>v \i\: m '-''(&£££$ ' ■ i ." -. -: - ■ 1v ; '■ - •-.•'.'.,' ?M: £&?:& NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The National Center for Homeopathy J^iaesimund (Extnrimq Library 19! ffi '174. &% ^OE^ MEDICAL AND SURGICAL LECTURES ON THE DISEASES OF WOMEN, A CLINICAL AND SYSTEMATIC TEEATISE. BY R. LUDLAM, M. D., Professor of the Medical and Surgical Diseases of Women in the Hahnemann Medical College and Hospital, of Chicago; Late President of the Amer- ican Institute of Homceopathy, and of the Chicago Academy of Medi- cine; Corresponding Member of the Homoeopathic Medical Societies of Great Britain, France, Massachusetts, and New York; Author of a Volume of Clinical Lect- ures on Diphtheria; Member of the State Board of Health of Illinois, ETC., ETC. LECTURES DELIVERED FROM 1870 TO 1887. sixth edition; revised, enlarged and illustrated. CHICAGO: HALSEY BROTHERS, 1890. Entered according to Act of Congress, in the year 1888, by HALSEY BROTHERS, in the office of the Librarian of Congress, at Washington. imA PRESS OF THE McCLUER 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 PREFACE 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. COJN TENTS. INTRODUCTORY LECTURE. LECTURE I. THE SEVEN CRITICAL PERIODS IN THE LIFE OF WOMAN. GENERAL PATHOLOGY. PAOK. Puberty............35 Childhood—Girlhood—Womanhood—Clinical history of—Com- parative risks of—!N ot identical with nubility—Early marriage and; delayed. 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 cachexia?— Ditto of mal-treatment—The menstrual cachexia. LECTURE IE. general pathology — continued. 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 wM pregnancy—Ovarian and fibroid tumors, etc. LECTURE III. general pathology—continued. Parturition...........56 Effects of, on the nervous system—In primiparae; ditto on mul- tipart—Traumatic lesions of. PUERPERA.LITY...........57 Diseases of—Uterine involution, results if defective—Laceration 5 CONTENTS. of the cervix as a cause of post-puerperal diseases—The ca- chexia. PAGE. 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..... .... 63 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 gynecology. 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 —Theli touch " per vaginam—Conjoined manipulation and when it is of use—The uterine " touch" and the conditions requiring it. LECTURE V. physical diagnosis—continued. Physical Diagnosis ....... 78 The three kinds of rectal touch—Manual exploration of the rec- tum, or Simon's method—The "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............93 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. 7 LECTURE VI. PAGE. ^"HLOROSIS.............97 Digestive, cerebral *od 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, Iron in—The citrate of iron and strychnia in—Special indications for remedies—The diet—Exercise and travel. LECTURE VII. AMENORRHEA. J. 2)ELAYEr> MENSTRUATION...... J3 Etiology of—symptoms of—diagnosis, prognosis, and t* >tment. 2. Suppressed Menstruation........117 Etiology—Symptoms, diagnosis, and treatment—Speoal indica- tions for remedies. 3. Retention of the Menses . .....128 Etiology, symptoms, diagnosis, prognosis, and treatment, both medical and surgical. LECTURE VIII. amenorrhcea—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. ♦final Irritation, with Amenorrhea, Vicarious Vomiting, ETC..............144 Convulsions—Causes of—Theories in—Treatment—Subsequent history. Amenorrhcea in Advanced Phthisis......149 Remedies and prognosis. 8 CONTENTS. LECTURE IX. PAG £ 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 dysmenorrhcea—Sequelae, 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 Dysmenorrhcea..........,183 Definition and varieties— Causes— Symptoms, complications, sequelte—Diagnosis—Prognosis—Surgical xreatment. Obstructive Dysmenorrhcea from Post-Puekperal 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 Dysmenorrhcea from Stenosis of the Uterine Cervix and Pelvi-Peritonitis.......201 Rule for operations on the cervix—Post-surgical peritonitis. Obstructive Dysmenorrhcea from Retroflexion of the Uterus.............202 Causes—Symptoms—Diagnosis—Sequelae and treatment. Neuralgic Dysmenorrhcea ........210 The importance of physical signs—A neurosis—Symptoms- Relation of the flow to the degree of pain—Treatment. CONTENTS. {) PAGE Spasmodic Dysmenorrhcea ........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 Dysmenorrhcea . . . .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- orrhceal haemorrhage—Haemorrhage at the climacteric—Practi- cal conclusions. Menorriicea—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 avitii Remittent Fever......262 Complication with malarial fever—Uterine disorders not always easy of cure. Menorrhagia with Rheumatism.......263 i 10 CONTENTS. LECTURE XVI. PAGE Menorrhagia—Continued.........26a Menorrhagia with hemiplegia — Menorrhagia from a uterine fibroid. 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. II PAG E. Chorea during Pregnancy........318 Etiology—Nature —Anaemia — Symptoms — Localized chorea — Prognosis—The fatal form—Treatment—Remedies. LECTURE XX. Abortion wiTn Misplaced Pains.......326 The habit of aborting — Intermittent abortion — Treatment— Gelsemium in. The Sequel.e 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—Renal 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 ....... Etiology—Treatment—The physiological action of ergo!— Indi- cations for secale, china, etc, Sub-involution and Recurrent Abortion .... Types of abortion—L'eculiar cause of—Treatment—Peculiar sus- ceptibility—Remedies. Sub-involution and Chronic Metritis of Eighteen Years Standing ............ Causation—Physical signs. Sub-involution, Chronic Metritis, Menorrhagia and Pro- lapsus ...........' 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 353 361 364 365 12 CONTENTS. —Remedies—Macrotin—Pelvi-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 ......38S 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 xo uterine surgery—Diag- nosis—Sequelae—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 fistulee 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 haemorrhagic 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 haematocele 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 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— Antigalactics—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 leucorrhcea 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 at 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- menorrhcea and amenorrhcea—Pruritus at the climacteric—Pru- ritus during pregnancy—Prognosis—Treatment—Remedies. Abscess of the Labia Major a 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—From follicular vulvitis—Prognosis—Treatment. CONTENTS. 15 PAGE. Infantile Leucorrhcea......... 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—Remedies 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.....583 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 exclusively—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— What 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— Contra-indica- tions for the pessary—Local expedients. Prolapsus Uteri with Right Latero-version . . . 612 Latero-version from an over-loaded rectum—Treatment. Prolapsus wiTn 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........ . 63J 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-partum 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 leucorrhcea—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 Leucorrhcea may be critical—Local and general causes—Consti- tutional causes—Scrofulosis in—Treatment—Remedies. 18 contents. PAfiE. Irritable Uterus—Hysteralgia.......yyl 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- orrhcea 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 XLVI. Ovarian Neuralgia—Ovaralgia.......757 Etiology—Clinical history—Diagnosis — Prognosis — Treatment Remedies. Ovarian Irritation—Ovarian Dyspepsia.....768 A pathognomonic sign—Exciting causes—Remedies. contents. 19 LECTURE XLVH. Hysteria ............PA^ 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 XLVIII. Hysteria, Continued..........735 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...... .815 Causes—Peculiar organization a predisponent—Of nervous origin —Symptoms, reflex and direct—Spinal irritation and uterine dis- ease—Diagnosis—Prognosis—Treatment. Physometra i..........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 .... .843 20 contents. PAGE. Vaginismus ... .........8 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 LIII. Vesu o-vaginal Fistula.........870 The varieties of vesical and vaginal fistulae— Vesico-vaqinal fis- tulce—Causes, from child-birth, from wounds, calculi, syphilis, 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 ..........8901 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 LVI. 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 LVII. 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 wrhich 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 Ovariotomy.........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 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 LXII. Diseases of the Uterine Appendages ...... 1016 Class of women who are subject to—From imperfect development, obstructive and membranous dysmenorrhcea, 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 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 of the Uterus—Continued ..... 1056 Interstitial Fibroids—Symptoms—Dysmenorrhcea—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 OE 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 1884-5. 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. 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 is capable of sifting it, and of selecting those points which are of rea] 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 (Velpeau, 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 turn 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 view 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 always in accord with your text-books concerning the ultimate causes of ill-health among women, or the best method of curing 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 so, 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? 28 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 of 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 the 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 the 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. 31 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 conditions 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. LECTURE 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. Menstbdation—Causes of Suffering in; three steps in; Influence of diathesis upon; do. of travel; do. of the haemor- 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 THfc 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 study, and by a conscientious improvement of the advantages which it is my duty 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 " 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 in the seven critical 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 nursin« period; and (7.) the Climacteric, or the " change of life," as it is commonly 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. Xo 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- i , /• ,1 • a , = , ,, . , of these crises. ulea ot tne influence which these periods exert 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 function. The infancy of the girl does not differ essentially from that of the boy. There is, perhaps, a touch of softness, of delicacy, and Chiidh d °^ pl^bility in her organization, that are half- 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, al though 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 clinical history. , ..-■,. . n •, • t i • i i n clinical history, for 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 wre 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. , , . .„ . , , at puberty. held 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 arenboetrttheaSaLnUbllltyto 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 o-irl 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, Early marriage. . . ,. . . ° ' 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, J!™™™ and 8Glf" in ^ beget fey coq_ 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. The first of these. You wil1 often have occasi°n 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 The second. gl'eatei' 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 The third. t0 the time when the l)roper discharge has ceased, or changed into a leucorrhceal flow. Very exceptionally, as in inter-menstrual dysmenorrhcea 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. , . ,, .. . , . , .L . 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 stao;e of lab6r, 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- . . . . . a . toms menstruation, or one m which the flow 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 OF 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 while 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. This, 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,,, . -. . etc> that are not catamenial, impress themselves upon this class of affections also. There arc 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 disease? of which we are Influence of travel. . \' * . . . 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 journeyino- from one end of our country to the other. Some of you remember a very marked illustration of the modi- ^ ^ , lying influence of the haemorrhage diathesis Influence of the haem- . ~ orrnagictendency. upon menstruation that we have had in 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 ren^d^ease^ mtercur~exaniple, 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 amenorrhcea 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- i0unsticachCeex"rbeVar' sia' and hePatic 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 inflaenceof n:ai-treat-called upon to cure are the sequela? of an excess mont- 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 urinary derangements. The diseases that are cured by pregnancy; the vis medicatrix of. Diseases that co-exist 'jftth 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 who 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 Preg-SUSpen(}eci; if the circulation and innervation 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 ofTe^rmeT"6111 often 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. 1 o j ' " 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 observed this obliquity in our puerperal wards when we have been studying the changes that occur in the womb during the first ten days of the lyino-Jin.; 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 mio-ration of GENERAL PATHOLOGY—CONTINUED. 47 the svomb from the pelvis to the abdomen, and the stretching of all the uterine ligaments are so many factors in Effect upon the uter- , • t t^- ,it, ineligaments. 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__..__i tut ,i -,.„» and ulceration. never became pregnant. I allude to the differ- 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 ramoUissement 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- 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, changes in the endo and of the greatest possible interest to the o-yn- metrium. n i t~j secologist. 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 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 very great, and Effects of. •.. V the consequences may last lor years in the form of ordinary chronic metritis, exfoliative metritis, menorrhagia, or an intractable uterine leucorrhcea. 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 conges.of peritoneal fail to 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 moorinos of the womb are made of the same material, with a few muscular fibres interspersed. This is the genital peritoneum. Rouget 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 tonmsin0fmetr°"Perl" ullion 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 GEN ERAL PATHOLOGY—CONTINUED. 49 much more troublesome and common than you may have sup- posed. If my own experience in private prac- tonitfs.a °f pelvicpen" tice, and as a clinical teacher, may be taken as a 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 litis"21" 3G U" ^ie history of many cases in my clinic 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 iar tunfc68 m thG VaS°U" wnen Ave come to speak 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 The common diseases f th general economy. In this regard the of pregnancy. ^ « f 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 sequela?. 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 arc liable during pregnancy. The groups of diseases naturally involve the more prominent organs and functions, and are more or less serious, according to circumstances. 50 THE DISEASES OF WOMEN. TABLE OF THE DISEASES OF PREGNANCY. The Circulatory System. The Nervous System. The Digestive System. 1. Of the Blood: a Plethora. b Anaemia. c Chlorosis. 1. Of the Mind: a Irritability, timidity. b Melancholia, vertigo. c Capricious inclina- 1. Of the Movth. a Stomatitis. b Toothache. c Ptyalism. d Uraemia. e Hydraemia. / Chloraemia. tions. d Often entire change of temperament. 2. Of the Circulatory Organs: a The heart. 2. Of the Sensory Nerves: a Pain: headache. 2. Of the Stomach: a Morning sickness and b Palpitation and syn-cope. b Neuralgia. c Over-sensitiveness. anorexia. b Nausea and vomiting. c Hypertrophy, etc. d Veins; varicoses. d Insensibility. c Pyrosis. d Cardialgia. e Haematemesis. / Capricious appetite. g Catarrh of the stom-acn. 3. Of the General Circulation. a QEdema. b Haemorrhoids. c Haemorrhages. d Varicoses. 3. Of the Motor Nerves: a Spasms; convulsions b Eclampsia. c Epilepsy ; chorea, etc. d Paralytic conditions. 3. Of the Bowels: a Constipation. b Diarrhoea. c Dysentery. 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 through dulagp'regnlncyl00d puerperality and lactation, so as to impair the 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-third 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 the 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 sorifetimes 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, we may look for valvular complications which are Effects of the rheuma-. J x . tismof pregnancy. in the way ol a perfect recovery, lor 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 appear in dropsical, haemorrhoidal, 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 Nervous affections. 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-cerebraidisor- ter class'of cases especially, that the most serious conditions of mental derangement^nay 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 pregnancy 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-like thoge of diphtheria. Exceptionally, how- rebro-spinal nerves. L L "7 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 before 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 durino- 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- na°yorrgeans0f ™*"*' ment of BriSht's disea*e> with its accompanying albuminuria, urasmia 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 Pulmonary disorder, function> or °f both> pulmonary disorders that may occur at this time have no especial sio-nifi_ 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 The vi* medicatrix of health> Xervous, hysterical and dyspeptic dis- pregnancy. J " , 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, dysmenorrhcea, chronic metritis and prolapsus uteri. I think that in our day it is generalty conceded that the effects of pregnancy upon the development of phthisis Effects upon phthisis. . ,. . ,,. , ,, ,. ., pulmonalis, is that, although tor 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 Preo:nancyovari.m 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 uponovarianfoetus jg ^eiopi™ jn utero. But their course tumors, etc. j. o . -, ,. » 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, or of epilepsy, is all the more likely upon The diseases of preg- l r J ^ L nancy may recur in theexposure to have a second attack, so a woman non-pregnant. wn0 nas Sllfj*ei-e(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- x, . . tion may afterwards act as an exciting cause Menstruation may be J & the exciting cause forthereof, so that, practically, it is as if gestation t is relapse. 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 primiparae ; do. multipara; traumatic lesions of. 5. Puerper.vlity.—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. 1. 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 of parturition. This'is true, whether she goes system. L . a to term or not. For the extrusion of the ovum necessarily involves a drain of nerve force, and a shock, also, if 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 Da pnmiparae. 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 n 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 Koberton 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 . Every woman, whose first labor was very pain- ful and protracted, and accompanied by 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 multipara? without any reference to the lying-in as a factor in tneir 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 . . , . a affections that are practically unknown in women who have never been pregnant. Amono- 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 vaoina 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'^ SGlf" eases of the puerperal period are self-limited, providing, of course, that they are not improp- erly treated. AVe 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 an}' unci 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 concerns the entire varjous tissues : and that if it is defective, either uterus. 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 Avomen. At my last clinic I showed you a case of exfolia- * De la paralysie diphtherique. Rech6rches 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?tS °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 ^?SSinvSS^'catarrhal and P>'^ic for™, this lesion is likely 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 faulty nutri- tion occurs as a consequence of some injury received clurino- 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 must, 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 Effectsof cervicaiiacer- is no question that such lacerations will often ac- count for the erosion, the ectropium, or eversion of the cervical mucous membrane, the cervical leucorrhcea 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, wiiieh we imd 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 days Effects of inconsider- „ p, 1 1 • T .. . r ate counsel. alter delivery, I must caution you against the mischievous habit of alio wing 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 arc silly in the last degree. Moreover, when a physician who is in general practice ad- maynerd\oTqlTimed,vises his Patient to sit up and nurse the child 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. clinicfl.1 test tion them closely and answer if the great majority of them have not had menorrhagia, prolapsus, and a uterine leu- corrhcea ever since the child was weaned, if not from the date of vts 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. ^ 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-partum con- The natural stimulus tl.actjon 0f the uterus. In a reflex way the for uterine retraction. tit- • r 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 pyaemic 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 why 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- tioEn^n^orUo0n."laCta" tion is the first steP towards the normal involu- 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 linincr 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 Avill serve as an illustration. Case.— Mrs. S., aged 2(5, had a miscarriage at the fourth month of her first pregnancy, five months ago, in consequence of which GENERAL PATHOLOGY—CONTINUED. 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. . 1 . n . 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 of lactation, is prophylactic of uterine whynarsingisavai- disease> The fact that while a woman 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 afflux 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 Weaningmaybeharm-men an(j also by jncreasino- the risks of tOO ful. ° 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 in 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 nee- h the menses have been re-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 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 give rise to functional and organic disease of the womb, to sub-invo- 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 Undue lactation. GENERAL PATHOLOGY--CONTINUED. 63 thirty-five years old, and had been married but ten years, ye* during that brief period she had nursed a baby for about eighi years! VII. The Climacteric.—This is the last act in the physiolog- 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 General qualities of their r00t in 01ie °f three Conditions of the geil- the climacteric disor- eral 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 they may not have been subject to it The plethoric troubles., -,.,., , . before, which is due to the suspension of an habitual discharge, aud 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. We 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 trou es. cn|orosjs# The 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 " hydrogenoid 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. , ., it,.. what was incident to menstrual life, 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 dcwn 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 conclusions. clinical history 0f 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 ^lSoZZ CaWed by which are caused °y this crisis> those which are iQis crisis. t 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, leucorrhcea, haemorrhoids, dyspepsia and the vomiting of mucus and of blood, flushings and local perspira- * Traite de la Menstruation, ses rapports avec l'Ovulation, la Fecundation, etc., par A Raciborsici, 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- aemia, 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 Diseases cured by it. /», . i -. , fibroids and to the various uterine displacements, to leucorrhcea, 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. Amenorrhcea, dysmenorrhcea, 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- ^Diseasesthatco-extet tically 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- Post-ciimacteric af- ^-m gjJ|n an(j kowej affections, and phthisis, there fections. ti -i 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. s LECTURE 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. fBy the vagina. By conjoined manipulation. By the rectum. I By the bladder. [ By the use of the sound. 4. Percussion. 5, Auscultation. 1. Inspection.—The examination by the sight is resorted to in four different ways; [a] To the external abdo- Varieties of inspection. , men; \b\ directly by the unaided eye in diseases of the external genitals; [c] indirectly to the vagina and uterus, by means of the speculum; and [d] by the forcible eversion of the rectum. Abdominal Inspection.—In inspecting the abdomen the patient should either lie upon her back or stand erect. In many cases it is a good rule to place her in both of these positions successively. b The " Touch." - physical diagnosis in gynecology. 67 This mode of examination detects any abnormal projection, such as the tumor formed by the gravid uterus at or after the fifth month, a considerable enlargement of either of the ovaries, fibroid tumors, an excessive accumulation of urine, and ascites. It is not an accurate means of exploration, for it often happens that abdo- minal tympanitis may cause such a projection of the parietes as shall simulate the tumors of which I have just spoken. Inspection of the External Genitals.—Direct visual inspection is resorted to in diseases affecting the vulva, as, for example, in vul- vitis, vaginitis, pruritus, abscess of the labia, abscess of Duverney's gland, vulvar enterocele, and hematocele, and also in urethritis and vascular tumors of the meatus, gonorrhoea and chancre, cyst- ocele, rectocele, and external displacements of the uterus. This method of examination, however disagreeable it may be, is some- times indispensable. It should be made in a strong light, and in order to prevent a necessity for its repetition, should be as thorough as possible. Here is a speculum for the labia that is sometimes useful. Fig. 1. Wire Speculum for the Labia. Inspection by the Uterine, speculum.—By the aid of the uterine speculum, which is a very old instrument, the neck of the womb Fig. ~. Ferguson's Tabular Speculum. and the wall of the vagina are exposed to our view. Here, upon the table you will find a variety of speculae, from which we must 68 THE DISEASES OF WOMEN. select the most appropriate for the case that is under treatment. The simplest, and cheapest, and one that will answer for ordinary practice, is Ferguson's tubular speculum, which is made of a tube of glass that is coated with quicksilver, covered by India-rubber, and afterwards varnished. There are two forms of this instru- ment. Fig. 3. Ferguson's Modified. Ill either of its forms this speculum has, however, such a limited range of application that it will not do to depend upon it exclu- sively. Indeed there is no speculum in the form of a tube that fills as many indications as the valvular instrument. And I recom- mend you either to buy Cusco's duck-bill speculum, or some mod- ification of it. Here it is: This instrument, which was devised by a prominent oculist in Paris, has, like the obstetric forceps, been changed and modified a great many times, but without being materially improved upon. For all the prac- tical purposes to which a bivalve speculum can be applied, the old Fig. 4. Cusco's Duck-bill Speculum. form is the best. I advise VOU not to buy one that is too short, as some of them are; for I have mu ^ , found it a good thino- to have a speculum which The best speculum. . - x can be used either as a long or short one, just as I have found it .best to supply myself with the lono- obstetric forceps which can be used at the inferior strait also, when it is necessary. You can make use of a long Cusco as a short instru- ment, if you need to; whereas a eho^ odr would not always answer your purpose. It is a good rule in gynaecology, and in general surgery, not to a sensible rule. multiply or to load yourself clown with instru- ments. If one speculum will fill a number of indications, you do not need to. be burdened with half-a-dozen sizes or as many kinds of the same instrument. PHYSICAL DIAGNOSIS IN GYNAECOLOGY. 69 I also advise you not to select a bivalve speculum in which one blade is shorter than the other, for if you become expert in the Cautions USe °^ *k's instrument, and are careful to adapt it properly,you will do better work if the blades are of equal length. The reason is, that in the latter case the speculum is applicable to all kinds ot cervical deformities and deviations, while in the former it is not. Xor should you select one in which the upper blade is divided, for when it has been passed, and the blade separated, the roof of the vagina will be very apt to fall between them and to obstruct the view. This is the objection to Xott's Nelson's, Meadows', Graves', Bozeman's, Jenks', Ball's, and also to Hough's five-blade speculum. Here is a specimen of my friend Nelson's instrument, which, Fig. 5. Nelson's Speculum. when the blades are divided, in case of a redundencyof the vagirial tissue, will permit it to fall between them on all sides, and so defeat our purpose. Hunter's short and stubby bivalve is especially adapted to those cases in which the cervix is either very short congenitally, or as a consequence of amputation or of excessive cauterization. There is no practical advantage in having one of the blades cut open as some of these are for the purpose of passing the uterine sound, and for its manipulation afterwards. I shall refer to this matter when I come to speak of the uterine sound. There is no doubt that Dr. Marion Sims' discovery of the spec- 70 THE DISEASES OF WOMEN. ulum that bears his name was one of the most important events in the history of American Medicine and Sur- sims speculum. aery. This speculum also has been variously modified but without being materially improved since Sims' first Fig. 6. Sims' Speculum. used it as a perineal depressor, in making the operation for vesico- vaginal fistula. As the patient is lying upon her left side, the posterior com- missure of the vulva and the perineum are drawn steadily back- ward to ward the sacrum and coccyx. The air dilates the vagina and by means of this wire depressor applied at its anterior portion the cervix is fully exposed to view, by what is practically a bi- valve speculum. As you will readily infer this speculum is specially adapted for use in surgical operations within the vagina. I shall therefore have occasion to show you how and when to use it when we come to the operating table. There is a modification of it however, Fig. 7. Dawson's Sims' Speculum. which adapts it to ordinary practice, and which has the advantage of being portable and of affording two sizes of the same instru- ment. This is known as Dawsons' Sims'. In the use of this instrument the single blade is passed over the perineum with its concave surface looking towards the symphysis- pubis. Here is a modified Sims', attached to a self-retainino- rubber PHYSICAL DIAGNOSIS IN GYNECOLOGY. 71 harness that runs along the back and over the shoulders of the Fig. 8. Self-retaining speculum. patient. Happily, I have forgotten the name of the " modifier." Although Dr. Barnes has really improved upon Xeugebauer's instrument, I have found it inconvenient and objectionable. For even with the greatest care in its introduction and withdrawal, one is very likely to pinch the vaginal folds and to hurt the pa- tient. Fig. 9. Barnes' Neugebauer's Speculum. As to the mode of applying the speculum, authorities are not quite agreed. Without quoting all they have said and thereby confus- ing your minds on this subject, I will briefly state what my own How to apply the speculum. 72 THE DISEASES OF WOMEN. practice has been. The patient is usually placed upon the back with the hips drawn to the edge of the bed, or, of the operating chair or table. We may use Wilson's chair,(Fig. 10), or Archer's (Figs. 134-5-6), or Chadwick's table, (Fig. 11); but in the hospital you will observe that my patients are placed upon a short, firm table, which has been made expressly for that purpose. The bed or table should be drawn before a window in a strong direct light, for the sunlight is better than any The table. kind of an artificial ii It is well> howeVer, to vary the position that is chosen with the object sought for by the exam- 76 THE DISEASES OF WOMEN. ination. Thus, if you desire to examine the vulva and the vagina thoroughly on all sides, to feel along the course of the urethra, to ascertain if the uterus or the bladder is prolapsed, or to meas- ure the length and the circumference of the cervix, (if it is not beyond reach) she had better lie upon her back. But, if you wish to know by the touch whether the womb is flexed upon itself, if it is high in the pelvis, to explore the posterior roof of the vagina, and to sweep the finger around the cervix, place her on her left side. In order, however, to examine the right or the left lateral cul-de-sac, it is sometimes best to have the patient lie upon the opposite side, and to use the index finger of the right or of the left hand, as the case may require. Where there are intra- pelvic tumors which affect the size and the position of the uterus, the bladder, or the rectum, we may find it necessary to apply the touch while the patient is standing erect. In the virgin the touch is best applied by placing the patient on the left side, with both knees drawn up and closely applied to each other. The finger, or fingers, for it is sometimes necessary to use more than one, should first be anointed as directed for the speculum. Then, the patient being covered with the bed-clothing, or with a sheet provided for the purpose, the index The use of the finarer. _ /•,-,, t . ,\. finger which is flexed upon itself, may be passed between the labia with its point toward the anus and its palmar surface looking backwards. Once within the vulvo-vaginal orifice, the necessary manipulation should be slowly and carefully made. The object of the " touch " as thus applied, is to note the heat and dryness, or moisture of the vagina, its capacity, the integrity of the vesico- and of the recto-vaginal walls, What may be learned . ° ' from it. the size and sensibility of the uterine cervix, any inequalities of its surface, the form and comparative size of the two lips of the cervix, the shape and patency, or the closure of the os-uteri, the mobility of the womb, and the presence of tumors in the retro-uterine pouch. Thus you will see that the skilful gynaecologist will need to have the means of diagnosis literally at his finger ends. Conjoined Manipulation.— What is sometimes styled bi-manual palpation consists in the use of abdominal and vaginal palpation at one and the same time. While the index finger of one hand is within the vagina, the bladder having been emptied and the knees flexed, the other hand is placed upon the abdomen, and by pres- PHYSICAL DIAGNOSIS IN GYNECOLOGY. 77 sure with the tips of the -fingers directed toward the superior strait, the pelvic organs can be readily felt around the symphysis pubis and between the two hands. This method of exploration is not, however, applicable when the patient is standing. This double mode of palpation is useful where the uterus rests very high in the pelvis: where its size is in- When it is applicable. -, . creased as in pregnancy, sub-involution and hypertrophy: in case of uterine and ovarian tumors, and abscess of the broad ligament; to detect the anchorage of the womb in cancer, or as a consequence of pelvi-peritonitis, or of pelvic cellu- litis; in flexions and versions of the uterus; and in the diagnosis of all kinds of retro-uterine tumors. Its application is very easy in thin and delicate women, and, as a rule, directly after delivery at term ; but it is more difficult in those who are fleshy, or who have never borne children. In order that it shall be successfully employed the patient should understand what it is that we are about to do, otherwise, it might happen that through fright or timidity the abdominal muscles would be so contracted as to interfere with our purpose. The combined touch is sometimes very useful also, as an aid in the diagnosis of intra-uterine growths and The uterine touch. ' T i • r- • • tumors. In this case the finger is passed into the uterine cavity, which permits of a tactile examination of the lining membrane of the womb, by which we may recognize the presence of granulations, polypi, fibroid tumors, and abnormal growths of various kinds; and also of the conjoined examination of the uterine parietes and of the neighboring organs. It is sometimes, although not very often, of great importance to have the womb so under our control that wTe can examine it as thor- oughly and as carefully as if it were lying on the table before us. But, in order that the uterine " touch " may be practised suc- cessfully, two conditions are indispensable, (1) that the os-uteri be thoroughly dilated, or dilatable; and (2) conditions for apply- tnat the uterus shall be so free from abnormal inif it- .,,.... attachments as to permit ot its being pressed downward into the pelvic cavity by the hand that is upon the abdomen, so that the finger may be applied to its internal surface. Without the former, the admission of the exploring index finger would be impossible; and, without the latter, the retreat of the uterus would be inevitable. LECTURE V. PHYSICAL DIAGNOSIS---CONTINUED. Physical Diagnosis, continued. The three kinds of rectal touch ; manual exploration of the rectum, or Simon's method; the "touch" by the bladder: the touch by the sound, why and when it should be employed; directions as to time and mode of its introduc- tion, the position of the patient; the conjoined use of the speculum and the sound, a rare Case. Sim's elevator as a sound. The sound in fibromata; do. instead of the tenaculum, i. Percussion—Object and range and use of, in pregnancy, ascites, ovar- ian dropsy, and uterine tumors. 5. Auscultation—Use and range of, cases to which it is adapted. At the close of my last lecture I had not finished the subject of palpation, as one of the modes of physical diagnosis in the dis- eases of women. It, therefore, remains to speak of the " touch" as it is sometimes applied through the rectum, the bladder, and by means of the uterine sound and the probe. The Rectal " Touch."