either of the forms of leucorrhcea just named, which le^rrhffia 55 ° aused by might, without any great impropriety, be styled ovarian leucorrhcea. As our patient's disease commenced before her marriage, there are the best of reasons why she has never been pregnant. Treatment. — It is possible that enough has already been said to illustrate the importance of a correct knowledge of special pathol- ogy in cases of this kind. And yet I must iai T P h a e thSSgy ance ° f spec ~ embrace so favorable an opportunity to say a few words upon a subject concerning which you will find so much in our books and journals. I apprehend that no man or woman ever yet made a prescription without having in his or her mind a theory of the ailment to be treated. However improperly it may have been done, the simplest domestic remedy is not given until the disease has been classified. And among the fraternity, nolens volens, we are as much addicted to the habit of naming diseases before we treat them, as to the naming of our babies before they are baptized. And because this theory, which represents our idea of the special pathology of the disease in ques- tion, and typifies our knowledge or our ignorance of it, is "as inevitable as one's shadow," it is vitally important that it be cor- rectly established. If we would unravel the tangled skein, we must get hold of the proper thread. In order to be skillful and successful in the interpretation and cure of diseased states, we must begin at the right end of the series. According to the theory that the ulceration gave rise to the leu- corrhcea, and that what would heal the former would also cure the latter, this patient has been cauterized by three physicians in turn. Their applications may have patched up the case, but, for reasons which you now understand better than they seem to have done, the cure was not permanent. The lesion of the os reappeared, simply because the ovarian affection had been overlooked and neg- lected. And not only did the cruel expedient to which they LEUCORRHCEA WITH CHRONIC OVARITIS. 675 resorted fail to cure the lesion of the os uteri ; it also increased the ovarian congestion and inflammation. For the sympathy be- tween the cervix and the ovaries is such that whatever harms one will almost certainly implicate and injure the other. Your preceptors are fully aware of the fact that a large share of the ovarian affections which they are called upon to treat have been caused in this manner. And your own indiscriminate cauteri- f u ture experience will one day confirm the zation of the os uteri. -L «/ observation, that the indiscriminate employment of escharotics in uterine ulceration is mischievous to the last degree. If those three doctors had been more competent diag- nosticians, they would have been less likely to commit such an unpardonable error in practice. Let us endeavor to improve upon this treatment. We must study this case most carefully, not for the purpose of naming the disease, and afterwards treating it by name, for that plan has already been tested ; but to analyze the symptoms presented, and to remove them in the most rational and sensible manner. In a case of this kind the ovarian symptoms are a thousand times more significant than those which pertain to the leucorrhceal discharge. The proper plan is, therefore, first to treat the disease of the left ovary, and afterwards, if anything remains of the uterine ulcera- tion and its consequent discharge, to address our remedies specifi- cally to them. The prominent symptoms for which we must select a remedy in this case are, therefore, severe j)ain in the left ovaiy, which is of a "burning character, extending down the corresponding limb, which recurs with every return of the catamenial period, and is aggra- vated by riding or walking ; the menses become more scanty, and are accompanied and followed by leucorrhoea. The appropriate remedy is thuja oc, of which she will take a dose every evening during the month. The most proper and effective treatment in cases of this kind is one that is brought to bear during the inter-menstrual period. Palliatives and kindred expedients, only de- Inter-menstrual treatment. . signed to relieve suffering while menstruation continues, are in no sense curative. The persistency of the symp- toms just named, and the unequivocal indication presented for the thuja, warrant us in promising a great, although it must be a 676 THE DISEASES OF WOMEN. gradual, improvement in our patient's health. In addition to the internal remedy, she should syringe out the vagina twice daily with tepid castile suds. In some cases of this kind I add a few drops of the crude tincture of thuja, and in others of calendula, to the water injected into the vagina. But it should be an indict- able offense, for the physician to prescribe or apply astringent washes and escharotics, for the relief of such a case of leucorrhcea as that to which your attention has now been called. You will not understand me to recommend this prescription for all cases of ovarian inflammation indiscriminately. Before the ses- sion has closed, I shall doubtless have occasion to advise the em- ployment of various other remedies in the treatment of this disease. CHRONIC LEUCORRHCEA AND THE SCROFULOUS DYSCRASIA. Case. — Mrs. V., aged 36 complains of a chronic leucorrhcea which she has had for years, indeed it has been more or less constant since- puberty. She has three children, and says that she has no exemp- tion from this discharge during pregnancy. Her youngest child, which she continues to nurse, is thirteen months old. The quantity of the leucorrhoeal flow is large, and has always been so, excepting while she suckled her children. She always had a copious secretion of milk " enough for two babies instead of one." She is slender and delicate, takes cold very easily, and is subject to severe attacks of diarrhoea, which, together with the leucorrhoeal flow, weakens her very much. There is no especial aggravation of her symptoms at the month, or at any other time. The menses are regular, but rather copious. Her family are scrofulous, one of her brothers having had "a white swelling," and a sister having had numerous abscesses of a scrofulous character. For practical reasons, it is well to divide the varieties of leucor- rhcea into the acute and the chronic forms. Acute leucorrhcea may be physiological, critical, and even salutary, as crmcaT rhCeamaybe spermatorrhoea may exist without being, in a proper sense, pathological. A leucorrhoeal flow sometimes affords a means of escape for an excess of serum that has accumulated within and about the glandular structure of the cervix uteri, and which has been attracted or driven thither by some temporary local excitation, or reflex emotional cause. Like a perspiration, or a free diuresis, it may be designed to open a safety- valve in order to prevent a local congestion or inflammation* CHRONIC LEUCUIJRHCEA, ETC., 677 Such a flow may be critically prophylactic of bronchitis, a fit of indigestion, a diarrhoea, or an attack of " sick-headache." As my friend, Prof. Sanders has shown,* it may furnish a means of elimination and of ready exit for morbid products that would be mischievous if they were retained. Or it maybe contingent upon some slight menstrual irregularity, a temporary displacement of the uterus, functional disorders of the bladder or of the rectum, or upon an irritation of the mammary glands, or of the ovaries. But if it is acute, it is more likely to be salutary than harmful. And in every such case, provided we do nothing to increase the difficulty or to prolong its duration, it will cease of itself as soon as its transient exciting cause has been removed. When, however, as in this case, a leucorrhcea becomes chronic or habitual, when it has persisted, without cessation, for weeks or months, draining away the patient's strength, pa ^ landffenerai making her wretched, one of three things is certain : ( 1) either there is some local cause, near or remote, which gives origin to the disease, and sustains it ; or (2) there is a bad habit of body, a depraved condition of the general system, a cachexia, a morbid bias, or a dyscrasia, inherited or acquired, which perpetuates it; or (3) these two sets of causes are combined. Perhaps we should approximate the truth most nearly by as- suming that, of all the cases of leucorrhcea that have come to our individual notice, one-third of them were of the acute, or self- limited kind; another third were intimately connected with the history of some local lesion, or lesions, of the generative apparatus ; while the remaining third were essentially of a constitutional character. But the physician who is engaged in a general prac- tice will find these proportions to vary considerably. It may happen that only the first class of cases will fall under his care. This is especially true in the cities and larger towns, where the more serious and protracted examples of female disease, of what- ever variety, are placed in the care of the specialist. Hence it would not be strange if the general practitioner anI a -esufts 1UflUenC S snou ld draw a wrong inference concerning the results ot his experience, or the universal efficacy of his particular method of treatment. If, for example, he had * Vide Transactions of the Twenty-sixth Session of the American Institute of Homoeo- pathy, page 490. 678 THE DISEASES OF WOMEN. relied exclusively upon internal medication, basing the choice of the remedy upon the indications which are ordinarily given, and the result was favorable, he might conclude that nothing else would be required in any possible case of this kind. On the other hand the specialist, who sees a much larger pro- portion of cases of leucorrhcea which belong to the second group, is almost certain to adopt the current theory that there is always a local lesion at the bottom of the difficulty. To him a leu- corrhceal flow is synonymous with inflammation and ulceration of the uterine cervix, and it is difficult to persuade him that any- thing excepting an escharotic will cure it. Or, if it is ail excep- tional case, and he is sufficiently discriminating to exclude these lesions as the cause of the trouble, it is altogether improbable that he would depend upon any other than surgical means for its relief. The conclusions, therefore, are founded upon peculiar and indi- vidual experience both with respect to the variety of cases in which the doctor has been consulted and the apparently uniform success of the exclusive treatment which he has employed. It is not difficult to discern, therefore, that, while these parties may be equallv honest, both are deceived as to the facts in the case. For each has been working in a hemisphere, and neither of them has made the whole circuit of the question at issue. Generally speaking so little is thought of the constitutional causes or modifications of this affection that they are regarded as of little consequence in its treatment. Especi- Constitutional causes. n . .,. . „ . , -. . i • i t ally is this true ot those dyscrasire which under- lie and complicate it, and which because they are latent and obscure, are apt to be overlooked and ignored. Without any disposition to magnify the importance of this class of causes, or to construct a predetermined rule, or system of invariable practice, in the treatment of this or of any other disease, I shall remind you of the influence which one of these morbid states of the constitution exerts upon the clinical history of leu- corrhcea. Whatever the differences of opinion among medical men con- cerning the existence of scrofulosis 'as a distinct disease, it will be conceded that it represents a faulty state of the general health which often predisposes to, and alters the clinical history of other diseases. Its modifying in- CHRONIC LEUCORRHCEA, ETC. (579 fluence over affections of the skin, and oi the mucous membranes especially, is well known. There is nothing new in this very general idea; but when applied to the etiology, pathology and treatment of leucorrhcea, its practical lessons are scarcely recog- nized by the profession. This fact may be verified by reference to the works of the most distinguished writers of all schools, who say little or nothing on the subject; and also by a consultation with experienced physicians, who either know nothing of it, or who, taking an exceptional advantage thereof, have perhaps been enabled to make some remarkable cures. Now this case is atypical one. When you are consulted for the cure of a leucorrhceal discharge and find the patient with a rough, dry skin, a pasty, unhealthy look, an indolent habit of body, with swelling of the lymphatic ghrnds, deficient in stamina, impaired digestion, and a tendency in the leucorrhcea to alternate with some other affection, as a cough, a catarrhal disorder, or a diarrhoea, you may conclude that the strumous habit complicates the difficulty, and that your success in curing it will in a great measure depend upon your recognition of this fact. If to these more ordinary symptoms of scrofula it is added that the patient con- tinued to have the leucorrhcea throughout gestation, and that she habitually has a very copious flow of milk when suckling, as nearly all scrofulous women do, the modifying influence of this dyscrasia is the more pronounced and positive. Here then, is a constitutional cause which will serve to account for the intractable nature of the disease in a large proportion of cases, and for their failure to respond to the best Practical inferences. . ... . . ... chosen remedies, when those remedies are selected by the usual method. For there are not a few cases of this kind in which, in order to be successful, you must direct your attention to the underlying cryscrasia. You cannot cure this leucorrhcea by local applications. Merely to seal the flow by astringents, or by the use of any kind of caustic, would not touch the cause of the difficulty, and could not be thorough. The scrofu- lous habit, and the predisposition to glandular disease must be broken up by constitutional treatment before the local symptoms can be radically cured. Whether we are justified in promising entirely to rid our patients of a scrofulous, any more than of a rheumatic or a syphi- 6^0 THE DISEASES OF WOMEN. litic cachexia, I very much doubt. And it follows that, if we cannot do so, we should be very careful about promising- to cure a chronic case of scrofulous leucorrhoea like this one. Treatment. — Women are generally better economists than men, but in the matter of wasting their own physical resources, they are sometimes very prodigal. Here we are in Economy of streng-th . " ° .... , the middle or winter. Ihis woman s child is more than a year old. Her health is wretched. She is a bank- rupt in strength and physical resource. But still she continues to drain away her little remaining vitality from a sense of duty to her child. The greater the lacteal secretion, the more copious the leucorrhoeal flow. She will never get well in this way. Ablactation, or weaning, is therefore the first remedy. The second is to put her upon a good diet. Milk, fo ^ d eaningandjrood cream, lean meat, eggs, and good bread and butter, are the best things for her to eat. Fresh air and the avoidance of fatigue are also indispensable. The third requisite is to find and supply such medicines as will counteract and overcome the influence of the scrofulous dyscrasia. Other remedies may be oriven incidentally and The remedies. . , upon the ordinary indications, for reflex and accidental complications, but the main dependence will be upon such medicines as calcarea carb., calcarea phos., mercurius, jod., arsenicum jod., silicea, natrum phos., ferrum phos., and jodium, or hepar sulphuris. This patient will take calcarea phos. 3, four times daily, and report. You will remember the case of M , a sewing-girl 23 years ol age who came to our clinic a martyr to a constant and copious uterine discharge. When she was not menstru- C(X86 ating, she had the leucorrhoeal flow, and this double drain had induced the most unmistakable symptoms of chloro-anaBmia. She had palpitation, with cardiac irritability on exercise, and very decided symptoms of cerebral and spinal anaemia. Once she had a partial paralysis of sensation in the whole of the left half of the body, and which responded to the internal use of rhus tox. 3. For the leucorrhoea and the menorrhagia she was given calcarea carb. 3, with a steady improvement in all of her symptoms. The IRRITABLE UTERUS. 681 monthly excess was the first to yield, and the anaemic symptoms soon disappeared. For the leucorrhcea she afterwards took sepia -3, with the affect to cure it. She was of a scrofulous diathesis, and this afforded an additional indication for the calcarea car- bonica. In this class of cases you will sometimes do well to prescribe the cod liver oil as a diet that is espec:ally adapted to the scrofu- lous constitution. It is an aliment merely, and not a medicine, and we may use it as we do the vegetable acids in stomatitis, or milk in Bright's disease, without any risk of interference with the action of appropriate internal remedies. IRRITABLE UTERUS. — HYSTERALGIA. Case. — Mrs. J , 27 years old, married, with three children the youngest of which is two years of age, has been an invalid for nine years. She is naturally delicate and sensitive. She was mar- ried at eighteen, and left home directly for a wedding trip, which was to consist of an excursion to a distant city and a visit of a fortnight to her husband's relatives. When she reached home she felt as if her nervous system was very much shattered. She attributes this result to a want of entire sympathy and accord with her husband, who she says, never understood her, and never took any especial pains to please or to gratify her. During her girlhood, alter fourteen, she suffered a great deal at her monthly periods, more especially for the first ten or twelve hours. For this she usually took hot teas, and gin, and kept to the bed. Since the birth of her children this dysmenorrhoea has not returned, but she lias not been well for a moment. Her chief complaints are of a fugitive character. She is wretched when she goes out, and when she comes in ; in the morning and at night. The only pains that she has are shooting, shifting and transient, mostly in the lower part of the back and of the abdomen. At intervals she has spells of lying in bed with these pains for several days. Sometimes there is strangury, particularly after coitus, which always worries and unnerves her. Menstruation is regular, but less free than it should be. She is most happy when in general society. When she can forgot herself, and be thoroughly diverted, she feels like another person. For this reason she likes to go away from home on a visit. Her nights are wakeful, and she dreams of every event, whether pleasant or painful, in her past life. Her feet are always cold. Examination does not reveal any sign of organic disease about or within the pelvis. The uterus is very irritable and tender to the touch. It seems to be slightly enlarged, but is not displaced. When the finger comes into contact with it she says it produces (>82 THE DISEASES OF WOMEN. the same painful tension and disagreeable feeling which she has: always experienced during intercourse, and which is so intolerable to her. There is a large class of diseases, of which this case is an exam- ple, in which the obvious organic lesion of the uterus and its appendages is the poorest possible criterion of the real nature of the complaint, of the suffering involved, and of the difficulty of curing it. The irritable uterus is not inflamed or ulcerated, con- gested or displaced. There is no lesion of Has no definite lesion. . structure connected with it necessarily. It yields no characteristic or critical discharge. Its measurements are normal, its regional anatomy is unchanged, and it offers no especial obstacle to menstruation, conception, or parturition. So far, therefore, as its morbid anatomy is concerned, it resem- bles nitrogen in being negative in its character ; for it consists essentially in an excitable or irritable condition A 'species of hyperesthesia. ,.,.,. , . of the womb, in which its nervous sympathies and relations are exaggerated and discordant. Inflammation of this or adjacent organs may exist as a sequel, or complication, but they are not a necessary part of the disease. So, also, in some cases there are incidental symptoms of spinal irritation, and of reflex disorders of every conceivable kind, which are contingent upon the morbid exaltation of uterine sensibility. This disease is limited for the most part to menstrual life. It occurs in the case of the married and the unmarried, but is more frequent among the former. Those who have Limited to menstrual life. been pregnant, whether they have gone to term or not, are believed to be more subject to it than such as have never conceived. There are, however, many exceptions to this rule. In general, those women who are weak, Predisposing causes. . nervous, and impressible, and who have been subject to slight, spasmodic and painful irregularities of menstrua- tion, are very prone to this disorder in after life. Unhappy mar- riage, the loss of property and of position in society, the lack of occupation, disappointment, solitude, the dread of having some "female weakness," inordinate use of tea and coffee, chagrin, jealousy, frequent abortion, too rapid child-bearing, erotic thoughts, and sexual excesses, belong also to this class. IRRITABLE UTERUS. 683 of causes. The rheumatic and neuralgic diatheses are powerful predisponents of this form of hysteralgia. The exciting causes are also numerous. Whatever can directly or indirectly exalt the nervous susceptibilities and sympathies of the uterus (even if the stimulant he natural and harmless under different circumstances) is likely to work mischief if too frequently and carelessly applied. The emotions, which properly controlled are healthful and useful, may be in league with the passions to derange the uterine nervous system, and either or all of the functions connected therewith. Under their influence the womb may become so irritable that menstruation shall be suppressed, or become intermittent, scanty, profuse, or perhaps very painful, Or, through the uterine irrita- bility that is induced, a fruitful intercourse may be impossible, and sterility will be the result. Ungratified sexual desire is undoubtedly almost, if not quite, as injurious to the female in many instances as an excess of venery. For women are not only subject to sexual passions and propensi- ties similar to those of men ; but they are also under the dominion of a periodical crisis, that is attended by a peculiar exaltation and excitement of the generative system. These crises can not always be passed with impunity. They involve certain vicissi- tudes which derange the uterine innervation. And coming as they do so frequently, these nervous derangements are perpetu- ated. It is sometimes as difficult to tide a woman over "the month" as it is to carry a popular patient, who is very ill, over the Sabbath, or through a holiday, without a relapse, or an exac- erbation of his disease. The contingent excitement and re-action are so mischievous that it is almost impossible to counteract them. The result is an irritable condition of the uterus and of the whole sexual system. Other causes of this kind are the fitful, too frequent,and incom- plete performance of the sexual act, without regard to the menses,, or to the emotional state and desire of the female ; exercise, as in riding or walking while menstruating, or directly after the flow has ceased; getting up too soon after delivery, and especially after abortion ; too prolonged lactation ; frequent miscarriages ; the use of harsh or cold injections with a view to prevent concep- tion ; constipation, from paralysis of the rectum ; dancing, skating, 684 THE DISEASES OF WOMEN. horseback riding, blows and falls upon the spine ; excessive Oi constrained muscular effort, as in running the sewing-machine, prolonged standing upon the feet, or sitting in a confined posture at a desk ; prolapsus, retroversion or retroflexion of the uterus ; pressure of the bladder, of the bowels, of the ovaries, or of some pelvic or abdominal tumor against the womb ; spasmodic and me- chanical obstructions of the cervix uteri ; ulceration of the vagina •or vulva ; nymphomania ; vaginismus, and ovarian irritation. The uterus is generally exempt from this form of irritation until after puberty. Some of the most intractable and painful cases of irritable uterus that I have ever treated have occurred in those women who, having been married for several years, From an early abortion. -i-ii t have had no children. In many of them con- ception took place almost immediately after marriage, but for reasons which seemed to them to be justifiable at the time, and without any adequate idea of the harm involved, measures were taken to force the flow, and, in short, to bring en an abortion. These measures were successful. The uterus was emptied of its contents. But the indirect consequences remained to torture them, and to impair their health and happiness for years to come. I could tell you the story of more than one beautiful woman who has suffered with this trying disease, whose health has been ruined, who has remained childless, and who would give the world if, when she was the bride of a few weeks, she had not swallowed somebody's "never-failing pills," or taken the wretched advice of a neighbor in this respect. Another fertile source of this uterine irritability is the reckless cauterization of the cervix of which I have already spoken so fre- quently. There are certain subjects upon From escharotics. -it • i • • n r> i whose delicate organisms this species oi retmed cruelty reacts with a most damaging effect. And it is a singular fact that those physicians who resort to it habitually become blinded to these results and indifferent of the consequences. Let me cite you a case to which I was called yesterday : • Case. — Mrs. , an intelligent, active woman of twenty-two, of nervous temperament, mother of one child two years old, has not been well for six months. Her household cares, and the worry with servants, the heat of the weather, and having to entertain an IRRITABLE UTERUS. 685 avalanche of friends, had worn her down, and she was reduced in strength and spirits. She had no positive symptoms to complain of, excepting that she suffered from more frequent and severe at- tacks of sick headache (to which she was accustomed) than usual. For some weeks she tried to cure herself by means of domestic remedies from her own case, and finally by tonics of various kinds at the prescription of some of her friends. But her symptoms remained as before. She continued her household drudgery, did her own shopping and marketing, and, as usual, went to church and to Sabbath-school. Finally, through the advice of a neighbor, she consulted a lady ph}'sician, who cauterized the neck of the womb, and continued to do so twice each week, excepting the menstrual week, for six weeks. From the first application, she feh herself very much injured, and made worse ; but was advised to persevere, on the theory that, when she had once passed this purgatory, her feelings and experiences would be blissful enough. Each repetition of this cruelty unnerved her more and more. She could not sleep^ but walked the floor at night, lost her little remaining appetite, had cold, fainting spells, in which she would be unconscious for a long time ; she became discouraged and disheartened, melancholy, and, so her husband told me, practically insane for many hours after the caustic had been used. With this there developed a most tormenting strangury, and, after the second week, a corro- sive, itching leucorrhcea, although she had never had the slightest sign of either of these complaints before. At the end of the seventh week, after having had twelve of these " treatments," she deliberately came to the conclusion that her health would be utterly ruined should she persevere in this course. She therefore relinquished it, discharged her physician T and sent for me. Symptoms. — It would be quite impossible to give you all the symptoms of this curious disease in detail. In general the pain that is experienced is disproportionate to the Location of the pain. . uterine lesion. It vanes m its seat, and char- acter also. Usually it is located somewhere in the lower part of the back, or within or near the pelvis ; but very often it is situated in the head, the spine, the chest, or the abdomen. The pains are transient, paroxysmal and neuralgic, being for the most part, unaccompanied by any profound or peculiar constitutional dis- turbance. They are greatly influenced by emotional states, being either aggravated or relieved by certain conditions of the mind. Posture modifies the recurrence and severity of the paroxysms. 686 THE DISEASES OF WOMEN. Most women who have an irritable uterus find it difficult to main- tain an upright position for any considerable Effect of posture and of length of time. They can not stand or sit more motion. o J than a few minutes without great suffering, and going up and down stairs is almost impossible for them. Often the reclining posture is the only one that can be tolerated. They may have a mortal dread of defecation and of urination, either of which is apt to be followed by extreme pain, exhaustion or faint- ness. Sometimes there is an irresistible desire to pass water, especially when she lies down ; again the urging to stool is equally tormenting whenever she sits up. And still the urine may be unchanged in quality, and the bowels remain costive. To these symptoms we must add those which simulate certain local disorders, as in the mimicry of Hysteria. The most common of these are dyspnoea, aphonia, palpitation of* €a ^ s ay sImulate other dis - the heart, angina pectoris, pleurisy, neuralgic pains in, and swelling of the breasts, especially before or during menstruation, ovarian aching and irritation, headache, facial and orbital neuralgia, gastrodynia, dyspepsia, chronic vomiting, depression of spirits, monomania, numbness of the extremities, muscular paralysis, and stiffness and uselessness of the joints. The nervous symptoms include insomnia, flatulent distention of the abdomen, dejection of spirits, emotional distress, great fluctu- ation of the feelings, sourness or suspiciousness Nervous symptoms. " . . oi temper, loss ox seli-control, lassitude, indif- ference, hypochondria, extreme sensitiveness to ridicule or to reproach, fickleness, jactitation, unrest, local or general spasms, tremors, partial paralysis, and circumscribed alterations in the temperature of the part affected. Of course these symptoms are not all present in every case of irritable uterus, but for every one of them that is lacking, you may find that ten or twenty others have been cio S u y s mptoms may be capri " acLclecl - I n brief, the symptoms are subject to the same variations, and are many of them as inexplicable as they are in hysteria, to which disease this affection is so closely allied. They are generally aggravated at the month, and are largely influenced by the state of the patient's emotions. She may be suffering severely, for example, with a pain which IRRITABLE UTERUS. 687 alarms her family and makes her seriously ill. A friend calls to invite her to a drive, or a visit, and forthwith the symptoms van- ish. The family are horrified at her going out so soon ; and the doctor, who left her an hour before at home, may meet her miles away on a mission of mercy or of pleasure. Such a patient, who can not sit upright in her chair for five minutes consecutively, will sometimes get into her carriage, and r in a half-reclining posture, ride by the hour, or Contradictory nature of. . all the day long, without the least sign of fatigue or suffering. Or she will manage the affairs of her household, of the church, or of some charitable enterprise, with all the exec- utive ability of one who is well and able to withstand any amount of fatigue. And yet, in so far as the mastery of her own move- ments is concerned, she may be as helpless as an infant. An examination per vaginam, as in the case of Mrs. J., reveals a more or less sensitive condition of the womb. The cervix is tender to the touch, and if you push the organ Physical examination. -. , . . . . , toward the superior strait it pains the patient •exceedingly. In some cases the pain upon pressure is limited to. a small spot. The most delicate manipulation with a view to intro- duce the sound or the speculum occasions more of suffering than usual. Sometimes the uterus feels swollen and slightly enlarged. Occasionally it is more or less prolapsed, and in very rare instances it is either retroflexed or retroverted. Diagnosis. — This disease is sometimes confounded with coccy- odynia. But, in coccyodynia, whether from an injury sustained dur- ing labor, or from a fall or a blow, the patient From coccyodynia. . . . can not sit down squarely, or rise again without immediate and most excruciating pain, which is always referred to the point of the coccyx. In irritable uterus the pain is not always so limited, and she can usually sit from five to fifteen min- utes before the pain and the ill feeling come on. In the former the reclining posture is as painful as the upright one in sitting ; but not so in the latter. In the former there is likely to be a great increase of the neuralgic pain while at stool, and pressure with the finger in any direction induces a local paroxysm ; in the irritable uterus the suffering at stool is such as usually attends a consti- pated state of the bowels, and pressure upon the coccyx does not cause any very distinctive or extreme pain. 68& THE DISEASES OF WOMEN. You would differentiate this affection from organic diseases of the womb by the absence of such discharges as are produced in uterine ulceration, and leucorrhcea. It need D F s r m?norfhSa disease ' _ not be confounded with dysmenorrhea, for in irritable uterus, although it is apt to be worse at the month, the pain recurs without any regard to menstruation,, and often continues from one month to another. Treatment. — Whatever predisposition the patient may have inherited or acquired should, if possible, be removed, in order that the proper remedies may work more effi- Remove the cause. . •tit ciently. bo also of the avoidable causes, pro- viding you can determine what they are, which in some cases is extremely difficult. To fulfil these indications may require much time and an infinite deal of tact, but, if you have the full confi- dence of your patient, and are sufficiently persevering, you will succeed in making life tolerable to her, if not in performing a rad- ical cure. In general you should remember that this class of patients are weak, debilitated, and badly nourished. If they take a sufficient quantity of food, it does not build them up as it stSngfh up the general should. Their vital force is low, and their strength is below par. They are too prone to depend for subsistence upon tea and toast, and crackers, and various little delica- cies which can not sustain them properly. They are very apt to loathe meat of all kinds, milk and all varieties of animal food r and from their habits in this regard to develop a species of neu- ralgic dyscrasia, which frequently underlies and may even cause the worst form of hysteralgia. The first thing to be done for such patients is to fortify their general strength and vigor by stimulating their digestion, and supplying them with the proper aliment. In- The mode and time of s t e ad of mincing their meals and eating under eating. <=> <=> protest in their rooms, apart from the family and alone, they should be brought to the table with others and tempted to eat more freely of good, substantial food. Let them " follow copy," as the printers say, and imitate those who have better appetites. The fresh air and sunlight are indispensable ; but the amount, and variety of exercise to be taken must depend upon the patient's IRRITABLE UTERUS. 689 original strength, and the peculiar complications and history of the case. The more marked the hysterical tendency, Fresh air and exercise. 1 _ " ' the greater the need of will on her part, and determination to overcome the physical obstacles that lie in her path. Some of these patients need almost to be put out of doors before they will make the necessary effort to walk or ride, and thus learn for themselves that locomotion is among the possibilities. But it will not do to insist that all are alike in this respect. For, on the contrary, some of them will go too much and too far. They overdo in this direction, and need to be re- varying ability to take strained. And others are absolutely too weak exercise. J and too ill to take active exercise, regardless of its cost or consequences. The best rule with which I am acquaint- ed is to observe carefully how each one is influenced by the effort of going to ride or to walk, and thus to learn what she can bear and take within the limits of actual fatigue. She may be able to ride three squares not only with impunity, but with decided bene- fit, when to add one more square to the length of the drive would do her a positive injury. Long journeys are more tolerable for this class of our patients than they were before the days of the sleeping-car, but notwithstanding this improvement, many are yet injured by travel on the railways. When it is possible, and con- venient, it is best for them to journey by water. You will have so much trouble in regulating the habits of some of these patients in many particulars, that I am tempted to let you into a little secret which may help you to carry A practical hint. . J l J j your point, and to adapt your counsel to the end in view. First, make up your mind deliberately what prac- tice, or habit, or influence it is that lies in the way of their re- covery. Then set to work to reform or to remove that custom or influence, whatever it may be, by gaining the entire and willing assent of the patient herself. These indications cannot always, or perhaps frequently, be met in an off-hand or intuitive manner. They require the exercise of thought and of tact. And unless you can secure her confidence and co-operation, you certainly will not succeed. It may need a large measure of skill and of perseverance to bring it about, but you will learn that the art consists in hav- ing your own way, while she is under the impression that she has hers also. 6*K) THE DISEASES OF WOMEN. A very common error in the treatment of the irritable uterus is to suppose that uterine surgery, as it is technically styled, and ordinarily practiced, will help to cure it. For Surgery contra-indicated. ^ *- the. truth is that, in this class of cases, it does more harm than good. There is not a single operation, or expe- dient of this kind, that is advisable in an uncomplicated case of hysteralgia. Caustics, the knife, the sponge-tent, the bistourie cachee, the sound, the probe, and pessaries of whatever variety, are so many instruments of torture. They invariably aggravate the disease. It is only when some of the incidental conditions that require such aid are superadded to the irritable condition of the uterus itself that the intelligent physician employs them in this disease at all. For the relief of the spinal, sacral and pelvic pains various topical applications are permissible and useful, the same as in other forms of neuralgia. Bathing the back Topical expedients. . with salt-water, dry frictions along the spine from above downwards, hot or cold water locally, the shower bath, pediluvia, wearing a thick layer of cotton batting along the back, the wearing of silk undervests and wrappers to insulate and protect the person against sudden electrical changes, paint- ing the painful part with the oleaginous collodion, dry cupping, porous plasters, arnica plasters, magnetism, electricity, galvanic belts and plates, and the use of bland and soothing injections per vaginam are the most common and useful of these expedients. I once called an old physician in counsel in a case of diphtheria. We had agreed upon the internal remedies, when my friend sug- gested that something, and the simpler the Why we should use them. better, should be prescribed lor external use, chiefly in order to keep the nurse and watchers busy with that which would do no positive harm, even if it did but very little good; for, said he, you know that "Satan finds some mischief still for idle hands to do." Acting upon this principle, and remembering the propensity of human nature to overdo in the matter of nursing especially, you had better advise some simple expedient that will "keep the nurse and watchers busy," rather than let them " fly to evils that they know not of." It is unnecessary to repeat what I have already said of the? IRRITABLE UTERUS. 691 choice of remedies when speaking of the treatment of hysteria. There is no specific for the relief and cure of No specific treatment. . the irritable uterus. 11 the proper conditions are supplied and secured, medicines will achieve the most marked results. Otherwise they are powerless. The symptoms are so complicated, and oftentimes so contradictory, that you will find it very difficult to choose the most appropriate remedy. It is very probable that among the newer remedies, which of late have attracted so much attention, we may yet find a more ready means of cure for the various nervous The new remedies in. •<••-!■ disorders which are symptomatic of uterine dis- ease and irritation. For myself, I have come to place a deal of confidence in macrotin, gelseminum, caulophyllin, the lilium tigri- num, and senecin. Other members of this class are Scutellaria, ambra grisea, cypripedium and veratrum viride. But the old polychrests should not be forgotten. Mrs. J. will take a dose of macrotin three times daily, and have electricity applied along the spine twice per week — every Tues- day and Friday evening. I think it best in Prescription. i • • i i i ' i i • these cases that electricity should be used in the evening rather than in the morning or the early part of the day. She must also play the part of a good Christian philoso- pher, and not let her little domestic cares and trials fret and worry her too much. LECTURE XLII. UTERINE CANCER. Carcinoma uteri. General observations. Varieties. Causes. The subjective symptoms-.. The physical signs. Diagnosis. Course and duration. Case.— The cancerous Cachexia Prognosis. Treatment, local, medical and surgicl. General observations. — The term cancer is applied to malignant disease of the womb, and a peculiar interest attaches to its clinical history. Without entering into a discussion of the histology of carcinoma, it is enough to say that in all of its forms it is a fear- fully fatal disorder, and that its essential nature as well as its treatment are not fully understood. Varieties. — For practical purposes we recognize three forms of this disease: (1) the fibrous, or scirrhous, (2) the medullary, or the encephaloid, (3) the epithelial, or the cancroid form. The first, or the scirrhous variety is known among authors as the chronic form of the disease, and one in which the uterine tissue becomes hard, of a white or greyish white color, with such an absence of moist- ure as causes it to creak when it is cut with the scalpel. In the encephaloid cancer the surface is of a pinkish white, or rose color, with a caseous consistence, like that of the cerebral mass. The epithelial form is fungous or vegetating, with a tendency to ulceration. Most authors treat of two general varieties of uterine cancer, viz. that of the body of the organ, and that of the cervix, but they are essentially the same. Causes. — The most powerful predisposing cause is heredity. Age comes next, for it is most frequent at and after the meno- pause. Rapid child-bearing, and frequent abortions, especially if they have been induced artificially; chronic menstrual irregu- larities ; sexual excess, particularly in those who have borne chil- dren; and the immoral influence of city life belong to the same class of causes. It is very doubtful if any exciting cause could produce this disease independently of the cancerous dyscrasia. Symptoms. — There is no proper order for the advent of the UTERINE CANCER. 693 symptoms; in fact they have usually existed for a considerable time before we are consulted. Perhaps the most constant of all the symptoms in every variety of this disease is the haemorrhage, and yet it is not present in every case. The form which it assumes, especially in the early stao-e of cancer, is that of menorrhaffia. But farther on the flow is more copious, or long-continued, and recurs without regard to the month. Generally, the nearer the approach to the climacteric the greater the amount of blood lost by this recurring haemorrhage, which, when the interval is prolonged, is sometimes mistaken for a continuance of menstruation. This haemorrhage in uterine cancer may anticipate the pain and the peculiar leucorrhceal discharges Avhich almost always accompany the disease. In advanced cases it is characteristic of this flow that it is caused or increased by the slightest movement; by mental excitement; by local irritation as from the contact of the finger, the use of a syringe, coitus, couching, or straining at stool; by the most care- ful introduction of the speculum or the sound, by lying upon one hip or the other, or by standing or stooping. The quality of the blood that is lost depends upon its excess and the duration of the disease. As the cancerous cachexia is more fully developed it becomes thin, mixed with a sanious pus and with the debris of the uterine tissue. The leucorrhceal discharge that accompanies the different forms of cancer, is sooner or later of a watery character, and peculiarly offensive. If the patient has been subject to leu- disc h h e ar^?° rrhCeal corrhcea, she is apt to make very little account of it, and you may be the first to suspect its connec- tion with a malignant disease. But you are not to suppose that because she has a fetid and watery discharge, therefore she must have uterine cancer ; for this quality of leucorrhoea may arise from the presence of a polypus or of a sub-mucous fibroid. In the early stage of epithelioma the odor is not offensive, but when it changes into the medullary form it becomes very much so. (Fig. 114.) If a thin, acrid, and fetid leucorrhoea follows or alternates with an alarming haemorrhage, with a greenish yellow, a brownish, or a chocolate colored discharge, the chances are that the flow is of a cancerous origin. The odor of the flow which is characteristic, is 694 THE DISEASES OF WOMEN. sometimes so bad as to render the patient an object of pity,, and even of loathing to herself. Some authors have claimed that the contact of this ichorous discharge has not only caused a pronounced vaginitis, with more or less erosion, but also an increase of sexual desire. I believe this is a mistake. The quality and the degree of pain vary in different cases accord- ing to the seat and the extent of the lesion and the duration and the severity of the disease. Sometimes it is lacking altogether; again it does not appear until the affection is far advanced; and still again it may ccme at intervals The pain. Fig. 114. A sloughing epithelioma (Sims). and then disappear for a time. Its caprices in this regard, and the possibility that it may not be present are sources of deception, not only to the patient but also to the physician. As a rule the mucous forms of cancer are the least painful ; while those which involve the peritoneal coat of the womb are most so. The location of this pain is not always directly over the body of the organ, but on account of the infiltration of the cellular tissue in the broad ligament, it is very apt to be seated in one of the sides of the pelvis. If the infiltration has taken place around the cervix, as in pelvic peritonitis, the uterus will not only be anchored firmly, but the pain will be of such a character as to be aggravated by motion, the position of the body, and by the various causes already given. UTERINE CANCER. 695 As the disease extends and encroaches upon other organs, the intra-pelvic pain and distress becomes more severe and constant; the lancinating pains give place to a dead, dull, heavy aching, with dragging sensations that torture the patient exceedingly. Horrible suffering is sometimes induced by the invasion of the bladder, and in other cases by its attacking the sacral nerves. Under these circumstances there is no rest and no comfort ; the patient cannot sleep, or eat, and is borne down in spirit by the knowledge and the thought that she will surely be a martyr to this disease. The reflex symptoms of uterine cancer are not distinctive; nevertheless the patient often complains of neuralgia, and ot radiating- pains in one or both of the mammary rii Hp rsflsx symptoms. glands, in the intercostal spaces, in the face, and in the upper extremities. The touch, either combined or singly, is of especial value in each of the varieties of cancer. The sensation imparted to the finger will vary with the location of the tumor, Physical signs of. . °. .... ., -, . . . , , its size, its texture, its age and period of develop- ment. Its sensibility, its immobility, the ease with which it is made to bleed, and the odor of the discharge upon the finger after direct palpation. In cancer of the womb especially, the touch will indicate the degree of phagedenic ulceration, the friability of the granulations, the extent to which the tissues have been destroyed, and the encroachment of the lesion upon the neighbor- ing structures. On account of the pain and the haemorrhage, that are induced by the most careful employment of the speculum, it sometimes happens that the physical examination of uterine cancer is limited to the touch. When it is practicable the speculum maybe used to confirm the signs that have been revealed by the finger. But it is only in the case of limited, or incipient cancerous ulceration, or of cancroid growths upon the cervix that we shall find what is distinctive in the field of the instrument. The irregular, fungous, or bleeding surface, which is of a greenish or brownish color, the tumefaction, and deformity of the cervix, and the quality of the discharge are included in these symptoms. In examining a case of this kind, it is of no use to employ a Ferguson's speculum ; and if you pass a duck-bill speculum, you 696 THE DISEASES OF WOMEN. should be very careful in separating its blades not to induce an attack of metrorrhagia by wounding the ulcer- Jhe proper speculum ated gurface . ^ in ^ the diseage hag inyolved the vaginal walls, to create an opening into the bladder or the rectum. Sometimes a Sims' speculum, if care- fully applied, will do best ; but now and then you may expose the cervix most thoroughly and successfully by putting the patient in the Sims' position and separating the labia very widely with the fingers. I have known great harm to be done by the introduction of the sound in some of these cases. Besides the pain and the haemor- rhage that are likely to be induced, there is danger, when the tissues are devitalized, that it may pass into the peritoneal cavity. Diagnosis. — It is only in the first stage of the disease that the different varieties of uterine cancer are difficult of recognition. Fortunately it is most frequently located in the vaginal portion of the cervix, which is readily accessible to phys- In the early stage. . . . _ L icaJ exploration. 11 you are careful to remember and apply what I have said of the haemorrhage, the leucorrhceal flow, the character of the pain, and the constitutional symptoms, yon will not give a wrong diagnosis. In cervical hyperplasia, or corporeal cervicitis, the use of the sponge-tent, according to Speigelberg, dilates ^From corporeal cervi- the part and c ii st i llg ui s hes the lesion from the fibrous, or scirrhous cancer of the cervix, upon which it would fail to make an impression. An intra-uterine fibroid might be attended with copious watery discharges that were offensive and bloody, but the sound and the conjoined manipulation would detect a tumor Prom uterine fibroids. . , T , , ~. . , , in utero. Moreover the larger size fibroids and polypi are almost never attached to the uterine cervix. The same rule applies to fibrous polypi, which as a class, have a disposition to appear at the internal os uteri, and then to recede; which are not sensitive when a needle is thrust From uterine polypi. . . . . into them ; which increase m size at the month, and which occasion expulsive pains like those of labor. There is however, a condition of degeneration of these fibrous growths which is styled sarcomatous, in which if the tumor sloughs away. UTERINE CANCER. 697 or is removed, it grows again. These are the recurrent fibroids which are believed to be cancerous in their nature. So that, while in general we may say that a woman who has a uterine fibroid is in no danger of dying from cancer, we should be careful to qualify our diagnosis and prognosis in the case of these sarcoma- tous polypi. In very rare cases syphilitic ulceration may destroy the uterine cervix, and eat its way through the rectal or the vesical septum, as the cancerous ulcer is prone to do. But the uicer^ion PhllltlC varying constitutional symptoms, and the clini- cal history of the case will enable us to discrim- inate between them. Course and duration. — Although uterine cancer is a self-limited affection which, sooner or later, ends fatally, its course and duration are not constant. It may creep on insidiously, and continue for years without very serious impairment of the general health; or it may develop rapidly and run its course in a very few weeks or months. In all cases very much depends upon the period at which the ulcerative stage begins, the ability of the tissues to resist its inroads, the integrity of the general health and absorption of septic matters from the decomposing tissues and fluids. The rapidity of its course is shown in the following case, for the notes of which I am indebted to the husband of the patient, Dr. P. B. Hoyt, late of Paris, Illinois: Case. — I positively know that there was no local manifestation of the disease in the case ot Mrs. H , as late as the first of June, 1879. On the 20th of August, at her regular monthly period, she was taken with severe haemorrhage, which continued with more or less severity until about the 20th of November. The character ot the haemorrhage and of the other symptoms led us to believe, that she was passing through the climacteric period, and therefore created no apprehensions. The remedies, ipecac, hamamelis, and more particularly secale €ornutum and sabina, controlled the haemorrhage so well, that we w r ere certain she would come through all right, nor did the haemorrhage present any unusual appearance until about the middle of October, when she passed a number of very dark clots, attended with considerable pain in the back, and running down the left thigh. Sometimes these pains were very distressing but Pulsatilla, and gelsemium, relieved her. Some days she passed as many as from twenty to forty of these clots. There were strong contractions of the womb which caused the most excruciating 698 THE DISEASES OF WOMEN. pains. On the 18th of Nov. she Avas suddenly taken with bearing down sensations attended with shooting, stitching, burning pains, which she compared to hot needles run up into the abdomen, causing her to bend forward, and support the abdomen with both hands. She laid down at once", and I gave her a dose of bella- donna 3. This entirely relieved the pain, Ave had visitors during the evening, and she Avas happy and cheerful as usual, she retired about 10.30 p. m., and slept quietly all night. The next day about 9.30 a. m., she Avas dusting the parlor, I was sitting in my office across the hall, and the doors were open, when suddenly I heard her cry out ; I sprang to my feet, ran into the room, and asked, " What is 1>he matter?" Her answer Avas " those same pains that I had yesterday, have come again, only ten times Avorse." I assisted her to the lounge, and at once gave belladonna as before, but this time it did not control the pains. It Avas several hours before she became even comparatively easy. Suspecting something serious I proposed an examination, but the opportunity did not offer until bed-time. On introducing the finger, I Avas never more surprised. The os-uteri Avas indurated, and enlarged, until it was at least tAvo and a half inches in diam- eter, and it and the Avhole cervix Avas covered with nodules, like little warts. After carefully noting her symptoms, I commenced treatment with calcarea carb. every tAvo hours, washing the parts Avith hot calendula water, and at night applied a cotton tampon, satu- rated Avith glycerine. My idea Avas, that if it Avas not purely of a cancerous character, the glycerine Avould reduce the induration,, but it tailed to accomplish this. I used at various times, as seemed best indicated, arsenicum alb., and arsenicum jodatus, silicea, and conium maculatum. I continued to apply glycerine medicated with the tincture of calendula, but to no purpose. Dec. 31st, 1879, we visited Cincinnati and consulted Drs. Hartshorn and Wilson. Dr. Hartshorn's diagnosis Avas " probably cancer." He recommended an application of chemically pure nitric acid, and to give internally, arsenicum jodatus, conium, thuja, or any remedy which seemed best indicated from time to time. The nitric acid treatment I did not approve of, because I felt sure that such strong applications would only aggravate the dif- ficulty. At Mrs. Hoyt's earnest request I did make one applica- cation, under protest, hoAvever, and the result confirmed my judg- ment and was not repeated. I iioav at the request of Dr. I. R. Haynes gave her juglans cinerea 6, internally, and applied glycerine medicated Avith the tincture of the juglans locally. This caused an increase of the profuse Avatery discharge from the vagina ^ After using it tAvo or three days I made an examination, and to> my delight found all the nodules gone. UTERINE CANCER. 699 Two weeks previous to this we had visited Chicago, to consult Dr. Ludlam, who made a careful examination, and gave me his valuable advice for which I shall ever feel grateful, but his prog- nosis was decidedly unfavorable. When I found the nodules had disappeared, and Dr. Haynes having assured me that he had cured one case, and benefitted several others, I felt a little hope that his prognosis might prove untrue. But I soon found that the indura- tion had not subsided in the least, and that the ulcer was increas- ing in size and depth, and the parts were very tender to the touch* with a continual bearing-down pain. Indeed there was a decided prolapsus. At this time, the hips, back, thighs, and abdomen were very painful and tender, and the left thigh near the groin was much swollen. I now used the extract of hamamelis very freely, which mitigated the pain. A severe peritonitis now set in, whicu came near terminating her life, but by the local application of linseed- meal poultices, with the use of belladonna and aconite internally, we succeeded in reducing the inflammation, and she seemed better. There was, however, a great accumulation of fluid in the abdomen, which finally degenerated into pus, and was discharged per rectum the night before her death. After the peritonitis had subsided, we found the left ovary enlarged and very sensitive, and this condition continued until she died. Her strength now failed, and I could see that she was sinking rapidly. About five days before her death, she began to vomit, and no remedy was found to control it. The substance ejected was of a dark <4Teen color, almost black, and of an incliscribable odor. Towards the last, nothing was retained on the stomach for more than five or ten "dilutes, and finally after taking three or four spoonfuls of tea, she began to vomit worse than ever, and so rapidly that she could not raise it, and choked to death, at eight o'clock a. m., March 25, 1880. When the course of this disease is rapid it may carry the patient off before the symptoms that attend upon chronic cases have developed themselves. But when it has con- cachex C ia nCer0U8 tinued for months or years, and h is extended to the neighboring organs, with ulceration and sloughing, fetid and ichorous discharges, severe hagt.-iorrhage and intolerable suffering, the nutritive functions become impaired, there follows a species of slow poisoning, and the development of what is termed the cancerous cachexia. This cachexia is recognized \>y a peculiar earthy, or waxy, or tallow complexion of the skin, n ith a tendency to dropsical infiltration of the integument. 700 THE DISEASES OF WOMEN. You must be careful however, not to confound it with copraemia, which is a form of blood poisoning that depends upon the reten- tion and absorption of faecal elements from the « Th ! «T^ mi t and intestine, and which produces a sallow, dirty, cancerous complexion. ' i ' J > hue, with unpleasant exhalations from the skin. I have known a prominent surgeon to pronounce a case as one of undoubted cancer, when the tumor and the peculiar complexion of the patient depended upon a lage accumulation of faecal matter. The case was afterwards cured by rectal injection thai softened the mass and brought it away. In some cases the final result is hastened by the occurrence of pregnancy, or rather by labor or abortion. If the induration of the cervical zone of the uterus is very marked nanc^anriaborupoT 11 ma y interfere with delivery, or resulting lacerations may cause a serio'is haemorrhage, or facilitate a fatal sepsis, It has even happened that, under these circumstances, the entire cervix has been torn oft* during labor. Prognosis. — The most that can be hoped for in any c se is that the course of the disease may be stayed and its inevitable result postponed. For, even where the lesion is most decidedly local, and we remove it, the disposition to a recurrence is a characteristic and constant symptom. So that, whether the constitution is primarily or secondarily implicated, the result is the same. Cases of spontaneous recovery that have been reported, are exceptions to the rule, and are not likely to be multiplied in your field of observation. Cases that have been reported as cured by this or that remedy are not authentic. It sometimes happens that a woman whose mother or sister may have died from cancer of the womb, or of the breast, has such a dread of this disease that we must not declare Carcinophobia. ... .. . , . our diagnosis too early, or too decidedly, bor a lack of cave in this regard may develop the form of mania that Dr. Thomas styles carcinophobia, or a dread of dying from this terrible disease. On the contrary, but under the s*»me circumstances with respect to heredity, a woman's mental and neivous condition may be such that she will not be satisfied unless you tell her she has cancer of the womb. It is not a fortnight since I was dis- charged from such a case because I could not find any trace of carcinoma, and had the conscience to say so. UTERINE CANCER. 701 Many of you saw upon my table recently the case of a poor shop woman who had been under treatment for uterine cancer by a thief in the disguise of a doctor. Out of her Case. scanty earnings she had paid the scamp two dol- lars for each local application, which was repeated twice in each and every week, for more than a year. And yel, as you will witness, there was not a trace of cancer to be found anywheie. One mode of death from uterine carcinoma is shown in the case that I have just cited. Others die from fatty degeneration of the heart, from the supervention of cellulitis, septic Causes of death from. . „ . . , , , . J# , , , :, . infection, uraemia, phlebitis, and lymphangitis, with plegmatia alba dolens, and others still from inanition with marasmus. Treatment. — In the local treatment of this form of cancer you should not forget that the affected organ is strangely intolerant of irritants. Indeed, it is a serious nuestion whether the use of astringents, caustics, and stimulating washes, in cases where there was a suspicion ol malignant disease of the cervix, has not really developed it. I have no doubt that the use of these harsh means has often hastened, if not really induced these morbid growths, and it is not impossible that the radical change in uterine thera- peutics, which promises to put an end to the indiscriminate cauter- ization of the cervix, and to treat its diseases more rationally, will lessen the proportion of cases ol cancroid degeneration, and per- haps of other forms of uterine cancer. Whether Dr. Emmets' idea, that laceration of the cervix uteri, from being neglected is often the cause of epithelioma, and per- T .. „ +u haps of other varielies of cancer, is true or not, Laceration ot the ... . . . cervix, and uterine if this method of treating these lacerations is generally adopted, the uterus will soon be exempted from injuries that have been inflicted blindly, and with- out regard to their ultimate effects. If " prevention is better than cure," and his discovery really diminishes the proportion of cases of this terrible disease, Dr. Emmet will have builded better than he knew. The objects to be met by local treatment in Indications for local j j L ±. / 1 \ j. treatment. advanced cases of uterine cancer are, (1) to relieve the intra-pelvic pain, (2) to control the hemorrhage, and (3) to disinfect the discharges. 702 THE DISEASES OF WOMEN. The best means of filling the two first of these indications is the resort to hot water vaginal injections. In very bad cases, how- ever, where the pain is chronic and insufferable, suppositories of opium or some other anodyne may be required. Iodoform mixed with almond oil, or with laid, one drachm to the ounce, may be applied by means ot a cotton tampon ; or a mixture of chloroform, glycerine, and sweet oil may be used in the same way. Occasion- ally we may take advantage of the anaesthetic properties of very cold applications, and Aran's expedient of passing a cylindrical speculum and filling it with broken ice may relieve the pain more promptly and decidedly than anything else. Local anaesthesia by the ether- spray, or the use of the styptic colloid with which mor- phia has been mixed, may do best. In some cases both the pain and the haemorrhage may be con- trolled by the local employment of hamamelis; and the styptic cotton is an expedient that is worth remembering in this connec- tion. Rest, during menstruation especially, and sexual abstinence will often prevent severe paroxysms of pain and of flooding ; and care as to the kind and degree of exercise that is taken will have the same effect. To overcome the fetor of the discharges, various means are in vogue, and you may need to try them all. Acetic acid, lemon juice, carbolic acid, pyroligneous acid, the chloride of lime, the sulphite of soda, thymol, bromine, iodoform, the perchloride of iron, the chlorinate of soda, or a weak solution of the iodide ot lead. Glycerine is an excellent anti-septic and will readily mix with most of these substances as a vehicle. It is very important to keep the parts clean, and for this purpose a little powdered alum, a few drops of creosote, or of a weak solution of the chlorate of potassa may be put into the water with which the vagina is syringed. This precaution not only keeps the parts clean, but it prevents infection from putrid absorption. I will not detain you with any extended remarks upon the medical treatment of this disease. For, although it is not unusual to find reports of cures that are claimed for iri- The medical treat- t x remedies t believe that such a result has meat. ' never really been accomplished. As you may suppose, the lesion being seated in an organ with a wide range of sympathies, and with functions that are peculiar, and the tendency UTERINE CANCER. 703 of the disease being- always to involve other organs, and finally to implicate the whole economy, a great variety of indications may be presented, and a large number of remedies called for. When these indications present themselves you will affiliate the remedy, or remedies, to the case in point, as nearly as possible. There are a few remedies, however, which seem possessed of a clinical, if not of a curative relation to the cancerous diathesis. These are arsenicum jodatus, hydrastis can., conium, juglans cin., platina, phytolacca, kreosotum, and cod liver oil, it it can be called a remedy. Their use is very important, not only because they modify the dyscrasia, and thus prevent the more rapid develop- ment of the disease, but also because they may postpone its recurrence, when surgical means have been resorted to. As I shall tell you when I come to speak of epithelioma of the uterus (see Lecture XLIII), there seems good reason to place reliance upon the arsenicum jodatus especially. Here is a case in point: Case. — Mrs. W. , aged 45, a hospital patient, gave the following history; she is a widow, but has had no children, and no miscarriages. Her menses ceased five years ago. She inherits the cancerous diathesis, and is positive that a sister died of cancer of the womb. She dates her illness from an injury which occurred twenty-five years ago. While lifting a heavy weight she felt something give way within the lower abdomen. This sensation was accompanied by a report, or " snapping," and she insists that she has not felt comfortably for an hour since that time. She has had a more or less constant discharge from the uterus and the vagina, which is of a very offensive and corrosive character, and the internal genital organs are the seat of a burning pain, with extreme and almost insufferable tenderness to the touch. Since the menses ceased she has never had any haemorrhages. The abdomen is very sensitive, and after severe attacks of pain in the uterine region she sometimes passes a gill or more of pus, from the vagina. The stomach and abdomen are so tender and sore, that the weight of her own hand causes great pain when placed upon them. Sometimes these symptoms almost entirely disappear and the suffering is transferred to the mouth, the throat and the stomach. Again, she has a terrible burning, itching, and crawling sensation over the whole body, as if needles were sticking into every pore of the skin. Then red bunches, which vary from the size of a grain of wheat, to that of an e^g, and which also burn and itch severely are formed here and there. Before entering the hospital she had been under the treatment 704 THE DISEASES OF WOMEN. of various physicians, chiefly for uterine catarrh and ulceration. She has worn pessaries and medicated cotton, and has been cauterized very severely for months together. She says that, on one occasion after the cotton had been applied as a means of in- troducing some very severe agent, its removal brought away the lining membrane of the vagina, and not in strips or shreds, but li the whole of it together." Local examination with the speculum revealed a high state of inflammation of the vaginal portion of the cervix. The posterior lip of the os uteri was the seat of a ragged looking and very vascu- lar ulceration, the anterior lip was knobby, swollen, and irregu- lar. By the touch the cervix was found to be fixed and immov- able, and very great distress followed the introduction of the finger into the Douglas pouch. The vagina was very narrow and exceedingly sensitive, although its w^alls were indurated, even down to the vulva. This condition had rendered it impossible to pass any but the smallest speculum. This woman remained in the hospital for three months under treatment, which consisted of the local use of the carbolized cosmo- tine (applied without the speculum) and internally, arsenicum, jodatus, in second decimal trituration, she also took lachesis 30, a few times. At the end ol that time her health was so much im- proved, that she went to the country where she remained for a year. Then she came back to the Hospital in much the same con- dition. But several months of careful treatment and-nursing was ineffectual in staying the progress of the disease. Feb. 10, 1881. Another year has passed, and her general health is improved, but locally the colpitis and the vaginal induration are no better. The cervix uteri which is nearly gone, is ulcer- ated, tunneled, and excavated, with hard margins and extreme tenderness, the old feted ichorous discharge has not lessened in quantity or improved in quality. She has found more benefit from the internal use of arsenicum jodatus 3, than any other remedy, and is satisfied that, without it, she must have died long ago. The question of surgical interference, whether by the excision of the diseased part, or the extirpation of the The surgieai treat- u t erus re vives the old idea that in some forms ment. ' of cancer, the disease is local before it becomes general, or constitutional. If the structural change is limited to the vaginal portion of the cervix, and to the lining membrane of the os and cervix uteri, and there are no evidences of a dys- crasia, it may be expedient either to amputate the cervix, or to remove the diseased mass by Sims' method, which I shall describe in my next lecture. UTERINE CANCER, 705 The operation for the total extirpation of the uterus in malig- nant disease is a very serious one, and should Extirpation of the not be imc i orta ken in ordinary eases. Its risks uterus in. > J are fearful, and thus lar at least, the results scarcely warrant its performance. The difficulties in the way do not concern the operation itself, so much as the impossibility in a given case, of knowing* that the disease is primitive and purely local, and of deciding that it is limited to the uterus. For, it the constitution is involved and the cachexia is already established, or if the infiltration has invaded the broad ligaments, the pelvic cellular tissue, the peritoneum, the rectum, the bladder, or the glandular structures, its recurrence is inevitable. The whole issue hinges therefore, upon the strict localization of the lesion in the uterus. If you are satisfied upon this point, the way is clear for the resort to hysterotomy, or more properly, to hys- terectomy. You should be careful not to confound the question of ablating the uterus in carcinoma, with its removal in the case of an interstitial, or of a sub-peritoneal fibroid. " The first extirpation of the carcinomatous uterus was made by Andreas a Cruce, in 1650. In 1812, Gutberlet operated through die abdominal walls. Langenbeck and Delpech operated by this method, the latter successfully. Langenbeck and Sauter in 1822 operated through the vagina. Sai iter's operation was successful. [n 1828 Blundell operated successfully per vaginani. Kecamier, in L82y, modified the operation per vaginam by ligature en masse of die lower part of the broad ligament by means of a curved needle. Delpech, in 1830, proposed a combination of the vaginal and abdominal extirpation. In 1876, Hering operated successfully without ligating the broad ligaments. Freund's operation, 1877, differs from all previous operations. He was the first to close the wound from the vagina into the abdominal cavity by sutures." Freund's method of hysterectomy is partly abdominal and partly vaginal. An incision is first made along the Freund's operation. ^ . . ° Imea alba, as in ovariotomy, but care is taken that its inferior extremity does not extend so far through the peritoneum as it does through the integument. The object of this precaution is to avoid the separation of the peritoneum from the anterior wall of the pelvis. The body of the uterus is then seized and held securely by the fenestrated ovariotomy forceps. The ovarian ligaments and the Fallopian tubes are next ligated, but in order that one thread shall be on each side of the uterine 706 THE DISEASES OF WOMEN. artery, for its ligation when necessary, one end of each ligature is brought out through the abdominal wound and held, while the other end drops toward, and finally into the vagina. A trocar needle is then passed from the peritoneal cavity to the vagina and back again on each side of the broad ligament. This ligature, which does not include the Fallopian tubes, the ovarian liga^ ments, or the round ligaments, enters the vagina and emerges from it so as to include very little of its tissue; after which it is tied, and the ends are cut off. The next step, the bladder being protected by a sound, is to make a transverse incision through the part of the peritoneum which lies upon the anterior surface of the uterus, after which a similar incision is made through the retro-uterine peritoneum. Loops of silk are then passed through these peritoneal flaps, so that they can be held out of the way while this tissue is being dissected from the uterus. The con- nective tissue is separated from the cervix by the finger, or by the handle of the scalpel. Having reached the roof of the vagina, or nearly so, the utero-vaginal septum is divided by a curved bis- toury, and two fingers having been inserted in order to steady the organ, the uterus is finally separated and removed. The smaller arteries are secured by the ligature or by torsion-; all the loops and ligatures are brought down into the vagina; the abdominal incision is closed as in ovariotomy; and the vagina is filled with a large tampon or pledget of carbolized lint, which is kept in place by a proper bandage. This operation, which in the hands of its author gave a mortal- ity of 73 per cent., has been variously modified Bardenhauer's method, and improved upon. Bardenhauer combined the abdominal and the vaginal methods of extirpa- tion, by first detaching the cervix from below the vaginal roof; then opening the abdominal cavity and drawing the womb upwards; and afterwards, instead of ligating the broad ligaments en masse, tying each vessel separately, and finally by draining the peritoneal cavity through the vagina. This plan shortened the operation, made the haeniostasis more perfect, and by exposing the ureters to view, obviated the risk of their being ligated or otherwise injured. But in any manner, and by whomsoever it is made, the opera- tion of removing the entire uterus, including its supra- and infra- cervical portions, is a very severe and dangerous operation. It is UTERINE CANCER, 707 l)ad enough to make a supra-vaginal hysterectomy and to ampu- tate the womb at or about the internal os-uteri, Caution. but you should not forget that even that operation is not to be compared with the complete extir- pation of the organ by way of an abdominal incision. These two terrible expedients are often confounded in the minds of physi- cians, and are spoken of so flippantly in our day, that those who are rash and inexperienced are sometimes tempted to undertake them. Of vaginal hysterectomy, and especially of Pean's mode of removing the uterus without the use of the liga- Vaginai hysterectomy in ture, I shall have something to say under the head of Uterine Fibroids. It must suffice to state in the present connection, that this form of uterine extirpa- tion, whenever it is practicable, is preferable to the supra-pubic method because of the readiness with which the separation of the organ is effected, the hemorrhage controlled, and abdominal drain- age secured. The risks are also lessened by avoiding a section of the abdominal wall and all injury to the peritoneum above the pel- vic brim. The consideration of Sims,' Schrceder's, Baker's, and other methods of surgical treatment for epithelial cancer of the uterine cervix, must also be deferred to another lecture. (See Lecture XLIII, page 717). LECTUEE XLIII. EPITHELIOMA OF THE UTERUS. Epithelial cancer of the womb. Two cases. Nature and clinical history of. Pathological anatomy of. Insidious course of. Symptoms. The cachexia. Diagnosis ; clinical observation versus the microscope in ; from cervical hypertrophy, and from uterine polypi and fibroids. ProQnosis. Effect of local irritants. Treatment, surgical and medical. Those, of you who were present at my sub-clinic, on Wednesday last will remember that, of the eight women who were placed upon the table for local examination and diagnosis, two of them had epithelial cancer ot the womb. I have thought to make those two cases the text for some remarks upon this form of uterine cancer. Case. — Mrs. T , aged fifty-one, ceased menstruating ^bout ten years ago, and four years ago her present illness began. She complains of intra-pelvic pain and distress, bearing-down sensations, increased desire to urinate, and prostration and debility, that are very much aggravated by exercise. She is subject to a leucorrhceal discharge, which is not very copious, neither is it offensive nor excoriating in character. Within a short time this discharge has become sanguineous, and the flow is perceptibly increased by straining at stool, by urination, and by ordinary exercise. Local examination showed that the cervix uteri was consider- ably tumefied but not discolored. The anterior lip was denuded of its epithelium and covered by a papillary growth, which was of a very dark red hue, and which bled upon the slightest touch. The outline of this formation was serrated and irregular. There was no evidence of scirrhous deposit in the surrounding portions ot the cervix. This patient was also the subject of a large umbilical hernia. The remedy prescribed was arsenicumjodatus, 3d dec. trituration, to be taken three times daily. An injection was also ordered, consisting of castile suds, glycerine and warm water. Case. — Mrs. , fifty-three years old, is the mother of eight children, the youngest of which is eleven years old. She says she has had a falling of the womb for twenty years. She complains of bearing down sensations within the pelvis, and pressure upon 708 EPITHELIOMA OF THE UTERUS. 7oy the rectum whenever she is upon her feet, and whenever the bowels are moved. She has had a leucorrhceal discharge which is slightly offensive, and which consists of a bloody mucus; and which is increased by exercise. With the displacement, brought on by standing or at stool, there is a great deal of burning within the lower pelvis, which is sometimes almost intolerable. The menstrual flow ceased six years ago. Local examinations showed the uterus to be very much pro- lapsed ; the body of the organ was mobile, but the cervix was anchored in front, and considerably deformed posteriorly. It was Fig. 115. Cauliflower excrescence (ims). also nodulated, of a purplish hue, with a patch of epithelial ulceration of the same villous character as was observed in the former case. The ulceration was even more irritable and vascular than in Case 8,162, but the same treatment was prescribed. Nature and Clinical History. — These two cases illustrate a form of uterine cancer which is interesting, not only because of its comparative frequency, and its insidious character, but also because it is the only form of this terrible disease, if indeed there is one, that is curable. You remember the villous coat of the vaginal portion of the 710 THE DISEASES OF WOMEN. cervix uteri, and the beautiful arrangement by which each papillit- is covered with epithelium. It is these papillae, pathological anatomy and thig delicate i liyes ting membrane, which first become the seat of the morbid process in epithelioma of the neck of the womb. The former develop inor- dinately, and their loops of vessels and nerves supply the means for the exuberant hypertrophy of the mucous membrane which characterizes the disease, and which finally results in the ulceration and disintegration of the tissues involved. Fig. 116. Epithelioma of anterior lip ^ims). -This is the local beginning, the distinctive lesion of this variety of uterine cancer, which some very excellent authorities insist is always a local disease, the " cancroid" before there are any con- stitutional symptoms or complications whatever. Epithelioma, or papilloma of the uterus, is many times more common than the true cancer of the womb. It usually begins upon one or both lips of the cervix, in the form of a sort of tubercle, or prominence, which grows more or less gradually towards the os-uteri. This tubercle spreads, flattens out, is pretty hard to the feel, and bleeds very easily when touched. If it grows EPITHELIOMA OF THE UTERUS. 