—There are three kinds of rectal touch that we may find of service in our specialty: (1) the introduc- tion of the index finger into the rectum ; (2) the combined appli- cation of the finger within the rectum, and of the thumb of the same hand within the vagina; and (3) the passage of the hand into the bowel, for the purpose of a deeper and a more thorough exploration of the cavity and the contents of the pelvis. Neither of them, however, can take the place of the vaginal touch to which, indeed, they are complementary. Of course the rectum should first be emptied of fsecal matter. With the finger. ^ °h°iCe °f the fill"er tlmt k t0 be illtr0" duced is quite as important as is the choice of the hand in the performance of podalic version. Do not forget, therefore, that you are to select the index finger whose palmar surface, when it has been passed, will look toward the vagina. For this is the side of the bowel that you will need to explore, and through which you must learn whatever you can of the posi- tion and condition of the pelvic organs. This simple touch per rectum is especially useful in the detec- tion and diagnosis of posterior and lateral displacements of the uterus, and of retro-uterine and fiscal tumors, prolapse of the PHYSICAL DIAGNOSIS--CONTINUED. 7D ovaries, and also in ulceration, paralysis and perforation of the anterior wall of the rectum. In young girls it is sometimes resorted to instead of the examination per vagi nam. This mode of the touch may also be conjoined with abdominal palpation. For, by external pressure the uterus The recto-abdominal ft be d t descen(1 and to be held g() touch. that the internal rectal exploration may be more extensive and thorough than it could otherwise be. This expe- dient also enables us to note the changes in the position of the womb which have been caused by the morbid development of the rectum. Some of the members of the class will recollect the examina- tion that I recently made in their presence, of a The recto-vesical touch. *■ . . woman twenty-four years of age, m whom no trace of a womb could be found. The final, and the most com- plete test, consisted in passing the catheter into the bladder, and then, with my index finger in the rectum, observing whether I could touch the point of the instrument. If the uterus had not been congenitally absent it must have lain between the finger and the distal end of the catheter, and I could not have felt the latter as I most certainly did. This fact was confirmed by our friend, Dr. Miessler, who brought the patient to my clinic. But the form of double touch that was practised by Recamier, and extolled by Tilt and others, is the recto- The recto-vaginal touch. . . ". ... . , . ,, vaginal exploration, which consists in the sim- ultaneous passage of the thumb and the first finger of the same hands into the vagina and the rectum. G-ailard prefers the first two fingers, the index and the medius. We may resort to this mode of examination to measure the thickness and density of the recto-vaginal septum; and, also to learn if the smaller tumors as, for example, a prolapsed ovary lying at the lowest extremity of the posterior cul-de-sac, and in this septum are sensitive, movable, or fluctuating. It also permits us to measure the anteroposterior diameter of these tumors or abscesses, as the case may be, and to decide whether and when it is safe or expedient to resort to sur- gical means for their cure. It is indispensable in the diagnosis of rectocele and rectal cancer, and also in some cases of laceration of the perineal body. Tilt recommends it for the detection and removal of foreign bodies lying in the recto-vaginal space. 80 THE DISEASES OF WOMEN. Ill a paper read before the Surgical Association in Berlin, April 13th, 1872, Prof. Simon, of Heidelberg, advised Manual exploration of a method of exploration which consists in the dilatation of the anal sphincters, and the pas- sage of the hand into the rectum. He had already practised this method for some years, and was very sanguine of its adaptation to cases in which it was impossible otherwise, to make a complete diagnosis of certain pelvic and abdominal tumors. You will find the full text of Dr. Simon's essay in the American Journal of Obstetrics, etc., for February, 1873. In performing this exploit, or expedient, the patient will first need to take an anaesthetic. The hand, which in its greatest cir- cumference must not measure more than ten inches, should be thoroughly warmed and anointed, and in what is called the "bloodless" method, the sphincter forcibly stretched with the four fingers of the operator's hand. In the " bloody" method, the anus being very narrow, its margin is enlarged by several notches through its cutaneous border. In rare cases an incision along the raphe and through the sphincter is advised. When four fingers have been introduced up to the origin of the thumb, it constitutes what Dr. Simon styles an'■'examination with half of the hand;" and when the whole hand and part of the fore-arm are passed into the rectum, we have an " examination by the hand, or manual examination." He says: " When the whole hand has been brought into that part of the rectum lying in the concavity of the sacrum as far up as the promontory, we can then introduce three, and even four fino-ers still further up and a small distance into the sigmoid flexure, and reach above the umbilicus without in the least injuring the intestines or the peritoneum, and the upper portion of the rec- tum and the sigmoid flexure being extremely movable, can palpate the whole abdomen as far as the lower edge of the kidney.* If all violence be avoided during the exploration of the upper por- tion of the intestines, and especially if no attempt be made to introduce the whole hand into this part, the examination is entirely without clanger. In introducing the hand through the anus, however, more force is occasionally required, and is perfectly admissible, since neither dangerous injuries nor any damao-e to the subsequent contractility of the sphincter are to be appre- *The lower point of the kidney can be reached if the thigh of the person under exam- ination be strongly flexed. PHYSICAL DIAGNOSIS—CONTINUED. 81 hended. If the muscle be so dilatable as to allow the passage of the hand without difficulty, or after superficial incision of the cutaneous margin, no disturbance of its function is produced; if it be necessary to divide the sphincter, the incontinentia alvi lasts ten or twelve days until the wound is healed. The importance of such a dilatability of the anus during anaesthesia, and the possi- bility of safely palpating the organs of the pelvis and the abdo- men up to the middle of the latter cavity, the finger being only separated from the organs to be examined by the thin intestinal wall, is very evident. For it is possible, as already mentioned, not only to find foreign bodies in the lower part of the sigmoid flexure, and to extract them without injury to the intestine, but we can also diagnosticate diseases of the rectum, uterus, ovaries, and the pelvis in general, which consist in changes of shape, position, and consistence, with much greater certainty than by the former methods of examination. In examining with four fingers, and, better still, with the fingers of the whole hand intro- duced into the rectum, we can reach the fundus and anterior wall of the uterus from behind, grasp the ovaries between the thumb and the other fingers, and feel any increase in size or irregularity; we can, in the male, palpate the bladder up to its vertex and detect any diseased condition, such as stones, their size, shape, and number. I am convinced that, the whole hand being intro- duced, we can, with the fingers, by direct palpation, ascertain the presence of invagination, accumulation of fteces, strictures, etc., as far up as a portion of the sigmoid flexure, feel tumors of the posterior abdominal wall, the mesenteric glands, kidneys, and most of the other organs which are situated in the lower two-thirds of the abdomen or reach down as far,* and thereby gain most useful diagnostic aid. In two cases of ovarian tumor, in which I made use of the manual examination, and in which the result of the exploration was controlled by the subsequent extirpation, I accurately determined the length and size of the pedicle, the nature of the healthy ovary, the absence of adhesions to the brim of the pelvis, and, in one case, two fibroid tumors of the size of cherries, which were situated at the fundus uteri. In a case of multiple fibroid tumors, where I explored in this manner, I distinctly felt the site, size, and breadth of base of the tumors on the corpus and fundus uteri. In one case, I even combined a therapeutical act with the exami- nation, in liberating one of the fibroids of the fundus, which had become wedged into the pelvic cavity and could not be loosened by the fingers alone, from its incarceration, and pushing it with the hand into the abdominal cavity, where I could palpate it with the enlarged uterus in its Avhole extent. In one case of hydro- * Tumors of the liver, stomach, and spleen must be palpable in the same manner, if they reach as far down as the umbilicus. 82 THE DISEASES OF WOMEN. nephrosis I could distinctly ascertain that the tumor had no con- nection with the pelvic organs, which were entirely devoid of adhesions and allowed me to pass my hand between them and the tumor to the anterior abdominal wall, thus permitting me plainly to recognize the lower body of the hydronephrosis and its attach- ment at the posterior boundary of the abdomen. The extensive- ness of the field of exploration thus opened through the rectum, and the accuracy of the results of palpation lead me to consider the examination with the half or whole hand as applicable to all cases of important affections of the pelvic or abdominal organs, when the modes of exploration hitherto usually employed do not give sufficient information. The inconvenience of putting the patient under chloroform is, in my opinion, completely out- weighed by the importance of the information obtained in this manner. The manual examination may be assisted by the simul- taneous palpation of the organs in question with the other hand through the abdominal walls (bi-manual examination) as is like- wise clone in the ordinary explorations per rectum with one or two fingers." In his monograph on the " Manual Palpation of the Rectum" this author subsequently modified his views and qualified his state- ments concerning this mode of exploration. The general expe- rience now is, that too much has been claimed for it, and that it is only adapted to those rare and difficult cases in which every possible means of clearing up the diagnosis is justifiable. Theo- retically it is all that we could desire, but practically, as a single resort, and by itself, it is not to be depended upon. The opinion expressed by Emmet is quite to the point.* " I have succeeded in passing my hand into the rectum several times, and without the slightest bad result, as the sphincter en- tirely regained its power in a few days; but I succeeded in gain- ing no further information than, nor even as much as I could with one or two fingers alone, since, from the cramped position of the hand, there was no freedom of motion. To introduce the hand it is always necessary to administer an anaesthetic. If this is done I can, with two fingers, reach well up to the sigmoid flexure, and by conjoined manipulation make a still more thorough exploration of the pelvis. As the sigmoid flexure is so bound down, I cannot divest myself of the conviction that it is dangerous to attempt to pass beyond it." When we reach the subject of uterine and ovarian tumors, more especially in my clinic and at the operating table, I shall have * The Principles and Practice 'A Gynaecology. By Thomas Addis Emmet, M D etc etc. 1879. p. 70. PHYSICAL DIAGNOSIS—CONTINUED. 83 more to say of the use and abuse of Simon's method of rectal exploration. The " Touch" as applied to the Bladder—The definite propo- sition to pass the finger into the bladder for the purpose of apply- ing the " touch " to the body and fundus of the uterus anteriorly, was first made by Noeggerath in 1875.* The operation consists in the dilatation of the urethra, either slowly, by means of a suit- able instrument, a long sponge tent, or laminaria Mode of applying. . . TV? i ,1, i n bougies, or rapidly, by a Molesworth s hollow rubber bougie, or by the direct and forcible introduction of the finger. The patient should be placed under the influence of chlo- roform or ether, and, on account of the risk of haemorrhage, the dilatation should not be practised at or very near the menstrual period. The rectum should first be emptied, and the vagina cleansed with an injection of carbolic acid and water; and, in order to counteract the effect of the vaginal Precaution. , . „ .. ,. ^ „ mucus on the urine, as a cause of alkaline fer- mentation, the finger should be anointed with carbolized cosmoline, or a similar disinfectant. Since the course of the urethra is parallel to the posterior sur- face of the symphysis pubis, the patient should lie upon her back, with the limbs drawn up, as for lithotomy. The index finger of the left hand having been passed into the blad- The vesicovaginal and d that of the v[ ht h{md m alsQ be intro_ the recto-vesical touch. . . duced into the vagina, or into the rectum, as the case may require, and either form of conjoined manipulation be practised at will. This gives you an idea of what is known as the vesico-vaginal and the vesico-rectal touch. The kind of cases in which it is claimed that these methods of exploration are useful and practicable are those Cases to which it is ° wnich on account of the density or rigidity suited. , . i n -i nil of the abdominal and vaginal walls, the usual application of the " touch " has not been satisfactory. These cases include the recognition of small tumors within the pelvis; a final test for inversion of the womb, and for a congenital absence or malformation of the womb; the early diagnosis of pregnancy; for protecting the bladder against injury while removing a por- tion of the supra-vaginal cervix, and to complete the diagnosis of heteroplastic tumors in the neck of the uterus. *The American Journal of Obstetrics, etc., Vol. VIII., p. 123, 84 THE DISEASES OF WOMEN. The risks of this expedient are serious enough to more than counterbalance the good results that ma.y be expected from it, and the consequence is that it is not often resorted to; nor is it in very good repute with careful gynaecologists. Risks and sequelae. ^. . . , , , -. ,. l . , Ihese risks include the danger from haemorrhage. from paralysis of the sphincter, with a resulting incontinence of urine, and lacerations and inflammation of the neck of the bladder. The range of use for this method of exploration, when it is expe- dient, is very limited, for it would not be warrantable in the early diagnosis of pregnancy, nor in the matter of detecting a con- genital absence of the uterus, is it in any wise preferable to the conjoined touch afforded by the catheter in the bladder and the finger in the rectum. The " Touch" as Applied by the Uterine Sound.—You are doubtless well aware that this instrument, of which you will find several varieties upon the table, has been in use for cen- turies. By the ancients it was regarded as a In diagnosis. . " . curative means. They scarcely used it for any other purpose than to replace the uterus when it had become dis- Ftg.12. The Uterine Sound. located. But, in the hands of modern gynaecologists, it is regard- ed almost exclusively as an aid to diagnosis. In this manner it enables us to diagnosticate: (a.) Certain Diseases of the Uterine Cervix.—If we know what the proper dimensions and length of the neck of the womb are, or should be, by passing this instrument, we can In diseases of the cer- -i • i •/• . 1 • ~ , vix decide it the case is one of hypertrophy, atrophy, or immobility of this part of the organ ; if it is imperforate; if there is cervicitis, or a polypus, or uterine dis- placement. Atresia, obliteration and flexures of the cervix, as well as a more or less permanent closure of the internal os uteri in mechanical and spasmodic dysmenorrhcea, are also recognizable by means of the sound. (6.) In diseases affecting the cavity and body of the uterus.__The PHYSICAL DIAGNOSIS—CONTINUED. 85 very ease of introduction of the sound through the internal os uteri, during the inter-menstrual period, sug- caIvityiseasesoftheuterine gests tnat a11 is not rignt within the cavity of the womb. It is a sign of endometritis, or of the presence of some foreign growth, as, for example, either sub- mucous or interstitial fibroids, polypi, hydatids, cauliflower ex- crescence, or of cancerous degeneration. (7.) To measure the size of the uterus.—In health the unimpreg- nated womb measures about two and a half inches from the os to the fundus uteri. But this organ is so disten- For measurement. . sible, so given to development and to variations in its size and capacity from pathological, as well as from physio- logical causes, that we may sometimes learn much in a diagnostic way from its actual measurement. This, of course, is best accom- plished by means of the uterine sound. Passing the instrument in the direction of the axis of the organ, through its whole length, and taking care to indicate the extent to which it has entered the uterus, we obtain the longitudinal measurement of that organ. If it is lengthened to four, six, or more inches, and the woman is not pregnant, or has not very recently been delivered, the informa- tion thus obtained makes us confident that something is wrong. By this means, therefore, we may be able to In uterine hypertrophy. ,. - diagnosticate a longitudinal hypertrophy ot the womb, a very interesting case of which, I will take an early occa- sion to show you. By it, also, we may detect sub-involution and super-involution, as well as enlargements of the uterus due to the development of various kinds of tumors, as, for example, uterine fibroids, within its cavity. Thus, in the case of Mrs. H., you will remember, although she had a large ovarian cyst which was re- moved in presence of the class, the uterus measured six inches, and was found upon actual inspection to be very considerably enlarged. In order to be accurate in tliis kind of measurement, it is well sometimes to use the graduated sound. (77.) To test the mobility of the Uterus. — In not a few cases the non-susceptibility of the uterus to motion is a diagnostic test of great value. We apply this test by introducing the sound, and then observing whether, when we move it laterally and carefully, the womb moves along with it. If it does, the organ is free, and 86 THE DISEASES OF WOMEN. not bound down by adhesions or organic change; but if it does not, some pathological change has been going on which has resulted in its becoming glued or adherent to the neighboring parts. This sign is present in cancer of the inferior segment of the womb, and in certain confirmed cases of pelvic cellulitis, and more frequently in pelvic peritonitis. We also In uterine carcinoma ^^ ^.^ .^ ^ ^^ ^^ ^ ^ ^^ cases of retroversion and of retroflexion of the womb, in which the organ is anchored, so to speak, by strong adventitious bands attached to the rectum and the posterior pelvic tissues. This, as you know, is one of the means of differentiating between uterine and ovarian and other abdominal tumors. Plac- ing the left hand over the abdomen, and mov- ing the sound in utero with the other hand, as I have just indicated, if the motion of the womb is communicated to the tumor, or, in other words, if the womb and the tumor move simultaneously, in the same direction and to the same extent, we are assured that the tumor is uterine. But if the uterus can thus be moved independently of the tumor, there is no doubt of its being extra-uterine. (7.) In the diagnosis of Uterine Displacements.— It will occur to you, without doubt, that any considerable disorder of place in the womb would necessarily include a deviation In deviations of uterus. . of its axis from the normal one. I he direction of its long diameter, and therefore of its curve, would be changed. Now, in order to ascertain what direction the luxated organ has taken, and the extent of the displacement, more particularly in versions and flexions thereof, we must depend almost entirely upon the sound. If the womb is in situ, what might be termed the pelvic curve of the instrument (as we speak of the pelvic curve of the obstetric forceps), looks forward, toward the sym- physis pubis, and the point thereof corresponds with the axis of the superior strait. But if the womb is bent forwards, or back- wards, or laterally, the curve or concavity of the instrument will be found towards the bladder, the rectum, or the right or the left iliac fossa, as the case may be. Sims' uterine probe, which is a modified or attenuated sound, is sometimes very useful in this class of cases. In prolapsus the sound enters more readily, and its point takes PHYSICAL DIAGNOSIS—CONTINUED. 87 the direction of the axis of the inferior strain or of the vagina, and looks toward the hollow of the sacrum, or toward the sacro- vertebral eminence. In procidentia, the os being at the lowest part of the tumor, the sound may be readily introduced. By this means we differentiate between procidentia and inversion of the womb; for, in the latter, the os uteri can not be found before the organ is reposited, and therefore in inversion it is quite impossible to pass the sound until that operation is performed. Of late years, as I have already said, the ordinary sound is not often used as a means of replacing the uterus. In exceptional cases, however, it may still be used for this wo^bthereposition°fthe PurPose- Drs. Elliott, Sims, and others, have brought out such improvements upon the old instrument as render it much more safe and valuable as a means of fulfilling this indication. I have known physicians to fail to learn anything from a resort to the sound because they did not have tact enough to discover, and no one had told them, that there were certain times and sea- sons in which this instrument could be used to more advantage than in others. As a rule, I think you will find that the sound can be more readily passed in the early than in the later part of the day. If you can be per- mitted to make the operation early, before the patient is up, or has been upon her feet in the morning, it may be much more easily and thoroughly accomplished than if you wait until toward evening or bedtime. Sometimes it is well to select a time which is a few hours, or perhaps a day in advance of the menstrual period. The prepara- tory dilatation having been effected in advance in advance of the month- 0f the flow, the internal os uteri is lazily agape, ly flow. ill and less irritable than usual, and the sound is made to enter with but little delay, pain or trouble. You would not attempt to pass it when the patient is very much alarmed or excited, agitated and appre- When the patient is calm, j^^^^ ^^ WQuld [t b(? advisable in case of menstrual retention with softening of the cervix, lest the 00 THE DISEASES OF WOMEN. woman might prove to be enceinte, and you might bring on a miscarriage. Nor would it do any good, but might possibly do harm, to introduce it too soon after menstruation, or directly after delivery. Its use is also contra-indicated in pelvic peritonitis, pelvic cellulitis, and pelvic hematocele, for in cases of this kind it would cause great pain and might work serious mischief. Unless the cervix uteri is closed by an atresia of its canal, which is comparatively rare, the chief difficulty in introducing the sound is met with at the internal os. This obstruction ^Difficulty at the os in- ig cauged either by a change in the course of the utero-cervical canal at that point, or by an irritable condition of the muscular fibres (which form a sort of sphincter about the orifice) which causes them to contract spas- modically on the approach of the instrument. It is a very common error to suppose that the healthy uterus is nearly straight, when in fact it is not so. Cruveilhier, and other TT . anatomists, have shown that, even in little girls, Uterine axis not straight. ./>■..-, n -, its fundus is thrown forward, as in anteversion, toward the bladder. Opposite the junction of the neck with the body of the organ, there is a curve which is in the form of an obtuse angle, as is shown most clearly in this beautiful model, and in the diagrams on the black-board. Now, in order to enter the uterine cavity, the instrument must follow this curve at the internal os uteri, otherwise its point can .... . not reach to the fundus. If the curve, or Variation in uterine curve. ' flexion forward, were uniform and unvarying, in different women, there would be little trouble on this account. But it is not so. For we find that, even in healthy persons, there is the greatest possible difference, not only in the shape, size and position of the womb, but also in the course and direction of its canal. This explains the fact to which I have before alluded, that, having learned the individual peculiarity of a patient in this respect by the passage of the sound, it will be less difficult to perform the operation upon her in the future. There are many exceptions, however, to this rule. It is because of the varying course and curve of the uterine canal in different subjects, and in health and PreKferadbl'lsoundthatis disease, that it is best to use a flexible sound, which is capable of adapting itself to the exist- ing curvature, instead of a very stiff one, which would not yield, PHYSICAL DIAGNOSIS—CONTINUED. 89 and which would require more of force to introduce it. For this reason, the copper sound, and in some instances the whalebone probe, is preferable to Simpson's old-fashioned sound. This copper sound will insinuate itself, whereas in a considerable pro- portion of cases, the old one can not be introduced without an unwarrantable degree of force. Where the uterine canal is bent acutely, forming an elbow, or the uterus is twisted upon itself spirally, we may sometimes pass a Sims* probe, such as I hold in my hand, and then withdraw it so carefully that it will retain its shape. The larger sound can then be bent into the same form, and afterwards passed more readily. Concerning the best position for the patient to assume, some- thing will depend upon the nature of the case which is to be examined. Usually, it is best for her to lie Position of the patient. i r> • n upon her left side, on the bed or couch, to have the thighs flexed on the abdomen, and the legs on the thighs. This will enable you to find the cervix most readily, and to give the proper direction to the point of the instrument, when it has passed into the cervical canal. If she lies upon the back, and the uterus is not prolapsed, more especially if the vagina is long and your index finger is short, you will experience considerable diffi- culty in reaching the neck of the womb at all. And when you have reached it, the finger will come against the anterior lip, and the organ will recede into the hollow of the sacrum, so that it may be next to impossible to pass the sound even through the external os uteri. There are exceptional cases in which the womb is displaced in an upward direction, in which, no matter what the position of the patient, it is very difficult to pass the sound. In these cases, it is recommended to let the patient stand upright, with her back against the wall, while the operation is being performed. But ordinarily this is not requisite. If there is retroversion or retroflexion, the woman may be placed on the bed, couch or table, as for the introduction of Sims' speculum, on the left side, far over upon the in displacements back- abdomen, with the right thigh flexed and the wards. ° ° left one straight. Or, if this is not sufficient, with the aid of gravity, to bring the fundus forwards, so that the sound may pass readily, she may take the knee-elbow or prone 90 THE DISEASES OF WOMEN. position. In the latter case, before she gets upon the knees, you had better secure the cervix for fear it may recede and pass beyond your reach. This indication may be met by means of the uterine tenaculum, an ordinary volsellum, or what answers equally well, and is less painful, by introducing the sound as far as may be before she turns over, then keeping it within the cervix while she is changing her position. In anteversion and anteflexion you may take the precaution to recommend her to lie on the back for a number of hours before m displacements for- yon pass the sound. She should also be ward* instructed not to void her urine unless it is absolutely necessary, for about the same interval, in the hope that its accumulation in the bladder may help to restore the womb to its proper position. Indeed, you should not forget that the full- ness or emptiness of the bladder and the rectum may greatly influence the facility with which it is possible to pass the uterine sound. It is the habit of some physicians always to use the speculum as a means of facilitating the introduction of the sound. Since the invention of Sims' speculum especi- lumTnd "ounT °f specu" allJ' this practice 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 lielp 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 tuct are to place the patient in a proper position, to ascertain the direction Points to be observed. of ** *terhie Clirve' to manipulate carefully rather than forcibly, to have the proper instru- 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, „ J ,. . while being guided by the left hand, and made Mode of introduction. i a 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 forcenger fr°m t0° much an<^ PasKes lnto fhe 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. , . 1 . ligent 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 92 THE DISEASES OF WOMEN. than you perhaps imagine. At any rate you will be more likely to fail than to succeed if you are rash and pre- ••Festinaiente." cipit.lte 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 form Prof. of you will remember a case in my clinic during the spring term, in which it was impossible to pass any of uterine sound that we could find. —, an expert gynaecologist, being Sims' elevator as a sound. 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 The elevator in fibroils. ... 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 ail- FlQ-1*. 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 sound in fibroids. PHYSICAL DIAGNOSIS—CONTINUED. 93 Another of my "wrinkles" is to use the sound instead of the tenaculum or the vulsella, to bring the uterus towards the vulva for a more careful inspection and exploration. Sound versus the ten- tm • • 1 1 • -^ /• n ,, i ftcu,um. Ibis is done by passing it carefully through the internal os-uteri to the fundus and allowino- 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 will 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 very The uterine probe. J narrow or tortuous canal of 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 useful. There are several varieties of these probes, of which the flexible silver one, known as Sims' probe is the best. Fig. 15. Sims' Silver Probe. ^Q Thomas' hard rubber probe, and his elastic probe also, are some- times of excellent service. Fig. 16. Thomas' Hard Rubber Probe. 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 The position of uter- fortunate that they almost always come me tumors. J J i • -n forward and lie against the abdominal walls. I>v 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 exists in 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- are g() fil|efj witQ ^as ag to „\ye rjso tO what is nance. . '- 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 increa-es with advancing pregnancy, the area of dullness on The uterine tumor in percussion also increases. So that, in this case pregnancy. l 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, wdiether 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 Jthe intestines away, either lat- erally, posteriorly, or upwards into the epigastric region. 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 Tn fl,SCitGS 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. In ovarian dropsy. **' th(J tUn1.01' is kl»e enough to extend beVOlld the umbilicus, with very few exceptions there will be dullness on percussion throughout its whole extent, and the 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- pa?ent°8tUrft0f ^ sion is aPPlied whilp 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 ha\c, 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 m uterine /falsely S0-Called), cysts of the broad ligament, tumors. \ J /' - r> 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 hematocele. 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. i • 1 1 t • j_ •> 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 gyne- cology in our clay 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 LVIII.) 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 LVIII). Part Second. THE DISEASES OF PUBERTY. LECTURE VI. CHLOROSIS. Chlorosis. 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 amemia ; 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 suffers 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 aloe nasi are almost colorless. The eyelids and features are slight- ly edematous, particularly after sleeping. The teeth are decayed, the finger nails 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 porosis and amenor-almost invariable an accompaniment of chloro- sis, that some authorities have regarded it as identical in nature with amenorrhcea. Otheis 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- Digestive symptoms. pitation, 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 other 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 clue to a functional Cardiac symptoms. ~ change m the rhythm of 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 may 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 has menstrual retention from dysmenorrhcea, and all her suf- .tf^SSSdS?£ST ferinS8 are referred to the cardiac region. 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- rhcea, prolapsus, ovaritis, and chlorosis. By physical exploration we can detect no difference in the incidental conditions of the heart. The whole praecordial 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 The pulse. forty-five or forty-eight. Xow and then, how- ever, you will encounter a case in which it is considerably quick- ened. As a rule, the more marked the anosmia 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 thereby. The anaemic murmur, (bruit de diable,~) which, in most cases of chlorosis, may be heard over the praecordial region, but more dis- tinctly along the course of the great vessels, as The anaemic murmur. •tip i • • • -i the carotid and femoral 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. t-i-i.-i-ii-ilm ^ s likely to be indulged. Mie 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. . . . i t i ti i i-i tions of 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 haematemesis 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 local, 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 amenorrh ii first symptoms, l ou will be consulted lor 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 which 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. "? . will note the order m which they made their appearance ; }Tou 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 amenorrhoea 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- disEeasentiallyaglanduIar 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 amenorrhoea, there is more or less liability to ^ovario-pectorai sympa- the development of pectoral disease. In" the majority, the arrest of the menses predisposes to pulmonary haemorrhage. This is the reason why haemoptysis 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 eases 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 AMENORRHCEA. 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 wras first recognized and described by the late Prof. Simpson. It consists in what he styled super-involution of the uterus following uterUuPser"!nvoluti°n °f the labor. 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 Nervous and vascular signs signify that some portion of the internal systems deranged. o c . Jr 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- chlxil amenorrhoeaI 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 may be 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 was 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 truth. 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 was 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 AMENORRHCEA. 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 every 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 clue 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 u change of life." The age of the patient, and inquiries into her family From " change of life." * l 1 . . J 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 which 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- rhoea is secondary, is also applicable in case of 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 For pectoral complica- • t , , x i "i • tj • -n tions. 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 amenorrhoea, 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- Forsuppression alternat- i i t, • , . ln , ing with ophthalmia. cnoly. 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 amenorrhoea, which persisted for from three to six months at a time. The suppression came without any apparent cause, and AMENORRHCEA. 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 cold.—Belladonna, gelsemium, pulsatilla, dulca- mara, chamomilla, caulophyllin, or macrotin, gelsemium, sepia, sulphur, rhus tox. From check of perspiration.—Cuprum, chamomilla, aconite. From changes in the weather, cold and dampness.—Dulcamara, rhus tox., rhododendron, mix mosch., pulsatilla. From kiking cold by getting the feet ivet.—Aconite, pulsatilla. With leucorr/uea'and constipation.—Alumina, natrum mur., sepia, graphites, collinsonia. From fright^pr chagrin.—Aconite, lycopodium, coffea, opium veratrum vir. From atony of the uterus and ovaries.—Aletris far., caulophyllin, helonias. From mental causes.—Aurum, cimicifuga, lycopodium, ignatia, veratrum alb., aconite, pulsatilla. From defective nutrition.—Aletris far., natrum mur. With congestion of the head and face in plethoric icomen.— (jrlonoine, aconite, belladonna, gelsemium, sabina, sulphur, opium. With eruptions here and there, oozing out a sticky fluid.—Grap- phites. With eruptions when the menses should appear.—Carbo veg., dulcamara. With prolapsed or ante-verted uterus.—Lilium tigr., collin- sonia. 126 THE DISEASES OF WOMEN. With spitting and vomiting of blood at the menstrual period.— Phosphorus, belladonna. With corrosive leucorrhcea in pAace 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. —Sabaclilla. In thin married women, with forcing pains in the uterus.—Secale cor., caulophyllin. With nervous headache and hysterical affections, with cold hands and feet.—Veratrum alb., macrotin. With painful pressing down 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 pale 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. tor 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. AMENORRHCEA. 127 almost clear water in lieu of the menses, and an acrid, corrosive leucorrhcea, silicea. With abdominal tympanites—Belladonna, phosphoric acid, chamomilla. With dropsy—Apis mel., for incidental anasarca, swelling of the feet, puffiness of the cellular tissue ; helleborus, 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 amenorrhoea 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 }tou 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 amenorrhoea, 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- s^ idiopathic suppres- brane# This may be accomplished without 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 gi\en with excellent result. Dr. C. D. Williams reports some remarkable cures with xanthoxylum.J * 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. , , . . P p , . , mate and occupation, it you are careful 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 AMENORRHCEA. 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- Accidental causes. 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. " . "~ t-» • the sanguineous flow from the vulva, rains in the back and loins, around the pelvis, and clown 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 coming 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 qjinical 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. t-» • -i i a i > i • i sound, or probe, Priestly 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 local 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. . being curved like a retort, and the canal of 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 AMENORRHCEA. 131 require a caieful dissection of its adherent mucous surfaces, after which the freshened edges must be separated andnofSihe hySe"^ 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. AMENORRHCEA—CONTINUED. Amenorhoea, 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 spnxma. Case,—remote disease from an arrest of the menses,— "forcing the now,"—effect of rest and quiet,—Amenorrhcea with supra-orbital neu- ralgia. Ca-e,—vari ties of menstrual neuralgia,— lo al and specific treatment.— Spinal irritation with amenorrhcea, convulsions, etc. Case.