711 rapidly the papillae become swollen and enlarged, and take on the form of exuberant granulations that may fill the cervix like a cork, or find their way into the uterine cavity, or lie in, or crowd, the vagina in the form of what is commonly known asa " cauli- flower excrescence." The rapid proliferation of the cells covering the papillae, extends to the pavement epithelium on the free surface of the cervix and between these prolongations. When they have been so qi.ickly and imperfectly formed, the cells easily take on the morbid pro- FiG. 117 (Sims). cess, and inflammation or ulceration follow. So that if the growth is hastened, the local lesion becomes more serious and profound, and the general health begins to be impaired. You can readily understand why this affection may exist with- out the patient or any one concerned having thought of it. Its usual course is to creep along insidiously. Neither of the patients whose clinical history has just been read to you, have, as yet, any idea of the nature of their disease, which at their next visit, perhaps, must be explained. I Insidious course of. 712 THE DISEASES OF WOMEN 7 . have said, in their hearing, that they have a form of carcinoma, and that satisfies them for the present. Symptoms. — During the early, or indolent period, there are few symptoms that direct attention to this disease, and, in fact we seldom see it until it has passed into the ulcera- The pain. . ,.,.,.. tive stage. 1 he pain complained ot is never acute, and is often lacking altogether. When it is present, it has a burning, stinging character, and is almost always worse alter exercise, coitus, coughing, sneezing, or straining at stool. If the cervix happens to lie forward against the neck of the bladder the chief distress is likely to follow urination. The vaginal discharge is not so constant nor so characteristic as in the other varieties of uterine cancer. In the early stage it is often absent, and it is not very rare to meet with The discharge. . cases, especially alter the climacteric, m which, although the disease may be far advanced, there is no increase in the amount of mucus that is secreted. But, when the vegetations are very luxuriant, and the case has taken on the form ot the cauliflower excrescence, or the " mushroom cancer," there will be a more copious and abundant flow of a watery mucus, or serum, that may deluge the patient, and cause the growth to shrink, to look very pale, and, perhaps, almost entirely to disappear for a time. The watery discharge usually, but not always, has an offensive odor, and is more or less corrosive in its character. At first it is not bloody, but, bv-and-by, as the ulceration The haemorrhage. , *1. ~ , . progresses, and the little loops ot vessels within the epithelial buds become involved, the flow is more sanguineous. Still, as a rule, these cases are not accompanied by such alarming haemorrhage as is common to the medullary cancer, and in rodent ulcer of the womb. The watery flow sometimes causes an intoler- able pruritis. Upon passing the speculum ver} 7 carefully (as you saw me apply it,) so as neither to cause pain, nor to bring on a haemorrhage, you will observe the growth. Its surface should Inspection of. . . ° .... , be mopped off m a very delicate manner and deliberately, and the patient instructed not to resist or to strain against the instrument while it is in situ, else the flow of blood will prevent you obtaining a correct view of the case. It may EPITHELIOMA OF THE UTERUS. 713 happen that the vagina itself is either so involved, or so filled with the growth, that it is not expedient to use the speculum, in which case we must rely upon the touch. Observe that, unless it is far advanced, this " villous cancer," as Rokitansky styles it, has not the form of an excavated ulcer, but of a growth that is super-imposed upon the cervix uteri. (Fig. 118). Its outline may vary, and there may be two or more distinct portions of it, but it's character is that of the cock's comb Fig. 118. Epithelioma oi both lips of the cervix (Sims). granulations which sometimes spring from the surface of ulcers, or of exuberant vegetations that may grow to ies1on? nSi ° n 0t thG almost any size. If the ulceration has progressed very far, the surface of the growth may be fur- rowed and bathed with pus. If caustics have been used, or a pes- sary worn, or the parts very much irritated from any cause, the lesion may have spread over the whole circumference of the cervix and to the roof of the vagina. (Fig. 114. ) In rare cases it extends to the meatus urinarius, where it causes great suffering from strangury. We had a very marked case of this kind (No. 1,763) in my clinic last winter. At other times, either through a con- tinuous extension of the lesion, or by inoculation from the leucor- rhceal discharge, it may reach the vulva. Instances have occurred in which the growth has begun upon the labia, and finally ex- tended to the uterine cervix. 714 THE DISEASES OF WOMEN. Some months, or even years, may pass before the cancerous cachexia declares itself. The length of the interval varies with circumstances, as a rule, the disease develops cachJxi^ 1116111 ° f thG more rapidly at, or about the menopause, in consequence of rapid child bearing, or prolonged lactation, in women of a hemorrhagic diathesis, and of an im- poverished constitution, and especially in those whose domestic life has been unhappy or unfortunate. The delay in the develop- ment of the worst symptoms and results of this disease, in a con- siderable proportion of cases, has given rise to the belief that this form of cancer is sometimes radically cured. The average dura- tion of confirmed cancer of the womb is shorter than that of any other organ. The general symptoms, which indicate that the nutritive system,, especially, has become depraved, are a pallor of the face, the tallow complexion, with swelling and puffiness of the ment tritlVe deraD8:e " features and a lack ot expression, or a pinched,, anxious and care-worn look; weakness and! debility, loss ot appetite and disgust of food; emaciation and an aphthous tongue ; palpitation and cardiac disturbance upon slight emotion or exercise; alternations of constipation and diarrhoea; wakefulness and nervousness, with irritability ; paralysis, or coma, and even convulsions; increased fetidity of the discharges; dropsy of the extremities, with menorrhagia, and a kind of hectic fever, with signs of blood-poisoning, and a quick pulse, as in phthisis pulmonalis. Exceptionally these formidable symptoms run their course very rapidly, in which case, if the first stage of the disease has escaped detection, the poor patient may die almost before anybody realizes that she is, or has been in danger. But, usually, if she is not already very much enfeebled, their course is less rapid and alarming, and there is ample opportunity for confirming the diagnosis and for doing whatever we may for her comfort. Diagnosis. — Even when this stage of affairs is reached, it is not always an easy thing to differentiate this form of uterine cancer from affections with which it may be confounded. For this reason I urge you to study this subject very closely, and more especially also because in the whole range of medical experience, there is, perhaps, no disease in which the prognosis turns upon the diagnosis with greater precision and delicacy. EPITHELIOMA OF THE UTERUS. 715 Do not forget, therefore, that, in this as in all forms of uterine and ovarian disease, where it is a question if tumors, or bits of tissue, discharges or ulcerations, are cancerous Clinical observation . ^ character, it is much safer to depend vs. the microscope. l upon what you will learn from careful clinical observations than upon what you can detect with your microscope. For, invaluable as that instrument is in the diagnosis of renal or other diseases, too much has certainly been claimed tor it in the detection of malignant disease of the womb. The educated " touch" is a better means of diagnosis, in epithe- lioma of the cervix especially. The peculiar feel of the growth, its form and friability, the ease with which one may rupture the thin covering of the blood-vessels, the swollen and sometimes nodulated condition of the neck of the womb, and the very ap- pearance of the finger when it is withdrawn, are of real diagnostic value. The flow may have an offensive odor in case of a partially de- tached or decomposing polypus or placenta, or from the decom- position of retained blood; or it may be very copious and watery where there is an infra-uterine fibroid, or from hydatids ; or it maybe heemorrhagic from chronic metritis, sub-involution, uterine polypi, membranous dysmenorrhcea, abortion, fibromata, or var- icose ulceration of the cervix; but the signs of the cancerous in- fection will be lacking in all these conditions. Reliable physical Thege iuc]ude the peci Vi iar fragility of the os and signs. l a j cervix uteri; the development of other tumors, either upon the neck of the womb or elsewhere ; and the anaemic and straw-colored hue of the skin. For, although one of them may be lacking, the others will not, in a case of genuine cancer of the cervix that has passed beyond the indolent stage. Epithelioma of the uterine cervix is a very rare affection before the thirtieth year ; and physicians of large experience have never seen ic in a woman who has not been pregnant. As in both of the cases under review, it is most common at and after the climacteric. You may know a case of simple inflammation and hypertrophy of the glands of the cervix, from one of epithelioma in its first stage, by the following symptoms: A cluster of glands, and not a single one only, are certain to be involved in glandular inflam- 716 THE DISEASES OF WOMEN. mation; the mucus is stringy, and has the properties of that which is secreted by these glands in health ; no Diagnosis from cer- matt how lai ™ tlae gj an d s have become, they vical hypertrophy. so- » J remain soft and do not bleed easily when they are touched ; and there is a line of demarcation between them and the cervix, that is lacking in epithelioma. The diagnosis ol cauliflower excrescence, within the cervix, from fibrous and mucous polypi of the uterus, is sometimes very difficult. Here again, we must rely chiefly upon the touch. If the growth that is felt is short and soft, and shaped like a raisin, it is a mucous polypus; but if it is long and narrow, it is probably a fibrous polypus. A polypus may retract, From uterine polypi. Fig. 119. Vaginal epithelioma (Sims). and bleed only when it lies within the cervix, which is not true of a papilloma. Besides, there is nothing about a polypus of any kind which gives the sensation as if it was brittle, and could be broken off, as tliere is in these malignant excrescences and papil- lary outgrowths. In epithelioma, the granulations are sessile, and, as I have already shown you, are found in patches of considerable size. The innocent growths that sometimes, although more rarely, follow a laceration of the cervix, are more fibrous and less vascular, and do not ultimately develop into a form of cancerous ulceration. As in examining for other varieties of cancer, you should not EPITHELIOMA OF THE UTERUS. 717 forget the significance of the family history, nor of the co-existence of morbid growths in other localities. In a case The family history. c - . that was sent to me, during the last summer, from Ontario, the patient had had an epithelioma removed from the tongue a year before, and, some months before coming to Chicago, had found a suspicious tumor in her right breast. Where the local affection is far advanced, you will be very apt to find more or less swelling of the inguinal glands, and fixity, or anchorage of the cervix as a result ot the cancerous infiltration, just as in ordinary uterine carcinoma. Frognosis. — If this affection, whether it be local or general, or both, is really cancerous, the prognosis, in so far as the ultimate result is concerned, is, of necessity, fatal. Where cases seem to have been cured, the disease either returns or is translated to an- other tissue, or there has been an error in the diagnosis. Gruerin says*: " I have seen old women who have lived five or six years with an epithelioma of the cervix uteri. Those who live the longest are those who have escaped the application of topical irritants. In one of our cases (No. 8,164), the probabilities are that the development of the disease, from this date forward, will be very rapid: (1,) because a local examination shows that the cervix is im- movable, from the cancerous infiltration; (2,) because the neck of the womb is nodulated by reason of the deposition of the Fame morbid material into its substance; (3,) because the patch, which in this case is secondary, involves the pavement epithelium chiefly, and may therefore pass more readily into the ulcerative stage; and (4,) because, when once the process of destruction of the cervix begins, its course will, in all probability, be more speedy from the fact that it is already the seat of carcinomatous disease. The co- existence of these two structural forms of uterine cancer proves their real identity. Treatment — The surgical treatment of epithelioma of the uterus is in the best repute with those who hold most jhe surgical treat- strongly to the theory that in its early stage the disease is local, and may, therefore, be got- ten rid of by its destruction or removal. The first of these indi- *Lecons CI niques sur les Maladies ries Organes Genitaux Internes de la Femme. Par A.. Guerin. Paris: A. Delahaye, 1878, page 507. 718 THE DISEASES OF WOMEN. cations can be met by the use of such agents as the actual cautery, or the application of fuming nitric acid, or of chromic acid ; and the second by amputation, either with the electro-galvanic knife, the curette, or the ecraseur. The objections to the use of the electro-cautery in the removal of an epithelioma of the cervix uteri are that it is almost impos- sible to avoid injuring the vagina and the urethra, and that there is great risk of primary and secondary haemorrhage. Still the Paquelin cautery may sometimes be used with the Sims' spec- ulum. Dr. Sims' plan is to exsect the cervix piecemeal. His opera- Fig. 120. After the exsection. tion is not one of mere superficial amputation, but of complete extirpation of the diseased part. In a very Dr. Sims' operation. . . r . _ . interesting case, the detaus or which you will mid in the American Journal of Obstetrics, (Vol. XII, page 455.) the growth was attached to the anterior lip of the cervix. After its removal the neck of the womb presented the appearance shown in Fig. 120. Twelve months after the operation the patient returned to Dr. Sims with a recurrent epithelioma that was located on the pos- terior lip of the cervix. Fig. 121. Dr. Sims says : EPITHELIOMA OF THE UTERUS. 71i) " The most unfavorable cases lor operation are those in which the epitheliomatous granulations penetrate deeply into the cavity of the uterus, and which can be readily removed with the curette. (Fig. 122) represents just what I mean. In such cases the mass of epithelioma projecting into the vagina is always easily broken down with the curette. There is but little work for the scissors, and more for the knife. The granulations in the body of the womb are removed in great masses with facility, and unfortunately, in all such cases, the haemorrhage will be profuse, and if the operator is not prepared to arrest it promptly it might become alarming and even dangerous. It is always of a bright arterial color, and seems to pour out from a thousand little arteries; for doubtless each filament of granular matter has its arteriole hypertrophied according to the nutriment necessary for fungoid growth." Fig. 121. Recurrent epithelioma of the cervix (Sims). Fig. 122 represents a rapidly fatal case of epithelioma of the cervix. I will quote the conclusions which are set forth by Dr. Sims in his excellent monograph : ". . "Do not amputate or slice off an epithelioma of the cervix uteri on a level with the vagina, whether by the ecraseur or by the electro-cautery. 720 THE DISEASES OF WOMEN. 2. Ex sect the whole of the diseased tissue, even up to the os internum if necessary. 3. Arrest the bleeding, when necessary, with a tampon of styptic iron, or alum cotton-wool. 4. Be careful not to apply the tampon with such force as to lacerate the excavated cervix uteri. 5. When the styptic tampon is removed, cauterize the granu- lating cavity from which the disease was exsectecl, with chloride of zinc, bromine, sulphate of zinc, or some other manageable caustic, capable of producing a slough. Fig. 122. Epithelioma of the cervix and cavity of the uterus (Sims). 6. After the removal of the caustic and the slough it produces, use carbolized warm- water vaginal douches daily till cicatrization is complete. 7. After the cure, put the patient on the use of arsenic as a protection against the cancerous diathesis, and urge the importance of examination every two or three months for the purpose of detecting 1he recurrence of the disease. 8. Then if fungous granulations or knobby protuberances not larger than a pea are found, lose no time in removing them; and treat the case afterwards with caustic just as in the first instance. 9. Almost every case may be benefitted by operation, even when there is no hope of giving entire relief." EPITHELIOMA OF THE UTERUS. 721 Qalifying- indications. It is sometimes a very serious question to decide upon the pro- priety of resorting to these fearful expedients, more especially because the ' k localists," as they are called, are not always justified in asserting that, at any period whatever, the disease is wholly confined to the cervix uteri, without in the least involving the general constitution. And even if we were sure of it in the very incipiency of these growths, not one in a thousand of them is brought to our professional notice before the cancerous infection has taken place. It is not a parallel Fig. 123. An epithelioma in the field of the speculum (Sims). case with that of the " smoker's cancer," on the lip, where we can see, and watch, and then remove the suspicious-looking tubercle as soon as it begins to form, and can afterwards repeat the experi- ment as often as is necessary. You may depend upon it, that the surgical instinct is very apt to lead one astray, and under the circumstances in which these patients come to us, to tempt us to promise too much for them And moreover, when operations for the removal of this form of cancer are made, after the general system has become involved, they certainly tend to hasten the course of the disease. I have seen cases of this kind in which I would no more think of operat- ing with the electro-cautery, the knife, the curette or the ecraseur, 46 722 THE DISEASES OF WOMEN. than I would expect to cure a case of malignant diphtheria by stripping the membrane from the throat and fauces, or a case of anginose scarlatina by chopping oft* the tonsils. The local treatment that is permissible, at least in my own judgment and experience, is such as will tend to restrain the haemorrhage, if it is excessive, and to soothe and The local treatment. ° . . assuage the mtra-pelvic pain and distress. Hut we must be careful, at least in some cases, not to seal up the watery discharge too suddenly and entirely, else the suffering will be very much increased. The local use of hamamelis, hydrastis, calendula or thuja, with glycerine and water, often answers a very good pur- pose. All straining at stool, or in urination, should be carefully avoided and remedied. The bad odor of the discharges may be relieved by weak solutions of the chloride of lime, the perman- ganate of potash, or carbolic acid, or, in a domestic way, by pulverized charcoal, yeast, or lemon juice. To prevent re-infection, the parts should be kept clean, and the clothing also. Concerning the medical treatment, I am compelled to say that there is not upon record a single well authenticated cure of this disease by any remedy or remedies. A radical cure is not to be expected. And yet, if we begin in good season,- and continue perseveringly, and if the constitutional symptoms are not too grave, nor the course of the disease a very rapid one, very much may sometimes be done to retard its development and to delay its fatal progress. With this end in view, my own experience has led me to place my chief reliance upon two or three remedies, the first of which is the arsenicum jodatus. I usually prescribe it in the third deci- mal trituration, to be taken from one to four times during the day; and I really believe that through its employment some of my patients with epithelial cancer of the womb have been kept in a tolerably comfortable condition for months, and, in a tew cases, for years, before the inevitable result has finally overtaken them. The second ot these remedies is the mercurius corrosivus 6 which seems especially applicable to cases in which there is either a taint, or a strong suspicion of syphilis, and also where the lesion is located, as it is in very rare instances, about and within the orifice of the urethra. In the case to which I have already referred (No. 1,763), the effect of this remedy was very marked and persistent. EPITHELIOMA OF THE UTERUS. 723 You will find the history of this case in one of my clinics that was published in the United States Medical Investigator for December 1, 1876. Three years and a half have now elapsed since this patient first came to us, but she is still active and comparatively well. Other remedies are mere, jodatus, nitric acid, natrummur., kreosotum, phosphorus and silicea. In one case which has been under our observation in the hospi- tal for three years, the chief complaint has been of the itching and burning ot the external genitals caused by the discharge that came from a cervical epithelioma. Under the internal use of arsenicum jodatus 3., and the local application of the carbolized cosmoline, which she applies once or twice daily, and sometimes oftener, that symptom has been kept under control. Before dismissing you I must remind you that the scraping of the part down to the healthy tissue by the dull The curette. curette, is a justifiable resource if the lesion has not extended too deeply toward the peritoneum, and if you use it carefully and in a good light, the parts being irrigated meanwhile with hot water. Still another expedient is what is known as Dr. Baker's oper- ation, which consists of applying the thermo- Dr. Baker's operation, cautery at a red heat. When this is thoroughly done the patient is put to bed and left undis- turbed. The hemorrhage will have been controlled, and there is no need of subsequent dressings. The slough is cast off in about a fortnight, leaving a granulating surface. The relief that is claimed may extend from a few weeks to several years. I shall speak of vaginal hysterectomy under the head of uterine fibroids and sarcomata. LECTURE XLIV OV4T11TIS. Ovaritis. Synonyms. Causes, medical, mechanical, epidemic, traumatic. Symptoms,, Prolapse of the ovary. leritoneal ovaritis. Dysmenorrhea and menorrhagia in. Case.— Gonorrhoeal do. Inflammation of the ovaries has been designated in medicine as ovaritis, oophoritis, oaritis, ovarite, and ovarian folliculitis. There are two excellent reasons why you should study the medical history of this affection most carefully. In the first place, the disease occurs more frequently than is generally supposed ; and in the second, our literature is lamentably deficient in respect to its pathology and treatment. Ovaritis may be acute or sub-acute. Some authors speak of a chronic variety, but this is included in the sub-acute, which is the more common form of the complaint. Indeed fre^lent ub " acute form most smce they differ only in severity and duration, one description must answer for all. Most authorities are agreed that the left ovary is more frequently inflamed than the right one. Out of forty cases collected by M. Chereau, the affection was double in four cases, seated in the right ovary in eleven, and in twenty-five cases in the left one. Tilt found the right ovary inflamed in but five out of seventeen cases. M. Tanchou suggests that the nearness of the left ovary to the rectum, and the mechanical pressure of fsecal matters upon it, may account for its greater liability to inflammation. Causes. — Ovaritis is rarely an idiopathic affection. It is liable to occur immediately before, during, or immediately subsequent to the appearance of the catamenia. In many Generally symptomatic. » _ . •, . cases, every return ot the menstrual period is characterized by marked symptoms of ovarian irritation and inflammation. The ovaries bear much the same relation to the uterus, that the Malpighian tufts do to the tubes of Ferrein and Bellini in the kidneys. Bearing in mind this intimate functional relation, you will readily perceive that amenorrhea, or retention 7a t OVARITIS. 725 of the menses, from occlusion of the vagina, by an imperforate hymen or os, or atresia of the vagina, or of the uterine cervix, would be likely to induce congestion of the ovaries, as well as of the uterus and Fallopian tubes. The repletion occasioned by the non-exit of the menses might be harmful in various ways, but the most painful symptoms incident thereto would be those of ovarian inflammation. A sudden suppression of the menstrual flow, as from cold, or coitus, has sometimes caused a severe attack of ovaritis. It may be due i;o spasmodic, obstructive or mechanical rw antls fr ° m dysmenor ~ dysmenorrhea, arising from partial obliteration of the uterine cervix. It is a frequent conse- quence and complication of membranous dysmenorrhcea ; and Drs. Rigby, Simpson, and others treat of a variety of painful menstruation under the title of Ovarian Dysmenorrhcea. If the monthly return is characterized by very considerable suffering, neuralgic headache, fugitive and erratic pains, and hysterical symptoms, one may suspect that the focal point of the disorder is in the ovary. There are perhaps few examples of menorrhagia of long stand- ing that are not dependent upon or associated with ovaritis. A frequent cause of the disease under consideration is the improper and harmful use of emmenagogues, which are given with a view to relieve menstrual suppression, From medical and me- or to i n d uce abortion. The resort to mecliani- chamcal causes. cal expedients for the same purpose may pro- duce a like result. These villainous appliances all act as irritants to the delicate structure of the ovary, tending to derange its innervation, circulation and nutrition, and thus, directly or indirectly, to induce the inflammatory process. Inordinate sexual indulgence, especially after prolonged or unusual abstin- ence, may cause ovaritis. I have met with several examples of this kind in women whose husbands had but just returned home after a long absence. Ungratified sexual desire, in those who are of amorous disposition, may likewise cause ovaritis. Some most painful attacks, due to this cause, are met with in young widoAvs. The same result has been witnessed in prostitutes when placed in confinement. The employment of unnatural means for the gratification of the sexual passions ; nymphomania ; 726 THE DISEASES OF WOMEN. gonorrhoea ; or Menorrhagia in the female ; a too forcible coitus* as in rape ; falls or blows upon the iliac region ; the use of astringent vaginal injections, causing the sudden suppression of leucorrhceal, or a hsemorrhagic discharge ; the employment of eseharotics in ulceration of the os uteri ; the extension of endo- metritis through the oviduct to the ovary ; retroversion of the womb, and constipation, especially at the menstrual period ;. sudden exposure to cold, and check to perspiration ; emotional causes, as the reading of novels by those who are young and of sedentary habits ; unrequited affection ; the abuse of aphrodisiacs and alcoholic liquors, are among the more frequent and ordinary causes of ovaritis. Scanzoni reports having observed many cases, in which this disease was developed in consequence of an inflam- mation of a portion of the intestinal canal, and especially of the rectum. I have known it result from a sudden and intentional suppression of milk in a mother who had been suckling her child. The intimate relation existing between the functions of the: mammary glands and the ovaries is significant of ovarian lesions incident to the puerperal state. If the lacteal Epidemic ovaritis. . secretion does not appear at the proper time, the ovary is very liable to become irritated, and even inflamed. This inflammation extends by continuity of surface, to the peri- toneum. Hence arises a common sporadic and insidious form of puerperal peritonitis. . In 1746 an epidemic of this form of puer- peral fever prevailed at the Hotel Dieu, in Paris, and another in Vienna in 1819. Of fifty-six females who had died of puerperal fever, Dr. Robert Lee found that in thirty-two cases the ovaries, were red, swollen and softened ; and in two hundred and twenty- two cases of the same fever M. Tonelle found evidences of ovaritis in fifty-eight. Kiwisch remarked that, as contingent upon lying-in, ovaritis occurs generally in groups of cases, an observation that corresponds with the idea advanced by certain authorities, that it is sometimes epidemic. Kiwisch has often " made from ten to twenty consecutive autopsies without meeting with any considerable inflammation of the ovaries, after which the disease was observed, in more or less considerable develop- ment, in from six to ten individuals consecutively." Traumatio causes, incident to labor, sometimes give rise to- OVARITIS. 727 ovaritis. Metritis may supervene upon delivery, and the inflam- mation extend through the generative intestine Traumatic ovaritis. . to the ovary, in some such manner as inflam- mation of the duodenum may indirectly extend to the liver. It is possible that, by reason of being compressed against the bony pelvis, the ovaries are sometimes injured during labor, but, 1 as the gravid uterus occupies the superior strait, this result could happen only in exceptional cases. In the puerperal state, the absorption of post-organic matters from the cavity of the womb sometimes gives origin to a painful and dangerous form of this disease. Pus and other deleterious products may be conveyed by the oviduct from this cavity direct to the ovary, or lodged in the peritoneum, and thus serve to light up the inflammatory process. In rare cases, the rheumatic diathesis acts as a predisponent of ovaritis. This is an inveterate form of the complaint. In an example of the kind that I now have under treatment, the patient has, for six years, suffered almost martyrdom from rheumatism. For six months past she has had amenorrhcea, with prolapse of the left ovary, and ovaritis. A peculiarity worth mentioning is that an elder sister of hers died of rheumatism with menstrual suppression that had persisted for more than a twelvemonth. The " hysteric constitution," as it is styled by Roberton, is a marked predisponent of ovaritis. The class of patients most lia- ble to this inflammation are recognized as the nervous, irritable, and hysterical, those whose temperaments are mercurial and volatile. Symptoms. — In acute, post-partum ovaritis, the constitutional symptoms are marked and decided. As in inflammation of the serous tissues generally, the attack commences with a chill, followed by fever, acceleration of the pulse, and local pain. This pain is sometimes described as sharp and intense ; again it is forcing, throbbing, or dull, sicken- ing and paroxysmal. It may be seated in the upper and posterior portion of the vagina, in one or both of the iliac fossae, the groins, the lumbar region, the sacrum, the hips, or in the thighs, and occa- sionally reaches to the end of the toes. Sometimes, in lieu of a positive pain, there is a disagreeable feeling of weight and smart- ing in the region of the ovary, and patients not unfrequently com- 728 THE DISEASES OF WOMEN. plain of a burning sensation in the same locality. On applying the hand to the hypogastric region, you may discover that there is really an increase of heat in the part affected. When decidedly paroxysmal, the sufferings may either remit or intermit. The iliac and hypogastric regions become exceedingly sensitive to the touch, so that pressure, palpa- Exercise — position. . . . tion and percussion are insupportable. I he least motion, more especially the attempt to sit upright in bed, increases the suffering, and syncope may result. In milder cases, riding and walking have a similar effect. One of my patients complains most of riding in a railway car. The thigh that cor- responds with the affected side is sometimes flexed, cannot be extended without causing much suffering, and on this account is rendered almost useless. She cannot sit, or stand erect, without extreme pain. When in the horizontal position, she prefers to keep the thigh flexed on the abdomen, and the leg on the thigh, in order to procure ease by relaxing the intra-pelvic and abdomi- nal muscles, and thus relieving pressure upon the tender and inflamed ovary. If the lesion involves any considerable portion of peritoneum, you may expect general abdominal tenderness, with tympanites, and other symptoms of true peritoneal inflam- Peritoneal ovaritis. . ..,,., mation. In post-partum ovaritis, whether it be a sequel to labor at full term or to abortion, the disease has its origin in this membrane (which is reflected over the ovary), whence it spreads rapidly, In consequence of its increased weight, produced by a species of strangulation and inflammation, the ovary is liable to a hernia or descent, posteriorly into the recto-vaginal space or cul-de-sac, laterally along the sides of the vagina, anteriorly between the uterus and the bladder, and even occasionally into the labia majora. In rare cases, this hernia of the ovary is congenital. The following interesting case of this kind is cited by Billard, (Traite des Maladies des Enfants nouveau-nes. Paris, 1833, p. 474). " Josephine Romer, seventeen days old, was brought xo the Infirmary, September 12th. She was strong, and seemed pos- sessed of a good constitution ; the abdomen was somewhat tense ,* and at the left inguinal region there was a round tumor of the OVARITIS. 729 size of a filbert, somewhat hard to the feel, which could not be returned to the abdomen, neither reduced in size by pressure, nor was its volume increased by the crying of the child. Its direction was obliquely towards the labium of the corresponding side, which it did not quite reach. On considering the location of the tumor, and although the sex of the child forbade the supposition, one could hardly resist the conviction that it was a congenital ingui- nal hernia. Our judgment was accordingly suspended until, at the end of twenty-six days, the death of the child from pneumonia allowed us, by dissection, to ascertain the nature of the tumor. * * * * The hernial tumor was formed by the left ovary, that had descended through the inguinal canal and ring, which were much larger than one usually finds them in girls. The uterus, drawn by the round ligament, and by the ovary that formed the hernia, had left its natural position, and was inclined to the left side of the bladder. The left kidnej^, instead of being on a level with the other, was drawn downward by an enveloping cel- lular tissue, and also by a fold of peritoneum, intimately con- nected with the orifice of the sac ; the renal artery and vein had also yielded to this traction, and both were elongated and nar- rowed ; and finally, the ovary and the fimbriated extremity of the Fallopian tube, somewhat reddened and swollen, were lodged at the base of the sac formed by the prolongation of peritoneum, with which cavity it communicated. There were no adhesions between the intestinal convolutions and the surrounding parts, and the opposite ovary was in its usual situation. " A careful examination of the round ligament on the side where the hernia was, satisfied me that it was much shorter than that of the opposite side, and that, in place of losing itself in loose fila- ments, it terminated in the labium by an aponeurotic expansion ; from which it would seem tnat the ligament, shorter, and more firmly fixed to the labium, had, in the first place, caused the uterine displacement, and subsequently drawn the ovary through the inguinal ring. It followed, from this abnormal adhesion, that all the movable, connected and contiguous parts on the left side of the abdomen were drawn to the side of the hernia, for they were not separated from each other, nor did they follow the abdomen in the intra-uterine development and enlargement of the foetus." The benign tumor formed by the displacement in ovaritis, 730 THE DISEASES OF WOMEN. may vary in size . from that of a large almond, to that of a hen's; egg, or even larger. It is more swollen and sensitive at each men- strual period. This drawing, on the blackboard, will give you a pretty correct idea of the posterior and more frequent dislocation of the ovary, which you will remark has dropped into the recto- vaginal pouch, so that it is situated between the anterior wall of the rectum and the posterior wall of the vagina. The swollen ovary feels like an enlarged gland, is convex, and sometimes throbs and pulsates beneath the finger. The anal and vesical symptoms correspond with the variety and extent of the ovarian displacement. As a rule, the lower the organ, the greater the suffering. The tumor may press upon the broad ligaments and cause uterine deviations, or upon the veins and nerves within the pelvis, and occasion great suffering, paralysis, and, according to Cams, convulsions of the inferior extremities. But since, as Becquerel insists, these symptoms are common to- inflammation of all the organs contained within the lower pelvis,, how are we to decide, in a given case, if they depend upon ova- rian inflammation and consequent displacement ? In the more acute attacks of ovaritis, and particularly in lean persons, it is sometimes possible to detect the tumefied organ by examination through the abdominal parietes. In this case the swelling is cir- cumscribed and extremely painful to the touch. This is the most severe, or peritoneal form of the disease, which Scanzoni teaches. " is the only form accessible to palpation." In diagnosticating the sub-acute and chronic varieties, it is nec- essary to resort to the "touch." Upon making an examination per vaginam, we find the " tender spot" com- The vaginal " touch." . . . , plained of to correspond with the position of the prolapsed ovary. We may discover the tumor at the right or left sacro-iliac symphysis, or in one of the sacro-sciatic notches. If the displacement is a lateral one, we may confirm our suspicions by an examination of the corresponding groin, or iliac region, through the abdominal walls with one hand, while with the other we explore the vagina. It frequently happens that the patient winces or complains when the finger touches the uterine os or cervix — a Characteristic pains. circumstance that, unless one is very careful, may mislead in the diagnosis. Pressing the vaginal portion of the OVARITIS. 731 cervix, backwards and laterally, occasions acute pain in the af- fected ovary. She declares that " she cannot bear to be touched just there," and may proceed to tell you that the same suffering is sometimes caused by contact of the male organ with that spot during coitus. One of my patients made a similar complaint in consequence of having touched the posterior vaginal wall at its superior portion, with the pipe of her syringe, which she had been told must be introduced high up into the vagina. The displaced and inflamed ovary is most easily felt upon exam- ination by the vagina when that canal is short, and the uterus and its appendages are not far removed from the The rectal " touch." . . vulva. But when the vagina is long, and the womb high up in the excavation, it is necessary also to resort to the expedient of exploration by the rectum. Plac- ing the patient in the obstetric position, with the thighs well flexed, the finger introduced into the rectum may be made to reach further, and acquaint us more fully with the degree of ova- rian swelling and displacement, than any other means at com- mand. This end is facilitated by the thinness and elasticity of the coats of the rectum, and the possibility of exploring the pos- terior surface of the womb, and even of the ovaries, in their nor- mal state. And this mode of examination may be rendered still more valuable in certain cases, by the employment of the free hand in abdominal manipulation — it being sometimes possible thus to press the tumor upon both its anterior and posterior sur- faces at the same moment. In the worst examples of prolapse of the ovary into the recto- vaginal space, the same end is gained by a resort to what has been styled the "double touch" of Recamier, which The " double touch." . . p . consists m the introduction 01 the index finger into the rectum, and of the thumb of the same hand into the vagina. By forcing the perineum upward, this expedient permits us to compress the morbid growth between the thumb and finger. The character of the resulting pain, and the shape r position and mobility of the tumor, are believed to be pathogno- monic of the disease in question. One of the most painful and persistent symptoms consequent "jpon a posterior prolapse of the inflamed ovary is an intolerable 732 THE DISEASES OF WOMEN. sense of strangulation and obstruction of the bowel, following" the effort at stool. Rigby compares the charac- ter and quality of this suffering to that proper to orchitis, which, as you know, is almost insupportable. It is undoubtedly due to the pressure of foecal matter, and to the peri- staltic movements of the rectum upon the dislocated, swollen and excessively tender ovary. It may continue for hours after defe- cation has been accomplished. The symptoms induced thereby are sometimes mistaken for those of retroversion of the womb, and of stricture of the rectum. Constipation is an almost necessary consequence ; and it is possible, as has been claimed, that, in some cases, it may even tend to produce the displacement of the ovary. The whole alimentary system is liable to be deranged. The tongue becomes coated, the patient complains of thirst, anorexia, and, in rare cases, of obstinate heartburn, and even vomiting, as in the early months of pregnancy. The febrile symptoms corre- spond with the suddenness and severity of the attack. The vesical symptoms are sometimes so pronounced as to lead to suspicion of idiopathic disease of the bladder, and possibly of the kidneys also. When there is strangury, Vesical symptoms. . . .. i dysuria, heat and pressure m tile bladder, and these symptoms are greatly aggravated, or recur, only at the men- strual period, they signify that a sub-acute inflammation of one 01' both ovaries may be the cause of the suffering. You are not to conclude that they are necessarily the result of anteversion of the uterus, which affection, I repeat, exists more frequently in im- agination than in fact. The menstrual irregularities incident to ovaritis will not fail to attract your attention. The physiological theory that menstrua- tion consists essentially in the ripening and discharge of the unfe- cundated egg, or the " parturition of the ovum," as Tyler Smith most appropriately terms it, is now the generally received explana- tion of this process. The ovary is par excellence the organ of menstruation; the ma- turation and extrusion of the ovum, the first direct step in the process. This little organ, at once the most diminutive and im- portant of all the pelvic viscera, is a species of alarm clock, that introduces the element of time into the generative system, and presides over this function with respect to its occurrence and OVARITIS. 733 regularity. Its organic symptoms are wonderful, and almost unlimited in their range and significance. Physicians are accus- tomed to speak of the " uterus and its appendages ;" a more cor- rect phraseology would be, " the ovaries and their appendages."' Retention of the menses is one of the most common and serious symptoms of sub-acute and chronic ovaritis. Young women are especially liable to that form of amenorrhcea, Menstrual disorders inci- described by the older writers as emansio men- dent to ovaritis. sium, a condition in which the menstrual flow has never been established. "When a simple suppression of this discharge- — suppressio mensium — occurs during the course of other diseases ; as, for example, in phthisis pulmonalis, and the protracted fevers, or from incidental causes, it may signify that one or both ovaries are inflamed. The cause has operated indirectly. The lesion is secondary or symptomatic. The effect is none the less palpable, and equally prejudicial to a complete recovery. It is impossible to treat properly such cases of menstrual irregu- larity without a knowledge of their special pathology. Some slight obstruction prevents the escape of the menses from the uterine cavity or the vagina. The new and abnormal pulse is reflected upon the ovary. Inflammation is the result, and the regularity and completeness of the function is disturbed for months, and possibly for years. Not to speak of the harmful con- sequences supposed to result from the non-elimination of certain matters contained in the menstrual blood, the suspicious charac- ter of the vicarious haemorrhages sometimes induced, or the lia- bility in many cases to the development of pectoral disorder from this cause, there is no question but that, in the great majority of instances, amenorrhcea is intimately connected with, and depend- ent upon, ovaritis. The varieties of dysmenorrhoea known as spasmodic, mechani- cal, and obstructive, implicate the ovaries in a similar manner, and are, therefore, to be regarded as incident ri Dysmenorrhoea and ova- to? anc i not dependent upon, the disease under consideration. The ovarian form of dysmenor- rhoea is always accompanied by ovaritis. The physiological injec- tion of the organ, so necessary to its functional activit} r , becomes excessive and exaggerated. The first stage of the inflammatory process is present, and the congested viscus is tender and painful. 734 THE DISEASES OF WOMEN. All the suffering, which is paroxysmal, tormenting, and neuralgic in character, may be referred to the ovary. The lower part of the abdomen becomes extremely sensitive, and the patient undergoes a monthly martyrdom, accompanied by a distressing headache, neuralgia, and hysterical symptoms of every shade and variety. In my lecture on menorrhagia, you will recollect that I called your attention to the clinical fact that the most inveterate ex- amples of that affection had their origin in sub- Menorrhajia and ovaritis. . . . acute and chronic ovaritis. 1 o members of our school of medical faith, this fact is especially significant. The recognized superiority of our remedies for the arrest of profuse flooding can only be explained by their power to regulate, harmo- nize and restore the delicate vascular sympathies that exist be- tween the ovaries and the uterine mucous membrane. In illus- tration, I will read you the notes of a case upon which my advice was desired by Dr. B., a member of the class from Wisconsin. Case. — Mrs. , aged 18, married one year, came under my professional charge about three years ago. She is troubled with menorrhagia. The attacks have recurred at intervals for a period of two }^ears, for the relief of which she has taken domestic and allopathic medicines in large quantities. She was formerly strong and robust, but, on taking a sudden cold during the catamenial period, the menses were suppressed for nearly a year immediately preceding her last illness. The attacks of flowing last for a period of one or two weeks, and weaken her so much that she can scarcely raise her hand. The interval varies from three to four weeks, but is sometimes extended to eight or ten weeks. The flow is always long-continued, and profuse in amount. She had lost all reckoning as to the time for the recurrence of the regular flow. The discharge is sometimes dark and clotted, but more frequently of a thin, fluid character. Sometimes — and especially when the clots are passed — it is attended by much suffering, but, except- ing in the region of the ovaries, there is in general no pain. Both ovaries are tender and exceedingly painful, but only during the flow. She had been taking internally, and also by injections into the womb, most of the astringents laid down in the Materia Medica. In three months, by the use of pulsatilla, sulphur, nux vomica and sabina, giving the first two night and morning for a fortnight, and the last two for a like interval, and then repeating, I suc- ceeded in establishing the regular ''periods." Menstruation would then seem to be natural, the proper flow to continue for three or four days, after which, instead of decreasing, it would OVARITIS. 735 increase, and consist of clots with arterial blood. The discharge would then continue for ten days or a fortnight, despite my best efforts to suppress it. For a time, drop doses of hamamelis seemed to check it, bnt after a little it lost its effect. This patient has never had any children, or, to her own knowl- edge, ever been pregnant. At times she has leucorrhcea, which is readily relieved by appropriate remedies. When I first saw her, the appetite was morbid, and she had lived upon rich and highly- seasoned food. She craved pickles especially. In this case, the nature of the exciting cause, the amenorrhoea, and the ovarian tenderness, assure us that the haemorrhage could not have been due either to prolapsus uteri, hydatids, or a cancer- ous affection of the womb. The doctor's success in establishing a periodical return of the menstrual flow is confirmatory of the view that its essential pathology was to be sought for in the ovaries. The throwing of astringent injections into the uterine cavity, by his predecessor, was a species of malpraxis which, besides being a positive injury, demonstrated the ignorance of the practitioner. Gonorrhceal ovaritis is, I am persuaded, more frequent than is generally supposed. According to M. de Meric ("London Lan- cet" for September, 1862), it is most liable to Gonorrhceal ovaritis. . occur during the acute stage of gonorrhoea m the female. In this it differs from the onset of orchitis in the male, which occurs towards the decline of the gonorrhceal discharge. This rule has many exceptions. The same author states that such an effusion and induration as takes place in the epididymis, when the testicle is inflamed, does not occur in the ovary in consequence of gonorrhceal ovaritis. Nevertheless, the character of the suffer- ing induced is very similar. However much the patient may com- plain of the vaginitis and urethral symptoms in case of gonorrhoea, the acuteness and severity of the pain in one or both ovaries, when they are the seat of this specific inflammation, is still more marked and decided. It closely resembles that of orchitis. As a concomitant of gonorrhoea in the female, ovaritis may undoubtedly result, as Dr. Tilt suggests, from " the immediate application to the ovaries of the blenorrhagic pus which has been convej'ed by the same capillary attraction by which the seminal fluid is conducted ; " from extension of the disease from the vagina ; or possibly from inoculation of the whole glandular sys- tem, including the ovaries themselves, with the specific poison. 736 THE DISEASES OF WOMEN. The excessive tenderness of the vagina in cases of this kind, inter- poses a barrier to the employment of the "touch" in making a careful diagnosis, and hence this affection has been overlooked by a majority of writers and practitioners. I can not give you a better idea of this form of the disease than by quoting a case from M. de Meric's excellent paper. " On October 27, 1858, 1 was asked to see the wife of a wealthy tradesman in one of the metropolitan suburbs. She was said to be very ill, and I found her in bed. The patient was then about thirty-two years of age. She stated that, for three weeks at least, she had noticed an abundant discharge, which had consid- erably stained her linen with large yellow spots. The discharge had of late inci eased, and she had been obliged, on the day of my visit, to take to her bed, owing to a severe pain in the left iliac region. There had been a certain amount of uneasiness in mic- turition, but that had passed off. The last menstruation had occurred about three weeks before. " On examination, I found the patient suffering from feverish- ness; the linen shown to me was marked with large yellowish spots, and pain on pressure over the left ovary was very acute. The diagnosis of a case of this nature was seemingly easy enough. I suspected sub-acute metritis, the inflammation having suddenly extended along the Fallopian tube, and reached the ovary. This latter circumstance was explained by an imprudent exposure to cold, viz., driving home from the theatre in an open carriage. The pain was so acute that I did not propose a vaginal examination, but at once ordered fomentations to the left iliac region, a gentle purgative, an antimonial mixture, low diet, and rest. " It should be noticed that the lady was suckling a child about seven months olcl. " On leaving the house, the husband accompanied me, and inquired about the state of his wife, hoping it was nothing seri- ous. As he had been under my care, some years before, for gonor- rhoea, I thought it my duty to ask him whether anything of the kind had happened again ; and I learned that he had been suffer- ing from a slight discharge, which was going off. " The case now took a different aspect; and, after weighing all the circumstances, I came to the conclusion that my patient had been infected, and was laboring under gonorrhoea, the inflam- OVAEITIS. 737 rnation having traveled to the ovary by way of the uterine cavity. u On the 29th, two days after my first visit, I saw the lady again, and found the discharge had diminished ; the pain over the left ovary Was still severe, though the pulse had somewhat come down. I proposed leeches, but so much repugnance was expressed that I advised counter irritation by mustard poultices, and the use of the same lowering means. The case progressed very favora- bly ; a few astringent injections were made as soon as the acute inflammation had gone by ; and in about three weeks the patient had so far recovered as to resume her household duties. I did not think it necessary to advise the weaning of the child. The father also regained his health in a short time." Some most painful attacks of gonorrhceal ovaritis arise from the use of strong astringent injections designed to stop the vaginal flow. I have recently treated a case of this kind, in which the husband ventured to prescribe the same injection for his wife that had been ordered for himself by a quack doctor. After a few hours she did penance for his infidelity and presumption, in a most severe attack of inflammation seated in both ovaries. Women sometimes resort to such harmful expedients at their own sugges- tion, and in a fit of desperation. I am greatly mistaken if in the future your professional experience does not prove that ovaritis is a frequent and most painful contingent of gonorrhoea in the female, Dr. Simpson and others to the contrary notwithstanding. At my next lecture I shall speak of the pathological anatomy, the differential diagnosis, prognosis, sequelae, and treatment, of ovaritis. LECTUEE XLV. OVARITIS — (CONTINUED) . Morbid anatomy of. Abscess in. Diagnosis. Prognosis. Case.— Sequelae. Menstrua disorders. Sterility. Treatment, do. of the puerperal form. Remedie in the cosm* mon form. Case.— Local remedies. In my last lecture your attention was directed to the nature, causes and symptoms of ovaritis. As related to the history and treatment of this disease, other points remain to be noticed. And, first, of its Pathological Anatomy. — You will not be surprised to learn that, until quite recently, the physiological anatomy of the ovaries was so little understood that distinguished physicians have been known to mistake healthy for morbid appearances, in these organs, at post mortem. It is related of the eminent anatomist Vesalius, that he referred the origin of symptoms of uterine strangulation, amenor- rhcea, and chlorosis, to the presence of yellow spots-, the modern corpora lutea, in the ovaries of four unmarried women, upon whose bodies he conducted an autopsy. The structural changes incident to ovaritis vary with the acute- ness of the attack, the brevity of its course, the seat of the lesion in one or another of the ovarian textures, its- relation to the last menstrual period, to labor, whether premature or at full term, and to the grand climacteric. As with inflammation seated in other organs, so in ovaritis, the more rapid the course of the disease, and suddenly fatal the attack, the more marked are the evidences at post mortem of congestion, and its immediate consequences. The line of demarcation that separates the physiological changes proper to the maturation of the ovum and the dehiscence of the follicle at each menstrual period — id est, the escape of a small amount of blood into the cavity of the Graafian vesicle, the retrac- tion of its walls, the formation of a clot, the fading hue of the coagulum, and the final cicatrix — from the more marked engorge- ment and effusion proper to acute attacks of ovaritis, is very indis- OVARITIS. 739 tinct and illy defined. In this connection, the following differential diagnosis between healthy and morbid ovisacs, as detailed by Dr. Farr, and re- arranged by Dr. Clay, in his notes to Kiwisch,* is of practical interest : NATURAL FOLLICLE. I. Always near the surface when prepar- ing for dehiscence, and often projects considerably above the level of the ovary. Coats unequally thick ; thinnest at the most prominent part of the follicle. 3. Considerable vascularity above the elevated part, plainly visible exter- nally. Walls of follicle at this stage, of a bright yellow color. The liquor folliculi is either clear and limpid, or intermixed with blood, or the center of the sac is filled with a coagulum, which is at first bright red, and afterwards becomes pale, and at length nearly white. The coagulum may adhere to the walls, and undergo fibrillation and subsequent conversion into a solid body, or into a dense white membrane ; or it may be rapidly absorbed. MORBID FOLLICLE. Often not peripheral, but more or less central in its position in the ovary. It may attain to the size of one-third or half of the ovary, without necessarily causing any distinct prominence above the surface, especially when occurring singly. Walls are equally thick, and exhibit at no part any evidence of attenuation or absorption. No preparation for rupture is indicated externally, by any peculiar arrangement of vessels, or by any marked increase of vascularity. The walls do not exhibit the remarka- able yellow color, or the cerebral fold- ings, characteristic of the advancing normal ovisac, the tissues being com- posed of the undeveloped Graafian follicle. Contents of the sac are neither the clear liquor folliculi, nor the bright clot, nor the developed fibrin, but gen- erally a collection of dark coffee-ground matter, resulting from the admixture of a quantity of decomposing blood corpuscles, and fragments of membrana granulosa, intermixed with a dirty fluid. Any considerable engorgement of the ovary with blood, occa- sions an increase in the size and weight of the organ. The tum- efaction is accompanied by softening of tissue, ^ The discoloration and the increased vascularity, and a change of color to a rusty dark red or blue, or even a mahogany hue. In idiopathic cases, which are rarely the subject of post mortem examination, an apoplectic effusion of blood into the fol- licles, and the subsequent formation of a coagulum therein, some- times results. As in cerebral apoplexj^, the size, complexion, and €haracter of this coagulum varies in different cases and in differ- ent stages of the disease. The masses are irregular or rounded, r isch on the .diseases cf the Ovaries, by Clay, London, i860, p. 63. 740 THE DISEASES OF WOMEN. and sometimes as large as a cherry. The softer the c]ot, and the lighter its color, the more chronic or protracted has been the inflammatory process. Recent effusions" may supervene upon those of earlier date, in which case different follicles will be occu- pied with coagula of varying hues and consistency. Sometimes the wall of the follicle is hypertrophied, and rendered more firm than natural. In rare cases it is friable, and this species of hae- matic cyst may be ruptured, and its contents extravasated within the stroma, and the enveloping membrane (tunica albuginea) of the ovary, or into the peritoneal sac. Scanzoni details the case of " a young girl of eighteen years, who died suddenly during men- struation, with all the signs of an internal haemorrhage. The autopsy demonstrated in the right ovary, which was slightly amplified, a pocket of the size of a pullet's egg Haemorrhage into the ovary. ~,, , . -. . filled with coagulated blood, m the posterior wall of which was found an opening of nearly nine-tenths of an inch long, through which nearly seven pounds of blood had pene- trated into the abdominal cavity." In septic states of £he blood, as in the ovaritis of lying-in women, caused by the absorption of post-organic matters from the cavity of the uterus, the ovary may be engorged with effused blood from passive haemorrhage. These, and similar disclosures by the knife of the anatomist, have some- times caused the ovarian lesion to be entirely overlooked, and an off-hand, uninstructive diagnosis of pelvic haematocele to be made by the physician. Any of the various "terminations " of inflammation may some- times be recognized in the ovary. A very considerable effusion of serum into the peritoneal investment of the Dropsy as a sequel. . „ , n . -, . , ororan, or the collection of the same tluid m the distended vesicles, discloses a dropsical condition that may have escaped notice during the life of the patient. In the former case the tumor is unilocular, in the latter multilocular. It is more than probable that, as in pleurisy and pericarditis, this serum is at first exuded as a critical means of relief to the inflamed structure, and that subsequently the absorbents are not capable of removing it. When resolution has taken place, the structure of the ovary is changed. The retracted cicatrices make it more solid in consis- tence, with an irregular, bosselated surface. The glandular structure disappears, and may be substituted by various forms of OVARITIS. 71:1 -heteroplastic growth ; as, for example, the cartilaginous, calcare- ous, cancerous, and possibly the tuberculous. Nearness to the grand climacteric increases the liability to atrophy of the whole organ. Puerperal ovaritis, whether peritoneal, parenchymatous, or fol- licular, and whether it occurs as a contingent of labor at full term, or in abortus, is most liable to terminate Liability to suppuration. . . . m suppuration. Abscesses of the ovaries are by no means uncommon. Their history is of the greatest clinical interest and importance. After death from puerperal fever, the puriform exudation may sometimes be found deposited in the folli- cle, which is thus enlarged to the size, perhaps, of a hazel nut. A description of these abscesses is thus given by Kiwisch (pp. cit. p. 90) : " Follicular abscesses, after a long continuance, may attain a very considerable size ; indeed, according to our own observations, they have contained about sixteen pounds of pure pus. The cyst w r all may resist perforation for some time, and, in isolated cases, for a long period of years. The parenchymatous abscesses are generally not so large, though we have seen them reach the size of a child's head ; and we have also to observe that they com- monly increase much quicker than those previously mentioned. These abscesses often proceed from several small foci, which coal- esce in the course of time, and the greater part of the stroma of the ovary is destroyed, or a sinuous cavity is inclosed in its rudi- ments. After a protracted duration of the disease, these collec- tions of pus are surrounded by a membrane ; but it is difficult to separate from adherent parts, and it cannot be anatomically demonstrated to any extent. The disposition to perforation is a characteristic feature of these abscesses ; in the acute form of the disease, it may take place in the course of a few days or weeks. The cystless abscesses in the neighborhood of the ovaries, are also disposed to perforation. Consecutive collections of pus, in previously degenerated follicles, seldom burst, with the exception of those cases in which the contents have an ichorous property." The pus contained in the ovarian abscess, in most cases, is laud- able ; but, occasionally , ichorous and corrosive. The danger of rupture and extravasation of the contents of these abscesses, is proportionate to the bad 742 THE DISEASES OF WOMEN. quality of this purulent matter, complicated perforations being more frequent where the pus is of an ichorous and disorganizing character. The abscess may discharge its contents directly into the abdo- men, with fatal consequences. A case of this kind is cited by Dr. Seymour, from Guy's Hospital Reports.* " The patient was a young woman, of the lowest and most un- fortunate class of females. She was greatly emaciated, had a very quick and feeble pulse, a shining red tongue, and constant watchfulness. She suffered from constant and irrepressible diar- rhoea, and for many successive days vomited both food and medi-' cine , the catamenia were absent. * * * * After having been in the hospital about two months, she suddenly complained of the most acute pain over the abdomen, and, in a few hours,, expired. " On opening the abdomen, death appeared to have been pro- duced by the effusion of a large quantity of pus into the peritoneal cavity, which escaped from an abscess in the right ovarium, which abscess appeared to arise from suppuration in the substance of the viscus, similar in every respect to phlegmonous abscess in any part of the body, and not connected with any cyst, or change, or addi- tion of structure, the product of morbid growth." Collections of benign pus in the ovaries may find an outlet through the bowels, the bladder, the uterus, the vagina, or the abdominal parietes. They seldom perforate the Extemporized outlets for sma u intestine, but more frequently communi- cate with the rectum, on the left side, and the colon on the right. Serious consequences, from the escape of the purulent collection, are prevented, by the formation of adhesions between the neighboring structures. Many obscure cases of renal, uterine, and rectal disease originate and culminate in this effort of nature to extemporize an outlet for the contents of an ovarian abscess. Fistulous abscesses of this sort are sometimes salutary, and again intractable, chronic, and necessarily fatal. In rare cases they may discharge, repeatedly, through the unnatural out- let. It should not be forgotten that, although it may take place in the unimpregnated female, ovarian suppuration occurs most frequently, in consequence of post-partum injury or inflammation^ * Seymour on Diseases of the Ovaria ; p. 38. OVARITIS. 743 The quantity of pus contained in the ovarian abscess may vary greatly. In most cases it is not very large. Examples are, how- ever, recorded, in which an incredible amount P u? formeT quantity ° f lias been observed. Dr. Taylor, of Philadel- phia, reports a case of chronic ovaritis affecting the right ovary, in which the sac weighed seventeen pounds, and yielded sixteen quarts of pus. It sometimes happens that the purulent matter, with which the stroma of the ovary and the tissues of adjacent organs are infiltrated, is itself decomposed. In this case the evidences of fatal peritonitis are superadded to lesions already noted. Kiwisch says (pp. tit. p. 92) : " The more acute the progress of an ovarian abscess, the slighter is the thickening of its walls, and the more benign its pus ; but much more frequently it happens that, after its contents have been evacuated externally, complete contraction and obliteration of the pus cavity takes place. This is observed particularly after parenchymatous inflammations, and the intra- peritoneal suppurations surrounding the ovaries. Those absces- ses, however, whose walls are highly organized, which are not excavated for months or years, particularly when the point of rupture has no favorable direction, generally cause exhaustion, in consequence of the frequent renewal of the decomposing pus, or become fatal by the supervention of pyaemia." The post mortem disclosures in ovaritis, chiefly affecting the peritoneal investment of the ovary, are of the kind proper to serous tissues generally. Sometimes the most extensive adhesions are formed. " Thus the ovary may become agglutinated to the broad ligaments, to the pelvic parietes, the uterus, the bladder, or the rectum and the sigmoid flexure, to the caecum, the vermiform process, and the small intestine ; and it is generally attached to several of those viscera at the same time.*' The fibrous bands that connect these various organs and surfaces, belong to the variety of pseudo-membrane, classed by Laboulbene as " perman- ent," which are themselves subject to diseased conditions. In some cases a considerable increase in the size and weight of the ovary may be due to an excessive development of the fibrinous exudation. The various lesions we have detailed are seldom found uncom- plicated with, those of inflammation of adjacent organs and 744 THE DISEASES OF WOMEN. structures. This is especially true of puerperal ovaritis, which, as we have said, is apt to run its course with metritis, endo- metritis, or peritonitis. Beraud, Trousseau and others, treat of a form of ovaritis which is contingent upon variola, (l'ovarite vario- Variolous ovaritis, . leuse). It may attack either the parenchy- matous structure or the peritoneal envelop of these organs. Diagnosis — The diagnosis of ovarian affections is, sometimes, very difficult. This is especially true of the sub-acute and chronic varieties, unconnected with the puer- Characteristic symptoms. peral state. When the patient is extremely sensitive, and especially where it becomes necessary to explore the rectum, we may resort to the employment of anaesthetics with advantage. I have already given you a full description of the symptoms of ovaritis. The character of the suffering, its periodi- cal aggravation with each return of the catamenia, the menstrual derangements incident thereto, the symptoms of strangulation and inflammation from a hernial descent, or other displacement of the floating organ, the circumscribed swelling, the constitu- tional effects, and the sequelae, are sufficient to enable you to distinguish this from other diseases of the female generative system. In making out the differential diagno- The principle of ^ exciu- s j s f ovaritis, in its various forms, it is well to sion. ' 7 proceed upon the clinical principle of exclusion. Having examined if there be any disease of either of the neigh- boring organs, and not finding it present in a given case, we are confirmed in our diagnosis that the affection is ovarian. As explained in my last lecture, the ''touch" is an invaluable aid in all doubtful cases. Prognosis. — In the milder forms of ovaritis uncomplicated with organic disease of other portions of the generative apparatus, the prognosis is favorable. Very considerable structural changes may be resolved away, and the general health and vigor rein- stated. The most obstinate examples of this disease are com- plicated with menstrual disorders, more particularly with menor- rhagia. In the gonorrhceal type, when it does not result in suppuration, the symptoms are likely to become intractable and obscure, although most cases recover sooner or later. When there is ulceration of the womb, and the patient has been under OVARITIS. 745 treatment therefor, especially if the os and cervix have been frequently and severely cauterized, the prognosis should be guarded. When acute ovaritis supervenes upon abortion, the danger is in ratio with the advanced state of pregnancy at which the miscar- riage has taken place. The more advanced the The danger from ovaritis period of gestation, the greater the danger. after abortion. i o ' O O Much depends also upon the cause or causes that have produced the abortion. As the normal stimulus for uterine muscular contraction is derived from the ovaries, so it is reasonable to suppose that any agency that produces a like result, whether medicinal or mechanical, vital or villainous, must oper- ate through the same medium, and thus implicate these organs more or less seriously. The prognosis will vary accordingly. As a contingent of child-bed, the danger varies with the history of the previous labor, the patient's vigor of constitution, the cir- cumstances by which she is surrounded, the _^As a contingent of lying- care & \ ie receives, and the epidemic prevalence of puerperal peritonitis. The occurrence of rigors that alternate with fever of an irregular type, local ovarian pain and anguish, a frequent pulse, colliquative sweats or diarrhoea, suppression of the milk or lochia, with tympanites, dyspnoea, great prostration, and copious deposits in the urine, are untoward symptoms. Rupture of the haematic cysts, and of the ovarian abscesses, and the extravasation of their contents, ma}^ prove sud- denly fatal. Under these circumstances, the patient sometimes dies as abruptly and unexpectedly as if from perforation of the intestine in typhoid fever, or from the bursting of an aneurismal sac. Ovarian suppuration is not necessarily fatal. We should, how- ever, qualify our prognosis most carefully. Where the accumula- tion of pus takes place rapidly, especially dur- Danger from suppuration. ... ing lymg-m, and symptoms of adynamia, and decomposition of that fluid, are present, there is danger from purulent infection and infiltration. Other things equal, the more depraved the state of the blood, the greater the danger from ovarian abscess. If the formation of the "pus cavity" is slower, and its secretion more benign in character, and more especially if adhesive inflammation has served to protect the adjacent viscera bm implication, and to afford a means of final discharge, the 746 THE DISEASES OF WOMEN. case may terminate favorably. Sometimes a period of months, or even years, is consumed in this critical process. If the case becomes tliiis chronic, there is danger from exhaustion, caused by the drainage of the patient's nervous energies and nutritive resources. This is especially true of scrofulous subjects, who present a cachectic appearance, and finally succumb to vital losses of this character. Becquerel* reports the case of a young woman of twenty-three years, in which death followed the discharge of" an ovarian abscess into the rectum. Kiwisch says, (op. cit. p. 86) : " The course o± these pelvic tumors is various. In favorable cases, the tumor, and with it all uncomfortable 'symptoms, com- pletely disappears, after a duration of some weeks or months. We have observed tumors the size of an adult head, exceedingly hard, and apparently in direct contact with the external abdominal integument, terminate' in that manner. In other cases, suppura- tion extends, and perforation takes place in various parts of the surrounding structures, finally terminating favorably. On the contrary, when the course is unfavorable, the continued or relaps- ing acute attacks, or the profuse suppuration, or the dissolution of these tumors, causes the exhaustion of the patient. A rare, fatal termination happened to us in one case, from strangulation of the adherent small intestine, two convolutions of which, strongly dis- tended by gas, burst spontaneously, during violent contraction.'' A spontaneous removal of ovarian tumors of various kinds, inci' dent to the inflammatory process, sometimes occurs. This may take' place even when the tumor has become so tumors lution ° f ovarian large as to be pushed out of the lower pelvis. in order that it may have sufficient room for development, as happens with the uterus, or at about the fourth month. Dr. Meigsf relates several cases in illustration of this fact, from which we select the following : " May 23, 1852. I this day examined the hypogastric region of Miss M. This lady, who has a very great spinal curvature, wag examined by me about nineteen or twenty months since. I then found a very solid, incompressible, and immovable tumor, large a? a child's head at term, which occupied the hypogastric region, and which was not a womb. It appeared to come up out of the * Traite Clinique des Maladies de l'Uterus et de Ses Annexes, Paris, 1859. Tom. II ; p. 476. f Woman, her Diseases and Remedies. Phila., 1859 , p. 357. OVARITIS 74? pelvis. I considered it to be an ovarian tumor — and, of course, my opinion was, that it was incurable, and must, in the course of time, destroy her life. To-day, no trace of it is discoverable — nor is there any reason to suppose it exists. I take comfort from this example — one of the most extraordinary I have met with — for all future cases of a similar character. I am wholly at a loss, to account for its disappearance, since I am sure it was not a hypertrophied womb that I detected nineteen months ago — and that it was not any glandular or hygromatous tumor. She is well in February, 1859." Apart from the danger from rupture and discharge of its con- tents into the abdominal cavity, from the pressure and weight of the tumor when very large, and the drain ch?r r ^ n fr ° m excessive dis " u P on tne patient's strength to nourish and sustain the mass, some allowance should be made for the liability to recurrent attacks of peritonitis, which always imperil the life of the patient. The same may be said of co-existing lesions of adjacent organs. Adhesions, resulting from the formation of adventitious mem- branes are not more dangerous than those which are incident to other serous tissues when inflamed — as, for consequences of structu- example, the tunica vaginalis testis, or the ral change. 1 ' o pleura. They may take place in consequence of a slight attack of ovaritis, usually styled " menstrual colic,' 1 in the newly-married female, or from metastasis of mumps to the ovaries, as happens to the testicle in the male subject, without any untoward results. This remark applies also to simple hypertro- phy, atrophy, and induration of the ovaries. Cancerous, calcareous, cartilaginous, and tuberculous degenera- tion of the ovary necessitates an unfavorable prognosis — unless, indeed, the surgical expedient of excision may promise somewhat of good. Sequelae. — Besides the lesions already spoken of as incident to ovaritis, there are others that should not be overlooked. These are chiefly related to the functions of menstruation and generation. Menstrual derangements are very liable to follow ovaritis, whether it involves the follicular or Menstrual sequelae. . _ , -. r the peripheral structure of the ovary. Many examples of amenorrhea, dysmenorrhoea, and menorrhagia, are 748 THE DISEASES OF WOMEN. to be regarded as sequelse to attacks of ovaritis, the more evident symptoms of which may long since have passed away. The tex- tural changes detailed when treating of the pathological anatomy of this disease, are sufficient to explain the menstrual sequelae which are so often entailed upon the patient. It would not be reasonable to expect that the delicate process of evolution could proceed in an uninterrupted, physiological manner, after the Graafian vesicles had once been transformed into hsematic, serous or purulent cysts, and their walls hypertrophied, ruptured, or cica- trized. If blood or pus have infiltrated the stroma, or pseudo- membranous adhesions attached the organ to neighboring viscera ; if the fimbriated extremity of the Fallopian tube is bound down to the ovary, and that portion of the generative intestine occluded, the menses will either be entirely suppressed, or their escape and discharge become painful, scanty, insufficient, irregular, or too frequent and profuse. Nor are the evil results of these ovarian lesions limited to the ovaries. The intimate sympathy existing between these organs and the uterine mucous membrane is certain to implication of the uterine i m pii cate the i a tter in whatever pathological mucous membrane. -l jr o process affects the former, With each return of the catamenial period — no matter whether all its phenomena are present or not — this mucous membrane becomes highly injected and very vascular. If the proper flow is established, &l the proper time, and in proper quantity, this physiological 3iflu> of blood is quietly remedied and removed, as in the case of cthe* mucous membranes after their secretions have been poured out On the contrary, if the natural stimulus, originating in the ovary, is withheld, or perverted in its action or qualities, uterine de- rangements are a necessary consequence. Hence the intractable, nature of many examples of sub-acute and chronic metritis. Moreover, a long chapter of reflex disorders may be indirectly due to the same cause. I am inclined to the opinion that, as a sequel to ovarian inflam- mation, sterility is more frequently met with than is generalb supposed. The history of menstrual disorders Sterility from ovaritis. ... ,.,. ,-. -, -, . r» xi * and irregularities, just alluded to, connrms tnis idea. Indeed, whatever imperils the integrity of the catamenial function may also implicate fecundity. When lesions of the ova- OVARITIS. 74^ xies are sufficient to prevent the completion of the process of ovu- lation, they also prevent conception. If inflammation of both ovaries were as common as that of a single one, sterility would be as familiar a complaint as almost any other. As it is, while one of them escapes, other things equal, the power to procreate is continued, by a species of compensatory relation, as in the case of the male, when one of the testicles is diseased or has been re- moved. Induration of both ovaries, when it occurs in conse- quence of disease, is as inevitable a cause as atrophy from old age. The ovaries may be so displaced as to remove them from the reach and grasp of the fimbriae of the Fallopian tubes. In this, case they would have no communication with the uterine cavity ; and if the ovum were furnished by the follicle, it could not be conveyed to the womb. Sometimes, as a result of ovarian disor- ganization, diseased and imperfect ova are formed and furnished by the female. These may be impregnated, but subsequently are imperfectly developed, and abortion is a natural and necessary consequence. Hyperplastic formations and adhesions about the ovary may interfere mechanically to prevent conception, in some such manner as an excessive deposit of fat in the omentum some- times prevents women, who are remarkable for their pinguidity,. from having children. Sterility is not an uncommon sequel to gonorrhoeal ovaritis. A moment's reflection will convince you that this variety of the dis- ease under consideration is more likely to affect rhSa r i r ovar?tis fr ° m s ° nor * Dotn o™ r ies at the same time than any other, not even excepting the puerperal form. The lesion resulting therefrom may involve the most serious conse- quences to the generative function. Hence sterility not unfre- quently follows an attack of gonorrhoea ; and those who have had gonorrhoea repeatedly, are not apt to become pregnant. Without doubt, this result is sometimes chargeable to the blighting effects of the specific virus upon the ova, which it destroys in some such manner as it does the vivifying influence of the spermatozoa in the semen masculinum. But I apprehend that, in the majority of cases, actual lesions of the ovary are produced by the modified inflammatory process, which lesions are sufficient to account for the sterility that follows. Bernutz styles ovaritis " female orchitis." In the male sub- 750 THE DISEASES OF WOMEN. ject inflammation of the testicle, accompanying or following a severe attack of gonorrhoea, may, and I believe frequently does, prove itself a cause of sterility. The same remark applies to those women who, having suffered from this form of ovaritis, find them- selves barren in consequence. My professional experience confirms this view. Physicians are often consulted for the cure of sterility in the persons of women whose husbands have been wild and profligate in youth, and whose bad habits may have perpetuated themselves. Careful inquiry into the history of such a case, may disclose that the patient has had one or more attacks of gonorrhceal ovaritis, from which, indeed, she may be suffering at the moment of consulta- tion. It is more than probable that such examples of ovaritis are modified by the specific gonorrhceal taint, however faint the im- pression and remote its cause. This clinical fact affords a plaus- ible explanation of the source of difficulties among the higher families and orders of society, on account of their lack of progeny, with which history and human experience abound. Although it may doubtless be true that, in exceptional cases, nymphomania results from ovaritis, yet experience has demon- strated that the most common effect of the dis- Nymphomania from ease j s ^ Q diminish rather than increase the ovaritis. sexual feeling. Dr. Ashwell* says: "In two instances, I am perfectly convinced that the result of the malady was entire aversion to intercourse, and it is now allowed that nymphomania more generally depends upon the external organs, so far as physical causes are concerned." Treatment. — This is divided into general and local. Owing to the present imperfect state of the materia medica, the pathoge- netic indications for remedies in the treatment General treatment. . , . . oi ovaritis are neither very explicit nor very numerous. Its special therapeutics must, therefore, be founded upon our knowledge of its pathology, the proper use of such provings as we have at command, the similarity of textures impli- cated in this and other well-known diseases, and the results of clinical experience. In the puerperal form, when the attack comes on a few days * A Practical Treatise on the Diseases peculiar to Women. Phila., 1855 ; p. 445. OVARITIS. 751 after delivery, and the symptoms are those of surgical fever, with pain in one or both ovaries, and violent ovIrkf s tmentofpuerperal constitutional disturbance, aconite and arnica may be given for some hours, in rapid alterna- tion. If not of traumatic origin, belladonna may be substituted for the arnica. The symptoms and conditions which indicate belladonna, deserve especial mention. It is particularly adapted to the early stage of peritoneal inflammation, where the pains are Belladonna. . . . circumscribed and stabbing in character, or dart- ing, lancinating, and such as mark the acute stage of inflammation in other serous tissues — as, for example, in the arachnoid mem- brane. The diffuse peritonitis that sometimes supervenes, may also require the same remedy. If the attack occurs in conse- quence of taking cold, or is erysipelatous in character, belladonna is strongly indicated. The same is true of great cerebral disturb- ance, delirium, insomnia, dilated pupils, also of hysterical com- plications, neuralgia, and spasms. If the attack is ushered in by marked symptoms of local con- gestion, this remedy is particularly appropriate. This is true of the idiopathic, as well as of the post-partum varieties. In many sub-acute cases, aggravated at each menstrual period, the bella- donna may be given for a few hours with manifest advantage. If the pain is somewhat neuralgic in character, it may be equally useful. Next to belladonna, in the treatment of peritoneal ovaritis, colocynth, I am persuaded, is more useful than any other remedy. This is most marked in ovaritis supervening Colocynth. . . r ° upon abortion. 1 am anxious that you should not forget this fact. In this connection it is too frequently over- looked. You will find the symptoms that indicate colocyntn detailed in the materia medica. It is especially appropriate to those cases in which the bowels, and indeed the whole abdominal contents, are implicated, with stitches in the ovaries, diarrhoea, colic, pressure in the abdomen, suppression of the lochia, and tenesmus. Also in puerperal fever after vexation. Colocynth is recommended by some authorities for chronic ovaritis. The good repute of veratrum viride in puerperal metritis, its apparent capability of restoring the lacteal secretion and the 752 THE DISEASES OF WOMEN. lochia, when they have been suppressed by the inflammatory pro- cess, renders it probable that this agent is pos- sessed of some specific relation to the ovaries. As a remedy in ovaritis, it should be given in an early stage of the disease, when the organism is most perturbed by reason of vascu- lar and nervous derangement. Mercurius vivus is useful at a more advanced period, more espe- cially, it is said, when there is reason to apprehend that suppura- tion may occur. Many practitioners rely chiefly upon this remedy in alternation with belladonna. The symptoms, mostly abdominal and symptomatic, which indicate mercurius vivus need not be detailed in this connection. During the summer term of lectures in this college for the year 1864,* I called attention to the efficacy of the hamamelis virginica in ovaritis. The remarkable effects of this rem- edy, locally and internally, in orchitis, led me to infer that it would also be useful in some forms of ovaritis. I have prescribed it in numerous cases with remarkable results. It seems appropriate to the sub-acute attacks of this disease, which are incident to pregnancy and menstruation. In the former case, I have no question of its power, in some instances, to prevent abortion, where such a mishap threatens in consequence of ovarian irritation and inflammation. In the latter, it allaj^s the pain and averts the menstrual derangement which is so liable to follow. It is also useful in gonorrhoeal ovaritis, in which variety the suffering is sometimes extreme. This affection bears a close analogy to the gonorrhoeal orchitis of the male, in which hamamelis is almost spe- cific. For internal use, I prefer the second or third attenuation. The lauded virtues of gelseminum in gonorrhoea and sperma- torrhoea of male subjects, suggest that it might also be useful in ovaritis. The same is true of its power to excite uterine muscular contractility, and to allay hysterical spasms. Lachesis is indicated in ovaritis accompanying scanty, tardy, irregular menstruation, vicarious leucorrheea, and menstrual de- rangement incident to the critical period. When Lachesis. ..-.., ... , -. -. conjoined with metritis, in sub-acute and chronic cases, this remedy is sometimes very useful. It is recommend^ * See Medical Investigator, Vol. Ill, p. 62. OVARITIS. 753 lay Hering in chronic enlargement with induration or abscess of the ovaries. The following cases were kindly furnished by my friend, Dr. A. H. Botsford, of Grand Rapids, Michigan : " Miss M — — had suffered many months from dysmenorrhea, with scanty menstruation. She complained of great tenderness in the iliac region, sometimes on both sides, and at others only on one, and I remarked a fullness in the region of the ovaria, when felt through the abdominal walls. She was so lame and sore that she could not walk. The attacks would culminate in a diarrhoea, the discharges having all the appearance of pus. Under the use of lachesis she gradually improved. Indeed it never failed to relieve her most signally, and the early employment of it invaria- bly prevented the recurrence of the acute symptoms and of the purulent discharge by the rectum. This patient ceased to men- struate at twenty-seven or twenty-eight years of age, and had no further trouble of the kind. She died at thirty-five, of pulmonary congestion. " Mrs. B , aged about 35, came under my care five years since. Ten years ago she was ill during the whole summer, with pain, soreness and swelling in the region of the ovaries. Is of opinion that she recovered in spite of medicine. She had chronic diarrhoea, with stools like 'matter, as if from a boil.' She had also an abscess communicating with one of the intercostal cartil- ages on the left side of the thorax. I gave her lachesis and hama- melis. She was very soon relieved, and now keeps the medicine within reach. She has no family. Menstruation is regular, but she is liable to acute attacks of ovaritis with each monthly return, especially if she overworks or is much fatigued." In frail, scrofulous subjects, predisposed to excessive purulent . discharges, these ovarian abscesses sometimes secrete an enormous amount, and for a long time. This drain produces a species of cachexia in which other remedies may also be of service. The hepar sulphuris, calcarea carbonica, china, and phosphoric acid have been recommended to meet this indication. Bryonia does not appear to be so well adapted to inflammation of the peritoneum as to that of some other serous tissues — as, for example, the pleura and synovial membranes. Bryonia alba. op 'j. 1 '£1 So far as we are aware, it has no specmc rela- tion to the ovary. In the puerperal form of ovaritis, where the 48 754 THE DISEASES OF WOMEN. attack sets in with chilliness and rigors, and especially in case of threatened mammary abscess, the breast being large, hard, tense and painful, it may, however, be very useful as an intercurrent remedy. We have sometimes employed it with advantage in rheumatic ovaritis. The same remarks apply to the rhus toxico- dendron and the cimicifuga or macro tys. The ovnlar theory of menstruation is confirmed by clinical experience. Excepting those already named, and a few others which are given for specific reasons, all the The menstrual disorder aids m choice of the rem- remedies or considerable repute, in the treat- ment of sub-acute and chronic ovaritis, have been prescribed for the relief of menstrual irregularities. More- over, it is especially significant that each of these remedies is said to have caused abortion, a fact which confirms the idea advanced by Tyler Smith, that the specific stimulus of uterine contraction resides in, or must operate through, the ovaries. From these observations, certain therapeutical deductions are obvious. There is no question but that many examples of ovaritis, complicated with catamenial derangement, have been unwittingly cured by secale cornutum, sabina, apis mellifica, pulsatilla, sepia, platina, cantharis, and caulophyllin. The best criteria for, the use of these remedies in ovaritis, will be found in their adaptation to menstrual disorders, as amenorrhcea, dysmenorrhoea, menorrhagia, and also, in many cases, to leucorrhcea. Ovaritis, complicated with ulceration of the os uteri, requires to be treated most carefully. A resort to astringent injections, or cauterization, is too frequently had, by those who covet notoriety, and are reckless of consequences. The proper constitutional and local treatment for uterine ulceration will be detailed in a subse- quent lecture. For atrophy and induration of the ovaries, with which sterility is almost always associated, jodium, conium, plumbum and baryta muriatica, are in good repute. Change of air, atrcpTyT^dSnLrrdoiT 11 an( ^ diet, trave l & n & diversity of scenery, are sometimes of lasting benefit. I have succeeded in curing one case of barrenness, in which there was chronic indu- ration and insensibility of both ovaries, with an almost total atre- sia of the canal of the uterine cervix. This canal was dilated artificially, while, at the same time, remedies were given to restore OVARITIS. 70J the menstrual process. Conception followed, and the ovarian lesion disappeared. When there is reason to suspect that either the gonorrhoeal or syphilitic taint is present, the mercurius solubil- ovIr?tfs tmentfors ° norrh which are themselves sec- to cure, v or they may be, and often are, them- selves secondary upon some inter-pelvic disor- der. Under these circumstances you will be compelled to analyze the symptoms, to go back to their first cause, and in selecting the remedy, to recognize the relative importance of the uterine and the ovarian symptoms. For example, in a case of utero-gastric or utero-cardiac disorder, HYSTERIA. 80y the symptoms that are referable to the pelvic viscera may afford a more reliable guide in the treatment than the c a JdSc°2 a ringem n ent" tero " gastric or the cardiac symptoms, separately con- sidered. One of my patients had an intractable pniesis Avhich the best chosen internal remedies failed to relieve. In addition to the vomiting, she had a great variety of hysterical symptoms, which alarmed her family exceedingly. Feeling confident, at last, that in her case the remote cause was located within the pelvis, I proposed a vaginal examination. The touch revealed the uterus badly pro- lapsed. It was replaced and kept in position, and not only did the vomiting cease, but the hysterical symptoms also were cured from that moment. Another lady suffered from violent attacks of palpitation of the heart. Her physician had decided that she really had organic dis- ease of the heart. These attacks of palpitation followed riding, walking, defecation and coitus. They had occurred repeatedly at intervals for more than three months, when I was called to see her. The nervous system had become so much involved that these paroxysms finally merged into a species of hysterical fit. Vaginal examination with ihe speculum disclosed an abrasion of almost the whole of the ante- rior lip of the os uteri. I applied the oleaginous collodion a few times, ordered her to keep off her feet, and in a fortnight the heart disease and its hysterical outgrowth had entirely disappeared. She has had no return of either affection within the last three years. These cases are exceptional, but they will serve to illustrate the importance of striking at the root of the real difficulty, when it is possible, instead of contenting yourselves with lopping off a branch here and there in the shape of an impertinent symptom, or class of symptoms. Hysteria occurring at the climacteric period, or during preg- nancy, labor, the parturient state, or lactation, didons" compllcating con_ w ill need to be treated with especial reference to these states or conditions, which are prime factors in the production and modification of its symptoms. During the winter I shall have frequent occasion to elaborate and apply these general rules for the treatment of Hysteria. I will therefore spare you the infliction of a lecture upon its special 810 THE DISEASES OF WOMEN. therapeutics this morning. In the present connection it must suffice to remind you that it is one thing to put an end to the hysterical fit, by the use of such expedients as any old nurse could suggest and apply, and quite another thing to treat the various forms of this disease intelligently, thoroughly and successfully. For no other affection is so complicated, so enigmatical, so per- sistent, and so trying in every respect. And yet there is no other more amenable to rational, persevering and appropriate treatment. [In a recent lecture on neurasthenia in a hysterical subject, Prof. L. said that many of the mental symptoms were distinctly referable to a state of permanent congestion of the pelvic organs, with a coexisting anaemia of the brain or of the spinal cord. The cerebro-spinal anaemia in these cases is likely to be increased by Neurasthenia. tne ^ oss °^ blood at the month, and by the weakened condition of the digestive function. This is often the real state of things in the hysterical neuroses. In the young gill it is developed from brain-fag in the boarding- school, and from sedentary and luxurious habits at home, where dress and inaction determined intra-pelvic congestion and men- strual derangements. In married women the same train of symp- toms are exaggerated, and back-ache, headache, womb-tire, weari- ness and physical dilapidation are the result. Sometimes, and especially toward the climacteric, and in women of a highly intellectual cast, these conditions of local hyperemia and anaemia are reversed. The cerebro-spinal axis is surcharged with blood, while the pelvic viscera are not supplied as freely as they should be. But here also are nervous symptoms that are peculiar and very difficult of cure. The general remedies for this peculiar form of hysterical neuroses includes the careful use of electricity ; of massage, with friction, kneading, tapping and percussion; of the motion of the joints and their extremities ; of good feeding and of seclusion from every one but the physician and the necessary attendants.] HYSTERICAL HEMIPLEGIA. Case. — Mary J , aged 29, seamstress, unmarried, had been in poor health for more than a month, complaining of head- ache, fatigue, debility, drowsiness, loss of memory, and disinclina- tion to work. Two weeks ago she was suddenly seized during the night with a violent fit of hysteria. The spasms of the voluntary muscles were very severe. She talked foolishly of her little HYSTERICAL HEMIPLEGIA. 81 i love affairs, of church matters, and upon all kinds of topics. In about half an hour the paroxysm passed off with alter- nate laughing and crying, and finally with the escape of a large quantity of colorless urine, The next morning her right arm and leg were paralyzed. The muscles were relaxed. She could move the leg a little, but only with the greatest effort. The arm was quite powerless. Her consciousness was complete, and had been from the subsidence of the fit. The face Avas not paralyzed, nor did the tongue turn to the right angle of the mouth when she protruded it; her speech was unimpaired, but it was sometimes difficult for her to sAvallow. She complained of frontal headache and inability to sleep. The right pupil was considera- bly enlarged, but the left one remained unaltered. The bowels were obstinately constipated. The menstrual flow, which had begun only a few hours before the hysterical attack set in, was arrested, and did not return. She has been subject to amenorrhcea, and sometimes passes several months without any " show." She has frequently had hysteria in a mild form, but these paralytic symptoms are new, and have alarmed both herself and family very much. This case is apropos to the preceding one. It furnishes another illustration of the hysterical mimicry of which I have already spoken. One would say, at first thought, that Hysterical mimicry. . it would be quite impossible tor this or any other affection to imitate so grave a disease as hemiplegia. But here you see a case in which the right half of the body is power- less. This poor girl had to be carried into the amphitheatre, for she cannot stand alone. When she attempts to walk, the right limb, which seems a little stronger than it was at first, swings with a pendulum-like motion, directly forwards and backwards, but its abduction and adduction are impossible. You will observe that the arm hangs helpless by her side. There is an evident paralysis of the nerves of motion. Let us see if the nerves of sensation are in the same state. For these two forms of palsv have no necessarv relation to each other. A practical test. Observe that when 1 stuck the pin into her arm, to test this question, it was done without her knowledge. If I had told }'Ou in her hearing what I intended to do, and she had seen the point of the pin coming towards her, she would have imagined that she felt it, whether she really did so or not. We must be cautious in these little matters. I once introduced a sound into the female bladder, and on turning it about observed &12 THE DISEASES OF WOMEN. a clicking noise, which exactly resembled that caused by the striking of a metallic instrument against a calculus, which disease she was supposed to have. Having withdrawn the instrument, I was about to declare that my patient had stone Caution. •iTiii l ••in in the bladder, when, upon turning its handle, I discovered that it had become loosened and gave forth precisely the same click that I had heard before. This shows the impor- tance of being always on our guard, lest we arrive at wrong con- clusions in diagnosis. Naturally enough you w r ould like to know what variety of unilateral paralysis it is from which this patient is suffering. I have no doubt but that it is hysterical, and my Diagnosis. , judgment is based upon the following reasons. 1 . She is of the hysterical temperament. This peculiar constitution is as different from the apoplectic habit as the scrofulous cachexia is from the sanguineous temperament. The fact that she has been subject to hysteria before precludes the probability that her paralysis is due to effusion, either of blood or of serum, within the cerebro-spinal cavity. 2. Hysterical attacks commence abruptly, and are not accom- panied by marked signs of congestion, fever, coma or constitu- tional disturbance. There are no lesions of the perceptive centers in hysteria, as there are in apoplexy, whether it be ner- vous, serous, or sanguineous. 3. The relation of the menstrual arrest to the initiatory parox- ysm. A mere suppression of the menses in one of her slender form and delicate organization would not be likely to induce such a determination of blood to the head as to result in apoplexy, or such a disorder of the cerebral nutrition as, in the short space of a fortnight (more especially in one so young), to cause softening of the brain. In such subjects as this the menses are very apt to be scanty and irregular. Hysterical paralysis is more frequent at puberty and the change of life, when these particular crises influ- ence the general nervous system so decidedly, than at other times. 4. The sweeping motion of the leg, and the absence of paraly- sis of the face and tongue, enable us to exclude the more ordinary forms of hemiplegia, and to identify the hysterical variety. Other signs are classed as diagnostic of this singular affection. HYSTERICAL HEMIPLEGIA. 813 Among them are the ability to move the palsied extremity under sudden and powerful emotional impulse. Such Other differential signs. . , , n a patient may sometimes be so shocked or start- led as to use the limb automatically, and without thinking of what she is doing. One of my neighbors, who had not walked a square for months, left her bed suddenly, the night of the great fire in this city, in October last, and marched three miles in order to save her life. If the patient feigns paralysis of the arm especially, you will observe that when she stoops forward she keeps it close to her side. In absolute paralysis of that member it Position of the arm. -i -i i • mi^i ,t r i would be impossible lor her to do so, lor, hav- ing no voluntary control over it, it would fall forward when she stoops towards the floor. Another distinguishing peculiarity of the hysterical paralysis is that there is very little atrophy of the muscles of the affected part. If the arm or the leg, or both, are helpless and Absence of atrophy. useless tor months, their size is not so apt to be diminished as in ordinary palsy. The limb does not become- shrunkp'"> and attenuated, but remains as plump and fleshy as the soul_ ^ne. In many cases, the hyterical fits recur from time to time, with or without choreic movements of the other voluntary muscles. Sometimes there is an incidental aphonia, and globus liystericus is the rule and not the exception. Hysterical hemiplegia is not a very common form of paralysis. Hysterical paraplegia is more frequently seen. In the former it is said that the left side is more apt to be affect- Mav occur in males. ed than the right one. Being largely the result of emotional causes, there is no doubt that it may occur in men as well as in women. Indeed it is very probable that a large pro- portion of the cases of paralysis that are cured by itinerant pre- tenders through the "laying on of hands," animal magnetism, and every species of mummery, are hysterical, functional, emotional, circumstantial, self-limited, and not dependent upon any struc- tural lesion whatever. Unless the disease is complicated with some serious lesion, either of the brain or spinal cord, the prognosis is generally favor- able. It may require a long time to effect a cure, but the patient 814 THE DISEASES OF WOMEN. and persistent use of the proper means will ultimately succeed. In many cases the affection leaves as abruptly Prognosis. . as the hysterical aphonia or meteonsm are apt to do. If the paralysis comes on during the climacteric, the more or less serious nature of the incidental disorders, and the condition of the general health Avill modify your judgment of its severity. Treatment. — - The auxiliary treatment of this affection is very important. It includes the proper employment of friction, elec- tricity, animal magnetism, the movement cure, the health-lift, Faradization, bathing, and ex- ercise, both physical and mental. It prescribes fresh air, sun- light, change of scene, travel, pleasant and agreeable society, good, healthy, and nourishing food, and the careful use of stimulants. It orders the removal of whatever may cause her to become impa- tient and irritable, or that can in any way disturb her mental equi- librium. Ignatia, gelseminum, belladonna, secale cornutum, cuprum, plumbum, rhus tox., coccuius, causticum, baryta Internal remedies. . carb M caulophyllm, phosphorus, and zincum me- tallicum, are the remedies most frequently indicated. A ready expedient for the detection of hysteria consists in the application of pressure which has the effect to A pe diigno& nt in shorten the paroxysm or to solve the diagnostic riddle if the disease is not paroxysmal. One method is to press firmly with the thumbs over the supra-orbital notches, no matter what struggles the patient may make. Another is to press upon the ovarian region, or upon one or another of the hysterogenic points of Charcot until the fit is arrested, or the mus- cular and mental symptoms are controlled. Pressure upon the abdomen, and even in the inguinal region, will arrest the hysteroid, the hysterical and the hystero-epileptiform fit in boys and men as well as in women. LECTURE L, SPINAL IRRITATION — NOTALGIA. Spinal irritation, bsck ache. Case.— Causes, predisposing and exciting-, traumatic and nervous. Symptoms, reflex and direct. Spinal irritation and uterine disease. Diag- nosis in post-traumatic cases, difficulties of, from myelitis. Prognosis. Treatment for the mensirual, rheumatic and neuralgic, complications, local treatment, Faradiza- tion. Physomctra. Case.— Causes. Diagnosis. Treatment. Some of the more advanced members of the class have fre- quently consulted me with regard to the treatment of spinal irri- tation. This woman has suffered from that disease for many years, and her clinical history will doubtless interest you. Case. — Mrs. M., aged fifty, enjoyed excellent health until her eleventh year. At that time, while running at play, she fell and struck the back of her neck against the corner of a table. The blow was upon the most prominent of the lower cervical vertebrae, (vertebra prominent). In consequence of this injury she Avas for six Aveeks very ill in bed, and so extremely weak and sensitive that they had to move her on a sheet. Several months elapsed before she could wear a dress. She finally got around again, but for several years her physicians did her but little good, and none of them referred her poor health to the injury that she had received. Finally, another physician, Dr. , while visiting her mother one day, touched the spot where the blow was received upon the neck, and she suddenly fainted away- Then followed a thorough course of blisters, with tartar emetic dressings, cups, leeches, and four years of barbarous treatment, which to think of, makes her "shudder to this day/' With this treatment, there was much sloughing of flesh from the back, which is all scarred up now. It was a regular field-day when these sores Avere dressed. She cried, her mother cried, and all hands cried, but they could do no better, and she facetiously says, "it was equally impossible to do anything worse.'* In consequence of this injury, the left foot and limb were changed, the heel being drawn up as in a form of club-foot (pes equinus), in Avhich position it remains. She did not menstruate until she had reached her eighteenth year, and then only once. She "never saw anything again" until after she was nineteen years old. From the time that menstrua- tion was really established, she began to improve, and kept toler= S15 816 THE DISEASES OF WOMEN. ably well. At twenty-two she was married, and for eighteen months more her health remained pretty good. Then she skipped one month, and was supposed to be pregnant. At the eighth week she began to flow excessively. The haemorrhage continued, better and then very much worse, without interruption for two months more. Despite this flooding, her size increased until she measured one and one-quarter yards (forty-five inches) around the body over the abdomen. She was said by the physicians to be four months advanced in pregnancy. The flooding reduced her to death's door, and was not relieved until labor pains came on and continued severely enough to expel an enormous mass, which proved to be hydatids. With this mass many gallons of water were also discharged. The mass consisted of small bodies, which, ''varied from the size of a pea to that of a walnut, and which were strung together like grapes upon a stem." Two months elapsed before she could sit up. The lower limbs became powerless, and remained as if paralyzed for many weeks. In a little while the most severe and agonizing headaches com- menced. These recurred frequently, and kept her ill the whole summer. They were excruciating, and so severe that u it seemed as if she would go crazy with them." In eighteen months more her first child, a son, was born. In two years from his birth she had another child, which did not live but a year ; and in five years her third and last child, a daughter, was born. In every instance pregnancy and labor 'were normal in all respects. The labor was very severe, averaging about twenty-four hours, and the children were large. Her first and third children are still living. When she had been married thirteen years, she received a second injury. While on her way to church, and walking on an icy place down hill, her feet slipped from under her and she fell. She thought of her back and neck, and "tried to save them." For this reason she struck upon her right elbow and her head was twisted backwards. She was lifted upright, and, with a woman's courage, walked home again. When she got up her head was fixed backwards, the muscles of the neck were rigid and spasmodically contracted, so that she could not turn the head or straighten it without taking hold, as she did, with her hands upon either side, and forcibly bringing it into position. When it turned, "something cracked as if a bone had suddenly gone into place." To this day she can not look up to the ceiling without supporting her head from behind with her hands. In consequence of this second accident she was kept in bed for about three months. The head could not be moved except by others, or rather excepting by her husband and one lady friend. This had to be done most carefully else it brought on paroxsysms SPINAL IKRITATION, ETC. 817 of screaming, and agony that was almost unbearable. The head- ache returned, but in a different form. The first symptom of an attack was a feeling "as hot as fire almost," in a spot on the top of the head. If the husband began early and promptly when this burning commenced, to rub first over the spot and then to follow along down the body and extremities, the pain in the head would vanish. From that time until now, the region of the spine, for the space of nearly an inch on either side, and running from the base of the skull to the last dorsal vertebra, has been so exquisitely tender that the weight of a feather brush would excite the keenest suf- ferin?. Even if one should point the finger towards the back it would make her "scringe." The lower part of the spine has remained perfectly well. In no sickness that she has ever had, so her husband says, has her mind seemed to be affected in the least. She has frequently been un- conscious and oblivious to passing events, but never in the least delirious or " out of her head." Before the birth of her last child, and for a short time only, she had some pain with menstruation. With this exception, she has never had dysmenorrhcea, or indeed any " female weakness " of any kind. The spine is not as straight as it should be, but is curved posteriorly at a point midway between the shoulders. She can lie best upon her back, and could do so during all her sick- ness ; but, on account of pulling sensations in the opposite direc- tion, cannot lie upon either side. At times the head has felt very heavy, as if the shoulders could not sustain it, and as if it pushed directly downwards toward the body. It is impossible for her to sit upright without something to lean her head against. She can use her hands from the wrists automatically, providing her head and body are snugly fixed and padded, and there is no necessity for moving them.- Beside the experiences in falling she has incurred other risks, among which was the swallowing of a tea-spoonful of the strong tincture of iodine, which a druggist's clerk had put up for Indian hemp ! Opium throws her into violent, frightful spasms, which last for days. She once suffered severely in this manner from taking a small quantity of this drug contained in a cough mixture. She cannot bear either very cold or very warm weather. Her worst attacks of prostration always occur in the winter and spring, generally in the months of February and March. The menstruation is becoming scantier, the flow is very debili- tating and very irregular. As she approaches the climacteric her general health is somewhat improved. Here is a case that would puzzle a clairvoyant. A spinal in- jury of a very serious nature is received at the impressible age of 818 THE DISEASES OF WOMEN. eleven years. Its effect is to delay the establishment of the menstrual function. While the system is suffer- mg, not only from the traumatic lesion of the spinal nerves and muscles, but also from retarded puberty, she is placed under such treatment as would undermine and ruin the health of the strongest person. This voluntary martyrdom was continued for four long years. And } r et she lived. At eighteen, when she had discontinued these barbarities, Nature renewed the attempt to establish the catamenia. The flow came once, but Avas not repeated for more than a year. After her marriage she be- came pregnant as she supposed, and the doctors insisted. Then after two months of flooding on her part, and of blundering on theirs, she is finally rid of a hydatid mass. Months elapsed and she barely survived. Then followed the birth of her three children. After thirteen years of married life she sustained the second in- jury, while on her way to church. (Perhaps it has never oc- curred to you that the men are almost never injured on their way to church.) Then the fearful suffering with the crampings in the muscles of the neck, the hyperesthesia of the superior spinal region, the headache, and the confinement in bed for several months. And, finally, the incidental vicissitudes and experiences so common to the female portion of humanity. This is but an outline sketch of thirty-nine years' experience on the part of this good woman. Causes. — Spinal irritation, as it is styled for the lack of a bet- ter name, most frequently arises from a traumatic injury, as, for instance, from a direct blow, or a fall upon Traumatic causes. . . some portion of the spinal column, or from a railway jar, or contusion. Of course men and women are alike subject to such accidents. But in women, who are more deli- cately organized, whose spinal muscles and predfspon r ent^ gaRization a neryes are softer and more susceptible of injury, the first shock is more severe, and its secondary effects are more lasting and permanent. Add to this the peculiar impressibility of her general nervous system, in many cases amount- ing to a decided hysterical predisposition ; and the perturbing influ- ences of the crises through which she is always passing, or is about to pass, and we find there are especial reasons why she should SPINAL IRRITATION. 819 suffer more severely, and why such mishaps are more difficult of cure in her case than in men. The full significance of this idea is not apparent at first. Not only does it concern the fact that women are especially prone to this kind of martyrdom, but that a large meas- Practical inference. ure of their consequent suffering and mal-treat- ment is due to ignorance thereof. "What a woman wants more than anything else when she is ill, is sympathy. And if her dis- ease is largely nervous, there is still greater need for this kind of universal emollient. But her family and friends are usually the iast to realize how a slight fall, blow or shock, can so completely unhinge and demoralize her physically. They talk about resolu- tion and will on her part, and insist that she shall get up and go around, make some effort to throw off this incubus, and develop strength by the use of it. As a rule, the stronger they are, and tne more muscular, the less their sympathy with this class of patients. This, of course, reacts upon the victim, and she can not accomplish what might be possible under different circum- stances. > A similar mis;udgment on the part of the physician may lead him to adopt such a means of treatment and of exercise as shall only add fuel to the flame. This happened in A common error. the case of Mrs. M. While her nervous sym- pathies and susceptibilities were at their utmost tension, she was put upon the rack and tortured afresh. Her physician made no allowance for sexual impressibility and excitability, and hence the means employed were fitted to increase her suffering rather than to alleviate it. There can be no doubt that the doctor did the best that he <30uld "with the light he had;" but it was the dark lantern of empiricism that he carried. He evidently mistook the case for one of spinal meningitis with effusion. But in this he was in error ; for whatever direct injury of the meninges may have fol- lowed the first fall, received some years before, the symptoms showed clearly enough that dropsy of the cord was not the real cause of her illness at the time she fainted from pressure upon the spinous process of the cervical vertebra. If any considerable effusion had existed and continued for so long a time, there must have been chronic and complete paratysis. 820 THE DISEASES OF WOMEN. The very fact that puberty was arrested, without any intra* pelvic lesion, and that menstruation came on spontaneously when the treatment was suspended, shows that the Of nervous origin. 1 . . disorder was mainly, it not altogether, of a nervous character. And whatever had a tendency more and more to derange her nervous system could only produce further irritation, perturbation and unrest. The marvel is that she sur- vived such unskilful and harmful treatment at all. Other causes of spinal irritation are strains, as from lifting, or jumping, lying, sitting or standing habitually in such a posture as to keep the spinal muscles on the stretch, and Exciting causes. ^ thus to weaken and paralyze them. Rheuma- tism and neuralgia being predisponents of this disease, persons who have either of them are more or less decidedly susceptible to changes in the weather. For this reason, among others, as with our patient, extremes of heat and cold, and more especially of dryness and moisture, influence it greatly. The jar of travel by rail, in a rough carriage, or upon horseback, may induce it. And so, also, of tight lacing, the wearing of high-heeled shoes, and of articles of dress which are fastened at the waist and not hung upon the shoulders. Symptoms. — The symptoms are almost endless in their variety. If the disease has been caused by direct traumatic injury of the spine, the most severe pain will be located there, and we may accordingly find the suffering referred either to the lumbo-sacral,. the dorsal, or the cervical region. If it is in the sacral region the pain will be less acute than when it is higher up along the vertebral column. It will be dull, aching and heavy in character, with complaint re ^™™ in J ur y in the sacral 0I> g rea t weariness, exhaustion, and perhaps of numbness also. The patient wishes something to be pressed "into the hollow of her back," or to have her hips rest firmly upon something for support. She often stuffs a pillow or her shawl, or something of that kind, beneath her, or behind her, to rest her back and to give her ease. These pains are often accompanied by intra-pelvic pains, bearing down and distress, as if the womb were displaced. Indeed, they are often wrongly attributed to some slight and temporary deviation of the womb, and the attempt is made to cure them by pessaries, injections, etc. SPINAL IRRITATION. 821 When the results of the injury, or the lesion, if there is one, are located in the dorsal region, the pain is more acute, with super- sensitiveness of the skin over the spinous pro- re? °n m injuryin thedorsal cesses of the dorsal vertebras. Sometimes these processes are exquisitely tender to the touch. Direct pressure upon them, although it may be slight, may cause her to fall, to faint, to vomit, or to shriek as if she had been shot. I have seen two cases in which the pain produced in this way was compared to that from stabbing with a very sharp knife. The dorsal vertebrae are most frequently affected. If the blow has been received, or the injury clone to the spine, in the cervical region, the pain and soreness will vary according to circumstances. The suffering is apt to be From injuryin the cer- y er y severe. Sometimes the arms become pow- vical region. J J- erless from injury of the nerves which consti- tute the brachial plexus. Other branches of the cervical nerves being injured by the blow or the shock, the muscles of the back part of the neck are more or less implicated. These muscles, which }^ou know are very numerous, including the splenius colli, splenius capitis, cervicalis ascendens, transversalis colli, the tra- chelo- and sterno-mastoid, complexus, spinalis cervicis, trapezius and the obliquus superioris, are those which were spasmodically affected in the case of our patient, It was the painful cramp or contraction of these muscles that caused her head to be almost as immovably fixed as it is in torticollis, or wry-neck. Pressure upon the tender cervical vertebra may even stop the pulse at the wrist. When the symptoms are produced by other than mechanical causes, they are usually less intense but more erratic in their nature. The spinal tenderness is more diffuse. From incidental causes. . . It may be located m any portion of the back from the occiput to the point of the coccyx. Light pressure on the spinous processes of the tender vertebrae produces consider- able pain, while firm pressure may be borne without flinching. This shows its neuralgic character. Now, from what I have said you will infer that the causes of spinal irritation act either centrically or ec- trkaction entnc and eccen " centrically. In the former case a mechanical injury is done to some portion of the vertebral column. The shock is felt by the spinal nerves, and the muscles 822 THE DISEASES OF WOMEN, participate more or less in the painful result. In the eccentric- variety, however, the cause is more remotely applied. The irri- tant is at work at the incident nerves in their distribution to some muscle or organ, and, in a reflex way, the spinal center may be- come implicated even to the extent of producing absolute organic disease of the medulla, or of its enveloping membranes. The pain and trouble may become localized, but the irritation caused in these nerves is more apt to be reflected from the cord again to some particular organ or apparatus, as, for example, to the stomach or the bowels, to the bronchi and the lungs, to the heart, the head, or the liver. It is in this manner that utero-meningeal disorders originate and are perpetuated. There are undoubtedly many cases of spinal irritation that are in no way connected utfrfnTdbe2e ion and with uterine disease. And there are other cases in which, for sexual reasons, and on account of the perturbing influence of the menstrual molimen, or of maternal contingencies, the womb becomes indirectly and sec- ondarily implicated. But there are other cases also in which the uterus has been the prime factor in this morbid process ; cases in which the spinal nerves and the medulla itself have become de- ranged and diseased in consequence of some pre-existing uterine lesion. For this reason there are few confirmed examples of " irritable uterus," in which these two affections do not co-exist. Moreover, most of the fugitive, peculiar, inexplicable local pains, burning and suffering that are incident to confirmed dis- eases and deviations of the womb, arise from Reflex symptoms. . ... . uterine irritation which is conveyed by the sensitive nerve filaments to the cord and then reflected to these different points. It is thus that the infra-mammary pain is pro- duced. You remember that Dr. Simpson said this pain was as characteristic of uterine disease as the pain in the point of the shoulder is of hepatic disorder. We may refer the occipital headache of menstruation to a similar cause. The point which I wish to make is this, that the continued application of this irri- tant, brought from the suffering part to the sentient center, in the person of delicate, nervous women, is almost certain to cause a greater or less degree of spinal irritation. And what is true of the uterus is also true of the ovaries. The SPINAL IRKITATIOX. 823 most troublesome cases of spinal irritation that I have ever treated originated in ovaralgia. The contingencies that From ovarian implication. . , , , beset ovulation even when the periods are regu- lar ; that may derange the innervation of these organs at puberty and the climacteric ; that may result from intemperate coitus and similar causes, are indirectly responsible for a large proportion of cases of what are termed spinal irritation. There may be cases in which the converse is true, and wherein the ovarian disease is sec- ondary upon the spinal lesion. Indeed, it is sometimes extremely difficult to decide between the cause and its effect, and to say positively whether the ovarian lesion is idiopathic, or vice versa. As a rule, however, I think you will find that the other coinci- dent disorders which sometimes attend upon spinal irritation are almost always secondary. Such are the dis- Secondary diseases. . . _ eases ot the respiratory system. It is seldom that aphonia, spasm of the glottis, dyspnoea,' or a violent nervous cough, in these cases is not directly referable to the spinal lesion. So also of functional troubles of the heart, and of the digestive system. We look to the spinal center for their cause, and hope to relieve them by its cure or removal. Diagnosis — Providing it has been caused by direct injury, and is therefore traumatic, the diagnosis of spinal irritation is not very difficult. This is true, no matter how long a In post-traumatic cases. . . period may have elapsed since the injury was sustained. It holds in Mrs. M.'s case, for example, although thirty-nine years have passed since the date of the accident. For this reason you should take especial pains to enquire whether such a patient has ever fallen, or received a blow upon any part of her back. It is possible that so long a time has elansed since the accident occurred, or that the mischief itself was attended by so little pain and immediate illness, that it may have been for- gotten. She may have tumbled down stairs, fallen upon the ice, from her horse while riding, or from a chair upon which she was about to sit, and hurt her back long ago, but because she thought it a trivial affair at the time, may forget to mention the circum- stance unless you enquire for it. Or it may happen that on account of mechanical injury to the coccyx during labor, a similar train of symptoms may have 824 THE DISEASES OF WOMEN. been induced. In a word, whenever you can refer the lesion to a traumatic injury, however complicated the May arise from coccyodynia. . . , -. attendant symptoms, or trivial and remote the date of the accident, the original idiopathic disease will not be difficult of recognition. But, under different circumstances, the case is very different. When neither the patient nor her friends can recall such a misfor- tune, and there is no reason to believe that any di£™si!, lties in the way ° f portion of the vertebral column has ever been directly injured, it will not be so easy to decide the question. The tenderness of some portion of the spine upon contact and pressure, more particularly if it is constant, or habitual in certain positions of the body, is quite characteristic. If this tenderness is aggravated by the return or interruption of the menses, by coitus, by emotional states, or by sudden displace- ments of the womb, there is manifest spinal irritation of a reflex nature. Sometimes this exacerbation of pain and super-sensitive- ness in the spine alternates with the sexual infirmity or excitement, and this fact will help you to differentiate it properly. In very rare cases there is a cutaneous anaesthesia, which is allied to the pseudo-narcotism of hysteria, and which is almost invariably due to uterine or ovarian disease. Spinal irritation should not, and need not be confounded with inflammation of the spinal cord or of its membranes. Its advent is not characterized by a chill, rigors or fever. no™! n thtcorT^c f : amma ~ Tlie P ain is circumscribed in extent, erratic in character, and, in general, is worse upon slight, than upon steady or firm pressure. There is less dread of motion, and, unless in case of traumatic myalgia, more ability to move about than in real meningitis and myelitis. In the adult, menin- gitis is almost always either traumatic or epidemic. If paralysis occurs in spinal irritation, it is self-limited and not permanent, as it is apt to be in consequence of inflammation with serous effusion into the spinal canal. This disease may be distinguished from true neuralgia by the diffuseness of the pain which does not follow the track of any nerve or nerves, but is characterized, so far as it extends, by a general cutaneous tenderness. The reflex irritability is exagger- ated, and sometimes intensely so. Spinal irritation bears a pretty SPINAL IRRITATION. #25 eiose resemblance to neuralgia, however, in such cases as we have had under review this morning. For where the cervical vertebrae are injured, it presents many of the symptoms of cervico-brachial neuralgia. This is especially true in highly neurotic patients. Prognosis. — The prognosis will depend upon the location, nature, extent, severity, and duration of the spinal lesion, the age of the patient, her peculiar nervous impressibility, and the more or less serious derangement of the menstrual function. The dan- ger is not usually proportionate to the degree of suffering. Coin- cident disorders of respiration may be more grave in character than such as implicate digestion. The nervous symptoms are usually more alarming than serious, although it is possible that permanent paralysis of some of the voluntary muscles may fol- low. In some cases there is a form of hysterical mania that is quite unmanageable by the ordinary means, which is, however, likely to terminate of itself, providing too much is not done in the way of treatment. In case the irritation has been caused and maintained by a lesion of the generative organs, the possibility of cure will depend upon one of two things ; (1), the curability of the uterine or of the ovarian disease, whatever it may be, and (2), our ability to remove such sequelae as may remain when the antecedent affection has been remedied. Patients with spinal irritation frequently recover when the climacteric has passed. Treatment. — These are the patients who travel from one physi- cian to another. By the time you have them fairly in hand you will find that they are experienced itinerants. Itinerant patients. tit r> Iheyhave run the whole gamut ot the profes- sional possibilities, and, at last, are persuaded that, if you can not benefit them, nobody can. But, in a short time, unless you are very skillful in treating them, or successful in satisfying them that you do really understand the case and expect to cure them, they will be adrift again. If from any cause the symptoms of spinal irritation are devel- oped, as they were in this case, at a time when the menstrual function is about to be established, or when the ^Guarci the menstrual func- c ] mn g es ^.^ are i nc i(l en t to puberty have already begun, you should take the greatest possible care to do nothing that can interrupt this process, or pre- S26 THE DISEASES OF WOMEN. vent its accomplishment. Your aim should be to remove all obsta- cles thereto, and so to regulate the operations of the nervous system as to favor and assist Nature in her critical effort. For it is manifest that if puberty is not delayed, and the catamenia appear as they should, the nervous and other functions can not be in a very bad condition. If the symptoms of spinal irritation appear when the menses. have been suppressed, as after pregnancy, lying-in and lactation, or from amenorrhoea, a similar indication will In amenorrhoea and at ex ist. Alld if they COHie Oil with the dimaC- the climacteric. J teric period, you will bear in mind what I said in my last lecture concerning their treatment under these circum- stances. Incidentally, whatever disease may drain the patient's strength or exhaust her energies, should be remedied as speedily as possible. A quarter of a century ago, when this poor Remove any dangerous woman suffered for two consecutive months condition. with uterine haemorrhage that was due to the presence of a hydatid mass in utero, there may have been some excuse for a lack of promptness in emptying the womb and stop- ping the flow. For the sponge-tent was unknown, Bnd physicians had almost as great a dread of manipulating or operating upon the uterine cervix as surgeons had of opening the cavity of the peri- toneum. But now such a haemorrhage should not be permitted. The neck of the womb could be readily dilated and the foreign body removed. In order to counteract the peculiar impressibility of your female patients, and thereby to put them in a condition that is favorable to the cure of spinal irritation, you will need Tact and sympathy. . to exercise a great deal ol tact and a large measure of sympathy and discretion. Rough treatment may sometimes be tolerated in other cases (although it is inexcusable) r but in this disease it will not be borne. The patient's perceptions are too acute, and she is too susceptible and sensitive to be treated in such a way. Your manner should be kindly, your words fitly chosen, your tone sympathizing, and your faith in her desire to get well, and not to deceive you, unbounded. If you are fully impressed with the tenderness and delicacy of her organization on the one hand, and with the irritable, excitable and wretched state SPINAL IRRITATION. 827 of her nervous system on the other, you will never be guilty of adopting such a mode of treatment as must necessarily make her worse instead of better. If the attack originated in a strain, shock, blow, or fall, although years may have passed since the injury was sustained, arnica, rhus tox., calendula, or the hypericum s P Fn°a r i hljury^ 015 ° f the P er f-> w iH be indicated. I have s^reat confi- dence in the latter remedy given internally and applied locally at the same time for traumatic injuries of the spine and its membranes. The other medicines named may also be used both constitutionally and externally. For rheumatic and neuralgic complications the most prominent remedy in many cases is macrotin, after which there are rhus tox., bryonia, spigelia, belladonna, atropine, aconite, raigfc symptoms and neu ~ veratrum alb., veratrum vir., colocynth, lachesis, caulophyllum, nux vomica, colchicum, and gel- seminum, with the leading indications for which you are already familiar. Whatever uterine or ovarian diseases have been sufficient to cause or to complicate the spinal lesion, should first be treated as if they existed separately and idiopathically. But rian°s ^m t l oms ne and ° va " wnen these are removed or cured, such spinal and nervous sequelae as remain may be treated more directly and specifically. Uterine deviations, cervicitis, hypertrophy, and ulceration of the cervix uteri and hysteralgia are the more frequent of these affections, which have the first claim on our professional attention. To these may be added sub- acute and chronic ovaritis, and ovarian neuralgia. The respiratory, digestive, hepatic and general nervous derange- ments which are secondary upon the spinal trouble, will usually yield to treatment that is addressed to the cure For contingent disorders. n i t • oi the lesion upon which they are dependent for a cause. The symptoms must be carefully studied and the remedy affiliated properly, else there will be but a poor prospect of success. Local adjuvants are sometimes of the greatest possiole service in the treatment of this troublesome com- Local treatment. plaint. They are not only grateful and useful on account of the relief which they afford, but do really assist in 82S THE DISEASES OF WOMEN. the cure. I suppose that their modus operandi is by excluding the presence and pressure of the atmosphere upon the tender sur- face along the spine. My own preference for these local expedi- ents has been based upon the following indications : If the muscles of the back or of the neck are cramped and very painful, I direct that the surface shall be thoroughly anointed with camphorated oil. This may be gently For painful cramping, etc. . tit rubbed over the painlul part, or applied by means of flannel compresses. The oil soothes and softens, and the camphor relaxes the muscular spasm. Bathing with spirits of camphor is less efficacious, because both the camphor and the alcohol evaporate so quickly. Where there is less pain and more diffuse tenderness, it gives great relief to coat the surface with the oleaginous collodion. If the disease has resulted from a mechanical cause, you will not forget the local use of arnica, hypericum, calendula and hamamelis. I believe these topical applications Topical expedients. .',.-.. . have the best effect, m this disease especially, when they are diluted in and applied by means of hot, instead of cool or cold water. In mild cases, a porous plaster will sometimes afford relief. Dry cupping, and the exhaustion of the air by means of cups to which the air-pump is attached, affords a useful expedient in some cases. But sinapisms, blisters, pustulation by croton oil or tartar emetic, and issues and setons of all kinds are harmful and unnecessary. The spine should be insulated as it were, by a layer of cotton batting, or of oiled silk, wwn next the skin. The cotton may be sewed into the clothing and kept constantly applied, day and night. It should extend from the neck throughout the whole length of the back. In many cases, more particularly in those who are predisposed to rheu- matism, the patient should wear a silk vest, or under- wrapper, to protect her from sudden vicissitudes of the weather, and from electrical changes. Sponging the back from above downwards with warm, or hot water, may help to remove the extreme sensitiveness of the integu- ment. It should be done very carefully how- Available expedients. -, . n •-> n i l ■ • ' • ever, and, if possible, by a person who is m sympathy with the patient, and towards whom she has no feeling SPINAL IRRITATION. 829 of antagonism. In chronic cases, with marked debility, salt- water spongings along the spine are sometimes very beneficial. In certain cases, the shower-bath, electricity, and animal magnet- ism may also be useful. They should, however, be administered with care and discrimination, else they may only serve to increase the difficulty. The electrical bath answers as an available tonic, when the general strength is very much reduced, and the patient's nervous system needs a ready means of support of some kind. A recent writer says: " There is one special phase, however, of spinal irritation which is very amenable to a direct treatment, viz., cutaneous and mucous tenderness. When- Faradization. . , . . , . . ever the 'ny persist he tic part is within reach, so that we can apply Faradization, we can almost certainly eradi- cate the morbid sensibility very quickly. The secondary current of an electro-magnetic or volta-electric induction apparatus is to be employed; the conductors should be of cliw metal, and the negative one, which is to be applied to the painful surface, should be in the form of the wire-brush. The positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backward or forward over the sensitive skin, a pretty strong current being employed. The process is painful, so much so that it will often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the Faradization. A very few daily sittings of four or five min- utes length, will generally remove the morbid tenderness com- pletely. When the tender part is within one of the cavities, as the rectum, bladder, vagina, or pharynx, we must of course use a solid negative conductor of appropriate form, and must content ourselves with applying it to one point after another of the sensi- tive surface." Here are the notes of a case of " back-ache" which applied for treatment a few days ago. Case. — Mrs. , aged 27, living in Wisconsin, is the mother of two children, the youngest of which is eighteen months old. From her marriage at eighteen, until the birth of her child in the twenty-first year, she was subject to uterine catarrh, and was in wretched health in consequence. But after the baby was born she recovered entirely, and was well until the birth of her second child, two years later. " Her second labor, which was more tedious and difficult than the first, was natural, except that the placenta was 830 THE DISEASES OF WOMEN. so adherent that the doctor had great difficulty in removing it. For four years she has not seen a well day. Her symptoms are a con- stant pain in the back which unnerves her, keeps her off her feet, and " drags the very life out of her." The stomach is upset, the emotion are demoralized. She is bankrupt physically, cannot sleep, eat or think as she should, and, more than all has been through the hands of five doctors. A local examination disclosed a decided prolapse of the womb and the vagina, and a laceration of the perineum as far as the sphincter and, she had never been examined but once before, when, she says she was almost killed by an instrument that was forced into the vagina ! It really was unnecessary to use a speculum, for with the perineum laid open and the vagina almost everted, the uterus fell readily into view by the mere separation of the labia. It seems incredible that so many physicians could have prescribed for her without havinff made a local examination. But it is not strange that she should have had so many symptoms of dilapida- tion, and that her nervous system should be such a wreck, when the pelvic organs were in such a condition. PHYSOMETRA. Case. — May, 1864. Mrs. B , aged twenty-tour, of san- guineo-nervous temperament, has been married six years, and is the mother of two children. She was delivered of the youngest ot these, one year ago, — during the riots in the city of New York. She says she had a short and easy labor, after which she did well until the third day, when, the report having been circulated that the house in which she was living would be fired or destroyed, she was obliged to remove to another. The distance being only two squares, she insisted upon walking, and really accomplished the task, but under great mental excitement. The result was at first a partial, and after the fifth day, a complete suppression of the lochia. In a short time her present symptoms began to trouble her, and they have continued during the whole year. There is a circumscribed enlargement of the abdomen, situated in the mesian line, and extending from the pubis towards the umbilicus. This tumor increases in size so that at times she is quite as large, and looks as if she were seven months advanced in pregnancy. At other times, and especially after a good night's rest, its size is greatly reduced. Exercise and excitement increase its volume. When she reclines the tumor gravitates or rolls toward the side upon which she is lying, but without any change in its form, and PHYSOMETRA. 83 without borborygmus. It is still circumscribed, and always tym- panitic. The neighboring parts yield their normal sounds on per- cussion. The only pain she has had is a species of soreness from outward pressure, or distension. She is at times sensible of hav- ing had a discharge of flatus per vaginam, but has never had eructations. Sometimes, she says, this tumor or swelling feels as if it were rising into the stomach, and again into the throat. Occasionally she has headache and a flushed face, especially in the afternoon. She is a very intelligent woman, and is confident that she has never before had any uterine difficulties. The urinary function is normal, and in every other respect she is healthy. She was unable to nurse her child. It may be a long time before you will see so good an illustra- tion of this curious affection as we have here this morning. Indeed, owing to its rarity, many physicians of The tumor. . . large experience have never seen a case of this kind. If you observe the physical characters of this phantom tumor, } r ou will note that its outline is as well-defined as that of an ovarian cyst. It may be very hard, or it may yield to pressure, like a soft foot-ball, and is tympanitic on percussion. You hear this sound distinctly. The tumor changes its position when she turns upon either side, and rolls about to a limited degree, but there is no bulging in the lumbar region, and no flattening of the anterior surface of the tumor when she lies upon her back, as in ascites. Physometra, or the collection of flatus in the womb, is almost always, directly or indirectly, related to gestation, or to the par- turient state. Sometimes, however, it occurs during menstrua- tion, and again in consequence of the presence of uterine hyda- tids, moles, polypi, and such intra-uterine growths as are liable to become decomposed, either before or after their detachment. Whether as cause or effect, hysterical symptoms are always pres- ent in these cases, as in other forms of tympanites to which women are more especially, but not exclusively liable. The lochia, the milk, and the menses, are suppressed. Sometimes, however, the breasts fill as they do in pregnancy. The nervous symptoms predominate. The most commonly accepted cause of this singular infirmity is the retention and decomposition in utero of the foetus, of some 832 THE DISEASES OF WOMEN. portion of the secundines after delivery ; or similar changes in fragments of intra-uterine growths which have failed to be expelled by nature, or removed by the physician. The gas that is formed in consequence of the decomposition of organic matters is fetid, reSfneT 1 " 05 ^ " ° f ma " er ancl is incarcerated in the cavity of the womb by the spasmodic closure of the cervical outlet. It is possible that similar changes may take place in the men- strual excretion, and also in the membrane (decidua menstrualis), which is sometimes exfoliated during that process, and which if it is retained by closure of the uterine neck, might also undergo chemical decomposition. Occasionally the arrest of the lochia results in the development of this form of uterine tumor. This cause is more powerful when conjoined, as in this case, with apprehension and anxiety, as well as with premature exposure and excess of fatigue almost immediately after the birth of the child. Some writers ascribe the uterine enlargement in physometra to a collection of atmospheric air in the womb, which is either drawn into that organ by a species of suction, or passes ^suction of air into the i n ^ ft w h en the os uteri is open and other mat- ters have so escaped as to leave a vacuum, into which the air may rush until it is filled. Dr. Harley cites a case of alternate admission into, and expulsion of air from the vagina.* Something of this kind, it is thought, may, in very exceptional cases, take place in the womb. But there are instances in which, unless we ascribe it to mental excitement, it is quite impossible to detect any cause for this tumor. Acting upon a hysterical predisposi- Mental causes. . tion, there is no valid reason why an excess of flatus might not be as readily secreted or formed within the ute- rus, as it obviously may in the bowel or the stomach from a simi- lar cause. And nothing is more common than hysterical tympan- ites from emotional causes in this class of patients. But I will not detain you with further remarks on this subject. The diagnosis is much easier than it was a few years ago. You have only to put the patient under the influ- ence of chloroform or ether, and the differenti- ation of this species of tumor will declare itself. For if it is a case transactions of the Obstetrical Society of London, Vol. IV., page 173. PIIYSOMETRA. 833 of physomctra, or indeed of a phantom tumor of any kind, the enlargement will disappear altogether. You can satisfy your- selves that the accumulation has been in the womb and not in the bowel, by passing a small can u la, or a male cathether, through the os uteri. Then, by placing the outer extremity of the in- strument under water you can evacuate the tumor through it, and be assured of the escape of gas therefrom. I tried this ex- periment on our patient yesterday, and, therefore, am confident in my diagnosis. The treatment consists in removing any decayed substances that may have remained in utero ; and in preventing their retention in the future. The cervix may be kept open for the free discharge of such matters, and of the gas also, by the use of the sponge-tent and the ordinary means of dilatation. If the case is a recent one, and the lochia have been suppressed, they should, if possible, be restored. If the patient is hysterical, this tendency should be counteracted by appropriate medical, moral and hygienic means. If the excessive size of the tumor worries her, it may be evacuated a few times for her com- fort during the day.* In case the uterine tympanitis depends upon the retention and decomposition of water within the womb [hy- Tappins the uterus. drometv ^ G f blood within the same cavity [hsematometra], or of pus [pyometra], the fluid or its debris must be evacuated either by paracentesis, or by the forcible dila- tation of the cervix uteri. But, you should remember that the mere expansion ot the neck of the womb and the escape of the decomposing fluid is not all that would be required. For putrid or purulent changes would only be hastened by insuring its contact with the air ; and hence it is quite as necessary to cleanse the uterine cavity of its poisonous materials as it is to furnish an out- let for them. Although it is the fashion just now to carbolize the intra- uterine injections when they are necessary, both tions ra " UterinelnJeC " in the Puerperal and the non-puerperal state, my own preference is for a solution of the chloride of lime, which is a better disinfectant, and quite aa good an anti-septic. As you have seen us use it in our puerperal * In four weeks this woman was well and menstruating' normally. 834 THE DISEASES OF WOMEN. wards, you may add a tablespoonful of the officinal solution of the chloride of lime, which you can obtain from the druggist, to a quart of warm water that already contains a tablespoonful each ot glycerine and calendula. If the odor is extremely offen- sive, the proportion of the lime-water and the glycerine may he doubled. In a very interesting case of physometra that was brought to me by Dr. A. J. Howe, of California, there was a marked increase in the gaseous accumulation whenever the patient had an excess of mental work or worry, and her greatest relief was obtained by letting the mind rest, more especially at the time of the monthly period. Part Ninth. THE SURGICAL DISEASES. LECTURE LI. UTERINE SURGERY VERSUS UTERINE THERAPEUTICS. Uterine surgery vs. Uterine therapeutics. The gynaecological chair or table. Vagm» ismus. The line of demarcation between sanity and insanity, animal and vegetable life, and this world and the next, is not more indefi- nite than that which separates surgical from therapeutical indica- tions in the cure of many diseases. This is especially true of the treatment of the Diseases of Women. What reliance shall be placed on manual operations, and what upon medicinal influences in curing them, is an unsettled question. There are those who insist that, in this specialty, surgery is almost omnipotent, and^er contra those also who claim that constitutional remedies alone are adequate to the end in view. The attentive student of gynaecology is aware that within the last quarter of a century, Uterine Surgery has developed from a rudimentary to an almost perfect branch of Value of uterine surgery. -..,. T , n . , -. • -i i medical science. It has furnished us with the most approved and available means of diagnosis, and with a mul- titude of resources for the relief and cure of certain diseases that w^ere the opprobrium of medicine. It has fulfilled old indications with new and approved instruments, reconstructed the special pathology of sexual disease, and re-organized our aims and pur- poses and expedients in such a manner as to add very greatly to the comfort and welfare of woman. It has added another chair to the medical curriculum, augmented and improved our litera- ture, and developed a new and most useful specialty, which al- ready is more popular than any other, and which, at no distant day, bids fair to engross the attention and to appropriate to itself a large share of the medical talent of this and other countries. It was a very natural consequence of this rapid growth in the professional and popular favor that the claims set up for Surgery^ 835 836 THE DISEASES OF WOMEN. as applied to the treatment of the Diseases of Women, should he somewhat exclusive and extravagant. Dr. Extravagant claims. . Joennet irames his formula that ulceration and induration of the uterine cervix lie at the bottom of nearly all the diseases peculiar to the sex. Local cauterization will frequently remove these conditions — which he has been shrewd enough to confound in his writings, and therefore escharotics are specific. The generalization is the bait, the manipulation attracts, and the parade causes a premium to be placed on the operation. Forth- with his experiments and deductions are the text and the theory for an indiscriminate local treatment designed alike for all kinds of uterine affections and utero-visceral derangements. Sir Jas. Simpson incised the cervix as a remedy for obstructive dysmenorrhcea. Sims adapted his scissors as a uterotome, and improved upon the operation. The same oper- Illustrations. . ation was soon recommended tor the cure ot sterility, and retro-flexion of the uterus. Then it was applied to the relief of the intractable uterine haemorrhage, and as a means of exploration and of facilitating excision in uterine fibroids. Now, in multitudes of cases, the uterine cervix is slit open, with every possible kind of result. The operation is a favorite one, for blood is shed, and there is some cutting in the dark, — which is always attractive in ratio with the risks that are taken. The various modifications and varied uses of the uterine specu- lum, the sound, the probe, the sponge and other tents, the explor- ing needle, the endoscope, and physical exploration by palpation, auscultation and percussion, have engaged the almost exclusive attention and confidence of uterine pathologists. Armed with these instruments, and aufait in using them for purposes of diag- nosis and of treatment, it is not at all strange that they have come to place an almost exclusive reliance upon them, and that the claims of a coincident and conservative thera- tiSi? ri r e nore e d apeuticsprac "P eu ^ cs should, have been either overlooked or disregarded. They esteem the proposal to unite a course of medical with the surgical treatment of uterine ulceration, cervicitis, or endo-metritis, for example, as altogether superfluous — a species of superf (station. When their resources are sufficient, and their work is substantially clone, why propose to add anything, or. to substitute it with what is less attractive, UTERINE SURGERY VS. UTERINE THERAPEUTICS. 837 ilashy, seductive and sensational ? For, with all our boasting, it remains that, in this class of diseases, the operation of the best chosen internal remedies, is not and cannot be instantaneous. The relief they bring in chronic uterine and ovarian affections especially, comes only "after many days.*' They do their work quietly, and without any of the ad captandum eclat of a surgical exploit, or a sanguinary battle from the possible effects of which the patient may never recover. It is an axiom in midwifery that, whether natural or induced, the most rapid cases of labor are not the safest. In uterine surgery the risks are in ratio with the bold- ness and dispatch of the operator, which qualities are almost insep- arable from its employment. It is equally obvious that the disproportionate development of uterine surgery is due to causes that can be explained, and which are avoidable. Let me call your attention to a few of them. 1. The groiving scepticism in the minds of specialists concerning the effects and efficacy of internal medication. Providing he is edu- cated and thoughtful, the pursuit of a medi- JcESfclr respecting cal specialty invariably inclines the physician to place less reliance, than does the general practitioner, upon constitutional treatment as a means of cure. The oculist and the aurist are not given to the common weakness of dosing their patients. Those who treat the diseases of the respiratory organs exclusively and most skillfully have more con- fidence in hygienic measures than in medicine. With every class of specialists, the higher the grade of their qualification, and the broader their field of observation, the lower their estimate of general treatment. For these men are sufficiently educated to discriminate and to differentiate. Their knowledge of physiology and of pathology assures them that, not only does every part suffer with the sick organ, or member, but that for the same rea- son, whatever lowers the general vitality will lessen the chances of recovery. Uterine pathologists necessarily reach a similar conclusion. Un- less their ideas of medicine, and of its capacity to cure, or to injure, are stereotyped and more or less anti- Abandonment of old ideas- quated, they gradually abandon the old thera- peutics, and learn to place an increased trust in modern surgery, with its topical expedients and its manifold resources. The 838 THE DISEASES OF WOMEN. cultivated gynaecologist of our day would as soon think of resorting to general blood-letting in hysteria, as to the use of emmenagogues in amenorrhcea. When Dr. Thomas coun- sels that the bowels shall be left in a constipated condition in endo-metritis, it implies not only that he has a clear idea of the indications that are presented for the cure of that disease, but also that, in proscribing cathartics, he is interested in removing a fertile source of mischief in uterine complaints.* Without pausing to elaborate this idea, it must suffice to call your .attention to the fact that the cultivation and practice of this specialty, as of every other, has had a two-fold result ; (1) it has stimulated a development of a special branch of surgery : and (2) it has impaired the general confidence in wholesale medica- tion for the cure of limited functional and organic disease. 