—Amenorrhcea in advanced phthisis. Case. We will continue the study of amenorrhcea. The notes of the first case concern one of my private patients, and were written by the woman herself. The case is one of AMENORRHCEA, WITH PROLAPSUS UTERI AND OBSTINATE VOMITING. Case. — I am 22 years of age, and married ; have been ill with an intractable gastric difficulty at intervals for six years. This affection first manifested itself after a severe attack of diarrhoea, which was followed by spitting up of the food while it was parti- ally digested, or still unchanged. This symptom used especially to trouble me in the evening, after supper, but sometimes fol- lowed the other meals also. Coffee, pastry, and all rich food, new vegetables, and many kinds of fruit, were the first articles to be rejected by my stomach. Consequently, my diet was reduced to meat and bread. For a time all kinds of fresh meat were well borne, but finally beef-steak was the only one that would be tol- erated. The first attack of this indigestion came on late in the summer and continued for several months. It returned the next year at the same season, and lasted until the middle of the following winter, being accompanied by three months of suppressed men- struation. These combined troubles occasioned severe headache, and bloating of the stomach and the abdomen. However, I rap- idly gained in flesh, which was soon lost when the menses returned. The next season I derived much benefit from a resi- dence of nine months in Saratoga. After drinking its waters I returned home with my disease apparently cured. Two years of comparative health followed, with occasional symptoms of the old trouble, which were generally relieved by the regulation of my diet. The third attack was preceded, accompanied and followed by AMENORRHCEA—CONTINUED. 133 bilious fever and dysentery, with which diseases I was very ill for several weeks. The gastric difficulty did not leave as usual in the winter season. The symptoms continued for more than a year, the nausea and vomiting increased in frequency and vio- lence, and were accompanied by great acridity of the matters ejected, distress and burning. I could compare the feeling which predominated to no sensation except to that which wTould be pro- duced by many pieces of apple-core moving about in the stomach. Constipation and bloating of the abdomen were constant symptoms. Medicine seemed powerless; one article of diet after another was abandoned; my strength gradually decreased ; I became nervous ; my nights were wakeful, with unpleasant dreams, and a dumb ague at last set in. Meat and other solid food could not be toler- ated by my stomach, and soon the entire system yielded to utter prostration and debility. The region of the stomach now became very hard to the feel, but extremely sensitive to the touch. For seven months menstru- ation was entirely suspended. From September to the middle of 1 )ecember, I became wreaker and weaker. I then began gradually to improve, but the vomiting continued nearly every day for about four months longer. For six months I had eaten no solid food whatever, but had subsisted on porridge and farina. For two months I lived exclusively on milk, and a weak strained broth. The first discharge of matter or pus by vomiting took place in September, and from that time on I continued to raise it. In November this matter became more copious, and was thrown up as often as every hour in the day. The most abundant of these discharges of pus were preceded by sinking spells, with difficulty of breathing and numbness. Beside this matter there was also vomited a clear fluid which made the throat, mouth and lips burn and smart severely. But a thick froth resembling the beaten white of an egg, generally accompanied the pus. Intense nervousness, wakeful and often sleepless nights, and severe pains in the head, and also in the back and hips, racked my delicate constitution terribly. For six months, with but a few exceptional davs, the vomiting spells followed each other every one to six hours. I was entirely confined to my bed for four months. This was the condition in which I found this patient on my first visit. She was a bride of a few months. Her husband and family were extremely solicitous concerning her, for, excepting that at times she had a rosy English complexion, she really appeared like one who could not live very long. Further examination of the case from time to time, as she could bear it and as opportunity offered, elicited the following additional symptoms: 134 THE DISEASES OF WOMEN. A large portion of the time, during which she suffered from these attacks of vomiting, the appetite was craving and almost ravenous. This was accompanied by extreme depression of spirits. For several months after the vomiting came to be of almost daily occurrence, there was little or no loss of flesh, the cheeks were red and the eyes bright as in perfect health, but the complexion had a peculiar bluish hue, especially in the morning. The feet and hands, which at other times were almost as cold and colorless as marble, became hot and burning. The perspiration had a strong, disagreeable odor. This odor was especially bad when the vomiting of pus was most frequent and copious. For many weeks the stomach was so sensitive that she could tell the moment the food entered it, and in what part of the organ it was lying. A marked and peculiar feeling for months prior to her illness was that of a sharp distress (the "apple-core" sensation) just at the entrance to the stomach. This was accompanied by a feeling of faintness from lack of food, which eating only increased. Each of these attacks was characterized by a more or less pro- longed arrest of the menses. She also complained of weakness and lameness in the small of her back and hips, with dragging down sensations, occasional dysuria and obstinate constipation. My first impression of the pathology of this case was, that it was one of perforating ulcer of the stomach, and, as you may suppose, my prognostications were very cautiously given. caus°!apsus the exciting My second visit disclosed the menstrual com- plication, and the third interview decided me to request an examination per vaginam. It was accordingly made. I found the vulva in a state of hyperesthesia, with considerable constriction of the vaginal orifice. The uterus was prolapsed upon the floor of the pelvis, and exquisitely tender to the touch. After a little delicate manipulation this organ was lifted as far toward the superior strait as possible, and the patient directed to lie for the most part upon the left side. 1 prescribed nux vom- ica3, a dose to be taken every three hours. The next morning her pelvic and sacral pains had vanished, the headache was relieved, the vomiting had been less frequent, and she was hopeful. In brief, she kept to her wo^fb.ct rep a"ng the bed for about three weeks more, on account of the prolapsus, and also of the menstrual flow, which returned within a fortnight. Once in four or five days the womb was restored, in case it had fallen, with the index finder. Calcarea carbonica3 was the only remedy that she took after the AMENORRHCEA--CONTINUED. 135 first few days, excepting caulophyllin and coffea, which were given incidentally to promote rest and sleep. Menstruation soon became regular and normal in every respect. Subsequent history, J L I he gastric difficulty lessened until almost any kind of food could be taken, relished and retained. Her •• dumb ague" disappeared, and her old flow of spirits returned. In a few weeks her health was perfectly restored. In six months she became pregnant, and now she has a bright, healthy child, which is about a year old. She passed through gestation without any morning sickness or vomiting; and through labor and lactation with no untoward or unusual symptoms. Two years have elapsed and there has been no return of her disease. My object in reporting this case is not to reflect upon either of the physicians who preceded me in its management, but to make a few practical points that will be available to you bye and bye as practitioners. The first of these is that your skill in diagnosis, and }^our success in treatment will depend upon the thoroughness with which you examine and analyze the case in hand. Much has been said of the importance of the " totality of the symptoms" as the basis of treatment. In a knotty, complicated case like this, the " total- ^Totaiity of the symp- ifcy of the svmptoms" inciudes a great deal. It classifies and arranges the gastric, the alimen- tary and the nervous symptoms as the more prominent and sug- gestive; but it is found that those physicians who claim to pre- scribe in accordance therewith are very apt to overlook the menstrual and uterine complications, or, at least, they do not always give them their due prominence. And this fact explains some of their failures. For if we should place undue stress upon the character of the matters ejected, or the frequency and other peculiarities of the vomiting, as interpreting the nature of the disease, and as indicative of the remedy, which is characteristic and most appropriate for its relief—the result would be that our pathology would be at fault, and our therapeutical progress would take the wrong direction. In a case of this kind it is sometimes very difficult, and even impossible to decide which class of symptoms The cardinal symptoms. .^ reaUy the m0St significailt. If OUr judgment concerning them is based upon their objective consequences, and 136 THE DISEASES OF WOMEN. not upon their subjective cause and relation, we shall be very apt to declare in favor of the former. Hence, it frequently happens that the most clamorous signs get the credit of being characteristic and sufficient when, in fact, they are not so. This is a case in point. The uterus was .badly prolapsed, and evidently had been each time that she had suffered from the gastric derangement. The cause of her illness Practical deductions. . n . ., . . , was mechanical and, while it acted, was con- stant in its operation. The reflex functional disorder of the stomach was so severe and long-continued that it finally developed into an undoubted ulceration of that organ. But even when the symptoms connected with that ulceration were at their worst, there was nothing distinctive in them either as to the cause of the difficulty, or the best mode of curing it. The second proposition is that while we are careful not to exclude some of the symptoms arbitrarily, or through neglect, we should not exalt others to an unmerited pro- pro^efsfmptomsWeight'° mmence indiscriminately, and without good reason. The uterine deviation and the men- strual arrest were the cardinal peculiarities of the case under review. When they were relieved the more remote gastric symp- toms disappeared. Now it would not be safe to conclude and to insist from this that pessaries and emmenagogues are the best means of cure in a case of ulceration of the influences proper clinical stomach with similar vomiting; neither to declare that these symptoms are invariably due to the same, or to any remote cause, whether sexual or other- wise. It is the inference we deduce, and the lesson we learn from such an experience that interests the profession, and our patients also. It is the physician's tact in taking hold of the right thread that enables him to unravel the tangled skein of disease. And whoever, in a case of utero-gastric disease, can tell which is the primary lesion, and which is the secondary one ; which symptoms are first in importance, and which Key to success. ' L are not; will have a key to the choice of the treatment proper to these compound cases which he could not otherwise obtain. Starting from this point, he may select the remedy or remedies, surgical or medical, by a reference to his experience, to his library, to his materia medica, or through a AMENORRHCEA--CONTINUED. 137 species of " unconscious cerebration ;" but he will gain his object more speedily, safely and surely than if he took a less compre- hensive view of the case, and always persisted in beginning at the other end of the series. You will readily understand how the extreme and persistent irritability of the stomach, in a case of this kind, might finally involve the most serious consequences. When vomitiS.cts °f excessive all the food that is swallowed is rejected, and the vomiting is so nearly constant, it is impos- sible for the patient to be properly nourished thereby. Her assimilative functions are sure to be impaired. The digestion, the circulation, respiration and innervation cannot escape. And thus the general health Avill be undermined. ( hganic disease will be the indirect consequence, and prostration, debility and death may follow. Indeed the diseases of any portion of the gastro-alimentary mucous membrane are more serious when complicated with uter- ine and menstrual disorders than when they serious nature of utero- C\Q no£ C0-exist. For this reason, in women, gastro-alimentary disorders. 7 the worst cases of intestinal derangement, and indigestion, constipation and diarrhoea are those which are com- plicated with intra-pelvic difficulties of various kinds, as for example, uterine displacements, ulceration, chronic cervicitis, ovaritis, menstrual retention, leucorrhcea, and menorrhagia. The remoteness of these several lesions, — which complicate even when they have not caused the alimentary disorder, and the absence of any very prominent signs of uterine or ovarian trouble, may lead to their being overlooked as prime factors in the case. If we acid to this that a proper physical examination of the pelvic organs is usually the last thing to be thought of under these circumstances, you will see how it is possible for such com- plicated diseases to resist treatment, and finally terminate fatally. These cases vary so much, and are so unlike, that one descrip- tion will not answer for them all; nor will one kind of treatment cure them indiscriminately. Whatever the nature of the indirect cause, its effect should be counteracted by its removal. Possibly not one in a hundred cases of chronic and persistent vomiting may depend so directly as this upon uterine displacement. But 138 THE DISEASES OF WOMEN. the fact that it may happen should not be forgotten, for the very case to which you are called may be one of this kind. Xor need there be any clashing or mischievous interference on account of what may be termed the surgical and the medical indi- cations sometimes presented by the same case. no^ntTdomf ^^^ The uterus can be reposited, its cervix dilated, or the os uteri medicated topically, if needs be, while the constitutional treatment, based upon other and different indications, is still being pursued. * AMENORRHCEA WITH CHOREIC SPASMS. This case illustrates the relation of the nervous system to the function of menstruation. Sometimes it is next to impossible to say whether the menstrual trouble has preceded or followed the nervous derangement. But careful study will help to decide this very important question. Case.—Miss----aged 19, of full habit and general good health, is almost never ill. Her mother says that four days ago, on Sunday last, she took cold while in attendance upon the Mission Sabbath School. In consequence of this her menses were arrested, and the same evening she was seized with a severe headache, which has continued with abated violence day and night until the present time. This pain is described as acute at intervals, extending over the whole head, and aggravated by noise and light. The pupils are slightly dilated, and the face occasionally flushed. She sees objects distinctly, and is rational all the while. Since the onset of the attack, however, she has not been able to sleep more than a very few minutes at a time. Two hours ago a new train of symp- toms was developed. These symptoms have alarmed the parents and friends exceedingly, and for their explanation and cure we have been consulted. Her relatives are in great dread of paralysis. The right hand and arm commenced to jerk spasmodically, so much so that at times it became quite unmanageable. Sometimes the arm and forearm were thrown about wildly, and then extended and flexed quickly and violently. Again, the muscles of the shoul- ders were so severely convulsed as to threaten the dislocation of the head of the humerus from the glenoid cavity of the scapula. Occa- sionally, during these paroxysms, the shoulder is thrown high up alongside the head. These movements are involuntary. It is quite impossihie for the patient to control or suppress them, and when they have ceased temporarily she complains of great fatigue in the affected arm and shoulder. • The paroxysms recur as often as once in five minutes, and, as you will observe, are somewhat *Ten years have passed now (1830)since the above record was made, and this pitient has been well and hearty the whole of that time. The cure ssems to have been radical and permanent, and the daughter is almost a young lady. AMENORRHCEA—CONTINUED. 139 grotesque as well as painful to behold. Excepting the left arm, which is but slightly affected, the remaining portions of the body and extremities are not implicated. The pulse is only 80, and nor- mal in every respect. She urinates freely and frequently, but the catamenia have ceased entirely since Sunday. She thinks that when the nervous twitching and spasm commenced in the arms and shoul- ders the headache became less severe in degree than it was before. It often happens that the menstrual flow is suddenly checked by " taking cold." Getting the feet wet, exposure from insuffi- cient clothing, or from sitting in a draught of air, may induce a complete arrest of the discharge. In the case before us this result was produced by some such apparently trivial means. Practically speaking, there is a distinction between suppression and retention of the menses, which you should never forget. Sup- pression of this function implies its complete prSlKnd SSnT arrest, or rather, that the ovaries and the uterine mucous membrane have'failed to furnish the products which constitute the true menstrual secretion. Retention of the menses signifies that, although the catamenial fluid has been secreted into the cavity of the womb, yet, for some especial reason, or reasons, its escape has been prevented. In the one case it is not poured into the uterus ; in the other it is not poured out of it through the vagina. This distinction corresponds with that made between urinary suppression and retention. In the former, the urine is not secreted, its elements are not selected by the renal organs from the blood which is brought to them. In the latter, although the kidneys have done their work, the ureters, the bladder, or the urethra, are in a condition which obstructs the flow and prevents the discharge of their proper product. A sudden arrest of the menses, *; while the flow is on," is likely to re-act either upon the circulatory or the nervous system, or upon both together. This is a fruitful source Remote disease from 0f m health among women. While this func- arrest of menses. o tion is being performed, it is the easiest thing imaginable, by such means, to convert a physiological injection of the ovaries, and of the uterine mucous membrane, into a patho- logical state of congestion and inflammation. This is a short step, and it is taken in a twinkling. The most serious and intractable results may follow. Other and remote organs with which the 140 THE DISEASES OF WOMEN. pelvic viscera are in sympathy, may be implicated. Here we have evident determination of the blood to the brain, which is directly attributable to this cause. Sometimes this result is even more pronounced and alarming. There are those in whom the slight- est and most temporary arrest of the menstrual flow will induce cerebral lesions that threaten to destroy both reason and life. Our patient has suffered extremely from symptoms of this kind. Fortunately she has escaped the delirium which is usually present in such cases. In its stead, however, there is the insomnia which implies great nervous perturbation and derangement. The spasmodic phenomena have followed indirectly. They are symptomatic. In their production it is probable that the cere- bellum has been especially implicated. For, Symptomatic nervous according to Flourens, Dalton and others, it is phenomena. o ' the particular function of that part of the brain to preside over and co-ordinate, or harmonize the voluntary mus- cular movements. In these choreic jerkings we have evidence that this function is disordered. This young lady suffers from what has been improperly styled " insanity of the muscles.*' The muscles of the right shoulder and arm are in a state of insubor- dination to the will. She commands, but cannot control them. Their irregular and forcible action is exhaustive, and it is not strange that a temporary arrest of the spasms is accompanied by a sense of weariness of the affected parts. Excepting from extreme exhaustion, there is no danger of her becoming paralyzed. If, instead of the cerebellum, the cerebral lobes were involved in this case, there would have been marked delirium, and perhaps a mild and self-limited form of mania. Cerebral troubles, depend- ent on sudden interruption and arrest of the menses, are apt to be characterized by wakefulness, and oftentimes by utter inability to sleep. The hysterical peculiarities which this case presents are also due to the menstrual complication. Treatment. — The choice of remedies for the symptoms just detailed and analyzed is between belladonna and gelseminum. I prefer the former, because it corresponds more nearly to the patient's habit and temperament; to the probable cause of the menstrual suppression ; to the brain symptoms dependent on the same, in all their minuteness ; and to the reflex spasms of the vol- untary muscles of the shoulder and arm. It is better adapted to AMENORRHCEA--CONTINUED. 141 the congestive tendency dependent on the arrest of the catame- nial flow than any other remedy. If this patient had been seized immediately with the spasms ; if the choreic symptoms had devel- oped the moment the menses ceased, we would have ordered the gelseminum. For, in that case, the suppression would have de- pended on a sudden contraction of the cervix, analogous to that which sometimes takes place in labor. And the gelseminum is even better fitted to overcome that contraction than the bella- donna. But here the nervous symptoms were preceded by an evi- dent afflux of blood to the brain. This was the primary lesion, and the order of sequence is a significant factor in the choice of a remedy for any given class of symptoms. Belladonna not only corresponds with the cerebral lesion, but is equally applicable to the relief of the muscular symptoms arising from it. Precisely what degree of importance should attach to a restora- tion of the menses in these cases, it is sometimes difficult to deter- mine. The old method was to force their should the flow be forced return by the use of emmenagocues, cathartics, to return ' «/ o •-> 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 they 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 amenorrhoea. When some exciting cause Subsequent trouble from ^g suppressed the discharge suddenly, and suppression. ■»■ *■ ° when, after a few hours, or days at the far- thest, the flow is not resumed, the chanees vf 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 dysmenorrhcea, 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 wTith the resumption of the flow 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. * x J J likely find 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 example, the small-pox. This will have the effect to scatter those mischievous comforters, whose sympathy is a curse instead of a blessing, and 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. AMENORRHCEA—CONTINUED. 143 The patient will take a dose of belladonna 3d, once in three hours during the clay, and we shall see how promptly and satisfac- torily she will recover. AMENORRHCEA WITH SUPRA-ORBITAL NEURALGIA. Case.—Mrs. K., aged 30, 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 sufferino- 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 of 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, nJTS8°fmenStrUalthe teeth, or the ears. There are those who 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 Local peculiarity. '. . , . . " 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. _ . . „ . n , ,. 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 AMENORRHCEA, 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, who 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 1 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 lbij2, the corner of a falling door struck me be- tween the shoulders, and left me insensible" for a clay 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- AMENORRHCEA—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 1x64,1 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 18(.!7, I think it was, 1 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 a-re 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 ha^matemesis. "■. <» t i i rr n 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 heviache to complain of " strange " sensations in the head, or of " forgetful- ness;" or they will tell you that '-half the Peculiar symptoms. . , time they do not know what tney and the larynx, renders this com- plication more frequent among females than Avith males. The loss of voice in this case is significant and seri- ous. If it Avere hysterical, it Avould not have persisted so many months. In aphonia from spinal irritation, (unless it be trau- matic), the attack comes on abruptly, continues for a feAv days or a Aveek 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 objectiA'e signs, which must be interpreted as premonitory of pulmonary tuberculosis. Treatment.—The remedy for this case is calcarea phosphorica; and you Avill be surprised to observe Iioav 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 oavh preference is for the third decimal trituration, of Avhich this Avoman will take two grains three times daily. Not unfrequently the bichromate of potassa, phosphorus, sodium, or spongia, Avill relieAre the hoarseness Avhich is incident to these1 cases of incipient phthisis. For this purpose they may be given incidentally, or if othenvise 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 AVOMEN. remedy. First and foremost this patient should, if possible, remove to a climate Avhich is less humid than this upon the lake shore. This expedient is especially advisable at this season (February). For the Aveather of the late Avin- Season and climate. , , , . ,, . ,,. . . ., ter and early spring months in this vicinity is too changeable, and withal too damp, for persons avIio are predis- posed to laryngeal and pulmonary difficulties. She should, moreover, have a good diet, and plenty of fresh air, Avithout 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 Avhat 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. DYSMENORRHCEA. Dysmenorrhcea— Definition and varieties — Obstructive Dysmenorrhcea. Case. — causes, symptoms, complications, sequelae, diagnosis, prognosis and surgical treatment. Ob- structive dysmenorrhaia from post-puerperal atresia. Cose.—dates from puerperaiity.— the result of adhesive inflammation and stenosis, a clinical lesson, a contraindica- tion for anae ahetics, the use of the uterine stem. Most Avomen suffer considerably during menstruation. The kind and degree of pain experienced at the month, hoAvever, varies greatly Avithin the limits of health, and Avith the ability ot the subject thereof, to bear it uncomplainingly. It is only Avhen the pain is sufficient to make her ill, and to disable her, or to send her to bed, that Ave say of a Avoman that she has dysinenor- rhcea. But this form of menstrual disorder is not only painful; it is also tardy, sIoav, scanty and irregular, and the discharge Avhich is more or less changed in character, escapes Avith great difficulty. Authors have described several varieties of dysmenorrh:ea, 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 Avhich your attention Avill iioav be called. 1. OBSTRUCTIVE DYSMENORRHCEA. One of my most intelligent and amiable patients has written the following history of her case, Avhich for the sake of the bene- fit that may accrue to others, she has consented that I may read to you : Case.—I hardly knoAV if I Avas a healthy child, but I was active, impulsive and sensitive. At eleven years of ao-e the menses ap- peared, the result, perhaps, of the grief and excitement caused by my mothers death. For about one year they returned regularly, Avith little pain, and then ceased, owing, I think, to wetting my feet, and improper exercise. The result Avas a cough, dyspepsia, and other bad symptoms. My father employed a physician for 184 THE DISEASES OF AVOMEN. me, avIio, after several months of medical treatment, brought on the menses again, but Avith much pain. At seventeen years of age I Avas married, after Avhich I resided four years in Boston. During these years, in Avhich I experienced great mental suffering also,"l suffered each month, resorting to such remedies as Avere prescribed in a domestic Avay by my friends such, for example, as ^in, injections of laudanum, chloroform. etc. About this time I Avas seized with "vomiting attacks," ii- Avhich 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 Avith purging, continued, the pain avouIcI lessen and finally disappear. The nausea and retch- ing avouIcI leave suddenly and Avithout 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 Avas 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 Avas in- duced to try a Avater-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." I remained three months under treatment, but still continued to suffer during menstruation. xV feAV years later I Avas placed under the care of a noted speci- alist in this city, avIio told me there avus an " enlargement and retroversion" of my Avomb. 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 Avent to another Hygienic Institution in New York. Here I Avas told that the " uterus was enlarged, in- durated, retroverted, and fastened clown, 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 Avas rather discouraging neAvs. I remained at this institution four months, Avhence I Avas discharged, not as cured, but better. Still I suffered Avith menstruation. In the Avinter of 1870, severe pain preceded the flow for several hours, and in addition to symptoms threatening a return of all my former difficulties my bladder Avas 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 DYSMENORRHCEA. 185 he found Avas "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 Avas mostly in the abdomen, and of the nature of colic. AVarm 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 ahvays increased the pain. Finally, after nearly thirty years of painful menstrua- tion, I have at la5t found relief! There is one point of interest in this case that is Avorthy ot remark. It is that, the form of painful menstruation,from Avhich 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, Avhen the function was established, it could not continue to be regular and normal as it might have clone under different circumstances. In young girls of this temperament it often happens that menstrual disorders are attributed to getting the feet Avet, and other acci- dents, Avhen the real cause of the mischief lies in the too suscep- tible nerve centres. Her early marriage, the anticipatory vomiting, 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. 4aicl 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 avouIcI not have been difficult to have read her temperament " betAvccn the lines." Obstructive Dysmenorrhcea is a variety of painful menstruation Avlnch depends upon a partial or complete closure or obstruction of the canal of the uterine cervix, Avhereby the menstrual Aoav can only escape, if at all, Avith irreat suffering and more or less irregularity. Although it is by no means a rare affection, the history of this case 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 Avhich case, from the very first the " periods," are ahvays characterized by unusual delay and suf- fering. More frequently, hoAvever, it is acquired at a later stage of menstrual life. It may result from a flexure of the Avomb, in Avhich 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 ot 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, such as a polypus, a sub-mucous fibroid, or an old From intra-uterine growths. .. • i i • i coagulum, and, notAvrthstandmg the most vio- lent efforts to expel the Aoav, 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 Avhich the epithelial lining of the canal is exfoliated and lost, and, as a consequence. From cervical atresia. „ - . adhesions are formed 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 Avho have borne children, Avhether prematurely or at term, are supposed to be exempt from dysmen- orrhcea. But this form of the disease is by no means a rare sequel to the abrasions and injuries consequent upon labor, as Avell as to the local inflammations Avhich may occur about and within the cervix and the vagina during the puerperal state. The harsh and indiscriminate employment of escharotics for the cure of uterine ulceration (against which I have so frequently DYSMENORRHCEA. 187 cautioned you), is very mischievous in this respect. The actual cauteiy, or its potential substitute, the potassa From cauterization. *■ cum cake, 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 Avere removed by a burn, and the surgeon who dressed it did not knoAv enough to keep them apart until a new cuticle had formed. Frcni 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 avcII as of the more severe and reckless cauterization to Avhich 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 dysmenorrhcea for several years. The symptoms were sufficiently marked to suggest their oavii 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. J attend upon the menstrual effort. But in this case they are greatly exaggerated. When the patient is one Avho 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 ay ho have borne children, and Avho have this form of dysmenorrhcea subsequently, the Avomb, if not really more capacious, is yet more tolerant of the retained fluid. These women therefore do not commonly suffer so severely as those Avho belong to the former class. In both classes, hoAvever, the presence and pressure of the blood, Avhich has no adequate outlet, excites the peristaltic con- tractions of the uterus with a A'ieAV to OAer- Uterine tenesmus. . in come the obstruction and to force the Hoav. 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 AVOMEN. fibres of its muscular coat are lacking. But it often happens that they are more painful than in real labor. The antagonism be- tAveen the body and fundus and the circular fibres about the inter- nal os uteri is A'ery 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 Avith Reflex disorders. L ° J L eA^ery return of 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 dilated 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 Aoav comes on Avithout any considerable delay, and pretty freely, the vomiting is likely to persist. And, aa hat 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 tAvelve hours. Our patient says that she vomited " every ten or fifteen minutes for tweh^e hours, but never for a less time." Some cases of obstructive dysmenorrhcea are met with in Avhich the menstrual arrest and derangement have given rise to very Ind. estion complicated disorders of digestion, which many 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 pi£K and "ctal 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 Avith that proper to the first stage of labor. Coincidently Avith the tenesmus of the pelvic organs there is often, and indeed usually, a train of nervous symptoms Avhich are more or less pronounced and alarming. Head- Nervous disorder. . .... ache, restlessness, insomnia, jactitation, spasms, and even convulsions are not infrequent, all of Avhich, howeAer, 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 Avomen 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 aa ho 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 Aoav finally causes it to become profuse. In this respect it Menorrhagia infrequent. . „ „ . . . ,. , differs from the congestrve, the spasmodic, and the membranous varieties, Avhich are all of them likely to be either accompanied or folloAvecl by 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 Avhich 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 Avhich interfered Avith the men- steriiity from obstructive strual exit, Avill preA'ent the ingress of the dysmenorrhea, -i r> 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 AVOMEN. If the dysmenorrhcea depends upon congenital mal-formation of the cervix uteri this condition can be readily 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. . , [• p • 1 liquify, 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 impeiwious, a little patience and tact Avill enable you to succeed. You may sometimes insinuate a small Sims' probe, AArhen 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 Avill gain an entrance into the uterine cavity in this manner much more easily "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 signinesflow' and what il ^s that there is a mechanical impediment to the 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 enclo-cervi- citis and to uterine ulceration as it does to perimetritis or to hfema- tocele, and to confound them is both inexcusable and mischievous. The prognosis will vary yvitli the cause of the disease, and also with the consequences of the menstrual irregu- The prognosis. ° lanty. If the original organic defect, aa henever it exists, can be remedied or compensated by surgical means, DYSMENORRHCEA. 191 recovery will follow. If the acquired or accidental obstruction, whatever it is, can be removed, the result may be faA~orable. Something, however, Avill depend upon the state of health, Avhich is secondary, and Avhich 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 Avith symptomatic endometritis, gastritis, gastro-enteritis, ovaritis, cys- titis, chronic hepatic and digestiA'e 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 gynaecology consists in having supplied us with the means of cure for most cases of this Surgical treatment. _^ , „ . disease, from the nature ot its causes, you will infer that the treatment of obstructive dysmenorrhcea 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 Avill 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 hapx uis, it is at the os internum, it Avill be most prudent to try the virtues of dilatation, and reserve the cutting as a dernier rcssort. Dilatation is equally applicable to most cases of atresia of the cavity of the neck of the organ. When the passage is very narroAv you will begin with a small copper sound, or probe, Avhich 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 Xotfs dilators, and finally by the sponge tent. And although (in order to take advantage of the natun. 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, tAvice each Aveek 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-iearnec[ the course and curve of the canal in 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 Avell as by obliquities of the womb, that any rules which I might indicate Avould 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-elboAV 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 Avith reference to the axis of the superior strait. The most diffi- cult cases are those in aa hich the cerA'ical 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 oavii opinion, Avhich needs a word of ex- planation, and Avhich 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, coirvulsions, and DYSMENORRHCEA. 193 cn-en hysterical tetanus, have sometimes followed the use of the - t . . , dilators and of the sponge-tents is doubtless iceported clanger from. •*■ ° 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, Avhich was passed Avith- out difficulty, for more than ten minutes at a time. If I had not taken the precaution to remain Avith her and to observe the effect, but had left her Avith 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 slipperv-elm or a sea- A barbarous practice. *■ •*• tangle tent at his office, and afterwards permit his patient to travel by stage or by rail for some miles to her resi- dence, before it Avas removed ! But this is not an infrequent occurrence, more particularly with those who practice most largely among the loAver 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 diiatantcions.ions concerning tip, 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 eight 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 ansAver a very Of the various tents. "' good purpose Avhen they are smooth and small enough to permit them to take the shape of the canal through which they are to pass. But Avhen a larger tent is requisite, they are too stiff and straight to suit many cases. A large sea-tangle is 194 THE DISEASES OF AVOMEN. tent expands so sIoavIv 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, Avhich items are much in their favor; but they are too blunt for use in the early stages of treatment, Avhen the passage is very narrow. If the sponge tent is an old one, it is apt to be hard and unsuitable. MoreoArer, when kept in contact Avith the cerAuco-uterine fluids, such a bit of sponge will more readily de- compose. Noav that our sponge tents are carbolized, hoAvever, it is quite probable that some of the evil consequences attributed to the use of this instrument Avill be omitted in future. The rashness and injudicious haste Avith which dilatation has sometimes been practised, haAe excited a prejudice against it in the minds of many. There are physicians Avho diiatetfoUn!°ns in practising undertake to dilate the contracted cervix in obstructive dysmenorrhcea Avith the same dis- patch Avith Avhich a surgeon would amputate a limb, or excise the tonsils. The whole operation must be performed at once, and the unfortunate results that may folloAV 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 Avay," as the phrase is, and to take plenty of time in order to overcome the obstruction Avithout any serious shock to the patient's system, or any risk of the diseases which I have named as contingent upon this operation. If you 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 Avas 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 or< jf after haying 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 DYSMENORRHCEA. 195 cervix is a final resource. I do not say that you should neA-er iAa\re recourse to this latter expedient before haA'ing tried the .nethod by dilatation, but only that I think it more prudent and preferable to hold this operation in reserve, both because it is beset Avith more real clanger, and also because, if it Avill answer, die simpler means is the safer of the two. There are cases, un- doubtedly, in Avhich the incision or slitting of the ceiwix is indis- pensable. Rapid and forcible dilatation of the cervix is very popular with some gynecologists for the cure of dysmenorrhcea and sterility as well as for opening of the cervix for the Rapid dilatation. purpose of intra-uterine exploration and opera- tion. Of the several instruments devised for this purpose, all of which are savage unless very skilfully and cautiously used, Goodell's is the best. In employing it so as to expand the cervix at one sitting, the patient should be placed pro- foundly under an amesthetic, and should be kept in bed several days afterwards. It may or may not be best to follow this opera- tion with the introduction of the hard rubber stem, which will have the effect to keep the cervix open and to prevent any irregu- lar cicatrization within its canal. This method of rapid dilatation is contra-indicated by active inflammation within or about any portion of the uterus or pelvis, and also by the near approach of the menses. It should be practised within a week after the flow has ceased, a precaution that will give time for the parts to heal before the monthly cycle has returned. It may be necessary to repeat it once a month for two or three times. Usually, we do not need to persist so long with dilatation in treating dysmenorrhcea as in the treatment of sterility. This rapid method, if carefully done, is more satisfactory in every Avay, than the old Mcintosh method Dilatation by graduated which was first practised many years ago and bougies. which consisted of the use of graduated bougies that were passed and allowed to remain for a little while. (Fig. 45.) The introduction of these blunt bougies is often very painful, and the relief that they afford is not lasting or permanent. 196 THE DISEASES OF WOMEN. Prof. Simpson first conceived the idea of slitting the cervix so as to overcome the constriction of its canal and incision of the cervix, to open up a way for the ready exit of the men- strual floAV. His operation, which was exten- sively practised by Sims and others has gone out of date. The form of this operation, most commonly resorted to in this country, was that of Sims, which consisted in passing one blade of a pair of curved scissors within the os uteri, and as far up as the junc- tion of the cervix with the vaginal roof. The scissors were then closed so as to cut through the cervix from the outside. The instrument was then turned 'round and the opposite side was mutilated in the same manner. It was in this way that those who had not borne children were made to suffer from an artificial lac- eration of the cervix which was very similar to the accidental wound of the same organ in the mothers who are now the subjects for Emmet's operation. I very much prefer the operation of discission as it was advised by Peaslee. It consists in the uniform division Discission of the cervix, of the cervical canal from the internal os down- wards through the external os uteri, but without a complete and unnecessary section of the vaginal cervix. The incision is bilateral and is made without repetition. The steps of the operation are few and simple, the patient should be anaes- thetized, not only because the operation would be somewhat pain- ful, and because there might be such a degree of hemorrhage as would alarm her, but also because it is best to have her lie quietly during the operation. The hips should be brought to the edge of the table and the patient placed in Sims' position. The next step after having retracted the perineum with a Sims' speculum, is to seize the cervix and bring it into view. This can be done with a trusty tenaculum, and has the double effect of rendering the man- euvre of passing the uterotome more readily, and of lessening the risk of hemorrhage, for to cause the uterus to descend in this Avay is practically to place its lower segment in a tourniquet. The uterotome that was devised by Peaslee (Fig. 21) is prefer- able. It carries two concealedblad.es, the expansion of which, after it has been introduced, is regulated by a screAv in the handle. It may be gently and carefully passed, like the uterine sound just within the internal os, and when the blades are slightly spread, it should be slowly and carefully withdrawn, so as to cut both sides of the membranous canal as it passes out. It DYSMENORRHCEA. 197 may be requisite to repeat the operation tAvo, or eAren three times. Without great care in its performance, there is danger of sud- den and fatal haemorrhage, haematocele, peritonitis, cellulitis, or endo-metritis. The risk of these accidents is Dangers attending. . . . in ratio with the extent and depth of the in- cisions Avhich are made through the os internum, and also in the abdominal portion of the cervix uteri, at a point superior to the insertion of the A-agina. You should remember that in their distribution the uterine arteries pass cloAvnwards on either side of the womb, to its neck, and then ascend in a tortuous course by the side of the organ between the layers of the broad ligament anastomosing with the ovarian artery. In order to avoid cutting this artery or any of its branches at the internal os uteri, I recommend you to cut from before backAvards and vice versa, i. e., towards the rectum and the bladder, instead of laterally, being careful not to cut far toward either organ. Fig. 21. Peaslee's Uterotome. After the operation she should be kept in bed for a number of davs. Fatal peritonitis has been knoAvn to Precautions. „ ... occur, from a lack of care in this regard, as late as the tenth day after the incision. In every case the patient and her immediate friends should be made acquainted beforehand Avith the nature of the proposed operation, the dangers with Avhich it is beset, and the possibility that it may need to be repeated before the cure can be considered complete. OBSTRUCTTVE DYSMENORRHCEA FROM POST-PUERPERAL ATRESIA. Case.— Aug. 6th. This Avoman is 35 years of age. She gave birth to a child eight years ago, Avhich lived but five months. One month after the child's death her menses appeared, but never have been regular, and continue but one or two days. Previous to the' flow she has sharp uterine pains; following it the pains are dull and heavy, she also has pain in her hips. Including the 1 98 THE DISEASES OF AVOMEN. ante-menstrual effort and the duration of the Aoav, her sickness lasts for ten or twelve days. Local examination revealed an almost complete stenosis, or closure, of the cervix uteri. The os Avas barely large enough to admit of the introduction of a Sims' probe. This lesion Avas evi- dently the result of puerperal endo-cervicitis from Avhich she must have suffered eight years before, for she is positive that she has not been pregnant, neither has she had an abortion since that time. The treatment was begun in the presence of the sub-class by the introduction of the uterine sound, and the patient Avas directed to take belladonna 3. Aug. 15th. The cervix Avas exposed and expanded by the use of Xott's dilator. Being on the eve of menstruation she Avas directed to take gelsemium 3, every two hours. (See Fig. 22.) Aug. 20. She has flowed a little more freely than usual since the dilatation, and is now menstruating. Aug. 21. Complains of great dizziness, she does not flow freely enough. The os uteri Avas again dilated Avith the same instrument, and found to be less rigid than before. Aug. 29. The same operation Avas repeated, after which Cham- ber's split rubber stem Avas introduced, and, unless it should prove to be too painful, Avas directed to be left in position until e\'ening Avhen it was to be removed. Belladonna 3. (Fig.23.) Sept. 5. Upon passing the dilator, the internal os Avas still rigid. The cervical canal Avas thoroughly dilated and the patient ordered to take arnica 3, three times a clay. Sept. 12. She is improving. The cervix Avas again dilated and the same remedy continued. Sept. 19. She is much better; dilatation was practised as before, there being very little obstruction to the passage of the instrument. Belladonna 3. Oct. 3. She is still improving. No more headache, or flushed face, but feels more like herself than she has for years. The operation Avas repeated, and the same remedy continued. Oct. 17. She had her Hoav for three clays last Aveek. It Avas easy, and natural in quality. She is very happy over the result and delighted Avith the relief obtained. The same remedy Avas continued. Dec. 5. She is still improving; the menses haAre been free, prompt, and painless. At the last period the Aoav continued four days. The sound passes very easily, and the depth of the uterus is three and one-half inches. She Avas recommended to continue belladonna 3. For some Aveeks she continued to come occasion- ally to the sub-clinic, Avhen the dilation Avas practised, especially in advance of the period, as prophylactic of thedysmenorrhoea. This is an exceptional case, but it will serve to illustrate tAvo or DYSMENORRHCEA. 199 three points that are of practical interest. The lesion undotibt- Fig. 22. Nott's Dilator. edly originated in a form of puerperal metritis, but Ave may safe- -taa. , ly infer that the inflammation Avas limited to Dates from puerperal- , . ity. the cervical portion of the uterus. For if it had involved the lining membrane of the uterine cavity, or, in other Avords, if she had had puerperal endo-metritis, Fig. 23. Chambers' Stem Pessary. there would have been sub-involution, menorrhagia, and increased depth of the organ as necessary sequelae. Instead of these con- ditions having been entailed upon our patient, rhe resuitof adhesive howevei% we have such a stenosis and oblitera- inflammation. . . tion of the cervical canal as could only have re- sulted from adhesive inflammation of its lining membrane. The poor Avoman, avIio knoAVS next to nothing of her chilcl-becl expe- rience, cannot tell us Avhether she had any inflammation at all, and this is a sample of the information that you Avill derive from a large class of post-puerperal cases. A clinical lesson. Fig. 24. Atlee's Dilator. The practical point in treating such a case as this is not to rely too exclusively upon internal remedies alone, and, above all things not to incise the cervix in a careless, off-hand Avay, regardless of the previously existing inflammation which has been so prominent a factor in causing the obstruction and the dysmenorrhcea. If we had cut this cervix 200 THE DISEASES OF WOMEN. freely in the beginning of our treatment, or if Ave had dilated it very rapidly and forcibly, the patient might have had cellulitis or pelvi-peritonitis in consequence of our temerity. The same result has sometimes folloAvecl the use of the sponge tent under similar circumstances. It is much safer and quite as certain to bring about a good result if we proceed more slowly. In this connection I am satisfied of another thing, Avhich is that, Avhen the neck of the Avomb has been narroAved by serious inflammation, Avhether puerperal or traumatic, foAniTtneUcr0^1011 or from an GX('ess of local treatment, it is ahvays safer not to administer an anaesthetic before performing any surgical operation for its cure. The sensi- bility of the patient, if she is not altogether too timid and nervous, will help to decide hoAv far we should proceed with the incision or the dilatation, and to keep us from putting our patient's life in jeopardy. The object in the introduction of the Chambers' stem, Avas to keep the canal of the cervix open, and by steady The use of the uterine pressure to increase its calibre. This little in- strument is especially useful in the case of Avomen, who although they have atresia, have once borne chil- dren. (See Fig. 23.) LECTURE XII. OBSTRUCTIVE DYSMENORRHCEA FROM STENOSIS OF THE UTERINE CERVIX AND PELAT-PERITONITIS. Obstructive Dysmenorrhcea from stenosis of the cervix. Case—rale for operations on the cervix—post-surgical peritonitis—obstructive dysmenorrhaca from retro-flexum. Case— causes, symptoms, diagnosis, sequel* and treatment of dysmenorrhoaa from retro- flexion. Neuralgic dysmenorrhoca. Cane.—The importance of physical signs—a neu- rosis—symptoms—relation of the flow to the decree of pain—treatment. Spasmodic dysmenorrhcea. Case.— effect of stimulants—do. of opiates—medicinal aggravations— gelsemium and other remedies. The following is the history of another very interesting case of obstructive dysmenorrhcea: Case.—Miss—, a Swede aged 24, has been ill for eight months, she suffers from Aery severe pain Avhich comes two Aveeks in advance of the monthly period, and continues until the Aoav stops. The flow itself is Aery slight, sometimes coming almost drop by drop, and never lasting more than three or four hours. After the pain begins, the distress Avithin the pelvis increases until, at the time of the discharge she is so Avretched that she is forced to quit her Avorkand go to bed. When the flow stops the blood is deter- mined to the head and face, and for a clay or two she is almost insane Avith a headache, Avhich gradually Avears aAvay so that she can resume her duties. At these times she is very much annoyed by a fine rash which appears on her face and neck. She gives an intelligent account of herself, and says, that tAvo years ago her sufferings Avere of precisely the same character. When they became unbearable she consulted a physician, avIio made an operation upon the neck of the Avomb, Avhich, from her understanding of it, must have consisted in its incision perpendic- ularly, after the manner of Simpson or of Sims. For a little Avhile her sufferings Avere very much relieved. The pain and congestion passed away, and the Aoav became more free and natural, than it ever had been before. But, in consequence of over Avork, Avith a lack of care, she soon felt an increased tenderness and pain Avithin the pelvis and about the neck of the Avomb, after Avhich, the old symptoms returned. Local examination, found the cervix nar- row, and elongated, veiy sensitive, and almost impeiwious to the sound. The os-uteri had the shot-hole form, and there was a great deal of tenderness Avith manifest signs of chronic pelvi- peritonitis. The treatment Avas begun Avith careful dilatation of the cervix, and the prescription of belladonna (5, four times a da v. -01 202 THE DISEASES OF AVOMEN. This treatment Avas continued for several months, Avith a decided improvement of the local and general symptoms; but the relief Avas only partial and not permanent. When the dilatation Avas persevered Avith, and she did not alloAv more than one period to pass Avithout reporting herself to the sub-clinic, she got along very Avell, the Aoav avouIcI come promptly and avouIcI continue for two or three days. But if she staid a way and neglected herself, she soon relapsed into her old experiences. Other remedies, includ- ing gelsemium and ignatia Avere given from time to time. This case is analogous to that shown you at the close of my last lecture. But that, as you will remember, dated from childbed, Avhile this, in all probability, is congenital. It Rule for operations js a ru]e amono; Gynaecologists that all opera- on the cervix. . , • , ' -i'' • -i , *"~ ,, tions Avhich are designed to open the cervix are dangerous Avhen there is inflammation about the uterus and within the pelvis, but more especially Avhen there is peritonitis or cellulitis. This explains our delay in the use of the sponge tent as a more active means of dilatation. The pelvic peritonitis has therefore been in the Avay of a radical cure. From Avhat avc can learn it is very doubtful if our patient had this form of pelvic inflammation before she Avas operated upon tAvo years ago. You will often meet Avith cases of ^post surgical periton-^ kindj for the sequelre 0f careless and excess- ive slashing of the cervix are Arery common in our day. And I urge you not to forget that post-surgical periton- itis needs to be handled very carefully. The occurrence of the eruption upon the face is often met Avith in cervicitis and also in dysmenorrhoea, but its exact relation to these conditions is not knoAvn. Sometimes this The facia eruption . n. -. . _ rash disappears and is transferred to the uterine mucous membrane Avith an aggravation of the menstrual symptoms, and facial eruptions often result from an excess of local treat- ment, more especially from cauterization of the uterine cervix, in scrofulous subjects. In this case Ave Avill first strive to cure the pelvi-peritonitis, and afterAvards proceed, if necessary, to opera- tive interference. She Avill take belladonna 3, three times a clay. OBSTRUCTIVE DYSMENORRHCEA FROM RETROFLEXION OF 1HE UTERUS. Case.—Mrs. X. set. 2K years, is the mother of two children, the youngest ot Avhich, if it had lived, would iioav luwe been seven OBSTRUCTIA'E DYSMENORRHCEA. 203 years old, and since the death of which she has not been well. Her confinement occurred in the country Avhere she only received the attention of the volunteer nurses in the neighborhood. After labor she evidently had a pretty severe attack: of metritis, Avith Avhich she Avas ill for a long time. The child lived four months, during all of which time she continued to nurse it. When after its death, her menstrual function was resumed, the Aoav Avas observed to be scanty in amount, and thick and coagulated in character. There was much intra-pelvic pain and distress, a bearing down in the rectum, aching in the sacral region, and obstinate constipation. The suffering at the period sometimes begins as early as ten days in advance of the Aoav. It generally commences about a Aveek before, and during the twenty-four hours preceding the beginning of the discharge, is sometimes so severe as to make her very ill indeed; but as soon as it comes on freely her acute sufferings subside. At the appproach of the monthly crisis there is a manifest determination of blood to the head and face, and sometimes to the lungs and heart. In the former case she suffers from a distracting headache which nothing but the eruption of the menses relieves. This headache is accompanied by an intolerance of light and sound, and excessive nervousness and tension of the mental iaculties. Sometimes she can divert herself from the thought of suffering by a strong effort of the Avill, as by setting to Avork violently, or by reading intently. The pains in the back and limbs, howeA^er, prevent her from being much upon her feet Avhile the Aoav is threatening, and usually, until it has ceased altogether. When the head symptoms are less pronounced, or lacking entirely, she has clyspmea, Avhich prevents her from lying down, and cardiac oppression and palpitation that are very distressing to witness. Her husband and friends have often thought that she was surely about to die from them. Sometimes there is choking, and even entire inability to swallow. Again the respiration is hurried and panting, and she has fits of a smothering suffocation, resembling spasmodic asthma. She imagines that she has heart disease, and at least one lugubrious doctor has told her that, one of these days, she Avill die suddenly of an obscure cardiac affection. Careful an 1 'repeated examination of her chest has failed to disclose any evidence of organic disease either of the heart or of the lungs. There is not the least sign of trouble there excepting at the period, and then it alternates Avith the brain symptoms. The uterus, hoAvever, is retroflexed, curved upon itself like a retort, but more acutely. The os is in situ, but the fundus uteri falls over backAvards and is felt pressing against the anterior Avail of the rectum at the Douglas* cul-de-sac. There is no ulceration or other visible lesion of the uterine cervix. 204 THE DISEASES OF AVOMEN. It may, perhaps, have occurred to you as someAvhat remarkable that a majority of the cases brought to your notice in this clinic are of long standing, and chronic in their history. There are three reasons for this fact: 1st, in the greater portion of cases of the diseases of Avomen the physician is not consulted in the early stages of the complaint; 2d, no otner ailments are so prone to relapse and to self-perpetuation; and, 3d, there is no other department of medicine or surgery in Avhich such egregious errors are committed in diagnosis, and therefore in treatment, as in this. In the light of this explanation, it is not a mere coincidence that these tAvo chronic cases have come before us this morning. They represent a class in Avhich the ill effects of delay and of a mischievous treatment are conjoined,—a class that will give you a great deal of trouble bye and bye. In retroflexion of the womb the organ is flexed or bent back- Avards, the fundus being toAvards or against the anterior Avail of the rectum, and the cervix but little if at all Description of. ... . , . . . . displaced. 1 he point ot curvature Avhich is the most acute is, therefore, the posterior cervical Avail beloAv the internal os uteri, and opposite the loAver margin of the peritoneal coat of the Avomb in front. VirchoAv and others have taught that the fact, that the external or serous 'envelope of the uterus being deficient upon the anterior surface of the neck of the Avomb, predisposes to the various kinds and degrees of flexion to which this organ is prone. Other causes of retroAexion are such as are common to uterine deviations of different kinds. These are, too violent exercise, jumping, skating, calisthenics, constipation, habitual retention of the urine, prolonged sitting or standing, tight lacing, fibroids, polypi, etc. There are tAvo especial causes, hoAvever, to Avhich I am inclined to attribute a large proportion of the cases of retroflexion Avhich come to our notice. The first of these is the species of post-puerperal hyper- trophy Avhich folloAvs abortion prior to the fourth month. You are aAvare that the structural changes Avhich occur in the Avomb in the early months of gestation are usually, and almost exclusively, confined to the body and fundus of the organ. The cervix does not participate in these changes until about the tenth week. Noav, if abortion occurs under these circumstances, the OBSTRUCTIVE DYSMENORRHCEA. 205 body and fundus of the uterus being disproportionately developed, and the cervix somewhat softened and relaxed, but otherwise unchanged at the time of the delivery, the accident Avill be verv likely to predispose to a flexure of the organ in some direction, either anteriorly, posteriorly, or laterally. "More especially avouIcI this be true if folloAving the abortion, and from any cause whatever, the proper retrogressive changes in the uterine structures took place irregularly, or Avere arrested altogether. And so it may happen that a chronic retroflexion shall date from an early abor- tion Avhich took place years before. The other cause to Avhich I have alluded is a delay or obstruc- tion to the ready exit of the menses. That dysmenorrhcea may cause this kind of uterine deviation is just as true as that an acute flexion of the Avomb sometimes gives rise to very painful menstruation. In not a feAV cases these causes act and react, and exceptionally it may be cpiite impossible to say which is the cause and Avhich the effect. But Avhere the internal os is either spasmodically or mechanically closed, so as to prevent the escape Dysmenorrhcea.either ... 1 i- 1 i acauseor an effect. °1 the menstrual discharge, the uterine tenes- mus may be so prolonged and violent, and Avith- al exercised in such a direction, through the conjoined contraction of the diaphragm and abdominal muscles (as in true labor), as to force the fundus toAvard the IioIIoav of the sacrum Avithout dis- placing the cervix. In those cases ot dysmenorrhcea Avhich are characterized by hours of suffering before the flow appears, and Avhich correspond Avith the first stage of parturition, the true uterine axis is certain to be changed; and deviations at the month are very apt to perpetuate themselves. These contingencies of gestation and of menstruation should not, therefore, be lost sight of Avhen you study the etiology of retroflexion of the uterus. The symptoms vary in different cases, depending some Avhat upon the degree of the displacement, and the susceptibility of the patient to nervous and other complications. The pain and distress may lie near or remote. Such pains Avithin the pelvis, with rectal urging, paralysis of the bowel and ftecal accninulation, weakness, and coldness of the lower extremities as our patient complains of, are very common. Nor is the congestive headache, the precordial oppression, or the 206 THE DISEASES OF AVOMEN. cardiac irregularity by any means rare. Naturally enough these symptoms are aggravated each month. For, in the effort to empty itself, under the disadvantage of an acquired deformity, the suffering is the more severe and protracted. At this time not a few such patients have hysterical symptoms, Avhich simulate other diseases, and may mislead the doctor. Or this incident cause may finally develop a species of reflex insanity, and thus render the patient a most pitiable object. By the "touch" AATe find, in a case of retroflexion, that, Avhile the os and cervix uteri are where they should be, there is a tumor at the Douglas cul-de-sac. On tracing the out- line of this tumor Ave find that it is retro-cervi- cal, smooth, regular, and that it is connected, by a curve Avhich is more or less acute, Avith the upper extremity of the neck of the Avomb. If necessary, the rectal touch may be resorted to in con- firmation. In a majority of cases this tumor is reducible by steady pressure, or by placing the patient for a little in the prone position. But the best diagnostic sign is afforded by the introduction of the sound. If, Avhen the instrument has passed the os-internum, its point shall turn backAvards instead of for* The use of the sound. .. , . . ,. .. . . , A\rards,toAvards the hollow ot the sacrum, instead of toAvards the bladder, there Avill be little difficulty in deciding upon the kind as Avell as the degree of the displacement. It may happen, hoAvever, that the deviation of the uterus shall be so intimately associated Avith the dysmenorrhcea as only to occur tem- porarily, and for a limited period, at the month; in Avhich case this sign of retroflexion avouIcI be present at one time, and not at another. OAving to this very simple reason, I have known of some grievous errors in the diagnosis of retroflexion. For it almost never happens that the degree of this displacement is the same for two successive Aveeks, and it is possible that, during the inter- menstrual period, the organ might be spontaneously reposited, a result Avhich Ave avouIcI not expect in retroversion. The prognosis turns chiefly on our ability to remove the cause, Avhatever it may have been; on the general state of the patient's health; the exemption from acute or malignant disease, either in the, uterus, the ovaries, or elseAvhere; and on a regulation of the contingencies of menstruation in such subjects. Even in those OBSTRUCTIVE DYSMENORRHCEA. 207 cases which are least severe and chronic it is not safe to promise a speedy and permanent cure. In old cases a radical cure is some- times impossible because the tissue of the uterine Avail at the seat of flexion, in the angle formed by the bend of the organ, has been so atrophied that it will not aflord the proper support to the Avomb Avheil it is upright. One frequent and troublesome sequel of letroflexion is sterility. Another is a tendency to abortion, in consequence of the inability of the uterus to right itself and to rise above the brim of the pelvis, in order to be properly de- veloped. A third and not infrequent result of this deviation is the induction of a species of pathological moulting of the uterine mucous membrane at each catamenial period, causing membranous dysmenorrhcea. Treatment.—In a case like the one before us our duty is plain, Nothing could be more obvious than the necessity for lifting the uterus into its proper position, and for keeping it there when it is restored. Such an expedient is not requisite in all cases of retroflexion indiscriminately. But Avhenever the displacement interferes Avith the readiness and free- dom of the menstrual flow, it must be corrected; otherwise the most severe suffering may be induced, and the gravest lesions entailed upon the patient in consequence. Fortunately, as a rule, the reduction of the dislocation is not difficult. Careful manipulation with the sound, a Sims' or Guern- sey's elevator, Elliott's sound, or better still Avith Reposition of the or- ^q index finger conjoined with the proper posi- tion of the patient, Avill be sufficient. So much more easily is this deviation corrected than in retroversion, that it is seldom necessary to manipulate with the finger introduced into the rectum. The patient should lie either in the semi-prone, or prone po- sition, so that gravity may aid in the correction of the misplacement. In some cases it is quite sufficient to pass a Sim's speculum and re- tract the perineum, when, the vagina being filled Avith an unusual quantity of air, the uterine body and fundus will immediatidy be lifted into position. At other times the bladder or the rectum may require to be evacuated before attempting to reposit the uterus. But, having fulfilled this indication, Iioav shall Ave keep this 208 THE DISEASES OF AVOMEN. Keeping it ir. place. intractable organ from deflection in the future? My OAvn plan of procedure is to confine the patient to the bed or couch, and, as much as possible, to the semi- prone position during the whole menstrual period; to remove all ligatures from about the body; to prevent fa?cal accumulation in the rectum, and the retention of urine, also, and to facilitate the prompt escape of the menstrual secretion, Avhen it is requisite, by the artificial dilatation of the cervix uteri. In many cases I have passed a sponge tent, or an ebony dilator, some hours, or perhaps the night before the time for the Aoav to begin. By this means the instrument not only served to expand the internal os uteri, and thus to remove any particular necessity for a parturient effort on the part of the uterus, but likeAvise also to act as a means of keep- Fig. 25. Hard Rubber Dilators. ing the organ erect until the discharge Avas freely established. I prefer these hard-rubber dilators, Avhich, as you see, are of vari- stem dilators oussizes, because, by heating them over the gas or lamp, they can be bent to suit individual cases more accurately than the slippery-elm or sea-tangle tents could be. Moreover, it will not unfrequently happen that the uterus Avill tolerate this instrument for several days, in Avhich case it may be left in situ Avhile menstruation is going on ; and unlike the sponge, it Avill not interfere Avith the exit of the catamenia. Some of my patients Avith retroflexion have Avorn these stem dilators for a night, or for tAventy-four hours or more, each Aveek during the inter-menstrual period. Others, again, avIio could tol- erate them, have carried them within the canal of the cervix, Avith impunity, for a fortnight or more consecutively. But you must not suppose that such foreign bodies are not sometimes mischievous and harmful, Avhen they are introduced or kept for any considerable OBSTRUOTIAE DYSMENORRHCEA. 20(J titiiv, in the cervical canal. There are cases in which they could not be borne for the space of half an hour, without inducing such alarming diseases as peritonitis, cellulitis, cramps or convulsions. Fortunately, hoAvever, when the retroflexion and dysmenorrhoea are combined, these means of dilatation Avill usually do no harm " at the month," and this is the period of their greatest utility. Another means of retaining the uterus in position, is to place a support for it in the posterior cul-de-sac. Gariel's air pessarv might serve to cushion the organ and to keep its fundus throAvn forwards, or a pad of cotton or sponge might be applied in the same manner. A physician of my acquaintance extols the use of Fig. 26. Cutter's Pessary. a roll or a wad of oakum thus applied. Thomas's Cutter's pessary sometimes ansAvers the same purpose, and Hodges' or Thomas' also are serviceable in others. I feel the more inclined to emphasize the importance of keeping the uterus in its proper place, Avhen it tends to retroflexion, be- cause it is unreasonable to suppose, that where the displacement is allowed to continue, the structural lesion Avhich has caused it could be cured while its proper circulation,- innervation, and nutri- tion are so seriously impaired. Even the slightest atrophy of the tissues at the point of flexure could not be cured Avhile the uterus remains bent upon itself. Therefore, this indication precedes and anticipates the selection of the remedy or remedies. Indeed, in most cases, Ave shall find that Avhen it has been accomplished, there are but very few symptoms remaining. In this respect, and in point of fact, the retroflexion of the uterus is a veritable disloca- tion. Having removed the local cause, and corrected its more direct consequences, the symptoms and lesions that remain are to be 14 210 THE DISEASES OF AVOMEN. treated to the best of our ability, and by such internal remedies* as are most appropriate. The proper time for Medicinal treatment. ,, . , , . ., - n i • • their employment, mtlns case, for example, is in the inter-menstrual period. For then the Avay is clear, and we shall make a more decided impression than if Ave prescribed our remedies regardless of proper conditions and indications. We Avill iioav pass this ebony dilator, in Mrs. N.'s case, and if it does not cause very much pain, leave it in the cervical canal for a clay or tAvo. The operation Avill be repeated according to circuui- stauces. Meanwhile she will take a dose of belladonna 3, every three hours. NEURALGIC DYSMENORRHCEA. Case.—I Avas called September 16, 1860, to visit Mrs.----, aged 21, of tall, sleucler habit, nervo-sanguine temperament, and most amiable disposition. Found her suffering from intense neuralgic pains in the uterine, lumbar and ischiatic regions. Her period had passed as usual more than a fortnight before, and for ten days previous to my first visit, these paroxysms of neuralgia had taken on an intermittent type, recurring every afternoon. My patient had first menstruated at the age of thirteen. She has never had any retention of the Aoav, but has ahvays suffered extremely. Has been married about six months, but has not been pregnant, nor has she experienced the least change in her men- strual symptoms since her marriage. In February last, Avhile residing in Western New York, she had a severe attack of diph- theria. This Avas folloAved by rheumatism, or rheumatic neuralgia of the left arm. When the menses returned at the next month, there Avas a metastasis of this pain to the lumbar and uterine re- gion. From that time until the present the "period" has been characterized by the most intense sufferings. Indeed there is no very decided remission of her suffering excepting for about one week in advance of the Aoav. For the day and night immediately preceding the appearance of the catamenia her sufferings are al- most intolerable. She becomes exceedingly nervous, and restless, or wild with excitement, delirious, or has cramps and spasms of the most frightful kind. For the relief of the neuralgia, I prescribed, in turn, arsenicum, cocculus, coffea, hyoscyamus, and with the return of the scanty NEURALGIC DYSMENORRHCEA. 211 Aoav, apis mellifica, and caulophyllin. These remedies were re- peated at reasonable intervals,—each of the two latter palliating somewhat the severity of the symptoms at first, but subsequently proving of no efiect. On the afternoon of the third day of the Aoav, she had severe hysterical convulsions, which Avere controlled by moschus in the third decimal trituration. This remedy, hoAvever, only made her the more sensible of her sufferings. After treating her most assiduously through the next menstrual interim—during Avhich time she experienced but partial relief from the neuralgia,—the recurrence of the catamenia, on the 2.")th of October, Avas marked by precisely the same symptoms as before. It Avas impossible to discover that a single point had been gained by some six Aveeks' faithful trial. Convinced of the existence of a local cause for the mischief, I proposed an examination per vaginam. Passing my Anger care- fully towards the external os uteri,—the vaginal Avails being al- most as closely contracted as in vaginismus, and the patient in intense pain,—I found the Avomb in situ, and the loAver extremity of the cervix quite normal to the touch. On going a little higher, in order to ascertain the condition of the upper portion of the neck, my finger fell into a groove Avhich extended all the Avay around the organ at the junction of the vaginal portion of the loAver seg- ment of the womb. This very marked constriction led me to infer that there Avas a decided spasm of the circular fibres of the neck of the uterus, or in other Avords a stricture of the cervix, leaving it much in the same condition as if it had been ligated at that point. Simpson's sound Avas passed Avithout difficulty as far as the os internum, but by no manipulation could I succeed in carrying it into the uterine cavity. A smaller probe, made expressly, Avas aftei'Avards introduced, then the sound, and finally this little silver instrument, Avhich resembles one of Simpson's intra-uterine pes- saries, Avas passed completely through the cervico-uterine canal. This instrument Avas carefully adjusted at nine in the evening, one day in ad\'ance of the expected Aoav. She Avas instructed to lie quietly upon her back as long as possible, in order that it might not be displaced, or drop away. It Avas retained until twelve o'clock—three hours—when it came aAvay of itself. After this she enjoyed a tolerably good night's rest. The next 212 THE DISEASES OF AVOMEN. morning the flow came on, and more freely than usual, and Avith less of suffering than she had experienced for years before. Once only during this period the Aoav became scanty, Avhen a feAv doses of apis mellifica 3, brought it on again, but Avithoutany return of the neuralgia. Contrary to my expectations, the relief seemed permanent. During the next inter-menstrual period she appeared to be quite Avell; "rode out almost daily, attended evening parties, danced and sang (for she Avas a favorite singer), and was indeed the happiest woman in the city. The only subsequent trouble experienced was six months later, when she had a slight attack of uterine colic,, Avhich Avas promptly relieved by ignatia3. There are several points of interest connected Avith this case, the practical relations of which may interest you. Apart from its chronic nature, and the degree of suffering The importance of phys- involved, the fact that she had been treated by ical exploration. several eminent physicians in different parts of the country Avith such a signal Avant of success, leads one to in- quire into the reasons for their failure. The more obvious of these reasons evidently Avas the lack of a correct diagnosis. The husband assured me that but one of the doctors had ever proposed an examination of this case per vaginam, and that one Avas not permitted to make it. For this reason, — because they did not pursue this investigation as they should have clone, — the Avhole corps, embracing distinguished practitioners of both schools, failed to bring relief. Indeed my immediate predecessor had told the patient's friends that nothing could be of more than temporary benefit, and accordingly prescribed the free use of the sulphate of morphia, which I found her in the habit of taking ad libitum, and in incredible quantities. Such an oversight is scarcely excusable upon any grounds Avhat- ever. As physicians Ave should respect the delicacy of the sex, and the cautions enjoined and practiced by the profession against all unnecessary and unwarrantable officiousness in trivial cases, where a manual examination is uncalled for; but to alloAV any squeamish scruples to be in the Avay of the patient's recovery, or to fancv that constitutional remedies given in the dark, are capa- ble of removing a mechanical difficulty of this kind, argues both a criminal and a crazy neglect of duty on the part of the doctor. It is worthy of remark that by proper means the diagnosis Avas NEURALGIC DYSMENORRHCEA. 213 not difficult, and that the relief afforded by the single introduc> tion of this dilator Avas complete and perma- sinfptVraJfvVexpe^enf. ^nt. I saw my patient three years later, and 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 Avith 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 Avere no eATiclences of existing or of previous inflammation: and if there had been, Ave can not suppose that so simple and transient a means could possibly dispose of them so instantane- ously almost, and so entirely. This case Avas 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, A neurosis. - unaccompanied either by inflammation or its consequences, but presenting its symptoms both during the monthly Aoav and also in the interval betAveen the periods. In most cases of neuralgic dysmenorrhcea, the pain and suffer- ing are limited to the monthly return. Any undue determination of blood to the uterus, or eA'en a slight delay in symptoms of neuralgic {\ie appearance of the discharge, incidental irri- dysmenorrhoea. i J- ~ 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 pehic or the OAarian regions, or it may assume the form of neuralgia located elseAvhere, as in neuralgic headache, neuralgia of the face, the teeth, the eves, the fingers, the toes, the mammae, the intercostal spaces, the stomach or boAvels. 