2. The natural preference which physicians, and their patients also, have for operative interference instead of internal treatment, whenever the former is possible. As compared Surgery more popular. -,1,1 ,-t l • • i i j with the surgeon, the physician labors at a great disadvantage. And the reward of his skill and patience are often disproportionate to the time and care bestowed on the cure of intricate and dangerous diseases. Although they may be equally skillful, each in his own department, my friend the professor of surgery will most likely gain more eclat by cutting off a limb, or excising a tumor, than my colleague in the chair of theory and practice will from curing a case of cerebro- spinal meningitis, Bright's disease, or of angina pectoris. All of which implies that we involuntarily place a premium on the manual operation, while it is such an ordinary affair for the phy- sician to tide his patient over his difficulties in a more quiet way, that but little relative stir is made concerning it. We do not criticize this propensity, although it has sometimes led to deplorable results. For it is impossible that such a large number of earnest and able workers should devote t Ie e n r e Te U cted S . oughtnot their lives to the study and practice of uterine surgery without bringing it to a certain de- gree of perfection. And the more popular, the larger the field of experience, the greater the number of those who are competent to * A Practical Treatise on the Diseases of Women ; by T. Gaillard Thomas, M. D„ etc., etc., Philadelphia, 1872, page 227. UlERINE SURGERY VS. UTERINE THERAPEUTICS. #39 practice it, the older the study, the more thorough its literature, the greater, better and more lasting will be the benefits conferred by it upon the profession and upon the race. But an evident result of this bias toward surgery is a neglect to cultivate and develop the curative sphere and relation of our remedies to the class of diseases under con- Studythem. . . . sideration. We study the special therapeu- tics of other ailments most carefully. It is not permissible to transfer them to the domain of a different branch of the healing art. Every species of clinical enquiry and analysis is entered upon and prosecuted with a view to the proper selec- tion of the remedy or remedies. The symptoms are balanced, the signs are translated into a familiar language, everything is made available, medically, to effect a cure through the opera- tion of the vital forces. If we could point to therapeutical results in gynaecology which compare with those of uterine surgery, results which were as carefully obtained, as accurate and trustworthy in every particular, as critically analyzed and as readily available, our usefulness would be doubled, and the little world in which we now work as specialists would consist of two hemispheres instead of one. 3. The comparatively limited opportunities and skill of those who have labored especially to develop uterine therapeutics. — The allure- ments to surgery, and its very general prac- spSfaulr 1 ^ 65 ° f the tice among physicians and specialists, diminish- es the number of those who are laboring to define and determine the special therapeutics of uterine and kindred diseases. And the tendency of patients who are thus afflicted to estimate what is done for their relief and cure by the scale of suffering and risk at the hands of the doctor, lessens the number of those who are willing to trust and to wait for the results which might often be obtained by fitly-chosen remedies. Acid ., -, peculiarities, habits and education ot the phy- sician, and also, as we have shown, upon a variety of circum- stances. To declare that either of them is superfluous, and to declaim against its employment, very naturally excites a pre- UTERINE SURGERY VS. UTERINE THERAPEUTICS. 841 Judice against those who talk and act so unreasonably. It is a question of boundary lines merely, and since the whole field belongs to us, we can shift the fences from time to time and cultivate the crop of expedients that will prove to be most valuable and useful. To compensate for this lack of interest in medicine as applied to the treatment of the diseases of women, it will be necessary, 1. To have a series of new provings, on women, which shall be made with the greatest possible care and discrimination. — The health of woman is beset by so many contingencies, and ^7.1^^™°™™ she is subject to such crises as to render it very difficult to find one who, both in her- self and her surroundings, is suited to become a prover ; and the physicians who are really competent to superintend such a proving are perhaps equally rare. For, if such an index to the remedial relations of a drug shall be trustworthy, it implies that the physician who undertakes this labor is fully conversant with the whole range of uterine pathology ; that he has subjected his patient to the test of a most searching examination ; eliminated all the symptoms which • are naturally incident to menstruation, maternity, puberty, the climacteric, and also to her relations as wife and mother, to the church and to society, as well as to the distinctive susceptibilities that pertain to her sex, and which are so perplexing to all of us, and retained and classified only those symptoms which were unmistakably due to the action of the drug. The fact that this labor has not already been perfected, and that it is a task of no small magnitude, should not deter those who hope for better things of uterine therapeu- 3n^eTr b krotiedge. to tics, from its faithful and persistent prosecu- tion. And I urge it upon you as members of this class to determine that you will add something to the com- mon stock of knowledge on this subject, something tangible and available, something that will be of service to those who are suf- fering, and which will prove that the pains you have taken in the study of special pathology and therapeutics have not been lost either to yourselves or to the profession at large. For, suppose that we had a full and complete proving of calearea carbonica, or of sepia, or of any other remedy, made with particular reference 842 THE DISEASES OF WOMEN. to the female organism, and under the eye of a skillful specialist , there is no question that its influence fur good would outweigh that Avhich attaches to the invention of a new instrument, even if that instrument were as useful as the uterine sound. 2. The most painstaking study of the differential diagnosis of the diseases of the female generative system. — This condition is requi- site not onlv because it concerns the skillful Study diagnosis. pi rr treatment of these affections, but- also because it bears a vital relation to gynaecological literature. If he keeps them to himself, the physician's short-comings are self- limited ; but if he publishes his blunders, he perpetuates their remembrance and ensures their repetition. Therefore, he should know what he has done, as well as what he is doing. With all due respect to those who have directly and indirectly contributed to our knowledge of materia medica, as it is applied to the diseases of women, it must be confessed that their labors would have been more fruit- ful of good if they had been better versed in uterine pathology and diagnosis. The clinical history of hundreds of cases that have been reported confirms the truth of this remark, and shows the need of culture in this direction. If every woman who takes a drug with a view to its physiological effects, were carefully examined, both physically and otherwise, before, during and after making the "proving;" if she could be removed from all the vicissitudes which are certain to derange her sexual sympathies and to upset her health, the symptoms evolved and collected would be a better criterion of the range of action of the drug than we can otherwise obtain. And if every physician were fully posted in the matter of diagnosticating the contingent symptoms, or deviations from perfect health, which occur in most women (which are necessarily transient and self- limited), and such as are really pathological and persistent, those which do not get well of themselves, and are not often cured, as well as those caused by emotional states, independently of our remedies, the value of our clinical record would be increased a thousand fold. This opens an avenue for usefulness and distinction ; for it is left for our school of practice to develop the medical side of this* THE GYNECOLOGICAL CHAIR. 84a And pathogenesis. question. We deed such a chart of the remedial action, both pathogenetic and clinical, of medicines that are suited to the female organisms, as we do not at present possess. This is a sine qua non. It can not he obtained by the exclusive study of symptomatology after the old method, (1), because many of the resources of surgery are necessary as a means of determining whether or not the prover is in good health beforehand; (2), without these facilities, we could not know the variety, extent, nature or seat of the lesions present in a given case, whether they are func- tional or organic, and therefore our testimony concerning their cure could not be depended upon ; and (3), it must be true of the tissues which compose the generative intestine, as it is of other textures, that they have their proper pathological and therapeu- tical, as well as their anatomical, physiological and surgical his- tory and relations. And symptomatology. Fig. 134. Archer's gynaecological chair. THE GYNAECOLOGICAL CHAIR OR TABLE. Before we discuss the important operations in gynaecological 8U THE DISEASES OE WOMEN. surgery, something more should be said of the chair, or table, upon which our patients are to be placed. After much experi- ence I think that, for an office chair upon which all the minor operations aud many others, including those tor laceration of the cervix uteri, and of the perineum, and for vesico- and recto- vaginal fistulse, the best is that rrade by George W. Archer, of Rochester, N. Y., and which is known as the Archer chair. (Ti°- 124.) V "' Fig. 125. The same chair in position, with foot-arms and supports extended. The advantages of an adjustable chair which, if need be, can be converted into a table, are peculiar. With the class of pa- tients that consult us, we must be careful not to offend the most delicate instincts, or to frighten them beforehand by the display of instruments, or of surgical accessories of any kind. If a wo- man comes into your office and sees an operating table already equipped, she will very naturally forbear to tell her whole story, lest it may be necessary for her to climb upon that table. The very idea of a table is repulsive. If she is a stranger, she will run away from you, and will perhaps never come again, put, if she can first be seated in a comfortable arm-chair like this, (Fig. 125 ), and after a little lifted quietly into the desired position, as if she were in a dentist's chair, the whole thing can be easily managed, her sensibilities will not be shocked, and all will be done decently and in order. And, when you are through with THE GYNECOLOGICAL CHAIR. 845 the examination, the chair can be restored, and she will slip from it with a very different feeling from that with which she would dismount from a table. As you see, this chair can be so shifted as to fill a variety of indications. Fig. 126 shows an arrangement by which the patient can be brought into the knee-elbow, or into Sims' position very readily. In operating upon a lacerated perineum especially, the parts can be brought so near to the edge of the bed, and are so accessible that the whole operation is greatly facilitated. In this regard this chair is decidedly superior to that shown in Fig. 10, and also to Chad wick's table. (Fig. 11.) The "wrinkle" by which the outer edge of the seat can be lifted a few inches, and the chair inclined is sometimes of very great advantage. Fig lg6. The same, with the seat extension to permit of the knee-chest, and of Sims* position, and also the step or platform. When, however, we make these operations away from home, we must adapt ourselves to circumstances, and extemporize a suitable couch or table upon which the patient may rest. An extension table may be so shortened as to answer the purpose very well, or in lieu of it, you may use a common dining table, which is not too large, and which stands firmly upon its legs. In case you are frequently called upon to practice ovariotomy, peri- neorrhaphy, or any of the major operations in gynaecological surgery, it might be best to have such a table as you have seen used in my sub-clinic. 846 THE DISEASES OF WOMEN. VAGINISMUS. Case. — Mrs. , aged 20, consulted me six months after her marriage for the relief of a forced continence which was extremely painful, and which made her morally wretched. The condition which she described very clearly, and which was confirmed by a local examination of the parts, was that of a spasm of the vulvo- vaginal orifice, which was induced by the slightest touch, and which spasm was sufficient to prevent the introduction even of my little finger into the vagina. The general health of my patient was good, and her menstruation normal, but she was very nervous and apprehensive, more especially on her husband's account. She was anxious to have the difficulty cured, not only because he was very kind to her, but also because she wished if possible to become a mother. The treatment adopted in this case consisted in the internal use of belladonna 3, three times daily, and in the gradual dilatation of the vagina, twice in each week. The dilatation was effected by an anal speculum, such as I hold in my hand (Fig. 127). fig. 127. Rectal speculum. ' This instrument was chosen because it was slender, could be easily anointed with cosmoline, and insinuated, and afterwards could be expanded gradually and held in position by the screw. She was a plucky little woman, and anaesthetics were not necessary. In six weeks she became pregnant. I afterwards delivered her with the forceps of a nine- pound boy, who is now the jolliest little fellow in my parish. Case. — Mrs. N , twenty-three years of age, married, has been out of health from the time her menses made their appear- ance, which was while she was at school, in her fourteenth year. She had all the usual symptoms of neuralgic or spasmodic dys- menorrhoRa with each monthly return The flow, alter the first day, was quite free, and it usually continued about a week. She was married at eighteen, five years ago. Soon after this the dys- menorrhcea ceased, and the "period" has been quite easy and natural until now. She has never borne any children, nor ever had a miscarriage. She menstruated as usual last week. A slight and temporary leucorrhcea sometimes succeeds the catamenial flow. She complains of great fatigue on slight exertion. This is VAGINISMUS. 847 especially marked at intervals, which intervals have no knowi? relation to the monthly cycle. At other times she is as active and vigorous, and can walk or ride as far as any one almost. There is a good deal of pain and soreness along the superior por- tion of the spinal column, extending from the upper cervical to the last dorsal vertebra. Sitting, standing, and writing increase this pain and aching, which do not appear to be influenced by exposure to changes of weather. Sometimes she says there is a burning sensation along this portion of the spine, and again the burning is referred to the region of the left ovary. Occasionally the pain leaves the back and goes to that ovary. While it re- mains there, the left iliac region becomes tender to the touch, and she involuntarily retracts, or flexes the thigh upon the abdo- men. Her chief complaint is of pain and extreme tenderness at the ostium vaginse. This orifice is so sensitive, and the slightest con- tact is so very painful, as to render marital intercourse almost impossible. For more than four years she has consented to it only a very few times, and then has suffered an indescribable martyrdom. Physical examination finds the parts quite normal, excepting that just within the vaginal orifice, there is great tenderness to the touch, and the moment that the finger comes into contact with the marginal remains of the hymen, there is an immediate spasm of the muscular coat of the vagina, which causes extreme narrowness of that canal, and prevents its admission without con- siderable force. The superior portion of the vagina is flaccid and capacious enough. The uterus is in its proper place, and does not appear to be changed in any respect. The bladder and the rectum are healthy. This complaint is a very painful one, and one from which women sometimes suffer in silence for } r ears together without the courage to consult a physician for its relief. I believe that, in its milder forms, it is more frequent than is generally supposed. It may occur in the virgin, or in the case of those who are married, but not in those who have ever had a child or children. The symptoms are similar to those which our patient has de- tailed. There is almost always spinal tenderness, soreness, and lameness, which are generally located between the shoulders and along the cervical portion of the spine. Sometimes, however, it is lower down the spina] column, and is described as a weakness of the back and hips. The soreness or weakness is paroxysmal, and is aggravated by 848 THE DISEASES OF WOMEN. exercise, but more especially by sexual excitement. In its recur- rence it is very apt to alternate with ovarian pain, burning and irritation. A hysterical cough, aphonia, headache, or a tendency to general spasms, are not unfrequent accompaniments of this spinal irritation. Spasmodic dysmenorrhcea and strangury often complicate the case, and cause additional suffering. (Exit the 'patient.) But the peculiar and distinctive symptom of vaginismus is the hypersesthesia of the vulva and of the outer extremity of the vagina, which is so very sensitive that even the Local hjrperaesthesia. _ _ . slightest touch causes a spasm ot the sphincter vaginse, and a closure of that canal. The closure may also extend to the sphincter ani. The location and. extent of this sensitive sur- face varies in different subjects. In. virgins, it may be limited to the outer face of the hymen, which membrane, in these cases, is thicker and more firmly organized than usual. In those married women in whom the hymen has been ruptured, the tenderness is frequently most marked somewhere along the marginal remains and attachments of this membrane. The carunculse myrtiformes may be exquisitely sensitive. In many cases the most tender point is upon the side of, or near to the meatus urinarius. In others, it is about the orifice of the vulvo-vaginal gland, and sometimes at the fourchette. In this condition the contact of the finger, or even of a camel's hair brush, or of a feather, may cause the greatest agony, and perhaps throw the patient into convulsions. Coitus is impossible, and you can not introduce the smallest speculum without almost killing her ; indeed, in some cases that I have treated, the vaginal orifice was so closely and tightly constricted that I could not pass my little finger, or even a female catheter, into the vagina with- out exercising undue force. The sexual act being more or less completely performed, the suffering finally becomes so great that the parties are forced to desist, and most of these patients con- fess either that they have altogether relinquished the attempt and concluded to live apart, or, as they sometimes do, as brother and sister ; or that it is undertaken only at long intervals. Usually such women remain childless. It has happened, however, that even under these embarrassing circumstances, conception has VAGINISMUS. 849 taken place, and gestation and parturition have cured the case spontaneously. If these symptoms continue for years, and the patient is sub- jected to all the mental worry that is their indirect consequence, and to the contingent diseases which such a Causes. _ . . state oi the nervous system is almost certain to induce, her general health will finally become impaired, and she will pass into a state of decline. She will become prematurely old, emaciated, dyspeptic, hypochondriacal, and a wretched " ner- vous wreck." The worst results may happen to her household and family. She is very apt to conclude, and may even be told by her physician, that she has an incurable disease of the womb. Her husband is likely to become estranged, and her married life to prove a disastrous failure. This disease is frequently complicated, either as cause or effect, with spasmodic dysmenorrhcea. Sometimes it arises from a pru- ritus of the vulva, which is due to vulvar eruptions. Or it may be caused by caruncles of the meatus urinarius, vulvar follicu- litis, vesical, urethral or rectal tenesmus, haemorrhoids, fissures of the anus, or of the vulva, vaginitis, uterine displacements, an irri- table uterus, nodular neuromata of the vagina or vulva, or by the contact of acrid discharges in utero-vaginal leucorrhcea. The most cultivated and gifted women, those of a high moral or emotional nature, are most subject to this affection. This is especially true of such of them as inherit the hysterical disposi- tion, and who are liable to the different forms of spinal irritation. All this large class of women are exceedingly prone to be mis- mated, and to suffer from personal antagonisms which jar their sensi- bilities and derange the sexual sphere. Thus it may happen that a delicate, sensitive, impressible woman, who, if she were properly mated, would be exceedingly happy and contented, is tied to one whose brutal approaches become more and more loathsome and repulsive, until finally this morbid sensibility which ruins her health and happiness is developed. I have seen one case of the kind which really was more painful to witness than anything beside that has ever occurred in my professional experience. There are no toxical influences which are so difficult to antidote as those which arise from sexual incompatibility. You need have no difficulty in establishing the diagnosis. First 54 850 THE DISEASES OF WOMEN, examine the patient by means of the " touch." If she is extremely nervous and apprehensive, shakes like one in a jOiagnosis. . tit ot ague, and is almost or quite convulsed the moment the vulva is touched ; if there is a manifest spasm of the sphincter and the constrictor muscles of the vagina, so that the finger cannot pass into the canal without causing her more or less agony, you had better desist, and proceed to put her under the influence of an anaesthetic. A few whiffs of ether, or of chloroform, will quiet her apprehension, overcome her opposition, allay the super-sensitiveness of the vulvar mucous membrane, and more than all relax the spasm so that the finger, or speculum, will enter quite readily. Dr. Sims has given us the differential points in vaginismus in one of his laconic sentences: " The supersensitiveness is diagnos- tic ; the spasm pathognomonic."* The prognosis is generally conceded to be favorable. If, how- ever, the disease is the result of a profound lesion of the nervous centers, as sometimes, although very rarely, happens, it is not likely to be radically cured. Something depends also upon the dura- tion of the disease and the serious inroads it has made upon the general health. But, in almost every case of vaginismus, you will expect to cure your patient, providing your instructions are carried out, and she has the patience to wait for the result. Treatment. — The treatment is both medical and surgical. The remedies most frequently indicated are those which are suited to the relief and cure of the intercurrent disorders, Medical treatment. . n . . . more especially ot menstruation, innervation, and digestion, and to the pain and suffering in the bladder, the urethra and the rectum. These should be carefully chosen and affiliated. I am not aware that any of them hold an especial curative relation to the vaginismus separately considered ; nor is there on record a well authenticated cure of this disease by .the use of internal remedies alone. Belladonna, atropine, thuja^ macrotin, sepia, cocculus, conium, platina, mix vomica, pulsatilla, hyoscyamus, ignatia, and mercurius, include those which are more likely to be indicated than any others. If necessary, (and it often is,) either of them can be given in conjunction with the surgical treatment. *Clinical Notes on Uterine Surgery, by J. Marion Sims, M.D., etc., etc. New- York, 1866, p, 320. VAGINISMUS. 851 As usnal in gynaecological questions, authorities are divided on the question of employing the knife for the radical cure of vagi- nismus. My own opinion, based upon the suc- cessful treatment of numerous cases, is that, unless there is some especial reason why the cure should be speedy, it is best to try the milder means first. This is especially true of cases which are not very severe. One of the means designed to overcome this disposition to spasm of the vaginal muscular fibre is the dilatation of the canal, or rather of its constricted portion, by graduated Dilatation. . at i bougies. An ordinary rectal bougie may be cut in two, and one half anointed with simple cerate, glycerine, olive oil, or with an ointment consisting of the extract of belladonna, one part, and lard or simple cerate, six parts. This may be very carefully introduced and allowed to remain, according to circum- stances, for a period varying from a few minutes to an hour or more, when it should be withdrawn. Of course the patient should keep the horizontal posture meanwhile. You may be obliged to commence with a very small instrument of this kind, but gradu- ally the larger ones can be used, and their presence will be toler- ated so that they will no longer occasion pain. The patient can soon be taught to introduce and to remove them herself. After a time, with proper diet, remedies and regulation of the habits in every respect, you will find that it is possible to pass the largest size of the rectal bougie without suffering, and that the case is practically cured. The complete interdiction of coitus while this dilatation is being effected, is a condition of the cure. Case. — March, 1862, Mrs. consulted with me for the relief of an irritable and sensitive condition of the vagina which, during her three years of married life, had caused her untold suf- fering, and interfered most positively with sexual congress. She was a most intelligent person, frank and candid in her manner, and extremely anxious that something should be done for her relief, more especially lest her husband should become disaffected, and her family and friends continue to ridicule her for never hav- ing become a mother. On physical examination there was nothing abnormal about the external generative organs, except the hyperesthesia of the vulva and of the vaginal outlet. The slightest and most delicate touch with the finger caused the vaginal spasm immediately, and she 852 THE DISEASES OF WOMEN. was thrown into the same state of suffering which she said she had always experienced in the conj iigal act. I placed her under the influ- ence of sulphuric ether by inhalation, and these symptoms disap- peared. The dilatation with bougies anointed" with the bella- donna and simple cerate, was begun and continued every two days for a fortnight, then every day for another week, and the barrier to intercourse was removed. She soon conceived, and now has a son, a beautiful boy, nine years old. I gave her no medicine. In most cases to which this plan of dilatation is equally well adapted, the cure will not be so speedily effected. It generally requires about two months, sometimes a little more, and some- times less, to accomplish the desired result. If you prefer, you can make use of a series of conical glass dilators, such as I hold in my hand, instead of the bougies. These were invented by Dr. Sims, and answer a very good purpose. The warm bath and electricity are useful auxiliaries to this treatment, in which I have gr«eat confidence. Scanzoni treated one hundred cases of vaginis- mus by a very similar plan and cured them all without recourse to the knife. A very few cases are reported to have been cured by excision of the irritable tumor which is sometimes found at the mouth of the urethra. Others have been remedied by Excision of irritable tumors. . the removal of the vaginal neuromata, the cure of vaginitis, fissures of the parts, and such diseases as could be more easily reached and removed by local and general treatment.. Dr. Tilt recommends to effect the forcible dilatation of the con- strictor muscles of the vagina in the same manner as your pro- fessor of surgery, only a few days since, over- Dr. Tilt's operation. pi • • ■ came a spasm of the sphincter am m a patient which he had before you. Having anaesthetized the woman, he introduces both of his thumbs with their backs toward each other, into the vaginal orifice, and then stretches it firmly and forcibly for the space of five or six minutes. After this a plug, or dilator, is introduced and kept in position for several days by a T bandage. This mode of treatment, however, is not applicable, while there is any coincident or remaining uterine or vaginal disease. Dr. Sims practices deep incisions on the right and left side of the mesial line of the vagina posteriorly. The patient should be placed upon the back, and brought thoroughly under the influence VAGINISMUS. 85a of ether or chloroform. With a pair of curved scissors remove the remains of the hymen. In order to sepa- Dr. Sims' operation. ^ ^ ^^ laterally> to opeu the cana l as wide as possible, and to draw the tburchette very tense, the index and middle fingers of the left hand are to be passed into the vag- ina. Then with a common scalpel you make an incision through the vaginal tissue, a little to the right side, bringing it from above downwards, to the raphe of the perineum, thus making one side of a Y ; then insert the knife on the left side and cut obliquely toward the other incision, so as to join it at the raphe. Follow along through the raphe itself until the cut is Y-shaped. Thus the incision will pass across the sphincter vagina for about half an inch, but not through it, and, in all will be nearly two inches in length, varying in different subjects according to the development of tissue in each. If t ere is considerable hemorrhage, pressure, the local appli- cation of ice or of the per-sulphate of iron will arrest it. If the flow of blood is free, but not excessive, the dilator may be intro., ' vaginal fistula is one in which there is an open- ing between the bladder and the vagina; a vesico-uterine fistula implies that the uterus and the bladder communicate; in a recto- Fig. 137. Diagram showing the principal varieties of vaginal fistulas. 1. The fundus uteri. 2. The rectum. 3. A utero-vesical fistula. 4. A vesico-vaginal do. 5. A recto- vaginal do. 6. The vagina. 7. A urethrovaginal fistula. 8. The urethra. vaginal fistula the wall that separates the vagina from the rectum is perforated ; in a urethro-vaginal fistula the urine may escape into the vagina without passing through the meatus-urinarius. 8~2 VESICOVAGINAL FISTULA. 873 The site of these several lesions is shown in this drawing. (Fig*. 137.) There are other kinds of genital fistulae in women that are more rarely seen. Thus we may have a vesico-utero-vaginal, a ureto-uterine or a ureto-vaginal fistula, a redo labial, an entero- vaginal, a perineo-vaginal, or a peritoneo- vaginal fistula. But, of the urinary fistulee, the vesico-vaginal is by far the most frequent; while of the fecal fistulae, the same is true of the recto-vaginal variety. I shall first speak of those cases in which there is a fistulous orifice between the bladder and the vagina. In these fistulas the opening may be so small that Ave can find it only by injecting the bladder with colored water and then watching for its means of escape, or large enough to involve the whole posterior wall of that viscus. In the case of large-sized fistulae the older they are the smaller they become. Here is an excellent model which I brought from Paris that shows the exact relation of the parts in vesico-vaginal fistula; Fig. 138, A vesico-vaginal fistula. 1. The fundus uteri. 2. The rectum, 3. The retro- uterine pouch. 4. The bladder. 5. 1 he vagina. 6. The fistulous opening. and this diagram (Fig. 138) will give you a correct idea of the lesion when it is located above the bas-fond of the bladder. Causes. — The chief cause of vesico-vaginal fistula is the pres- sure of the foetal head against the pubis in labor, and the trau- matic inflammation and sloughing that follow it. It is, therefore, 874 THE DISEASES OF WOMEN. a contingent of difficult and tedious delivery. In rare cases it is undoubtedly caused by the hasty and improp- birth 0n8m m Chld " er use °f tne ODS tetric forceps, more especially by the up and down, or pump-handle move- ment of the instrument while making traction. More rarely still these fistulas have been caused by the wearing of an ill-adjusted pessary, or of one that has been left in the vagina after it has decomposed and o-iven rise to ulceration and Other causes. \ ^ . sloughing oi the vesico-vagmal septum. I hey may also arise from injury during craniotomy. In other cases the bladder has been perforated by needles or pins that have been passed into it through the urethra, and by vesical calculi compli- cating labor, as well as by syphilitic and cancerous ulceration. This variety of fistula is a possible result of puerperal vaginitis; and I have already told you (Lecture XXXVI.) that it is some- times induced artificially in the treatment ot cystitis, and of stone in the bladder. Symptoms. — The first symptom to attract attention is a more or less constant and involuntary flow of urine, The pathognomonic ^^ commences at a period varying from three sign ot. l j n to thirty days after delivery. This dribbling is usually noticed within the first week, but where there is a large slough, more especially from puerperal vaginitis, it may not come on until a fortnight or more has elapsed. The fact that the lesion is always upon the posterior wall ot the bladder, or about its sphincter, usually renders the flow of urine constant while the patient is lying down ; but exceptionally it may be relieved by this position. If the fistulous orifice is above the insertion of the ureters, she may be able to retain a considerable quantity of urine while standing. One of my patients had arranged a sort of time- table to the capacity of the bladder, and for six years had seldom allowed the urine to overflow into the vagina. In her case the fistula v^as small and very high. It was cured by a single opera- tion. Courty reports the following: Case. — I have lately seen a young woman with a fistula which would readily admit the first phalanx of the index finger, but in spite of its size, by a singular mechanism, the urine was habitually retained in her bladder, sometimes for an hour, and escaped only when she was obliged to let it go suddenly. This result was clue to the fact that by the settling down of the uterus the vesical V.KSICO- VAGINAL FISTUL^E. 875 mucous membrane in the median line was made to cork up the orifice, after which the urine accumulated in the right and left diverticula of of the bladder.* In acute cases the overflow, or incontinence of urine is almost always preceded by haemorrhage, and, if the slough is extensive, by the discharge of bits and shreds of tissue. The parts have been rendered so insensible by the traumatism of labor In recent cases. J that there is little or no pain. But, when the case has become chronic, the symptoms are apt to include those of an inflammation of the neighboring parts, as vaginitis, with spasmodic constriction of the passage, vulvitis, cystitis, endo- metritis, and even pelvic cellulitis and peritonitis. In extreme cases the soft parts may have sloughed so generally that little or nothing of the vaginal canal is left. The worst ex- ample of this kind that I have ever seen was sent to me two years ago from New Orleans by my friend Dr. W. H. Holcombe. The lesion had resulted from a labor which had lasted actively for a week, and which was finally ended by the use of the forceps. The patient lived in the interior of the southern country, and could not have the proper medical assistance. I shall never forgive you if in your note-books, you place the credit of this terrible result either to my friend Holcombe, or to the forceps, for, unfortunately for the poor victim, neither the one nor the other of these excellent agents was within her reach at the right time. Beside the symptoms already given, the unnatural flow of the urine over the vaginal mucous membrane causes irritation, exco- riation and ulceration, with vesicular eruptions erythema and pru- ritus of the vulva, the perineum, .and even of the thighs. In old cases the edges of the wound are often covered with incrustations of phosphatic deposits that break and fall into the vagina, and that cause great pain and discomfort. Sometimes these deposits accum- ulate within the bladder, whence they will need to be removed through the fistulous opening or the dilated urethra before an operation for the radical cure is made. The physical signs are obvious and satisfactory. In minute capillary fistulas you may need to resort to the expedient already * Traite pratique des maladies de 1' Uterus, des Ovaries et des Trompes, par A„ Courty- Professor, etc., Paris-. .1872, p. 1,199. bib THE DISEASES OF WOMEN. given. But in all ordinary cases, the touch conjoined with the The physical signs. P assa g e of the catheter through the urethra, or what remains of it, and out through the wound into the vagina will detect the rent. And the use of a Sims' spec- lum in the semi-prone or the prone position will reveal its site and dimensions, and make it thoroughly accessible. In March, 1874, Dr. T. M. Martin, a member of the class from Wisconsin, brought a woman to my clinic who had had a vesico- vaginal fistula for sixteen and a half years. The following is the record of her case : Case. — Mrs. , aged 34, was married eighteen years ago. Her first child was born eighteen months after, the labor being very severe and prolonged. Her mother says that the head of the child becoming impacted in the pelvis, the attending physician gave her considerable quantities of ergot in order to complete the delivery. But this failed, and two other doctors, who found it necessary to resort to craniotomy, were called in. After this operation she was very ill, and came near dying. In five or six days the urine began to run away, and from that time until now (sixteen and a half years) she has neve.' passed it naturally, nor has she been able to retain it for a moment, in any posture, after it has been discharged from the ureters into the bladder. For two years after the accident she was a cripple* during the first of which she could not stand upright, and throughout the second year she was obliged to walk on crutches. Her general health, however, did not really mend until she again became preg- nant. She reached term, and was safely delivered of her second child; and now, in all, she has had six children since the fistula was formed. These children were born without instrumental aid, and are alive to-day. Her mother, who has been her nurse, and who used frequently to dress the fistula through a speculum, is confident that the opening into the bladder has become a little smaller with each successive confinement. For the most part, for seven years she was compelled to remain either in bed or in a sitting posture. The general health is now good, but she is a pitiable martyr to an incessant flow of urine. I made the operation before the whole class, when it was much smaller than now, and the result was that at first there was an incontinence of urine, and a very slight leakage, both of which soon ceased entirely.* For some months she was well, but un- fortunately she again became pregnant, and after her next labor *Vide, The U. S. Medical and Surgical Journal, Vol. IX., p. 330. VESICO-VAGINAL FL>TULJB. 877 there was a small fistulous opening which caused a return of the old symptom. She afterwards came before my private class, when Fig. 139. Curved scissors. the lesion was identified, but she would not consent to another operation. Prognosis. — If we except those cases in which there is a depraved constitution, or a vicious cachexia, like syphilis or cancer, the rule is that all cases of vesico-vaginal fistula are curable. If the rent is very large, and the sloughing and loss of tissue has been very extensive, the case may not justify an operation. Some of them get well spontaneously, others by caustics and the milder means, and others still require two, three, or more operations. Dr. Thomas makes this remark concerning vaginal cystotomy as compared with these fistulae : * "It is a curious fact that, when for the relief of chronic cystitis a vesico-vaginal fistula is intentionally created by the knife, it is difficult to keep it open. In spite of the occasional introduction of the sound for this purpose, such openings obstinately heal of their own accord, so that it becomes necessary to place a species of button or stud in the opening to prevent a result which, under these circumstances, is undesirable. This case seems parallel with that of perforation of the tympanum, which, being effected by an instrument, heals rapidly ; while the closure of an opening, the result of disease, is usually impossible." Treatment. — The treatment of these uro-genital fistulas divides Fig. 140. Bozeman's curved scissors. itself into that proper for acute or recent cases, and that which is adapted to chronic cases. When a fistula is discovered during * A practical treatise on Diseases of Women, by T. Gaillard Thomas, M. D., etc. Fifth edition, 1880, p. 237. 878 THE DISEASES OF WOMEN. the lying-in there is nothing to do except to keep the patient quiet, in the recumbent posture, to wash out the vagina and the bladder with warm calendula water, to place a Skene's, or a Sims' catheter in the urethra per- manently, if the patient can bear it, and to wait in the hope of a spontaneous cure. For at this time there would be an intolerance of the suture, nor, under the circumstances could it be so readily applied as afterwards. Some French authorities advise the use of the serre-fines, but in order to adjust them, the rent must be acces- sible, and you will need to be very expert. Fig. 141. Bozeman's double curved scissors. Outside of the puerperal state many attempts have been made to heal these fistulse by the use of caustics, either with or without an appliance that was designed to keep the edges of the wound in apposition. This mode of treatment seems m post-puerperal and begt a( j ap t e d to those small and very minute chronic cases. x . . fistulas m which there is little or no loss ot sub- stance. A shot-hole orifice might thus be healed by the use of the nitrate of silver, caustic ammonia, or potas- sa, nitric acid, tincture of iodine, the tincture of cantharides, sulphuric acid, chromic acid, the acid nitrate of mer- cury, or the galvano-cautery. In a remarkable monograph upon this mode of treating vesico- vaginal fistula, Dr. E. F. Boque gives the details of 204 cases and the results obtained.* Of these, in twenty-one cases the size of the fistula was from one to six centimetres, in twenty-four from one to three fingers could be passed through the orifice, and in a still larger number the opening would admit the uterine sound. His comparative tables show as good results as were obtained up to the year 1875 by the more usual operation that was first prac- tised in this country by Dr. Sims. * Du traitement des fistules uro-genitales de la femme par la reunion secondaire, etc.. par Ed. F. Boque, Paris. 1875, pp. 261. VESICO- VAGINAL FISTULA. 871) In the Archives de Tocologie, etc., for May, 1880, you will find the record of a most remarkable case of vesico- vaginal fistula which had been operated upon and closed with silk sutures five times in succession without a Fig. 142. A serrated clamp and its mode of application. cure, by Dr. Gerassimides of the Faculty of Pisa. He finally devised an instrument for holding the edges of the wound securely until they had united. Fig. 142 shows the mode of application of this serrated clamp from the vaginal side. 880 THE DISEASES OF WOMEN. The American The usual operation for. We must not omit to mention that in the repeated operations made in this case, the silk and not the silver wire suture was em- ployed. operation, so styled because it was first elabo- rated and applied by Dr. Sims, of New York, is the prevalent mode of cure for these, as well as for other forms of genital fistulae. The prepar- atory treatment consists in the removal of bands and adhesions that may have formed, by means of their division and dilatation, as in other kinds of anaplastic surgery. For if The preparatory treat- th ^ f tissue that is to be operated upon is ment. l i not free from tension, and tolerant of the suture, the result will be a failure. In extreme cases it may happen that weeks will be spent in getting rid of these obstacles, by exposing them and cutting the bands with the scissors, after which the vagina is dilated mechanically with sponge that is covered with oiled silk, or with a glass vaginal plug. Meanwhile, the inflamed and tender surface of the vagina may be healed as far as possible, by soothing applications. Pig. 143. Bozeman's position for vesico-vaginal fistulas. When we are ready for the operation five indications should be kept clearly in mind. (1), to expose the rent, Special surgical indi- ^ ^ make Jt ihorouo;hly accessible; (2), to freshen its margin as perfectly as possible ; (3), to apply and to secure the sutures so as to close the fistulous orifice with the greatest accuracy; (4), to drain the bladder while VESICOVAGINAL FISTULA. 881 the wound is healing; and (5), to remove the sutures very cautiously in due time. The first of these indications is met by placing the patient in the Sims', or the prone position upon a proper wound ViCW ° f the table or cnair > ancl in a g' oocl light. Some oper- ators prefer Bozeman's plan in which (Fig. 143) the patient is secured in the knee-chest position by an arrange- ment which can be screwed to the table. A Sims speculum is then passed and the perineum is retracted. Lateral retraction, by Sims depressor (Fig. 144) may also be applied so as to expose the affected part more thoroughly. It the rent is high in the anterior Fig. 144. Sims' depressor. cul-de-sac, or lateral, and not readily accessible, it may be best to seize the uterine cervix and bring the womb down to the extent of everting the anterior roof of the vagina. If necessary the cervix can then be secured by a loop, and given in charge of an assistant. To freshen the edges of the wound is always a delicate, and sometimes a difficult task. It must be done as g iIi VifyinB thG ^ freel y and as thoroughly as possible, but from the vaginal side only. The vesical mucous mem- brane should not be cut, or pricked, or injured in any way. Simon, of Heidelberg, intentionally included the bladder, but it is not Fig. 145. Emmet's double-curved scissors. safe. Every bit of mucous, or of cicatricial tissue upon the bor- ders of the fistula must be removed before we can reasonably hope for a good result. The plan which I have found most convenient is to secure one lip of the rent at a time with a Sims seizing for- ceps (Fig. 149 ) and then to pare the edges with the curved scissors, 882 THE DISEASES OF WOMEN. (Figs. 145, 146, 147) or with the knife (Fig. 148). The art of vivifying the margins and bevelling them properly is acquired with practice and care, and when you have made the operation a dozen times you will have acquired sufficient dexterity to do it well . Fig. 146. Bozeman's angular scissors. I am fully convinced that Emmet's idea of using the scissors in preference to the knife in these cases, because it exercises a kind of torsion of the capillaries as we proceed, is the correct one. If there is considerable haemorrhage, the hot-w T ater irrigation, as in trachelorrhaphy, will arrest it. Fig. 147. Emmet's curved scissors. The next step is the insertion of the sutures, which should always be of silver wire. The whole secret of su^ure i s nSerti ° n0fthe passing them properly is to remember that the vesical and vaginal mucous membranes are sepa- rated by a layer of cellular tissue, and that the needle must pene- trate the vaginal side and pass through this intermediate tissue without puncturing the bladder. =cf Fig. 148. Sims' rotary knife. Taking a Sims' needle-holder, (Fig. 151,) and one of Sims', of Emmet's, or of Hodgen's needles, its point is introduced at a third VESICO-VAGINAL FISTUL^E. 853 to a quarter, or even half an inch from the margin, is made to pass through the freshened edges and across the fistulous orifice, so as to emerge at the same distance from the opposite lip of the wound. Fig. 149. Sims' seizing forceps. The suture is drawn through, the border being steadied by this little fork ( Fig. 152) , and cut oft' at the proper distance. (Fig. 153 ) The first of these is passed at the upper end of the fistula and the others in succession, from above downwards, until all are in position. Then, before twisting them down and closing the wound, the bladder and the vagina should be carefully washed and cleansed of blood-clots and of all foreign substances. Fig. 150 Tubular needles. Here is an expensive case of tubular needles which I brought from Mathieu, m Paris, that are designed to pass the silver wire directly by means of a reel in the handle. I have tried them sev- eral times, with the result of satisfying myself that they are 884 THE DISEASES OF AVOMEN, of great service when the vagina is narrow and the rent is high and difficult of access. The varying curves of the needles fit them for use especially in recto-vaginal fis- tulae. The careful adjustment of the freshened borders may be effected with the fingers and by the manipulation of the sutures. It must be done slowly and cau- Adjustment of the .• -i i i lips of the wound. tiously, so as by bringing the edges together exter- nally to turn their united margin into the cavity of the bladder. This not only brings the scarified surfaces into close contact, but it makes a ridge within the bladder that turns the water like the peak of a roof. It is be- cause this bit of tailorino;must be water-tiofht that you should take the greatest care so to twist the sutures as to bring the parts into exact apposition, and not to close the mouth of either of the ureters. Asa rule we always begin by twisting those sutures Avhich are nearest to the vulvar outlet, but they must not be drawn too tightly. Concerning the best method of securing these sutures, when they have been carefully fig. i5i» Sims' needie-hoi- twisted, there are various opinions. The der - simplest plan is to cut them off and bend them at a right angle with the wound, as you have seen me do after an ovariotomy. Some prefer to pass a per- forated shot over the wire and then to com- press it firmly; and others use a thin disk of perforated lead, which is known as Bozeman's button (Fig. 154), and which can be trimmed to suit special cases. Sometimes both are used together. (Fig. 154). In the majority of cases, since the principle is the same, there is no compensation for the extra trouble of fitting and adjusting a Bozeman's button, or anybody's clamp. The interrupted suture is sufficient. In order to prevent an accumulation of urine, which would strain Tightening the sut ures. VESICOVAGINAL FISTULA. 885 Vesical drainage. f \ \ 1 the wound, interfere with its union, and give rise to pain and suffering, the bladder must be drained, at least for the first forty-eight hours. If the urethra will tolerate it therefore, a Sims improved, or a Skene's self-retain- ing catheter (Fig. 69) may be passed and allowed (D to remain in position. Unfortunately, the cases (/ in wnich the lesion is at the bas-fond ot the blad- der, are those in which the instrument is not very well borne, and you will need to remove it occa- sionally, or perhaps to take it away altogether. In two of my cases I found the flexible rubber catheter to answer the purpose. The catheter will need to be removed now and then in order to cleanse it, and it may be necessary to draw off the urine at regular intervals during the first fort- night. The sutures should be carefully removed on the ninth or the tenth day. The ease with which this maybe accomplished will depend upon circum- FlG 152- Thewiread stances. If the rent is high, or the parts are i^hook^' an< tumefied and the sutures are buried out of sight, it may be very difficult. It is sometimes necessary to seize the neck of the womb and draw it down again. If the wire is not readily ac- cessible, you will have to take the blunt hook (Fig. 152) and fish up the loop so that you may pass one blade of the scissors through it as shown in Fig. 1 56. Care should be taken to straighten the cut end of the suture before turning it out, lest you tear the tissues. You should not be dis- couraged if, upon the removal of the sutures there is a slight leakage of urine into the vagina. In very bad eises this is likely to happen, and may be only temporary. But sometimes a small orifice may remain, and this w r ili need to be treated by a subsequent operation. It is commonly supposed that the operation which I have just and Removal of the su- tures. Caution, and encour- agement, Fig. 153. The sutures x position. THE DISEASES OF WOMEN. Fig. 154 button sutures Bozeman's described is tree from danger, even where it is not successful. Our American authors are almost silent upon this The dangers of the . operation. point. Hie fact is that there is no other opera- tion which belongs to anaplastic surgery that is so dangerous as this one. In a remarkable memoir upon this sub- ject, contained in the Annates de Gynecologie for January 1877, Doctor Vemeuil treats this subject very thoroughly. He says: "t am pursuaded that the newer methods of operating are less dangerous than the old, first, because ot their usual success at the first trial, the repeated operations that were once necessary are not called for; and also because in the different steps of the operation the tissues are better managed, and, as a rule, the preparatory incis- ions, dilatation, etc., are dispensed with. In spite of all this however, at least il I may judge by my own experience, the mortality is still pretty large. In- deed, in my- unfortunate cases I do not think that I have committed any great surgical error either before, during, or after the operation, and yet I have lost five women in about eighty operations ! Two others have threatened to die, one of erysipelas, and the other of embol- ism land several have been very ill with pelvic troubles, but they have finally recovered." Fatal results have also been recorded in consequence of second- ary haemorrhage, traumatic fever, pelvi-peritonitis, cystitis, al- buminous nephritis, hydronephrosis, and uraemia. In the journal just referred to for the following month, page 129, M. le Dr. Puech gives the statistics of 229 cases which had been operated upon by various physicians with a loss of thirteen, or one in every seventeen cases. The practical inference is therefore, that, even in the most promising cases, this operation should not be undertaken without care in the selection of subjects, nor yet without qualifying our prognosis with reference to a possibly fatal result. Beside the operation which we have consid- Eiytropiasty ^^ ^^ . g ft form of ves i co _vagmal anaplasty that is very rarely practised in our day, which consists in closing VES1CO- VAGINAL FISTULJE. 887 the fistula by means of a flap that has been dissected from the pos- terior wall of the vagina, the vulva, or the buttock, and stitched into the fistulous orifice. Another expedient consists in the closure of the vagina, as in the extreme cases of procidentia of the uterus spoken of in Lecture XXXVIII. Episiorrhaphy. Fig. 156. Introduction ^f the sutures. KECTO-VAGINAL FISTULA. In this form of fistula the recto-vaginal septum is open and permits the escape of gas and of faces from the rectum into the vagina. A good idea of its most common form is given in Fig. 137. The extent and location of the orifice varies. It may be small enough merely to admit the point of a probe, or large enough to reach from the posterior cul-de-sac to, and even through 888 THE DISEASES OF WOMEN. the sphincter and and the perineum. In some cases it is so high as to be found with difficulty, but oftener it is within easy reach. Causes. — For the most part the causes are the same as those of vesico-vaginal fistula, — protracted labor, pressure from an im- Fig. 157. Straight scissors. pacted head, traumatism from manual interference, an abuse of the forceps, or, more frequently, an unwarrantable or unavoid- able delay in using them; the wearing of mal-adjusted, broken, or decayed and decomposing pessaries, abscesses, excessive and Fig. 158. Sims' knife-h lder. misapplied cauterization, the ulceration caused by hardened fseces, stricture of the rectum, penetrating wounds of the vagina, and syphilitic and cancerous ulceration. Physical signs. — The objective signs of this disagreeable infirmity consist in the passage of faecal matter and of ffatus into the Fig. 159. Notts' double tenaculum. vagina. If the rent involves a rupture of the sphincter ani and of the perineal delta, as my friend Dorion termed it, the rectum and the vagina have a common outlet, and the patient becomes a monotreme. The physical examination may be made with the patient lying upon her back. The hips should be brought squarely to the edge ot the table, and a Sims speculum passed in a reverse way from RECTO- VAGINAL FISTULA, m that in which it is usually employed. With this the anterior wall of the vagina is lifted, and the recto-vaginal The physical exam- . " . ■.-..., ination. septum falls into view. Ihe location and limits of the rent may then be known by pass- ing the finger into the rectum. If the fissure is small and high up toward the roof of the vagina, it may be best to turn the Fig. 160. Nott's depressor. patient upon her left side. In either case the margins of the opening are less likely to be inflamed and excoriated than in the ease of vesico-vaginal fistulas. Prognosis. — Contrary to what you may have supposed a larger proportion of cases of vesico-vaginal fistulas are curable than of those now under consideration. Indeed, fecal fistulas of all kinds Fig. 161. Sims' uterine tenaculum. are rebellious to treatment, and we must not promise too much for any of them. I have long been satisfied that better results will be obtained in these cases when we realize that a single mode of operation is not suited to all of them indiscriminately. It is a fallacy to suppose that because a general surgeon has been Fig. 162. Bozeman's wire adjuster. successful in the ordinary line of his work, he must, therefore, be skilful and successful in these cases also. Briefly, the prog- nosis will vary with the kind and degree of the lesion, the general condition of the patient, the nearness or remoteness of the puer- peral state, the mode of operation that is employed, the neces- sity for its repetition, and the dexterity and the special experience of the operator. The Surgical Treatment. — The simplest mode of operation con- sists in freshening the edges of the orifice upon the vaginal side, 890 THE DISEASES OF WOMEN. in drawing them together accurately by interrupted silver sutures, in twisting these sutures, in passing the perfor- The usual operation. ,-,■■,,-, • , i ^ i ated shot and compressing them, the same as in vesico-vaginal fistulse. In this case, therefore, you will need the same instruments that I have already advised in the former part of this lecture. The freshening may usually be done with a pair of straight scissors (Fig. 157). If the fistula is far away, however, you may need to use a Sims knife-holder and adjustable blade, (Fig. 15b ) instead of these or the curved scissors. For hold- ing the margins firmly, a Notts' depressor (Fig. 160), or double tenaculum (Fig. 159), or a Sims uterine tenaculum (Fig. 161) may be necessary. In vivifying the margins, as well as in passing the needle, the introduction of a rubber ball, like a Gariel's air- pessary, Avhich can be passed into the rectum behind the fistula and inflated, will sometimes expedite the operation. I have found Bozeman's wire-adjustor of real service in twist- ing the sutures closely in some cases of recto-vaginal fistulae and I much prefer to secure the wires with perforated shot that can be compressed with these forceps. (Fig. 163). Fig. 163. Shot compressor. In the after-treatment, it is really a question whether the old practice of keeping the bowels bound does not The after-treatment. , , 7", i t»t i do more harm than good. My early experience convinced me that the passage ot hardened fecal masses into the rectum after a period of forced constipation was very likely to> interfere with a good result; and I consequently adopted the practice of keeping the bowels in a soluble state by the use of laxative food and fruits, and by the occasional prescription of nux vomica, plumbum, or collinsonia. Vaginal injections of warm water with the tincture of calendula may be used daily. The sutures may be removed in eight or ten days, and the patient allowed to take moderate exercise after the second week. To EECTO- VAGINAL FISTULA. 891 admit of the escape of flatus, and to prevent tenesmus a rectal tube should be worn for some days. Another mode of operation is to bevel the edges of the fistula, and to sew the wound on the rectal instead of Newer modes of ope- the inal sur f ace . This is easily accomplished ration. & . by stretching the sphincter with the two thumbs (as should be clone in all modes of operating,) and the introduc= tion of the speculum through it into the bowel. In order to avoid the trouble and pain of removing the rectal sutures, Dr. Goodell prefers that they should be of fine gut. An ingenious method consists in splitting the margin of the fistula all around, and afterwards uniting them by two sets of sutures, one of which is in- the vagina and the other in the rectum. In another plan of operation, which is highly recommended by Dr. Goodell, " A shallow cut is made around the vaginal mouth of the fistula, about half an inch away from it, and the mucous membrane dissected up to its rim in a frill. This is n^xt inverted and pushed into the rectum through the opening, which is now closed by rectal and vaginal stitches — the former uniting the raw surfaces of the frill, the latter the raw strip around the vaginal rim of the fistula. Should the opening into the rectum be too high up to be reached, the rectal stitches can be passed per vag~ inam in the following manner: Before the mu- cous frill has been inverted, metallic sutures are passed through its edges, each end of each one entering the raw surface and emerging on the mu- cous surface. The free ends of the wires are next secured temporarily by twisting them over a per- Fig. 164. Agnew's forated shot. After all these sutures have been adjuster, passed, the shot are pushed through the fistula into the rec- tum and out through the anus, and the frill is inverted ty traction on them. The sh<~>t are then run up one by one to the rectal wound and clamped, and the operation is completed by sewing up the vaginal wound." LECTUKE LIV. LACERATIONS OF THE VULVA AND OF THE PERINEUM — PERINEOR- RHAPHY. These lacerations are often confounded. The anatomy of the vulvar orifice. Lacera- tions of the fourchette. Anatomy of the perim um. The peineal body. Physiol- ogy of the perineum. Case. -Varieties of perineal laceration. Frequency of do. Symptoms. Treatment. The primary and secondary operations. In the practical study of lacerations of the perineum we shall avoid contusion it we are careful not to confound those of the perineum proper with those of the vulvar or- Theseiacerationsoften ifice> p although these lesions are usually confounded. ... described as identical, they are not really so; and much trouble has been occasioned by the fact that the anat- omy of these parts has not been separately considered and studied by gynaecologists. The peculiarities of structure of the vulvar orifice are- the raphe, or the junction of the vaginal mucous membrane with the integu- ment; the fourchette, and the form and direc- Anetomy of the vul- . r , , . . , . , var orifice. tion ol the sphincter vagmse muscle, which sur- rounds the external orifice of the vagina, and which is attached posteriorly to the central portion of the perin- eum, where it mixes with the transversalis and the sphincter ani muscles. These structures guard the vaginal orifice and permit of its distensibility and dilatability, which qualities are essential to a safe and natural labor. The sphincter vaginae is an orbicular muscle, which is more easily broken than you would suppose, if the force that is applied is not in the direction of the axis of the vagina. Hence, in very rapid labors, when the presenting part is driven through the vulvar outlet there is not sufficient time for adaptation, and the sudden extrusion results in a rupture of the sphincter. This rupture may occur laterally and involve the labia, or superiorly, through the anterior commissure of the vulva or the nymphae, where it 892 LACERATION OF THE PERINEUM. 893 Laceration of the fourchette. bleeds freely; but more frequently it takes place at the posterior commissure of the vulva. In primiparse the fourchette is almost always torn in labor, but, if the deeper structures are not involved, the case is not one of laceration of the perineum. So long as the wound is limited to the vulvo-vaginal orifice it is really as distinct from a case of ruptured per- ineum as it is from one of laceration of. the cervix uteri. The fact is that the co-existence of rigidity of the os uteri with what is usually styled a ruptured perineum in labor is a mistake; a practical hint. for tne external part which is unyielding is the vulvar orifice, and not the perineum. The careful obstetrician will tell you that, if labor is retarded by an undilatable os-uteri, the presenting part is sure to be arrested in a Fig. 165. The form, location and relations of the perineal body. similar way at the vulva. And the gynaecologist will tell you that the resulting lacerations ot the cervix and of the fourchette tally exactly with this state of things. The peculiarities of the perineum concern the form, the posi- tion, the structure, and the relations of what mtuT mJ ° f ^ Per " has been a P% termed the perineal body. This is a triangular muscular structure which is lo- cated between the orifice of the vagina and that of the rectum. 894 THE DISEASES OF WOMEN. Its broadest part is at the integument, or along its cutaneous bor- der, and its apex merges into the recto-vaginal septum. So you observe in this model (Fig. 165), its anterior The perineal body. . . v . ' margin is along the posterior wall of the vagina, and its posterior border is anterior to the rectum. It lies be- tween the two, and its purpose is to prevent a prolapse of the bowel into the vagina, as well as a descent of the vagina itself, and also of the uterus and the bladder. The physiology of the perineum is peculiarly interesting. It may not have occurred to you, and you may not have read in your text-books, that the changes which take place th?p e errne y um 10 ^ ° f in the Perineal body during gestation, and after delivery are as pronounced in their way as are those which are proper to the mammary gland, the heart, the liver, or even to the uterus. Whatever interferes with the devel- opment of this inverted keystone during pregnancy will predis- pose it to traumatic injuries during labor; and whatever arrests its puerperal involution will prevent the reparative process after- wards. There are cases of laceration of the perineum which re- sult from the imperfect development of these structures, and from their forced expansion during labor, which, strictly speaking, are due to an organic defect, for which no one is to blame, and for which there is no known prophylaxis. Observe that, in order that we may have a case of lacerated perineum, this perineal body must be torn, or split, and the rent must extend into its structure, or perhaps through it, to the recto-vaginal septum. The rupture may be partial or complete, and it may or it may not involve the sphincter ani, and the sphinc- ter vaginae. In rare cases the perineum' is perforated, and the child has been extruded without injury to either of these sphinc- ters. When the laceration has begun at the fourchette and ex- tended to the sphincter ani, both the vulvar orifice and the perineal body have been stretched and torn; and when it has involved the recto-vaginal septum, the case is complicated with a recto-vaginal fistula. One of the classes has recently seen me operate upon a very marked case of this kind in my sub-clinic. Causes. — Premature delivery, tedious, impracticable and in- strumental labor, the too rapid extrusion of the foetal head, puer- peral convulsions, the delivery of the shoulders, dry births, LACERATION OF THE PERINEUM. 895 irregular, vertex and face presentations, and version, are the most common causes of this accident. It is more likely to result in first than in subsequent labors; and there is a tradition that women who have their first children late hi life are especially liable to it. Laceration of the perineum may also arise from a direct wound, and from the careless delivery of uterine tumors. Case. — I once had a case in my clinic in which the patient was brought before the class for the removal of an enormous fibroid which had escaped from the os uteri, and which filled the pelvis completely. It was severed by a strong copper wire i . the ecraseur, but the wire broke twice before it was finally detached. When I removed the instrument I found that the catch on the back side of the staff had split the perineum all the way down to its cutaneous border! The tumor, which afterwards weighed six pounds, was so spherical that it could not be delivered by the usual means. I then applied the obstetric forceps, but it was too dense for compression and I was forced to desist. My only re- maining resource was to cut it in pieces and to take it away in sections, which was carefully and successfully clone. The patient had been so long under the influence of the anaesthetic, and was so very weak and anaemic from the fearful menorrhagia to which she had been subject, that it was not safe to make the primary operation for the cure of the lacerated perineum. Six months later I made the operation of perineorrhaphy upon that woman in this amphitheatre, with an excellent result. The last heard of her, for she was a farmer's wife in Wisconsin, she was riding upon a reaping machine in the harvest field. Varieties. — The three varieties, that are usually described are (1), a shallow superficial rent, extending through the fourchette, and scarcely touching the perineal body; (2), a rupture of the perineum proper as far as the external sphincter ani, and (3), a laceration that extends from the posterior commissure of the vulva through the sphincter and into the bowel. For reasons that I have given you the first of these should properly be re- garded as a laceration of the vulvar orifice and not of the peri- neum. They are the kinds of laceration which often heal spon- taneously. Frequency. — What I have said of the relative frequency of lacerations of the cervix uteri is quite as true thle i^ons 10 ° k f ° r of ™ lvar and perineal lacerations. The mere fact that physicians and obstetricians have often overlooked them, does not disprove their existence. In recent 896 1HE DISEASES OF WOMEN. cases we cannot be certain of their location or extent without a careful examination after the labor. This examination should be made with a competent assistant, a sponge and some warm water, and by means of a candle or a lamp. For the touch alone, no matter how educated or experienced, cannot decide this question. It is not always practicable or expedient to inspect the teo-u- mentary perineum at the close of labor; but the fact remains that these lesions within or through the vulva, and into the peri- neum more or less deeply, do really exist in a considerable share of cases. What that proportion is I cannot say. Perhaps in one labor out of four or five occurring in primipara they could be found if we should look for them very carefully. For the sake of your own reputation, as well as for the cure of your patients, I recommend you to examine these cases for yourselves, and not ta trust to the ipse dixit of the nurse, or to your own post-partum impressions. It is not unusual for physicians to insist that, in all their ob- stetric experience, not a single woman has been "torn;" and that, with the proper care, such a mishap may always be avoided. Butt, since we cannot vouch for the integrity of the perineal and vulvar tissues, and cannot always control the direction or the degree of the forces that are necessary to effect delivery, this claim is unwarranted. Lacerations on the vaginal surface of the fourchette especially, are the rule and not the exception. Symptoms. — The physical signs of the laceration are easily made out. By placing the patient on her back and separating and flex- ing the thighs, the rent is easily exposed. The labia may be stretched apart and the posterior commissure found to extend to- ward the anus. If the case has become chronic, the pelvic organs will be prolapsed, and the degree of the cystocele and the recto- cele will be in proportion to the duration, the extent and the depth of the laceration. If some time has elapsed since the accident the margins of the rent will be cicatrized, and this condition of the surfaces may be a source of general ill health. For, while this tioTof Ct the°rent CatriZa " heterologous tissue is often harmless, its pre* ence in delicate, slender and nervous women especially, is likely to give rise to a series of reflex disorders that are impossible of cure, except by an operation for its removal. LACERATION OF THE PERINEUM. 897 Treatment. — The treatment naturally divides itself into that proper for acute and for chronic cases. If you are called to a case in which not more than ten or twelve hours have The immediate treat- edi j accident, and before the mar- ment in recent cases. *■ _ ' gins of the wound have healed over, it will be a question as to whether you shall stitch it up or not. Some au- thorities will tell you that you ought always to resort to the suture, and others will insist that it is never necessary. Both are right and both are wrong in their extreme views. If the lacera- tion does not extend more than from one-third to one-half of the depth of the perineum, and if you can depend upon the patient and the nurse to obey instructions; if there are epidemic diseases in the house or the neighborhood, or if there are other puerperal cases under the same roof, you had better not pass the needle through the tissues, but keep them in apposition by other means until adhesive inflammation sets in. In such cases my own practice has been to cleanse the parts thor- oughly with warm calendula water, carefully removing all clots, bits of fat and shreds, and then to mould the edges as carefully as possible so as to bring the tegumcntary perineum into its proper position. Then I place a firm compress that has been moistened with a mixture of equal parts of calendula or of hamamelis, glycerine and warm water, against the perineum, and while the limbs are flexed, put two or three adhesive straps across the but- tocks to keep the compress in position. This adjustment of the parts should be made with the patient lying upon her side. The compress may be freshened two or three times in twenty-four hours, and weak injections of calendula water may be given per vaginam once or twice daily until the wound is healed. The knees should be tied together, but not tightly, for the first fort} T - eight hours. The bowels should be let alone, the patient should lie upon her side, and the urine should betaken with the catheter. I have practised this simple plan of treatment for almost thirty years, and am confident that in a great majority of cases it is quite sufficient. It mav sometimes be supplemented The use of serre-fines. . . , by the use of serre-nnes, which, if they are of the right kind and are properly adjusted, will keep the edges of the wound from slipping before they have healed. If the patient is very nervous and apprehensive, she need not know that they 898 THE DISEASES OF WOMEN, have been applied, and the compress can be used at the same time, The primary operation is not difficult unless the wound has passed through the sphincter ani, or involved the recto-vaginal septum, in which case it will be necessary to The primary operation. . . .,■ .. , -. administer an anaesthetic and to proceed as we do outside of the puerperal state. Under these circumstances the operation is really contra-indicated, because of the exhausted con- dition at the close of labor, and because of the mischievous effect of the lochia in so extensive a wound. When, however, the degree of the laceration does not include the sphincter ani, or the septum above the apex of the perineal body, the wire sutures may be passed from the cutaneous surface and twisted as in the usual operation of perineorrhaphy. The secondary operation, for chronic cases, ought not to be made until at least three months have elapsed from the date of the delivery, and six are better than three in The secondary opera- m0gt ^^ The old rule wag to w ^ f ^-j tfae tion. child was weaned. The preparatory treatment for perineorrhaphy is to allay any existing local inflammation of the parts, to have the bowels thoroughly opened a day or two be- forehand and the patient in a good general condition. In a few cases I have found it necessary first to obtain the control of a copious leucorrhceal discharge before operating, lest the flow should interfere with the union of the parts. The operation is comprised in three steps: (1.) The freshening of the perineal angles; (2) the introduction of the sutures, and (3) the closure of the wound by the tightening The freshening pro- of the sutures> The vivifying process is the cess. m . same as that described for vesico- and recto-va- ginal fistulae, except that a much larger surface is freshened. In removing the cicatricial tissue care should be taken to avoid injur- ing the rectal mucous membrane. The patient being placed in the lithotomy position, with the nates drawn to the edge of the table in a strong light, and the anterior vagina lifted with a Sims' speculum, it is well to make an incision along the border of the space that is to be freshened, so as to mark the outline of the per- ineal body. When this is done on both sides, the membrane that covers the wound is dissected off carefully with the knife, or bet- ter still with the scissors, and no portion of it is allowed to re- LACERATION OF THE PERINEUM. 899 main. If the laceration has extended to the septum above the perineal body, its margins will also need to be freshened, the same "Fig. 166. Surface denuded in complete perinea] rupture and first two sutures in posi- tion (Thomas). as in recto-vaginal fistula. Fig. 166 represents the outline of this newly-made wound, in a case of complete rupture through the anal sphincter. While these lateral triangles are being pared of their cicatri- cial tissue if there is much haemorrhage, it should be controlled by the use of hot water, or, if there are spouting arteries, by Pean's hemostatic forceps. The index finger of the left hand should be passed into the anus to assist in freshening the surface at the bottom of the furrow which separates the two halves of the perineal body. The second step of the operation concerns the introduction of the interrupted sutures. Most authors prefer smure P s aSSaffe ° fthe the silver wire, but they are not agreed upon the propriety of passing them through either of the three surfaces of the perineal body exclusively. Some prefer to introduce them from the cutaneous border only, others from the cutaneous and vaginal surfaces, and a few on the rectal side also. Here is a variety of needles that have been devised for the passage of the perineal sutures. I prefer a straight needle, 57 900 THE DISEASES OF WOMEN. about one and a half to two inches in length, the point of which has been ground like a glover's needle. It should be of the best material and not too small. For the deep stitch in a complete lac- eration I use Pean's curved needle, which is something like Ash- ton's (Figs. 170 and 168) and which, having an eye in its point, allows it to be threaded after it has been passed. Dr. Bantock's method of suturing the perineal wound has a wide range in differ- ent cases and degrees of operation. It is well shown in Figs. 1-SL Pig. 167. Lacerated perineal surface denuded, and the sutures in position (Thomas). Peaslee's needles (Fig. 170), are better than Skene's (Fig. 171), being narrow and therefore less likely to cut the perineal vessels. Skene's needle is weakened at the point by the size of the eye, which cuts it half off. I had one of them break while being passed and was obliged to dissect out the fragment. A new needle with a holder which is very useful m this and kindred operations is Eeverdin's (Fig. 169). The careful intro- duction of the sutures is very important. Their course may be directed by the finger in the rectum. In case the sphincter is torn the two lower stitches should be hidden in the recto-vaginal sep- tum. All the sutures should be passed and the wound thoroughly cleansed before any of them are tightened. In twisting them we always begin with the lower one and are very careful to adjust the lips of the wound most accurately. For this purpose it may be neces- sary to insert a few superficial sutures, which should be of cat-gut. LACERATION OF THE PERINEUM. 901 Some authors, notably Bantock, use the silk-worm gut instead of the wire sutures. Others employ the carbolized silk, but the ware is preferable. The mode of securing the silver wire in these eases is to twist and bend the sutures at right angles. The perfor- ated shot and the bit of tubing through which they are sometimes passed are of no especial advantage. Fig. 168. Pean's curved needle. The after-treatment consists in tying the knees together with a roller and a compress between them; in having the urine drawn every four or five hours for the first day and night, after which it can be voided naturally; in limiting the patient's diet to nourish- ing soups and broths, and semi-solids; in keeping the bowels in a laxative condition by the use of small quantities of saline waters, to be repeated every alternate day; and having the patient's posi- tion changed from side to side. I think it very important to abstain from the use of washes and injections during the first Fig. 169. Reverdin's needle. thirty-six hours, after which the vagina may be gently cleansed by an injection of calendula, glycerine and warm water. This should be repeated every morning and evening until after the sutures have been removed. After the first forty-eight hours the patient is apt to complain of a drawing, burning and smarting along the line of the. wound. This may be relieved by the direct application, over the wires, of a compress, which has been soaked in equal parts of the tincture of calendula and of glycerine. On the eighth or tenth day, unless she has menstruated mean- while, the sutures may be cut and removed in the same manner as after the operation for ves- icovaginal fistula. The result will be successful providing the patient is not scrof- ulous, or syphilitic, or the victim of a dyscrasia which has under- mined her reparative forces, and providing the operation has been Removal of sutures. 902 THE DISEASES OF WOMEN. properly made and she has had the proper care in the after-treat- ment. In old cases in which the perineal body is either absent or atrophied, the best result that can be expected or promised is a recovery of the control of the sphincter ani. Fig. 1. (Bantock). Fig. 2. (Bantock). LAWSON TAIT'S METHOD OF PERINEORRHAPHY. There was much force in the remark of Doleris in one of his recent clinics that he never made a perineorrhaphy twice alike* Either he used the continuous suture or did something different from what he had practised before. The original operation, as made by Brooke and Baker Brown has been variously modified, Fig. 170. Ashton's needle for ruptured perineum. like the old obstetric forceps, without material improvement. The only exception to this rule is that of Lawson Tait, which, in many respects is a decided improvement on the old, or the "butterfly'' method. It is particularly suited to the complete laceration which extends to a greater or less distance through the recto-vaginal sep- tum, and to those in which the integrity of the perineum is sorely- impaired. LACERATION OF THE PERINEUM. 