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 Avhich I have spoken, Avhere the local spasm or irritation of the cervix is perpetuated, tbe 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 miy lead you to suppose that it has no possible connection Avith the uterus. In those who are predisposed to this form of dysmenorrhcea, and avIio are generally of a neuralgic tendency, the slightest exeit- 214 THE DISEASES OF AVOMEN. ing causes may induce it. One of my patients, a very observing and truthful person, Avho had had this disease Causes of dysmenorrhoea. -1 -i l i i for 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 Avould increase the suffering in a ten-fold degree. All those habits of mind and body, Avhich induce prostration and perturbation of the nervous system, are likely in those avIio are impressionable, to bring on this form of painful menstruation. The incidental suffering, as in neuralgia, is ahvays periodic and paroxysmal. A predisposition to this peculiar kind of nervous derangement, Avhich implicates menstruation and involves great suffering, runs in families, and, during the first feAV years of their menstrual and sometimes of their married life, every daughter Avill be the victim of these functional derangements. Not unfre- quently the most aggravated cases of neuralgic dysmenorrhcea occur in the experience of those Avomen Avhose married fife 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 hoAvever remote its location. But sometimes the relief is more direct and positive. Only yesterday a the degree of Painflow t0 ladv tolcl me that &ne ahvays felt light of heart and buoyant immediately the Aoav began, al- though but a feAV 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 Avay 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 folloAved by inordinate sexual desire, amounting to temporary nymphomania. You Avill sometimes, but not ahvays, find the distinctive and characteristic indications for the remedy in the remedi"'.'0115 f°r 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 DYSMENORRHCEA. 215 you Avill 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 tAvo of cold Avater may cause a spasm of the uterine cervix, with scanty and painful Aoav, X*,v /^ water™instead °f c°ld mY friend, 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 Vith the Gelseminum. . happiest results. In this form of dysmenor- . u rhoea, at or near the climacteric, he has great confidence in verat- *V^ rum viridel, five drops in the same quantity of Veratrum viride. 1. j warm Avater, and the same close repeated every ten or fifteen minutes. Yet, it often happens, that Avhat will re- lieve one case will in another case seem to be Avithout effect, even where the symptoms are very similar. There are some cases of this disease which can be cured most promptly and satisfactorily, and Avithout any harmful conse- quences, by the use of local means. Careful Dilatation. * . .,.,... dilatation may suffice — as it did Avith my pa- tient — to paralyze and overcome the morbid spasm and hyperes- thesia of the uterine cervix, upon Avhich the Avhole mischief really depends. In neuralgic and spasmodic dysmenorrhea, I think it better to perform this operation Avith solid than Avith sponge tents. Indeed, in some cases of this kind, I haAe remarked a singular ag- gravation of the suffering from the use of the latter, especially when introduced in advance of the flow. SPASMODIC DYSMENORRHCEA. Ill illustration of the fact that neuralgic and spasmodic ctys- nenorrhcea are essentially the same, and that their treatment varies chiefly on account of the individual peculiarities of the patient, I iioav present you Avith the following case: Case.— Miss----, age tAventy-three, has been out of health for a year and a half. She first menstruated at fourteen, and experienced no unusual difficulty until eighteen months ago when in advance of the Aoav, she began to suffer unbearable pains in the stomach and over the Avhole abdomen and extending down the limbs. Her only means of relief is in Avhisky or gin, which she takes and goes to bed, and after sleeping two or three hours 210 THE DISEASES OF WOMEN. the pain ceases and does not return until the next period. The flow is regular as to time, but Avith 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 Aoav commenced yesterday at tAvelve o'clock, and continued three hours without pain, after this for a few' hours there Avas 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 Avith it and Avhich she never had before. Continue ignatia 3. Feb, 18. She ''feels AA^ell." Continue the ignatia until the Aoav 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 by the use of gin or The effects of the gin jjkettles the question* as to the form of are diagnostic. J' \ dysmenorrhoea to Avhich she Avas subject. But her experience is of little use to us except in a diagnostic point of vieAv. No amount of gin avouIcI 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, Avasthat her dysmenorrhcea Avas local, spasmodic, and therefore of a purely nervous character. This temporary lesion Avas engrafted upon the hysterical temperament, and that was all there Avas of it. If she was a married Avoman, and had borne children, the case would have been different, for a pure spasm of the cervix Avhich is sufficient to obstruct the flow, and Avhich is Exceptional hint. .,.,..„.. independent ot uterine flexion, is very rare Avith those Avho have ever been pregnant. Under those circumstances a local examination avouIcI have been necessary before Ave 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 avouIcI have been the same as Avhen she took the Effects of opiates etc. . . . gm, and the rebel Avould 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 DYSMENORRHCEA. 217 sleep, furnish the prominent indications for the remedy that Avas given her. The headache that followed was not tton^for^nawa.1011' due to a medicinal aggravation, although it might have been a consequence of having taken ignatia. In cases of a true medicinal aggravation some of the original symptoms must be increased in severitA^; but Medicinal aggravations. ." here Ave have a new symptom altogether; a state of things Avhichcloes notcontra-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 Avomen. It is not always best to stop the use of the remedy directly there are si an* of its " taking hold." My recommendation for gelsemium, to be taken during the Aoav is based upon the observation that it is adapted to overcome any disposition on the part of the cervical fibres to Gelsemium. contract and to cause the Aow to intermit, Avhich state of things sometimes induces a local spasm of the neck of the Avomb. These are ca-.es of spasmodic dysmenorrhcea for the relief of Avhich gelsemium is prompt and effectual. It is adapted to hysterical Avomen avIio suffer severely in anticipation of the flow, and avIio in consequence of a delay, Avhich is not the result of a displacement of the Avomb, of a polj'pus, or of atresia of the cervix—are kept on the verge of spasms, Avakeful, restless, neuralgic and wretched. The indication is strengthened by the occurrence of occasional attacks of oArarian 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 Avill Other rGmetlies 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 inch, caulophyllum, coffea, collinsonia can., macrotin, hamamelis, hyoscyamus, lilium tig., moschus, natrum mur., platina, pulsatilla, thuja, veratrum alb., viburnum opulus, and xanthoxylum Dr. dousset has often succeeded Avith magnesia carb. Avhere the periods are tardy and Avhere, OAving to the pains, the flow is arrested. Dr. Richard Hughes says that " When it is rather the uterus 218 THE DISEASES OF AVOMEN. which suffers neuralgic pain in the performance of its monthly function, chamomilla and coffea are recommended; and Avill often (the former especially Avhen the temper is much disturbed by the suffering) give full satisfaction. Should they not succeed, or should the general hypersesthesia calling for either be absent, I can commend to you the xanthoxylum frax. I am in the habit of givino- this medicine in most cases Avhere dysmenorrhcea co-exists with some degree of neuralgia; and can speak of several cures with it. If Dr. Masscy's key-note for it, "prolongation of the pain down the crural nerve," is confirmed, it would seem to correspond to ovarian dysmenorrhcea also." In some cases galvanism is curative, and in others, hot baths, electric baths, and Dr. Chapman's hot-Avater bags are all that can be desired during the paroxysm. A feAV 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 Batteys 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. LECTURE XIII. MEMBRANOUS DYSMENORRHCEA. Membranous Dysmenorrhcea. 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 folloAviug re- markable case, Avhich is reported by the patient herself : Case.—I Avas born in July, ltfo-4, in 0----, 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, Avith the exception of this eruption, Avhich appeared almost every year during the summer months, and generally upon the lower parts of my limbs, I Avas 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 Avas plentiful, but attended Avith no pains or incon- venience Avhatever. One year after they Avere suppressed about three months — caused by thin shoes, Avet feet, and not early acquainting my mother Avith the fact. I Avas soon set right Avith tk Cooper's pills." I felt Avell during the suppression. At sixteen, Avhile at boarding-school, my appetite grew voracious, and I ate immoderately of all kinds of food, pickles, and SAveetmeats. The rash had somewhat lessened in its appearance each summer as I grew older. It was, hoAveA'er, upon my body one clay Avhen, just after dinner, in passing through a hall to Avhich the outer doors Avere open, I met a furious,gust of Avind from an approaching thunder-storm. At the moment I noticed no uncomfortable sen- satfon, but Avas shortly seized Avith great difficulty of respiration and extreme prostration, and in less than an hour my life seemed hopeless to those around me. This Avas the first attack of any- thing like illness since my babyhood. Tavo physicians were speedily called, av1io said, " the rash had suddenly struck inward." Two days before this I remember to have been very nervous, so 219 220 THE DISEASES OF AVOMEN. that I could not go to sleep on retiring, but did not know that anything ailed me. The doctors gaA*e me tumblers full of a mixt- ure of asafoetida ; valerian Avas also given. I do not knoAV Avhat else Avas administered, as I Avas only partially conscious. My suf- fering Avas almost Avholly from the gasping and struggles for breath. The rash never made its appearance again until I Avas thirty-four years old. I Avas left Aveak and sick (7 think, from the effect of the dosing). It Avas one or tAvo days before I could be removed home. Very soon my monthly period came on, attended Avith some pain. My mother told the physician, and he gave me hyoscyamus. My school days ended with my first illness. I Avas never able to return to school-life again. The remainder of that summer I Avas Aveak, and very nervous frequently; had seveie palpitation of the heart, and often could scarcely control my limbs and face from tAvitching 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 Avas to be dropped, •• eighty drops every tAvo or three hours." I knew nothing of modern glass-drop measures, and Avent entirely through the "dropping" ordered each time as prescribed. During the fol- loAving eighteen months dyspepsia and nervousness Avere my prom- inent troubles; also obstinate constipation, occasionally having some pain at my menstrual periods, Avhich greAv someAvhat irregu- lar ; but I entered into the usual duties of life, and passed for being in pretty good health. I Avas married at eighteen. After marriage, nothing about my menstrual periods attracted my attention for three months, Avhen I passed over seven Aveeks Avithout them. My form greAv some- what fuller, and I craved certain articles of food. I took " Coop- er's pills" at myT own instigation. When the discharge made its appearance it Avas attendee! with great pain, so that I Avas obliged to go to bed. I felt very sick, and a physician Avas called — one Avhom I had never seen. He gave me soothing medicine, but never said Avhat ailed me. He attended me several months, but never inquired about anything but my constipated habit, and the nervous condition of my system. The folloAving monthly period I Avas able to keep out of bed by taking spirits of camphor, Avhich 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 1'cav months I suffered extremely Atith every menstrual period the first tAvelve or twenty-four hours. I then Avent to C----, to the care of the physician Avho had attended at my birth, and had knoAvn me all my iife. He Avas the first Avho made vaginal examination. He reported a partial " retro- version of the uterus," and said I had "ovarian tumor." I Avent MEMBRANOUS DYSMENORRHCEA. 221 through a long series of blisters on my spine and abdomen, purga- tives, etc. I Avas in his care more than a year. As I could not live in the city, I was not constantly Avith him. I never could myself discover the slightest soreness or enlargement in the ova- rian region, and Avondered that I could find no evidence of the tumor. About this time I began suffering Avith Avhat seemed to be rheumatism in my right limb, particularly Avhen on my feet, or standing much. I rarely ever had it Avhen Avarm or in a reclining posture. In a year or more I greAv Aveary of going into C----, of blister- ing and doctoring, and did Avithout professional aid for a year or tAvo. I did better Avithout it than Avith it, as my general health Avas better. About this time, I once took chloroform to have a tooth extracted. It Avas Avith great difficulty that I Avas revived from its effects, and for sixteen hours I kept constantly sinking away. I next Avent 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 Avhole body daily rubbed Avith 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, Avhich continued several months, improved my general health more than any I had had. Yet my menstrual Aoav did not come right. Finally, he one day ran his fingers violently through his hair, and said "he could not see Avhat did ail me." I Avent home discouraged, and again did without medical aid for tAvo years more. Indigestion, cold feet, rheumatism, attended \y the Avhole train of disorders of the nervous system, had been, .-nd Avas, 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, Avith 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 Avas introduced. Finally, after nearly tAvo years of constant treatment, it Avas satisfactorily dis- covered that I had " rheumatism of the Avomb." I Avas 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 ahvays borne travel well, enjoyed it thoroughly, 222 THE DISEASES OF AVOMEN. and fellow-travelers seldom have discovered that I Avas not in health. in February, 1808, I remoAred to Chicago. The cutting Avinds affected me so that in less than three Aveeks I dreaded to go out of doors — they seemed to search my Aery bones. A thirst Avhich could not be satisfied soon set in, and, shortly, a retention of urine, Avith rheumatism in my Avhole right side. I Avas very sleep- less. The atmosphere seemed too cold for me to breathe, and I Avas 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 Avere 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 Avould catch my breath in going about in common employments, and drew long, deep sighs in my sleep. I Avas nervous and wretched — and the monthly period Avas attended Avith increased suffering. In July I Avent to the sea shore, as had been my custom for several years, and from Avhich I had always returned in much more comfortable health. The Aveather during the journey Avas exceedingly hot, the Avarmest known for years. On reaching Philadelphia by a morning train, Avith scarcely a dry thread upon me from perspiration, I found my body covered Avith rash or prickly heat, Avhich I had not seen for eighteen years. It did not avholly disappear at once. I had passed through the catamenia] period just before leaving home. We reached the sea-side, and the sea-breeze Avas, as usual, invigorating and refreshing to me. I bathed for one Aveek. I Avas very fond of SAvimming, 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 Avarming 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 Avas seized Avith 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 Avas taken to Capon Springs, Hampshire county, Virginia. This MEMBRANOUS DYSMENORRHCEA. 223 spring is celebrated for its use in " the different forms of dyspep- sia, and as a remedy in gravel its \-irtues are said to be unques- tionable ,' Avhile externally applied in the shape of cold or Avarm baths, its results " are proved beneficial in rheumatism and diseases of the skin." I spent three Aveeks here, and my heart Avas entirely relieved ; but, after leaving, I Avas again attacked, in about a Aveek, in the city of Brooklyn. The medical attendant there never said Avhat he thought my disease was, but " supposed my trouble proceeded from the spine." He Avas positive there was no disease of the heart. All the physicians said I must not return to the climate of Chicago, so I Avent to my relatives in the Avest, to R----, Avhere I Avas attended by a physician t\vo months. There Avas a great deal of soreness to the touch about my heart, Avith constant, severe pain, and I could not endure a breath of outside atmos- phere, though it avus only the first of October. He said I had "angina pectoris," and "hydro-pericardium." I had noticed I suffered more Avith my heart about the time the menses made their appearance—generally a few hours before, and I asked him to find Avhether there Avas not something Avrong in connection Avith the uterus, as I had had no attention to that organ for five years. He made examination and told me I " Avas all right there." Suppose Ave recapitulate the chief points in this case, Avhich our patient has detailed in so interesting and truthful a manner. Her first menstruation Avas prompt, plentiful and painless. One year later, amenorrhoea (suppressio mensium), from cold and Avet feet. At sixteen inordinate appetite, the rash declining — sudden and severe illness from repercussion of the eruption, Avhich did not reappear for many years — inAreterate 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 retroA*ersion Avith ovarian tumor — blisters — purgatives, etc., for a year — apparent rheumatism in the right limb, Avorse on standing, relieved by Avarmth and rest in the reclining posture — Avas a confirmed im'alid at tAventy, but dis- abled only for the first few hours of the " period" — abandoned all treatment for a year or tAvo, 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 AVOMEN. disorder unchanged — the doctor at his Avits' end — abandoned all treatment for two years more — nervous disorders continue — still another physician — tAvo years treatment and a diagnosis of "rheumatism of the Avomb" — continue treatment four years more (six in all) — with a faithful trial of DeAvees' prescription of guaiacum —1865 in Europe—l*i>S removed to Chicago — prairie Avincls in spring unfavorable — critical and salutary boils — increased cardiac trouble — rheumatism of right side — monthly symptoms Avorse — goes to the sea-shore in July — after a copious perspiration the eruption, Avhich 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, Avhich Avere given me Avhen I took charge of this case, are the folloAving: About five months after her marriage she commenced passing membranous shreds, and since then has never escaped more than two consecutive "periods" Avithout 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 Avithout them. The degree of pain and discomfort vary Avith the presence or absence of the membrane, and also Avith the amount of exercise taken at the time the Aoav commences. If she lies in bed for a clay or so, there is little relati\'e 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 Avay, that they Avere the result of a, miscarriage. None of them ever made any inquiry Avith 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 Aoav, from a circumscribed pain in the right ovarian region. She could cover the spot with the tips of her three fingers. The pain avouIcI radiate someAvhat, and extend thence along the limb. It Avas invariably Avorse in clamp weather and after exercise. While the cardiac symptoms Avere more or less constant, they were greatly aggravated at the month. Indeed, her sufferings at this time Avere extreme and alarming. She had discovered that aconite 2nd Avould relieve this distress in a very feAV minutes, but disliked to take it on account of unpleasant symptoms, Avhich MEMBRANOUS DYSMENORRHCEA. 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 Avas exceedingly sensitive to pressure throughout its Avhole extent, for the relief of Avhich 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, Avhich she had Avorn habitually for years past, she could not stand or Avalk. With this deviation of the Avomb there Avas more or less of strangury, Avhich 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 sIioavs hoAV 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, Avhile at the same time they put great stress and emphasis upon such as are merely incidental. Membranous dysmenorrhcea is a rare affection, and, when it does exist, is Arery apt, as in this case, to have continued for some years before being recognized. In exceptional looked6 _may be over" cases, it occurs in young girls, but is usually met Avith in married Avomen. In the majority of instances it begins soon after marriage, Avhen 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 A'ery Avell knoAvn. DeAvees and others have taught that it occurs most frequently in Avomen of a rheu- Causes. .,.,.-, . . . . . , matic diathesis. Some authorities insist that the membranous formation, Avhich is its chief characteristic, is ahvays the product of conception. But this cannot be true, for it may occur in the Anrgin, 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 15 226 THE DISEASES OF WOMEN. miscarriage, the continuance of the complaint is not necessarily connected Avith 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 Ave 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 Avomb 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 Avhich has been repelled from the surface, with the appearance of Avhich its symptoms seem to alternate. Here are tAvo excellent specimens of the membrane Avhich this patient has expelled with the menstrual Aoav. Let us examine-. into its anatomical peculiarities. The old au Anatomical peculiarities thors thought it to be a kind of croupou;. of the membrane. o -T 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. DeAvees even suggested that these membranes might be formed from the lymph contained in the menstrual blood. If Ave compare this membrane Avith the decidua vera in the early weeks of pregnancy, we shall discoArer an exact correspond- ence. It is triangular, smooth Avithin, and ^identical with decidua r0Ugh anci villous on the outer surface. If the entire cast has come aAvay, or if Ave can place the shreds together properly, Ave 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 Avhich 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 VirchoAV named it, is not a new or heterologous membrane Avhich 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 moultjjng. MENBRANOUS DYSMENORRHCEA 227 Noav, inflammation is not a factor in the organization of the decidua menstrualis, any more than in that of ^Inflammation is acci- the decidua vera> Qr tJle outer ellvelop 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 Avith the frequent exfoliation of the uterine mucous membrane in ria^nfl'ence1160^^0^" this class of subjects. In case of conception, this influence undoubtedly initiates those changes Avhich 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 mav induce a similar physiological change in the uterine textures as a contingent of menstruation? In the former case, the ea'sr is retained throughout the period of gestation, and finally extruded at term. In the latter, it must escape, Avith its accompanying Aoav, as soon as practicable. In both, the deciduous wrapper is sooner or later expelled. This vieAv has its confirmation in such clinical facts as the fol- loAving : When the " period " sets in, the ovaries are often found to be SAvollen, tender, and the seat of discom- Its clinical confirmation. fort. In a majority^ ot cases there is considera- ble pain in one ovarian region (usually the left), Avhich persists until after the escape of the Aoav, 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 Avay or other this pain is connected Avith the formation of the membrane. The intimate functional relation betAveen the OAaries and the uterus lends sup- port to the vieAv that in a morbid condition of the ovary — a functional perversion, so to speak, of its influence OArer the uterus — Ave 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 shoAvn A'ou in this specimen. Sometimes, although Clinical history. * . r rarely, it comes aAvay m the xorm 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 AVOMEN. taken for a mole. Usually, hoAvever, it is in shreds and pieces, which vary in size from that of your thumb nail shape and size of the ^0 two or three square inches. These pieces membrane. -1- ■"■ may be so regularly formed that you 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 Avomb has been stripped of its lining membrane throughout. In some cases a very considerable quantity of this menstrual decidua is throAvn of. It may happen that this membrane Avill be seen but once in the same patient. Or it may be observed each month regularly in others. Sometimes it appears at alternate Regularity of its appear- m0nths, and again only once in three months. ance. . Iii the case which I have just detailed, my patient did not for many years pass more than tAvo consecutive "periods" Avithout 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 an early abortus, and in other varieties of dys- menorrhcea. 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 Avomen suffer as severely as they avouIcI 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 Avhose 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 Aoav occasions extreme suffering. Scanzoni reports that t\vo of his patients " could ahvays say, Avith perfect certainty, one or two Aveeks 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 DYSMENORRHCEA. 22y that proper to healthy menstruation. This can be readily explained as the consequence of detaching the lining The ' flow' proper. „ , „ membrane ot the Avomb trom a sub-mucous sur- face Avhich is unusually vascular. It corresponds in every Avay with the haemorrhage incident to abortion prior to the formation of the placenta. Sometimes the Aoav 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 ahvays, ceases. Where some small shreds are retained, there is danger of subsequent loss of blood. In Avomen of an hemorrhagic diathesis, the Aoav may degenerate into a pass- ive hemorrhage 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 Aoav may be scanty in amount at one period and copious at another. The reflex nervous symptoms Avhich 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- Reflex gastric symptoms. bie vomiting results. Our patient has suffered from this symptom for nearly a fortnight at a time. In others, the greatest care is requisite to a\'oid severe fits of indigestion. A majority of these patients are habitually costive. If she is of a rheumatic diathesis, the cardiac symptoms may be so pronounced and so clamorous as to lead to the belief that the heart is the real seat of the difficulty. It Avas Reflex cardiac symptoms. . . . . . - ,v , this state of things Avhich induced my prede- cessors in the management of Mrs.----'s case to form an incor- rect diagnosis. In the frequent recurrence and severity of her paroxysms of dyspncea, the palpitation, cardiac pain, oppression and perturbation, there Avere evidences of functional derangement, but of nothing more serious. The doctors must have draAvn on their imagination for the physical signs of organic disease of the heart. At least, I have examined her repeatedly, and most care- fully, Avithout 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 Avas put upon the remedy Avhich Avas 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 AVOMEN. of the heart, and of other organs, Avhich are dependent upon uterine disease of AvhateA~er variety, are invaria- Practical deductions. _"... 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, hoAvever, that organic disease of the heart may finally result from such an indirect cause, when that cause is in almost constant operation for many years. But such cases are exceptional. As in other forms of dysmenorrhcea so in this, uterine displace- ments, more especially prolapsus and retroversion, are very apt to result. In some cases the most obstinate and tio(nsnsequentuterIneaffec" distressing anteversion has been caused by mem- branous dysmenorrhcea. 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 avouIcI diagnosticate a case of membranous dysmenorrhcea from one of abortion, by the regular return of the monthly period, by the membrane usually coming aAvay in tio^.iagnosis-from abor" shreds, 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 hemorrhage, but that Avould be very rare. A continuous and copious loss of blood might Prognosis. ° 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 Avho 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 DYSMENORRHCEA. 231 disease, most cases Avould be curable. Sterility is an inevitable, but not ahvays an incurable, consequence of membranous dysmen- orrhcea. Treatment. — The proper management of this disease will draw largely on your skill, j^our professional knoAvledge and experi- ence, your tact, your deliberation, and your General therapeutics. . J patience. 1 ou aviII 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 Avhich is suited to all cases of mem- branous dysmenorrhcea alike. An exclusive idea of its therapeu- tics avouIcI certainly mislead you. Some cases of this disease are undoubtedly rheumatic, Avhile others are not. The susceptibility of our patient to the damp, chilling prairie Avinds in the spring, the fugitive Special therapeutics. , . -i-i-iTi ■, pains in her chest and right limb, the cardiac symptoms, 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 avIio Avas predisposed to rheumatism, avouIcI suggest such remedies as For rheumatic compiica- aconite, brvonia, rhus tox., nux vomica, mercu- tions. ■ -j 7 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 Aveather. She should be Avarmly clad, and in a measure insulated by flannel or silk Avrappings. Above all things, the night air is especially inju- rious to this class of subjects. In a few Avomen, 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. . . „ . n . abort; and it they do not become pregnant, they are fit subjects for the disease in question. This abortive habit is a poAverful predisponent of membranous dysmenorrhcea. Most of the hints Avhich 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 Avill 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, Avith prompt _ in case of repelled eruP- anc[ evident relief of all her sATnptoms. This tion. " *■ was prescribed on account of the chronic nature of her disease, and its manifest relation to the eruption Avhich had been repelled. A few doses of apis mellifica 3d Avere then given for the ovarian pains, the urinary trouble and the cardiac symp- toms, and she Avas finally ordered calcarea carbonica 12th, which she is now taking. In so far as the reflex symptoms are concerned, there are but very feAV of them that are distinctive, sugges- Reflex symptoms irrek- tive, or reliable. They are quite too sensa- tional to be trustAvorthy. 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 Ave can recognize and remove For 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 Ave understand the origin and structure of the decidua menstrualis, the stereotyped advice to employ such remedies foi the cure of this disease as are given in pseudo- tio"nn antiquated PrescriP- membranous croup and diphtheria, Avould 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,*, hoAvever, applied the kali chlor. directly to the uterine mucous membrane, at short intervals, for the space of ten months. The effect Avas to interrupt the for- mation of the decidual product while he continued the applica- tion, but as soon as he desisted, it Avas formed and expelled as before. There is no evidence that local applications to the uterine sur- * A\Tiener Med. AYochenschrift, No i, 1869. MEMBRANOUS DYSMENORRHCEA. 233 face have ever accomplished any more in this disease than in the case just cited. The good they do is temporary, temPrrLayPbenefitnsareof and even tllis is more tnan counterbalanced by 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 unAvarrantable 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 Ave 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 vieAv to dilate and remove any obstruction of the cervix which prevents the The sponge-tent. „ 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 noAv spoken to you at such considerables 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. ., ,. , ., j dysmenorrhcea. 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 Avith labor-like pains and suffering, which continued for several days, during which time the cutaneous eruption disappeared. She first took a'rsenicum 3, and after- wards the 30th, with excellent effect. The irritation of the skin was relieved and cured by dulcamara 3. ] LECTURE XIV. MEMBRANOUS DYSMENORRHCE A—CONCLUDED. Membranous dysmenorrhcea arising from repelled eruptions, from the repercussion of cutaneous eruptions; cases; sterility as a sequel; statistics; result of treatment, etc. Ill 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 Aue\vs 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 in a year, as in the cestruation of animals, it would still be remarkable for its delicacy, and for the peculiar contingencies with Avhich it is beset. But, in woman, its monthly repetition multi- plies the risk of its becoming disordered, and there are compara- tively feAV who pass through the whole period of menstrual life without suffering some of these consequences. Membranous dysmenorrhcea is not so Ave 11 understood, nor so skillfully and successfully treated as other kinds of painful men- struation. This fact is partly clue to its relative que°nTratiVe ^^ "frequency. For, 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. Noav that the shreds, or casts, thrown off in this disease are known to l>e 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 auatomy is very much simplified. And the fact that this product is decidual MEMBRANOUS DYSMENORRHCEA. 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 dysmenorrhcea is incomplete. For, although the felt-like shreds, or strips, Avhich Non-inflammatory. ^ 1 1 . . . 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 hypertrophied mucous membrane which, from the rapid produc- tion of free cells, is detached and throAvn off at stated periods; on the other, that the process is inflammatory and exudative, and not a mere exfoliation. Experience proves, hoAvever, that Avhile a woman Avith membranous dysmenorrhcea may also have endometri- tis, she is quite as likely to have ovaritis, or even endocarditis as a coincident affection. Accepting the vieAv of Oldham and others that the cause of this disease may frequently be found in ovarian irritation and inflam- mation ; the idea of DeAvees that the rheumatic A variety of causes. ■%..■,•• • i i /• • • . diathesis is responsible tor its existence in a certain proportion of eases; 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 Avhich 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 From cutaneous Qf a cl,taneous eruption. This eruption may, eruptions. L ., i , * indeed, have been slight and possibly have been forgotten by the patient herself. It may 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 Avas positive •Dr. Beigel, in the Archiv. fur Oynakol, Band ix. Heft I. 236 THE DISEASES OF AVOMEN. 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 Avith 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 Avas the direct result. In one of my patients, avIio Avas very ill with this form of dysmenorrhcea, the repercussed eruption had not been seen for eighteen years until it blossomed out as the result of my treatment; and I have recently cured another in Avhose case the " salt rheum " had disappeared tAvelve years before, Avith the immediate advent of shreds and bits of membrane in the monthly discharge. The comparative frequency of eases of this kind, Avhich have been more or less intimately associated Avith skin affections, precludes the possibility of their accidental relation. For, Statistics. P . , ,. , , , out ot tAveive cases ot real membranous dysmen- orrhcea Avhich I have treated within the last five years (187<>), eight of them have been of this sort. In this list I do not include those milder cases Avhich 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 Avith 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 Sterility as a sequel. ' a case ot this form ot 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 Avay, have interfered Avith the function of reproduction. The remarkable effects of certain mineral Avaters 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. MEMBRANOUS DYSMENORRHCEA. 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- _„ 4. ji ,\ • , ine mucous membrane. 01ie to the °ther 1S m no W1*e rare or remarka- ble. Indeed it is very common, more espe- cially in cases of those membranes Avhich, like the lining of the nose, of the throat, and of the utero-vaginal tract, arc in direct continuity Avith the external integument. The modern classification and description of skin affections is quite in accord Avith the idea that, under certain circumstances, almost any of them might be translated to the uterine mucous membrane. The moment Ave define eczema as " a catarrhal inflammation of the skin,"* Ave have declared upon its proneness to migrate from the outer to the inner surfaces of the body, and to Avork mischief in them. Manifestly, the internal lesion, Avhich is clue to this cause, will be intractable, if not grave in character, in ratio Avith 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 stops, that such an invasion avouIcI almost certainly interrupt or modify. And it might Aery 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 folloAv the repercussion of an eruption, lam fully persuaded, not only because I have been able to trace the beginning of a membraneous dys- menorrhcea 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. Tavo of my colleagues have recently consulted me concerning the best treatment for membranous dysmenorrhcea, each of them having a case of the kind under his professional care. The above *A Handbook on the Theory and Practice of Medicine, t# F. T. Robert, M. D., etc., p. 1018. 238 THE DISEASES OF AVOMEN. theory of its exceptional origin Avas explained, and they Avere asked to inquire particularly Avith reference to corroborative experi- th clinical history of a previous or coincident ence. J L skin affection. The folloAving evidence afterAvards supplied by these gentlemen, has the merit of being fresh Avithout having been fabricated expressly to support the theory under con- sideration. Case.—This case is reported by Prof. G. 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 Avere natural until her marriage at tAventy-two. She has two children, the first of Avhich Avas 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 Avas troubled Avith the ' hives,' or nettle-rash, but after the birth of the child it ceased, and she had nursing sore-mouth for Aveeks. This Avas folloAved by a chronic diarrhoea, Avhich lasted for several months. The tongue has remained soft, patulous, and spongy, and is sometimes slightly ulcerated. After the diarrhoea Avas 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 Aoav. It looked very red, and Avas attended Avith an intolerable itching, but it disappeared nearly three years ago, at the time of her miscarriage. The latter Avas not painful, but after a moderate floAving for twenty-four hours, the embryo and placenta Avere thrown off intact. Ten days later she had secondary haemorrhage Avhich lasted for ten weeks. She Avas greatly reduced in strength, and has never fully recovered her health. " Four Aveeks after the cessation of that Aoav the menses Avere resumed, and for the first time the membranous shreds and casts, of Avhich I send you 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- Avhere else externally. The catamenia are now attended Avith moderate pain and flowing for three days, Avhen the membrane is extruded, after Avhich the pain ceases, and the Aoav continues for three days longer, but moderately." Case.—For the details'of this case I am indebted to J. E. Mor- MEMBRANOUS DYSMENORRHCEA. 