903 The essential features of this operation are that there is no sac- rifice of tissue in the freshening process. Instead of paring, or dissecting off the edges of the wound to make the necessary flaps, the raw surfaces are obtained by splitting the tissues. The cut- ting is done in the direction of the original cicatrix, and the sur- faces which are to be opposed can be made as wide as the operator chooses. The sutures, which may be of raw silk or of other Fig. 171. Peaslee's perineal needle material, are so placed that two of the flaps are turned into the rectum and two into the vagina. The septal stitches must be care- fully placed or a fistula may result. Of the perineal stitches there should be at least three and usually four, and they should be intro- duced along the margin of the integument and not beyond it. They should emerge, or cross the chasm, at the line which separ- ates the flaps. Fig. 172. Skene's needle for ruptured perineum. I have frequently made this operation both in hospital and private practice, and am persuaded of its adaptation to some of the worst cases that come under the eye of the gynecologist. Indeed it has never failed in my hands to bring the desired relief. The following case is one in which it was entirely successful in a woman who had suffered a complete laceration of the perineum for more than thirty years. Case. — Mrs. , aged fifty-five, was sent to the Hahnemann Hospital by Dr. W. H. Gibbon, of Chariton, Iowa. She had had eight children, the eldest of which was thirty-three, and the youngest twenty years old. Her first labor was a footling case, and the child was born at the end of four days and nights of labor under the direction, or the misdirection, of a country midwife. During the last two days of this prolonged labor the patient was in an unconscious condition. The delivery was finally accom- plished by pulling the child forcibly away. The consequence was that the perineum suffered a complete rupture, it being torn 904 THE DISEASES OF WOMEN. through the sphincter, and through the recto-vaginal septum to the extent of two inches or more. Since that time she had had seven more children, each of the labors lasting from two to three days and nights. In the whole thirty-three years she had had absolutely no control over the escape of the foeces, or of flatus from the bowel. The operation was set for October 6, 1881. The patient was put under the influence of ether, and Class No. 2 was admitted to the operating room. There were also present Prof. Comstock, of St. Louis; Dr. H. N. Keener, of Princeton, and Drs. Dewey, Hislop and Reynolds. On careful examination the perineal tissues were so atrophied and shrunken that the perineal body could not be found. The lacera- tion was A. shaped, and its margins were of the same thickness from the apex in the recto-vaginal septum to the base of the wound. Consequently there was no surface which could be freshened as in the usual mode of making the operation of perineorrhaphy; and the retraction s of the parts forbade the removal of tissue, which could not be spared in bringing the lips of the wound together. Under these circumstances I determined to perform Lawson Tait's operation as the only expedient which promised a successful result. The incision was made very carefully and freely; the hem- orrhage was controlled by hot water. The quadruple suture was passed with Mathieu's tubular needle; the rectal and vaginal flaps were adjusted carefully; a flexible catheter was left in the anus, and the patient put carefully to bed with the knees tied in the usual way. The rectum and the vagina were washed out each day by small injections of tepid water, containing a little carbolic acid and cal- endula. The diet was laxative but nourishing, and no effort was made to lock the bowels. Portions of soft, faecal matter were dis- charged with the injections occasionally; but the nurse observed that from the first no part of the injection ever passed through the wound from the rectum into the vagina, or vice versa. The urine was regularly drawn with a flexible catheter. The sutures were removed on the twelfth day, when, upon passing my finger into the anus, the sphincter grasped it firmly. The patient stated very frankly that for the first time in thirty-three years, she had been able to control the escape of flatus from the bowel, and the natural sensation of the parts had returned. Two days later the colon had been emptied by thorough enemata, and the patient felt so well that she wanted to go home. October 27, just three weeks from the date of the operation, she was discharged cured, and left the hospital for her home in Mis- souri. LECTUKE LY. THE PATHOLOGY OF OVARIAN TUMOR©. Tarieties. 1. Ovarian cysts: Morbid Anatomy of ; cyst-contents; the ovarian cell; Etiology: — Clinical history of; Symptoms; the subjective signs; adhesions; the physical signs, inspec- tion, mensuration, palpation, percussion and auscultation. 2. Dermoid cysts of the ovary : Morbid Anatomy of; Etiology of; Diagnosis and Treatment. 3. Fibroid tumors of the ovary ; their pathology and clinical history. There are four general varieties of ovarian tumors ; ( 1 ) ovarian cysts, (2) dermoid cysts of the ovary, (3) fibroid Varieties. tumors, and (4) malignant tumors. The first three are usually benign, and consist of an extra- ordinary growth of the proper ovarian tissues; the last is malig- nant, and arises from cancerous deposition and degeneration. I. OVARIAN CYSTS. 1. Morbid Anatomy. — Ovarian cysts are single or multiple, sim- ple or compound. A monocyst is a single sac, and a unilocular tumor of the ovary is a one-lobed affair. Where there are two or more cysts the growth is multilocular. When the added cysts grow and multiply on the inner surface of the sac the tumor is endogenous; and when from its exterior, like sprouts on a potato, it is exogenous. The original sac is sometimes styled the parent- cyst and the others are the child-cysts. In number there may be an hundred or more of these proliferating cysts, whose aggregate weight may vary from a few ounces to a hundred and fifty pounds. In February, 1878, I removed an ovarian tumor weighing eighty pounds, and the patient made a good recovery. The thickness and strength of the cyst-wall varies in different cases. Single cysts are more apt to be thick and fibrous than are those which are multiple; and older ones are usually thinner and more fragile than the younger cysts. This arises partly from their distention and partly from the cor- rosive action of the contained fluid. Hence the danger from the rupture of an old, parent-cyst. Sometimes the wall of the sac will be thin in one place and thick in another. If its thickness increases as time goes on it is probably sarcomatous. 905 906 THE DISEASES OF WOMEN. The vascular supply to these growths is furnished through the fibrous capsule of the cyst. Only their external surface is sup- plied with blood vessels. This is a fact of which advantage is taken in the enucleation of unilocular cysts. Sometimes the veins on the surface of the cysts are large and tortuous, which is usually regarded as a sign of their malignancy. The character of the fluid contained varies in the different cysts which compose the same tumor, and in the same cyst, if it has been repeatedly tapped. The oftener it is The cyst-contents, emptied the more depraved the quality of the fluid. In polycysts, one small sac may contain a. clear, amber-colored serum; another, a honey-like fluid; a third, blood; a fourth, a stinking pus; a fifth, the brown or chocolate fluid, and in others, two or more of these products may be mixed. Some- times the contents are so thick and gluey as not to flow at all, a condition which belongs to the colloid cyst. Ovarian fluids of every description have a common characteristic which is that they are of a sticky, glairy or ropy character, and more or less viscid and gelatinous. Mehu attributes this peculiar quality of the ovarian fluid to the presence of paralbumen. When examined chemically this fluid is found to contain albu- men, paralbumen and metalbumen. It does not contain fibrin unless the ovarian is mixed with ascitic fluid, or unless the cyst from which it came is of the dermoid variety. Doran says: "The glairiness, or yellowish-gray coloration of ovarian fluid, is a phys- ical characteristic, practically sufficient for diagnosis from ascitic fluid. Chemical tests for ovarian fluids are not satisfactory, and are of a kind unsuitable for the surgeon who cannot keep up more than a superficial knowledge of the science of chemistry, nor carry spectroscopes and other apparatus about with him ; nor are medico- chemical authorities yet agreed upon a perfect test for ovarian fluid." So that the proposition once endorsed by Spencer Wells, to detect the presence of paralbumen in a suspected fluid by coag- ulating its albumen by boiling it, and re-dissolving the coagulum by adding double its volume of strong acetic acid and then boiling it again, cannot always be relied upon. The specific gravity of ovarian fluids varies from 1006 to 1020. When you can find it, the recognition of the Drysdale, or granu- lar cell in an abdominal fluid that is examined microscopically, is strong presumptive evidence of its ovarian origin. But the micro- THE PATHOLOGY OF OVAEIAN TUMORS. 907 chemical properties and the true clinical import of this cell are not yet fully determined. It is spherical, some- The ovarian cell. times oval, of a yellowish tint, with a very deli- cate envelope, which upon the addition of acetic or of phosphoric acid, becomes transparent, so that its glistening granules are easily seen through the cell wall in the shape of five or six bright shining points. It is a little larger than a pus cor- puscle, and has the distinguishing peculiarity that the addition does not dissolve its granular contents, as it will in case of the inflammatory corpuscle of Gluge. Drysdale insists that "this granular cell may be distinguished from the pus-cell, lymph-corpuscle, the white blood-cell and other cells which resemble it, both by the appearance of the cell and by its behavior with acetic acid." Other authorities are, however, equally emphatic in support of the opposite view. Thus Angus McDonald says: "The general character of the fluid, with the peculiar cells referred to, can hardly lead to a mistake, although it is to be remembered that the cells mentioned are merely evidence of rapidly proliferating epithelium, and may occasionally be obtained from fluid secreted in such a cav- ity as the pleura." Garrigues affirms that, "The large rounded cell-masses found in the cyst-fluid, Bennett's large corpuscles, are epithelial cells in fatty degeneration; while Bennett's small cor- puscle, or Drysdale's granular ovarian cell, is no cell, but the nucleus of an epithelial cell in a state of fatty degeneration. There is no pathognomonic morphological element in an ovarian fluid." And Lawson Tait settles the question for himself and his follow- ers by the following characteristic statement: "In fact, I place no reliance on the presence or the absence of these cells in a fluid removed by tapping, and as I never tap removable tumors at all now, I never have any occasion to look for them, or any oppor- tunity." The microscope also detects pus and blood corpuscles, coloring matter, fat globules and cholestrine, which is an almost invariable constituent of this fluid. Its proportion is sometimes very small, and on account of certain peculiarities that pertain to its crystaliza- tion, it may be difficult to find it. Sometimes, however, it is present in such a quantity as to form a thin, glistening pellicle on the sur- face of the fluid. 2. Etiology. — While on account of its follicular anatomy there 908 THE DISEASES OF WOMEN. is no other bodily organ which is so liable to cystic degeneration as the ovary, it is not always possible to find an adequate cause for the existence of these tumors. They occur in women of all classes of society, but are most frequent among those whose surroundings are unhealthy, whose diet is meagre, and who are exposed to hard- ships of various kinds. In quite a share of cases they happen in cancerous and tuberculous subjects. Indeed some form of cancer, or of phthisis has so frequently developed within a few months, or a very few years after I have removed an ovarian cystoma, even where such a dyscrasia had not been known or recognized before- hand, that I have come to be suspicious of their causative relation. Quite a share of these cases can be traced to some local injury. One of my patients had a multilocular cyst in consequence of fall- ing through the head of a barrel upon which she was standing. Another was jammed and injured in the abdomen by a runaway horse; and a third was kicked in the left inguinal region by a brute of a husband, after which a tumor of this kind soon began to grow. In other cases the traumatic cause is a strain from lifting, as in carrying coal or water up-stairs, when "something gives way" and the trouble with the ovary begins. While it may happen that dif- ferent members of the same family shall have ovarian tumors from accidental causes, the rule is that when these growths are heredi- tary they are either malignant or tuberculous. 3. Clinical history. — Although these tumors may occur in infancy and childhood, and are not infrequent after the climacteric, they are most common during menstrual life, or between the ages of 30 and 40. Their average duration is about three years, but they often begin their course so insidiously and develop so slowly that the date of their origin cannot be fixed with certainty. In 1880 I removed a compound ovarian cyst weighing fifty-six pounds which had been growing steadily for eleven years. In another of my cases a single cyst weighing forty-one pounds had appeared and developed within four months. Unless the cyst is single the more rapid the growth of the tumor the greater the chance of its being malignant. 4 Symptoms. — The first symptom to attract the attention of the patient is the appearance of a swelling or of a "lump" in the right or the left inguinal region. Usually, but not always, she is very decided as to the early location of this growth. She will have observed that it is movable and painless, and that in changing the THE PATHOLOGY OF OVARIAN TUMORS. 909 position of her body it disappears so that she can not always find it. This tumor may be tender at the month, and sometimes causes pain by pressing upon the sacral nerves. Any rough riding or jouncing, jumping, or straining at stool may excite nausea or cause her to vomit; but aside from these symptoms the swelling may exist for months, and possibly for years, without causing any seri- ous impairment of her health. In due time, however, the tumor increases in size, and grows toward the mesian line, the opposite side of the abdomen, and toward the umbilicus. Sometimes the sac fills very rapidly, and the strength fails in a corresponding ratio. The function of menstru- ation is variously affected. In a small share of cases the flow is suspended quite early, and the patient is sterile. Others have a temporary amenorrhcea, with a decrease of the flow and an increase of suffering. If the tumor is not traceable to a traumatic cause, there will almost always have been a history of dysmenorrhcea. These patients are often exempt from leucorrhoea, but perhaps one in ten or twelve of them may have had menorrhagia. The subjective symptoms in a growing ovarian cyst are such as we might expect from a distention of the The subjective signs, abdomen and from pressure upon the adjacent organs. Whether the bladder, the rectum or the uterus is most seriously disturbed in its functions will depend upon the direction which is taken by the developing tumor, and the degree of pressure upon the said organs. In the early stages, be- fore the cyst has mounted into the abdomen, these pelvic organs often suffer more than they do afterwards. Later on, when the uterus is retracted, as it almost always is, the sense of weight below the brim of the pelvis is relieved, and, if one of the sacs is not anchored within the retro-uterine space, the rectal symptoms dis- appear. If the patient has borne one or more children, the abdom- inal parieties will yield to the expanding tumor without any great feeling of distention or discomfort, until the freedom of the diaphragm is interfered with. But if these walls are put upon the stretch for the first time by the rapidly filling cyst, the patient will necessarily feel more pain than she otherwise would. In some of these latter cases, where there is an intolerance of the ovarian growth, symptoms analagous to those of pregnancy are present. One of the contingencies of the growing tumor is a tendency to repeated attacks of local peritonitis. This plastic inflammation 910 THE DISEASES OF WOMEN seals it to the neighboring tissues and organs, and not only- increases the amount of suffering from time to Adhesions. time, but augments the danger from ovariotomy. Adhesions to the omentum, the intestines and the liver, are especially apt to involve the digestive function; while the anchorage of the tumor and its increasing growth may cause an inveterate pain in the lumbar region, obstinate constipation, albuminuria, uraemia, dropsy of the lower extremities and cardiac oppression. Dr. Fenwick* gives three symptoms as indicative of a serious cardiac involvment from this peculiar cause. These symptoms are, (1) a very feeble, rapid, and excitable pulse; (2) very dull and feeble heart's sounds, especially marked over the right apex;(3) and a very short systolic rise in the sphygmographic tracing. In some cases he also noted a great tendency to syncope. The ultimate tendency of the growth is to induce exhaustion of the physical forces, emaciation, and a pronounced cachexia. The features become shrunken, the face and expression are somewhat peculiar, and hence the fades ovariana which was once thought to be pathognomonic of this affection. The tumor grows at the expense of the other bodily tissues, and there is finally a remarka- ble disparity between the size and form of the extremities and of the abdomen. In case of hemorrhage, or of suppuration within one or more of the cysts, there will be signs of collapse, or of hec- tic with chills and rapid prostration. The objective or physical signs are more clear and satisfactory. Beginning with inspection, we observe that the The physical signs, tumor may or may not be symmetrical. The side upon which the swelling was first noted is usu- ally, but not always, the more prominent. If the distention is con- siderable, the form of the abdomen is peculiar in that its shape does not alter when the patient changes her position. It's profile is unvarying. The umbilicus may be deflected, but it is not retracted or depressed, nor does the region about it become flatten- ed on the top when the patient lies down. In old cases the abdom- inal walls are stretched and attenuated, and the muscular fibres spread apart, as in advanced pregnancy with twins, or dropsy of the amnion, and the veins stand out prominently at the sides of the tumor. Exceptionally, when there is an unusual deposit of fat *On intra-abdominal tumors as a cause of Cardiac Degeneration. British Gynecological Journal, vol II, page 72. THE PATHOLOGY OF OVARIAN TUMORS. 911 "beneath the muscles, the striae are not to be seen npon the integu- ment. In oligocysts, where there are but two or three large sacs, the lines which separate them may sometimes be easily recog- nized; and the sulci between the solid and the cystic portions of certain ovarian tumors are quite significant. I have learned to place more confidence in the physiognomy of the abdomen as a sign of these tumors than I have in the face itself, although one may indeed help us where the other fails. By mensuration, the size and certain relations are easily made out. The measurements usually taken are from the xiphoid carti- lage (which may be deformed) to the umbilicus, and thence to the upper margin of the symphysis pubis. This is the perpendicular diameter, and recalls Professor Simpson's rule that, if its length below the umbilicus exceeds that which is above it, providing the case is well developed, the tumor is uterine, and not ovarian. Next comes the girth around the body and over the most prominent part of the tumor; and after that the oblique measurements, which extend from the umbilicus to the anterior superior spinous pro- cesses of the right and left ilia. These measurements should be recorded on the spot. Palpation, or the external touch, gives an idea of the abdominal heat and tenderness, the mobility of the investing integument and of the tumor, the simple or composite character of the tumor, its softness or hardness, the course of its outline, its compressibility, and of the sulci between its component cysts. If the abdominal parieties can be grasped by the handful, the growth is not a large one; if the latter can be carried upwards beneath the umbilicus, the tumor is not uterine. Bimanual examination shows that, if the cyst can be moved about without changing the position of the uterine cervix, it is probably ovarian. It is not very unusual for the neck of the womb to be so drawn up by the developing cyst as to be beyond the reach of the finger. I have now, 1887, made six ovariotomies where the uterus was so retracted and changed in its contour that it could not be felt or found before the operation. Three of the cases were benign, and made a good recovery, the other three were cancerous and fatal. Percussion is invaluable because it serves to mark the outline and certain physical characters that are peculiar to the cyst and its contents. The tendency of these tumors to come forward, to 912 THE DISEASES OF WOMEN. lie against the abdominal parietes, and to push the intestines with their contained gases upward and backward, out of the way, makes it possible by this means to map out these tumors and to decide whether their contents are fluid, solid or mixed. By it we can detect the water-line, and the fluctuating wave-line; can often tell whether the serum is contained in a single or in numerous compartments; can judge of its tenuity or of its thickness, and whether the case is complicated with ascites or some other incidental affection. (See Figs. 17, 18 and 19.) Abdominal auscultation being more applicable and serviceable in the detection of solid tumors has little more than a negative merit in cases of ovarian dropsy.* II. DERMOID CYSTS OF THE OVARY. 1. Morbid Anatomy. — These cysts are the most curious of all morbid productions. Their chief peculiarity is found in their con- tents, which consist of a comparatively small quantity of fluid mix- ed with such growths and foreign substances as are never found in other ovarian tumors. These foreign bodies consist of hair, teeth (of the bicuspid variety when they are numerous, and of the canine when not numerous), of bits of alveolar processes with teeth in them, of rudimentary teeth which are set in cartilage, of flat bony plates and spiculse, of finger nails, of skin with its com- ponent parts, and vessels filled with morbid deposits or sebaceous secretions, of nerve tissue and striped muscular fibres, of scales of cholestrin, and fat in considerable quantity, which may be as firm as lard or tallow, or oily and beaten up like a pomade. Sometimes the cyst is a suppurating one and may furnish a large quantity of pus, but if the quantity of pus is small it may have been replaced by a putty-like material resembling Chinese white. It is a singular fact that these dermoid tumors of the ovary may exist in infancy, and even in the foetus in utero. They often occur in young women, and are seldom seen in those who have passed forty. Doran cites a case in a woman aged 63, and Atlee one that was without a pedicle in an unmarried lady of 79, and who had carried the tumor for forty-seven years. They are almost always congenital, but remain latent through childhood until after puber- ity. Sometimes the occurrence of pregnancy stimulates their growth, after which they may occasion pressure upon the neigh- *For the Differential Diagnosis of Ovarian Cysts see Lecture LVII. THE PATHOLOGY OF OVARIAN TUMORS. 913 boring parts. It is only, however, when the tumor is solid, or when its walls are thick and firm, that it causes any considerable pain or discomfort. A single compartment of a compound dermal cyst of the ovary may contain such a medley of morbid products as I have named, while the remaining sacs are filled with the ordinary ovarian fluid. We occasionally find some of these foreign matters in multilocu- lar tumors of the ovary. 2. Etiology. — I have elsewhere treated of this subject in the fol- lowing manner:* These peculiar tumors "were in times past looked upon as inex- plicable marvels, and not only had their entry into museums as treasures, but were described with scrupulous verbosity. There is, however, nothing more extraordinary in them than in the appear- ance of bone in the gluteus, or imperfect brain-like matter in the substance of the mammary gland, or fibrous nodules in the lobes of the cerebrum. Their chief surgical interest is in the obscurity they throw over diagnosis, and in the complications they occa- sion. {Spencer Wells.) Various theories have been proposed in explanation of the origin of these cutaneous tumors of the ovary. The most popular was that of fcetal inclusion, a foetus within a foetus, which referred them to the blighting of a twin-f cetus, and its inclosure within the ovary of its mate, while the latter underwent the proper develop- ment and came to maturity. Another idea was that the contained morbid products could only have resulted from the impregnation of the patient; or in other words, that a dermoid cyst of the ovary was of necessity the result of an extra-uterine pregnancy. A third was that of parthenogenesis, or the development of an ovum with- out impregnation; and a fourth referred to incomplete embryonic development of the epithelial cells of the ovary itself. But such speculations are fanciful and not profitable. The conclusion of a recent writer on this subject commends itself: "I think the best solution of the question is that of the invagination of the blasto- dermic membrane, the external layer of which develops the organs of animal life. If, therefore, there should be an inclosure of any part of this membrane within any organ of the body, these epider- mal formations would readily be produced." (Helmuth.) "The dermoid ovarian cyst question appears to me to be closely and *Arndt 1 s System of Medicine, vol. II, page 365. 914 THE DISEASES OF WOMEN. inseparably linked with some of the most profound mysteries of organic life." (Doran.) 3. Diagnosis, — The fact that these dermal tumors may be car- ried for a long time without any very decided impairment of the general health, and without attaining any great size, as well as their firmness and solidity when their wall is thick and when they are filled with solid or semi-solid contents, has frequently caused them to be mistaken for uterine fibroids. Unless there is inflam- mation in some of their structures, or pressure by them upon the neighboring organs, both these kinds of tumors are insensible and painless, of slow growth and innocuous, and both may undergo cystic or sarcomatous degeneration. But there are, however, a few points which may serve to differentiate them. "With the fibroid growth there is a history of a coincident menorrhagia; the tumor has very little tendency to anchor itself through inflamma- tion of its capsule, or of its investing peritoneum; and it is very rare indeed for it to undergo the process of suppuration. On the contrary, the dermal cyst is seldom accompanied by a profuse menstruation; it almost always becomes immobile through adhe- sive inflammation , and it is very prone to suppurate. Most uterine fibroids which have attained a considerable size grow decidedly larger with the return of the monthly period, and, afterwards diminish with the decline of the flow, which is not true of these cutaneous cysts. Although it may be present, ascites is not a com- mon accompaniment of uterine fibroids, while it is almost never absent in a dermoid cyst of the ovary which is large enough to claim our professional attention. When the dermoid cyst is located either in the posterior or anterior cul-de-sac, or anywhere at the roof of the vagina where it is accessible to the touch, there is almost always a perceptible fluctuation. This is not true of uterine fibroids. When these clinical points are not sufficient to enable us to de- cide between them, it may be expedient to resort to tapping by the aspirator-needle, the careful introduction of which will help to determine whether it has passed into a sac or into a solid growth; while, if any fluid is withdrawn, it may serve to settle the charac- ter of its contents. If the fluid contains hair or epidermal scales, or if it resembles candle-grease or melted-butter, after you have forced it from the barrel of the instrument into a glass, and espec- ially if it solidifies so that you can turn the glass upside-down THE PATHOLOGY OF OVARIAN TUMORS. 915 without spilling it, and dissolves again by placing the glass in warm water, the diagnosis is clear. (Laroyenne.) The reduction in the size of the tumor by this species of tap- ping, and the facility with which it refills, are characteristic and confirmatory. It is important to remember that if the needle strikes upon a bony structure, or even if bits of bone, teeth, and the like are discharged through fistulous openings in the rectum, the vagina, the bladder, or the abdominal parieties, the case is not necessarily one of extra-uterine pregnancy. Mistakes of this kind have often been made, and have sometimes given rise to social un- happiness when it should have been prevented. , Since a dermal growth may be composite, and may have one or more cysts, which contain a proper ovarian fluid, and since one ovary may be the seat of such a growth while the opposite one has undergone the ordinary cystic degeneration, the mere removal of a quantity of ovarian fluid by tapping does not preclude the pos- sibility of a dermoid cyst. In these cases the diagnosis must be settled by the exploratory incision, or bv ovariotomy. III. FIBROID TUMORS OF THE OVARY. 1. Clinical history. — There are three points of interest in the study of fibroid tumors of the ovary: (1) their variety, (2) the dif- ficulty of their diagnosis by any means short of Their comparative the exploratory incision, and (3) their proper surgical treatment. Of their variety we may justly say that they have been found more often by the patholo- gist than by the gynecologist, in the dead than in the living. Un- til quite recently most operators have decided with Atlee that "when a tumor possessing the usual characteristics of a fibroid is found in the abdominal cavity, we may, as a general rule, decide it to be uterine." The aversion to cutting down upon a fibroid, and the tradition that while cystic growths were removable with comparative safety, the excision of fibroids, whether of th e uterus or of the ovary, was unaccountably and almost universally follow- ed by a fatal result, has caused many an ovarian fibroid to be over- looked. Now that laparotomy has put a window in the abdomen we shall probably see more of these peculiar growths, and remove them too, with safety to our patients. Another dictum which has hindered and yet hinders the recog- nition of ovarian fibromata in certain cases is the statement that 916 THE DISEASES OF WOMEN. they are always of a small size, and that a large abdominal fibroid must necessarily be of uterine origin. Even Tait endorses the statement of Peaslee, who says that: "Fibroids of the ovary are very rare, and do not often exceed the size of a goose-egg." But Greig Smith* reports having "successfully removed a solid ovar- ian tumor as large as a child's head, in which repeated examina- tions by competent histologists failed to show any other histologi- cal element than pure fibrous tissue." And Dr. Mann has been equally successful in extirpating an undoubted fibroma of the ovary that weighed seven pounds.f Doran gives a very interesting cut of a myoma of the ovary, which had been growing for eight years, which was successfully removed by Sir Spencer Wells from a single woman aged sixty-eight, and weighed 15 lbs. 2 oz. (See Fig. 173.) Fig. 173. Myoma of the ovary. (Doran.) 2. Morbid anatomy. — The first five of the conclusions of Dr. Coe in a remarkable paper on "Fibromata and Cysto-fibromata of the Ovary" J include all that you will need to know upon this part of my subject. They are as follows: 1. Fibrous tumors may and do arise from the ovary, independ- ent of the uterus or the other adnexa. 2. In structure these tumors are true fibromata, yet peculiarly rich in long spindle-cells, which closely resemble those of the nor- mal stroma; hence, 3. These fibromata originate, not by a local change, but as the *Abdominal Surgery, by J. Greig Smith, etc., etc., 1887, page 130. fThe American Journal of Obstetrics, etc., May, 1887, page 451. tlbid, Vol. XV., 1882, page 876. THE PATHOLOGY OF OVARIAN TUMORS. 917 xesult of a general hyperplasia of the ovarian stroma. Moreover, there is nothing to show that this process is of an irritative, or inflammatory character. 4. The resemblance between microscopic sections of ovarian and uterine fibroids is so close that the differential diagnosis is very difficult, if not impossible. 5. Cysto-fibromata of the ovary, like those of the uterus, are of secondary formation, and result from changes in previously solid tumors. 3. Diagnosis. — If the patient is intelligent and is quite positive that the hard swelling or "lump" was first detected in the ingui- nal region, or that it developed from that quarter, or that it has always inclined to either side of the pelvis, the fact is suggestive of its ovarian attachment. If it is, and has always been, very movable, rolling about whenever she changed her position from side to side, the symptom is confirmatory. If the growth is pain- less, or nearly so, and accompanied by dragging sensations, and downward pressure when she is standing; but more especially if the tumor has a rounded outline, a smooth surface, a hard and firm texture ; if it can be moved independently of the uterus, and if it is accompanied by an ascitic accumulation, the subjective symptoms may be said to be pretty well marked. They are not decisive, however, for the same symptoms might be present in an extra-uterine fibroid that was attached by a slender pedicle to the front or to the side of the uterus. There is this difference between them, that while the ovarian fibroid is almost always accompanied by ascites, the uterine myoma is not; and that, while the former does not give rise to menorrhagia, the latter almost invariably does. The signs revealed on auscultation are the same in both cases. It rarely happens that both ovaries are the seat of fibrous growths. More often one ovary is cystic and the other solid. It is well to remember, however, that the most expert and exper- ienced gynecologist can not always make an abso- La ?o8^^source iag " ^ e diagnosis of an ovarian fibroma without are- sort to the knife. The exploratory incision will not only enable us to complete the diagnosis, but to determine whether it is expedient to remove the tumor. ( See Lecture LVIII. ) LECTUKE LVI. THE PATHOLOGY OF OVARIAN TUMORS— Continued. Malignant tumors of the ovary.— 1. Cysto-sabooma. Case. Physical signs. Rupture of the sac. The rule for tapping. Aspiration. Differential diagnosis. Ovariotomy. 2. Cysto- OABCINOMA. Clinical history; Symptoms; Diagnosis. 3. Soibehtjs of the ovary; His- tory and symptoms. 4. Colloid ob Myxoma; not always cancerous. Tait on malignancy of. 5. Papilloma, epithelioma and oaulifloweb degeneration of the ovaby. Case. 6. Enoephaloid of the ovaby. Case. IV. MALIGNANT TUMORS OP THE OVARY. With very few exceptions malignant tumors of the ovary are composite, or partly solid and partly cystic. Usually, but not always, the solid portion is the first to be developed. The cystic portion is certain to become the more bulky of the two. The clin- ical varieties of these malignant ovarian tumors are (1) cysto- sarcoma, (2) cysto-carcinoma, (3) scirrhus, (4) colloid, or myxoma, (5) papilloma, epithelioma and cauliflower degeneration, and (6) encephaloid of the ovary. 1. CYSTO-SARCOMATOUS, OR FIBRO-CYSTIC TUMORS OF THE OVARY. The several important points in the history and diagnosis of this kind of ovarian tumors are the comparative slowness of their growth until the cyst has formed and is partly rilled; the irregular shape of its solid portion and its recurrent tendency after it has been removed; its disposition to mass the womb with the tumor so that it cannot be identified, and the refilling of the sarcoma-cyst or cysts, which are sometimes very large, after they have been tapped. The following case was sent to the hospital by Dr. E. D. Kan- ouse & Son, of Appleton, Wis., and the remarks appended consti- tuted my clinical lecture upon it, delivered in the hospital Febru- ary 19, 1885: Case. — Mrs. , married, aged forty-six, has conceived only once, which occurred twenty years ago. The child was still-born^ She enjoyed comparatively good health until fourteen years ago, when an enlargement was observed in the left ovarian region. This enlargement grew slowly for a period of five years, giving rise to no special inconvenience. The abdomen had attained a cir- cumference of between thirty-six and thirty-nine inches, when she 918 THE PATHOLOGY OF OVAKIAN TUMORS. 919 received a fall, soon after which the abdominal enlargement diminished. From this sudden disappearance of the tumor it was supposed that it must have been ruptured by the fall. No per- ceptible discharge occurred, neither did the patient suffer any spec- ial shock or inconvenience, saving a slight weakness for a few days. Following this accident, an enlargement appeared in the right ovarian region, developing quite rapidly for eighteen months, when it also was ruptured spontaneously. At this time a very small quantity of a thin, inoffensive fluid escaped per vaginam. This sac apparently refilled, and in one year more ruptured again; the abdomen decreasing in measurement within about twenty-four hours, from a circumference of forty-one to twenty- two inches. At this time there was a clear, inoffensive, syrupy exudation from the skin, necessitating a constant sponging of the patient for three days and nights, and then it gradually disappear- ed. No serious illness followed, and she was about as usual, after the lapse of ten or twelve days. But this did not end her trouble, for soon it was noticed that the -tumor was again developing. The progress of this growth has been very much slower than that of the preceding two, having cov- ered a space of six years in attaining its present size. During the last five years the menstrual periods have been very irregular. The flow is copious, dark-colored and clotted, lasting as a rule for ten days, and being preceded by and accompanied with intra-pelvic pain, notalgia and cephalalgia; and during the past two years the discharge has had an extremely offensive odor. She occa- sionally has slight pelvic pains during the inter-menstrual period. The urine is normal; the bowels are constipated; the oedema of the lower limbs is quite marked. Her mother died at the age of fifty-six of cancer of the womb, and an aunt, her mother's sister, died of some morbid growth of the stomach; but with these exceptions the health of the family seems to have been good. I will not repeat what has already been said and shown you, con- cerning the different methods of physical diag- Physicai signs. nosis in abdominal tumors, but proceed at once to discuss the peculiar clinical features of this case. Observe that percussion gives a singular outline to this con- tained growth. I will mark it with a pen, so that you can all see it. While its margin on the left side, and transversely below the thorax, is rounded, it gives us a triangular patch of resonance on the right side, the apex of which points across the abdomen, and nearly reaches the mesian line, about half-way between the umbil- icus and the pubes. ( See Figs. 174-5 ) Such irregularities of out- line, and there is a variety of them, almost always signify that the 920 THE DISEASES OF WOMEN. tumor is composite. That this tumor is partly cystic is shown in the history of its having been ruptured, as well as by a percepti- ble fluctuation, especially at its left and superior portion. Although you are aware that the womb is usually drawn upward and forward in ovarian tumors, it may surprise some of you to learn that it cannot be felt or found, per vaginum, in this case. When the uterus is lost in this way it may be a good or a bad sign. It is always an obstacle to diagnosis. It may have adhered to the wall of an ovarian cyst, and been retracted as the sac has devel- oped, and no harm come of it; but if it is included and imbedded in a solid growth which lies above the superior strait, the case is very different. We shall see. But what of the repeated rupture and the disappearance as well as the refilling of this tumor ? Briefly, there are three kinds of rup- ture which may either temporarily or perma- Bupture of the sac. nently dispose of the fluid contents of an ovarian cystoma : ( 1 ) there may be a leak through which the fluid is discharged very gradually ; or (2) there may be a break- ing down of the partition walls of a' multilocular cyst, so that its compartments may communicate, and the shape and size of the tumor be changed; or (3) it is possible to have a large-sized rent through which the fluid may be poured into the peritoneal cavity. The cause for either of these kinds of rupture is atrophy or disten- tion, or both, and not ulceration of the cyst-wall as is generally supposed. A considerable share of these cases of spontaneous rupture re- cover, and the cyst does not refill; but others are fatal. You should remember, that when the first rupture is not accompanied by shock, or followed by illness, and especially if there is no reaccum- ulation of its fluid contents, the tumor is a cyst of the broad liga- ment, or something else, and not a proper ovarian cyst. Not only does the true ovarian cyst fail to disappear by a spon- taneous evacuation, or even by a single tapping, but it is peculiar in another respect, which is that every time it refills its contained fluid becomes more depraved in quality, so that, although such a cyst might possibly break for the first time and pour its innoccu- ous contents into the peritoneal cavity without harm, this thing could not be repeated very often with impunity. We do not know, and nobody knows what kind of fluid escaped from this sac when it collapsed the first, or even the second time that it yielded; but THE PATHOLOGY OF OVARIAN TUMORS. 921 if this last accummulation is ovarian, it is next to impossible that it should not be vitiated. The irritating and poisonous qualities of the ovarian fluid, espec- ially if it conies from an old sac, are known to you. When such a tumor has been tapped a very few times it becomes septic in a high degree, and this is why repeated tapping increases the risks of a subsequent ovariotomy. Providing death does not follow from shock, or peritonitis, or hemorrhage, or from all these, an early or a repeated rupture of the cyst-wall will have the same effect. From this point of view, therefore, you perceive that, since this growth has so nearly attained its maximum size, or the point of distention at which it burst on two former occasions, our patient is really in a perilous condition. On the theory that the fluid which fluctuates beneath my hand is very poisonous, it should not be permitted to escape into the abdomen; for the greedy lymphat- ics, of which the peritoneum is almost entirely composed, would absorb it and develop a speedy and fatal infection. There is another reason why I have brought this woman before you, which is to illustrate the impossibility of making a satisfac- tory diagnosis in some of these cases without a The rule for tapping, resort to tapping, or to the exploratory incision. The former of these final methods of diagnosis has been very much abused — abused by those who have practised it without the proper discrimination, and whose carelessness has greatly increased the mortality from ovariotomy ; and more recently abused by a few leading specialists who go to the other extreme, and who insist that it should no longer be practised under any circumstances whatever. Now there are several good reasons why, in my judgment, tap- ping is advisable in this case, which is certainly an exceptional one. They are (1) to avoid the imminent risk of another rupture, for the circumference of the abdomen is thirty-nine and a-half, instead of forty-one inches; (2) to remove the fluid in order that it may be examined; (3) to get it out of the way of a further phys- ical exploration; (4) to decide whether the tumor is wholly cystic or if it is composite, and if possible, to find the whereabouts of the womb; and (5) to enable us to decide intelligently whether, and if so, what further operative treatment is expedient and necessary. Tapping is usually a very simple operation, but in such a case ^as this we must proceed cautiously. With the form and outline 922 THE DISEASES OF WOMEN. of this tumor, and this acute angle of resonance coming so near to the mesian line, we might puncture a coil of intestine ; or, if the cyst- wall happens to be very weak and attenuated, it may leak around the needle, or the canula, or possibly fail to close the orifice when the instrument is withdrawn. It will be safer, therefore, to use the aspirator than to take the ordinary trocar, although it may happen that the fluid is too thick to flow through its slender needle. The patient is sensible and intelligent, and is quite willing for 11s to do whatever is best. We will, therefore, try the aspiration as a means of relief to her and of information Aspiration. and help for ourselves, but not as a curative measure. Having selected a point on the linea alba one-third the distance below the umbilicus, the skin is touched with a strong solution of carbolic acid to anaesthetize it, and as an antiseptic precaution. In passing the needle I feel that it enters a cavity and is fairly within the compartment containing a fluid. My assistant exhausts the air-chamber of the instrument, and you will see in a moment what kind of fluid fills the sac, and whether my prediction that it is bad enough is verified. I turn this little stop-cock, it flows freely, and you can all see that it is of a dark > chocolate color. It is morally certain that, if this fluid had escaped into the peritoneal cavity, the risk of malignant infection would have been very great. I do not see how she could have sur- vived it. The aspirator empties these large collections very slowly, but it is a safer instrument than the old trocar, not only because there is no possible admission of atmospheric air into the sac, or the tissues, but because the discharge is so slow that it prevents shock, and permits the abdominal organs gradually to accommodate them- selves to their change of position. We have now emptied the tumor of its fluid contents, eleven and a-half pints in all of this chocolate-looking mixture, and I am going to withdraw the needle. This fluid is all of one kind, which is evidence that we have to do with a single sac, and we may learn something by the caref ul removal of the needle. Observe that I hold it in a peculiar position so that I may know if the sac has col- lapsed, and may be able to indicate its place of attachment when it drops from the point of the needle. She will now be carried to one of my private rooms in the hospital, where she will have every care to prevent any ill-effects from this operation; and if every- THE PATHOLOGY OF OVARIAN TUMORS. 923 thing goes on well, I will complete the examination and the diag- nosis in this amphitheatre in a few days, or as soon as it can be done with safety. Monday, February 23. — Our excellent house physician, Dr. Eddy, has had such a care of our patient that she has escaped all harm, and I have had her brought before you again. You will observe the difference in the contour of the abdomen. The enlargement at its upper part has disappeared, the belly is hollow- ed out, and the line of dulless is horizontal, passing transversely about one-third of the distance below the umbilicus. Above this line the abdomen is resonant, below it the sound is flat; above it the distended sac has collapsed and disappeared, below it the \ Fig. 174. Ovarian cysto-sarcofna before and after tapping. tumor that remains is solid and immovable. The uterus can not be identified, either internally or externally. The mass is irregu- lar, not rounded like a benign fibroid, and not sensitive as it was at the close of the tapping. The patient has stated one fact not contained in the record of her case, which is that, directly after the rupture of the sac, six years ago, the abdomen "was as flat as that of a young girl," and that there was no sign of any remaining tumor in it. If this is true, and I see no reason to doubt it; if the uterus was retracted then as it is now; and if the menorrhagia began soon after, it is fair to infer that the development of the solid portion of this 924 THE DISEASES OF WOMEN. tumor, followed the development of its cystic portion. This order of consequence is the reverse of what takes place in fibro-cystic tumors of the uterus. But in cysto-sarcoma, and also in cysto- carcinoma of the ovary, the solid part may be first and the cystic secondary, or vice versa. But, what is this solid growth? Is it benign, or malignant, car- cinomatous or not? It is manifestly ovarian although the uterus is certainly involved and included in the mass. I believe it to be a cysto-sarcoma of the ovaries, although in some respects it resem- bles cysto-carcinoma of the same organs. Here is a parallel between the symptoms of each: Ovarian cysto-sarcoma. Ovarian cysto-carcinoma. The rounded outline of the The surface of the tumor is tumor. irregular and nodulated. The tumor is not especially It is almost always tender and sensitive. sensitive. There is almost always a his- Menorrhagia is exceptional, tory of menorrhagia. Ascites and anasarca are the Almost never a pronounced rule and not the exception, ascites, or any dropsy of the feet. The pulse is like that of phth- The pulse is not habitually isis. rapid. In a confirmed case the each- There is no peculiar cachexia, exia is always present. The solid portion of the The more malignant the solid tumor develops slowly. growth the more rapid its devel- opment. Is this a suitable case for ovariotomy? I think not. The tumor, if not really malignant, is of the recurrent variety; the pelvic adhesions are very formidable, and the uterus is lost in the mass, and must come out with it. The case is very like the one in which you saw me remove both ovaries and a portion of the womb in October last, and which terminated fatally. I have now operated upon six cases in which the uterus could not be identified before the incision was made. Of these three have indeed recovered, but in each of the three that organ was adhered to the ovarian cyst, and had been retracted beyond reach. In the other three it was lost in a solid growth of this kind. At the request of my friend, Dr. John Moore, I saw a case like this when in Liverpool, two years ago. Within a month afterward it was removed by the cel- ebrated ovariotomist, Dr. Keith, of Edinburgh, but despite his acknowledged skill, the operation resulted fatally. So that, with THE PATHOLOGY OF OVARIAN TUMORS. 925 the history that has been given you, and the points that have been made concerning this patient's case, I think it most prudent and advisable to send her home without an operation, for, in all human probability she would not survive the removal of this mass.* 2. CYSTO-CAROINOMA OF THE OVARY. Although the ovary is more liable to undergo cystic degenera- tion than any other organ in the body it is com- ciinicai history, paratively exempt from cancer, especially in its primary form. Any and all of its textures are liable to this kind of degeneration and of infiltration. For this reason, if the trouble begins in the areolar or the fibrous tissues of the ovary it may develop slowly and for a long time without involving its follicular portion. True cancer-cysts of this organ when they are of secondary growth may be numerous, but they are not usually so large, nor is their wall so thick as in fibro-cystic tumors of the ovary. The symptoms vary with the size, location and firmness of the tumor, conditions that involve pressure within the pelvis and which give rise to local pains, neuralgia, sciatica, rectal Symptoms. and vesical obstruction, recurrent peritonitis and cellulitis with or without suppuration. This form of ovarian tumor is more painful than any other, and as in other varieties of cancer it is sooner or later accompanied by an impairment of the appetite and digestion, anaemia and emaciation. Anasarca and ascites are the rule and not the exception in old cases. As already stated, this form of ovarian cancer is usually second- ary upon the same lesion located elsewhere. By the time that it can be recognized the constitutional cachexia will have been developed. The coincident lesions, more especially the peritoni- tis, will have resulted in the anchorage of the tumor which in- creases the suffering and greatly complicates the possibility of its removal. "Any solid tumor of the ovary will awaken the attention and cause one to suspect the existence of a cancerous Diagnosis. growth. This suspicion will be the stronger if both ovaries have been attacked, if the pain is * Under date of September 2, 1887, Dr. K. writes that this patient is in better health than for the past six years. In the interval the tumor has been twice tapped, each time yielding about six quarts of a fluid resembling New Orleans molasses. 926 THE DISEASES OF WOMEN. intense, if the development of the tumor has been rapid, if there is a marked degree of ascites, and finally if the emaciation and the cachexia, and the general and local oedema are out of proportion with the size of the tumor. The age of the patient is also a sign that is worthy of note, for ovarian cancer is generally found in younger persons than is cancer of other organs." (Mustache*) The differential diagnosis between the cysto-carcinoma and cysto-sarcoma have just been given you. (See page 924) 3. SCIRRHUS OF THE OVARY. This form of ovarian cancer is extremely rare; is seldom larger than an orange, is almost always of secondary History and symptoms, formation, and connected especially with scirr- hus of the uterus and of the broad ligaments; it affects both ovaries at the same time; is most frequent in unmar- ried women; and is peculiar through its exemption from adhesive inflammation, its mobility, painlessness, and its failure to undergo any form of cystic or calcareous degeneration. The surface of this kind of tumor is comparatively, although not absolutely, smooth, and, therefore, it is not usually accompanied by ascites. Indeed this circumstance causes it to be confounded with fibroma, or myo-fibromata of the ovary. The chief distinction between these two varieties of ovarian tumor, both of which are rare, is that the development of the cancerous cachexia is incident to one of them and not to the other. The expediency of removing a scirrhous growth of the ovary by laparotomy, will depend upon the involvment of the uterus and the broad ligaments, and upon the constitutional condition of the patient, the family history, the duration of the disease, the emaci- ation and the digestive impairment; and since all of these condi- tions cannot be otherwise determined, it will sometimes be proper to settle the question by a resort to the exploratory incision. 4. COLLOID OR MYXOMATA OF THE OVARY. It is unfortunate that the term "colloid," which means a gelatinous substance, should have been applied to a variety Not always cancerous, of ovarian growths ; and still more unfortunate that authorities are not agreed as to the malig- nancy, or non-malignancy of these tumors. Formerly every ova- rian tumor that yielded this species of jelly-like discharge was .be- lieved to be cancerous, and the rupture of cysts with colloid con- THE PATHOLOGY OF OVARIAN TUMORS. 927 'tents was thought to be fatal through the absorption of cancerous material. Now we know that, unless the intra-cystic contents con- sist of some form of papillomatous growth, the mere fluid contents of the sac are not sufficient proof of its cancerous nature. I have repeatedly removed multilocular tumors of the ovary in which the cysts contained a large amount of this colloid material; but so far as I have been able to trace the subsequent history of these cases, in only one of them has there been any recurrence of the disease. In that case both ovaries were involved, much of the colloid materi- al was hardened into form like moulded jelly; the two tumors weighed sixty pounds; the patient made a good recovery and lived for eighteen months when she fell a victim to a rapidly developing cancer of the peritoneum with ascites. A prominent author says "the term colloid, as applied to tumors of the ovary, must be held to refer only to the Tait on coUoidtnmors consistency of the fluid contained in them, and in no way as a point for classification. I have never met with a description which has persuaded me that the so-called colloid cancer, as seen in the breast, intestines and peritoneum, has ever been met with in the ovary. What we see of it is the myxoma already described, and which is always quite localized in the tumor, a mere incident, as it were, never forming the mass of the growth. In other organs it is practically a malig- nant disease, but whether it is so in the ovary I do not know. It is, as I have said, the reversion of the stroma of the ovary to its young form, and may therefore be suspected." (Lawson Tait) 5. PAPILLOMA, EPITHELIOMA AND CAULIFLOWER DEGENERATION OF THE OVARY. Papilloma, or wart -like growths upon the ovary are either extra- or intra-cystic. They may be sparse or exuberant, are very fria- ble, and their presence is usually accompanied by a large amount of free fluid in the form of ascites, or large accumulation within the cyst- wall. When they are attached to the outer surface of the sac, they not only give rise to abdominal dropsy, but similar vege- tations are apt to be found upon the surface of the peritoneum. Sometimes these peritoneal sprouts are developed in consequence of the rupture of the cysts and the resulting extravasation of their contained fiuid. It has been claimed that frequent tapping of a benign cyst may possibly result in the formation of these papillo- 928 THE DISEASES OF WOMEN. matous growths, especially if any of the cystic contents shall have passed into the peritoneal cavity. Ovarian epithelioma usually begins within the cyst, and may be limited to its cavity; but, if the cyst is ruptured the lesion may ex- tend to the solid portion of the tumor, and to the neighboring sur- faces. The greater its extension the larger the ascitic accumula- tion, and the more pronounced the cancerous cachexia. Cauliflower degeneration of the ovaries, of which Plate II, taken from a specimen that was removed in my clinic, gives a faithful illustration, is undoubtedly the rarest of all the forms of ovarian tumors. Its symptoms are not distinctive from those of other varieties of ovarian cancer. Its morbid anatomy is peculiar in that its development results in the destruction and disappearance of the cyst-wall, while in old cases there is general anasarca, ascites, emaciation, the cancerous hue of the skin, and the usual evidences of a cancerous cachexia. Secondary cardiac and renal lesions are the rule and not the exception. The following case was first shown in my hospital clinic April 10, 1882: Case. — Mrs. , aged 43, the mother of two children, has always enjoyed good health and been in good flesh until about a year ago, when she began to grow thin, after which she discovered that the abdomen was very much larger than it should be. This enlargement began at the lower part of the abdomen and extended upward. A little while afterward she had a fall, which jarred her badly. Since July, 1881, now nine months, she has been tapped three times. The first time, the distention was enormous, and fifty pounds of fluid were withdrawn, after which an umbilical hernia was developed. In October, 1881, the operation of ovariotomy was attempted and relinquished by some physicians in the coun- try, and she was tapped again, but does not know how many pounds of fluid were taken. In January, 1882, she was tapped a third time, and thirty-one pounds of serum were removed. After the third tapping, the hernia once became strangulated, but was relieved by manipulation under chloroform. It is now very sore and she is obliged to wear a truss. There is a cicatrix four inches long, resulting from the incision made in October last, and several scars from the tappings and the sutures. The enlargement of the abdomen, which is much less than before the first tapping, is chiefly below the umbilicus, except upon the right side, where the dullness on percussion extends to the hepatic region. In the left lumbar region there is resonance on' percussion, the same as marks the outline of a cyst. The wave-line is very pronounced. The depth of the uterus is three inches. THE PATHOLOGY OF OYAKIAN TUMORS. 929 Her general condition is tolerably good. She is dragged and exhausted with the weight and refilling of the tumor, but makes more complaint of the hernia than of anything else. Her mens- truation has been regular, but not too profuse. She felt so badly after the last tapping, that she declares it shall not be repeated, and insists upon an operation if only for the relief of the hernial pro- trusion, and for the sake of clearing up the diagnosis of the case, in which latter item she is more deeply interested than any one else can possibly be. I have told her most plainly and frankly that it is very doubtful if she has an ovarian cyst, and that it may be necessary to relinquish the operation a second time, or, in the event of malignant disease, to remove the womb. Of her own free will she asks for this expedient, and we have resolved to give the suf- ferer her only chance of life. The Operation. — The operation was made at noon of Tuesday, April 18, 1882, in one of my ovariotomy rooms in Hahnemann Hospital. There were present Drs. Comstock, of St. Louis; Pol- lock, of Galesburg; Scott, of Oneida; Crawford, Reynolds, and Ehle, of Chicago, who very kindly assisted. The incision was made at the side of the old cicatrix. Coming down carefully on what seemed to be a cyst-wall, a separation was made for an inch or two in order to determine if we were really within the peritoneum. This could not be decided until the fluid was withdrawn by tap- ping. The two layers of the membrane were separated from each other for a little, when I became satisfied that they both belonged to the peritoneum. The incision through this membrane was en- larged, and the abdominal contents were displayed in situ. There was no cyst of any description within the abdomen or the pelvis. The fluid drawn off was thin, of a light amber color, ascitic, and weighed thirty-four pounds. The only peculiarity about it was that two or three little whitish bodies, as large as a split pea, passed through the trocar while it was flowing. Further exploration disclosed two tumors, one on either side of the uterus. When these were brought to the lower angle of the incision, it was found that the only expedient left was the removal of the uterus with the masses attached. Supra-vaginal hysterect- omy was therefore performed. The broad ligaments were ligated; the uterus was carefully separated from the bladder, and detached all around. The abdominal portion of the cervix was treated as a pedicle, and the womb, with the diseased ovaries was cut away. Yery little blood was lost, no accident happened, the toilet of the peritoneum was carefully made, the old cicatrix was removed, and the umbilical hernia disposed of after the manner of Koeberle. The wound was closed and the patient put to bed, the operation having lasted nearly two hours. She re-acted fairly well, and soon became conscious, although the weakened condition of the circulation which had persisted dur- ing the operation still continued. The pulse was often scarcely dis- 930 THE DISEASES OF WOMEN. cernible at the wrist, and, although she complained of being too warm, her hands and face kept cool, without any tendency to febrile reaction. At 4 P. m., the urine was drawn, the pulse was 120, with some vomiting of frothy mucus. At 8 p. M. the tempera- ture was 98.5°, the pulse 120. She complained greatly of pain in the back and down the right crural nerve. These symptoms continued with slight variation. She had no good sleep; the urine was drawn every three hours; the bowels were slightly moved; she had nausea, but no more vomiting; the coldness of the face and of the perspiration were marked at inter- vals ; the temperature did not increase ; the left radial pulse could not be found, and the pain in the back increased. At 4 A. M., the carotid was poorly defined. The cardiac murmurs were distinct and regular, but soft and undulating. The respirations reached fifty per minute and were quite labored. She was sensible until within half an hour of her death, talking quietly of her approaching end, and thanking those about her for all that had been done for her relief. She sank quietly away at 6:30 a. m., evidently from exhaustion, it being eighteen hours after the operation. An autopsy was held at the end of twenty-four hours, in the presence of those who had witnessed the operation ( excepting Dr. Scott), and also of Drs. Laning, Burnside and Glover. The incis- ion was re-opened and the abdominal cavity carefully examined. There were no signs of congestion, and no evidence of hemorrhage or any accident consecutive upon the operation. The ligatures upon the broad ligaments had not slipped; the pedicle was secure; the bladder had not been injured, and everthing was normal, excepting the peritoneum, which had formerly been mistaken for the wall of an ovarian cyst, and the presence of a quantity of ascitic fluid, wdiich had already poured into the abdominal cavity since the operation. 6. ENCEPHALOID OF THE OVARY. In this form of ovarian cancer the contents of the cyst or cysts have been changed and degenerated into a peculiar, brain-like mass, whence its name. Both ovaries are usually involved in this variety of malignant growth, from which the uterus and the neigh- boring tissues are exempt. In this latter respect the encephaloid differs from kindred affections of the ovary. But the other symp- toms including the peritoneal dropsy, and the constitutional involvement are of the same serious character. The course of the disease is sometimes quite slow and insidious ; but at other times it is rapidly fatal. In exceptional cases, as with encephaloid tumors in other parts of the body, the growth is traceable to a traumatic injury, but usually hereditary influence can be readily detected. THE PATHOLOGY OF OVARIAN TUMORS. 931 The most marked case of the kind that I have ever seen was one in which I made a double ovariotomy upon a patient of Dr. A. M. Eastman, in St. Paul, Minn., and in which there were forty pounds of ascitic fluid, while the tumor attached to one ovary weighed nine, and that of the other two pounds. The full history of this case was published, with a cut illustrating the same, in the Clin- ique, volume IV, page 439. I know of no more serious question than to decide upon the pro- priety of removing these encephaloid tumors of the ovary after having exposed them by an exploratory incision. My own rule has been to take them away if the pelvic adhesions are not so bad as to render it almost certain that the patient would die before the operation was finished. If the facts and the risks have been fully stated to the patient and to those most interested beforehand, and she or they insist that it shall be removed, I think we would do wrong to relinquish the operation while there was the least possible chance of recovery. LECTURE LVII. THE DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. I. From Ascites. 2. From encys ed peritoneal dropsy. Case. 3. From pregnancy. 4, From extra uterine pregnane}'. 5. From uterine fibroids. 6. From fibro-cystic growths. 7. From physometra. 8. From distention and prolapse of the bladder, 9. From enlargement and malignant disease of the liver and spleen. Case. 10. From tumors which are due to menstrual retention. 11. From renal cysts, etc. Within a fortnight I have shown you three cases of ovarian dropsy, and now I propose to teach you how to diagnosticate that disease from those with which it is often confounded. In two of these cases my diagnosis has been already confirmed, for the tu- mors which weighed twenty-seven, and forty-three pounds respect- ively, after I had removed them, were examined in the presence of the class. I. From ascites. — In the great majority of cases, abdominal dropsy is secondary upon some pre-existing chronic disease of the liver, of the spleen, of some portion of the digestive tract, of the kidneys, or, in rare instances, of the heart or lungs. In ovarian dropsy this rule is reversed, and the general ill health is the con- sequence of the development of the tumor. In ascites, if the patient lies upon her back with her knees drawn up, the abdominal tumor becomes flattened anteriorly, and " bulges," or spreads out laterally. The sides and flanks, as well as the front surface of the enlargement, except directly around the umbilicus, are dull and flat on percussion. Around the navel, however, there is a reso- nant sound in ascites. If she turns upon either side, there will be dullness upon that side, and resonance upon the other. But in ovarian dropsy the contour of the tumor is not changed when the patient changes her position. It is not flattened in front when she lies upon her back. Its margin is easily mapped out. The flanks are not distended. There is no dullness or bulging in the lumbar regions, but a resonance which is quite clear and charac- teristic, and which assures us that the intestines lie behind a cir- cumscribed sac, whatever its contents may be. This is so well 932 DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 933 shown in the chart (Fig. 18) that T am quite certain you will remember it as a chief means of diagnosticating ovarian dropsy from ascites. In ascites the " touch" recognizes a fluctuation in the Douglas' cul-de-sac, which is lacking in ovarian dropsy. In ascites, also, the accumulation begins at the lowest and most dependent part of the abdomen, while in ova- rian dropsy the tumor usually commences in the right or the left hypogastrium, or in one of the iliac fossae. When it exists, ex- treme dropsy of the abdominal walls is almost always conjoined with malignant disease. Coincident oedema, especially of the feet, may exist from the first in ascites, but never occurs in ovarian dropsy except in the last stage of the disease. It should be remembered, however, that in quite a share of cases, more especially if the growth is malignant, or semi malignant, ovari- an tumors and ascites may coexist. The larger the accumnlation about an ovarian cyst the more suspicious the character of the tumor. Tapping is a useful means of diagnosticating between these two affections. Having withdrawn the serum in case of ovarian dropsy, we find that the solid or semi-solid tumor does not float out of reach as before the operation, but that it may now be quite readily examined and grasped by the hand through* the abdominal parietes. After tapping, there- fore, the size, shape, and location of this tumor can be so well made out that we need not confound it with such hypertrophy of the liver, the spleen, or of the mesenteric glands, as might have attended upon ascites. Concerning the time and mode of tapping, it should not be done during the menstrual period, neither directly after a meal, nor vet in your office. I once tapped a very pl " ,a" ? ai 'S e °y st with a sma11 trocar > and ve ^ carefully, in my office, and my patient sank almost imme- diately into a state of collapse from which it took me two hours to rescue her. Dr. Peaslee lost a case from tapping with a fine trocar. The instrument should consist of a small exploring trocar, or of the long slender needle of the aspirator, the use of which prevents the admission of air into the cyst when it has been wholly or partially evacuated. Beside its diagnostic value, tapping is sometimes of the greai- 984 THE DISEASES OF WOMEN. est service in helping ns to decide upon the propriety, and indeed the necessity of an early operation. When you of T t b a e pping n ° StiCValUe succeed in drawing off a considerable quantity of fluid, which you are satisfied comes from an ovarian cyst, but have reason to believe that other cysts have not been reached, and cannot be emptied by the same puncture, the case is a compound one, and the clinical inference is that you should not keep on tapping one sac while the rest of the tumor is grow- ing, but that the whole mass should be removed as soon as possible. Some of you remember the case which was sent me a few weeks ago by Dr. L. Hall, of Minneapolis, Minn., in which, before she came into Dr. Hall's hands, the patient had been tapped nine times, with the removal of ninety quarts (by the husband's measurement) of a dirty wine-colored fluid. This had been done within eighteen months, but although the tumor had diminished, it had never disappeared in consequence. You saw that poor woman on the table ; you heard me give an unfavorable prognosis; you witnessed that I declined to operate, unless the husband and the patient took the whole risk; you saw her feeble condition, her courage, her cheerfulness, and her deter- mination not to leave this hospital until that tumor was removed. One of the sub-classes witnessed the operation, in which, through the most formidable and universal adhesions that I have ever seen, the tumor, weighing forty pounds and consisting of five large lobes, was removed. The next day it was examined before the whole class, and you saw the character of the contents of the four large sacs which had not been touched by the trocar, although an attempt had been made to open a second one. The smallest of these sacs had suppurated, and one of them contained more than a quart of dark, grumous blood. The large cyst, which had lain against the abdominal parietes, had no communication with the others. The patient lived only seven hours ; but the legacy left us was the conviction that if, when the trocar had told its story, the tu- mor had been removed, she might have gotten well again. It is important to remember that in ascites, after paracentesis, the re-accumulation of water is usually slow, while after the evacuation of an ovarian cyst, it is much more rapid and persis- DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 935 tent. In one of my patients who had oyarian dropsy, from whom I withdrew many gallons of water, the abclom- Refilling of the s,c - j tumor was quifce ag larffe ag ever at the or cyst. 1 end of the first week. In exceptional cases, however, ascites and ovarian dropsy co- exist, and both sets of symptoms are present at the same time in the same patient. The diagnosis between them is more difficult in case the cyst is unilocular than if it is multilocular, because in the former the abdominal en- largement is more rounded and uniform, and bears a closer resem- blance to that of ascites. II. From encysted peritoneal dropsy . — There is a form of ascites in which the accumulation of serum is localized by plastic peri- tonitis, and the tumor is limited, just as it is in hematocele. This sacculated form of peritonitis, which may occur in men as well as in women, may be traumatic, or it may be cancerous, or tubercu- lous; and it may follow an attack of: pelvi-peritonitis, or of hematocele. It is not of very frequent occurrence, but we have had three cases of the kind in the hospital in as many years. One of them was brought here by Dr. H. C. Thole, of D wight, 111., a description of which you will find in The U. 8. Medical 'Investi- gator for Sept. 1, 1877. The special signs of this form of dropsy are the lack of intest- inal resonance on the top of the tumor when the patient is lying on her back, and of the bulging in the flanks that is present in ascites ; the non-interference of respiration by the tumor; the highly albu- minous character of the fluid ; the constant peritonitis, and the usual co-existence of a grave cachexia. A very important sign also is that, when such a sac has been tapped, it almost never re- fills. This, indeed, is the kind of an " ovarian tumor" which is sometimes cured by electricity, and at others by internal remedies, when in point of fact it is no more an ovarian tumor than is a ease of dropsy of the knee-joint, or of the pleura. The only absolute test of encysted peritoneal dropsy is by tap- ping, and by the explorai ory incision. It has happened that cases of this kind have been cut down upon with the Case intention of performing ovariotomy, when there really was no other tumor than such as had resulted from this sac- culated form of peritonitis. On the fourth clay of September, 936 THE DISEASES OF WOMEN. 1874, I took my friends Drs. Dorion and Foster, and my brother, Dr. F. M. P. Ludlam, to a case which four physicians, two of whom were gynaecologists, had pronounced to be one of ovarian dropsy. The diagnosis was masked, and the patient was aware of the fact. We were prepared to operate in case it should be war- ranted after the exploratory incision was made. But a careful section of the peritoneum discharged the entire dropsical accumu- lation, and no sac or tumor could be found. The incision was closed, she made a good recovery, and now, when six and a-half years have elapsed, there has been no return of the difficulty. III. From pregnancy . — Pregnancy is self-limited, and its gen- eral history is so well defined that you might suppose there would be little risk of confounding it with ovarian fouTdeT 111 ^ C ° n " dropsy; but experience proves otherwise, for it has frequently happened to the surgeon to declare the patient ill with ovarian dropsy, when, in reality, she was pregnant, and upon making an abdominal section to find the foetus in utero, instead of an ovarian cyst within the cavity of the peritoneum. So frequent is this error in diagnosis, that it would not perhaps be extravagant to say that at least one-third of the cases of so-called ovarian dropsy, in which gynaecologists are con- sulted, prove to be cases of pregnancy. In ovarian dropsy menstruation is sometimes arrested. The reflex ovarian sympathies, which involve other organs, may simu- late those proper to gestation. The digestive Parallel symptoms. ,, J . . , „ ,° function is almost necessarily more or less im- paired. The mammary glands may be developed and become ten- der, as in pregnancy. The breasts may fill with milk, and even the areolae may become quite distinct. Usually, however, in ova- rian dropsy, unless both ovaries are diseased, the menses return irregularly, or are too frequent and copious. Last year I was consulted in a case of ovarian dropsy occurring A rare case. . -. . , . . , , m a wonan aged thirty-six years, who, by rea- son of a congenital absence of the vagina, had never menstruated. The patient's age will sometimes assist in diagnosticating ovarian dropsy from pregnancy. In general, we say that in pregnancy the abdominal tumor has some peculiarities of situation and growth which may perhaps serve to distinguish it from an ovarian enlarges r^t. For exam- DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 937 pie. it has originally been intra-pelvic; it ascends gradually or more rapidly, as the case may be, at about the Location and growth. , . fourth month, and its globular outline is easily recognized by palpation. It it deviates to either side of the median line, its margin is smooth and well defined. From the fourth until the eighth month it grows from below upwards. It assumes the form of a general swelling, and is never described by the patient as a " lump" in her side or elsewhere. But we must not forget that both these affections may escape observation or suspicion until weeks or even months have elapsed before our advice is sought. Under these circumstances, we shall be compelled to rely upon other signs in order to separate them and to treat them properly. The " touch" may aid very greatly in the diagnosis. In preg- nancy, after the fifth month, and more especially in multipara, the uterine cervix is considerably softened, in^thTates!