239 rison, M. D., formerly of Hyde Park, Illinois. " Miss G. M., 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, Avith a fine rash over the body, but especially about the Avaist. For the first three years, or until she Avas fifteen, her skin Avas never healthy, nor Avas the menstruation either painful or too pro- fuse. " About this, time, however, the eruption avouIcI 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 sIioavii itself; but the dysineiiorrhiea 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 seArere, and thus far has resisted all medical aid." Treatment.—Concerning the curative indications which are declucible from this bit of clinical experience, Ave have to acknow- ledge that as yet they are neither very explicit nor complete. To have treated only eight eases of this particular kind of membrane- ous dysmenorrhea, and to haA^e been consulted in perhaps a dozen others by letter and otherwise, does not Avarrant us in dogmatizing upon its special therapeutics. The temptation to speculate upon this subject, hoAvever, is Arery strong, but Ave for- bear. For Avhat a remedy " ought" to do, and what it really Avill do, are not ahvays the same thing. Where the precise character of the eruption Avhich has pre- ceded the menstrual lesion is unknown, Ave can not, perhaps, do better than to begin the treatment Avith the use of Sulphur. In the case already referred to, Avhere 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. avIio remembers just what it Avas; or, by the ferreting action of sulphur, Ave shall 240 THE DISEASES OF AVOMEN. knoAV better hoAv 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 othei'Avise. If-the eruption is, or has been, like urticaria, give arsenicum alb., rhus tox., or urtica urens. If Avhat is vulgarly called the " hives," apis mel. (in the third decimal trituration), belladonna, chamomilla. If it is, or Avas, herpetic or vesicular, cantharis, rhus tox. If squamous, or " scurfy," borax, arsenicum, nux mosch., dul- camara, silicea, sepia. If scrofulous, and otherwise unclassifiable, sulphur, ealc. carb., hepar sulph., mercurius. If syphilitic, thuja, nitric acid, mercurius iod., kali iod., meze- reum. If from suppressed rubeola, or if it alternates Avith 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- menorrhcea, 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 Avhich, although ihey are not iioav 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, bryonia, phosphorus, ustilago, and collinsonia canadensis. There are undoubtedly good grounds for confidence in the vir- tues of calcarea carb. 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, Avhen 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 Avhich 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. AVe have a forcible illustration of this quality of the calcarea, in its ability to discuss certain M EMBRANOU S DY SMENORRHCE A. 241 morbid growths, Avhich it resolves aAvay 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 cajcarea carb. in scrofulous and other skin affections, is suggestive of its value in the membranous dysmenorrhcea, which is secondary upon these eruptions. With the few exceptions in Avhich I have prescribed the sixth or the twelfth attenuation, I have ahvays given the third decimal tritu- ration in these cases. If Ave 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 gonorrhoeal inflam- mation. In a certain ratio of cases, the best-chosen remedy that is pre- scribed on these, or similar indications, Avill fail to complete the cure Avithout manual assistance of some kind. This is more especially true of the treatment of membranous dysmenorrhcea Avhen it co-exists with retroflexion (not retroversion) of the Avomb. 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, Avhen it Avould require to be treated accordingly. But the off- hand method of prescribing for it as though it Avere ahvays 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 folloAving case I am indebted to Dr. A. P. Throop, of New York. You Avill find it in the Transactions of the Homceopathic Medical Society of the State of XeAV York, vol. X, 1.S72, p. 279 : Case.—Mrs. P., aged 21 years, married fifteen months, came to 16 242 THE DISEASES OF AVOMEN. 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 folloAvs: Tin; menses appeared four or five days too early, and continued four- teen days unattended with pain. Eight months since she noticed shreds of membrane mixed Avith the menstrual discharge. There Avasatthis time no dysmenorrhcea, but the period occurred more fre- quently, every three Aveeks, and sometimes lasted for sixteen days. This condition continued until the patient applied for relief from the severe dysmenorrhcea, Avith intense uterine tenesmus or " bear- ing clown" pains from which she Avas suffering. Prescribed secale cornutum, pure tincture. The pain Avas 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 Avas passed. The menses again appeared on the 28th of September, Avith severe dysmenorrhcea, lasting seven days, at the expiration of Avhich time a much larger, though similar membranous substance Avas passed. The patient, on this occasion, describes the substance as being tAvo 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 ease Avas given in ansAver to my questions. The patient Avas 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, Avith that portion corresponding to the canal of the uterine neck a little longer than the angles corresponding Avith the cornea. It Avas ascertained to be hollow, and its external surface Avas studded Avith little villous prolongations. This membranous product, Avith the history and symptoms of the case, made the diagnosis easy,—membranous dysmenorrhcea. Treatment.--As suggested by Prof. Ludlam, of Chicago, pre- scribed Jiorjix^, three times a day, till the next period. The next period occurred the 25th of October. Dysmenorrhcea much less, uo cast, only shred*, less in size than for months, and the general condition better. The last prescription of borax 1, A\a> given November 21st. In January, 1872,1 called at the patient's home, being desirous to knoAV the sequel of the ease, and ascertained that there had been no more dysmenorrhcea, as the period had not again appeared, and the patient Avas pregnant. As pregnancy and1 membranous des- quamations from the inner Avail 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 fine, healthy MEMBRANOUS DYSMENORRHCEA 243 female child, and there have been no symptoms since of any uterine trouble. MEMBRANOUS DYSMENORRHCEA FROM EXFOLIATIA'E ENDOMETRITIS. Case.—Mrs. M., American, vet. 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 Avas 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 Avhether this occurred at the month. During the two following years menstruation re- turned four or five times, the periods unvariabl}' coming Avhile the patient was under some nervous strain. The floAvat this time Avas 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 Avay to and from school Avas often exposed to stormy Aveather. She remembers that frequently she has sat for hours Avith Avet feet. Two weeks after marriage the menses again appeared. At their cessation she Avas seized Avith an acute inflammation of the bladder and kidneys. This lasted four or five Aveeks in an acute form. The paki on A'oiding urine continued for more than a year. Upon recovering from this illness a leurorrhoeal flow began. LTp to this time her geueral health had been good, but it hoav began to decline. Tavo years later, during a menstrual period, a falling of the Avomb 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 Avoinb to replace the organ. This was repeated four or tive times. Fail- ing to keep the uterus in place a Macintosh supporter Avas ad- vised. After a four AveekV trial this Avas 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 oftheseAvere 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 Avith the blood black clots Avere discharged, pieces of decayed flesh, and stringy substances. A diagnosis of membranous dys- menorrhcea Avasthen made. No especial treatment has been taken since,—a period of six years. Xo change has taken place in the character of the Aoav. 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 Aoav, and do not again occur until six Aveeks or two months after the Aoav. Patient stopped menstruating one Aveek ago; feels weak; has bearing cIoavii pains Avhen erect, Avith a sensation of smarting in the Avomb, and an irritated feeling in the Angina; some pain on urinating; bowels constipated; and she is troubled Avith haemor- rhoids. On physical examination.—The cervix is depressed and points toAvard the holloAV of the sacrum, the Avomb lying transversely across the pelvis. The fundus is inclined forward (anteversion). 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- orrhcea Avhich is both membranous and inflammatory. The case is still further complicated by the uterine de- Rarity of such a case. . . , . , viation, Avhicn very likely had something to do with causing it. For versions of the uterus Avhich occur at or about puberty, are almost ahvays the result of flexions; and it is not improbable that this case may have begun Version as a factor of. ... , . „ . ' Avith the bending ot the uterus upon itself as a sequel of her first " period," and that the long interval betAveen it and the second, resulted partly, or avholly, from this cause. Be that as it may, the attempt to keep the organ in situ by means of an intra-uterine stem Avas the Avorst thing that could possibly have been done, for it almost necessarily Mal-treatmcnt by the . , ^ . . J stem-pessary. induced an inflammation of the lining membrane of the womb, Avhen that membrane had already been congested by the displacement. Under these circumstances . ,. the careful gynaecologist avouIcI no more think Contra-.ndications. . l-*/ . l of leaving a stem in the cervical canal than he would of placing a sponge-tent there Avhile there was any peri- uterine inflammation. There are tAvo or three reasons Avhy you should be careful to difl'erentiate this from the more ordinary forms Peculiar remedies. i of membranous dysinenorrhcea. In the first place the remedies that are suited to exfoliative endometritis are OVARIAN MEMBRANOUS DYSMENORRHCEA. 245 not those Avhich are most successfully used in the treatment of the common type of deciduous dysmenorrhcea. They include the dif- ferent preparations of arsenicum and mercurius, the mineral acids, and lniptisia. In the second place, all sorts of local treatment, including the use of sponge-tents, the resort to intra-uterine injections, the Avearing of pessaries, the dilatation of the cervix Special local contra- , ;. Q t} , f tlu, indications. . . i .- uterine sound, or the probe, Avill be mischievous, and are contra-indicated in exfoliative endometritis. We may permit the use of Avarm sitz-baths, or hot Avater vaginal injections, and of enemata, to keep the bowels open, Avithout fear of doing harm, and Avith the prospect of good results in some cases. This patient has iioav been five months under treatment. She has taken belladonna 3, during the period, and arsenicum jpd., 3j during the interval. The result has been that H suit of treatment. ' _ . . instead ot returning every nine or ten Aveeks only, her periods recur every five or six weeks, and her local suf- fering, as avcII 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 avouIcI he radically cured. OVARIAN MEMBRANOUS DYSMENORRHCEA. Case.—Mrs.----comes from a neighboring State. She is tAventy-six years of age, and has been married six years. She has never "had any children, but has had an abortion at the sixth Aveek. She began to menstruate at thirteen; there followed an interval of tAvo 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 ahvays 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, Avhen the Aoav con- tinues, "but Avithout pain. There is constant pain in the left ovarian region, and on the outside of the left ankle, but none in the limbs." The infri-mammary pain is pronounced, but passes •nvnv when the Aoav begins, and does not come at any other time, but is greatly increased i)V any unusual delay in the menses. She has no leucorrhcea', no vesical trouble, and no constipation 246 THE DISEASES OF AVOMEN. she sleeps best on the affected side, and has an almost constant vertex headache. On local examination, the Avomb Avas found someAvhat ante- Aexecl, the canal of the external os was patulous, and the cervix was SAVollen. The introduction of the sound revealed a tortuous canal, and the depth of the womb Avas three and one-half inches. There Avas a slight corporeal cervicitis, and a little haemorrhage followed the introduction ot the sound. In addition to the symptoms just given, there was a slight laceration of the cervix, Avhich, although it happened to be of little consequence in any other way, disclosed the fact The button-hole os that ghe had had .m aborti(m or rather, that some uteri. 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, Avhen she remembered that she had had such a mishap in her early married life. You must keep a sharp look out tor this button-hole os in making your local examinations. The theory advanced by Oldham, that ovarian inAammation is the prime factor in some cases of membranous tratedhamSthe0rSillU3"dysmeilorrhoea' is iUustrated by this patient's history. If Ave can cure the ovaritis, the men- strual difficulty Avill disappear, and there is no valid reason, at least in so far as her own health is concerned, Avhy she may not conceive and go to term. This Avoman has been taking gelsemium 3, four times daily Avith excellent effect. All of her symptoms have improved. The menses iioav return every four or five weeks, and in the tAvo 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 Avhole of it may be clue to the fact that for several months she has been living apart from hei* hus- band. LECTURE XV. MENORRHAGIA. Menorrhagia. Case.—Differential diagnosis in cancer; modes of examination; surgical treatment. Case.—Uterine disorders complicated with malarial fever. Cose. Case.—The first case to Avhich I Avill direct your attention, this morning, is one of menorrhagia. The patient, Mrs. A., is 4(5 years of age. Three years ago she had a miscarriage at four months, since Avhich time she has never been quite Avell. "Is the Aow 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 conies on Avhen 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 long as I continue to Aoav." " What is the character of the Aow; is it quite natural? " " At the first it is, sir, but afterAvards it is like any other bleed- ing, bating the dark clots Avhich sometimes come away Avhen I have those awful learing-doAvn pains." " Are your courses regu- lar?" " Xo, sir; they sometimes come on every three Aveeks, and sometimes not so often."< Menorrhagia signifies a profuse menstruation. It may or may not be painful. The Aoav is excessive, prolonged, hsemorrhagic, and debilitating. Women avIio have attained Definition of. ,. .. ,. . ,, i , the age ot our patient, in other Avords, avIio are more than forty years old, but avIio 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. , . . d , . , n . ' ,. this interval is so prolonged as to occasion dis- tressing symptoms, due to the suppression of an accustomed Aow, or anxiety, lest conception may have interrupted the function altogether. You will frequently be consulted in similar cases. A very im- 24« THE DISEASES OF AVOMEN. portant point is to make out a proper diagnosis. Hremorrhay-e from the uterus may result from polypi, fibroids, Differential diagnosis of. . . cancer, abortion, menstrual congestion, chronic metritis, or from sub-involution of the uterus, or after delivery at full term. Uterine haemorrhage from a polypus, or cancer, may occur at anytime and Avithout premonition. It is metrorrhagia and has no fixed period of recurrence. Menorrhagia is ahvays and evidently connected Avith the function of menstruation. The attack occurs with all the regularity of the menstrual Aoav. The interval is as Avell defined as in a case of intermittent fever. It may be of tAvo, three, or four weeks duration, but the haemorrhage is evidently determined by the accession of the catamenia. If you explore Avith the sound and the speculum you can detect a polypoid groAvth, or a cancer, if it exists, but a local examina- tion of the uterus in menorrhagia proper, re- Modes of examination. . veals nothing especially abnormal, or pathog- nomonic, unless it be an increased depth of the organ. The mucous membrane is injected Avith blood, and more highly vascular than in the inter menstrual period, but this is always the case in the monthly sickness. The Aveight of the Avomb is ahvays in- creased by the afiinx of blood to it during menstruation. Excepting chronic metritis, Avith uterine sub-involution, the lesion that you Avill most frequently recognize in menorrhagia is sub-acute ovaritis. One of the ovaries is tender Complicating lesions of. ■<• to pressure, especially at these times. The patient cannot lie upon the aA'ected side. She complains of lame- ness in the corresponding limb. At buch 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, Avhich is ordinarily dull and deep-seated, becomes 0varitis 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 fcetu* has From a miscarriage. . ^^u» lia' been carried long enough for the placental at- tachments to be well-formed. In the case before you an abortion MENORRHAGIA. 24(J 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, Avhich is acute at the menstrual period, and dull or sub-acute in the interval, Avorse 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. AVith the instructions Local examination. that you have already had upon the uterine sympathies you are prepared to understand Iioav ovaritis some- times causes menorrhagia. Treatment.—For practical reasons Ave 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 Aow is passive ^ Remedies during the ^f painl(^ or nearly S()> the patjent of an hemorrhagic diathesis, Avith haemorrhoids, or varicose veins, hamameljs is the appropriate remedy. It Avill also be indicated in ease of marked OArarian irritation or iiiAammation, especially if the attack is sudden and its course rapid. It may be applied locally over the ovaries and indeed upon the Avhole abdo- men. Given internally in the first or second-decimal attenuation, the close should be repeated at short intervals. If the Aow is bright red, but passive, and accompanied by gastro-intestinal irritation, you may give ipecacuanha. China is called for when repeated flooding* and leucorrhceal discharges have Aveakened 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. avouIcI be appropriate to menorrhagia Avhen complicated Avith dysmenorrhcea. The latter is more serviceable in post-partum haemorrhage. These Remedies ^r peculiar di t] e important aud reliable ill complications. l examples of the kind, Avhen the design is simply to arrest the Aoav. As auxilliaries, rest in the recumbent posture, quiet, the local use of hot water, and cool, acid drinks are neces- sary. 250 THE DISEASES OF AVOMEN. Ill the constitutional treatment proper to the interval Ave should take into account the peculiar temperament and dyscrasia of the patient, as Avell as the local lesions and symp- Treatment in the tomg> jf there jg g^-acute OVaiitis, the SVllip- interval. # . , ' . toms may require hamamelis, sepia, platina, bell., or some similar remedy. AVhen, as in the case before us, the menses are too frequent and profuse, and especially if the patient is of a strumous habit, Avith a tendency to pectoral disorder, the calcarea carb., is par excellence the appropriate remedy. AA"e pre- scribe for this patient hamamelis virg., 2d decimal trituration every tAvo hours during the Aoav ; and calc. carb. 3d decimal tritui^ijiojir- morning and evening, throughout the inter-mens-trual-period... In the Hahnemannian Monthly for December 1670, you will find an excellent article by my friend Dr. O. P. Baer on the therapeutics of uterine hemorrhage. His remarks are so plain and practical that I Avill cite a feAV of them. He says: "I think belladonna one of our best remedies in haemorrhage from the uterus? TTs sphere of action is greater than any other known remedy. I have watched its actions so constantly, for iioav nearly tAventy-five years, have noted the symptoms relieved by it so often (many of Avhich have never been recorded), that I have no hesitancy in terming it the king of remedies for uterine hem- orrhage. Ipecac does Avell in its limited sphere, of Avhich 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 Avith every effort to Aromit. This nausea does not affect the system particularly, otherwise than by inducing increased debility. Belladonna also relieves nausea, and particu- larly, Avhen there is«a Avave-like feeling, or undulating sensation, or pulsating tremor all over the Avhole person, from head to foot; and a sick pulsation even in the fingers and toes. This symptom I have often met Avith, particularly in severe hemorrhages of mis- carriages, and belladonna in such cases always gives prompt relief. Ipecac avouIcI fail. I have known it to fail in just such cases. The ipecac nausea gives a Aveight in the stomach and no further, while belladonna gives nausea Avith rumbling in the Avhole abdomen, Avith 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. AY here the moving of the MENORRHAGIA. 251 hands or feet cause the same feeling of nausea, Avith Avave-like swimming (vertigo) of the head, bell, again, is the only reliable remedy. * * * In the belladonna nausea the^e is rarely retching, or heaving, Avhile in ipecac there is upward heaving, raising the abdomen, boAving the back, and straining to vomit. The action of belladonna is deeper-seated, more quiet, and more insidious. Chamomilla nausea in hemorrhage is one accompany- ing fainting. A chamomilla nausea is rather light, though always attended by a feeling of fainting. Belladonna has a feeling some- Avhat similar, such as a sinking feeling, just as if the bed Avas going doAViiAvard by undulations. Podophyllum resembles l^elladoniia in one particular, Avhich is, an all-over sickness, and with the general nausea, she feels perfectly indifferent and desires to be let alone. I have seen cases Avhere podophyllum did good work, where the patient avouIcI say, "Oh, I am so deathly sick!" " Where are you sick?" the response avouIcI be, "All over." A feAV closes of pod. 30, or 200, avouIcI check the Avhole 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 w,prst symptoms fail to come." The surgical treatment of menorrhagia 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 The surgical treat- oran illations from Avithin the cervix. Excep- ment. ^ , . tionally, Avhere fibroma can not be removed, the haemorrhage may be arrested by a free dilatation, or even by an 252 THE DISEASES OF AVOMEN. incision of the neck of the Avomb; and in the worst cases of inter- stitial and of sub-peritoneal fibroids, Battey's operation may be expedient merely Avith a vieAv to the arrest of the hemorrhage. These forceps answer very Avell for tAvisting off the smaller mucous polypi located about and Avithin 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 Avere incident to the climacteric, that have resisted all the Metrorrhagia after or(liliaiT means of arrest> The hemorrhage abortion. J o has continued for Aveeks, 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 Avith- rN>tncacidasadernierout ay^ q^ the more ugual .^ fam[ymY 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 ansAver an excellent purpose. My habit is to give it in the second or third decimal attenuation, the close 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 2S, aborted at the second month. For the first few hours sbe had considerable pain. But the uterine contractions came on regularly, and the embryo Avas soon expelled. Of course, there Avas no Avell-formed placenta at this early period of pregnancy. The post-partum hemorrhage Avas profuse and long-continued. AVhen the pains had ceased, the secale Avhich she had been taking failed to have any more influence over the flow. The Aoav 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 Aoav to cease for a little, but upon the least change of posture, the discharge commenced again. Matters went on thus for nearly four Aveeks, in all of Avhich time she really had gained nothing, but lost much in strength, color and spirits." At i; p. m. Tuesday of I prescribed nitric acid in the second decimal attenuation, twenty drops in half a glass ot Avater, tAvo teaspoon- fuls to be taken each hour. On AVednesday she had had no Aow since midnight. The same medicine Avas directed to be repeated once in three hours. On Friday there Avas no return of the dis- charge, and she sat up a little. The remedy Avas discontinued. On bunday she came into the parlor, and afterwards recovered rapidly. I am aAvare that there is little in the provings of this remedy that is suggestive of its superior efficacA in this variety of hem- 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 hemorrhages from the mucous surfaces Avhich depend upon the destruction and desquamation of their investing epithelium. Hence we find it useful in passive hemorrhages from the nose, the throat, and the respiratory, alimentary and urinary passages. The escape ot blood by transudation in consequence of the removal of the protecting envelope, avouIcI occasion very different symptoms from those proper to an active and alarming hemorrhage, Avhile 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-menstruai AVlieu abortion occurs prior to the third month, haemorrhage. A 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 Avas attached, Avhen that structure is cast off in labor at full term. If it is not exfoliated entire, the decidua may come away in shreds, in Avhich case the attendant hemor- rhage persists for a much longer period, and is passive in charac- ter. The blood escapes slowly, and is for some special indications for time exposet| to tne action of the air before it nitric acid. L is expelled from the uterus and vagina. The discharges resemble those of melena. Occasionally they are quite profuse. In these symptoms, I apprehend, Ave have the most trustAvorty and practical indications for this remedy. 254 THE DISEASES OF AVOMEN. Iii the case just cited the other remedies failed to give entire relief, because the first stage, and the active symptoms to Avhich they Avere appropriate, had already passed. Then it Avas that the nitric acid could be used Avith the best results. Manv cases of dysmenorrhcea, more especially of the congestive and membranous varieties, merge into menorrhagia. The patient suffers extremely in the first stage of the men- rost dysmenorrhea^ struai period. The Aow is started with great haemorrhage. l _ c difficulty and prolonged suffering, Avhich is similar to the first stage of labor. But Avhen 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, lnne resulted in the partial or complete exfoliation of the endometrium, and therefore, Avhenever she menstruates, it is as if the Avoinan had had a veritable abortion. In one sense the hemorrhage is post-partum. In all important pathological re- spects, it is identical Avith that Avhich 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 hemorrhage, to the relief of Avhich the nitric acid is frequently, but not invariabl}', adapted. You are already aAvare that, at the climacteric, many Avomen are liable to protracted hemorrhage, Avhich is apt to be of a pas- sive kind, not profuse, but lingering, exhaustive "*™^bageatthe and debilitating. This Aoav is sometimes in- climacteric. ^ tractable. It may or may not contain strips or shreds of Avhat 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 4(5, had been ill for five Aveeks with a passive hemorrhage, Avhich dated from her last menstrual period. She was much reduced in strength, the pulse Avas Aveak and irri- table, the lips, tongue and ale nasi Avere very pale. She com- plained of occasional faintness, and di>gu>t of food and drinks. The feet Avere cold, and she had almost complete insomnia. Her friends thought her going into a rapid decline. Motion aggra- vated the Aoav. Prior to the last period she had a similar attack, which continued about four Aveeks before the Aoav Avas 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 hemor- 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 Avhich Ave meet Avith in apthous conditions and incipient ulcerations of the alimentary Practical conclusions. , mucous surfaces, as m stomatitis, typhoid fever, and in some forms of diarrhoea and dysentery. Here Ave 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 hemorrhage. The great benefit derived, in the treatment of hemorrhages, 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 Avay. MENORRIKEA—CERVICAL EI'ISTAXIS. 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 Avalk,and to some extent to enjoA7 the society of her friends. She began to menstruate at fifteen. The first period came on Avith a great deal of pain and difficulty, but Avhen the Aoav Avas finally established it continued for three Aveeks Avithout cessation. After five days' intermission it commenced again, but Avithout any considerable suffering. Again it continued until almost the end of the month, and again it returned Avith the regularity of the normal monthly discharge. In this manner, for four years, the Aoav has been almost constant. The longest interval in Avhich 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 Aow is passive and painless, and continues Avhen she is sleeping as Avell as during her Avaking hours. Sometimes under strong mental excitement, as Avhen 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 Aoav is arrested, she suffers no inconvenience excepting a "• rush ot blood to the head," accompanied by more or less ver- tigo, headache, Audied fac<\ dimness of vision, and a heavy, dull feeling, Avith disposition to sleep. At other times her mind is clear 256 THE DISEASES OF AVOMEN. ?nid her spirits are good. And yet she feels someAvhat weakened and enervated by the constant loss of blood. Her appetite is good. There is no intra-pelvic pain or distress, no hemorrhoids, no constipation, and no urinary derangement. The only suffering noted is a feeling of aching and Aveariness 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 Avas subject to a similar hemorrhage. This patient's general appearance does not indicate that she is ill. She has Avalked several squares to the Dispensary this morn- ing, with less fatigue than you would have supposed possible. Her color is someAvhat heightened by the exercise in the open air, for her sister says that she is usually more pale than iioav, except- ing only Avhen her hemorrhage has ceased and the blood rushes to her head. It is sometimes very important, in cases of this kind, to discoA'er the relation Avhich a passive uterine hemorrhage bears to the cata- menial function. If the Aoav dates from the Relation to menstruation. r> i • n first establishment ot this function 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. . . are some exceptions to this rule, as m case of 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 afterAvards (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, Avhich is a condition of the menstrual secretion, is relieved and removed Avhen the A physiological reason. healthy Avoman has menstruated. But, if she is not well, that extraordinary fullness of its vessels may continue, even although the menstrual Aoav has been discharged ; and there Avill remain a passive congestion of some portion of the uterine mucous membrane. This engorgement may relieve itself by a profuse and copious hemorrhage, as in menorrhagia, or even in metrorrhagia; or it may pass aAvay by a sort of cervical epistaxis, MENORRHAGIA. 257 01 passive flow, in Avhich the local excess of blood oozes out and escapes more leisurely. In the former case the critical and alarm- ing hemorrhage is sudden, and of short in ration ; in the latter it is a mere prolongation or continuation of 1 le menses, Avithout any very serious symptoms, until the month i? 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 hemorrhage, although so long continued, must be classed as menstrual — a real case of menorrhcea. It is that the amount of the Aoav is Peculiarity of the flow. • n iii • i • i i not influenced by the exercise which she takes, or by other circumstances, more decidedly than it is in ordinary menstruation. If that hemorrhage depended upon the presence of a sub-mucous or interstitial fibroid, a polypus, ulceration, can- cerous degeneration, or venous engorgement, the quaiitit}^ of blood lost would Arary Avith her habits. Above all things, it would not be lessened by riding and active exercise. Viewing this species of hemorrhage as in a sense critical, and remembering the " habit" Avhich has grown out of its continu- ance, Avith brief intervals only, for years, Ave should naturally expect that the arrest of the floAv avouIcI occasion more or less of suffering and disorder else- Avhere. Hence the "rush of blood to the head," of which this Avoman complains whenever the Aoav has ceased, and which sub- sides as soon as that Aoav is restored. The same cause Avill some- times induce a violent attack of facial neuralgia, or sick headache, vomiting, delirium, hysteria, spasms, coma, or even convulsions. To sIioav that this disease is not infrequent, and that the case before you is a typical one, I Avill read you some extracts from a letter received a feAV days ago from Dr. R. C. Sabin, of Wiscon- sin, a member of the class for 1*71-72 : Case. — •' My patient is now eighteen years of age. She com- menced menstruation at fifteen, and the Aoav has been almost con- stant ever since. The longest time in Avhich she has been free from it is tAvo weeks, when the interruption was caused by a jour- ney by rail. The discharge is of a bright red color, thin and Avatery, and has no odor. After continuing for a month or six weeks, the Aoav becomes stringy and thick, and then ceases for n 258 THE DISEASES OF WOMEN. two or three days. Her health is always impaired at the time the Aoav stops, and there is giddiness, sudden fiushes of the face, blindness, etc. These symptoms pass off as the Aoav returns. The urine is high-colored, and of a strong nauseous odor. "She is of scrofulous habit, short and fieshy, and is troubled with frequent moist eruptions. The constant drain does not seem to have the least effect in reducing her Aveight. She Avas ex- tremely fieshy 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 Aoav. Hamamelis will also check it in a feAV 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 be pursued. You may find the cervix uteri examination. i *' tender, SAVollen, 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 Avill account for the symptoms and give you a hint toAvard their relief. It is sometimes important to knoAV Avhether this or other men- strual disorders have been hereditary in the patient's family. Especial inquiries should be made concerning Modifying circumstances. . -,..-, . • p , i . • , 1 ^ the hemorrhagic diathesis, or it the patient has ever had chlorosis or anemia. 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 hemorrhage has persisted for seA^eral silh:ith^rmanffesrtfnyjSry: years is proof that it may continue indefi- nitely, and Avithout any very serious impairment of the general health. Its duration may even extend from MENORRHAGIA. 259 puberty to the climacteric, and then expire by limitation. Usu- ally, however, such persons survive the change of life Avith diffi- culty, for the arrest of the accustomed discharge is apt to induce disease of a more serious character elseAvhere. One of the most troublesome consequences of this form of uter- ine hemorrhage is sterility. Whatever the state of their general health, in Avomen Avhose pelvic circulation is Sterility from. being thus constantly drained, the vitality of the internal generative organs is Ioav. And even if ovulation is properly performed, the lining membrane of the generative intes- tine is not in a condition to favor conception. Moreover the san- guineous floAV itself would be very likely, to interfere Avith a fruitful intercourse. Hence'you Avill be consulted for the cure of barrenness Avhich, directly or indirectly, is due to such a hemor- rhage as this Avoman has had for the past four years. Treatment. — In the whole range of medical practice, I scarcely knoAV of a class of cases Avhich is better suited to illustrate the efficacAr of properh' chosen internal remedies, Medicine versus Surgery. . .l .. conjoined with suitable hygienic regulations, than this. Here is a case of hemorrhage Avhich depends upon a pathological disorder of one of the most prominent of all the bodily functions. It has a definite clinical history. Its symp- toms are significant. Its causes are obvious and avoidable. Its diagnosis and prognosis are not difficult. Its treatment is similar to that of other diseased conditions. And it can be cured by therapeutic means exclusively. In all these respects such a case as the one before you differs from uterine hemorrhage accompanying or folloAving labor or abortion, or from habitual and excessive losses Not to be confounded with 0f jjloocl in consequence of intra-uterine unavoidable haemorrhage. 1 groAvths. Ill them the hemorrhage is acci- dental and more or less dangerous. It is a mere contingency, and must be relieved at once, or the patient's life may be sacri- ficed. The simple expedient of emptying the womb and securing its contraction may be sufficient. But in the passive form of uter- ine hemorrhage, connected Avith menstruation, surgical appliances are either powerless or harmful, and no such very general indica- tion is presented. We are forced to depend upon uterine thera- peutics. 260 v '£ THE DISEASES OF AVOMEN. In the selection of a remedy, or remedies, we should not over- look the significance of certain incidental states or conditions, for example, the different dyscrasie, each of which General therapeutics. . , „ . , ",. . , , . mi is possessed of its OAvn clinical bearing, thus : If the patient is predisposed to hemorrhage, such remedies as __.china, ipecacuanha, sabina, platina, secale cornutum, ferrum, nux vomica, natrum mur., hamamelis, trillium, For the haemorrhagic p^g £ox calcarea carb., belladonna, crocus, diathesis. 7 carbo veg., phosphorus, arsenicum alb., and sulphuric or nitric acid may be indicated. She should be put upon cool acidulated drinks, and enjoined to keep as quiet as pos- sible during the first Aveek or ten days of the period especially. If she is in a state of chloro-anemia, the remedy must cover the symptoms which are most prominent. Among them you Avill ob- serve such as signify a profound impression of For the chloro-anaemia. the nervous and circulatory, as Avell as ot the digestive and menstrual functions. And, whether the hemor- rhage is the cause or the consequence of the impaired quality of the blood, the case Avill have to be treated as one of chlorosis Avith serious complications. In case of confirmed scrofulosis with menorrhcea, I apprehend it to be of the utmost importance to attend to the physiological needs of the organism in advance of medication. For the scrofulous First, select a suitable diet, one that can and cachexia. ' ' Avill be assimilated. It should consist of a proper and available proportion of the oleo-albuminous elements. These should be cooked and presented in a pleasant and palatable form, and at a suitable time of the day. The appetite should be encouraged by mental diversion and suitable exercise in the open air. For the function of hematogenesis, or blood-making, to Avhich the lymphatic glandular apparatus is especially devoted, must proceed properly, else the quality of the blood will become so seriously impaired that hemorrhage will almost certainly folio AV. The most prominent remedies suited to this cachexia, and the symptoms that are likely to spring from it in this form of cervical epistaxis, are cjfoarea carb., calcarea phos., herjar sulphuris, sili- cea, baryta carb., jodium, phytolacca, carbo veg., mezereum, mere. MENORRHAGIA. 261 sol., mere, jopbj^sulphur, and the nitric, muriatic or sulphuric acids, ' "In some obstinate examples of this form of passive uterine hemorrhage (if your experience accords Avith mine), you Avill find that Avhen the most carefully selected remedies cachexk6 syphilitic have failed, as they sometimes do, you will suc- ceed in curing it by giving medicines Avhich are anti-syphilitic in their character. In this Avay the Jsali jodatum,. kali hyd., thuja, mere, precip. ruber, and nitric acid, in such po- tencies as you shall select, may help you out of the difficulty. Of course, if you succeed by giving them upon the theory that there Avas a slight taint of syphilis in the lesion, it Avill not be either prudent or necessary to tell the patient or her friends Avhy this particular class of remedies Avas chosen. ()varian disease is so frequently at the bottom of these hemor- rhagic complaints that you should be Aery careful not to OArerlook it. For, as a rule, the OAraritis precedes the For ovarian complications. . hemorrhage, and is the cause both of its long continuance and of its periodical return. This is especially true if the chronic and unnatural Aoav dates from puberty. The reme- dies Avhich are best adapted to the cure of this complication are belladonna, colojrpith, hamamelis, liliumtig., lachesis, carbo veg., conium, Aeratrum vir., platma,~mercurms,£orr., andjnilsatilla. In a Avord, the cardinal symptoms that properly belong to the lesion of the ovaries, Avhen the ovaritis and the hemorrhage co-exist, are a more trustworthy guide in the selection of the remedy than the quantity, or even the quality, of the sanguineous Aoav itself. Since it is possible that a change of climate may aid in the re- covery, one avIio has lived in a mountainous region may be sent to a different section; or one avIio has resided Change of climate. it- i p i m a Ioav, marshy district, may be transferred to the mountains. Sometimes a cure AAill folloAv 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-Aroyage, or salt-Avater baths, may prove Arery beneficial. While it is requisite that such patients as Miss----should take sufficient exercise, it is equally important that Suitable exercise. i-it i tt i i • i • they should not overdo. Horseback riding, or running the seAving machine, skating, or dancing, for example, 262 THE DISEASES OF WOMEN. avouIcI 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 The~se cases. It is not, hoAvever, specific. She Avill take it four times daily, and report the result. MENORRHAGIA AVITH REMITTENT FEVER. Case.