^ ""^ swollen, and compressible, and the external os uteri patulous. In uncomplicated ovarian dropsy its shape, size and cartilaginous character remain unchanged. In pregnancy, at or after the fifth month, you would expect to find the cervix at the superior strait, not far from the promontory of the sacrum. And, although it is frequently drawn up and either ante-flexed, or displaced toward the affected side in ovarian dropsy, still its location will in most cases not differ materially from that of the unimpregnated uterus. If the internal os uteri was open, and the finger did not come into direct contact with the mem- branes, the placenta, or with some part of the foetus, the woman could not be pregnant. The easy introduction of the uterine sound, and its ready passage to the fundus uteri, would also enable you to exclude pregnancy from the list of probabilities. But the sound should not be used unless it is manifest that, if the patient is pregnant, her " term" is very near. The uterine souffle is so equivocal a sign of pregnancy that, except as confirmatory, we cannot place much dependence upon it; for it has been found that it does not arise, unre!iaWe ine S ° Uffle as was once supposed, from ai i increased devel- opment of vessels, and an augmented circula- tion of blood at the site of the placenta and through it. In other words, it is not necessarily connected with the utero-placental cir- 938 THE DISEASES OE AN OMEN. culation. It may be present in fibroids, in uterine cancer and hypertrophy, in tumors within the broad ligament, in aneurism ot the abdominal aorta, in case of a tumor pressing upon the iliac arteries, in sub-involution of the womb after delivery, and also in ovarian enlargement with or without dropsy. If you are fortunate enough to detect the foetal heart-sounds, all dcubt will be at an end. But, although this will afford you an unequivocal sign of pregnancy, if you can rec- The foetal heart-sound j {t ^ ^ not however be wise to unequivocal. ^ ■ . conclude that your patient was not pregnant simply because, after repeated trials, you failed to find it; for it might be so distant, indistinct and obscure, or so modified, that you would not know it from other sounds. Or the position of the foetus in utero might be such as to render it quite impossible for you to hear it at all. In advanced pregnancy, if the position of the child is favorable, and the abdominal walls are thin, it is sometimes possible to recog- nize the head, or the extremities of the foetus, by palpation. Quickening, if it were genuine, would confirm this condition. And yet it has happened that the irregular outline of the proper ovai- ian tumor has been mistaken for that of the child ; while the move- ments of the foetus in utero may be counterfeited in various ways. It is, therefore, more difficult to diagnosticate ovarian dropsy from pregnancy than you would have supposed. Sometimes they co- exist. In very rare cases the dropsy is contingent upon gesta- tion, and disappears after delivery. If you can not otherwise determine the rliagnosis, it will be best for you to proceed as in other cases where pregnancy is possible, id est, to wait until the proper limit for that ofTagno'sis! 1 6lement condition has passed, for, ordinarily, there need be no haste in deciding. If the woman is preg- nant, the tumor will not sensibly increase in size, or develop in an upward direction, after eight and a half months. When ten or twelve months have elapsed since the swelling was first noticed, it is tolerably certain that there is some kind of a tumor present which would be found in case of extra-uterine pregnancy, in which the foetus might be indefinitely retained. But this form of ges- tation is so rare as scarcely to deserve notice in this connection. In women, as you know, the natural limit for pregnancy is nine DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 93i> months, while the average duration of ovarian dropsy is about three years. IV. JPrmn extra-uterine pregnancy, — In the great majority of cases extra-uterine fcetation terminates by a rupture of the cyst, and pelvic hematocele, at or before the fourth month. I have already cited you a remarkable instance of this kind (page 428). Under these circumstances there is little risk of confounding the tumor with ovarian dropsy. But, when the sac has not burst, and the foetus has become encapsuled, more especially if it has not been mummified, but has developed and remained plump, with a large amount of serous fluid around it, it may be very difficult to diagnosticate it from ovarian dropsy. If you will remember that, although its cavity is not necessarily enlarged, the tissues of the uterus are softened and dilated in this form of pregnancy ; that the finger can be passed into it for the purpose of conjoined manipulation; that cases of extra-uterine pregnancy which are extended in this way are almost, always of the tubal variety, which makes the tumor accessible from the side of the uterine cavity ; and that extra-uterine ballottement is there- fore available to detect a floating solid just outside of the uterus, it may assist you greatly. Tapping with the ordinary trocar in such a case is murderous, for in extra-uterine pregnancy, unless there has been a great deal of adhesive inflammation, the walls of the sac will not collapse and close when that instrument is withdrawn, as they do after the needle of the aspirator. The consequence is an overflow of its vitiated contents into the peritoneal cavity, and death from sepsis. You will therefore take the aspirator in preference, and while its slen- der trocar is being passed, or afterwards, use it carefully as an exploring needle by which you may recognize the bony parts of the foetus, if there is one. Simon's rectal exploration is a danger- ous expedient on account of the risk of rupturing the extra- uterine sac, which is usually very delicate; and an unsatisfactory one, because, unless the foetus is mummified, it gives no positive evidence, and therefore could not help us to distinguish this form of pregnancy when it is most likel} 7 to be confounded with ovarian dropsy. V. From uterine fibroids. — Although ovarian dropsy may be accompanied by irregular menstruation, in which the flow may be 940 THE DISEASES OF WOMEN. either too frequent or too copious, or both, nevertheless we can not properly say that patients having this form Haemorrhage. r- -, V • i u t ot dropsy are prone to uterine haemorrhage, in- deed, the dropsical and the hemorrhagic diatheses are at antipodes, and seldom or never exist in the same person. But the hypertro- phy of the muscular structure of the womb, which is pathological and not physiological, or which, in other words, does not pertain to the development of the gravid uterus, but which follows abor- tion or labor, or an attack of metritis, is in the majority of cases attended by a more or less protracted and alarming menorrhagia. Statistics show that only nine per cent, of the cases ot ovarian dropsy are accompanied by uterine haemorrhage ; while as large a proportion of cases of uterine fibroids as seventy per cent, are marked by this symptom. This estimate does not include those extra-mural or sub-peritoneal fibroids from which such a haemor- rhage would be impossible. Whenever, therefore, you have a patient who is subject to con- siderable or continuous flooding- which begins and ceases without any special relation to "the month," and more particularly if she is not pregnant, and there is present a pelvic or abdominal tumor of considerable size, you will have reason to suspect that she has one or more uterine fibroids. In that case the tumor will most .probably be clue to hypertrophy of the uterine muscular tissue, while the haemorrhage is a species of critical outlet or safety-valve for the excess of blood carried thither. In uterine fibroids the tumor is hard and movable. Its mobility is diagnostic. When you can feel that a motion is imparted to the Consentaneous mobility whole maSS h Y a bloW from the &*&*. U P 011 the of the uterus and the posterior wall of the cervix-uteri ,as in ballotte- ment, or by introducing the uterine sound can lift the organ and satisfy yourself by the hand placed over the abdominal parietes that the entire tumor moves along with it, there can be little doubt of the presence of a uterine fibroid, Sometimes, however, it may happen in this form of neoplastic growth that the womb may be immovable, as it is in scirrhus ol that organ. The distance to which the sound will enter the womb is also significant. As a rule, if it passes in more than three inches the uterus is said to be enlarged ; and enlargement of the uterine DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 941 cavity is one of the most certain and constant signs of these same fibroid growths. In uncomplicated ovarian cavitT 11 ° f ^ Uterine ^opsy, if the womb is sometimes elongated, it is in consequence of its displacement, and of the unnatural pressure of the ovarian tumor upon it. The manifest changes in the length and size of the uterus which are present in a case of fibroids, do not properly belong to the clinical history of ovarian dropsy. Fibroids are of slow growth; and so, also, are ovarian tumors, in the early stages of the same. But ovarian tumors sometimes develop rapidly from the first, or having existed growth™ rapidlty ° f lor some months and grown very slowly, they suddenly fill the abdomen and give rise to much suffering and discomfort. Uterine displacements and leucorrhcea form a natural and almost necessary part of the history of fibroids, while they are generally absent in ovarian dropsy. VI. trom fibro-cystic growths — Those fibroids which are attached to the exterior surface of the womb, and which lie be- neath its peritoneal investment, sometimes undergo cystic de- generation. In this case the tumor, which may include a number of these degenerate fibroids, is likely to become 'of such size as to fill the abdominal cavity, and to be mistaken for ovarian dropsy, ascites, and even for pregnancy. So close is this resemblance, that in many cases the most skilful practitioners of this specialty have been unable to diagnosticate a fibro-cystic from an ovarian tumor, before making an exploratory incision. Fortunately, however, this species of fibroid is compar- atively rare. Dr. Routh's statistics show that in only three out of eighteen cases of fibro-cystic tumor was there any menorrhagia. Spencer Wells has several times diagnosticated thepres- £%££££? ™™™ of these fibro-cysts of the uterus by the es- cape through the trocar on paracentesis, of a thin serum containing from five to fifteen per cent, of blood, with which it is so intimately mixed as not to separate from it until after standing for some hours. Without enlarging upon these and other points that will help you to diagnosticate ovarian dropsy from fibro-cystic growths, I will refer you to a valuable classification of the more prominent ^42 THE DISEASES OF WOMEN. symptoms arranged by Dr. Charles C. Lee, and published in the "JST. Y. Medical Journal;' Vol. XIV., p. 474. IN OVARIAN CYSTS. IN FIBRO-CYSTS OF THE UTERUS. 1. Disease may occur at any period, even 1. Scarcely ever occurs under thirty— gen-. before puberty. erally from forty to fifty. 2. Development rapid — usually under two 2. Development slow — generally over two years. years. 3. Aspect of face unaltered, if the general 3. "Facies uterina" generally marked; health be fair. expression anxious and dejected. 4. Fluctuation equable over the whole sur- 4. Fluctuation confined to certain regions face of the tumor. —generally to upper portion, while the lower is hard and dull. 5. Vaginal examination shows little dis- 5. Va«inal exrminat on shows the uterus placement of the uterus — the mass high up or displaced. The mass either smooth and distinct from the uterus. not detected or continuous with the uterus. 6. Mobility of the uterus independent of 6. Independent mobility of the womb con- the tumor from the beginning — pelvic fined to the last stage of the disease, adhesions rare. Pelvic adhesions common. 7. Tapping causes complete collapse of 7. Tapping causes only partial collapse, unilocular cysts ; in polycystictumors, leaving the base of the tumor firm and it reveals the endocysts. indurated. 8. The fluid is clear, straw-colored, serous; 8. The fluid is either brownish, bloody, or viscid, clear, mucoid, and albumin- sero-purulent, or muddv ; or thin and ous. yellowish, containing shreds of lymph or of cholesterin. 9. When exposed by gastrotomy the sac is 9. The exposed sac is dark, vascular, thick, pearly blue, or white and glistening; and frequently fasciculated with but rarely vascular. fibrous bands. VII. From physometra. — Distention of the womb with gas is not very likely to be confounded with ovarian dropsy. If the abdominal enlargement, upon which I place my hand, is due to such a cause, the swelling will be tympanitic on percussion over its whole extent, instead of dull and flat as in dropsy. And then, too, the tumefaction could be very readily re* Empty the uterus. _. . . moved without resort to such a severe opera* tion as ovariotomy; for we could pass a male catheter through the cervix uteri and discharge its contents in a very few moments, Physometra is always attended by more or less troublesome hysterical manifestations, which do not pertain to ovarian dropsy, and which can be dissipated by means of an anaesthetic. VIII. From distention and prolapse of the bladder. — The skil- ful use of the female catheter and of conjoined external and in- ternal manipulation, would enable you to decide between either of these affections and ovarian dropsy. IX. From enlargements of the liver and spleen. — Hypertro- phy of the liver is almost invariably associated with chronic dis- DIFFERENTIAL DIAGNOSIS OF OVAKIAN DROPSY. 943 ease of that viscus. The form of dropsy that attends it is ab- dominal. When effusion has taken place into Physical exploration. , . , .,, ., , the peritoneal sac, you will recognize the phys- ical signs of ascites. The margin of the enlarged liver, which is well defined, the absence ot uterine complication, which is suggestive, the digestive and constitutional disorder, which are significant from the outset, and the general contour of the tumor, will help you to differentiate between enlargement of the liver and the presence of one or more ovarian cysts. In October, 1879, I was called by my friend, Dr. A. W. Burn- side, of Belvidere, 111., to a patient whose former physician had declared that she had an ovarian tumor. Dr. B. o-ave no opinion, but desired my diagnosis and my view concerning the ex- pediency of an operation. I decided the case to be a malignant hepatic tumor, and, of course, made no operation. In a little while the woman died, and a careful autopsy afforded a remarkable specimen of cancerous liver, which through the kindness of Dr. Buruside's pupil, Dr. W. A. McDowell, was shown to the class. The record of her case is as follows: Case. Mrs. — , set 52, is the mother of two children, the youngest of which is tweuty-two years of nge. Two years ago she began to be troubled with indigestion, and although she was under con- stant treatment, it gradually grew worse. About four months before her death she became unable to retain any food upon her stomach. In the early part of August there was observed a small abnormal growth near the umbilicus, which grew slowly until iibout three weeks before her death, when it grew very rapidly, with an aggravation of all her other symptoms. At times she suffered very severe burning pains which she referred to the stomach. Her feet and limbs became very dropsical, and her com- plexion finally became highly jaundiced. Almost the whole abdo- men was filled with the tumor, which, at the post-mortem, weighed eleven and a half pounds. The gall-bladder was full of gall stones, three of which were as large as a hickory-nut. There were extensive adhesions to the transverse colon, and also to the stomach. So, also, with an abnormal development of the spleen. The constitutional symptoms which accompany it are characteristic. One or another of the forms of aome, and im- Leucocytosis. . . pairment of the quality of the blood, with leu- kaemia and perhaps anaemia also, will serve to identify this lesion. 944 THE DISEASES OF WOMEN. The exploratory incision is the only means of an absolute diag- nosis in some cases of this kind, and it should be very carefully made. X. From tumors caused by retention of the menses, and of faecal matter. — The former would depend upon an imperforate hymen, atresia of the vagina, or of the uterine cervix, or of both these passages, or upon obliteration of the neck of the womb by some flexion or deviation of the organ, or by some foreign growth which served to block up its outlet. In either case the "touch," and the introduction of the uterine sound, would discharge the menstrual deposit and remove the tumor. Such an expedient would be useless in real ovarian dropsy. If there was excessive faecal accumulation, the previous history of the case, and, more than all besides, a careful examination of the tumor, would disclose the difference between it and the dis- ease we have under consideration. The tumor would be hard and irregular, and nodulated to the feel, and could be traced along the course of the rectum and the colon. Emptying the bowel by enemata of oil, castile-suds, or of a similar solvent, would settle the question most effectually. XL From renal cysts and floating kidney. — The' only form of renal cyst that resembles an ovarian tumor of considerable size is the sac in exceptional cases of hydronephrosis. The fluid con- tained in such a tumor may reach thirty pounds. The distinctive peculiarity of that fluid is that it always contains urine with pus or albumin. Serous and hydatid cysts of the kidney which may resemble the smaller ovarian cysts, can be known from them by tapping. In renal growths the tumor develops from above down- ward and may be moved toward the corresponding lumbar region. This rule applies especially to the migratory kidney, which, in cases cited by Atlee and others, has frequently been mistaken for a small ovarian cyst. LECTURE LVIII. EXPLORATIVE METHODS OF DIAGNOSIS. I. The exploratory incision; history of ; practical indications for; precaution; mode of mak- ing; suitable cases for; is sometimes curative: case; detailed instruction, case; practical results; practical rules for. II. Tapping; as a means of diagnosis; not curative; mode of operating; examination of the fluid that is drawn; the form of the abdomen after; tapping as a palliative; a dangerous expedient; case ; the sources of danger from; how it may increase the risks after ovariotomy. I. THE EXPLORATORY INCISION. EXPLORATIVE LAPAROTOMY. Although the usual methods of diagnosis in ovarian and other abdominal tumors were carefully considered in our last lecture, the subject is not exhausted until I have spoken of the explora- tory incision. Laparotomy, by which is meant a section of the abdomen, belongs to diagnosis, is its last resource and its final appeal in doubtful cases. The deliberate opening of the abdominal cavity for the purpose of making a precise and a perfect diagnosis in History of. the case of a contained tumor, was first practised by Walne in 1842. For more than forty years in pre-antiseptic days, it was unpopular, but now there is such a reaction in its favor that it bids fair to be abused unless the indi- cations for its employment are carefully considered. This is what is called the abdominal section, the exploratory incision, gastrotomy, or more properly, an explorative or a diagnosticial laparotomy. It should not be made carelessly, without hesitation, or without the strictest antiseptic precautions. Nor should it be done until the patient, or her family, or both have been fully apprised of the object in view, and of the possibility that nothing more than an incision may be prudent or permissible. Let Precaution. them understand that it is a pre-operative exped- ient which is intended to finish an imperfect and an incomplete diagnosis ; that it is not made for the sake of cutting, or from mere curiosity; and that its design is to expose the tumor to the direct touch and to sight in order that the question of its removal may be satisfactorily settled. 945 946 THE DISEASES OF WOMEN. 'There is no doubt that a good deal of rashness and a certain amount of incompetence is sought to be concealed by the practice of 'exploratory incisions.' No incision ought to be merely explor- atory; at the utmost, it ought to be ultimately diagnostic in a case of extreme doubt and difficulty. * * # * Before submit- ting our patient to what, after all, is a serious operation and a try- ing illness, we ought again and again to return to the examination of the disease, read and re-read the exhaustive history, and decide only after having done this. At different examinations the mind focuses its attention on different points, and travels in different directions; and each examination may give us new information. The help of a skilled friend is always valuable, but too much weight must not be given to it. Responsibility begets trustworth- iness; the man who operates is the man who must diagnose, and additional acumen is given to his powers by the heavy responsi- bility that waits upon their fruition." (J. Greig Smith). This form of laparotomy has a threefold value: (1) to enable us to complete the diagnosis by a digital and a visual examination of the tumor, and of the pelvic and the abdominal organs that are involved; (2) to enable us to decide upon the expediency and the propriety of an operation, and (3) that we may determine intelli- gently what particular operation shall be made. 1. To complete the diagnosis by a digital and visual examina- tion of the tumor and of the pelvic and of the abdominal organs that are involved. — After having cleansed the abdominal integu- ument with the same antiseptic solution that you Mode of making, intend to use internally, the incision is carefully made, just as in ovariotomy. And, no matter what the location or size of the growth or of the obstruction, it should be made in the mesian line. This drawing on the black- board (Fig. 175), shows the lines of incision that have been tried, or adopteii by various gynecologists; but the usual one is the ver- tical and median incision chosen by Mauricean for the Cesarean section. The wound should not be more than from two to three inches in length, just sufficient to admit the passage of two, or at most of three fingers; and all hemorrhage should be stopped be- fore the peritoneum is opened. When you are ready to open the peritoneum yo a may recall the maxim of my old friend, Dr. Palmer, to "look for the worst, hope for the best, and take what comes." For when it is properly made, EXPLORATIVE METHODS OF DIAGNOSIS. 947 the incision holds the key to all cases of doubt. It leads us to the seat of trouble in the most direct manner, and Caution. cannot be harmful if it is done with delicacy and not with a rough dispatch. But too much manip- ulation, or too long exposure of the parts may be very mischiev- ous. Once satisfied with the diagnosis, and of the impossibility of removing the tumor with safety and success, we must stop! It may be, and it usually is much harder to stop than to go forward, but we must not forget that a little rashness and traumatism might cost the poor woman her life. So I shall ask you to verify by sight USUAL LINE ATLEE DOPLSEY ST5RER Fig. 175. The various lines of abdominal incision. only what I may find in this case, for it has been well said that "death is a severe penalty to pay for the perfection of diagnosis." A recent author is justly emphatic when he says: "Having made this exploratory incision we must not be too rash in convert- ing it into an operative one. We ought to be sure, before inflict- ing the slightest injury upon the growth, that we can remove it. To have been forced to submit the patient to exploration by incis- ion, is grievous enough ; but to have added thereto additional risks from sheer meddlesomeness, is unpardonable. Difficulties and 948 THE DISEASES OF WOMEN. dangers, legitimate and unavoidable, are numerous enough, in all conscience, in abdominal surgery; let us not to these add risks that are illegitimate arid avoidable." (J. Greig Smith). The conditions in which doubts are apt to exist are various. Not only is it impossible in certain cases to decide suited 8 tc? which {t is by any other means whether the tumor is uter- ine, Fallopian, or ovarian, renal, splenic, hepatic, mesenteric, or pancreatic; what are its anatomical relations, and whether its attachments are slight or extensive, manageable or not; but without this expedient we may be equally in the dark con- cerning its malignancy. If a fenestrated opening can be safely made and closed again we shall have followed the rule of reserv- ing the instrument of greatest precision in diagnosis until the close of the examination. It completes the diagnosis, and literally opens the way for relief in pelvic abcess, pelvic hematocele, puerperal peritonitis and cel- lulitis with sero-purulent accumulations, in al] forms of salpingitis, and in case of cystic or sclerotic degeneration of the ovaries. It is essentially conservative, the same as the abdominal incision for gun-shot wounds of the intestines, or for the direct examination of the stomach, or of the gall-bladder. And not only will its care- ful employment with good surroundings result in the saving of human life in certain cases, which were supposed to be beyond relief before the daylight was let in upon them, but the specialist who makes these incisions with comparative frequency will there- by learn to recognize and to differentiate all sorts of abdominal tumors with a greater degree of aptness, precision and certainty. It ought to be added to the reasons given by Dr. Bantock in his ' ; Plea for Early Ovariotomy." You will occasionally be surprised to find that the exploratory incision, pure and simple, is absolutely curative, is sometimes curative. The best examples of this kind occur in tuber- cular peritonitis and encysted peritoneal dropsy, in chronic peritonitis, and in the dysmenorrhea of highly hysteri- cal subjects. In the former the good result is akin to that which follows a free incision of the tunica vaginalis testes for the radical cure of hydrocele ; but in the latter the mental shock produced by the idea of having undergone a serious operation (where nothing was removed) has so changed the clinical expression of the case that the hysterical symptoms will have disappeared. EXPLORATIVE METHODS OF DIAGNOSIS. 949 2. To enable us to decide upon the expediency and the propriety of an operation. — When the indications for explorative laparot- omy were less clearly established than now, it was a very common thing to speak of a case in which the incision had been made and nothing further done as an unfinished or an incomplete operation. Strictly speaking, it is not an operation any more than is tapping with or without the aspirator, and in the great majority of cases it is much more satisfactory. Dr. Sims is reported to have said in 1872: "I never know exactly what I am going to find when I gain admission to the abdominal cavity." And Tait says very express- ively: "Sometimes I now begin an 'exploratory incision' and end it as an 'ovariotomy,' while formerly I used to start an 'ovariotomy' only to end it as an 'exploratory incision.' " There is only one risk to a beginner in this, that he will have to learn when to stop at the mere exploration. To attempt the removal of a tumor and not be able to finish it, is the most fatal of all proceedings, and therefore the list of incomplete operations should always be a short one." The operation is not an unfinished one unless you have really tried to remove a tumor and have failed to do so. The following case will serve as an illustration. The patient was sent to my clinic by Dr. A. H. Van Voorhis, of Dakota, April, ■20,1887: Case 20001. — Mrs. , aged forty-eight, the mother of five chil- dren, was married at twenty-three, was always well until after the birth of her last, a boy, fourteen years ago. At that time she came near dying from inflammation of the right ovary, but she recovered in eight weeks. Then she had one severe shock at the death of her mother, and another by her husband's failure in business. Since the last mishap she has been obliged to work very hard, and has suffered much from ovaralgia. Two years ago while sitting at the table writing, and without previous warning, she suddenly felt what seemed to her like a foetus rising from the pelvic cavity to the right hypochondriac region. From this time she supposed herself to be pregnant; yet the menstruation continued regular and normal. In the autumn of 1885 the signs of pregnancy disappeared and her weight increased from about 140 to 180 pounds. In May, 1886, she had typho-malarial fever, from the effects of which she has not fully recovered. During the first fortnight of this illness she lost thirty pounds in flesh, and her emaciation disclosed a hard but painless tumor about the size of the fist, and located in the right hypochondrium. She was for some time in the care of a German physician, who promised to discuss this tumor by absorption. He 950 THE DISEASES OF WOMEN. said: "I make you strong, the tumor he grow faster; I make you weak, the tumor he no grow!" When she had lost in all about eighty pounds in weight, Dr. Van Yoorhis was consulted. He found an abdominal enlargement as in a six months' pregnancy; she was exceedingly weak and prostrate, the feet and ankles were swollen, the bowels were bad and the digestion was very much im- paired. She gained strength slowly, and finally determined, with all of a good, brave woman's pluck, to make the long journey hither for an operation. The patient being properly anaesthetized and everything in read- iness the incision was made through the linea alba. The hemorr- hage being under control and the wound perfectly clean and asep- tic, the peritoneum was opened. This disclosed a cancerous mesentery which was studded with hard, whitish deposits, and some of the veins of which were as large as one's little finger, full, turgid, and ready to burst. Beneath this envelope, which was quite adherent over nearly the whole surface of the tumor, was an immovable mass of cancerous infiltration which involved the intes- tines and the neigboring viscera. To the right of the incision was a cyst of the size and form of a goose-egg, which could be felt but for which no pedicle could be found. It was this which had been recognized as a small, knob-like protuberance by external palpa- tion. The malignancy of the growth was manifest. The diagno- sis being fully established, no attempt was made for its removal. The greatest care was taken not to wound any of the' vessels; the peritoneum was closed with the continuous catgut suture, and the external wound united with silver wire. The tumor that I showed you at my clinic on Saturday last, a condensed multilocular cyst of the ovary, had a history which illustrates the value of this form of exploration, when properly made and followed up with the appropriate operation. The woman from whom it was taken was a patient of Dr. J. E. Morrison, of Urbana, 111. The most careful examination by the usual means did not enable us fully to make out the diagnosis. The probabili- ties were largely in favor of its being an uterine fibroid. An explanation to this effect was made to the husband of the patient, and with the assistance of Dr. Morrison and Dr. O. M. Baird, of Champaign, I made the abdominal section prepared to finish with an ovariotomy, or a hysterectomy, or whatever else should be required, ivhen we had completed the diagnosis. The tumor was turned out, its pedicle secured, the wound closed and the patient left in good condition.* There are cases in which an explorative laparotomy brings great *This patient is now well again. EXPLORATIVE METHODS OF DIAGNOSIS. 951 relief with little comparative risk, even where it does not promise anything in the way of a radical care. I had such a case a week ago in Kendallville, Ind. Its clinical history, which was kindly prepared for me by the attending physician, Dr. W. M. B. Olds, is as follows: Case. — On April 27, 1886, I was called to see Mrs. , aged forty-two. She was married but had never borne children. She complained of gastric trouble ; a dull dragging in the epigastrium ; yawning; coldness of the extremities, with a burning, gnawing, cramp-like pain in the stomach, extending upward through the chest and throat. She had great dyspnoea, with laborious action of the heart, and a heaviness in the right hypochondrium, with headache and depression of spirits. There was a dragging sensa- tion in the pelvis and pressure on the rectum while standing; ex- treme constipation; the skin and eyes were yellow; sour eructa- tions; the tongue was coated yellow, pasty and dry, and the urine was dark brown and scanty; the menses had ceased; the family his- tory reveals no hereditary taint. She has been suffering for sev- eral years with the foregoing symptoms. Nux and Chelidonium were prescribed with good effect which lasted for a few days only. Under Coloc. and Apis, mel the flatulence subsided, and the urine cleared up for about three weeks, when the symptoms returned. July 1 she was very much bloated; the abdomen and stomach were highly distended ; she had extreme pain, palpitation, dyspnoea and a decided nervous prostration. Examination revealed the char- acteristic diagnostic symptoms of ascites, and I decided to perform paracentesis. On the 27th of July, 1886, 1 removed fifty-five pounds of fluid. She rallied readily and was about the house until August 25, when I took thirty-two pounds of fluid. This was repeated September 9, and each month following until November, when she was tapped every ten days until January, 1887, after which it be- came necessary to repeat it every seven days. After February she was tapped every four days. She suffered no inconvenience from these repeated tappings. She would keep her bed one day before the operation and then would be about her house the following morning. After the first tapping her general health seemed to improve. She was free from constipation, the appetite was good and she gained in weight. She was tapped forty-three times in all, and about 700 pounds of serum were taken away. In August, 1886, she first complained of ovarian pains and shortly after I discovered a tumor which gradually developed until it was thought best to consider the propriety of its removal by an operation. Physical examination showed that the uterus was firmly anchored, and that quite a mass was lying at the left lateral cul-de-sac, in- volving the broad ligament and probably the ovary also. At the right of the uterus there was a similar growth but of smaller size. 952 THE DISEASES OF WOMEN. In the right side of the abdomen there was a movable tumor which felt like a cystic ovary floating in ascitic fluid. The exploratory incision was determined upon on the theory that both the right and the left-sided growths at the roof of the vagina might possi- bly be impacted, and therefore removable; that at least the float- ing tumor might be taken away, and that its removal and the incis- ion of the peritoneum might, for a time at least, have the effect to arrest the rapid ascitic effusion. With the assistance of Dr. Olds and Dr. N. G. Eieff, of Albion, Inch, the incision was made after full preparation for any final procedure that might be necessary. The lateral growths were found to be due to cancerous infiltration, and were therefore let alone; but the floating tumor proved to be a cysto-carcinoma of the right ovary. It was removed and weighed ten pounds. I showed it to you and explained its peculiarities on Wednesday last. That patient is now at the ninth day and is sail- ing along without any troublesome symptoms.* Although the operation ends with the incision, the discharge of the ascitic fluid, and the cleansing of the abdominal cavity, the excellent results obtained from laparotomy in tuberculosis, and in encysted dropsy of the peritoneum make it one of our most valued resources. 3. To determine intelligently what particular operation shall be made. — In its recent progress abdominal surgery has -developed a variety of resources which cannot be properly applied in making a radical operation until the indications for their employment are plainly presented. Who ever has opened the abdomen very often in the living subject knows that every incision made through its walls is really explorative. Some one has said that "nothing is easier than to be wise after the event." When we have found the tumor, and determined its nature, its seat, its attachments, and the possibility as well as the propriety of its removal, it becomes a very serious question as to what form of surgical procedure is best suited to the case in hand. The fact that the intervening parietes are out of the way facilitates matters and enables us to do just what is most clearly indicated, and in the best manner, for the welfare of the patieni. Without a preliminary laparotomy the general surgeon could not decide what he would do in a case of visceral injury within the abdomen. He first finds the lesion and then fills the varying indications, whatever they may be, as carefully and as skilfully as possible. This was the way that our friend, Dr. W. E. Green, *In a month there was a slight return of the ascites. After recovering from the operation, and having been about her house and out of doors for some time, she took a severe cold that terminated in an attack of pleurisy from which she died. EXPLORATIVE METHODS OF DIAGNOSIS. 953 of Little Rock, Arkansas, proceeded in making the first successful laparotomy that was ever made for pelvic abscess.* This is the way to proceed in those cases of adherent retro-displacements of "the uterus in which salpingotomy, oophorectomy, or hysterorrha- phy, is requisite to the cure of the abnormal condition. And this, with proper precautions, is the proper course to take, not only in cases of abdominal tumor which can not otherwise be clearly iden- tified and intelligently operated upon, but also in such cases of intra-pelvic disease as are of a chronic and obscure character, and which cannot be cured by the. ordinary means. In the wide range of cases in which my services have been re- quired, both in hospital and consulting practice, Practical results. I have f ound that my confidence in the value of the exploratory incision as a dernier resort has steadily increased. I have often made it, and so far as I know but one of my patients has died in consequence, and that was many years ago, before the days of antiseptics, or of proper haemostatics, and when we knew but very little of the prophylaxis which is now so indispensable a part of peritoneal surgery. In six of my cases, however, in which an ovariotomy would not otherwise have been attempted, it certainly was the means of saving life. AYith few exceptions, and when made by one who has had experience in this kind of work, whose hands are clean and who takes the proper precautions, it certainly is a safer and a much more satisfactory test of the real condition of aif airs in doubtful cases than is the resort to tapping. When a woman is dying from an obscure ab- dominal disease, the exploratory incision is not only admissible but it is sometimes a necessary procedure. Barring his opposition to careful antisepsis, the list of precau- tions proposed by Dr. R. S. Sutton,J are the best that I have seen. They include : 1. Perfect cleanliness of the patient's abdomen. 2. Perfect cleanliness on the part of the operator. 3. Perfect cleanliness of the instruments. 4. The patient must be thoroughly anaesthetized. 5. Make a small abdominal incision, and secure every bleeding point before opening the peritoneum. 6. Carefully open the peritoneum, pass two fingers through into the abdominal cavity and search for information. If you fail to *The Hahnemannian Monthly, for August, 1883. $The American Medical Association Journal, for January, 1887. 954 THE DISEASES OF WOMEN. obtain the desired information, enlarge the abdominal wound in an upward direction, and search again. 7. Make a careful peritoneal toilet. If necessary pour in clean, warm water, and sponge it all out. Close the wound by passing the sutures over a flat sponge laid beneath the wound. 8. Never use carbolic acid or the sublimate solution; it is use- less and dangerous, unless it is merely used for the purpose of cleaning the operator's hands. 9. Only the operator is to put his hand into the abdominal cavity. 10. In tying the sutures, dry the lips of the wound with iodoform gauze. "Such are the precautions to be taken in making an exploratory incision, which if carried out will never be followed by any bad results." II. TAPPING.-OVAMOCENTESIS. I shall speak of tapping as a means of diagnosis, for "as a means of cure, tapping can never be supposed for a is not a curative moment to succeed in the case of distinctly mul- resource. _ ... tilocular cysts. This is admitted on all hands. The frequent tapping of such a tumor by a large trocar belongs to a past age, and is a cruel proceeding when done, as it yet too fre- quently is, by a practitioner who simply acknowledges thereby his inability to remove it and his unwillingness to ask any one else to do so." (Thorbum). Even in the parovarian cysts which yield the spring-water fluid, the tradition that they seldom or never refill after the first tapping and are therefore cured by it, is no longer tenable. And besides, as Pean* has shown, not only do these broad ligament cysts some- times contain a very different kind of fluid, but some of the sacs in a multilocular, and even in a malignant tumor of the ovary proper may be filled with this same clear, transparent, crystal-like, colorless water. So that tapping must not be too confidently de- pended upon either to settle the diagnosis or to result in the cure of a unilocular cyst of any kind whatever. The method of exploratory tapping has been greatly simplified by the use of the aspirator instead of the old- Mode of operating, fashioned dome-trocar. For, although the needle of the aspirator is of smaller size, and one might therefore suppose that the thicker ovarian fluids would not pass through it, they will usually be forced to do so by reason *Lecons de Clinique Chirurgicale, tome IV, 1886, page 1181. EXPLORATIVE METHODS OF DIAGNOSIS. 955 of the vacuum that is created in the instrument. Even where the fluid is too thick to run freely we may get a few drops of it, which will be sufficient for our purpose. The bladder should first be emptied. The aspirator-trocar should be perfectly clean, and so also should the surface of the abdomen through which it is to be introduced. Selecting a spot along the mesian line of the abdo- men, which is high enough to avoid the fundus of the empty blad- der, and low enough to take advantage of gravity in emptying the cyst, or cysts, that portion of the integument is touched with a little strong carbolic acid. This has the effect to render the sur- face asceptic and the wound insensible, or nearly so. The best position for the patient to assume is upon the back with the head and shoulders raised; or upon the side with the pro- jecting abdomen brought to the very edge of the bed or of the table upon which she lies. If the puncture is to be made through the vagina, or the rectum, Sims' position is the better one. The instrument (Fig. 43) should be clean and in the best order. Having anointed the needle and exhaused the bottle of atmos- pheric air, you are ready to proceed without anaesthesia. When the point of the needle has pierced the skin the stop-cock should be turned so that the moment the needle has reached a layer or collection of fluid it will begin to flow toward and into the cham- ber that has been attached for its reception. If the quantity of the cyst-fluid is large, and the bottle needs to be emptied, care must be taken to prevent the admission of air into the abdomen. Do not forget that the sarcomatous cyst-wall is usually very thick, and that you may sometimes have need to thrust the needle almost, or quite its whole length before reaching the fluid. In exceptional cases the abdominal walls are so laden with fat that the contained tumor lies very deeply. In one of my ovariotomies, although the growth weighed twenty-nine pounds, I had to cut through four inches of fat and integument before coming down upon the peri- tone am. The woman made a slow recovery, but the cicatrix has not been very strong* With careful practice you may learn to use the needle-trocar in such a way as to do the least possible harm, and to derive the greatest amount of information. In the case of an old tumor especially, and whenever there is reason to fear that the growth is malignant, the withdrawal of the instrument requires the greatest *The Clinique, Vol. II, Dec. 1881, page 413. 956 THE DISEASES OF WOMEN. caution. Remove it slowly, meanwhile pinching the integument between the thumb and index of the left hand, so as to secure the contraction of the tissues and the exclusion of air. Then cover the orifice with a bit of adhesive plaster, or of antiseptic gauze, pin a binder snugly around the body, and send the patient to bed for at least two days. It is not well to decide too hastily as to the significance of the fluid that has been drawn. It may be bloody The fluid drawn. from intra-cystic haemorrhage, or because you have accidentally punctured a small vessel on the interior of the cyst-wall, or because you have tapped a fibro- cyst of the uterus; or opalescent, if it has come from a parovarian cyst, or from one of the smaller cysts in a multilocular growth of the ovary. If it contains one or more hairs, it has originated in a dermoid cyst; and if it coagulates on standing, it is probably ascitic. I have already spoken (See Lecture LY. ) of the clinical value, or rather the lack of value, of the microscopical examination of these fluids. It is not to be depended upon as a diagnostic resource. The sticky, syrupy, adhesive quality of the true ovarian fluid is worth more to us in a suspected case, than the detection of any of its histological or its chemical elements. The form of the abdomen after the evacuation of the cyst, or of the compartment containing the fluid, especially The form of the abdo- if ^ j s a large one, is worthy of note. The scaph- men after tapping. > . . oid belly which was believed by Atlee to be diagnostic of a broad ligament cyst, when it had been emptied, is also, in exceptional cases, a sign of encysted peritoneal dropsy. But, if the clear, spring- water fluid has been drawn in considera- ble quantity, and the abdomen is afterwards concave, and palpa- tion fails to detect any trace of the thin, collapsed cyst, it will be pretty safe to conclude that the growth is parovarian. In a case of ascites complicating an abdominal tumor we may sometimes draw off the peritoneal accumulation in order to remove an obstacle to a thorough examination. This also will change the form of the abdomen, and give it a certain diagnostic value. The same is true of tapping the parent cyst in compound and malignant tumors. In this way the change in the form of the tumor that is left behind may signify a great deal more than either the quantity or the quality of the fluid that has been taken. More- over while it relieves suffering, the removal of the contained fluid EXPLORATIVE METHODS OF DIAGNOSIS. 957 facilitates whatever subsequent manipulation is necessary. This point was illustrated in my last lecture, (see Fig. 174). It is not safe, or prudent, however, to make these subsequent examinations until after the lapse of some days, when all risk of injury to the organs, or of exciting inflammation of the peritoneum especially, shall have passed away. Whatever objections may be urged against tapping as an imper- fect and even a dangerous diagnostic expedient, Tapping as a palliative, it is permissib]e with proper precautions as a palliative measure in pregnancy, or bronchitis, or chronic renal disease, in anasarca, chronic cardiac or heptic dis- orders, in violent neuralgic pains from abdominal pressure and in acute peritonitis whenever they complicate ascites or any form of ovarian dropsy. Especially is this the case if for any reason it is not possible or prudent to make the exploratory incision, or the radical operation for the removal of the tumor immediately. In a very remarkable case of this kind one of our alumni, Dr. O. B. Blackman, of Dixon, 111., saved a woman case. whose life was despaired of and who had been given up to die with a violent attack of acute per- itonitis conjoined with ovarian dropsy, by tapping and removing thirty-two pounds of ovarian fluid. In a few months the parent sac refilled slowly, and she developed a suppurative fever with chills, hectic and emaciation. I then removed the tumor, the largest sac of which was nearly full of pus, and she made an excel- lent recovery. The growth weighed twelve pounds.* I have no doubt that she would have died of the peritonitis if the distention of the inflamed membrane had not been relieved by the puncture. Simple as it is, old as it is, and often as it is made by the gen- eral practitioner, the operation of tapping through ex T SiFent s a dangerous the abdominal wall is not devoid of danger. In the old days, when a dirty trocar and canula were often employed and antisepsis was unknown, the mortality from tapping was greater than it now is from the capital operation of ovariotomy! The table of first tappings arranged by Kiwisch *The following note was appended to the published history of this case: Upon opening this tumor the next day, at the hospital clinic, it was found to contain, besides the fluid that was left from the tapping during the operation, at least a quart of cheesy, stringy, decomposed pus. The 6ac was then inverted and the inner surface of the lesion, at its fundus, exposed. The class witnessed that, for the space of five inches across the top of the tumor, and two inches in its depth, the_ internal surfaces of the sac had been firmly and inseparably united by adhesive inflammation, which must have followed the first tapping, and which had prevented its refill- ing to the same extent as before. This tuck had really taken in four inches of the circumfer- ence of the cyst-wall. (The Clinique, Vol. Ill, page 142.) 058 THE DISEASES OF WOMEN. gives a ratio of 17 per cent, of fatal cases; and Pean says* most expressively: "We can not forget that it was three cases of speedy death after the tapping of ovarian cysts in 1863, which caused us to resolve to make our lirst ovariotomy; nor that we have often known those who had been tapped by our confreres, to die within twenty-four hours, and just when they were disposed to have us operate for their relief. In March, 1884, this accident happened three times in one week. When, therefore, our patients are very much enfee- bled by previous disease, peritonitis, or affections of the heart or of the brain, it is better not to delay the radical operation by use- less tapping." That a lack of care in making so simple an operation as para- centesis of the abdomen may put a woman in peril even where it does not take her life, and that it may seriously complicate a sub- sequent ovariotomy is shown by the following case which came under my own experience : Case. — Mrs. K., of this city, aged fifty-four, the mother of six children, first noticed an abdominal enlargement five years ago. It has increased rapidly within the past four years. Two months and a-half ago she was tapped at a surgeon's office without any word of caution as to the risks of the operation; without the appli- cation of a binder, or any form of abdominal support; and she afterwards was permitted to go home as if nothing had happened. The shock and exposure made her very ill, and brought on an attack of peritonitis, which kept her in bed for three weeks, and nearly cost her life. She had never had any previous illness. January 31, 1882, three months later, with the assistance of Drs. A. K. Crawford, C. S. Penfield and B. L. Reynolds, I removed the tumor. Its weight was twenty-six pounds; the fluid was of the chocolate variety; and the growth was composed of four endogen- ous cysts. The large outer sac was adherent through every inch of its surface, on all sides, to the parietes of the abdomen in front, to the mesentery at its fundus, and to the intestines behind. These adhesions were the evident result of the recent attack of plastic peritonitis, which had been caused by the inexcusable and unchris- tian treatment of the poor woman. The pedicle was broad, thin and twisted upon itself. She reacted well and recovered without a single bad symptom. The sources of danger from exploratory tapping are various. There is a possibility that the puncture of the f rom sources of danger cyst-wall may develop into a rapture, with extra- vasation of its contents and a fatal collapse. In old cases in which the coats of the sac have become very thin *0p. cibat., Vol. IV, page 1179. EXPLORATIVE METHODS OF DIAGNOSIS. 959 because of distention, or from the corrosive action of the contained fluid, this result is very likely to follow. The escape of a very small quantity of the noxious fluid when the needle or trocar is withdrawn, may cause an attack of septic peritonitis. I once tap- ped an old cyst with a hypodermic needle for the purpose of get- ting a sample of the contained fluid. In five minutes after the needle was withdrawn my patient was in a state of collapse, and two hours or more had passed before I became fully satisfied that she would recover from the shock. A serious objection to tapping in case of an intra-papillomatous cyst of the ovary is that the possible escape of some of the cancer cells may cause an extension of the disease to the surface of the peritoneum when otherwise it would have been limited to the interior of the sac, and therefore removable by ovariotomy. The risk of haemorrhage from puncture of one of the large veins that often lie upon the surface of the cyst is greatest in malignant cases; and the possibility of auto-infection from a consequent deterioration of the fluid where repeated tapping is practised should always be borne in mind. Uterine tumors, whether solid or cystic, or composite, are intolerant of the trocar. We should never tap one cyst through another, nor should we forget that in emptying a suppurating cyst by aspiration, the needle will take away only the liquid portion of the contained pus. Repeated tapping certainly increases the risks after ovariotomy, by the possible development of plastic peritoni- afterSvariotom 1 ! 6 risks tis> as in the case just cited; by draining away the patient's strength and lowering her vitality; by vitiating the contained fluid, and thus increasing the risk of a slow and insidious absorption and of sepsis that may exist before the ovariotomy is made ; and by the possible extension of an intra- cystic cancer to the tissues and organs that lie outside of the tumor. LECTUBE LIX. OVARIOTOMY. An early operation is best; suitable cases for; indications for; do. for an immediate operation; contra-indications for; qualifying do; preparatory treatment; asepsis and antiseptics; proper place, day and season for the operation; surgical cleanliness of room, instruments, etc.; the anaesthetic, assistants and necessary instruments; the patient's position and the incision; the arrest of haemorrhage; opening the peritoneum; an essential precaution; emptying the cyst; the adhesions; enucleation in dangerous do; haemorrhage from do; management of the pedicle; the clamp, the ligature, and the actual cautery; objections to the clamp and to the extra-peritoneal method; the peritoneal toilet; hot-water flushing for shock; drainage; the deep, continuous and superficial sutures; the special do. for a retained cyst; the first dressing of the wound; the do. for the drainage tube; putting the patient to bed. The frequency and the flippancy with which ovariotomy is referred to of late in some of our medical journals may have caused you to look upon it as an operation that is adapted to a wide range of cases, and one in which the best results are almost certain to follow its performance. The glamour that is thrown over this subject by the remarkable success of a few noted specialists may have tempted you to suppose it an easy matter to make such a reputation, if only you can find the patients, and they will consent that you shall operate. , The truth is that the relative popularity and safety of ovari- otomy since Dr. McDowell first made it in Kentucky, in December, 1809, is due to such a persistent experimentation, training and drill iii everything that belongs to it, as has never been bestowed upon any other surgical operation. As a direct, although a some- what tardy result, instead of being rejected as hazardous, unwar- rantable and murderous, as it once was, ovariotomy is now made as successfully as any other capital operation. Indirectly its benefits are incalculable, for it has opened up the whole domain of abdominal surgery. Until it was practised, the peritoneal cavity and all that it contains was as inaccessible surgically as the chambers of the heart. But now there is not an organ that is covered with the peritoneum which can not if necessary be safely reached by the knife of the skillful gynaecologist; nor a scrap of tissue within its ample folds that is out of the range of his vision. 960 OVARIOTOMY. 961 The following reasons will be a sufficient answer for those who would postpone this operation: 1. We should not wait until the patient's general health has become impaired, or in other words, the prin- An early operation is c ipl e of such delay is a departure from that generally followed in the case of other diseases treated surgically. 2. The presence of the tumor is the cause of structural disease in other organs. 3. Ovarian tumors are liable to a variety of accidents, such as rupture, either from injury or spontaneously, and twisting of the pedicle, to morbid processes, such as inflammation, atheromatous degeneration of the blood-vessels, which with fatty change in the walls of the cysts leads to haemorrhages into their interior, etc. 4. The existence of adhesions, of degenerative changes in, and rupture, etc., of the tumor, greatly interferes with the success of. the operation. 5. On the contrary, the earlier and simpler the operation, the greater is the chance of recovery.* Among those who suffer from some form of ovarian tumor there is a choice of subjects for this operation. The proportion of favorable cases has greatly increased since I otom y ablecasesforovari " began to operate, about fifteen years ago. At that time the majority of these patients had either been repeatedly tapped, or neglected until it was almost or quite too late to operate upon them with a reasonable hope of success. But now such old and unpromising cases are compara- tively rare, for they have been weeded out; and the professional habit to defer the radical operation as long as possible has changed into a plea for early ovariotomy. Moreover, the tech- nique of the operation has been so perfected that certain cases which were once unsuitable are so no longer. This change of circumstances has had the double effect to increase the ratio of recoveries from ovariotomy, and to diminish the number of conditions that constitute a bar to the operation. The more rapidly the cysts fill or refill after the tapping, the stronger the reason for an early operation. A decided failure of the general health, with loss of appetite, insom- ovariotSSy ns for eady n ^ a ' gastric and intestinal irritation, dropsy of the face, hands, or feet; dyspnoea, inability to lie down, or to walk because of the size of the tumor, with evident "signs that she can not live unless she is relieved, are so many pressing indications for ovariotomy. The demand for an immediate operation becomes imperative in *A Plea for Early Ovariotomy, by G. Granville Bantock, M. D., Etc., London, 1881. 962 THE DISEASES OF WOMEN. case of a rupture of an ovarian cyst, with a discharge of its con- tents into the cavity of the abdomen. The pos- opCTSio f n. ranimmediate sibility that such an accident may happen where there is great distention, or where the parent cyst is an old one, suggests that we should always be ready for such an emergency, and that the operation should not be deferred. In July, 1884, a fine, healthy-looking woman came to me from Michigan to be relieved of a large ovarian tumor. The journey was by boat and she was sea-sick. After landing I made her two visits, when her vomiting ceased, the abdominal pain and soreness had yielded, and she was up and about her room. Two days later on turning in bed after an afternoon nap, she had a sharp, cutting pain, felt something give way, sank into collapse and, before I could reach her bedside half an hour later, was dead. Hemorrhage into the cyst, with or without torsion of the pedicle, furnishes what might be styled a dramatic indication for immedi- ate ovariotomy. The following case in which I successfully removed a hemorrhagic cyst, with a solid tumor weighing thirty- eight pounds, illustrates the importance of operating promptly. Dr. Frederic Stevens, our former house-surgeon, had the care of it after the operation, and has kindly furnished the following notes : A multilociriar ovarian cyst iveighing thirty-eigjii pounds — abundant haemorrhage into the parent cyst — ovariotomy — recovery. Case. — Mrs. , aged forty-seven, is the mother of four children. Fourteen years ago she had left-sided ovaritis. Since then she has been generally well, with the exception of some functional liver trouble. "In December, 1885, she noticed a slight general enlargement of the abdomen. This increased slowly until March, 1886, when she began enlarging very rapidly. About May 1 the growth of the tumor ceased, and from this time until the month of August, she decreased four inches in size. The diagnosis of cystic disease of the ovary was made by Dr. Lucllam in May, and an immediate operation advised by him. During August the tumor again grew rapidly, causing dyspnoea, constipation and general malaise. The emaciation was marked and rapid. On September 15, Dr. Ludlam was again consulted, and the date of operation was set for Septem- ber 25. In the night of September 19 she began failing rapidly, becoming blanched and extremely weak and nervous. "She called me for relief from fai?rfcing spells, to which she was unaccustomed, and I found it necessary to remain with her most of the night. She had marked signs of collapse, her pulse was thready and feeble; she felt certain that for some cause the tumor was growing, and, brave as she had always been, was now im- pressed with the conviction that she was about to die. I sum- OVARIOTOMY. 963 moned Prof. Bailey, who was near at hand, and with the aid of stimulants we got her through the night. "On account of the urgency of the symptoms the operation was made the next morning, September 20, 1886. There were present to assist Prof. Ludlam, Drs. E. S.Bailey, Frederic Stevens and B. L. Reynolds. The patient was extremely weak, on the border of collapse, and the pulse filiform, 120, and scarcely perceptible. The tumor had evidently increased and changed in form since it was examined five days before. "The tumor included four cysts, the largest of which, on being tapped, at first discharged a fluid of a very dark port wine color. The fluid soon looked and smelt like fresh blood, and was evidently hemorrhagic. The tumor was removed, the pedicle secured, the toilet of the peritoneum carefully made, the wound closed, and the patient put to bed. "The cysts and their contents weighed thirty-eight pounds; but when the fluid which had been taken from the large sac was poured from the tub in which it had been collected, it contained half a pailful of bright and large blood-clots. "The patient reacted promptly and made a rapid recovery, sitting in her chair at the end of two weeks. On the- tenth day the sutures were removed and the wound was entirely healed. After the first evening, when it was 104, the pulse ranged from 80 to 86, and the temperature, which was 100 \° with the first reaction, did not afterwards exceed 99° and a fraction." « At my hospital clinic on Wednesday, September 22, the parent cyst which had contained the blood was opened before the class, and the site and peculiarities of the ruptured vessel were clearly demonstrated. The profile of the abdomen before the operation is faithfully shown in Plate III. But for our prompt attention that woman could not have lived more than a very few hours. Unless in chronic cases of renal disease, with blood, pus, or tube-casts in the urine, the presence of albumin in that fluid would not interfere with the operation, except- ovariotom^ 10 ^ 10118 for ing to make us careful in the choice of the anas- thetic. Serious complications, whether acute or chronic, on the side of the heart, the lungs, the liver or of the nervous system, might render the subject unfit for the operation. And so also of old scrofulous or tuberculous affections of the mesenteric glands, with diarrhoea, hectic, emaciation and ascites. Diabetes with absence of the tendon reflex is regarded by a promi- nent authority as a positive contra- indication. Chronic bronchitis and pulmonary catarrh are serious obstacles, especially if the patient has passed the climacterie. I have already spoken of the frequent involvement of the right 964 THE DISEASES OF WOMEN. heart, especially in the case of cystic tumors within the abdomen. (Lecture LY., page 915). Old cases of cardiac degeneration,, and not of mere functional or even of valvular disorder, are much to be dreaded as complicating ovarian dropsy. A case of this kind to which I was called by my friend Dr. T. C. Duncan, of this city, will serve both as an illustration and as a warning. The history thereof was kindly furnished by Dr. Duncan. Cysto -carcinoma of the ovaries — double ovariotomy — death from heart-failure. — Case. Mrs. W. came into my hands some twenty years ago at the death of Dr. Lyman Kendall. She was subject to attacks of palpitation, and when very severe there was a loss of consciousness. Her friends often thought that she was dying. Dr. K. had often resuscitated her with spigelia. She was a tall, spare brunette; ambitious, active and hopeful, but subject to severe metorrhagia. She carried a sensitive spine, and at one time barely escaped meningitis. The spinal tenderness increased during severe and prolonged activity. The appetite was always poor, the tongue red and pointed and the stomach sensitive to the touch. Accute attacks of gastritis usually attended the times of extra overwork. As she approached the climacteric, the flow was almost constant, only a weeks interval occuring; but it was only while the stomach rebelled that medical help was solicited. I urged systematic treatment, especially after I had obtained con- sent to a local examination and had found an hypertrophied, prolapsed uterus. During last winter, for a severe attack of uterine distress, I was finally summoned. I found the hypertrophied uterus completely ante-verted, a high grade of inflammation present, and an undefined pelvic tumor. The uterus was reposited and the inflammation allayed. In May dropsical symptoms began to develop, notwithstanding the uterine flow was again almost constant. This was checked and she was able to get about. But in July all of the symptoms returned with renewed vigor. The most excruciating pain was located in the head and neck. "The heart attacks returned, but under the use of medicines this phase of the case rapidly and steadily improved. The neck and head symptoms also improved, and all went on well, except that she was very weak, had but little appetite, and the dropsy grew apace. The pelvic distress and fullness, however, was ever present. "September 4, the distension became so great that I tapped her and drew off ten quarts of a pale liquid. Through the now flabby abdomen was outlined a hard, nodular tumor. At this juncture Prof. Ludlam saw the case and advised abdominal section, with a view to the possible removal of the tumor, as soon as she could get an appetite and recruit sufficiently. He was of the opinion that the tumor was of a malignant variety, and that, if possible, the sooner it was removed the better. After the tapping the appetite became good and she improved in strength and spirits. The heart OVARIOTOMY. 965 seemed greatly improved. But in two weeks the abdomen again became enormously distended, and this was accompanied by severe pains on the right side. Again I tapped her and drew off as much highly albuminous liquid as before. "Again the appetite returned, and she insisted that an operation should be made before the abdomen refilled. One tumor was found to fill near the whole right side of the abdomen, and another was detected in the left side. But a few days elapsed before the ab- dominal distension was pressing. All felt that in this condition she had but a very short time to live. An operation offered a hope, and it was determined upon with the gravest fears that her feeble system might not withstand the shock. "September 30, 1886, Prof. Lucllam opened the abdomen and brought to light a very large condensed multilocular mass, parts of which were already gangrenous. There were no adhesions, and this mass, which involved the right ovary, was quickly removed and the pedicle secured. A smaller mass, including the left ovary and lying chiefly in the Douglas pouch, was turned out and secured in the same way. Not two tablespoon sful of blood were lost by the operation, which was made under sulphuric ether carefully given. The intestines and the omentum showed a high degree of peritoneal inflammation. None of the cysts were ruptured or tapped, nor did any of them burst, and consequently not a drop of the vitiated fluid escaped into the abdominal cavity. "When the second pedicle had been secured and the operator was about to close the wound, the patient suddenly, and without the least warning, ceased to breathe, and no expedient, even to the use of nitro-glycerine, was of any avail in restoring her." In that case the operation was made with a full appreciation and understanding, by the patient and by the family, of the immi- nent risks incurred. Every precaution was taken to prevent what has been styled an "unexpected collapse," and to bring the woman through the operation safely. I am satisfied that her sad and sudden death (which is the first and the only one that has ever happened to me while operating), was due to heart-failure and to nothing else. An autopsy was not allowed.* The more frequently the woman has been tapped, or tampered with by electricity, blisters, etc., the greater the risk of the oper- ation. We would not often be justified in removing an ovarian cyst that contained pus, if it has already found vent through an *If the reader is disposed to question the propriety of my having undertaken so serious an operation in this forlorn case, 1 beg leave to answer in the manly and memorable words of Prof. Goodell: "I have always contended that, for a surgeon to decline to operate on any case of ovarian tumor because it is not a promising one, is virtually the same thing as if he had operated on the case and had lost it._ Acting on this principle, no matter how desperate the condition of the woman, I have not in a single instance, refused to give the sufferer her only chance for life. * * * * * This regard for the woman and disregard for my statistics, has swelled my list of fatal cases, and has given me one death on the operating table; but, on the other hand, it has enabled me to restore to life, two women who had been abandoned bv other surgeons." {The American Journal of Obstetrics, etc., vol. XV, page 364). 966 THE DISEASES OF WOMEN. opening into the bladder or the intestine. Nor would it be safe or expedient, in most cases, to operate before the tumor was large enough to distend and develop the abdominal parietes somewhat. A few years ago, extensive adhesions of the tumor were thought to contra-indicate the operation, and they did very often cause it to be relinquished. But now we know that, excepting in case of pelvic and hepatic adhesions, their danger has been greatly exag- gerated. The same is true of a co-existing pregnancy. Yov should not perform ovariotomy during the prevalence of any severe epidemic, such as cerebro-spinal meningitis, diphtheria, puerperal fever, or erysipelas. The question of the safety and propriety of ovariotomy will turn upon these points. But, while we ought not to run too great a risk in resorting to it in extreme cases, we tiS? s alifying indica " should remember that it does offer a means of cure where everything else must fail. In so far as the heart and lung complications are concerned, my own practice has been to make the tolerance of the anaesthetic the test of its expediency. If the pulse and respiration are calmed and the ether has a pleasant effect, I go forward. You may find it advisable to cut down upon a cyst that has only partially refilled after tapping, because it is evident that the patiant can not recover if it is not taken away immediately. I made the operation in a case of this kind upon a patient of my friend, Dr. C. W. Crary, at Lake City, Minn., on the first day of June, 1878. Her baby was only three months old. She really had not gotten through with her puerperality. After her delivery, the tumor had grown very rapidly, and a week before my arrival the doctor had very properly tapped it. This afforded the greatest relief, but as soon as it began to refill, her strength gave way, and it became evident that she must sink from the drain. I cut down upon the flabby sac through a resonant abdomen, and, despite the worst possible enteric and mesenteric adhesions, we had the satisfaction of saving the poor woman's life. The dangers of the operation, and the contingencies that beset the first month after it has been made, should always be explained to the patient and to her family beforehand. For, like the doctor, she must enter upon it intelligently, or the result may be disastrous. For a week previous to the operation, unless you are forced to remove the tumor at once in order to save her life, the patient should have a nourishing but easily digested Preparatory treatment. -, . . TJ . , . • , -, -i , , -■ • ■ -i diet. It she is emaciated and the skin is dry and husky, let her take a warm bath the day before the operation. OVAEIOTOMY. 967 The bowels should be freed of any accumulation, and the morning and evening pulse and temperature taken and recorded for some days beforehand. It is very important that her mind should be tranquil and that her neighbors should not annoy her, and indeed that, as a rule, they should not know what is about to be done for her relief. Her urine should be carefully tested for albumin. On the morning of the operation she should abstain from all solid food and take only a light breakfast, otherwise the risk of vomit- ing while under the anaesthetic will be very much increased. Four or five hours before the operation she may have a cup of strong beef-tea. ' The peritoneum is so susceptible that we must be very careful not to expose it in an unsanitary atmosphere. This remark applies to the making of laparotomy for any fJpScs iB and anti " purpose whatever; and it explains the necessity of extraordinary precautions in abdominal, as distinguished from general surgery. In an amputation of the leg, for example, the wound is readily accessible and any unfavor- able conditions that surround the patient can be overcome by antiseptic and.hygenic measures that are available at any time — before, during and after the operation. But in ovariotomy the sensitive peritoneum is exposed during the operation, after which the wound is closed and corrective measures, excepting in rare cases, are thenceforth excluded. It follows that the proper time for aseptic precautions, in this and all kindred operations, is while the abdomen is open. To meet this indication, and to bring the full force of antiseptic treatment to bear as a prophylactic, the carbolic spray and the use of strong germicidal solutions was resorted to a few years ago, as in ordinary surgery. This was done to render the parts thor- oughly aseptic. But it soon became evident to the careful gyne- cologist, that the peritoneum is quite as intolerant of certain anti- septics, as it is of whatever might float in a vitiated atmosphere, and so occasion septic mischief. Keith observed that his ovari- otomy patients had hematuria when carbolic acid had been used; and, indeed, that he had it himself whenever he operated under the spray. And Billroth and others have reported fatal results from this intra-peritoneal asepsis with carbolic acid, the mercuric chlorides, iodoform, etc. The consequence is that the practice of throwing the spray directly into the abdomen has been very generally relinquished, and so also has the use of strong antiseptic solutions in ovariotomy. With the reaction against the early abuse of peritoneal asepsis gynecologists are now divided into two camps: those who still 968 THE DISEASES OF WOMEN. resort to it in a more or less modified form, and those who, reject- ing it altogether, prefer to depend upon absolute cleanliness as the best safe-guard against all septic and pysemic mischief. Most operators of experience belong to the former class, and even when they do not use antiseptics during 'the operation, insist upon all sorts of pre-operative precautions and of post-operative dressings. However, Keith, Bantock, Tait, and their followers discard these measures altogether, and contend that they are not only useless but injurious. My own idea is that the middle course is the safer one. Indeed my practice has been to combine the two methods, for I have failed to see how they could conflict. Surely there is nothing inconsistent between cleanliness and careful antisepsis, and, under the varying conditions in which we are called upon to operate, it would not be best to depend upon either of them exclusively. In deciding whether an ovariotomy should be made at the patient's home or in an hospital, certain practical considerations must be weighed. The advantages of a country theopCTat P ion Placefor nom e, if it is in a healthful locality, are that you are certain to have a good supply of fresh air and of sunlight, with wholesome, nourishing food, and an ab- sence of bad odors, dirt and noise. When the family is in good circumstances, and all the sanitary requisites can be supplied, these very desirable conditions will more than counterbalance the best and most scientific resources of the hospital. Moreover, there are certain very sensitive women upon whom the moral effect of going into a hospital for such a purpose might be very damag- ing, and consequently we must sometimes regard their very posi- tive preference. But the disadvantages of having to depend upon an indifferent or inexperienced nurse, and of having one's patient at arm's length after the operation, when the contingencies are so numerous, furnish a strong argument in favor of having it done at a first-class, special hospital, whenever the patient can afford, or will consent to go there. Now that we can control and regulate the physical surround- ings of the patient, it is no longer necessary to limit the season for making an ovariotomy to the early summer, seas h on day and the or to tlie autumn months. With the proper precautions it may be safely done at any season, excepting in the very hot weather, and even that is permissible in cases of emergency. I have operated, and successfully too, with a range of temperature of from 90° above, to 30° below zero; but the greatest care was taken to counteract the possible ill effect of these extremes of heat and cold. The day set for the oper- OVARIOTOMY. 969 ation should be clear and bright, with a wind from any quarter excepting the north-east. As in other gynecological operations it is better, but not essential, that this should follow instead of immediately precede the monthly flow. In the outfit for this operation, no instrument is more important than the thermometer — I mean the thermometer which is designed to regulate the temperature of the patient's rooS? perature ° f the apartment, both during and after the removal of the tumor. While the operation is in pro- gress, my practice is to keep the temperature at 75° F., and not allow it to fall below 70° day or night, for five or six days after- wards. This matter should be insisted upon not only because of the risk of chill and of the onset of inflammation from vicissi- tudes of temperature, but also because it has been found that tetanus sometimes arises from this cause. The room in which the operation is to be made should be thoroughly scrubbed, whitewashed, cleared of its carpets and rugs, disinfected and afterwards opened to the fresh Surgical cleanliness of . .-,-.. .. . , , .\ ,. -, ., the room, instruments, air. The operating table, the linen, and the towels, should also be thoroughly cleaned, and disinfected either by burning sulphur or by the carbolic, or the mercurial spray. The usual method is to leave these articles in the vapor while the room is tightly closed through the night preceding the operation. The instruments should be surgically clean. Each one should be thoroughly cleansed with hot water and soap; then wiped off with absorbent cotton saturated in glycerine and carbolic acid. After this they may be laid in the sun, or upon a hot stove for an hour or two; or better still, passed through the flame of a spirit-lamp before they are used. They should not be mixed with other instruments. During the opera- tion I usually have them immersed in Listerine. The sponges should be fine, new, and absolutely clean and aseptic. Some years ago it was my custom always to give the patient a dose of whiskey just before she took the anaesthetic. The object was to lessen the quantity of ether that would be necessary, to stimulate the circulation, and to promote rest and quiet after- wards. But I learned from observation that, especially in those who were unaccustomed to alcoholic stimulants, it; sometimes increased the vomiting and also made it necessary to give them more instead of less of the anaesthetic. Others prefer to resort to morphine for a similar purpose. My friend Helmuth recom- mends that some twenty minutes before the time set for the operation an hypodermic of ten minims of a solution of sulphate of morphine eight grains, and the sulphate of atropia half a grain 970 THE DISEASES OF WOMEN. to the ounce of water, should be administered. "This solution quiets the patient, stimulates the heart's action, and, very often, after the operation, secures for her a refreshing nap for an hour or two." Most operators are careful to know that the bladder has been emptied just before the patient is placed upon the table; but Keith advises to leave it in a distended state, in order that its outline and its attachments can be more readily made out, and to protect it from injury. If the catheter must be used during the operation, it should be passed by an assistant. The operation. — The last thing to be done before she is placed in position is to have the abdomen thoroughly cleansed with " ' warm soap and water, after which it may be Trip jmspstriptic *^ dried and coated over with such a solution of iodoform and ether as you have seen Prof. Shears inject into ab- scesses for their radical cure. Hegar's idea that it is likely to excite vomiting if the patient is allowed to take the anaesthetic before being placed upon the table should always be borne in mind. Unless there is albuminuria with or without tube-casts, or some valid sign of urinary disorder, or unless we have an old patient with bronchial catarrh, (broncorrhcea) sulphuric ether is undoubtedly the best anaesthetic. In that case we must use chloro- form ; but chloroform is not suited if the heart is crippled as it is likely to be from fatty degeneration of the right ventricle in old abdominal tumors. So we must proceed cautiously and be prepared for emergencies. For the ill effects of ether, hypodermics of rye whiskey, or ammonia; and for those of chloroform, injections of ether, or inhalations of the nitrite of amyl, with lowering the head and raising the body toward the ceiling are the best ex- pedients. If, as sometimes happens, the ether is not sufficient to produce the requisite insensibility we may give a few whiffs of chloroform with plenty of air, and very cautiously, until there is profound anaesthesia, and then resume the ether. Or it may be the best to substitute the Vienna mixture, which is composed of one part of alcohol, two parts of chloroform, and three parts of ether. Who- ever gives the anaesthetic should realize that, after the incision has been made through the integument, only enough ether is necessary to keep the patient quiet; that real narcotism is neither safe nor necessary ; and that, above all things, he must stop giving it so as to avoid collapse while a large cyst is being emptied, and also while the tumor is being delivered through the abdominal wound. When nausea occurs during etherization it may often be stopped by pushing the anaesthesia still further. OVAKIOTOMY. 971 The ether is best given with a Clover's inhaler, such as is used in my clinic. I prefer it because much less ether is required, and the patient is brought directly under its influence without carrying her to the point of saturation before she becomes insensible. If this instrument is not available, or if chloroform is used, the old- fashioned paper or rubber cone will answer. While the patient is being anaesthetized in another room, the assistants should be instructed concerning their special duties. Their number should be limited to five at the The assistants. . e i ji r» j i ii; V • most; or whom the first should stand vis-a-vis with the operator, use the sponges and apply the haemostatic forceps. The second should give the anaesthetic, and not be concerned with anything else; the third should have charge of the instruments, be ready to thread the needles and to apply the necessary ligatures; the fourth will cleanse the sponges for the first assistant ; and the fifth, who is the nurse, supplies the hot water, the bandages and blankets, and prepares the room and the bed for the patient. Each and all of them must have taken a general bath, put on clean and disinfected clothing, scrubbed their hands and arms and especially their finger-nails, and washed them in an antiseptic solution. They must be absolutely free from all sources of infectious disease. I once lost a young and beautiful woman after an ovariotomy because one of the physicians who was present at the operation told me that he had not treated a case of contagious disease for a long time, when he was actually in charge of a patient with malignant scarlatina. The puerperal and eruptive fevers, diphtheria, small-pox, and bad cases of typhoid fever poison the doctor's clothing, and one who has been thus exposed, or who has very recently performed or assisted in an autopsy, should not be allowed in the room, or in the building, during an ovariotomy.