—Mrs.----, aged 30, has been subject to menorrhagia for three years past, for the relief of Avhich she has had treatment by tAvo celebrated gynecologists, but Avithout avail. She has taken the most poAverful drugs, and been subjected to local treatment, Avhich 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 Avithin the uterine cavity, for her physicians have told her very plainly that such Avas 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 Aveeks, and continuing, Avith brief intervals, for from ten to fifteen days. The Aoav at times Avas copious and drenching, and she had frequent spells of fainting and exhaustion. She Avas pale and anemic, cachectic and bed-ridden. I saAv 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 Avhatever. She improved from the start to such a degree, that I resolved to let Avell enough alone, and gave her no other remedy. When the next period arrived, Avhich Avas a little later than usual, she Avas doing so Avell that the calcarea Avas continued. The Aoav lasted but six clays, Avas much less copious and more natural in every Avay than it had been for years. The same remedy and the same experience Avas continued and repeated for four months with the effect to lengthen the interval between the periods to four Aveeks, and to lessen the discharge to about the normal quantity. But at the end of this time she ob- served that each period Avas accompanied by febrile symptoms of a more decided character than she had ever noticed before, although she Avas persuaded that something of this kind had often been pre- sent during the monthly molimen. In order to be certain of her condition during the monthly period, I instructed her to go to bed and to staj'there until the flow had ceased. MeaiiAvhile, I visited her every day and discovered MENORRHAGIA. 263 that she Avas suffering from a pronounced fever of a remittent type, for Avhich 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 Avith one of the types of malarial fever. Sometimes this lesion iaria™n;verte "' ma~is the cause, and again it is the consequence of the fever. In the case under revieAv, when the calcarea had done its work, there yet remained a source of mischief Avhich 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 haA'e supposed, and that, consequently it is very sel- [Jterine disorders not L L . . J always easy of cure. dom that Ave can succeed in curing them radi- cally and entirely Avith one remedy, no matter hoAv carefully it is chosen, hoAv appropriate it may be to the more urgent symptoms of the case, nor hoAv persistently it may be given. If there is any class of diseases in the treatment of Avhich, the superior efficacy of our remedies can be demonstrated, it is in the different forms of uterine hemorrhage, Avhen that hemorrhage is non-puerperal. It is sometimes astounding to see Iioav our attenuations take hold even in the most unpromising cases. But the fact remains, that only a very feAV of them can be entirely cured by a single remedy. Here is another case Avhich illustrates the tendency of men- strual Ire morrhages to be complicated Avith the most varied and intractable disorders: MENORRHAGIA AVITH 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 Aoav returns every three Aveeks, lasts for from eight to twelve days, and is very copious. She has a great deal of pain in her back, Avith sharp catching pains, Avhich 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 advrance of the Aow 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 Clinical Medicine by Dr. Jousset; translated by Ludlam, p. 46. 264 THE DISEASES OF AVOMEN. 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 macrotin 3. He also took occasion to say that, in the case of rheumatism, or almost any other disease Avhich is complicated Avith uterine affections, and more especially Avith menstrual disorders, the rule that Ave should Avitbholcl our remedies as soon as they fane done any good, is unsatisfactory and fallacious. The reason tor 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 Avhich reneAvs the attack of rheumatism, or Avhat not, as soon as the first efi'ect 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 reflections.] LECTURE XVJ MENORRHAGIA—CONTINUED. Menorrhagia with hemiplegia; do. with Uterine Fibroid ; do. wittLConvulsions; suppres- sion of do. by Astringents; Aricarious Menstruation. MENORRHAGIA AVITH 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 Avas about three months along, she Avas sud- denly taken Avith paralysis of the left half of her body (hemi- plegia). After the child Avas born, however, she recovered from it, a result Avhich she attributes to an ex ~essi\re Aooding. 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 Aveeks later her general symptoms Avere very much im- proved. There Avas still some numbness in the left side, but she has not menstruated for six Aveeks. The same remedy Avas continued. The menstrual hemorrhage was elfjctually disposed of by this remedy, but she afterwards took belladonna Avith 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 Avith the hemiplegia, as the condi- tion of pregnancy. A .id the menorrhagia Avas ^a compound indica- certainiv contingent upon it. The proper therapeutics of the case, therefore, complicated as it Avas, turned upon a recognition of these facts and of these factors, and hence necessitated the use of belladonna after the hamamelis had done its Avork. MENORRHAGIA FROM A UTERINE FIBROID. Case.—Mrs. N., aged thirty-three, has had menorrhagia for eight years. She has never been pregnant. She Arst discovered the tumor about eight years ago, after having lifted and cared for a very sick sister. This tumor is sensibly increased in size Avith every retr.rn of the menses. The only pain that she has is with the flow, Avhich is very copious, but of a brief duration. At one time, hoAvever, the menses Avere suppressed for nearly a year. [The class examined this tumor very thoroughly. Its outline 'Mb 26b' THE DISEASES OF AVOMEN. 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 tAvo. He also said, that in this case, the menstruation had become regular and almost normal. The groAvth of the tumor had been arrested, and the patient's general health had greatly improved, under the use of the Trillin in the 3d deciimil trituration. ] MENORRHAGIA WITH CONVULSIONS. I have had frequent occasion to extol the virtues of Nitrid Acid in a certain form of menorrhagia. Here are the notes of a case for Avhich 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 Avas puny and small, and, though never very ill, the skin was ahvays of a yelloAvish 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 Avhose care she Avas placed succeeded in bring- ing on the menses, but the Aoav did not cease at the proper time. The discharge Avas 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 Avas unchanged for several months more when the mother besought the doctor to stop the Aoav. Some unknoAvn 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 folloAved, 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 Avas 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 greAv Aveaker and more nervous, and finally he also abandoned the case, saying that kk she would either outgrow it, or Avould 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 Avas 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 Aveeks, and then for six months more alternations of suppression and continuous Aoav. She Avas finally reduced to a mere shadovv, passed sleepless nights, her right side Avas constantly in motion, and she Avas 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" Avithout the doctor. So far as the discharge was concerned, she was in a someAvhat improved con- dition. But generally she Avas no better. In a feAV months the old difficulty returned Avith renewed violence. I found the patient in the folloAving condition. She is very much emaciated, and hardly able to walk; flesh flabby, skin soft, discolored in spots, very salloAV and dirty looking, hectic flush, sensitive, alternate chilliness and flushes of heat, eyes brilliant, Avith 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 Avhich lasts about tAvo hours, after Avhich she feels Aveary 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, Avith a constant feeling of w" 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 Avhite color. The boAvels 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 Aoav, 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 268 THE DISEASES OF AVOMEN. dungeon to an airy, pleasant one, exposed to the sunlight, and that she should continue under treatment until I pronounced her cured, Avhether it took a month or a year. She Avas 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 Avas nitric acid3 (centesimal), four pellets three times each day. '---■ April 17, tAvo 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 Aoav less ; appetite better ; but is very nervous and Avakeful. Coffea6 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 tAvice 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 Avildly about, can not sleep. Hyos- ■cyamusj^ 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 Avell, 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 Aveek. May 15. Found my patient much improved. She has passed through her menstrual period, Avhich lasted four days and ceased spontaneously tAvo days ago. She feels like a neAV creature, sleeps like a child, appetite good, stomach bears food Avell, 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 Avas in every respect the opposite of what she had been. The nervous symptoms had vanished, the menstrual irregularity had disappeared, and her health Avas entirely restored. This case illustrates the ill effects of " forcing the Aoav" at puberty. Here is a young lady of fifteen years. Nature is mak- ing an effort to establish the menstrual function. Emmenagogues at puberty. She is passing through the preliminary stage of the crisis, has been sick once, and in due time all will be welL MENORRHAGIA—CONTINUED. 269 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 Avhat contingencies it is beset, and hoAV easily its proper performance may be deranged, he prescribes something that is designed, not to prompt, but to compel the Aoav. The consequence is that a train of ills, which might haA*e been avoided, is fastened upon her. The Aoav appears, but it is not physiological and healthy. Instead of being folloAved 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 Avonderful 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 poAverful astringents. Now, gentlemen, you knoAV the mischief of the artificial induc- tion of abortion. I have shoAvn you how ruinous it is to the health of a Avoman to forcibly interrupt the Remote consequences. - ,ip,i* t i i • attachments and growth ot the germ. In this clinic your attention has been called to some of the sequelae of this abominable practice. But, let me tell you that, leaving the feticide out of the question, the consequences to the Avoman are no more serious and lasting than those Avhich frequently follow the taking of emmenagogues by young girls who are but just be- ginning to menstruate. The fact that Avith this patient the menses had already appeared should have been a sufficient guaranty that, if she Avere well in other respects, the Aoav would be regularly Menstrual intermissions established. And besides, as every experi- common. 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 tAvo or three, or perhaps even a year, before they return again. And this Avithout 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 AVOMEN. 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, amenorrhcea 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, Avho has a passion for what he calls " demonstrathe treatment," to soav 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 The nervous and the ha(i a convulsion, and Avhen the Aoav returned menstrual functions. ' the convulsions ceased. Each time the dis- charge was lessened, the nervous twitchings and choreic move- ments became more manifest. And eA*en when the convulsions were not induced by an arrest of the menses, these jerkings and twitchings Avere 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 Avithout 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 Avhen the catamenial function is established. There is a form of men- strual mania that may accompany amenorrhcea, or menorrhagia, Avhich, 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 Ave should consider in this connection is the folly of supposing that, in certain cases of uterine haemorrhage, the disease is cured if Ave only stop the Aoav. There are cases of flooding in Avhich if Ave fulfil this indication it is all that we can expect to accomplish, for in so doing Ave 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. "" placenta in 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 Avith medical means. But in such cases as this, Avhere the haemorrhage depends upon a pathological condition of the uterine mucous membrane, and a morbid state of the Avhole menstrual function, it Avill not suffice to check the discharge. For, even if the patient escapes having more alarming symptoms in consequence, the disease Avhich has caused the Aoav 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 Avill do no permanent good. The digestive derangement Avas a very natural and almost neces- sary consequence of the menstrual disorder. And so also Avas the ehloro-anamiia. Nothing could be better adapted The gastric and cbior-f tl■ y , tl 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, Avere useful auxiliaries toward the cure. Indeed, as the result proved, nothing could have been more appropriate than the treatment adopted. The nitric acid Avas perhaps the only remedy capable of correcting the menstrual irregularity Avithout aggravat- ing the nervous disorder, of intercepting the convulsive paroxysms, and of curing the alimentary derangement. But alone, it Avas not sufficient to effect a radical cure. SUDDEN SUPPRESSION OF MENORRHAGIA BY ASTRINGENTS THE CAUSE OF SUBSEQUENT ILLNESS. Case.—Mrs. R.----desires relief from attacks of Avhat has been diagnosticated as bilious colic, from Avhich she has suffered at frequent periods for eight months. The paroxysms almost ahvays 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, Avhen most severe, there is a slight inclination to vomit. The paroxysm generally lasts about an hour, during Avhich time she cannot lie doAvn, but must sit, upright in the bed. After the fit she sleeps soundly, and, Avith the exception of a loss of appetite for breakfast, and occasional headache, is cpiite Avell 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 Aveeks. Prior to the commencement cf these attacks she had, for some 272 THE DISEASES OF AVOMEN. months, suffered from too frequent and too profuse menstruation The Aoav returned every tAvo or three Aveeks, and the loss of blood was sometimes extreme. To arrest the haemorrhage, her physician ordered vaginal injections of strong alum Avater. This expedient arrested the Aoav, but induced a severe attack of metritis, from Avhich, in the hands of another physician, she barely recovered. The menstrual interval was subsequently extended to about four Aveeks, but the Aoav Avas still too profuse. All sorts of expedi- ents Avere tried to arrest it, but Avithout effect, until the patient, becoming wearied Avith it, took the responsibility of resorting again to the alum injections. As soon as she did so, the exces- sive Aow ceased, but in lieu of it she began to have these attacks of excruciating pain. During the eight months which haAre intervened she has had three other physicians, none of Avhom 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. . , . Avhich are connected Avith menstruation, the arguments against their indiscriminate employment are few and simple. In the first place, unless connected Avith 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 Avhich this flow depends. Take aAvay the cause and the effect ceases. To strike this single symptom out of existence Avould be to lose time and Avork 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 Avhich, for the welfare of crkLeaTrhasia sometimes the general organism, should not be too ab- ruptly closed. It is quite probable that the menstrual secretion is partly eliminative, and designed to expel certain noxious matters Avhich would prove harmful if retained. To suppress the Aoav voluntarily might induce the very symptoms which are present in case of retention from diseased states, a con- sequence Avhich it is our duty to avert. You Avill readily perceive that the sudden application of a solu- MENORRIIAGI V—CONTINUED. 273 tion of alum to the vascular mucous membrane of the superior n,_ . , . , vagina and uterine cervix, for the arrest of the Physiological argument against imra-utenne as- haemorrhage, Avould be very apt so to derange tnngents. " r & 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 umvarrantable expedient. Thousands of lives have been sacrificed in this very manner. These harsh astringents are often throAvn 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 clanger of inflam- mation and its sequelae, of the risk of throAving 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 Avay." We shall doubtless have frequent occasion to refer to the reflex relations existing betAveen the uterine cervix and the stomach. There is much that is curious and suggestive Digestive disorders from . -n i • 1 • • 1 l • i vaginal and uterine injec- therein. But there is a clinical hint connected Avith the history of cases like this, the signifi- cance of which you should appreciate. A large proportion of the cases in Avhich astringent injections of various kinds have been throAvn into the vagina, and thus brought into contact Avith the neck of the Avomb, are characterized by peculiar and inveterate disorders of the stomach and boAvels. Some of the worst examples of gastric indigestion that I have ever treated Avere 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 Avith Avhich the 18 274 THE DISEASES OF AVOMEN. 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 Avhich 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, Avhich had been taken to suppress the haemorrhage from the Avomb. 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, which, 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, Avhich greatly torments the patient. I have repeatedly had occasion to witness the most extreme suffering, sometimes gastric, again gastro-intestinal, or perhaps uterine chiefly, Avhich Avas entirely due to the presence and pressure of a polypoid groAvth Avithin 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, Avhich 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 Avhich I have just spoken. Treatment. — This is a case of neuralgia of the cceliac plexus, induced by the alum injections. Hoav 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 Ave find them ? This is a point upon which doctors Avould assuredly disagree. My own opinion is that, if the attack were more recent in its origin, and Ave 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, Ave 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 clay. If the paroxysm returns at evening, it may be repeated every t\venty 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 feAV doses of atropine 3d, and again Avith colocynth of the same potency. There are cases of refiex 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- inSonT" °f vaginal ries' tliat wil1 not viel(l to tlie Dest chosen rem- 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 Avould be proper to proceed upon the hint which I have given you concerning the possibility that there is a foreign body, a polypus, within the Avomb. The os should be so dilated Avith a sponge or other tents, that the proper exploration can be made. This should be done sloAvly and carefully, in the manner AA'hich 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. ''Hoav 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 AVOMEN. I sometimes have pain in my chest." " Do you ever raise blood?" " Xo, sir." "Hoav 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 Avith it? " " No, sir." " How often do you have your nose-bleed? " " Exactly once a month." " It comes very regular, does it? " " Yes, sir." '' Hoav long does the attack last?" " I have it off and on for about three or four days." **And then it goes aAvay and does not return at all for another month?" "It does, sir." "Is the cough Avorse 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 dnuvn to the periodical nature of her complaint. The ex- perienced physician Avill recognize the menstrual function as the one most likely to be at fault. If Avith 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 Avhat is termed vicarious menstruation. I have questioned this young Avoman, 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 cases of suppression. Epistaxis may occur in plethoric persons, in the early months of pregnancy. When a Aow of blood is established from some other part than the uterus, and that Aoav recurs Avith all the regularity of the cat- amenial discharge, and really supercedes it, Ave 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 hoematemesis, or haemoptysis, epistaxis, or haem- orrhage from the eyes, ears,axillae, anus, bladder, the rectum, the ends of the fingers and toes, from the stump ot an amputated limb, or from an ulcer. Usually, however, the vicarious Aoav comes from a weak and vulnerable organ or surface. Thus our patient is of scrofulous habit, narroAV-chested, Avith 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 aAvare that there is a close sym- pathy of function betAveen 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 epistaxis 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 Avould be different. Then the cause being physiological, the system Avould accommodate itself to the neAv order of things, and harm would not necessarily result. As it is, Ave must restore the natural Aoav and relieve the sup- pression, or serious consequences Avill certainly befall the pulmo- nary system. Treatment.—The indications are manifest. It is not important as in the former case, to prescribe any especial treatment for the haemorrhage. A more important Avork is to be accomplished. The principle function in the female economy is suspended. There is no compensating relation betAveenthe uterine and the respiratory mucous membranes, as between the skin and the kidneys, Avhereby 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 OAraries and uterus becomes a morbid irritant Avhen directed to the lungs. We must restore the conditions to functional order in the generative system; not by emmenagogues, that would compel a sanguineous How from the uterus, but by agencies designed to harmonize the delicate sympathies iioav 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 betAveen these tAvo very important functions. Calcarea carb., pulsatilla, calcarea phos., natrum mur., sangu- naria can.,TalunTfna,7"kali carb., ferrum acet., and possibly also, 278 THE DISEASES OF AVOMEN. caulophyllum, and hamamelis. I recommend you 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, Avithout any idea Avhatever of their signiAcance. 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 niagnosis 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 Avithin the last fourteen months. About the time the menses ceased she had a severe attack of dysentery, Avhich continued four weeks. This Avas accompanied and followed by evident inflammation of the bladder, the vagina, and possibly, also the Avomb, from Avhich she convalesced very sloAvly. Five months and a half later, she married. Her husband remained Avith her only tAvo clays, and then left on plea of business in a distant State. In that period only two attempts Avere made at coitus, in neither of Avhich did the male organ penetrate the vagina. She suffered extreme agony in these ineffectual attempts at intercourse. During the interval, Avhich is hoav eight and a half months, the husband has never returned. Four mouths 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 considerably, and afterwards be- comes as large as before. The only unusual sensation she has experienced Avas that resembling the gurgling of a liquid, Avhich seemed to pass upwards from the left hypochondrium toAvard the umbilicus. The abdomen is now as large as that of one avIio 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. 279 2.SO THE DISEASES OF WOMEN. Although the Avhole generative function is physiological, and does not necessarily include any morbid process Avhatever, still its contingencies are so numerous, and the changes Its great importance. , . , "" ., i , .,, . ,1 i • i 1 Avhich it develops Avithin the pelvic and ab- dominal organs or so pronounced, and Avithal so similar to those Avhich attend upon certain diseases, as to render the diagnosis of pregnancy a very delicate and diAicult 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 Avell as questions Avhich are purely professional in their character, and Avhich concern the proper treatment of the case in hand. Hoav to decide Avhether a Avoman is or is not pregnant, is one of the lessons Avhich you should learn most thoroughly. For nothing avouIcI 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 for a long period. A.nd, al- though women sometimes reach the climacteric suppression of the before their fortieth vear, there is reason to be- menses. lieve that Ave should not attribute the arrest of function in her case to this cause. If there Avas no uterine tumor, no development of the abdomen, and none of the other signs of pregnancy Avere present, Ave might, perhaps, charge the suppression of the accustomed Aoav 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, Ave 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 amenorrhcea Avhich shall lead us to suppose a Avoman 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 Avomb sometimes arrest the Aow by obliterating the canal of the uterine cervix. The presence of polypi, fibroids, hydatids, and other tumors Avithin 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 Aammation 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, Avhile this symptom is regarded by Avomen themselves a* an almost certain sign of pregnancy, physicians look upon it as equivocal, and not bv anA* means positive. "We An uncertain sign. . '. mi • can not rely upon it m a given case. This woman has not menstruated for fourteen months. The period during Avhich the arrest has continued is longer than that proper to gestation. Shall Ave therefore conclude that she is not pregnant, because she has passed the ninth month without being delivered of a child? ThatAvould not be a safe or satisfactory conclusion. For, in some cases, the catamenia are arrested for Aveeks and even for months, and conception takes place before they have been restored. This often happens Avith Avomen Avho become pregnant again Avhile 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 Aow 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 Avith other symptoms, it may help to settle the diagnosis, but singly and alone it is of very little consecpience. An additional reason avIiv Ave should not place an exclusive dependence upon it is that Ave are ahvays 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, Avhen 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, Avhen in truth, they have not appeared for months. It is the habit of some physicians to prescribe marriage as a remech for suppression of the menses, Avith al- Marriage as a remedy most a total disregard of its cause, and of the for suppression. /,,',• , i • r± • consequences ot taking such advice. It is my duty to warn you against this practice. For it is altogether 282 THE DISEASES OF AVOMEN. wrong. Thousands of persons have been made Avretched, Avhile feAV, very feAV, 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, hoAvever the uterine tumor inclines to the right Uterine obliquities. , i -i • ,• ,i n 1 j.i .li hypochonclrium, for the alleged reason that the rectum pushes it in that direction as the Avomb 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 someAvhat, a fact which is easily enough explained upon the theory that there is an accompanying meteorism of the abdomen, Avhich subsides of itself and recurs again. This Avould 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 pregnaucy. In many examples of gestation, they are wanting alto- gether from first to last. If she has really passed the eight mouth, ballottement avouIcI not be available. But the changes in the areola about the nipples, and in the breasts themselves, are more significant. In pregnancy, Avhatever changes take place in these glands affect both Changes in the breast., ... ,„, . . ,, ... breasts alike. 1 his is not true ot any disease to Avhich they are subject. Consequently, Avhen you find that both these organs are becoming larger, Avarmer,and softer, especially in those Avho have not already borne children, or been pregnant be- fore, or if there is a slight secretion ot 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. Heie 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 Avhich gives the areola the appearance of having been oiled. The cellu- lar tissue beneath and Avithin the nipple is in a state of turgescence. The discoloration about the nipple is so marked that you can sec it THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 283 across the lecture-room. This looks as if our patient Avere really pregnant, and some authorities Avould decide the question upon the evidence afforded by this single symptom. But Ave must look a little further. If Ave could detect the foetal heart-sound, resembling the tick- ing of a Avatch beneath the pillow, Ave should have a positive and „. . , u , unmistakable sign of pregnancy. But this Ave The foetal heart-sound. . . \ . have taited 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; Avhile, if it can be heard, Ave know that she is enceinte. It is not safe, hoAvever, to depend upon a single examination in a case of this kind. For you may imagine that you hear it Avhen you do not, or it may be impossible to hear it to-day, and the easiest thing in the Avorld 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 prei>'iiant state. At best The uterine souffle. ... _ it is only a confirmatory sii^n, which may be classed as a probable, but not as a positive symptom ot 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 Avoman really conceived Changes in the cervix. . ^ eight and a-halt months ago, the changes Avhich have taken place in the uterine cervix should be quite marked and decisive. And so I find them to be. The neck of the Avomb 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 Avithin 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 Avithout penetration of the male organ during coitus. Numerous cases are recorded in Avhich this result has followed imperfect in- 284 THE DISEASES OF AVOMEN. 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 Avith the ovum of the female somewhere Avithin the generative tract. The discharge of that semen Avithin the vulva may under certain circumstances and ex- ceptionally, produce the same result that avouIcI folloAv 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 Avere tolcl that, in forming a cor- rect diagnosis of pregnancy, an exclusive reliance upon any of its presumptive or of its probable signs avouIc! be likely to mislead you. Case.—Mrs. W----, aged 42, Avas married eight months ago. She Avas at that time a AvidoAv; but had never had any children. She says that Avithin 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 hemorrhage, or leu- corrhceal flow. When the menses ceased she began to have morning-sickness, Avhich continued for six Aveeks. She had also various caprices of the appetite, Avith faintness before dinner, and inordinate craving tor food. There Avas no perceptible develop- ment of the ovum, or enlargement of the abdomen. The mammae became SAVollen and sensitive. Six days ago, after Avalking to church, upon the icy pavement, she began to "Aoav." The haemorrhage from the uterus Avas pas- sive, irregular, and slight, until the third night, when, after having had a great deal of pain about the back and loins, Avith some head- ache and debility, she awakened out of sleep very much friirht- ened by the escape of a fieshy mass from the uterus and vagina. The flowing soon ceased, and to-day she has ventured to waik to the Clinique. In addition to the details already given, she says that all her unpleasant and indiscribable feelings about the hips and abdomen Avere greatly relieved by a bandage worn tightly about those parts. This Avas an example of spurious pregnancy, sometimes styled Morbid anatomy. flll!e conception, pseudo-pregnancy, quasi-ges- tation, molar gestation, and should not be con- founded Avith pseudo-cyesis. The product was a fleshy mole, which THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 285 the patient has preserved, and brought Avith her, and which Ave Avill noAv 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 Avails, we come cIoavii to the amnion, which is intact. Slitting this open, a slight Aoav of its proper liquor escapes. Here is the rudimentary embn'O, Avhich, 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. BetAveen the outer membranes, or rather within the thickened Avail outside of the amnion, blood has been effused, and small coagula are seen. These appearances indicate an arrest of embryonic develop- ment. Concej)tion probably took place as it should have done, and all Avent on Ave 11 for a limited period. But, for Death of the embryo. . , . some unknoAvn reason, the nourishing supplies that Avere derived from the uterine surface, and designed for the ovum, Avere appropriated to the abnormal, pathological groAvth of the chorion. The little embryo Avas therefore sacrificed. It died from a lack of those elements Avhich Avere necessary to the devel- opment and repair of its tissues, and the hypertrophied chorion and decidua constitute this carneous or fleshy mass Avhich is called a mole. Although women of all ages are liable to this form of spurious pregnane}", yet it is a singular fact, that those Avho have reached their fortieth year seem more prone to it than Influence of age. . „ those who are younger. As m the case before us, it is not uncommon among Avomen Avho 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 tAvo results folloAvs, either that expulsion takes place sooner or later, or the membranes of the ovum become remarkably changed, and con- tinue to groAV for some time longer, until at length they form a fleshy, fibrous mass, called a mole, or false conception." The true mole is ahvays a product of conception. When the mass has been expelled, it is not difficult to recognize it, and to 286 THE DISEASES OF AVOMEN. separate it from spurious formations Avhich resemble it in some re- spects, by the presence of a rudimentary embryo Retention of embryo. .,,.., . Ti. , ,, . within its cavity. It, hoAvever, the embryo died during the first month, it may haAre been dissolved, and we shall, therefore, fail to find it on dissection. Such a mole may be retained Avithin the uterus for many months, or it may be cast off and expelled at or about the period at Avhich the menses should have returned had the Avoman not been pregnant. It sometimes happens that the haemorrhage attendant upon labor of this kind is profuse and long-continued. Generally, hoAvever, it ceases AArith the delivery of the fleshy mass. Ambrose Pare cites a case in which a mole Avas retained in the Avomb for seventeen years. Among the clinical points worthy of note in the case before us, you Avill observe that, until her last marriage, this woman's men- struation Avas habitually regular and healthy. menstruauon.nancy and Jt is important to take this fact into account, for it sometimes happens that menstrual disor- ders predispose to abnormal developments of the membranes A\hich enclose the ovum. Membranous dysmenorrhcea may indi- rectly cause this form of spurious pregnancy. Following the arrest of the catamenia there Avas no \ricarious discharge. Morning sickness set in, and our patient was sup- posed to be pregnant. This continued for six nanc°ybables!gnsofpreg" weeks, 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 Avas 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 groAvth 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 jf 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 knoAving 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 sAvollen 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 Avhich provides for the extra- uterine needs of the infant, is arrested when, from any cause, the embryo dies. Even Avhen 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 Avill infer that, although the suppres- sion of the menses, the morning sickness, and the fickleness of appetite, are to be regarded as presumpthe These signs do not indi- . . ••pit cate the progress of preg- signs of conception, and may sigmh* that the fecundated ovum has reached the uterine cav- itv, 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 wreeks, but afterAvards the only remaining symptom of pregnancy aa as the non-appearance of the menses. And the pro- longed arrest of this Aoav 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- 'ery' strual cycle, when the physiological afflux of 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 Telaxed, as if menstruation Avere coming on, and some slight exciting cause, as, for example, a fall, or sudden shock, or forcible exercise, as in 288 THE DISEASES OF AVOMEN. Avalking on an icy pavement, may percipitate labor. Dilating pains follow or accompany the haemorrhage. In due time expul- sive contractions set in, and the Avomb is emptied of its contents. The suffering may be either slight or severe, its quality and degree varying Avith 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 aAvay Avith so little pain as this patient had. Although there are Avomen Avho frequently and habitually sutler from this form of spurious pregnancy, it does not folloAv 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 tAvo or more hours, and then cut open so as to reveal its internal structure. EXCESSIVE ABDOMINAL DEVELOPMENT IN PREGNANCY. It sometimes happens that symptoms Avhich are analogous to those afforded by the patient avIio has just left the room, depend on other causes than those already named. Only yesterday I Avas consulted by letter in a ease of this kind. My patient Avrites: 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 Avill relieve, although sitting up aggravates it. It has become almost unbear- able, Avearing my life and strength a\vay, and giving me no rest, day or night. " My little ones have ahvays been large, weighing tenor ele\ren pounds, and you knoAV I am a Avee bit of a woman. But hoav the doctor thinks it probable that there may be tAvo of them, Avhich are small but amazingly strong and active, Avhile there is evidently a great quantity of Avater contained in the Avomb. The child Avas 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 prod need the effect or not, one Aveek later it Avas pronounced ' all right.' " Will you be so kind as to inform me if there is anything that Avill relieve this pain in my side? If it should continue, Avould 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, Avhich cause the abdomen to feel as if turned into stone." This case presents several points of practical interest. As you aa ill 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 deArelopment for all, or even for single patients, Avho are successhrely preg- Size of the abdomen as a . sign and sequence of preg- nant. Hence the absolute impossibility of 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 Avomen, in multiparas than in primiparse, in those Avho are pregnant Avith tAvins than in case the womb con- tains but a single foetus. Its prominence ATaries Avith the laxity of the abdominal walls, the position of the uterus, the size of the ftetus, and possibly its position, and Avith 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 Avill 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 Avho 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 ahvays had very large child- 19 290 THE DISEASES OF AVOMEN. ren, my correspondent is carrying one now, and that most of her symptoms are referable to this fact. Women Avho 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 elseAvhere. It almost never occurs in those who are not of a dropsical diathesis. To the hand, Avhen placed upon the abdomen, the movements of the foetus seem dis- tant and indistinct. The foetus is almost ahvays 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 Avith gas. In the former case the hepatic function is almost ahvays 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 haAe 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 com-alescence in their lying-in. The chief danger from any of these symptoms, at Avhat- ever period of gestation they may occur, is from abortion. If you can avert this calamity, the patient Avill 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 Avith courage, and with the hope that all may yet be Avell. A lugubrious, long-faced doctor Avould ahvays be an additional affliction to her, but especially under these circumstances. Treatment. — The general indication is to make the Avoman 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 Avhich I gave you in my remarks upon the case that preceded this are equally appropriate here. The remedies indicated Avill vary Avith the special pathology of the case, or as the phrase is, Avith the symptoms presented. If the enlargement is due to abdominal or to amniotic dropsy, those remedies Avould be called for which are suited to the dropsical diathesis, and you Avould select from among them that one Avhich is most appropriate to the symptoms of each individual case. I should caution you, however, against prescribing the apis mellifica in a Ioav potency in case of dropsy of the amnion, lest it should precipitate a miscarriage. Incidental disorders of the intestinal tract suggest their OAvn 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 Avails in case the child is preternaturally devel- oped, or Avhere there are twins. I think that the induction of premature labor would not be jus- 292 THE DISEASES OF AVOMEN. tifiable in a case of this kind, unless the patient Avere in imminent danger from suffocation by dropsy of the am- turehi!bo?uctionofprema~ ni°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 oavh. Concerning the alleged poAver 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 sentotSI1*in mal"pre" (Feb., 1887) there is not a single case on record Avhich 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 rinde* 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 Avas accredited to the remedy that had been sAvalloAved ! 