* There is no need of making a parade of instruments sufficient to stock a cutler's shop. Two scalpels; a pair of straight and strong scissors; six pairs of plain haemostatic ment e s necessary instm " forceps (Fig. 176), and three ditto with gold- washed handles; a No. 7 or 8 steel sound; a Pe'an's trocar; two blunt tenaculae; two pedicle forceps; a Baker Brown's cautery clamp ; a Pacquelin, or some other form of cautery ; *"It is, unfortunately, a melancholy story that ever since surgery began, the most of the mischief was done by the surgeon himself. It was the willing and tender, though unclean hand, that carried the poison into the wounds. It is to this that Lister hasput a stop. With a proper antiseptic, an operator is now made to be clean in spite of himself, is compelled to have safe sponges, safe ligatures, clean instruments, and, above all, clean fingers. If one be careful enough— and few are careful enough— one may do all this as Mr. Tait does, with boiled water alone. Some such precautions are essential; beyond these, with ordinary care, we need not disturb ourselves much as to what is in the air."— Keith. A Contribution to the Surgical Treatment of Tumors of the Abdomen. Part I., pages 23-4. 972 THE DISEASES OF WOMEN. Wilcox's ovariotomy forceps; the necessary needles; a number of aseptic sutures and ligatures of catgut, silkworm gut, silk and silver wire (No. 26) ; six fine surgeon's sponges, and one flat one; a small ecraseur; with carbolic acid, or the sublimate solution (1 — 2000) ; drain tubes, adhesive plaster, iodoform, some kind of antiseptic gauze, a square bit of fine rubber cloth, and two ounces of rye whiskey ; half a dozen soft towels, and hot and cold water at command include all that you will need, even in complicated cases. The instruments and sponges should be counted before- hand, and a list of them kept in order to be certain that none of them have been left within the abdomen when the wound is closed. The table should be brought before the window into a strong light, and the patient's hips raised to facilitate the gravitation of the intestines away from the lower abdomen, The patient's position. v i j.- ■ j x. x> • i • \e an expedient practised by Kecamier in his first vaginal hysterectomy, in 1829. Her under-clothing should be of flannel, covered with a cotton night-gown, with woolen stock- ings; and the limbs should be wrapped in a woolen blanket. Care Fig. 176. Pean's forceps. should be taken so to arrange the clothing as to prevent its being soiled, and to avoid the necessity of its being changed directly after the operation. If you use the Macintosh, after the English method, it will be necessary to have her arms and legs secured. It the tumor does not extend far into the lower pelvis, a large sponge may be placed in the posterior cul-de-sac, to keep the Douglas pouch inverted. I prefer to make the incision in the mesian line, just as you saw me do at our last clinic (October 17, 1887). At first it need not exceed four inches in length. A recent author says: "With regard to the actual incision, it must be remembered that there is no linea alba below the umbilicus. Unless the muscles are separated by distension, the knife will open one or the other rectus sheath. The abdomen should be opened by precise, clean cuts ; a director is an abom- ination, and the practice of deepening the wound with the fingers belongs to the surgery of past ages." (Treves.) OVARIOTOMY. 973 The greatest care should be taken to stop the haemorrhage as you proceed. The hot sponges are haemostatic, but they should not be used in a rough way. Gentle pressure, haemorrhage. ° f the an( ^ no * a ru de mopping of the wound is best. We never put a ligature in this wound any more, but rely upon the artery forceps to control any active haemorrhage. Before a large vein is cut, two of these forceps may be so placed that the vessel can be severed between them. The more there is of venous oozing, and the lunger the time con- sumed in controlling the flow and cleansing the wound, the greater the probability of a multiple cyst, or of a malignant growth, with extensive adhesions, and with a depraved quality of the cyst-contents. Coming down upon the peritoneum it is caught up by a pair of forceps and nicked, after which the opening may be enlarged with the scalpel, or with the blunt-pointed toneum ing the peri scissors. By Atlee's test, which consists in passing the steel sound through the opening to observe if it glides beneath the umbilicus, we may not only decide the question of having gained access to the peritoneal cavity, but may also satisfy ourselves as to the existence, or the non- existence of anterior parietal adhesions. If the tumor is multilocular and a very large one, or if it has a large solid portion which is filled with condensed cysts, the original incision will need to be extended. This can best be done with the strong scissors, cutting between two fingers, which are placed as guides to prevent injury to the intestines, or the omentum. If the patient has an umbilical hernia, my practice is to cut directly through the ring, but if not, to go to the left of it. The edges of the enlarged wound should be everted, and the haemorrhage arrested immediately. An incision of medium length is better than either a very long or a very short one. The objection to the long incision is not on account of its subsequent healing, but chiefly incision ensth ° f the because of an unnecessary and dangerous expo- sure of the intestines. The objection to the very short incision is that you have less freedom in managing the adhesions, that multiple cysts are likely to be ruptured, and that the parts involved are more severely traumatised than if there was plenty of space in which to operate. Apart from the ordinary surgical precautions, the great point in ovariotomy is to keep the blood and all infective material out of the abdominal cavity. The greatest care is An essential precaution. ... .. , ,i , i , , requisite not to rupture the cysts, and not to 974 THE DISEASES OF WOMEN. suffer a drop of the contained fluid to overflow and to fall back again. This indication will not be filled if the parent sac is old and rotten, if the patient happens to vomit just at the wrong time, or if the trocar is allowed to slip out of the cyst-wall so that the nasty fluid may escape and deluge the parts. The possibility that it may happen in any case suggests the propriety of covering the edges of the wound and the intestines, if they are exposed, ^with soft warm towels, or flannels, before the cyst is emptied. Fig. 177. Pean's trocar. The tumor should now be tapped and the fluid run off in^o a basin or bucket that is held by an assistant. The point of the trocar should be passed so as to avoid wounding" Emptying the cyst. ,, i xi j -j? -j p t the vessels that ramity upon its surface. I prefer Pean's ovariotomy trocar (Fig. 177), to that of Spencer Wells (Fig. 178), as being more convenient and less savage and harmful. So soon as the cyst begins to collapse, it should be seized and drawn towards the ceiling by a Wilcox forceps, which Fig. 178. Spencer Wells' trocar. I consider a very valuable instrument (Fig. 179). In lieu of this, I have for many years employed a Sims' polypus forceps, which answers a very good purpose. Before the technique of this operation had reached its present state of perfection, I was accustomed to stitch up the sac and to leave a considerable portion of the fluid within it, so as to facili- tate the management of the adhesions, and of the pedicle, to keep the intestines warm, and to preserve the form of the tumor mean- while. But that is unnecessary now; the only requisite precaution being to keep the wound made by the trocar from pouring its dregs into the abdomen. OVARIOTOMY. 975 It is the practice of some operators to turn the patient upon her side, and then to make a free incision into ^ the cyst, so as to discharge its contents more quickly and rapidly. A better way is to use a Tait's cyst-trocar (Fig. 180), which is a curved tube and not a cutting instrument, and with which the partition walls of a polycyst can be broken down without introducing the hand into the sac. This large-sized trocar will empty a bucket of water in about a minute and a half. Whichever method is adopted, you should not forget to have the anaesthetic suspended while the evacuation is going on. The practice of rupturing the smaller cysts through the walls that separate them from the larger one is often, but not always safe or expedient. Fig. 179. Wilcox Forceps. If there are adhesions, and they are seldom absent in genuine ovarian dropsy, they should be managed very carefully. I first examine the anterior surface of the tumor, and separate them in front before disturbing those which are behind, below, or at the sides of the abdomen. Then, if the cyst, or cysts, can be drawn slowly and deliberately through the incision, the more distant adhesions will be disclosed, and can often be separated without putting the hand into the abdomen. Stringy, vascular, fibrous, and especially omental adhesions should be ligated twice with fine gut, or carbolized silk, and cut. between. It is sometimes necessary to include a mass of the omentum in a strong ligature in order to put a stop to the oozing at its torn edges; but in this case we should not forget that the arterial supply of the intestine might be readily cut off by the ligature. Or, being careful not to prick the vessels in the mesentery, we may darn up the torn edges with the continuous catgut suture. Enteric adhesions should be manipulated with the greatest care. By pressure with a hot sponge the gut is separated from 976 THE DISEASES OF WOMEN. the tumor (the stripping being always on the side of the tumor) and the intestine brought out upon the abdo- oJ adSon?. in danger " men where it is covered with a soft, warm, moist towel. If these, or any other adhesions can not be safely detached, the coats of the sac may be divided and so much of its peritoneal investment as corresponds with the extent of the adhesions left behind. In a terrible case, in which the tumor weighed eighty pounds, I resorted to this expedient and by the enucleation of nearly one-third of its surface averted death from haemorrhage.* My patient made a good recovery and was well eight years after. In a monocyst, if the wall of the sac is not too thin and tender, and if the adhesions extend over all, or nearly all of its surface, you may split its layers and enucleate the tumor and strip out Fig. 180. Tait's Cyst-trocar. its secreting membrane without disturbing the pedicle, or doing any serious damage. The hull will afterwards collapse and its surfaces adhere so as to dispose of the tumor. In October, 1873, I removed a thirty-pound accumulation of syrupy ovarian fluid in this way. The patient recovered, and twelve years after she had had no return of the tumor, f Sponge pressure, torsion of single vessels, forcipressure, liga- tion, the use of the Pacquelin cautery, and afterwards the filling and flushing of the abdomen with water at the temperature of 103° to 105° or even to 115° are the best means for arresting the haemorrhage from the torn adhesions. Wy lie's expedient of clamping the pedicle before the adhesions are disturbed may answer the same *The United States Medical Investigator, April, 1878. fT/ie U. S. Medical and Surgical Journal, vol. IX., p. 225. How to control haemorrhage from. the OVARIOTOMY. 977 purpose in exceptional cases. Oozing from a large abdominal surface may be arrested by making a fold in the integument, doubling the raw surface upon itself, and transfixing by an acu- pressure needle, or by the cobbler's stitch passed from skin to skin, as recommended by Dr. Kimball. Experience has taught me that pelvic adhesions are the most difficult to manage, and that when they are extensive the tumor is almost always malignant. The possibility that adhesions may have formed low down in the connective tissue, about the pedicle, should make us very careful not to lift the tumor so high as to tear them at an inaccessible point, and so to induce death from concealed haemorrhage. Dr. Emmet reports a death from undue traction upon the pedicle. How to treat the pedicle has involved more experiment and controversy than any other step in the operation of ovariotomy. Having turned the tumor out of the abdomen, P edfck geiIlent ° f the and in the kindest and safest way disposed of the adhesions, you look for the stalk upon which it has grown, and through which its chief sustenance has been derived. It may be long or short, thick or thin, broad or Fig. 181. Spencer Wells' pedicle forceps. slender, single or double, and may or may not include the body of the uterus. When fully exposed it should be seized and com- pressed with a Spencer Wells' pedicle forceps or with the Baker Brown clamp-forceps. Having secured it, without including a bowel loop, the edges of the incision should be held together, and the lower angle of the wound covered all about the pedicle with warm towels or flannels. Then the tumor is cut away and the forceps remain astride the pedicle. The towels keep the blood and the fluids coming from the tumor from falling into the ab- domen, and are afterwards removed, and the parts sponged clean. Another method is first to compress the tissues of the pedicle with the forceps, then remove them and to pass the ligatures and tie them before the tumor is cut off. This plan is best suited for single cysts or small tumors, and also for securing the pedicle in oophorectomy. 978 THE DISEASES OF WOMEN. Now you must settle upon one of the two general methods of managing the stump: either it must be secured and held outside the abdomen, which is the extra-peritoneal methods^. general method; or it must be ligated, or cauterized, or both, and then dropped back into the abdomen, which is the intra-peritoyieal method. In the former case some kind of a clamp, such as Thomas's, (Fig. 182), or Spencer Fig. 182. Thomas' clamp for the pedicle. Wells' (Fig. 183), is placed above, or below the forceps, screwed T , down and the forceps removed. The pedicle is then brought forward and the instrument placed across the lower end of the incision. If, however, you determine upon dropping the pedicle into the Fig. 183. Spencer Wells' clamp for the pedicle. peritoneal cavity, as first practised by Dr. Nathan Smith, of Con- necticut, in 182 L, the course to be pursued is very different. By lifting the forceps or the attached tumor, the pedicle may be pierced between its vessels either by a Skene's needle, or by a straight one, at each end of The ligature. OVARIOTOMY. 979 an aseptic silk ligature. If the pedicle is a narrow one, the Skene's needle will carry a loop that can be passed over the pedicle and secured in the form of the Staffordshire knot. {Fig. 184.) Or, if you prefer, you may cut the loop, and tie one thread each way about the two halves of the pedicle. But you must not forget to cross these two ligatures, or they may separate the halves of the pedicle and slip off. (Fig. 185.) If the pedicle is a stout one it cannot be safely ligatured either en masse or in sections. It must be sewed with the cobbler's stitch and made very secure before the forceps are removed. And, when they are taken off, it is well to seize it with a pair of haemostatic forceps on each side, so that it will not be lost sight of until you are ready to close the abdomen ; for it may be neces- sary to put a separate ligature upon one or more bleeding vessels. The small forceps with gilt handles should be used for this purpose, and also for the application of sponges within the ab- domen, it being desirable to identify them and their special use. Meanwhile the opposite ovary should be carefully examined and, if it is found to be diseased, drawn to the light, clamped with the WIIMM cr Fig. 184. Tait's Staffordshire knot. Fig. 185. The unsafe method. forceps and excised in the same manner. This will constitute a double ovariotomy. All the ligatures should be cut short before the pedicle is dropped. Having tied the pedicle and trimmed off its superfluous tissue the cautery may be applied to the stump until it is thoroughly charred. Dr. Keith, who divides the pedicle with the cautery and trusts to it without the ligature, applies it so as to heat the clamp-forceps and cook the part which is included in that instrument. In either case the eschar prevents all septic oozing and keeps the stump from be- coming attached to the neighboring organs. For the last three years my own practice has been to use both the ligature and the cautery as a double precaution, and as a consequence the results obtained have been much better than they were before. I am quite confident that by the revival of the Baker Brown method of treating the pedicle with the cautery clamp and to°the extra! and without the clamp, the elder Keith and peritoneal method. Lawson Tait have put the profession and oar 980 THE DISEASES OF WOMEN. common humanity under a lasting obligation. For the clamp is indeed "a coarse, unsurgical instrument," which, through the establishment of septic channels from the sloughing stump directly into the peritoneal cavity, has slain many a poor woman who but for it would most certainly have recovered. And what is true of the use of the clamp applies also to the whole extra-peritoneal method in ovariotomy. Not only does the use of the clamp render the seeping of the septic debris into the abdomen almost certain ; it also prevents the careful and thorough drainage from the Douglas pouch which is often so very necessary during the first few days. The cleansing of the peritoneum is a matter of the greatest moment. Not only must the abdomen be emptied of clots and debris, and all active haemorrhage stopped, but The peritoneal toilet. . , . . , , , , *? , ; , , the parts must be made absolutely clean, and the Douglas pouch especially be left as dry as a pocket. For slovenly surgery can be tolerated anywhere else better than within the abdomen and the pelvis. The more extensive the adhesions, and the older the tumor, the greater the danger of subsequent oozing and sepsis. If a rotten sac has been torn, or if from any other cause a portion of the fluid has escaped into the peritoneal cavity, extraordinary pains must be taken to clean it out thoroughly. There are two methods by which the abdomen may be cleansed after the delivery of an ovarian tumor and the necessary ligation of its pedicle. One of these is by careful sponging, and the other is by washing and flushing it. No matter how soft the sponges, or how carefully they are used, they are so likely to do damage, especially if the peritoneum or the omentum are diseased, that the best operators have learned how to get along without them whenever it is possible. The most efficient and harmless sub- stitute for them is the use of water at a temperature of 100°, or more if the hemorrhagic tendency is pronounced. This may be run into the abdomen, while the flaccid parietes are being held up by an assistant, through a Tait's trocar used as a syphon; by a fountain syringe; or it may be poured in slowly by the pitcher- full until it overflows. Meanwhile the hand or the fingers may so manipulate and rinse the intestines and the other organs about the pelvic brim that they shall be washed quite clean. Whichever way the water is introduced its use should be con- tinued until the overflow is clear and not discolored. I have had frequent occasion to confirm the value of Tait's remark that the best means for dissolving the thicker and more sticky ovarian fluids (including the colloid material which is so OVARIOTOMY. 981 apt to escape from its cyst-wall when it has one, and which can- not be removed by sponging) is to pour on it a slow and steady stream of warm water. For this reason the cleansing should as far as possible be done with water, and not by sponging. And in removing the water the patient may be cautiously turned upon her side, or the tube by which it was introduced may be used as a syphon to carry it off again. When it is all out the parts may be examined by an electric lamp or by a hand-mirror, and the retro-uterine pouch carefully mopped with a soft warm sponge, or napkin, or with a bit of iodoform gauze. Aprojios of this intra-abdominal bath, in making the toilet of the peritoneum I warn you not to forget the invaluable suggestion of one of Dr. Sims' pupils concerning the 6h?c°k twaterflurihingfor efficacy of the hot water flushing in case of shock and great exhaustion.* To fill the ab- domen in this way is the most rapid and available means of stimulating the necessary reaction. It possesses the double ad- vantage of being in a line with the necessary local treatment, and does not interfere with the use of other restoratives. The indications for drainage are identical with those which require that the abdomen should be thoroughly cleansed, with the added risk of hemorrhagic oozing and serous accumulation after the wound is closed. The older the patient the greater the necessity for drainage, be- cause the ability of the peritoneum to absorb and to remove effused fluids is sometimes very much lessened in this class of cases. Moreover, the vitality of women who have passed their fiftieth year and have developed an ovarian cachexia is often so low that they are easy victims of septic infection. The attempt to do away with the necessity for drainage by render- ing the peritoneal cavity thoroughly aseptic has been generally abandoned, and for the practical reason that it could not be made so and kept so without very great risk of poisoning the patient, no matter what antiseptic was used. The result has been that the old methods of drainage, which often did more harm than good, have been so improved that they may now be depended upon to keep the wound and all that it includes both clean and sweet. And since these conditions will avert sepsis and suppurative fever we must see to it that in all serious cases they are faithfully supplied. Having tested the various methods of drainage I believe that the one which you saw applied in my clinic a few days ago is the *Prof. W. Gill Wylie, in the Medical Record for March, 1887. 982 THE DISEASES OF WOMEN. best. If you will take a Keith's glass tube (Fig. 186), or a Tait's do. (Fig. 187) and insert it at the lower angle of the wound its perforated extremity may be easily passed over and behind the uterus into the Douglas pouch. Then, having care- fully dried the wound with a warm sponge, or with a bit of iodo- form gauze, the tube should be held in place with its open end upwards until you have passed the sutures and are ready to tie or to twist them. Or, if you prefer to do so, you may pass the sutures first, and afterwards put the tube in position, before the Fig. 186. Keith's glass tube. wound is closed. The perforated tube that is closed at its lower end, like a test-tube, is preferable. It will need to be left in situ for from two to eight or nine days, or so long as the discharge obtained from it continues to be colored. After counting the forceps and sponges, to be certain that none are left behind, a large, clean, flat sponge should be placed within the wound and over the intestines, to keep them The sutures. . . . , . -, .. -. x -, , warm, to prevent their being injured, and to keep all blood from the needle punctures from dropping into the abdomen. The sutures may be of prepared silk, the silk- worm Fig. 187. Tait's glass tube. gut or of silver. The first of these are so readily adjusted, so se- cure, and so thoroughly aseptic that I confess to a growing fond- ness for them in closing the wound in all cases of laparotomy. Whether they are passed from within or from without, the deep sutures, which are not more than one-eighth of an inch apart, should include a pretty wide strip of peritoneum along the margin of the wound, the intervening muscular layer and the integument. This precaution will secure the immediate union and closure of the peritoneum, and so prevent the admission of infectious material from without. It will also keep the intestines from protruding in the form of a hernia, which once was so frequent a sequel of ovariotomy Concerning the number and nearness of the sutures Dr. Keith says OVARIOTOMY. 983 "In the early days of ovariotomy, when the wound was closed by harelip pins put in at intervals of an inch, a hernial protrusion was the rule; but since I have put in a great number of sutures, and I think I put in twice as many as any one else, and take in the whole deep tissues of the wall, I have seldom had to see a patient on account of airy discomfort arising from the wound. There is no greater mistake than to include only the skin and peritoneum. This is Sir Spencer Wells' method. It saves trouble at the time perhaps, but in a month or two the patient suffers. It is said that the cicatrix comes to this in the end in all cases. It does not; with a properly united wound, with a sufficient number of deep sutures taking in all the tissues, no hernia ought to happen. I am not sure but the wound is firmer when the middle line is avoided, and the sheath of one of the recti muscles is opened throughout." It is a good plan to insert all the deep sutures before tying any of them, the ends being held on either side within the jaws Fig. 188. An emptied cyst, or sac, to be stitched to the abdominal wound. of the lock-forceps. This ensures the exact adjustment of the edges of the wound, favors the removal of the underlying sponge after they have all been passed, and enables one to decide upon the necessity of stitching the peritoneum separately. I like Thiriar's idea of first bringing the edges of the peritoneum together with the continuous ^atgut suture, and afterwards tying the deeper ones. This method is adapted to the closure of a long incision, especially if it had extended through the umbilical ring, and is '. , designed to dispose of a hernia, and also to The superficial sutures. °. , ■ i ,-, -n j_. . i 1 i one m which the walls or the abdomen are The continuous peri toneal do. 984 THE DISEASES OF WOMEN. unusually thick. If any superficial sutures are required they should be of catgut, in order that the dressings need not be dis- turbed for their early removal. In very exceptional cases the tumor cannot be removed and the only alternative is to empty its contents, stitch the edges of the cyst into the abdominal wound, and drain its aS£nS C c? 1 s r turcfor cavity. The sutures will in that case need to be passed in the same manner as for the radi- cal cure of pelvic abscess, or for the ultimate disposition of the sac in extra-uterine pregnancy. (Fig- 188). The wound being closed, the abdomen is quickly cleansed and dried, and the line of the incision sprinkled with iodoform. Then a compress of iodoform-, mercurial, or carbolic gauze two or three inches wide, is laid along the wound, and adhe- wound firstdressing ° fthe slve straps are put across it, so as to keep it in place, and to afford the requisite support in case of vomiting. Over this is a good thick layer of absorbent cotton, or of cotton batting, which is secured by a binder around the body. Before the binder is adjusted, however, if the drainage tube is being used, pledgets of the same gauze drai'nag^tub^ ° f the are placed all around at the lower angle of the wound. Then we take a square bit of thin rubber-cloth, as big as a lady's pocket handkerchief, cut a little hole in the center of it and put it down over the free end of the tube, after the fashion of the dentist's rubber-dam. This is care- fully folded, one corner afc a time, over the open mouth of the tube, and not only serves to keep the air from the abdominal cavity, but also furnishes a ready means of knowing what is going on inside. The soiled clothing having been removed, the bed should be open and ready, and the patient carefully carried to it from the table. Her body should not be doubled in the ^Putting the patient to middle? nor should the head be raised. Warm blankets should be placed about her legs and bottles of hot water (but not too hot) at her feet, and elsewhere, to arouse the circulation and stimulate a reaction. But, the operation being finished, we shall speak of the after-treatment and the results in ovariotomy at our next lecture. LECTUBE LX. THE AFTER TREATMENT IN OVARIOTOMY. The importance of; quiet and absence of visitors; the temperature of the room; shock and re- action; pain and restlessness; the.pulse and the clinical thermometer; thirst and appropriate drinks; the diet; flatulence and tympanites; Dr Jenks' expedient for; case; nausea and vomiting; do. with sepsis and peritonitis; from gastro-intestinal ulceration; case ; the urine; the condition of the bowels; salines in peritoneal complications; the care of the drainage tube; dressing the wound; re-opening the wound for secondary hoemorrhage; for the intra- peritoneal bath; case; for secondary drainage; the removal of the sutures; the convales- cence and the first getting up; case; contingent affections; bronchitis and pneumonia; cases; parotitis; phlebitis, phlegmasia, thrombosis; acute mania; case; bed-sores in old patients. The results in Ovariotomy ; the causes of the comparatively low death rate of late years. The after-treatment in ovariotomy, as in all cases of peritoneal surgery, is of the utmost importance. In everything that per- tains to the care of these patients you should bear in mind the homely old maxim quoted by one of my nurses a day or two ago: "It is better to be sure than sorry.'' All the little details must be looked after most care- fully, and the beginnings of morbid mischief averted or arrested without delay. Any preconceived notions of luck or fortune as connected with the recovery of ordinary surgical cases; any prejudice in favor of the all-powerful influence of antiseptic pre- cautions, or confidence in the patient's general good health, or her pluck to "pull her through," no matter what happens, should not be allowed to interfere with the most cautious and careful management of the case in hand. For, even in the simplest and most promising case, the technique of the nursing for the first fortnight, or longer, may be quite as important as that of the operation itself. To begin with, as soon as the patient .s put to bed, if the opera- tion has been made in the same room, the table, instruments, and everything that is not needed should be taken of Q viStor| nd absence away, and as quietly • as possible. From the very outset she will need the same general treatment as if she had passed through a perilous childbirth. No noise, or stir, or flurry, or whispering should be allowed; and as much as possible the patient should be left alone with the nurse. If she sleeps quietly and breathes well, let her alone. If she flounders, she must not be oermitted to turn uoon either side. 986 THE DISEASES OF WOMEN. If the weather is cold, or the nights are cool and damp, or if it becomes rainy, the temperature of the room should be care- fully regulated. A thermometer should be kept the h r e oom mperature ° f f° r this P ur pose and frequently consulted. For the first four days the temperature should not be allowed to fall, day or night, below 70°, nor should it exceed 75°. If the weather is warm, the windows must be kept open. Fresh air and plenty of it is indispensable in all cases. If the condition of the pulse and of the skin show that she is reacting from the shock, she may not need anything but to be kept warm in bed, and to have a good supply of Shock and reaction, » > • -i-> , • r? i 1 n ,-, "7 ■ iresn air. i3ut it she has been greatly exhaust- ed, and the pulse flags and the skin is cool, give her a hypoder- mic injection of rye whiskey every hour, or oftener. This will antidote the depressing effect of the ether, and tide her over the difficulty. In very weak cases I have sometimes ordered this prescription to be repeated every hour or two during the first night, or until food could be safely taken. In the case of an Irish woman living in a miserable shanty on Quincy street, and who had one of the worst ovarian tumors that I ever removed, the parent-sac burst and its vile contents were extravasated into the abdomen. This was before we knew anything of flushing the peritoneum or of drainage, and while we were still crucifying our patients with the clamp. She was extremely weak, did not react well, could take no food, and but for the whiskey, which she took by the mouth after the first twelve hours, must certainly have died. Inhalations of spirits of ammonia or of camphor, or, in case chloroform has been administered, a whiff now and then of the nitrate of amyl, or a hypodermic of sulphuric ether, may be of good service to stimulate and to resuscitate the patient. In some cases where the pain and restlessness are pronounced, it is a serious question whether an opiate of any kind should be given. Of late years I very much prefer not to Pain and restlessness. °-, , - . -, . , . / » j ' • • allow it unJess the necessity tor rest is impera- tive, when a hypodermic of morphia with atropine is best. My friend Helmuth extols the internal use of hypericum for this pur- pose ; but my reliance has generally been upon frequent doses of aconite 3, and arnica 3, in alternation. The pulse is more trustworthy than it is in a lying-in-woman. But, like either of the probable signs of pregnancy, it will not answer to depend upon it exclusively. We want something with which to compare it, and, so to speak, to balance its record. And that something is the clinical thermometer. THE AFTER TREATMENT IN OVARIOTOMY. 987 By the careful and intelligent use of this instrument we obtain a more accurate idea of our patient's condition than we can pos- sibly have in any other way. When a septic mom e ete?! mical ther ~ contingency is sprung, it sounds the first alarm. And not only does it notify us in season, but it often tells us whether or not we are doing the right thing. The information which it gives concerning the patient's condition will be as absolute and exact as possible. It will not be biased by the caprice, the fears, or even the sufferings of the patient, by the story of the nurse, nor by the hazy intuitions of the doctor. The temperature may be taken by the mouth, or by the vagina. If the respiration is normal, place the bulb of the instrument be- neath the tongue, and then have the mouth Manner of using it. , -. T ., ,, £ . , , closed. .Leave it there tor two minutes by your watch, and then make a note of the temperature upon a sheet of paper that is kept for the purpose. For the first day or two the observations may be taken every six hours, after which they should be repeated every morning and evening, as in our puer- peral ward. The pulse should be taken at the same time and carefully recorded. Keep these figures, so that you can consult them; for, not unfrequently it is quite as important to look oyer the past record of a case, as it is to forecast its future. The Value of the record. -i- • i -\ • ± j. j ■ • • i clinical hints, as to diagnosis, prognosis, prophy- laxis, and treatment, that you will derive from this study are the counterpart of those which are proper to the disorders of lying- in, and you can do no better than to translate and apply them in a similar way. Almost the first complaint is of thirst; and if you have not laid down the rule very plainly and peremptorily, the nurse or some kind friend will be tempted to give your patient ate^rfnS 01 appropri " something to drink. Sometimes the craving for water is almost irresistible, but it is so likely to excite vomiting that it is not safe to allow it within the first twelve hours. Meanwhile, the mouth and lips may be moistened with a cold, wet rag, or a pellet of ice may be allowed to dissolve in the mouth occasionally. When the effects of the anaesthetic are gone we usually begin with hot, instead of cold drinks. Hot water, hot tea, or better still, hot milk and water may at first be taken in very small quantities, and not too often, to test its toler- ance, and afterward more freely. If the stomach remains irritable, the carbonated soda or champagne may be given. A pint of tepid water as a rectal enema will sometimes allay a tor- menting thirst. For the first forty-eight hours the remedies THE DISEASES OE WOMEN. should be given in powders or pellets, else the water which holds them in solution may readily excite vomiting. Of all the articles of diet that are available for these cases, especially during the first week, the best is good cow's milk ; but, for fear of inducing colic, it should be diluted The diet. and taken very warm. Where it has disagreed with the patient heretofore, it may be peptonized. A light gruel of oatmeal is always permissible, and so also is genuine home- made beef tea. Barley water with cream may be kindly received by a delicate stomach, which will afterward tolerate good mutton broth, oyster soup, or something more substantial. The best rule that I know of in the matter of feeding these patients is to wait until flatus has first been passed by the bowels before giving them anything hearty. For this purpose my habit is to instruct the patient to tell the nurse when this has happened, so that we may know how to proceed. By this simple sign we can be assured that the proper peristaltic action of the aliment- ary tract has been resumed, and that neither emesis nor flatulence are so likely to follow the taking of food. And, although we do not in these modern times expect the patient always to drag through a tedious suppurative process before she recovers, it still is best to feed and to fortify her as soon as it can be done with safety. One of the most annoying and rebellious symptoms is flatu- lency. It may be due to the dyspeptic habit; to a superficial Matuience and tympan- ulceration of the gastric or the alimentary ites - mucous membrane that is septic in character and chargeable to auto-infection in old cases of ovarian dropsy and uterine tumors; or to the intestines having been chilled, or traumatized, or perhaps twisted when they were being reposited before the wound was closed. For the dyspeptic flatulence, if the patient is intelligent, it is a good rule to allow her to take whatever has relieved this symptom in her former experience. If she has observed that a drink of hot water would do it, let her have it again; or soda or camphor, or peppermint, or whiskey, or what-not ; but you must try the effect of these things carefully, for if this symptom persists it may develop into obstinate vomiting. If from the previous history of the case you have reason to believe that there is gastric ulceration, argentum nitricum 6, arsenicum alb., phosphorus, or nitric acid may Nausea and vomiting. . , , , L , \ an i - -re j_i • i possibly have a good elxect. It there is much distention give chamomilla, colocynthis, belladonna, or nux vomica, THE AFTER TREATMENT IN OVARIOTOMY. 989 and change the position of the patient. While this symptom con- tinues all food and drinks should be given by rectal enemata, and nothing except the dry medicine taken by the mouth. These means are also suited to overcome any slight intestinal obstruction, with or without tympanites, especially should the patient be turned toward one side or the other for tympanites from in- slowly and gradually, and propped in that testinal obstruction. •. • tt 1 1 i i 1 i u position. Her head and shoulders may be raised, and her position so changed as to favor the escape of gas and to add very much to her comfort. In the worst of these cases, where life is imperiled by the occlusion of the bowel and the accumulation of gas, recourse may be had to another kind of postural treatment that was first practised by Dr. E. W. Jenks, of Detroit, in 1878. He published a remarkable case, in which, at the ninth day after an ovariotomy, "the patient was seized with a severe attack of vomiting, which caused the clamp to be torn loose, the lowest suture to be also torn out, and the lower angle of the abdominal wound to yawn, through which gap the serum from the abdominal cavity exuded for two days." The usual remedies relieved the tympanites, and there was no "doubt of her ultimate recovery until the twenty-third day after the operation, when the tympanites again became troublesome, and she complained of her inability to pass any flatus by the rectum, and of pain in the region of the pedicle." All other means having failed, a long rectal tube was passed as far as the sigmoid flexure of the colon, where it encountered the seat of an obstruc- tion which a copious injection could not overcome. The symp- toms became more distressing in character, hiccough set in, the countenance was pinched and anxious, the vomiting was more frequent, and she grew rapidly feeble. "She seemed so near moribund from exhaustion that she was entirely indifferent as to what was being done for her. With the aid of my colleague, Prof. Andrews, and one of my assistants, I took the patient from her bed, and gradually inverted her; there was no effect manifest from partial inversion, but when we got her in the position of complete inversion, really standing upon her head, there was, to our gratification and the manifest relief of the suffering woman, a rush from the anus of the pent up intes- tinal gas, coming out with a force more remarkable than anything of the kind I ever before witnessed. The patient, as she began to experience relief, instead of being passive in our hands, complained in no mild terms of the unkind and ungentlemanly treatment she was receiving. From this time there was no further trouble; if the gas seemed to be accumulating or was not readily expelled, raising her hips, gentle kneading, or turning her from side to side 990 THE DISEASES OF WOMEN. would cause it to be expelled. The patient encountered no more difficulties, and made an excellent recovery.* If there is a form of volvulus which this expedient will not relieve, the wound should be re-opened, and the twist of the gut about its mesenteric axis, or upon itself, or whatever lesion may obstruct the passage of flatus, carefully sought for and relieved. This is a last resort, but it should not be deferred too long. "The trinity of peritonitis, tympanites, and vomiting are the furies of abdominal surgery. When they have taken firm hold of a case, we may make up our minds for a Nausea and vomiting. ^ . i ' -i i» " n i , i mi tierce struggle before they can be ousted. The longer they abide, the more difficult are they to be got rid of ; therefore, we ought to be prepared at every point to meet them with the most trustworthy weapons and the most approved tac- tics." — (Greig Smith.) That this triple source of mischief and of danger has been in a measure obviated by the adoption of the intra-peritoneal method of treating the pedicle, and by careful drainage, there can be no doubt. The dragging of the stump through the wound and its fixation by the clamp was often a cause of vomiting that nothing would relieve; and the sepsis which came from the accumulation of blood and serum in the Douglas pouch and behind the bladder often developed a dilatation of the stomach and the regurgitation of the ingesta which might be palliated but could not be cured. Now we know that these causes are avoidable, and that, with some rare exceptions, we need not be discouraged if the nausea and vomiting do not promptly yield to the appropriate treatment. It has been observed that vomiting is more apt to occur in cases in which numerous ligatures have been applied to the ad- hesions during the operation ; but now that the haemorrhage is arrested by sponge-pressure, by prolonged pressure with a soft cotton cloth, as advised by Dr. Kimball, or by a stream of very warm water, this cause of emesis is also avoidable. In most cases, however, the tendency to eructations and to an intolerance of food and drinks bears a certain relation to the flatulency, and the treatment already given for that symptom is also suited to this. A sip of hot water occasionally will sometimes settle a turbulent stomach just as a slight shower calms the stormy sea; but it will not always do it. And so also will a few doses of ipecac, or of mercurius, especially if the tongue is pasty, or of other remedies under their usual indications. In some cases relief is obtained, for a time at least, by having the patient drink a large quantity of warm water, so as to completely empty the * American Journal of Obstetrics, the Diseases of Women, etc., Vol. XI, page 513. THE AFTER TREATMENT IN OVARIOTOMY. 991 stomach. In others the same effect has been induced by rinsing the organ with the stomach tube, or gavage. But the serious question is whether a persistent vomiting, or one that occurs after the first few days or a week, is not due to some form of sepsis, or to peritonitis, or to both toStis. sepsi8andperi " these conditions. If it is, the most active measures will be necessary. We must look to the drainage of the abdomen, or we must resort to intra-peritoneal injections, and even, if necessary, reopen the wound to get rid of the local cause of the trouble. Under the old regime, nature cured some of these cases by bursting open the incision and giv- ing vent to the contained fluid, after which the patient recovered in spite of the doctor. If there is an accompanying diarrhoea it is evidently critical, showing that a form of intestinal drainage has been established which may prove salutary. Long before Tait had prescribed saline cathartics as prophylactic o£ peritonitis following abdominal operations, some of us had observed this fact; but it was for him to insist that we may induce free watery stools to abort this form of inflammation. If you are satisfied that your patient either has, or threatens to have peritonitis, you may remember this hint and act accordingly. In old cases it sometimes happens that, through a depraved cachexia, and the possible absorption of some int^ti^uicSSi. 111 " 1 rown fluid were withdrawn. In six weeks, she was again tapped, 992 THE DISEASES OF WOMEN. and eight quarts of a pale amber-colored fluid were taken. The third tapping was performed about ten days previous to the opera- ation, and Rye and a half quarts of a dirty brown fluid were removed. At each tapping the fluid was highly albuminous. Her menstruation had been normal in every respect, and she had not reached the climacteric, although there were signs of its near approach. I made the operation in the hospital, November 6, 1880, with the assistance of Drs. Shears, Crawford, Eaton, Keynolds and Paul. The patient bore the anaesthetic very well, and the operation lasted one hour and a quarter. There was a good deal of venous haemorrhage from the incision, and the parietal and lateral adhes- ions covered the whole right and part of the left side of the tumor. This tumor consisted of three lobes, the largest of which was crowded into the epigastric region. It weighed twenty-five pounds and proved to be of the endogenous variety, each of the lobes con- taining a great many cysts of various sizes. The patient reacted well, and gave the best possible promise of recovery. She was under the constant supervision of Drs. Shears and Eaton. With the exception of pain in the gastric region as from gas, and a great deal of nausea, which began on the second day, and continued with eructations, she was quite comfortable until the morning of the third day, when she vomited badly. She then became very thirsty, weak and tremulous, with heat of the head and of the hands, dryness and redness of the tongue, gastric tympanitis, and scanty urination. In the evening the abdomen was washed out, but the fluid that was withdrawn was clear and unchanged. On the fourth day the vomiting was almost incessant with absolute intolerance of food. Rectal enemata had the effect, apparently, to increase the vomiting. The epigastric reigon became enormously distended, and the urine less free. Remedies had no effect whatever on the nausea and vomiting, and she died at eight A. m. of the fifth day. The post-mortem was made with the assistance of Drs. Crawford and Paul, and in the presence of Profs. Hall and Leavitt, and of Class No. 8, from my sub-clinic. An incision was made parallel to that made in the operation, and two inches to the right of it. By careful examination, the wound was seen to have healed very kindly and completely, both internally and externally. The site of the extensive parietal adhesions was plainly observable, but there were no signs of peritonitis, either there, or anywhere within the abdomen or pelvis. There was no effusion of lymph upon the intestines, no blood, or bloody serum, or clots, anywhere, nor was there a drop of pus to be found within the peritoneum, along the incision, or about the pedicle or the clamp. In all respects the process of union and of repair had proceeded without any obstacle or complication whatever. The stomach was found to be greatly dilated. Its external THE AFTER TREATMENT IN OVARIOTOMY. 993 appearance was healthy. It contain 3d about three pints of dirty ochre-colored water. On being opened along the whole length of its greater curvature, nearly one-half of its mucous surface was found to be highly congested, and in a state of violent inflamma- tion. Near its middle portion, and along the larger curvature, where three distinct ulcers, the largest of which was as big as a three-cent piece. These were in the midst of the inflamed area, and were evidently acute and active in character, being partially covered with pus. On either side of these recent ulcers was a row of dark-colored spots which all who were present recognized as so many cicatrices of ulcers that must have healed. These spots had the appearance of so many shot-holes, and there were more than twenty of them. Sometimes this ulcerative tendency is coupled with strange caprices of the will, as well as of the appetite in old dyspeptics. Such patients have little pluck and fortitude, and are discouraged from the outset, or they antagonize all efforts to regulate the diet and to get them through without serious trouble on the part of the stomach. On May 17, 1883, I removed an old poly cyst from a patient, for my friend Dr. C. W. Crary, now of Kenwood, 111. The woman was 62 years old, a theomaniac, and therefore a confirmed dyspeptic, who did not caro. to get well, but who did "want to go to Heaven." She floundered through thirteen days of convalescence, gave the doc- tor and the nurses the greatest trouble and anxiety by rolling about and doing everything by contraries, and ended the scene by eating a lot of indigestible food. There were no septic symp- toms and the wound had united perfectly. The autopsy disclosed deep ulceration at three different points in the mucous membrane of the duodenum. Although we generally advise to have the urine drawn every few hours during the first afternoon and night, it is best to encourage the patient to pass it in a natural The urine. . way. Without the clamp there is no drawing of the pedicle over the fundus of the bladder and its gradual dis- tention can do no harm. By voiding it herself she is spared the strangury and the catarrh of the bladder and of the urethra which used sometimes to last for weeks. ' Much discomfort has been saved the patient by her being allowed to empty her bladder her- self, and not having this done for her. Why the catheter should be passed two or three times a day I have never been able to understand, when the patient can almost always accomplish this for herself. It was the rule, I suppose, just as it was the rule to have the bladder emptied before operation." (Keith.) Partial or complete suppression of the urine is a serious symp- 994 THE DISEASES OF WOMEN. ton. It either signifies that the bladder or the ureters have been injured during the operation ; that the patient labors under an old renal disorder; or that, from the use of the sulphuric ether, from the shock, or from some similar cause, the function of the kidneys has been suspended. The risks from uraemia added to those of septicsema are very great, and therefore, as soon as possible the flow must be restored. Aconite, apis, belladonna, hyoscyamus, or a kindred remedy may be indicated, and warm moist cloths should be applied to the pudenda. If the stomach will bear them, diluent drinks should be freely given. Thornton advises an expedient which, although it would seem to be hazardous, may yet be permissible in extreme cases, which is to bare the patient's arms and to pack them in towels that are kept wet with ice-water. Even in the simplest cases it is best to prevent the bowels from becoming constipated. Laxative food and cooked fruits may be allowed, if everything goes on well, after the bow h eis. ondition ° f the close of the first week - Nux vomica, lycopo- dium and kindred remedies are often useful. Rectal enemata of warm water are almost always grateful, and may be repeated, if the patient does not object, every third day, beginning at the fifth or sixth day. In some cases the mineral waters, especially Hunyadi water, are to be preferred. Hyper- catharsis is harmful unless an attack of peritonitis is imminent. I am fully persuaded of the efficacy of saline cathartics where there are signs of peritonitis following an abdominal section. The old idea that the bowels should be cramped compiS£ns erit ° neal an d put into a state of paresis with opium was all wrong; and so also was the practice of neg- lecting them altogether. Tait's habit of giving the sulphate of magnesia every hour until the bowels are moved is an invaluable resource where the pulse and the temperature are increased, the discharge from the drainage tube has stopped, or nearly so, and the local signs of peritonitis are present. The action of the drug can be facilitated by enemata of warm soap-suds; and the free watery stools that follow will secure a kind of intestinal drainage that will avert the threatening inflammation, just as a free sweat may abort a fever. He says: "If these symptoms advance to an alarming extent, I use still more active measures to get the bowels moved, because I always find that as soon as a motion has passed they rapidly disappear ." Whenever these symp- toms arise, if the bowels have not moved spontaneously and freely, we may have recourse to this expedient, beginning, if necessary, as early as the second day after the operation. Directly the wound is closed, especially if the adhesions were THE AFTER TREATMENT IN OVARIOTOMY. 995 extensive, there will be a more or less free discharge of bloody serum into the abdominal cavity. The quantity agetabe.^ ° f the dram ~ * nus secreted sometimes amounts to a pint or more without doing any harm, provided only, that it is not retained within the peritoneum. The object of the drainage tube is to collect this fluid and to convey it out of the body. That tube will also notify us of the existence of any secondary haemorrhage, with which the serous flow must not be confounded. To prevent the accumulation of serum in the Doug- las pouch, which is the most dependent portion of the abdominal cavity, the glass tube should for the first few days be carefully emptied at regular intervals. For this purpose the corners of the rubber cloth are turned back and a bit of clean, carbolized rubber tubing to which a syringe is attached is dropped into the glass drain, and the serum is sucked out of it very slowly and carefully. The tubing may be used as a syphon for the same purpose; or you may pass the long nozzle of a clean, hard rubber uterine syringe directly down the glass tube and so withdraw the mischievous serum. The rubber-dam should afterwards be closed as snugly as at its first application. In bad cases this little oper- ation should at first be repeated every three hours, but, if all goes well, it will not be necessary after a little to make it so often. In from one to four days, if the serum has lost its color and the patient's temperature is not above 100°, the drainage tube may be withdrawn, great care being taken to keep its old site covered and protected by antiseptic gauze until it has healed by granu- lation. Happily the dressing of the wound is now reduced to the min- imum of simplicity. If all goes well the only thing to do for the first week is to let it alone; and after that to Dressing the wound. , ., -i • i , i -i , i ^ n • keep the binder, the gauze and the clothing clean and sweet. The dry applications that were made when the wound was closed will secure union by the first intention, and that is exactly what is wanted. The pedicle is safely within the abdomen, where it belongs, and the serum that exuded is safely outside the peritoneum, where it can do no possible harm; and so the local conditions of repair arid of recovery are all that could be desired. Further on, if there are stitch-hole abscesses, or mural abscesses, or if there is evidence of suppuration along the margins of the wound, the topical use of calendula and the removal of the cotton, will be necessary. If the discharge of pus is free, or long- continued, silicea should be given internally, and a good nourish- ing diet ordered. If there is any odor to the discharge, an anti- septic may be added to the calendula lotion. 996 THE DISEASES OF WOMEN. It is only in extreme and very exceptional cases that it ever becomes necssary to reopen the abdominal incision. If the drain- age tube fills, and continues to fill with real Beopening the wound. , , -. -,., . P . « . -, . blood, and there are manliest signs or sinking from internal haemorrhage, some and possibly all of the sutures should be removed, the wound reopened and the pedicle and the site of the adhesions carefully examined to find the source of the mischief. Whatever it is, and wherever it is, h The secondary h^morr- thQ mogt prompt and thorough measures should be taken to overcome the difficulty, after which the peritoneum should be carefully cleansed and closed. Second- ary haemorrhage is sometimes induced by excessive retching, by rolling in the bed, or by getting up suddenly, and by the slip- ping of the ligatures in the pedicle. It sometimes happens in women of an hsemorrhagic diathesis, and in those in whom the pedicle is old and unsound. In the Medical Record for this month (Nov. 12, 1887) you will find the report of a very remark- able case in whicft- the abdomen had to be reopened in a hsemorr- hagic subject, and in which life was saved after extreme loss of blood by the transfusion of salt and water. A favorite solution for this purpose is that of Mikulicz, which is composed of the carbonate of soda eight grains, chloride of sodium one and a-half drachms, dissolved in one pint of warm distilled water. Of this solution twelve ounces may be slowly transfused into the radial artery or the radial vein. If pysemic conditions are developed and you are satisfied that suppuration has taken place within the peritoneum, you may open the wound at its lower angle sufficiently to bathf intra " peritoneal allow the passage of the aspirator - canula, through which the contained serum, or pus, may be withdrawn and the cavity afterwards flushed and cleansed. In one of Dr. Peaslee's cases this washing out of the abdomen was continued for fifty-nine, and in another for seventy-eight days, and both patients recovered. The following history shows what this expedient accomplished in one of my worst cases under the old clamp-and-no-drainage method : Case. — Mrs. B., aged twenty-five, was sent to the hospital by Dr. W. A. Allen of Rochester, Minn. She was a small and very deli- cate woman naturally, and was in a very weak condition when she came to us. I made the operation in the old hospital building, July 6, 1880. There were present as assistants Drs. Shears and Paul, house physicians, and Drs. E. S. Bailey, C. E. Laning, A. K. Craw- ford, and" B. L. Reynolds. The cyst was a compound one, and THE AFTER TREATMENT IN OVARIOTOMY. 997 attached both anteriorly and laterally by adhesions that were very firm and vascular. Listerism was freely used to prevent infection, for several of the sacs were so attenuated that, in spite of the great- est care, they were ruptured before the tumor could be delivered. The remaining cysts, which were afterwards opened in the presence of the Clinical Society, were many of them endogenous, and num- bered in all about one hundred. The tumor weighed thirty pounds. She reacted well, but the second day suffered from nausea and distention of the stomach with gas, and finally vomited a dark green fluid. This gastric irritability continued at intervals, with great thirst, flatuence, and intolerance of food, for three weeks. The clamp dropped on the seventeenth day, at which time a swell- ing had formed on each side of the bladder. On the twenty -third day the abscess found vent about the pedicle, and a large quantity of dirty grayish fluid with a foul odor escaped. At evening the abdomen was filled with a weak solution of chloride of sodium in slightly carbolized water at a temperature of 102°, which was thrown through the canula of the aspirator and afterwards with- drawn by the same means. The overflow was mopped with sponges, and the cavity of the peritoneum was thoroughly cleansed and irri- gated. This operation was repeated five times in all on alternate days, and always with comfort and relief to the patient. The second time that it was made nearly a pint of stinking pus was first taken by the aspirator. On the twenty-ninth day another large abscess, which was located between the lower angle of the wound and the pubes, and which contained half a pint of pus, was dis- charged. The stomach did not recover its tone, nor did the appetite return until after the flushing of the abdomen was begun. Besides, the pulse was not below 100 three times in three weeks until after the first abdominal injection. The highest temperature was 103°, the total variation, however, was only about two degrees. She made a final and complete recovery. Secondary drainage, if necessary, should be made with a soft rubber instead of a glass tube. It is not very satisfactory, how- ever, unless the noxious fluids are easily accessible, in which case the tube may lie beneath and parallel with the For secondary drainage. -. ^ -, , p, ,, .-i j_i a • i wound, and may be lett there until these fluids are thoroughly drained off. The outer end of the rubber tube which can be pierced and fastened to the binder with a safety- pin, must be carefully covered to prevent the admission of air into the peritoneal cavity. The object of placing the superficial sutures with catgut is that the wound need not be disturbed until the time has arrived for removing the deeper ones. That time varies S nto e es. emoval ° rthe from a week to ten days. If the wound is dry and sweet, and the line of union is perfect, 998 THE DISEASES OF WOMEN. The convalescence and the first getting up. and especially if the tumor was a very large one, or if the abdom- inal parietes are very thick, it is better to leave them until the tenth day. But if they excite redness or irritation, or if either of them acts like a seton, has gotten loose, or cuts into the tissues, it should be taken out. Now that the rule is for recovery to follow without suppuration, I prefer to leave the sutures a few days longer than was the custom some years ago. They do no harm and certainly afford additional security against a ventral hernia. It is good practice to remove a few of them at one time, say each alternate one, leaving the others for a day or two longer. For a day or two at least, after they are removed, the patient should not be permitted to lie upon either side. The abdomen must be carefully and constantly supported by adhesive straps and a binder, which latter, in the form of a snugly-fitting abdominal belt, should indeed be worn for six or more months after she is about again. The duration of the convalescence is by no means uniform. It is not safe for the patient to leave her bed within the first fort- night, and circumstances may require her to remain therein for five or six, instead of two weeks. The older the patient and the worse the character of the contents of the tumor, the more tedious the recovery, and the greater the risk of the first getting up. Three years ago I removed a large multilocular tumor from an old lady at Eochelle, 111., the patient of Dr. W. A. McDowell. The tumor was chiefly colloid and solid, and the adhesions were very bad. Through good nursing and care on the part of the doctor and her own daughter, she progressed so favorably that on the twenty- first day the doctor told the family that it would not be necessary for him to come again. The next day, while the daughter was out of the room for a few moments, the old lady conceived the idea of surprising her, and so got out of bed and walked to the rocking-chair ; but when the daughter returned her mother w T as dead ! She probably died of pulmonary embolism. The safer way is to prop the patient in bed, and gradually to bring her into the upright position. At first she should not be permitted to sit up but a little while at a time, the abdomen being carefully supported meanwhile. Little by little the length of these sessions may be extended, and finally she can stand and walk with safety. Women who are predisposed to respiratory affections are likely to have trouble during their convalescence from broncn\tfs e ^nd a P n C eunTo- ovariotomy. Elderly women are more subject ma " to bronchitis, broncho- pneumonia, and catarr- THE AFTER TREATMENT IN OVARIOTOMY. 999 hal affections of the air passages than those who are under fifty. If the operation was made in bad weather, or if it becomes stormy afterwards, these cases will require special care to prevent them from taking cold; and the first signs of a coryza, angina, or a cough, must be prescribed for promptly. Sometimes an ambitious woman will have overdone and exposed herself so as to contract a severe cold directly in advance of the operation, in which case she will enter upon it just as others do upon labor, only to develop some after-coming disorder. Mrs. M., living at 116 Gurley street, the mother of nine children, and 44 years old, cleaned, scrubbed, and helped to whitewash the room in which I afterwards oper- ated. She did much more beside, and contracted a severe cold in advance of the operation. The tumor, which was very con- densed and solid, was removed entire through an incision of fifteen inches. The omental adhesions were so extensive and vascular that it was necessary to ligate and to excise a large portion of that structure en masse. On the second day she had pains in the left chest and shoulder and a harassing cough. The case developed into a serious attack of broncho-pneumonia, which was not fully overcome until after the fifteenth day. The high- est temperature noted was 102-5°, and the highest pulse 130. She convalesced slowly, but made a complete recovery. More rarely there is a swelling of the parotid glands, such as sometimes follows other abdominal and pelvic operations, inclu- ding Emmet's operation for a lacerated cervix, Parotitis. . and the operation for vesico-vaginal fistula. This form of mumps is either of a sympathetic or of a septic origin. It may become pyemic, and sometimes the periosteum of the inferior maxilla is involved. Warm applications arid em- mollients locally, and mercurius, belladonna, or other indicated remedies should be given internally. This "parotid bubo" should not be lightly regarded, even although it may not be attended by grave constitutional symptoms. The glands do not always sup- purate, although the lesion is more likely to arise during the second or third week. Dr. Goodell is evidently right in suppos- ing that, while this complication may follow ordinary surgical operations, it is more liable to happen after those which have been made upon the sexual organs; and that the sympathetic form of this "parotid bubo" which is independent of blood-poison- ing is not necessarily dangerous. If the patient makes a special complaint of pain in either leg, and of a sensation as if it were swollen, and big- th?Sus i . s, pblegmasia ' ger than its fellow, particularly if the tumor has been a very large one and has pressed upon 1000 THE DISEASES OF WOMEN. the corresponding side of the pelvis, you may find local evidence of phlebitis, or of infiltration of the cellular tissue below the knee. This condition sometimes develops into a confirmed phlegmasia, and extends to the thigh, from which state it may easily pass on to suppuration, and become very painful and serious. Absolute rest with the affected limb in the horizontal position; hot applications, either wet or dry, as they are most grateful; wrapping the leg in cotton, and internal remedies as for a "milk leg" are the chief indications for treatment. Throm- bosis of the vein is possible in such a case, and the prognosis should be guarded. "Acute mania sometimes follows ovariotomy, especially when both ovaries have been removed. The attack is usually tempo- rary, but it sometimes ends in insanity, and Acute mania. -in • r» • • , even in death, as m one ot my own patients. Keith, Thornton, Tait, Bantock, Bryant and other leading ovari- otomists report analagous cases." (Goodell.) I have never seen a case of insanity following this operation, but, in November, 1882, I made an ovariotomy in the person of a woman who had suffered from a form of mania for many months, and who had been confined in an asylum for the year previous to the operation. She made no resistance, took the anaesthetic at the request of the husband, and was totally indifferent and oblivious to everything. The tumor weighed thirty-four pounds. She made a good recovery, but for some weeks did not fully regain her faculties. Finally her mental condition was restored, she became the mother of a very interesting child, and has remained well and happy ever since. Pains should always be taken to prevent bed-sores, a precaution which is especially important if the patient is an old one. This result can be obtained by having her changed from one side to the other occasionally, and not allowing her to lie upon the back all the time. THE RESULTS IN OVARIOTOMY. Up to this date (December, 1887), there is not upon record a well authenticated, radical cure of a true ovarian cyst by any other than surgical means. When this statement is coupled with the fact that those who survive the risks of ovariotomy almost always recover their health to a degree that seldom follows in other very serious operations, we naturally inquire into the rate of its mor- tality. What proportion of all of those* who are operated upon for the removal of these tumors outlive the immediate danger and regain their former health THE AFTER TREATMENT IN OVARIOTOMY. 1001 The results of this operation have improved immensely within a very few years, and, I believe, for the following reasons: 1. The change in the rule advising that it be not postponed until the patient is in a desperate strait, where the complications loill render her recovery next to impossible. — A month ago I showed you an ovarian cystoma which I had just removed from a patient of the Drs. Dunn, of Centralia, 111. The woman was 58 years old, and had carried that tumor for 28 years because her old doctor had told her "never on any account to have it tapped or otherwise interfered with." Twenty-five years ago it was tap- ped and but once. Afterwards it grew steadily and at the opera, lion weighed 62 pounds. She is now well again, but it is one case in a thousand, for the contingencies multiply very rapidly when such growths exceed three or four years' duration. It is the age of the tumor and not the age of the patient thai subtracts from the chances of recovery after an ovariotomy. Nine of my cases have been above sixty years old, and they all got well. One of them was a double ovariotomy in a patient of Dr. Li. W. Jordan, of Bucyrus, O. The largest tumor would have exceeded ninety pounds in weight if she had not been tapped for temporary relief just one week before the operation. In these old cases there is the double danger of draining the vital fluids into the cyst, and of the condition becoming cumula- tively septic through a distillation of the contents of the sac into the blood. My report to the Clinical Society for July, 1886, ^closed with the following propositions:* 1. That the absorption of a part of the cyst contents prior to the operation is a not infrequent cause of fatality in ovariotomy. 2. That this condition is incident to old tumors, to compound cysts, and to cases that have been tapped. 3. That this insidious, pre-operative form of sepsis is most likely to declare itself through an irritable state of the gastro-alimentary mucous membrane, with repeated attacks of vomiting and purg- ing, and to be confirmed at post-mortem by signs of gastric or enteric ulceration, 4. That, if the patient is predisposed to renal or hepatic dis- ease, the kidneys or the liver may be the seat of serious lesions of function or of structure, which really depend upon this auto, infection. 5. That the cardiac degeneration and involvement which are incident to this form of abdominal growths, as shown by Dr. Fenwick, may be ascribed to a pernicious anaemia that is of septic origin, and which has its source in absorption through and from the disintegrating tissues of the walls and partitions *The Clinique, Vol. VII, page 268. 1002 THE DISEASES OF WOMEN. of the cyst, and not alone in the size and pressure of the sac. 6. That when this septic infection has existed before the opera- tion was made the risk of its continuance and recurrence is very great, and the danger from it is due to the dyscrasia which it had insidiously developed. 7. That these facts present a new and powerful argument for the early performance of ovariotomy, and indirectly explain the increasing exemption from fatal consequences afterward. Briefly, then, we save more cases since the doctors have quit counselling their patients with ovarian dropsy to wait as long as possible before resorting to ovariotomy for their radical cure, and since the temporizing and harmful expedient of tapping has gone out of fashion. If these old notions had been dropped fifty years ago McDowell's operation would have made a much better record. 2. The improved technique of the operation itself, of the peri- toneal toilet, and of the after-treatment. — In this and in the pre- ceding lecture we have carefully considered each and all of these points in their proper connection. No ovariotomist, whether he be great or small, old or young, a beginner or a veteran, can afford to disregard the proper and essential prophylaxis of peri- toneal surgery, or the conditions upon which this particular kind of work is either expedient or successful. "Our best English operators — Keith, Thornton, Bantock and others — in the last few years had brought their death-rate down to the marvellously low figure of about ten per cent., more or less, when Lawson Tait's record beats all, by the extraordinary result of one hundred and thirty-nine cases without a death, and a general mortality over several hundreds of cases of less than five per cent. Surely this is the ne plus ultra, not only of abdominal surgery, but of all surgery. If it is not a justification for the performance of ovariotomy, wherever an ovarian tumor exists, it is undoubtedly a stern command to all who seek to perform the operation, so as to give their patients the best chance of life, to spare no pains to per- fect themselves in every detail of attainable knowledge. {Greig Smith. ) In a recently published record of his last series of one hundred cases, Dr. Thomas Keith, of Edinburgh, reports that he had only three deaths to ninety-seven recoveries. These remarkable results, which have not as yet been duplicated in America, did not spring" from accident or chance, but from a careful application and adap- tation of such rules and precautions as I have now given you. And they show most conclusively that, other things equal, the measure of success obtained increases in ratio with the special experience of the operator as an ovariotomist. LECTUBE LXI. OVARIOTOMY BY ENUCLEATION. Ovariotomy by enucleation. Miner's method of. Cases that are suitable for. Ludlam's method of enucleating an ovarian cyst. Case. — Ovariotomy by partial enucleation. Vaginal ovariotomy. Cases adapted to. Mode of operating* A new hint. The after-treatment. There are other modes of performing ovariotomy which remain to be descri bed and illustrated before we dismiss the subject. One of these is what is called ovariotomy by enucleation, which was first proposed and practised by Prof. J. F. Miner, cieli?o e n. Smetb0d0f enU " of Buffalo, N. Y.,* and which has been variously modified for the purpose of adapting it to a wider range of cases. As originally performed this plan consisted in fact, in the separation of the pedicle from its attachment to the tumor in the same way that the adhesions are usually detached, id est by a finger-dissection. Following this mode of separation there was no need of torsion, neither of the ligatures, nor yet of the clamp, for the torn vessels soon ceased to bleed, as in the separation of other adhesions. Dr. Miner says : — "Externally the ovarian tumor has a dense firm covering, and the vessels which sustain the growth enter it, if at all, only of capillary size. The attachment of the pedicle to the cyst is much more easily broken than any one would suspect who has not attempted its separation in the manner described. The same efforts which are made to separate the adhesions elsewhere if extended to the pedicle, will be found equally successful. The finger should be introduced under the central portions of the pedicle, fully clown upon the cyst, and by a gentle elevation followed out along the fasciculi of vessels as they extend over the walls of the tumor; nothing can be more easy of execution, or more readily accomplished." The cases to which this method of enucleation is especially appli- cable are those tumors which have broad and short pedicles that would be difficult of management either by the ligature or the clamp; those ovarian tumors which have no pedicle whatever; *The American Journal of the Medical Sciences for Oct. 1872, p. 391. 1003 1004 THE DISEASES OF WOMEN. and those cases in which the anterior wall of the cyst is covered by a sub-peritoneal vascular membrane, which makes it imprac- ticable to finish the operation in the usual way, bie a for. tbatareSUita " but in wllich [t is expedient to cut through this membrane very carefully, and afterwards to enucleate the tumor. It is also safer and more successful in sin- gle than in compound cysts. Some years ago I first practised a method of enucleation, which adds a new resource to the management of cases in which the adhesions are so general and so formidable as eau U ciea^>n meth0d ° f otherwise'to force one to relinquish the removal of the tumor. This plan, which [ had never heard of betore, consisted in the separation ot the coats of the cyst wall, in removing its lining membrane entire, and in leaving the matrix without disturbing any of the peri-cystic adhesions or visceral attachments. The records of this remarkable case were carefully preserved, and read as follows : Case. — Mrs. H., of this city, aged 22, is the mother of one child, which is two years and eight months old. Five years ago, at the age of seventeen, she began to have a pain in the region of the left hip, and the left side, sometimes extending- down the left leg. For some time the side had been weak and the pain not very severe, when she slipped and feel so as to strain the side severely. After this accident she suffered occasional paroxysms and attacks of acute pain, one of which lasted a whole week. She first observed an enlargement in the left iliac and ovarian region four months after her marriage. This was accompanied by a general bloating of the abdomen, which would subside and at times almost disappear. Then she became pregnant, and towards " term" her size was " enormous." She had a natural labor, and got up well, weaning the child wnen it was thirteen months old. In a month after the birth of the child, however, she had a severe attack of peritonitis. Then the tumor grew and filled rapidly. For some months she had local electrical treatments which caused the growth to diminish somewhat in size. During two weeks of this time she took a "treatment" of this kind every day on the doctor's theory that the enlargement was due to dyspepsia, which he told her arose from drinking coffee! In all she has had fourteen physicians, each of which has given a different diagnosis. One said she had dropsy and an ovarian tumor. Another decided that the ascites was so pronounced as to prevent a recognition of the ovarian tumor, if there was one. OVARIOTOMY BY ENUCLEATION. 1005 A third treated her for about three months for a " fattening of the apron" (omentum?) which " fattening," it was said, " pre- vented the escape of the wind and so caused the abdomen to become enlarged!" During the past two years she has had repeated attacks of what, from her description of the symptoms, appears to have been sub-acute peritonitis. These were generally induced by active exercise while on the feet, as for example by ironing, or by standing for a long time while cutting out garments Not unfrequently these fits of illness would either accompany or fol- low the menstrual period. The menses had been and continue quite regular. In former years the flow was very free, but of late it is becoming more scanty. The general health is good, the appetite fair, but at times she cannot lie down and sleep, owing to the dyspnoea caused by the mechanical pressure of the tumor against the diaphragm. The measurements (Aug. 2, 1873), were as follows: The cir- cumference of the body over the umbilicus was 37 inches ; from the ensiform cartilage to the pubes, UJ inches; from the ensiform cartilage to the umbilicus, 8 inches ; from the umbilicus to the pubes, 6 J inches; from the anterior superior spinous pro- cess of one ilium to the other, 14J inches; from the right ante- rior superior spinous process obliquely to the point of left float- ing rib, 19 J inches ; and from the left ditto to the point of the last floating rib on the right side, 16 J inches; depth of the uterus, 2f inches. The operation was made at the patient's residence, at 12:30 p. m., on Tuesday, October 14th, 1873, ten days after the cessa- tion of the last menstrual period. There were present Drs. W. Danforth, C. N. Dorion, and R. K. Paine, of the Hahnemann Hospital, and Messrs. C. D. Stanhope, H. W. Roberts and G. R. Parsons, of the college class. Dr. Paine administered the ether, and my colleague, Dr. Dorion, was my chief assistant. Although none of us had ever witnessed the removal of an ovarian tumor by any form of enucleation, I had previously determined upon this mode of procedure, more especially because it was evident that the cyst was bound on all sides by adhesions, resulting from the frequent and severe attacks of peritonitis to wdiich my patient had been subject. I made the incision, as usual, along the linea alba. At first it was only four inches in length, but it was afterwards enlarged to five inches. There was but little haemorrhage. Anteriorly the adhesions were so intimate and firm that it was only by the escape 1006 THE DISEASES OF WOMEN, of the abdominal fluid at the lower end of the incision, and the application of Atlee's test that we were certain that the peri- toneal cavity had been opened. The sound was passed beneath the umbilicus, but would not glide over the anterior surface of the tumor at all. A slight separation of the adhesions was at- tempted on each side of the incision, sufficient to prove that they were very compact and very vascular. This fact was so obvious that all the physicians present expressed themselves as satisfied that the operation must be abandoned, or the patient's life would be put in great peril by completing it after the old method. And this state of things caused me to renew my resolution to test the expedient of enucleation. At a glance it was evident, however, that the mode of perform- ing this operation as first recommended and practised by Prof. Miner, was impracticable. The tumor could not be turned out upon the abdomen, and the adhesions were in the way of getting at the pedicle. Therefore, in order to separate the cyst, we could not begin " under the central portion of the pedicle," but had to content ourselves with first detaching it at a point opposite the abdominal incision. Now this, as you may suppose, was a very delicate matter. The peritoneal layer being very thin, and the cyst- wall likewise, the o'reatest care had to be exercised in be^innino- and in corn- to O C 1 pleting their dissection and detachment. A very slight incision was first made, and then the handle of the scalpel was used to carry on the separation until it was sufficiently extended to allow of the fingers being employed in the same way. It was only with extreme care and patience that this part of the operation was performed, for the cyst required to be separated in this manner throughout its whole circumference. Indeed it took Dr. Dorion and myself nearly three- fourths of an hour to accomplish this object. And during all this time we exercised the precaution not to lift or to disturb the matrix of the tumor, lest we might rupture some delicate adhesions on its posterior surface, and thereby cause a concealed internal haemorrhage. The diagram on the black-board will give you a pretty correct idea of the pathological anatomy of the tumor, and also ot the relative position of the tissues which were separated during the operation. OVARIOTOMY BY ENUCLEATION. 1007 Having finally removed the cyst, we were prepared to appre- ciate Dr. Miner's remark: " No surgeon in the world was ever more surprised at what he had done than myself, when I found that I had removed a large ovarian tumor without ligating a single vessel, and without any haemorrhage worthy of notice." Here we had taken out this large sac without having applied a ligature, or resorted to torsion, or anything of the kind; and what was equally remarkable, without having seen the intestines, the uterus, the opposite ovary, or even the pedicle! It really seemed as if some important step in the operation had been omitted. But it only remained to clean the hull of the bloody serum which had oozed from the capillaries. After waiting a quarter of an hour, in order to be certain that ksemorrage would not set in, the abdominal incision was closed with silver sutures in the usual way. The cut was dressed with a compress moistened with a mixture consisting of the tincture of calendula, glycerine and warm water, in equal parts. The whole was secured with adhe- sive straps and a binder, and the patient put to bed again. The entire operation lasted two hours. The cyst and its contents were estimated to weigh thirty pounds. She rallied well, and the anaesthesia passed without any ill effects. She vomited but once. Aconite 2 and atropine 3 were given at intervals of an hour. At 7 p. m. she slept quietly, but at bed-time was harassed with a nervous cough, which was re- lieved by ignatia 3 and by taking half-teaspoonful doses of pure glycerine occasionally. The aconite was continued until the fourth day, when the menses appeared. At 3 p. M. she had quite a severe chill, with dyspnoea, which continued for half an hour. Re-action was induced by friction, the application of dry heat, and by the internal use of stimulants. The usual precautions were taken each day thereaf- ter to prevent the recurrence of the chill, and with success, but the dyspnoea came at 4 p. m. every day for a week. On the fifth day she took meicurius sol. 3 and bryonia alb. 3 every two hours alternately for the white pasty tongue and the cough. In the afternoon two of the deep sutures were removed, and she was turned upon her side for the first time. On the sixth day, from 7 to 10 p. m. she was very restless, and was troubled with a nervous cough, for which she took spongia 1008 THC DISEASES OF WOMEN. instead of bryonia, with arsenic nn: alb. 3. She had also a fre4. warm perspiration for the first time at 8 p. x. At 3 a. m. of the seventh day she had a sHght epistaxis, which continued for ten minutes. The blood lost was of a very dark color. At 4 p. m. she had a violent desire to urinate, but, although the quality of the urine was unchanged, the quantity was very small. The evident exacerbation of the symptoms at early even- ing, and the continued high range of the temperature, led us tn prescribe quinine, which was given for several days, at the rate of three grains per diem. The remaining sutures were removed. On the ninth day, at 5:25, a. m., she had a return of the nose-- bleed as before. The bowels were moved by an enema, and her clothing was changed. There was also slight abdominal tympan- itis, for which belladonna and arsenicum were prescribed. In the afternoon, while she was lying for a short time upon her leftside, a copious discharge of a thin, brown, serous fluid took place from the openings left by the sutures. The tenth day was characterized by greatly increased difficulty ot breathing after 3 p. m., the number of respirations being thirty- six to the minute; and by the temperature reaching 105° in the vagina at 9 p. m. In order to be certain that there had been no mistake in the latter regard, the thermometer was passed into the urethra, and the result was the same. The next day the breathing indicated thirty-two respirations to the minute, and the pulse and temperature had also fallen. When the wound was dressed on the twelfth day, there had been a free discharge of a thick, brownish, inoffensive and gelati- nous fluid from the lower extremity of the incision, and a healthy yellow pus from the openings of the sutures. On the fourteenth day, the purulent discharge being still copi- ous, silicea 3 was given. The menstrual flow ceased at this date,, and the urine was passed for the first time voluntarily. The day after, the bowels moved. From this date the patient gradually improved. She slept and ate very well, was in good spirits, and sat up the first time for about fifteen minutes on the twenty-third day. The pulse and the range of temperature were taken and carefully recorded each morning and evening for three weeks subsequent to the opera- tion. The free formation and discharge of pus in this case suggests the propriety of securing its drainage from the lower extremity of the incision in all cases of enucleation espec- ^Necessity for drain- ^^ rpj^ mfty be doRQ 1)y keepino; the l ower part of the wound from uniting, either by the introduction of a sponge tent, or ot a silk thread, a silver wire, or OVARIOTOMY BY PARTIAL ENUCLEATION. 1009 even of a gum elastic drain-tube, or of a catheter. The objection to the drain-tube, however, would be that, by lying in direct con- tact Avith the interior of the shrunken sac, its presence would be likely to increase and to prolong the suppurative process. TABLE OF THE TEMPERATURE AND THE PULSE. DAY. FIRST. SECOND. THIRD. FOURTH. FIFTH. A. M. 1 P. M. A. M. | P. M. A. M. | P. M. A. M. | P. M. A. M. | P. M. Pulse Temp' r'tui*e . . . . I 120 . . . . 1 103 120 1 120 102 | 103 11)0 j 106 101 3-5 i 102 104 1 108 101 1 103 108 1 108 101 3-5 1 101 3-5 DAY. MXTH. SEVENTH. EIGHTH. NINTH. TENTH. A. M. | P. M. A.M. I P. M. A. M. 1 P. M. A. M. | P. M. A. M. | P. M. Pulse Temp'r 'ture 106 1 112 102 1-5 1 104 104 101 4-5 112 104 1-5 Iu6 1 110 10:2-5 | 103 2-5 106 1 100 1013-5 i 1031-5 108 i 10t> 103 1 104 1-5 DAY. ELE ENTH. TWELFTH. THIRTEENTH. FOURTEENTH. FIFTEENTH. A. M. i P. M. A. M. | P. M. A. M. | P. M. A. M. | P. M. A.M. | P.M. Pulse Temp'r' ture 100 1 104 101 4-5 I 103 3-5 98 1 100 101 3-5 | 103 2-5 98 1 90 101 4-5 1 100 96 1 98 101 1 102 94 1 100 99 4-5 1 103 3-5 DAY. SIXTEENTH. SEVENTEENTH EIGHTEENTH. NINETEENTH. TWENTIETH. A.M. | P. M. A.M. 1 P.M. A. M. | P. M. A. M. P. M. A. M. | P. M. Pulse Temp'r' ture 92 I 100 100 1 103 2-5 92 101 100 103 88 100 1-5 84 100 1-5 86 99 3-5 90 101 2-5 .. .. | 90 »9 1-5 | 102 111 reviewing this case, I am satisfied that this modification of Dr. Miner's operation is an invaluable one. Especially is this true where the nature and the extent of the parietal and visceral adhesions render it unsafe and impracticable to remove an ovar- ian cyst by the more ordinary method. I do not suppose that this plan is suited to all cases of unilocular cysts indiscriminately; but, in this particular instance, it is evident that my patient owes her life to it and to the careful after-treatment and nursing which she received. Seven years have now passed (Dec. 1880), and this patient has had no return of her old trouble, nor any abdominal or pelvic sequels of any kind. OVARIOTOMY BY PARTIAL ENUCLEATION. There is another mode of extirpating an ovarian tumor, which consists in its partial enucleation, by splitting the cyst- wall so as to avoid a rupture of its external adhesions. You can readily understand that this method, unlike the one just described, is applicable to compound as well as 10 single cysts. What are called parietal adhesions, or those which fasten the tumor to the abdominal walls, can be stripped off carefully by a finger-dissection ; or, if they are stringy, firm and vascular, can be ligated and cut, as already directed. But the visceral attachments 1010 THE DISEASES OF WOMEN. of the tumor to the intestines, the liver, the uterus and the blad- der, and the pelvic adhesions that sometimes anchor it in the Douglas pouch, and to the rectum, must be disposed of by some other method. The latter represent the class of cases in which, only a few years ago, the operation of ovariotomy was relinquished as soon as they were found to exist, and the incision was closed without any further attempt at the removal of the tumor. But now, instead of turning these grave cases away to die, Ave make a delicate dissection of the coats of the sac, go within its vascular shell without rupturing its vessels, take away its lining or secret- ing membrane and g'ive them a chance to recover. I certainly have saved the lives of five women in this way. The difference between this mode ot enucleating the cyst and that of which I spoke at the beginning of my lecture, is that in this case only so much of the sac as is adherent is separated by the splitting process. Beyond the margin of the visceral adhesions the cyst wall is cut through and removed in the usual way. By this means we leave the patch ol adhesion, no matter how large or small it may be, just as it was before the operation, excepting that we have denuded it of its lining membrane. This method of operating is not new, but has been performed in various ways, and sometimes unwittingly, during the last few years. It certainly has great advantages over the expedient of cutting away the sac, leaving so much of it as was held by the visceral adhesions to be drawn forward and stitched into the lower angle of the wound without stripping the patch of its secreting membrane. The record of one of my most serious cases, one in which I successfully removed a tumor weighing eighty pounds, will prove its value when other modes are not available. Case — Mrs. A., aged forty-five years, ceased to menstruate two years ago. Formerly a citizen of Illinois, she moved to Montana in the spring of 1871, where she has lived up to the present time. Ten years ago she first noticed a swelling in the right inguinal region. Its growth was much more rapid the three years preced- ing than the three following her arrival at the west. Her health was very much improved by the journey to Montana, but the swelling did not disappear. During the past tour years the growth ol the tumor has been much more rapid. For some time before and after her removal the menses returned every two weeks. They were not excessive, but were slightly OVARIOTOMY BY PARTIAL ENUCLEATION. 101 i painful. She has a son sixteen years old, but the tumor is in no way connected with his birth. She has never had a miscarriage, nor as far as she can remember, a fall or a strain. Five months ago she was desperately ill, and almost died from protracted vomiting, which continued for five weeks, but with no diminution in the size of the tumor. When this disorder had ceased, a dropsy of the lower extremities commenced, and the calf of the leg finally measured sixteen inches in circumference. This effusion extended upwards along the thighs, sides, abdomen and back, and was present when she left home for Chicago, Dec. 27th, 1877. Previous to her departure from home, she had not been out of the house five minutes at one time in four months. The first four hundred miles of the journey were traveled in a farmer's wagon, over the principal range of the Rod^y Mountains. The remain- ing fourteen hundred were traveled on the railroad. The whole journey of eighteen hundred miles occupied two weeks. The patient bore the trip remarkably well, and even improved on the way. My first physical examination of the case was made on elan. 17th 1878, at the residence of her sister in Elgin, forty miles from Chicago, and the following conditions were found to be present: The uterus was normal in size, with left lateral version, the cer- vix was retracted, the os high up on a line with the symphysis pubis. There was no pouching or fluctuation in either cul-de-sac. 1 found a flatness on percussion all over the abdomen in front, the tumor lying chiefly to the right of the median line. The outline of the cyst was distinctly made out, on the right side especially. On the left there was dullness far back into the lumbar region. The wave-line and impulse were both very distinct. There was no history of peritonitis in the case, whether puerperal or other- wise. The sample of the fluid drawn by aspiration, was of a dark claret color, and quite thick. The operation was set for Thursday, Jan. 31st, 1878, but on account of a severe snow storm was deferred until Feb. 2d, 1878, when it was made at Elgin, 111., in the presence and with the assistance of Drs. A. L. Clark, H. K. Whitford, C. A. Jeager, D. E. Burlingame, C. E. Stone, and Messrs. J. W. Hutchinson and W. A. Barker, medical students. The operation was begun at two o'clock p. m., and lasted two and one-hall hours. On account of venous haemorrhage the abdomi- nal incision was made slowly and very carefully. The adhesions between the abdominal and cyst-walls, anteriorly, were so intimate that it was impossible to separate them, and the cyst was unavoid- ably punctured. After the sac w r as evacuated, and it was proved that an attempt to detach it in front would, of necessity sacrifice the life of the patient, (on account of the extent and vascularity 1012 THE DISEASES OF WOMEN. of the parietal adhesions.) the sac was laid open for the space of two inches, and it was determined to resort to enucleation. When more than one-third of the lining membrane of the sac had been carefully split or separated, (consuming more than an hour,) the outer wall was torn through and the remainder of the sac, which was not adherent, except to a strip of the omentum and also to the rectum, was brought forward and exposed to view, as in ordinary cases. The pedicle, which was six inches broad and very vascular, was tied in three places, with carbolized cat-gut ligatures, but on account of venous exudation, and the fear of haemorrhage after- wards, it was brought forward and secured by a Thomas' clamp. The wound was closed with silver wire sutures, and the incision covered with a compress wet in a mixture of calendula, glycerine and warm water. Adhesive straps were applied across the abdo- men to prevent any possible strain from vomiting. She was put to bed carefully, and reacted slowly but surely. The fluid contained in the cyst weighed seventy-four pounds and the sac itself six, making a total of eighty pounds. The fluid was of a very dark chocolate color, slightly acrid, and apparently on the verge of decomposition, having changed very materially since the previous examination. There was no vomiting until the twenty-third day. For the first twenty-four hours, the remedies were aconite and arnica in the second dilution. These were fol- lowed by verat. vir. 2 at longer intervals, until there were signs of suppuration, and the temperature fell to 9 7 J°, which was on the morning of the seventh day. On the evening of the sixth day, the bowels moved spontaneously, and for some hours she had a copious and very offensive diarrhoea, for which she took ars. alb. 3. For the debility that followed, and which continued for a few days only, grain closes of ( he sulphate of quinine were given. A slight irritability of the bladder at the twelfth day, was relieved by drinking gum-arabic- waier. There was a free, but not a copi- ous discharge of pus from the wound after the seventh day, at which time a few drops of carbolic acid were added to the solution of calendula and glycerine with which the wound has been dressed from the first. The clamp did not fall until the twenty-seventh day, when the incision was found to have closed perfectly. The urine was drawn every three hours, until the close of the seventh day, when it was passed naturally. The record of t*he temperature and the pulse was taken every morning and evening for four weeks. The patient was not free from symptoms of peritonitis until the close of the eleventh day. She had a good diet, and the window in the next room was kept open most of the time, although the air was frosty. For four days after the operation, however, the . temperature of the chamber was not below 70°. VAGINAL OVARIOTOMY. 1013 This patient made a perfect recovery, and in due time returned to Montana in better health than she had enjoyed for many years. I have never before observed so intimate and so extensive a union between the abdominal wall and the cyst-wall, as in this case. Their surfaces were, indeed, so closely adherent as to defy separation, at least without the greatest danger to the patient. And I am satisfied that but for the expedient already described we should have been forced to relinquish the operation for the removal of this enormous tumor. The fact is, that when the parietal adhesions rendered its separ- ation impracticable, the only way out of the difficulty was to splil the coats ot the sac, and to take advantage of the feeble vas. cularity of the cyst-wall within its external tunic. This was i delicate and tedious process, and the stripping of the first from the second layer, (which the clever old nurse compared to the "skim ning of a squirrel"), had to be done very carefully. When we haa finally reached the limit of the adhesions on the anterior surface of the tumor, covering about one-third of the sac, a farther dis- section was unnecessary. The outer layer was now broken through all around, and the operation finished in the usual way. To avoid a recurrent haemorrhage the fasciculus of omentum was ligated twice and cut between, as in tying the fuuis after delivery. It is evident that the absence of a pre-existing history of peritonitis is not always to be depended upon as a sign that an ovarian cyst is non-adherent. This is especially true in case the tumor is very large, where the pressure is very great and the motion is pre- vented. VAGINAL OVARIOTOMY. The removal of an ovarian cyst by way of the vagina, or vagi- nal ovariotomy, was first practised by Dr. T. G. Thomas, of New York, in February, 1870.* Prior to that time these cysts had occa- sionally been tapped and drained through the floor of the Doug- las pouch, but the frequent occurrence of septic infection and pur- iform degeneration of the contained fluid with fatal results had caused the practise to be abandoned. The class of cases to which this mode of operating is especially adapted is not a large one, and for many reasons it is not likely to become very popular with the profession. It includes those cysts *The American Journal of the Medical Sciences, April, 1870. 1014 THE DISEASES OF WOMEN. which are neither very old nor very large, which are retro-uterine and pelvic in their location, and are therefore ada a ted to wMch ** is accessible through the posterior cul-de-sac. Cysts from the size of an orange to that of the head of a child which is a year old, that lie in the Douglas pouch, and which are moveable, are best suited to this mode of extirpa- tion; but it also has been successfully applied to dermoid cysts that were small and very adherent. Goodell removed a compound cyst in this way, and although his patient was desperately ill, she finally recovered. Dr. Thomas speaks of the kind of cases to which this operation is suited, as follows: "It is not my belief that the scope of this plan of performing ovariotomy will ever be very great; but I think that in cysts of small size, which are unattached, it will offer a valuable resource for the avoidance of years of mental suffering while the disease is progressing, and of the capital operation of abdominal ovariotomy in the end, with all its attendant dangers and uncertainties. Even in a doubtful case, vaginal ovariotomy may be resorted to as a ten- tative measure, which, in the event of failure from attachment of the cyst, would in all probability be recovered from. * * * * * I feel sure that it has before it a future of usefulDess for the fol- lowing reasons: It is fully as easy of performance as abdominal ovariotomy; is evidently attended by much less danger; holds out to the patient the opportunity of avoiding many weary months o£ suspense in anticipation of that more grave procedure; is equally applicable to muitnocuiar and to unilocular cysts; and gives abundant facility for securing the pedicle." The best mode of performing this operation is to place the patient in the dorsal decubitus, just as if you were going to make a perineorrhaphy. Then, the vagina having been Mode of operating, thoroughly cleansed antiseptically, the perineum and the posterior wall of that passage are re- tracted with a Sims' speculum. The uterine cervix is drawn down and afterwards held out of the way, so as to put the fornix on the stretch. Now you are to make a button-hole opening through the roof of the cul-de-sac in the direction of a line running from the rectum towards the neck of the womb. On pulling down the for- nix with a tenaculum, this can be done with a Kuchenmeister's scissors, or with a Pacquelin's thermo-cautery. In either case, if the tumor lies behind the uterus there will be little risk of injur- ing a stray coil of intestine; but you should be careful not to rup- VAGINAL OVARIOTOMY. 1015 ture the cyst, or cysts, before you are ready to empty them with the aspirator, or with the simple trocar. The adhesions, if there are any, can then be carefully separated and ligated if necessary, with fine silk and catgut. Finally the pedicle may be pierced with a Skene's needle, a double ligature tied tightly about it, and the tumor afterwards cut away. The lig- atures should be cut off short before the pedicle is returned to the pelvic cavity, and if the intestine hes slipped through the opening it should be carefully replaced. By most operators it has been thought necessary to stitch up the incision thus made in the vaginal roof; but it is better to leave it open for drainage, and afterwards to secure immunity from the admission of air into the abdominal cavity by packing the vagina with two or more soft and clean iodoform sponges. This latter item is a part of the practical lesson that we have learned from the recent improvement in vaginal hysterectomy. Indeed, the expedient of ligating the pedicle a new hint. might also be dispensed with by applying a Pean's long forceps and leaving them in position for twenty-four hours or more. Meanwhile the drainage would be perfect and haemorrhage would be impossible. This simple expedient might also be extended to the removal of various other tumors per vaginam. The after-treatment is very simple, but should not be neglected. The same precautions should be taken against vomiting, flatulency, tympanites, and obstruction of the bowels as were The after-treatment advised in the last lecture after an abdominal ovariotomy. The sponges should be allowed to remain until the forceps are removed (in case they have been used), or until there is evidence of a free discharge of bloody serum, which will usually be on the second day. The vagina should then be cleansed by an injection of clear water at a tem- perature of 102°, after which fresh and clean iodoform sponges should again be applied. The necessity for repeating this dress- ing will vary in different cases; but it can not safely be dispensed with until the peritoneal discharge has entirely ceased. LECTUEE LXII DISEASES OF THE UTERINE APPENDAGES. The class of women who are subject to; from imperfect development; from obstructive dysmenorrhea; do. puerperal affections; do. gonorrhceal infection; do. membranous dys- menorrhoea; tubal and ovarian tuberculosis; in scrofulous subjects: forms of ovarian degeneration; varieties of salpingitis; often confounded with kindred affections; the diag- nosis of; Fallopian colic; case; the subjective symptoms; the objective do.; the physical signs; confusing elements of diagnosis; Battey's and Tait's operations for. Under this head we shall speak of those diseases of the ovaries and of the Fallopian tubes which from necessity can not always have a separate clinical history. They include cystic and atro- phic degeneration and sclerosis of the ovaries, and salpingitis, or inflammation of the oviducts. These organs lie in such close proximity and are so intimately concerned in the function of menstruation that their lesions are largely responsible for its most obstinate dis- classes of women who or( } ers . The classes of women who suffer most are most subject to. , therefrom include those who are young and unmarried; such as have suffered from the diseases of child-bed; and married women who have remained sterile. It is only too common to find a class of subjects in young girls at puberty, who, having reached the age at which the monthly flow should be established, are so immature o P ment. imperfect devel " ancl so imperfectly developed that nature can not assert herself. She struggles to effect the discharge and to furnish the physiological sign of womanhood, but either the function goes by default, or it is not properly per- formed, and an untold amount of suffering is the consequence. The different phases of anaemia and chlorosis, dyspepsia, and the neurotic disorders, such as hysteria and hystero-epilepsy, are, in these later days, clearly traceable in many cases to tubal or ovarian disease which has its root in the unsanitary habits and surroundings of the school-girl. I am persuaded, however, that in the case of girls and unmar- ried women salpingitis is more often the consequence than the first cause of painful menstruation. For it may From acute dysmen- ^ e due to obstructions to the flow that have orrhcea. originated in the uterine cervix. An acute flexion of the womb, or a spasmodic constriction of its neck, from 1016 DISEASES OF THE UTERINE APPENDAGES. 1017 some local or reflex cause, may involve its lining membrane as well as that of the tube in such tissue changes as will not pass away with the close of the monthly period. And, through the want of a ready egress, the arrest or the reflux of blood in the tube may easily excite the peristaltic contraction of its muscular walls and cause it to become very much distended and painful. And thus, beginning with a partial occlusion of the os-uteri, a secondary affection, which increases the suffering and complicates the case, is finally developed. In former times I certainly have cured some of these cases of post-dysmenorrhoeal salpingitis unwittingly by first addressing my remedies to the relief of the painful menstruation, or to a coincident pelvi-peritonitis, or by repositing the uterus before the flow and keeping it in position afterwards. The puerperal affections upon which the diseases of the uterine appendages are most often secondary are endometritis and peri- tonitis. When the lying-in woman is ill with From puerperal affec- ^ e f ormer affection the inflammation is very prone to extend by . continuity or texture until it reaches the ovary. And the distillation of the vitiated fluids which are sometimes carried from the uterus in septic and catarrhal endometritis following labor or abortion may be the cause of a long-lasting mischief in the tubes themselves. A large share of cases of chronic salpingitis and ovaritis with localized peritonitis of a relapsing character, as well as pelvic abscess, are due to this cause. When this condition is consecutive upon puer- peral peritonitis, the trouble begins at the outer extremity of the tube and travels from the ovary through this part of the genera- tive intestine toward the uterine cavity. Without accepting the life-long theory of Noeggerath, which holds that those women who have once been the victims of a gonorrhceal infection will never fully recover hreaHr^eSiL^ gonorr " from it, we may and must concede that when the disease has invaded the organs of which I am speaking, the woman will become either transiently or per- manently sterile. Like epididymitis in the male, this specific form of salpingitis is a secondary affection which may or may not involve the ovary; and therefore this tubal Menorrhagia is a frequent cause of amenorrhcea as well as of barrenness. The wives of such husbands as have been unchaste in their youth, and of men of immoral habits who are much of their time away from home, are very likely to suffer the evil consequences of an infection of which they are the unconscious victims. Even when these unfortunate women are neither sterile nor given to 1018 THE DISEASES OF WOMEN. abortion, they suffer from the various forms of peri- uterine inflammation that are symptomatic of salpingitis and oophoritis. In membraneous clysmenorrhoea the early obstruction to the flow, and the prolonged effort to discharge the contents of the uterus sometimes results in hyperemia, and a*mmorfhi nn o a wrong mierence respecting the efficacy oi this or any other plan of treatment. It is not unusual for these growths to increase or to decrease in size very rapidly, and sometimes to disappear spontaneously. A retrograde metamor- phosis may take them out of the way. The climacteric may arrest their development ; and other changes may cut off their nutrition and cause them to wither. These cures by limitation are often placed to the credit of such agencies as animal magnet- ism, spiritualism, electricity, and other imponderables, and even of medical treatment. But, making due allowance for all these exceptional cases, I apprehend, it remains that very great good of a positive kind may be done by means of fitly-chosen internal remedies. Together with these remedies, as already indicated, I am in the habit of employing the cotton tampon saturated with pure glyc- erine, or with glycerine containing a few Local means. drops ot the strong tincture ot calendula, of hamamelis, hydrastis, or of the same medicine that is being taken internally. This is an excellent adjuvant to the cure, and has the effect in many cases to avert the recurrence of frequent and dan- gerous haemorrhages. The surgical treatment contemplates the removal of the tumor either by excision or enucleation. Excision by the ligature or the ecraseur, not being available in non-peduncu- Surgical treatment. _ . lated growths, as a rule, and these fibroids being interstitial, the main dependence is upon some form of enucleation. This operation consists in making one or more free incisions into the tumor and through its cap- Enucleation. p . sule, irom the interior suriace ot the uterus. The fibroid is then turned out of its bed and, if possible, detached and removed at once. In many cases it is only partially separ- ated, and then allowed to slough away, care being taken mean- while to avoid pysemia and similar contingencies by frequent injections of carbolized or calendulated water, and appropriate internal medication. Although the risks of this expedient are sometimes very great, FIBROID TUMORS OF THE UTERUS. 1063 still it is growing in favor. It is sometimes resoited to for the removal ot the sub-mucous fibroids also, particularly in case of such of them as are attached to the uterus by a broad base. Dr. Atlee's operation is a modification of this. And so also is Dr. I. Baker Brown's plan of coring or "gouging' out a piece from the middle ot the tumor and filling the Drs. Atlee's and •, ^-^ h % th ^ fa d b dipped lll'olive Browns operations. ■> l l oil. The idea in both of these operations is to impair its nutrition, and to facilitate the sloughing and separation of the adventitious growth. In some of these cases there is such an exceptional intolerance of artificial dilatation of the cervix uteri, both on account of the haemorrhage that may follow, and of directly Danger in dilatation. . , . |~ , * fatal results, that the greatest possible care is requisite in the preparation of the patient for the removal of the tumor. Dr. Thomas reports two cases of sudden death from the use of the sponge-tent preparatory to enucleation, and sums up the dangers of this whole operation in the following forcible language: "If the cervical canal be well dilated, and the uterus susceptible of depression to the ostium vaginae, or the vagina be so dilatable as to admit the hand, the case should be regarded as favorable to the procedure. If the opposite state of affairs exists, the case is not only an unfavorable one, but the procedure will in all proba- bility fail. The prospect of success is, for these reasons, much better in multiparous than in uulliparous women."* TRILLIN IN MENORRHAGIA FROM UTERINE FIBROIDS. Case. — Mrs. , aged thirty-three years, a nullipara, has had menorrhagia sometimes to a very alarming extent, for eight years past. After having lifted and nursed a very sick sister she first observed a tumor in the lower part of the abdomen eight years ao'o. This tumor grew slowly, was not sensitive, was larger at B B - «/ ' - the month than directly after the flow, and finally caused symp- toms of prolapse of the womb when she was on her feet. When she first came to the Clinic she was very weak from the loss of blood, from an impaired digestion, improper nutrition, and from a depressed mental condition. At one time in the early history of the case, and without any apparent cause the menses were sup- pressed for nearly a year. She took the third decimal trituration * The American Journal of Obstetrics and the Diseases of Women and Children. 1872. Vol. V,page 10S. 1004 THE DISEASES OF WOMEN. of trillin with the effect to dispose of the monorrhagia, to remove all of the symptoms that were dependent upon it, and to check the growth of the tumor. Two years have now passed since she began the use of this remedy, and thus far there has been no occa- sion to resort to any other for the relief of the haemorrhage. Meanwhile, however, the growth of the neoplasm has extended to the neck of the womb, and so involved its posterior portion as to preclude the possibility of extirpating the growth without also removing the entire cervix. This remedy seems to be especially adapted to the menorrhagia and metrorrhagia which are almost always present m cases of interstitial and intra-uterine fibroids. For like secale it is of little effect in uterine haemorrhage unless from pregnancy or otherwise the muscular fibers of the womb have been very decidedly devel- oped. Incidentally, in a bad case for which I recommended it to my old friend Dr. W. C. Barker, of Waukegan, it not only con- trolled the alarming haemorrhage but it also relieved a severe neuralgia, and put an end to a tedious and harrassing couo-h that had worried and weakened the patient almost as much as the loss of blood. UTERINE POLYPI. Case. — Mrs. X., 39 years old, came to the Clinic a fortnight ago for the relief of pelvic pain and distress which she attributed to menstrual retention of three months standing* She had always been regular before, and felt confident that she could not be preg- nant now. She aiso complained ot a full pressing headache which was worse at the monthly cycle, although the flow did not appear. She had taken various remedies to force the flow but without the least e fleet. An examination of the os uteri in the field of the speculum showed that it was plugged with a polypus, which was examined by the class, and then carefully twisted off in their presence by the use of a Sims' polypus forceps. The next week she reported that the monthly flow followed directly after the removal of the growth; that it was normal in quantity, quality, and duration; and that with its advent all of her pelvic distress and headache had disappeared. This was a small mucous polypus that was attached, as most of them are, within the canal of the cervix, about Mucous polypi. . . the internal os uteri. Irom being very vascu- lar, these mucous growths are sometimes styled sanguineous; UTERINE POLYPI. 10G5 and, when they do not obstruct the cervix, are likely to be the source of severe haemorrhage. This indeed is a frequent cause of intractable menorrhagia. In rare cases these mucous polypi may be formed within the uterine cavity, as well as in the canal of the -cervix, where they sometimes exist in considerable numbers. (Fig. 208). Fig. 203. Multiple mucous polypi. (Beigel). It is well to remember that, whether single or multiple, these polypi may not only give rise to copious haemorrhage at the month, but that they may and do sometimes cause the most in- tractable form of uterine leucorrhoea. So that, as in the case which you have just seen, a polypus may cause Common characters- i ., ,„„ ^^.i,,^ tics or uterine poiypi. a menstrual suppression, or it may pioduce either menorrhagia, metiorrhagia, or a leucor- rhoea. This is true of each and all the varieties of uterine polypi, whether they are mucous, cellular, glandular, or fibrous in their character. When these bodies are accessible to the touch, and can be brought into the field of the speculum, their diagnosis is not difficult. But when they lie above the internal os, before the cervix has been developed by their presence or pressure, we need to explore for them, and to dilate the neck of the womb so that we may find them. For this purpose we begin with a sponge-tent, or a Nott's dilator Diagnosis. UTERINE POLYPI. 1066 (Fig. 22), or Atlee's dilator (Fig. 24), and, it necessary, follow it up with the careful use of Hunter's uterine dilator (Fig. 62), until the finger, or the probe, or both can be readily used for Fig. 209. Crushing forceps for uterine polypi. the detection, location and measurement of the moroid growth. It is a fortunate circumstance that the careful use of these means of dilatation causes the uterus to descend, without really drag- ging" it down, and to be more readily accessible. Treatment. Fig. ~l(J. Forceps for uterine polypi. When the growth is reached the question of its removal may be decided upon. If it is not very large or fibrous, it may be twisted with a pair of Sims' polypus forceps, or even with Pean's artery forceps (Fig. 48). Other varieties of polypus forceps are here upon the table (Figs. 209,210, 211, 212). Fig. 211. Polypus forceps and compressors. These instruments act by cutting off the vitality of the growth, and facilitating its removal without pain or haemorrhage. But if the polypus is too firm in its texture to be taken in this way* UTERINE POLYPI. 1067 it may be drawn down with a volsellum, and snared with a wire through Grooch's old canula (Fig-. 212), or by means of a wire eeraseur, of which the curved ones are the best. (Fig. 213). Fig. 212. Gooeh's canula. Fig. 213. Wire eeraseur for uterine polypi. If the peduncle, or stem of the polypus is narrow and slender,, no matter if it is fibrous in its character, Aveling's polyptome is strong- enough for its excision (Fig. 214. ) An excellent modifi- FiG. 214. Aveling's polyptome. cation of this instrument by Dr. Hodge, of Philadelphia, has already been used in my clinic. (Fig. 28.) When uterine polypi are large and their texture is condensed, they may grow slowly, may be accompanied by menorrhagia, the development of the uterus as in pregnancy, and by the occur- 1068 THE DISEASES OF WOMEN. rence of uterine contractions that resemble labor, or a threatened miscarriage. In rare cases these growths develop P ob e pL rrent flbr ° US ra P icll y and £ ive rise t0 copious periodical dis- charges of a watery fluid, which sometimes causes them to be mistaken for cancer. Under these circumstances it hsafe to suspect that the tumor is of the recurrent, or sarcom- atous variety, and our prognosis should be carefully guarded. In this connection I must remind you of w T hat I have already said of the failure of the microscope in deciding upon the real nature of some of these suspicious growths. (See page 715). The signs that are to be derived from careful clinical observation in these cases are really worth more than the report of the best microscopist in the world. It is best to say that the exact nature of these neoplasms is not absolutely known ; that time is a neces- sary element in the prognosis ; that heredity has its influence ; and that, after their removal, it is best to wait and see whether they will come again before you decide whether they are malignant or not. INDEX. A CLINICAL study of the crises, etc., 34. Abortion, effects of non-lactation in, 60. a contingent of retroversion of the gravid uterus, 313. with misplaced pains. 326, from over-exertion, 327. may become a habit, 327. intermittent, 3^7. cause of, 330. as a cause of disease, 333. sequelae of, 334, 329. ill effects of wrong diagnosis in, 335. difficulty of recognizing the seque- lae of, 335. treatment of, 336, 363. aconite and arnica in, 337. belladonna in, 337. local treatment of, 338. recurrent, and sub-involution, 361. frequency of, 362. types of, 362, a peculiar cause of, 362. importance of rest in, 363. Abortive dyscrasia, a predisponent of membranous dysmenorrhcea, 231. Abortionist, sophistries of the, 331. Abdominal inspection, 66. cramps in pregnancy, 229. supporters in uterine displace- ments, 599. Abscess of iliac fossa, diagnosis of, from pelvi-peritonitis, 375. of the broad ligament, 403, of the mammary gland, 471. treatment of, 473. local applications in, 478. demands a good diet, 474. prophylactic treatment for, 477. support for breasts during, 479. proper diet, during, 479. labia majora and of vulvo- vaginal gland, 534. causes of, 335. symptoms of, 535. diagnosis of, 536. Aconite and arnica in abortion, 337. Aconite and arnica in ovaritis. 756 in pelvi-peritonitis, 380. in pelvic cellulitis, 411. Acidulated drinks in stomatitis ma- tern a, 347. Accidental causes of menstrual reten- tion, 129. Acute diseases, cause of suppressed menstruation, 119. Adjuvants in spasmodic dysmenor- rhcea, 111. Affections of cerebro-spinal nerves, 52. After-treatment in ovariotomy, 985. do. in Battey's operation, 1031. Albuminuria in pregnancy, 297. signs of, 298. mereurius cor. in, 298. Alcohol in pelvic cellulitis, 414. Alexander's operation, 648. do. rules for, 648. Amenorrhea, 113. symptoms in, 114. definition and varieties of, 113. etiology of, 113. with incipient phthisis, 116. forcing medicines in, injurious, 115. diagnosis of, 115. prognosis in, 116. treatment of, 116, 128, 130, 140. anticipative treatment in, 116. insidious complications in. 120. when chronic, essentially a glan- dular disease, 120. the cachexia of, 122. pectoral complications in, 124. calcarea carbonica in, 124. Pulsatilla in, 124. alternating with ophthalmia, 124, with prolapsus uteri and obsti- nate vomiting, 132. choreic spasms, 138, 142. supra-orbital neuralgia, 143. menstrual epilepsy, 169. spinal irritation and vomiting, 144. • vicarious haematemesis in, 145. failure of dilatation in, 147. incision of the cervix in, 147. in advanced phthisis, 149. 1069 1070 INDEX. Ammonium carb. in stomatitis ma- terna, 350. Anaemic disorders at the climacteric, 63. murmur in chlorosis, 99. Anaemia, and chlorosis, diagnosis of, 105. from conjoined lactation and men- struation, 495. Analysis of fifty cases, showing date of menopause, etc. 510. Anasarca following the climacteric, 525. Anatomical predisponents of uterine flexions, 622. Anatomy of the vulvar orifice, 892. of the perineum, 893. Ante-flexion of the uterus, 626. Ante- version do., 638. symptoms of, 638. diagnosis of, 639. physical signs of, 639. reduction of, 639. rest and remedies in, 640. Antigalactics, 477. Aphonia from laryngitis, 781. Apis mel. in pelvi-peritonitis, 381. in pelvic cellulitis, 413. Apocynum can. in uraemia, 309. Apthous ulceration of os and cervix- uteri, 653. symptoms of, 654. diagnosis of, 654. treatment of, 654. reprehensible practice in, 655. a constitutional disease, 656. remedies for the vesicular stage of, 656. local treatment foi, 657. astringents in, 657. Arnica in pelvic cellulitis, 411. Arrest of menstruation, when physi- ological, 113. Arsenicum alb. in stomatitis mater- na, 349. Ascites, area of dullness in, 94. Ascites, 933. the "touch" in, 933. tapping in, 933. care in time and place for tap ping in, 933. prognostic value of tapping in, 932. Atlee's operation in uterine fibroids, 1041. Aspirator in pelvic hsematocele, 431. Asthma and hysteria, 781. Assistants and instruments for ovar- iotomy, 971. Atropine in ovarian neuralgia, 754. Auscultation, use and range of, 96. Avoidable causes of suppressed men- struation, 118. BAKER'S hysterectomy, 723. Baker Brown's do., 1063. Bardenhauer's do. 706. Battey's operation, 1025. Battey-Tait operation, 1028. Battey's operation, normal ovariot- omy, 1025. in uterine fibroids, 1042. Barnes' method of reducing inversion, 646. Baryta carb. in stomatitis materna, 350. Belladonna in amenorrhea, 140. in pelvi-peritonitis, 380. in menstrual epilepsy, 174 in abortion, 337. in pelvic cellulitis, 411. in cystitis, 579. in ovaritis, 751. Bilious derangement during preg- nancy, self-limited, 296. remedies for, 296. colic during pregnancy, 293. local palliatives for, 296. prophylaxis of, 297. diet, mental and physical exer- cise in, 297. china in 297. at the climacteric, 521. Bladder, diseases of the, 560 et seq. in retro- flexion of the uterus, 623. Blenorrhagia a cause of pelvi-peri- tonitis, 372. Blood-changes in chlorosis, 102. during pregnancy, 50. Borax in membranous dysmenor- rhoea, 241. Breast, changes in, during pregnan- cy, 283. Bronchoceie, and delayed menstrua- tion, 39. Bryonia in pelvi-peritonitis, 381. in ovaritis, 753. Burnside, case of malignant hepatic tumor, 943. pACHEXIiE, influence of, 44. \J menstrual, 44. puerperal, 60. chlorotic, 107. in delayed menstruation, 114. which complicates pelvic celluli- tis', 402. cancerous, 699. Calcarea carb. in stomatitis materna, 350. in amenorrhoea, 124. INDEX, 1071 Carearea phos.in menstrual disorders and phthisis, 181. Calendula in ulceration of cervix uteri 611. in ovaritis, 755. Cancer, uterine, 692. varieties of 692. causes of. 692. haemorrhage in, 693. leucorrheal discharge in, 693. pain in, 694. reflex symptoms»in, 695. physical signs of, 695. proper speculum for, 696. diagnosis of, 696. from corporeal cervicitis, 696. uterine fibroids, 696. polypi, 696. syphilitic ulceration,' 697. course and duration of, 698. the cachexia in 699. the copraemic and cancerous com- plexion in, 700. influence of pregnancy and labor upon, 700. prognosis in, 700. mode of death in, 701. treatment for, 701. and laceration of the cervix, 701. indications for local treatmentin, 701. medical treatment for, 701. surgical do., 704. extirpation of the uterus in, 705. Freund's operation for extirpa- tion of, 705. Baker's operation, ablation of, 723. epithelial variety of, 708. Cantharis in cystitis, 579. Carcinophobia, 700. Caustics in ulceration of cervix uteri, 611. Causes of pelvi-pcritonitisa source of confusion, 372. Cauterization, dysmenorrhea from, 187. Cellulitis, pelvic, diagnosis of, from peritonitis, 374. Cervical inflammation and ulceration, 47. atresia, dysmenorrhea from, 186. leucorrhea is not uterine catarrh, 453. Cervical metritis, acute, rare in nul- liparae. 438. differential diagnosis of, 440. treatment of, 440. chronic menstrual disorders in, 444. nature and cause of, 445. is a post-puerper al affair, 445. Cervical metritis, general indications for treatment of, 447. remedies in, 447. stenosis and pelvic hematocele, 421. ectropium in laceration of cervix. 859. Cervix uteri, mode of cleansing, 73. apthous ulceration of, 653. irritable ulcer of, 658. rules for operations upon, 202. dilatation of. in dysmenorrhea, 215. laceration of the, 855. Changes in the vascular tunic of the uterus, 49. in the heart during pregnancy, 40. in the blood during pregnancy, 50. of climate in stomatitis materna, 348. Characteristics of pelvi-peritonitis, 368. Childhood. 35. China in bilious colic of pregnancy, 299. sub-involution, 360. Chill and thirst in pelvi-peritonitis, 370. Chlorosis, 39, 97. and amenorrhea, 97. digestive symptoms in, 97. cerebral do, 98. cardiac do, 98. the pulse of. 99. anaemic murmur in, 99 appetite in, 99. incidental symptoms of, 99. menstrual irregularitus in, 100. and dysmenorrhea, 101. in pregnancy, 101. discoloration of the skin in, 101. mental state in, 101. etiology of. 101. and scrofula, 102. blood changes in, 102. and ha3matogenesis, 102. the spansemia in, incidental, 103. nervous theory of, 103. precedes amenorrhea, 104. menstrual complications sympto- matic, 104. and jaundice, 104. and anaemia, diagnosis between, 105. prognosis of, 106. treatment of, 106. danger from incidental disease, 106. remedies for general states, of 107. treatment for emotional causes, 107. 1072 INDEX. Chlorosis, remedies for the cachexia, 107. iron in, 107. citrate of iron and strychnia in, 108. phosphorus and calc. phos. in, 109. calcarea carb. in 110. kali carb. in, 110. ignatia in, 110. phosphate of iron in, 110. sepia in, 110. helonias in, 110. menses should not be forced, 111. spasmodic dysmenorrhea inci- dent in, 111. the diet in, 112. exercise and travel in, 112. Chorea during pregnancy, 818. may arise from anaemia, 319. from shock, 320. more common in primiparae, 320. symptoms of, 321. may be localized, 321. prognosis of, 322. fatal form of, 323. treatment of, 324. Chronic disease cause of amenorrhoea, 119. metritis, sub-involution, etc. 586. corporeal cervicitis, 443. metritis, of eighteen years, 364. cervical metritis, 443. Chronic cervical endo-metritis, uter- ine leucorrhoea, 451. a glandular lesion, 452. predisposing causes of, 453. is a sequel of labor, 453 scrofula predisposes to, 453. menstruation a predisponent of, 453. tuberculous diathesis a predispo- nent of, 454. and biliary disorders, 454. exciting causes of, 454. symptoms of, 455. the puriform discharge in, 456. the leucorrhoea a symptom in, 456. varying character of the flow in, 4^6. pelvic pains and suffering in, 457. constitutional effects of, 458. is characterized by weakness of the eyes, 458. quite common among unmarried women, 459. diagnosis of, 459. manner of mopping off the cervix in, 459. the discharge in, not from an ulcerated surface, 460. diagnosis of, from cervical metri- tis, 460. Chronic cervical endo-metritis, prog- nosis in, 460. treatment of, 461. proper diet for, 462. vaginal injections not essential in, 463. topical use of glycerine in, 463. indications for calendula and hy- drastis, in, 464. intra-cervical injections not safe in, 464. pessaries contra-indicated in, 464. escharotics harmful in, 465. a fallacious practice in the treat- ment of, 466. rule for examining the flow in, 466. practical hints in treating, 468. remedies for the ovarian irrita- tion in, 468. menstrual disorders in, 468. utero- digestive disorders of, 468. utero-pectoral disorders in, 469. utero-hysterical disorders in, 469. utero- vesical suffering in, 469. utero-rectal symptoms in, 469. Cicatrization from laceration of the cervix, 860. Cimicifuga in ovarian neuralgia, 766, Circulatory system during pregnancy, 40. Climacteric period, 499. predisposition incident to the, 500. diseases incident to puberty may return at, 501. new disorders induced by, 501. old complaints disappear at, 501. symptoms of the approach of, 501. haemorrhage frequent at, 502. many imitate pregnancy, 502. alimentary symptoms at, 505. disorders of the circulation at, 503. nervous symptoms at, 503. epilepsy not unusual at, 503. disorders of the special senses at, 504. diseases of the respiratory system at, 504. develops diseases of the genera- tive system, 504. rheumatism and neuralgia at, 505. prognosis of diseases at, 505. Climacteric the, 63. disorders of the, 69. anaemic troubles at, 63. nervous troubles of, 64. causes of danger at, 506. tuberculous diathesis and the* 506. guard against hereditary predis- position at, 506. INDEX. 1073 Climacteric the, treatment at, impor- tant, 606. remedies tor haemorrhage, at, 507. the tendency to phthisis at, 507. digestive disorders at, 507. disorders of the circulation, 508. nervous system at, 508. disorders of the generative sys- tem at, 508. rheumatism and neuralgia, 509. the comparative frequency of diseases at. 509. analysis of fifty cases, showing date of, 510. hysteria at, with cutaneous erup- tion, 511. character of eruption at, may in- dicate the remedy, 512. hysteria at, in woman aged sixtv, 513. incipient paralysis at, 517. critical diseases may precede the 518. prophylaxis of the diseases of, 519. significance of the discharge at, 519. remedies for the acrid flow at, 519. neurosis following, 520. rheumatism at, 520. remedies for, 520. bilious colic at, 521. complications at, 522. prolapsus uteri with dropsy at, 525. uterine deviation at, may date from parturition; 523. dropsy aud constipation at, cause of prolapsus, 523. treatment by perineal pad, of pro- lapsus at, 524. internal remedies, and hygienic treatment for, 525. anasarca at, 525. the hemorrhagic diathesis at, 526. Climate effect upon menstruation, 119. Clinical history of woman, 36. test, 59. rule regarding uterine displace- ments, 590. history of membranous dysmen- orrhea, 227. hints in treatment of pelvic-cellu- litis, 402. Clysmic spring water, 5S3. Coccyodynia and irritable uterus. 687. Colocynth in ovarian neuralgia, 765. pelvi-peritonitis, 360. Colic Fallopian, 1021. Collodion oleaginous, formula, 653. Combined touch in uterine flexions, 627. Congenital defects cause of delaved menstruation, 114. Conjoined manipulation, 76. use of speculum and sound, 90. Consentaneous mobility in uterine fibroids, 940. Constipation in pelvi-peritonitis, 379. from rectal paralysis, 613. Contra-indications for anaesthetics. 200. Convulsions, no prophylactic for, 298. puerperal, meic. cor. in, 298. Coprsemic and cancerous complexion, 700. Corporeal cervicitis and scanty men- struation. 447. treatment for, 448. tartar emetic in, 449. Courty's method of reducing inver- sion, 645. amputation of, 648. Crises in a woman's life, 34. Curette in epithelioma, 723. Cystitis, 575. diagnosis of. from urethritis, 554. causes of, 575. symptoms of, 575. diagnosis of, 516. prognosis and treatment, 577. topical medication of the bladder in, 578. Clysmic spring water in, 582. medical treatment for, 579. belladonna in, 579. other remedies in, 579. milk diet in, 582. surgical treatment for, 580 Cystocele, 560. symptoms of, 560. varieties of, 561. pathognomonic signs in, 561. treatment for, 561. operation for, 562. Huguier's, 563. . Jobert's, 563. Vidars 563. Thomas' 563. Cystotomy, operation for, 580. vaginal, objections to, 581. Simon's method of, 581. drainage in, 582. DEFINITION and varieties of pel- vic hematocele, 418. Delay of puberty, 113. Delayed menstruation, 113. Depraved nutrition. 38. Diagnosis of ovarian dropsy, 932. 1074 INDEX. Diagnosis from extra-uterine preg- nancy, 939. of ovarian dropsy from ascites, 932. encysted peritoneal dropsy, 935. pregnancy, 936, 279, 289. uterine fibroids, 939. fibro-cystic growths, 941. physometra, 942. distension and prolapse of blad- der, 942, enlargement of liver and spleen, 942. tumors from retention of menses and faeces, 944. Diathesis, effect of, 38. upon menstruation, 42. at the climacteric, 526. Diet for chlorotic patients, 112. woman with mammary abscess, 480. Digestive system in pregnancy, 50. in chlorosis, 97. derangements of stomatitis ma- tern a, 343. pelvi-peritonitis, 372. Dilatation of cervix in retention of menses, 130. of urethra as a means of diagnosis, etc., 565. sponge tents in, 566. in dysmenorrhea, 215. Diphtheritic ulceration of the os uteri, 663. constitutional. symptoms of, 663. physical symptoms of, 663. the pseudo-membrane in, 663. is a secondary disease, 664. cause of, 664. treatment for, 665. Diseases cured by puberty, 39. caused by pregnancy, 46. common to pregnancy, 49. cured by pregnancy, 54, that co-exist with pregnancy, 53. caused by the climacteric, 64. cured by the climacteric, 65. co- existing with climacteric, 65. of pregnancy, 279. Disorders of digestion, 52. the urinary organs, 52. the pulmonary system, 52. Double touch in ovaritis, 731. Dropsy as a sequel of ovaritis, 740. of the heart and hysteria, 779. Dyscrasiae which may complicate pelvic cellulitis, 404. Dysmenorrhcea, obstructive, from post- puerperal atresia, 197. the result of adhesive inflamma- tion, 199. a clinical lesson in, 199. | Dysmenorrhcea, from stenosis of the cervix and peivi-peritonitis, 201 . contra-indication for anaesthetics in operations for, 200. , use of the uterine stem in, 200. in retroflexion of the uterus, 202. description of, 204. causes of, 204. symptoms of, 205. either the cause or effect of re- troflexion, 205. use of the sound in, 206. sequelae of, from retroflexion, 207. indications for treatment of, 207. reposition of the organ in, 207. stem dilators in, 208. membranous, 219. medicinal treatment in, 210. Dysmenorrhcea, neuralgic, 210. symptoms of, 213. importance of physical explora- tion in, 212. entire relief of, by a simple ex- pedient, 213. causes of, 214. relation of the flow to the degree of pain in, 214. indications for internal remedies in, 214, 215. warm instead of cold water in, 215. dilatation of the cervix in, 215. spasmodic, 215. effect of gin in, diagnostic, 216 opiates in, 216. hvsterical indications for ignatia, "217. remedies in, 217. obstructive, definition of, 185. causes of, 186. from uterine deviations, 186, 202. intra-uterine growths, 186. cervical atresia, 186. cauterization, 187. symptoms of, 187. cause of uterine tenesmus, 187. and reflex disorders, 188. and indigestion, 188. with faecal and rectal disorders, 188. nervous derangements in, 189. menorrhagia infrequent in, 189. sterility from, 189. diagnosis of, 190. use of the sound in, 190. the flow in, and what it signifies, 190. prognosis in, 190. surgical treatment of, 191. dilatation in, 191. introduction of instruments in, 192. INDEX. 1075 Dysmenorrhea, choice of tents for use in, 193. failure of dilatation in, 193. dangers from the use of dilators in, 192. barbarous practice in, 193. precautions in practising dilata- tion in, 194. incision of cervix uteri in, 194 dangers attending, 197. precautions in surgical operations for, 197. and chlorosis, 101. and uterine colic, 165. Dystocia a factor in pelvic cellulitis, 393. EARLY marriage, 37. Eczema of the vulva, 538. Electricity and magnetism in men- strual headache, 159. Elytroplasty for vesico- vaginal ris- tulaB, 884. Elytrotomy in normal ovariotomy, 1025. Elytrorrhaphy, 618. Embryo, life of the. 332. Emmet's mode of reducing inversion, 646. laceration of cervix uteri, 866. Emmenagogues in amenorrhoea, 124. Encysted peritoneal dropsy, diagno- sis of, 936. Endometritis cervical. (See chronic cervical do ) Enucleation of ovarian cysts, 1003, 1009. partial, 1009. Miner's method of, 1003. Ludlam's method of, 1004. Epilepsy, menstrual, 168. at the climacteric, 503. uterine and ovarian, 169. with amenorrhoea, 169. inter-menstrual, 170. non-sexual causes of, 171. prognosis in, 172. treatment of, 173. belladonna in, 174. nux vomica in, 174. hvoscyamus in, 174. rhus tox. in, 174. diagnosis of, from hysteria, 791. Epileptiform hysteria with irregular menses, 175, 172. and hystero-epilepsy identical, 176. stages of the fit, 177. Landouzy's case of, 177. predominating symptoms of, 178. Charcot's case of, 178. Epileptiform, hysteria, treatment o* 179. diagnosis of, 178. prognosis of, 178. cardinal indications for remedies in, 179. Episio-perineorrhaphy, operation of, 618. Episiorrhaphy for vesico-vaginal fis- tulse, 887. Epithelioma of the uterus, 708. nature and clinical history of, 709. curette in, 723. pathological history of, 710 insidious course of, 711. pain and discharge in, 712 haemorrhage in, 712. inspection of, 713. extension of the lesion in, 713. development of cachexia in, 714. diagnosis, importance of, in, 714. the microscope in, 715. reliable physical signs in, 715. age most common tor, 715. diagnosis of, from cervical hyper- trophy, 716. diagnosis of, from uterine polypi, 716. family history in, 717. prognosis in, 717. treatment of, 717. Dr. Sims' operation for, 718. qualifying indications for remov- al of, 72 I. local treatment for. 722. Ergot in sub-involution, 358. . Eruption, in dysmenorrhea, etc., 202. Ervsipelas is allied to pelvic celluli- tis, 392. Escharotics, contra-indications for, 465. Excision of a vascular tumor of the meatus urinarius, 54y. Exciting causes of pelvic haeniatocele, 420. Excoriated nipples, 480. most frequent in primiparse, 481. local and general causes of, 481. symptoms of , 481. may become ulcerated, 482. may result in abscess, 483. treatment of, 4S3. prophylactics of, 483. with aphthous ulceration, 484. with linear ulcers, 484. remedies for, 484, 486. choice of nipple shield in case of, 485. benefits of the shield for 485. Exercise and travel for chlorotic patients, 112. 1076 INDEX. Exfoliative endometritis and mem- branous dysmenorrhea, 243. Exploratory incision, 945. practical indications for, 948. External generative organs, affec- tions of, 527. Extirpation of the uterus for cancer, 705. Extra-uterine pregnancy, diagnosis of, 939. and hematocele, 429. Eyes, weakness of, a, symptom of endo-metritis, 458. PAPT]S T ESTOCK. Dr., on apocynum in uraemia, 309. Faradization in spinal irritation, 829. Fashionable pretext for weaning in- fants, 475. Fallopian colic, 1021. Fever, remittent, and monorrhagia, 262. malarial, 263. Fibroids, uterine, the elevator in, 92. with, monorrhagia, 265. trillin in monorrhagia from, 1063. the uterine sound in, 92. relative frequency of, 1032. pathological anatomy of, 1032. symptoms of, 1034. the haemorrhage in, 970. the sponge tent as a haemostatic in, 1041. incision of the cervix in, 1041. Dr. Atlee's operation in, 1041. hypodermic injections of ergot, 1041. Battey's operation in, 1042. electricity and electrolysis in, 1042. an animal diet in, 1042. excision of the tumor, 1043. dilatation the first step, 1043. sub-peritoneal, 1048. frequency, number, etc., 1048. coincident disorders in, 1050. diagnosis of, 1050. from retroversion of the uterus, * 1051. ovarian dropsy, 1051. pregnancy, 1051. pelvic cellulitis, 1052. course and termination of, 1053. prognosis of, 1053. treatment of, 1053. gastrotomy in, 1054. extirpation of the uterus and ovaries in, 1055. Dr. Ormes' cases of extirpation in, 1055. interstitial, 1056. Fibroids, dilatation in, 1059. symptoms of, 1056. diagnosis of, 1058. the bi-manual examination m> 1058. the uterine sound in, 1058. prognosis in, 1059. treatment of, 1060. remedies in, 1061. surgical treatment for, 1062. Drs. Atlee and Baker Brown's' operation for, 1063. Fistulse, vesico-vaginal, 872. recto-vaginal, 887. the surgical treatment for, 889. Fixity of the uterus in pelvi-periton- itis, 370. Flexions and versions of the uterus, 622. two peculiarities of, 622. anatomical predisponent of, 622, varieties of, 622. most common, 622. the bladder and rectum in, 623. diagnosis of, 623. the touch in, 623. the uterine sound in. 623. reposition of the organ in, 624. pessaries in, 625. Flexion ante, of the uterus, 626. comparative frequency of, 626. cause and diagnosis of, 626. the combined touch in, 627. how to pass the sound in, 627. Sims' repositor for, 627. stem pessaries for, 628. Flexion latero, comparative fre- quency of, 629. causes of, 629. symptoms of, 629. physical signs of, 629. passing the sound in, 630. postural treatment for. 630. diseases contingent upon, 631. Foetal heart sound in pregnancy, 283, 938. Follicular vulvitis, diagnosis of, from vulvo-vaginitis, 541. Forcing medicines in amenorrhea, 115. Fothergill, on ovarian dyspepsia. 767. Frequency of pelvi-peritonitis in rheumatic subjects, 373. Freund's operation for extirpation of the uterus, 705. GALACTORRHCEA, 474. Gastrotomy in iibroids, 1054. Gelsemium in amenorrhoea, 140 menstrual headache, 159. dysmenorrhea, 215, 217, INDEX. 107' Gelsemium, membranous dysmenor- rhoea, 246. pelviperitonitis, 380. ovaritis, 752. General pathology, 33. Genitals, external, the inspection of, 67. Girlhood, 35. Gonorrheal ovaritis, 735. treatment for, 755. and sterility, 749. Goodell's operation for recto-vaginal fistula, 891. Guernsey's elevator in retro-flexion, 634. HAMAMELIS VIEG. in ovaritis., 752, 755. Hammond on arsenic and strychnia in chlorosis, 111. Hawkes, Dr. W. J. on nausea and vomiting of pregnancy, 310. Headache, menstrual, 151. peculiar symptoms of, 152. 157. from uterine deviations, 153. cause of, 153. ovulation and cephalalgia, 154. exciting causes of, 154. diagnosis of, from sick headache, 155. from congestive headache, 156. from hysterical headache, 156. prognosis in, 157. treatment of, 158. hygienic treatment of, 158. electricity and magnetism in, 159. internal remedies for, 159. Heart, the changes in during preg- nancy, 50. do. a predisponent of cardiac dis- ease, 51. Helmuth's operation for supra-pubic lithotomy, 587. Helonias in chlorosis, 110. Hseinatogenesis and chlorosis, 102. Hematocele, pelvic, diagnosis of, from pelvi-peritonitis,374. (See Pelvic hsematocele, 418.) Hemiplegia with menorrhagia, 265. hysterical. 810. Hemorrhagic tendency, influence of the, 43. diathesis in pelvic hematocele, 420. remedies in, 260. Hemorrhage, post-menstrual, 253. post-dysmenorrhceal, 254. at the climacteric, 254, 502. in uterine cancer, 693. Hereditary amenorrhcea, 100. Hereditary amenorrhea, tendency to suppression, 118. Hernia of the ovary, 728, 731. Holcombe, Dr. W. H. case of ovarian neuralgia, 765. on the treatment of pruritus vulvae, 534. Hot water injections in pelvi-peri- tonitis, 379. Huguier's operation for cystocele, 563. Hyoscyamus in menstrual epilepsy, 174. Hysteria, the pulse in, 515. coffea in, 515. and uterine colic, 165. at puberty, 39. the influence of, 43. at the climacteric, 511, 513. in a woman aged sixty, 513. incident to menstrual life, 514. caulophyllin in, 515. the pupils in, 514. treatment of, 515. a factor in irritable bladder, 585. and the menstrual molimen, 771, 772. during gestation, 773. emotional causes of, 773. suspicious symptoms of, 775. incongruous symptoms of, 776. a species of malingering in, 776. leading characteristics of, 777. the symptoms of valvular disease of the heart in, 778. diagnosis of, from dropsy of the heart, 779. the cough in, 780. diagnosis of, from pectoral dis- ease, 780. hypochondriasis, 787. asthma, 781. epilepsy, 791. from apoplectic aphonia, 782. from insanity, 783. the delirium of, 785. incident to fevers, 786. in puerperal peritonitis, 788. may counterfeit labor, 790. the aphonia of, 781. or spinal irritation, 793. may locate itself in the joints, 794. not a bona-fide disease, 795. treatment of, 797. narcotics and anti-spasmodics in the treatment of, 800. stimulants in, 801. domestic occupation a require- ment in the treatment of, 802. treatment of, during a fit, 804. do. in the interval, 806. 1078 INDEX. Hysteria, general rules in the treat- ment of, 807. coincident lesions of the uterus and ovaries in, 808. caused by utero-gastric andutero- cardiac derangements, 809. from neurasthenia, 810. a practical test for, 811. Hysterical complications of prolapsus uteri, 608. diathesis in ovarian neuralgia, 758. hemiplegia, 811. remedies for, 814. may occur in males, 813. prognosis of, 814. mimicry, 811. diagnosis of, 812. ischuria, 572. Hysterectomy, vagina], 723. Hysterectomy, supra- vaginal, 723. Hysterorrhaphy, 648. Hystero-epilepsy, 176. Landouzy's case of, 177. Charcot's case of, 178. TGNORANCE and self-neglect, 37. X Iguatia in chlorosis, 217. do. hysterical dysmenorrhcea, 217. Impoverished blood, 37. Tncision of the cervix uteri, 131, 194, 1041. Indications for calendula and hy- drastin, 464. and contra-indications for ovar- iotomy, 961, 963. Infantile leucorrhoea, 543. causes of, 544. treatment for, 544. isolation essential in, 545. Influence of remedies upon the uterus and liver, 296. Injections, intra-cervical, harmful in endo cervicitis, 464. Insanity and hysteria, 783. Inspection, varieties of, 66. of external genitals, 67. by the speculum, 67. table, chair, and lights for, 72. of the rectum by e version, 74. Inter-menstrual epilepsy, 1-70. Interstitial fibroids of the uterus, 1056. Intestinal resonance, 94. Intra-uterine astringents in monor- rhagia, 272, 273. Inversion of the uterus, 641. causes of, 642. symptoms of, 642. the tumor in, 642. diagnosis from procidentia, 643. Inversion of the uterus, diagnosis of the sub-mucous tibroid,643. the crucial test for, 643. prognosis in, 643 treatment of, 644. following abortion, 644. manual treatment of, 644. Tate's vesico-rectal method for reducing, 645. Courty's rectal do., 645. Noeggerattfs method for reduc- ing, 645. Emmet's do., 646. Sims & Barnes' do., 647. White's do., 647. Thomas' do., 647. Courty's method for amputation in, 648. Iron in chlorosis, 108. Irritable bladder, 584. causes of, 584. hysteria a factor in, 585. three points in the diagnosis of, 585. treatment of, 585. Irritable ulcer of uterine cervix, 658. the speculum not always neces- sary in, 659. removal of the protective mucus from, 659. appearance of the, 660. a sign of depraved vitality, 660. local treatment for, 661 . internal remedies for, 661 . do. uterus, hysteralgia, 681. has no detinite lesion, 682. a species of hyperesthesia, 682. limited to menstrual life, 682. predisposing causes of, 682. exciting causes of, 683. from abortion, 684. from escharotics, 684. location of the pain, 685. may simulate other diseases, 68& nervous symptoms in, 686. physical examination of, 687. diagnosis of, from coccydynia, 687. from dysmenorrhcea, 6S8. treatment for, 688. practical hint in, 689. surgery contra-indicated in, 690, topical expedients in, 690. new remedies for. 791. Ischuria, hysterical, 571. JOBERT'S operation for cystocele, 563. Jousset on the treatment of pelvi- peritonitis, 379. INDEX. 1079 KALI CARB. in chlorosis, 110. Kendell, Dr. Lyman, case, 124. Kiwisch on ovaritis and pelvic tu- mors, 746. LABIA MAJORA abscess of, 534. Labor a predisponent of proci- dentia, 620. Laceration of cervix uteri, 855. a cause of sub-involution, 862. discovery and description of, 855. as a cause of uterine cancer, 863. puerperal, 855. causes of, 856. symptoms of, 856. • varieties of, 858. cervical ectropium in, 859. cicatrizations from, 860. diagnosis of, 861. a singular fact regarding, 861. the certain test for. 861. and sub-involution, 862. and epithelioma, 862. and sterility, 863. prognosis in operation for, 863. prophylaxis of, 863. preparatory treatment for opera- tion for, 864. trachelorrhaphy in, 866. Laceration of the vulva and perineum — perineorrhaphy, 892. of the fourchette, 893. perineum, varieties of, 895. frequency of, 895. symptoms of, 896. effects of cicatrization in, 898. immediate treatment in recent cases of, 897. use of serre-fines in, 897. primary operation for, 898. secondary operation for, 898. freshening process in, 898. closing the wound in, 899. complete operation for, 899. and recto-vaginal septum, 902. Dr. Tait's method, operation for, 902. after-treatment in, 901. results of operation tor, 901. Lachesis in ovaritis, 752 Lactation, 60. the natural stimulus to uterine contraction, 60. effects of in abortion, 60. undue effects, 62. ill effects of, if prolonged, 476. the cause of unilateral neuralgia, 496. and menstruation, anaemia from, 495. extraordinary case of, 497. Langenbeck's operation in uterine cancer, 706. Laparotomy explorative, 945. mode of making, 946. Latero-flexion of the uterus, 629. Latero-version, 640. subjective signs of, 640. with constipation-, 613. physical signs of, 641. treatment for, 641. Leucorrhoea, the cause of impaired lacteal secretion, 489. and scrofulosis, 489. the cause of illness in the infant, 491. acts as a poison to the child, 491. and sterilty, 492, 674. treatment for, 492, 680. remedies and diet for, 493. infantile, 543. and ulceration in prolapsus uteri, 608. with chronic ovaritis, 671. may substitute menstruation, 673. inter-menstrual treatment of, 675. and the scrofulous dyscrasia, 676. may be critical, 677. local and general causes of 677. constitutional causes of, 678. scrofulosis in, 678. remedies for, 680. in uterine cancer, 693. Leucocytosis, 943. Listerism in ovariotomy, 967. and drainage, 981. Lithotripsy and vaginal cystotomy, 587. Lithotomy, supra-pubic, by Helmuth, 587. Local symptoms of pelvic hemato- cele, 423. Ludlam's method of enucleation, 1004. MACROTLN" in pelvi-peritonitis, 382. with rheumatism, 382. with spinal myalgia, 382. mental symptoms of, 382. Mammary gland, abscess of, 382. subsequent treatment of, 474. Manual exploration of the rectum, 80. Marriage, early, 37. McCleary, Dr. R. B., case of men- strual headache, 159. Meatus urinarius, vascular tumor of, 516. Medical experience should be quali- fied, 59. treatment of pelvic hematocele, 433. 1080 INDEX. Medical treatment for vaginismus, 850. and mechanical causes of ovari- tis, 725. Membranous dysmenorrhea, 219,234. the membrane in, identical with the decidua vera, 226. may be overlooked, 225. causes of, 225, 235. anatomical peculiarities of, 226. shape and size of the membrane in, 228. regularity of appearance in, 228. reflex gastric symptoms in, 229. expulsion of the membrane in, 228. reflex cardiac symptoms in 229. consequent uterine affections from, 230. diagnosis of, from abortion, 230. prognosis in, 230. treatment of, 231,239. rheumatic complications in, 231. the abortive dyscrasia a predis- ponent of, 23i. from repelled eruptions, 132, 234. reflex symptoms in, 132. treatment of ovarian symptoms in, 132. an antiquated prescription for, 132. local applications in, 233. sponge tent in, 233. comparative frequency of, 234. from cutaneous eruptions, 235. case of, 236, 238, 241, 243, 245. sterility as a sequel of, 236. the skin and uterine mucous membrane in, 237. borax in, 241. from exfoliative endo-metritis, 243. mal-treatment of, by pessary, 244. confrra-iuidications for pessary in, 244. peculiar remedies in, 244. result of treatment in, 245. ovarian, 245. button-hole os uteri in, 246. gelsemium in, 246. Menorrhagia, 247. differential diagnosis of, 248. modes of examination in, 248. complicating lesions of, 248. from a miscarriage, 248. and ovaritis, 248. treatment of, 249. remedies during, 249. remedies for complications of, 249. surgical treatment of, 251. Menorrhagia, nitric acid in, 252, 853. with remittent fever, 262. and ovaritis, 734. complicated with malarial fever, 263. with rheumatism, 263. with hemiplegia, 265. from a uterine fibroid, 265. with convulsions, 266. folly of stopping the flow in, 270. the gastric and chlorotic symp- toms in, 271. sudden suppression of, by astrin- gents, 271. intra-uterine astringents in, 273. sometimes salutary, 272. physiological argument against intra-uterine astringents in, 278. digestive disorders from vaginal and uterine injections in, 273. from polypi, etc , 274. treatment of, 274, 277. intolerance of vaginal injections in, 275. and tuberculosis, 180. Menorrhcea— cervical epistaxis, 255. ks relation to menstruation, 255. a diagnostic rule in, 256. a physiological reason for, 255. peculiarity of the flow in, 257. critical nature of the flow in, 257 necessity of physical examine tion in, 258. may persist without manifest in- jury, 258. sterility from, 259. treatment of, 259. medicine versus surgery in, 259 not to be confounded with un' avoidable haemorrhage, 239. remedies for the haemorrhagir diathesis in, 260. scrofulous diathesis in, 260. syphilitic diathesis in, 261. ovarian complication in, 261- the exercise most important in the cure of, 261. change of climate may aid the cure of, 271. Menses, should not be forced in chlo' rosis, 111. retention of the, 128. irregular, with epileptiform hys- teria, 175. suppression of, 280, 117. an uncertain sign of preg- nancy, 281. marriage as a remedy for, 281. Menstruation, 40. causes of suffering during, 40. three steps in the process of, 40. anticipating symptoms in, 41. INDEX, 1081 Menstruation, accompanying symp- toms in, 41. subsequent symptoms in, 42. influence of diathesis upon, 42. travel upon, 42. hemorrhagic tendency upon, 43. the exciting cause of relapse, in 54. the exciting cause of intercur- rent disease upon, 43, the arrest of, when physiological, 113. delayed, 113. vicarious, 275. Pulsatilla in, 278. and pregnancy, 286. arrest of, cause of disease, 139. nervous phenomena following, 140. frequent, in early phthisis, 179. treatment for, 181. and tuberculosis, 179. predisposes to chronic cervical endo-metritis, 453. Menstrual retention, etiology of, 129. symptoms of, 129. and uterine displacements, 160. diagnosis of, 129. headache, 151. epilepsy, 168. intermission common, 269. irregularities in chlorosis, 100. complications in chlorosis, 104. suppression and retention not the same, 117. suppression may be hereditary, 118. suppression, avoidable causes of, 118. relapses the rule in pelvi-periton- itis, 372. function in pelvic cellulitis, 401. life, duration of, 500. importance of the change in, 500 irregularities, cause of uterine deviations, 606. disorders incident to ovaritis, 733. sequelae of, 747. Meisuration, 74. Mental state in chlorosis, 101. Mercurius in stomatitis materna 319. viv. in ovaritis, 752. Metritis, acute cervical 437 varieties of. 438. rare in multiparas, 438. the monthly cycle a predisponent of, 438. causes of acute. 439. differential diagnosis of, 440. prognosis of, 440. Metritis, postural treatment for, 440. means of preventing, 441. local measures in the treatment of, 442. hot rectal douche for, recom- mended by Dr. Chadwick, of Boston, 442. chronic, cervical, 443. mechanical symptoms of, 444. chronic, direct and reflex symp- toms of, 444. menstrual disorders in, 444. nature and cause of, 445. may be connected with hepatic disease, 445. is a post-puerperal affair, 445. diagnosis of, from uterine cancer, 445. diagnosis of, from corporeal me- tritis, 446. a new diagnostic test for, 446. prognosis of, 446. requires postural treatment, 446. general indications in the treat- ment of, 447. remedies in, 447. local adjuvants in, 447. Metro-peritonitis, origin of, 48. cerebral disorders in, 52. Metrorrhagia after abortion, 252. nitric acid in, 252. Microscope in epithelioma of the uterus, 715. Miner's, Prof. J. F., method of enu- cleation in ovariotomy, 1003. Molar pregnancy, 284. Morning sickness of pregnancy and retro-version, 311. Multipara? effects of parturition in, 56. NAJA in ovarian neuralgia, 765. Narcotics and anti-spasmodics in hysteria, 800. Natrurn mur. in stomatis materna, 350. Nausea and vomiting of pregnancy, 304. sometimes fatal, 304. remedies for, 307. 308. a frequent symptom in pelvi- peritonitis, 370. in the after treatment of ovariot- omy, 990. Nervous exhaustion, 3S. system in pregnancy, 50. in parturition, 55. uterine disease, 61. troubles at the climacteric, 64. and vascular system in amenor- rhcea, 121. 1082 ' INDEX. Nervous exhaustion, theory of chlor- osis, 103. and menstrual functions, 270. symptoms at the climacteric, 503. in prolapsus uteri, 608. of irritable uterus, 686. Neuralgia, menstrual, varieties of, 143. cutaneous of pregnancy, 301. symptoms of, 301. unilateral, from prolonged lacta- tion, 496. Neuralgic dysmenorrhea, 210. diathesis, 757. Nidation, a factor in menstruation, 234. Nipples excoriated, 480. loss of, from erysipelatous inflam- mation, 494. Nitric acid in menorrhagia, 252, 253. Noeggerath's method of incision in ovariotomy, 943. mode of reducing inversion, 645. Normal ovariotomy— Battey's opera- tion, 10251 Non- specific urethritis, 551, 555. causes of, 552. symptoms of, 553. character of the urine in, 553. diagnosis of, from stone, 554. cystitis, 554. gonorrhoea, 554. Nursing, a prophylactic of uterine disease, 61. Nux vomica in menstrual epilepsy, 174. Nymphomania and ovaritis, 750. OLDHAM'S theory of ovarian influ- ence, 227, 246. clinical confirmation of, 227. Omental aunesions in ovarian tumors, 975. Operation for vesico-vaginal fistulse, 880. recto-vaginal ristulse, 887-9. laceration of the perineum, 897. removal of ovarian cysts, 960. Oophorectomy, 1025. Opiates in spasmodic dysmenorrhoea, 216. Origin of pelvic peritonitis, 49. pelvic cellulitis, 49. Ormes, extirpation of the uterus, 963, 990. Os uteri, diphtheritic ulceration of, constitutional symptoms of, 663. Ovarian dysmenorrhoea, 245. irritation and chronic cervical endometritis, 468. tumors during pregnancy, 53. resolution of, 746. Ovarian dysmenorrhoea, atrophy and induration, treatment for, 754. neuralgia, ovaralgia, 756. peculiar predisnonents of. 757. the neuralgic diathesis and, 757. rheumatic diathesis and, 758. hysterical diathesis and, 758. organic disease of uterus and ovaries a fertile source of,, 759. Ovarian neuralgia, peculiar sensa- tions in, 759. sexual excitement a fertile* source of, 758. when incident to menstrual disorders, 760. cause of the pain in, 760. peritoneal adhesions a cause of, 760. diagnosis of, from ovaritis, 761. from hernia, 761. from uterine neuralgia, 761. prognosis of .761. treatment «,£ 762. for «tie rheumatic com- plications in, 762. topical, 762. valerianate of zinc in, 764. atropine in, 764. colocynth in, 765. naja in, 765. ammonium carb in, 765. cimicifuga in, 766. irritation, case of, 766. dyspepsia, by Dr. Fothergill, 767. irritation at the climacteric, 768. a pathognomonic s«gnof,768. exciting causes of, 769. Dr. Woodward's case of, 769. remedies for, 770. Ovarian dropsy, area of dullness in,, 95. diagnosis of, from pelvic hsemato- cele, 429. from ascites, 932. tapping in, 933. refilling of the cyst in, 935. frequently confounded with preg- nancy, 936. changes in the cervix in, 937. length of uterine