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 sign 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." LECTUEE XVIII. BILIOUS COLIC DURING PREGNANCY. Bilious colic in pregnancy; Albuminuria in ditto; the Nausea and Vomiting of do.; Vari- cose veins. We Avill devote the first part of this hour to the study of a case of bilious colic in a woman avIio 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, Avhich 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 Avorry, as in ordinary bilious colic, but recur Avithout any obvious cause, sometimes waking her out of a sound sleep. She had them throughout both of her former pregnancies, but neAer 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 folioAved by jaundice. Her father and tAvo of her uncles Avere subject to severe fits of bilious colic. This case illustrates the peculiar relation existing betAveen the uterus and the liver,— a subject of study Avhich is really more important than you may haA'e supposed. For, tween the uterus and the not onh" are these A'iscera organically related liver. "■ , through the sympathetic and spmal nervous systems, but their Aascular 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, hsemorrhoidal, uterine, and ovarian plexuses of veins also communicate, by anastomoses, 293 294 THE DISEASES ,OF AVOMEN. 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 »v!duterashangesIn the °^ caPacify Avhich is in ratio Avith 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 Avoman 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 r^°^symPtomsinearIy immediately, the hepatic and intestinal func- tions are deranged. She has nausea and vom- iting, which, as in bilious affections uncomplicated Avith gesta- tion, are Avorse in the morning. The tongue is furred, the breath foul. She has no appetite for breakfast, there is disgust of Avater, 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 feAV 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 iumhe uterus a dlvertlcu" 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- vic organs. The uterus becomes a diverticulum Avhich receives « THE DISEASES -OF PREGNANCY. 295 and retains an unusual quantity of venous blood. Its Aveight 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, mSne affectgiongsementin or Porypi *> m 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 Avith some hepatic dis- turbance, so it is with these different lesions of the Avomb. And since a proper supply of bile is indispensable to intestinal diges- tion, we see at a glance Avhat a bloAV is aimed at nutrition Avhen 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. Noav the chief office of the liver, as an excretory organ, is to eliminate the cholesterin, Avhich results from the destructive changes going on in the nervous substance or Cholestraemia contingent . . . - i i i upon pregnancy and uter-neurme. 1 his post-organic product Avould be ine disease. . t • i l i l i ■ • poisonous if retained in the blood, and it is therefore expelled by Avay of the hepatic and intestinal outlet, just as urea escapes through the urinary apparatus. And, as Ave ob- serve that the muscular tissue, of Avhich 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, Avhich oavcs 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 Avhich 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 Avho, like Mrs. D., never have it except when they are preg- nant. Some, hoAvever, are liable to it Avhenever they menstruate; 296 THE DISEASES OF AVOMEN. others in consequence of excessive sexual intercourse or excite- ment j and I haAe knoAvn it to be caused by Avearing an ill- adjusted or a misplaced pessary. Treatment. — We have proof that a knoAvledge of the organic relations betAveen 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 and liver /> t /v> t i mi 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 Avhich 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 suggesthTe. In uterine lesions especially, the dial-plate upon Avhich their characteristic symptoms may The symptoms of uterine . disorder may be remotely be read, anct Avhich must be consulted before located. Ave can treat them understandingly and success- fully, is often located Avhere 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 e\'en 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 Avhile the cause is still in operation, Ave should be chary of promising a radical cure in a case of this kind. The disease being self-lim- ranghen\[rselHmTtUeSdde' ited; its symptoms may not wholly disappear until term. In exceptional cases, hoAvever, 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. i. j employed for 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 iustifiable in ex- Local palliatives. •-' J 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 Avrapped in flannel, or bottles of hot water, or clothes Avrung out in hot Avater and applied over the seat of the pain, are sometimes most grateful and bene- ficial. The Avarm bath is contra-indicated in case of bilious colic occurinar 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 knoAV precisely Prophylaxis. . . " Avhat that relation is. v\ hether it stops the destructive metamorphosis of neurine, and thus limits the produc- tion of cholesterin, or helps the liver to eliminate it more readily, is an unsettled question. At all events, Ave may avail ourselves of the (dinical fact that it serves to palliate and to prevent painful attacks of this disorder. When prescribed Avith 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. Avill take this remedy morning and evening. Her diet should consist of albuminous substances, and fruits. Fats, and all kinds of pastry, Avould be poison- Diet; mental and oug< The s>une jg tn]e of ^j^ an(j malt Jiquoi'S. physical exercise. _ 1 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, Aveighing 180 pounds, was admitted to the hospital at the eighth month of preg- nancy. She is of full habit and is troubled Avith headache and " flushes." On being tested by heat and nitric acid, the urine avus found to be highly albuminous. She had previously taken apocy- niun can., and arsenicum alb., Avithout any benefit. The feet and legs Avere enormously SAVollen, so that she could not Avalk or stand with any degree of comfort. She felt Avretched, 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 Avas a mere trace of it the clay before her delivery. Although Ave had anticipated convulsions, her labor came on naturally, and Avas completed Avithout a single untoAvard symptom. Her child is now three weeks old, and all the dropsical and urinary symptoms have entirely disappeared. I do not know Avhere you -will find a case of disease Avhich is 298 THE DISEASES OF AVOMEN. 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 Avho is approaching term Avill have p.njn^p^ral eclanipsia, 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 Avoman at the eighth month may have dropsical symptoms Avhich do not forbode any ill of this kind. But if she has decided albuminuria, Avith dropsy of the Signs of convulsibility. . , , .,. ... ... " face and extremities, Avith or Avithout amauro- sis, the probabilities are that, unless this is relieved, her delivery will be accompanied by convulsions. Hoav 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, and it has seldom disappointed Mercurius corrosivus. - . , , ,, me. Ihe clerk has furnished me notes ot an- othercase which occurred in the hospital some Aveeks ago, in Avhich the effect of this remedy Avas equally satisfactory. Case.—Nancy J., aged 29, primipara, Avas eight and a half months advanced in her second pregnancy Avhen she Avas admitted to the hospital. She reported that she had had dropsical symp- toms for tAvo weeks already. The legs and ankles Avere very much swollen, the ankles being so puffy that the infiltrated integument hung over her slippers. The face and eyelids Avere oedema tons, and she complained of much headache. On examina- tion the urine was found to be albuminous. She also had a partial amaurosis, Avhich 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 clay before her delivery no trace of it could be discovered. She passed through parturition and lying-in Avithout any convulsions. In presenting these cases the idea Avhich 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 J prophylactic for con- prophylactic of puerperal eclampsia. But if in vulsibility. . L l L one case in ten, you can recognize the incipient symptoms of this dreadful disease and avert it, you should knoAV hoAv to do it. Therefore, I recommend you not to fail to apply THE DISEASES OF PREGNANCY. 299 the tests for albuminuria Avhenever any of its symptoms are present in the latter months of pregnancy, and not to forget that the mercurius corrosivus is in many cases an invaluable remedy for it. When Nature " flags the train " Ave should ahvays 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 Aveeks past she has complained of occasional pains and cramps in the abdomen. These sufferings ate 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 Avoman prior to therfomurtSh 17 quickening. After the fourth month, however, and in exceptional cases as early as the third, they mtfy be the cause of much suffering. They depend on the changes Avhich the uterine and abdominal structures necessarily undergo in consequence of the development of the foetus. As you Avould naturally suppose, these symptoms are most frequently met in primiparae—those avIio have never borne children before. Occasionally Ave find a patient avIio always experiences them dur- ing pregnancy. As the uterus enlarges there is a gradual distention of the abdominal Avails. A very natural consequence of this distention is the production of muscular and neuralgic pains. These pains, Avhich 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 Avhich 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 AVOMEN. extreme tenderness, Avhen 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 aa hatever its seat and character, the suffering is increased by motion. Any exercise Avhich renders it necessary for the patient to suffer!!0" 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 theboAvels, or the move- ments of the foetus in utero ; may produce or aggravate it. It is usually wrorse when upon the feet than Avhen sitting, and when sitting than Avhen lying. There are, hoAvever, 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 Avind 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 betAveen the several varieties of abdominal pains to which pregnant women are subject. Among the lesions to which they are especially liable, Ave 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, Avhich rarely occurs except at the menstrual period, or at the time in the month Avhich corresponds to it during gestation. It usually Spurious peritonitis. -ii-ii commences Avith a chill and local pain of an acute, lancinating character, in the region of one or both ovaries. The corresponding limb is flexed, and cannot be straightened Avithout 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 neurafniaS'sfromcutane°us appropriate, and I quote them :* kk Having for some time made a special study of these abdom- inal, inguinal, and lumbar pains, Ave are convinced that very often they are clue 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 Avith the end of a pencil, or by raising it in the form of a fold which is to be gradually pinched betAveen the fingers. Pressure ought also to be made all along the crest of the ilium, in the direction of the genito-crural nerve. Should Ave be satisfied Avith merely questioning the patient, or depressing the Avails of the abdomen by the hand, Ave avouIcI incur the risk of obtaining very little information, or of suspecting the existence of deep-seated visceral pain Avhen the skin only is affected. This mistake, Avhich Ave see committed every day, would be avoided by taking the trouble to make the above-mentioned examination, and Ave 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 Avails. It very rarely affects both sides at the same time Avith equal intensity." If the abdominal muscles are the seat of the suffering, the pains are cramp-like, and accompanied by knotting,of the fibres, Avhich is Avorse upon pressure or motion. The suffer- Characteristic symptoms. . - „ , ing betAveen 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 bloAV or fall upon the abdomen. * Cazeau's Midwifery, Revised and Annotated by S. Tarnier. Phila. : 1868. p. 521. 302 THE DISEASES OF AVOMEN. 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, Avho 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 Avho 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- dis'easT!1311011 from ovarian pendecl and the condition which threatens their healthy action while menstruation continues is Avithdrawn. 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 Avalk, she is lame with it. In exceptional cases pregnant Avomen are, hoAvever, 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^ndde^ ever tney occur, hoAvever, 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 Avhole course, the state of pregnancy is beset with contingencies Avhich 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 Avhich Ave often encount- er in private practice, and Avhich are distinguished by this pecul- iarity— they are better managed by simple domestic expedients than by the most scientific prescriptions. Yet, as I haAre said, Ave 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 Avho 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 ansAvers 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 Avails 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 avouIcI 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, Avill often yield to the old and simple expedient of anointing it with sAveet 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 AVOMEN. tion and anxiety on her part; for, although anatomists have failed to demonstrate a nervous connection betAveen the mother and the foetus in utero, her mental emotions do influence it greatly. It is a bad habit for those avIio 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 Avelfare of the pregnant woman, by inducing abdominal pains and cramps whieh may result in abortion. Internally, a Arariety of remedies may be indicated. Where, as in this case, the suffering is aggravated by motion, however slight, bryonia Avill sometimes afford almost instant relief. Nux vomica, Pulsatilla, belladonna, rhus tox., ignatia and chamomilla, are also useful under appropriate indications. The patient Avill take bry- onia 3d, three times daily, and report at the end of a fortnight, or of three Aveeks 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 oSri^ ^ ^^ month> but may beSin or end at a»y time before delivery. The difficulty that has been experi- enced in curing it, is shoAvn 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 some days or weeks. The most persistent and uncontrolable vomiting of food may threaten to destroy life through inanition, and vet the patient may «iSSSr*"' «?»«»<*> in 8°°* *»*• >'. «> ^"g as this 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 Avho is suffering from excessive gastric disturbance during pregnancy, begin to show Sis-nificance of a coin- • ?• ->. ' . '"■.-. ... , ,'' , t cident jaundice. sl«lls ot jaundice, especially if she has never had it before, or if there are coincident symptoms of acute yelloAv 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 v 4 1 -4.1 1 uterine deviations. disturbance is neither very severe nor long con- 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 Avhich is explained by the effect of gravity in bending the uterus upon itself. There are cases, hoAvever, in Avhich 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 stretching ot the uterine muscular fibres during their development, to chlorosis, to albuminuria uraemia, and to sympathetic irritation of the pneumogastric. After the seventh month it may be clue to mechanical pressure of the gravid uterus upon the stomach or the liver. The matters vomited will vary Avith circumstances. If the attack recurs Avhen the stomach is empty, the egesta Avill consist of a viscid or slimy fluid; if there is a great deal The matters vomited. . tit of 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. !•./•«•■ paroxysm, the degree or quality ot suffering, or the disgust of food, such indications for our remedies as will ahvays help us to prescribe both accurately and successfully. Even Avhere certain remedies have been extolled, there is often a doubt concerning their efficacy, because some- Questionable results. .. . , ' . " , -i. thing else has been given, or done, simultane- ously for the relief'of the suffering. Here is a case in point, Avhich 30 306 THE DISEASES OF AVOMEN. I Avill quote from the iV. E. Medical Gazette, vol. 4, page 153, to which it Avas contributed by my friend Dr. W H. Holcombe, of New Orleans: Case.—I Avas called, tAvo Aveeks ago, to a very distressing case of this kind; and the treatment, Avhether strictly homoeopathic or not, was so promptly efficacious that it is Avorth recording. The lady Avas pregnant last year, and suffered horribly for seven Aveeks under allopathic treatment. She Avas only relieved by an abortion. This time she had suffered for three Aveeks before I Avas 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 Aveek or ten days. She Avas much emaciated, and greatly prostrated from Avant of nourishment and sleep. She Avas cold, trembling, and Avretchedly 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 clay, but not enough so to satisfy me that I Avas on the right remedies. So I examined my case more thoroughly. I found two peculiar symptoms, Avhich I regarded as key-notes. She Avas ahvays greatly Averse on Avaking from her little naps of sleep. Indeed, she declared she had rather not sleep at all than to awake Avith such dreadful sensations. Secondly, she referred her nausea entirely to a strange trembling, like a mass of jelly, Avhich reached from the umbilicus to the ribs, and over the gastric and hepatic areas. I felt this tremulous motion Avith my hand for a long time. It Avas a quick sub-cutaneous quivering, almost Avithout intermission. These symptoms belong especially to lachesis. I ordered lachesis 2000, every hour. When I Avent next day, I found my patient in ecstacies. She had slept half* the night, had vomited only a feAV times, and the trembling sensations had almost disappeared. What a brilliant laurel this avouIcI 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 Avhich effected the cure. Afraid to drop either, and consulting the good of my patient in preference to my oavii 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 Avas 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 Avas the curative agent,—firstly, because I THE DISEASES OF PREGNANCY--CONTINUED. 307 believe lachesis in the higher and highest dilutions to be a remedy of astonishing value; secondly, because it covered my case homeeopathically; 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 Avith any decided result. Xux 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, Avill repay careful study in difficult cases. Nourishment by enemas of beef-tea, cream, milk-punch, etc., should be early and steadily employed. The folloAving indications for some of our Avell-knoAvn remedies have a clinical confirmation: For the vomiting of a viscid mucus, especially on rising, nux vomica and cocculus. For constant, or occa- Special indications for . , . . . . remedies. sional Amounting, Avithout regard to the position ot the body, and for vomiting of Avhatever is sAval- lowed, the egesta being mixed Avith bile or mucus, ipecacuanha. If the mucus is milky and the patient has had, or is having, leucorrhcea, and yelloAv spots on the skin, sepia. For the vomiting of fluids as soon as taken, Avith thirst, great uneasiness and restlessness, bitterness in the mouth after eating or drinking, Avith pallor of the countenance, and thirst for cold drinks, arsenicum. For the vomiting of a greenish, frothy mucus, Avhich is some- times relieved, temporarily, by drinking cold A\rater, especially if •' there is a copious Aoav of saliva, cuprum metallicum. For the vomiting of bile Avith the food, a rancid heart-burn, unci ptvalism, especially at night, mercurius. Other remedies, the special indications for Avhich you Avill look to the materia medica, are, apis mel., berberis, a list of possible rem- bismuth, conium, cimicifuga, calcarea carb., chamomilla, ferrum, ignatia, kali carl)., 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 morninof sickness of pregnancy is a self-limited disorder, because Avhen a disease inclines to get well of itself it may easily happen that Avhatever has been prescribed will sometime or other get the credit of having cured it. 308 THE DISEASES OF AVOMEN. There are a feAV medicines and expedients that have been used empirically with advantage, among which are Empirical remedies th 0 alate of ceriUm, apomorphia, pepsin, the and domestic expedi- L L ' L L ents. sulphate of soda, the arsenite of copper, gossy- pium, the bromides of soda and potassa, good old wine, cham- pagne, coffee, luke-Avarm gruel, and very Aveak green tea. If the uterus is displaced its careful reposition Avill be necessary. I shall speak of this directly. Exceptionally, if Oth.Gr resources the os uteri is badly ulcerated, it may be neces- sary to treat it locally Avith 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 neAvest expedient, Avith which a distinguished gynaecologist has proposed to do aAvay Avith morning sickness Stretching the cervix. . A , . . . n., • ,. , 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, Avith a rotating movement, until one-half of the first phalanx has been introduced. In the case of multiparas this is easily done; but with primi parse 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 Avas discoA^ered by Copman, in 1875, avIio, for the purpose of causing an abortion for the relief of vomiting in a case of pregnancy, dilated the cervix Avith his finger, and cured the vomiting Avithout any other result. The fact that, in very rare cases, Avhen the life of the Avoman is seriously threatened, the induction cf abortion or of premature labor is sometimes necessary for the relief of ab^rtionPedienCy °f this and kindred disorders, makes it incumbent upon me to saya Avorcl or tAvo upon this subject. There are buttAvo indications which can render thisextreme 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, Ave are learnino- in THE DISEASES OF PPEGNANCY. 309 various Avavs that the human organism can Avithstand and survive an almost total lack of food for a considerable The danger from in- iod perhaps there is no condition iii which anitwn. *■ A a Avoman can be placed, in Avhich so small an amount of food Avill suffice, as during the first few Aveeks of preg- nancy, Avhen 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 Avhat may seem an incredible time, all food Avhatever shall be either refused or rejected. Such patients will not be likely to die of starvation, and therefore, you had better Avait and Avork for a favorable change, rather than resort to an expedient Avhich in- volves a moral Avrong. A mere functional disorder of the liver, the kidneys, or any of the pelvic or abdominal viscera avouIcI not Avarrant the recourse to such a terrible expedient. In case of pressure, pUo^feZT^^Von 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 Avhere the best treatment has failed to bring relief, it mav become a question Avhether the induction From hepatic disease. * . ot premature labor is not both right and proper. For, under these circumstances the expedient concerns the saving of the child's life, as Avell 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 mav need to From unrmia, etc. , . . . " <■ n n balance this same question most carefully and conscientiously. The mere giving of remedies, or even the hypodermic injection of apocynum to stimulate a Aoav of urine, so strongly ueeommencled by my friend Dr. Fahnestock at our Clinical Society, Avill not ahvays 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 Avhether you must hasten the delivery in all cases of uraemia Avith albuminuria occurring in ♦Vide The Clinique for October, 1880. 310 THE DISEASES OF AVOMEN. pregnancy; but Avhether, Avhen the means that are usually suffici- ent have all failed, Ave should try this as a last resort. This is the question that you must settle for yourselves in each individual case Avith the aid of the best counsel that you can procure. In the same journal for November, 1880, you Avill find a report upon the treatment of nausea and vomiting in pregnancy that Avas read before our Society by my colleague Prof. Hawkes. This paper gives the details of several very interesting cases that Avere cured by mercurius, cocculus, arsenicum and lycopodium. The discussion that folloAved its presentation drew forth some inter- esting facts and points of a clinical kind, more especially Avith 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 Avoman avIio had suffered so severely from this disorder that she Avas compelled to take to her bed and to stay there during the Avhole of gestation. She had tried, during her successive pregnancies, both schools of practice, and had been under the care of Dr. Constahtine Hering, but Avithout relief. Finally, an old woman cured her promptly Avith a tumbler of hard cider, Avhich 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 Avoman, Prof. L. expressed great confidence in the value of hamamelis. He gives it internally in the tnird 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 Avater, Avhich is to be applied by cloths or compresses that are Avet Avith the lotion. Sometimes relief is afforded bv 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 Avith pregnancy; but, at term, it should always be regarded as a predisponent of puerperal phlebitis. LECTURE 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 Avhich 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 tAvo children, a son and a daughter, were carried to term and are iioav living. She has aborted twice at about three and a half months, in consequence, as her physician told her of retroversion of the Avomb. The chief peculiarity ot the case is that the nausea and vomiting Avhich are incident to the early months of gestation are experienced by her at night only. It commences each evening at ten, and continues, Avith occasional interruptions, until after midnight, and sometimes until tAvo o'clock in the morning. She enjoys her breakfast and dinner, but has no appetite for tea. She is very confident that Avhen she Avas pregnant Avith her tAvo living children, the gastric symptoms came on as Avith most women, in the morning and not at night. And also that, in case of the tAvo 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, Avho 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 Avomb has ahvays palliated 312 THE DISEASES OF AVOMEN. the gastric distress, and sometimes stopped it entirely for daya 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 Reflex gastric symptoms the theme for a feAV practical remarks. The in early pregnancy. x case is a typical one, Avhich illustrates the in- timate relationship through indirect nervous communication, betAveen the uterus and the stomach. This peculiar sympathy is shoAvn in various ways. I have knoAvn a patient to vomit Avithin five or ten minutes after, and in consequence of the application of the nitrate of silver to the uterine cervix. A sudden dropping cloAvn of the Avomb 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, Avhen 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 Avorst cases of " morning sick- ness" are referable to this cause. Uterine displacements are knoAArn to produce it, and it is more than possible that the slight prolapse of the Avomb, Avhich is incident to the first months of gestation may help to account for this Aery 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 Avhich is relieved Avhen 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 backAvards, they not only press upon tlie anterior sacral or sciatic plexus of nerves, Avhich 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 Avith Avhich 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 Avill often happen, that by placing such a patient in a proper posture, and regulating her diet, as Avell as the time of eating her meals, and the amount and quality of exer- cise- taken, Ave 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 Avoman's Avomb Avill pass out of the pelvic basin into the abdominal Abertion a contingent of . , retroversion of the gravid caATitA\ in order that it in a a* undergo the proper uterus. " ~ *■ i development. If Ave 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 loAver pelvis, its liability to dislocation will be removed, and the proneness to gastric derangement cease. Provided the retroversion is not inveterate, the gastric disorder Avill be self- limited. The idea has long been entertained and advocated by obstetri- cal Avriters that, unless a pregnant Avoman has "■ morning sickness" if not excessive, morn- at some period of gestation, she Avill be apt to Apt w «"urn at nlghTin miscarry, or perhaps to have a difficult and dangerous labor at its close. Although there are frequent exceptions to this rule, many persons passing through pregnancy from first to last Avithout any particular derangement of the stomach, and finally doing Avell, 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, Avhether 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 Avrong abo\nongunSwa?rainted!able avhich this patient's former physician commit- ted aa hen he declared it impossible for her ever to cany another child past the fourth month. His opinion Avas not properly deduced from the facts of the case, and is, therefore, 314 THE DISEASES OF AVOMEN. fallacious. Because this poor woman had retroversion in the early stage of two successive pregnancies, and afterAvards aborted, it by no means folioavs that a third or a fourth attempt to com- plete the process of gestation can not prove successful. If such a verdict Avere as harmless as it Avere unjustifiable, Ave would pass it by without further notice. But you are Avitnesses to the fact that it weighs doAvn 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 lh ing child. Daily experience proves that even the most learned and reliable practitioners are likely to be mistaken Avhen they pass such a sentence upon their patients. The range of physiological possibilities is a wide one, and since Nature Avill do as she pleases, it will be wise in us not to assume to limit her poAvers 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. x ° made Avith one or more of the fingers 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 sIoav 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, hoAvever, find it best to place her in the prone position upon the knees and breast, over one or more large pilloAvs, 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 boAvel behind the displaced organ, and afterAvards so inflated as to lift the fundus, and compel the Avomb to corre- spond as it should Avith the axis of the superior strait. Or you may employ this little instrument, devised by my friend, Prof. Guernsey,* Avhich is admirably fitted to fill the same indication. * Vide Guernsey's Obstetrics, etc., 1S67 ; page 16. THE DISEASES OF PREGNANCY. 315 In using this instrument, Dr. G. 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 elboAvs, so that the force of gravity may assist in the reduction. The ball of Fig. 29. Dr. Guernsey's Uterine Repositor. the instrument, Avell lubricated, is to be brought to the anus, with the convex surface of the rod upAvards, then gently pressed until Avithin the sphincter, Avhen the handle should be slightly elevated, so as to bring the ball against the anterior Avail of the rectum. The instrument is iioav to be firmly and carefully pressed up the rectum, Avhen the ball Avill 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 Avhether for purposes of exploration or of treatment, you should carefully abstain from the introduction of any The uterine sound as _ J J a means of reducing instrument Avhatever through the canal of the the dislocation. cervix into the uterine cavity. Such an opera- tion Avould be almost certain, sooner or later, to be folloAved by abortion. And I flatter myself that no member of this medical class Avould Avillingly commit the crime of murder, even for the sake of curing a case of prolapsus, or of retroversion of the Avomb! I have knoAvn a physician, however, avIio, 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 uiiAvarrantable expedient. But simply to replace the organ in such a case Postural treatment. J, , „ . *~ . ~, . as the one before us is not ahvays sufficient. Unless we provide against a recurrence of the displacement, more 316 THE DISEASES OF AVOMEN. especially Avhen the patient assumes an upright position, the in- creased size and Aveight of the Avomb Avill bring it cIoavii 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 h*as ascended into the abdomen, the vomiting will be greatly relieved, and perhaps cured, and, Avhat is still more important, the chief clanger of abortion Avill also be averted. It is only iioav and then that a pessary is of real utility in the uterine deviations contingent upon pregnancy. The Avatch-spring pessary, covered Avith rubber, The pessary. ' . aviII sometimes ansAver 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 tAvo similar instances I have succeeded in Pessary. keeping the Avomb 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 Avith air, this rubber bag becomes a species of cushion against Avhich the uterus may rest Avithout 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 'abortion. Some practitioners prefer fig. 31. Cutter's Pesllu7. 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 Avhich I have indicated will not serve to replace the Avomb and to keep it in position. A few cases are recorded in Avhich the displacement has per- p^rSuir »"ted until the end of gestation. AVhere the retro Aersion is in\reterate, 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 Avill find the folloAving instructive case: " I Avas consulted in August 18o!», by a lady, a patient of Dr. Duigan, of Gainsborough. She Avas the mother of two children, and, in the previous May, had a miscarriage, Avhich left her iu a very Aveak state. She had lost blood largely, and had since been irregular at the periods. Her chief complaint Avas of a distressing pain at the bottom of the back, and the least attempt at Avalking or exertion produced faintness. On making a digital examination, the uterus Avas found to be retroverted, the fundus hanging upon the loAver part of the rectum, and so enlarged as to make me be- lieve that pregnancy existed. She remained in toAvn 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 Avhich 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 Avith a precision Avhich cannot be obtained Avhen 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 would soon return to the position of retroversion. Acting on this hint, I introduced an air-pessary of considerable sizeAvhich gave great relief, and enabled her to move about to an extent Avhich had been previously impossible. With the air-pessary the uterus remained in a state of semi-retroversion. She continued to Avear the instrument, Avith great comfort, for upAvards of two months, and only left it oft'avhen quickening and the movements of the child made it certain that the uterus had risen out of the pelvis. She avus 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 Avas no vesical symptom Avhat- ever. I have seen this patient tAvice since her delivery. The first time there Avas 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 AVOMEN. turned to some extent, and I advised the use of the air-pessary again." CHOREA DURING PREGNANCY. Case.—Mrs. S., primipara, is tAventy-five years old. Her menses appeared at thirteen and a half years; but, Avithout realiz- ing Avhat might folloAv in consequence, she took a cold bath at the time and afterAvards suffered from spasmodic dysmenorrhcea. At the age of sixteen she had an ulcer on the left leg, over the tibia, Avhich began as a blister and spread extensively, finally in- volving the knee. The ulcer Avas healed, after two months treat- ment, by topical applications. The cicatrix has since been the seat of tingling sensations, Avhich Avere aggravated by cold. For three years past this patient has not menstruated more than six or eight times in tAvelve months. The Aoav has ahvays been painful. She is iioav eight months advanced in pregnancy. At the first month she began to have choreic twitchings in the left hand and arm; afterAvards the corresponding foot and leg became affected in the same Avay. Then there Avas 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 Avet-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 ahvays escaped. From the date of conception, hoAvever, 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 Aveather. She has often avoiui damp clothing, and gone for many hours Avith Avet 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 Avhile a child, nor does she knoAV 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 Avith the subject of chorea, Ave shall find that its clinical his- tory is full of interest. You may have supposed that chorea Avas exclusively a disease of childhood, Avhich, in the case of girls espe- THE DISEASES OF PREGNANCY. 319 ciallv, terminated at puberty. But here it complicates pregnancy in a Avoman avIio is twenty-five years old. In most cases of this kind, and they are not very common, you Avill discover that the patient has had the chorea Avhen a child. Aery likely the former attack ceased Avith the regular establishment of the menstrual function, for, as a rule, Avith young girls, it is a self-limited affair. But this Avoman 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 folloAving. And, even Avhere the disease does not become fully developed, there is often a latent predisposition to it, in Avhich 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, Avhich at one time Avas thought to be almost universal. But Avith Avomen du- ring gestation, a large proportion of those avIio have had chorea have also had sub-acute rheumatism. In the case before you the nervous symptoms, Avhich have been charged to an " insanity of the muscles," and Avhich are so pronounced Avhile I am speaking, are engrafted upon the rheumatic diathesis. This form of chorea may spring from anremia, 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 groAvth of the foetus in utero drains the blood of its best constituents, and predisposes the mother to nervous affections of various kinds. This case is in evidence that dysmenorih 4.—The Menstrual Molimen, Direct blows upon the head or back, 5.—Zymotic Diseases : Cerebro-spinal meningitis, Syphilis Cerebro-spinal effusion, Mercurialization, Hysteria and Epilepsy. Variola, 2.—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, 1.—Malformation of the Ovum. Falls, jumping, blows, etc., 2— of the Membrane (moles, Functional and Organic Disease of hydatids). the Womb, 3. —Placental Abnormalities : Ditto of the Ovaries, Mal-location of, (placenta prsevia.) 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 Avas called to the rescue, no one had an intelligent idea of this poor woman's condition. The first doctor who came to her, andAvho sealed up the flow so promptly, should haA'e impressed upon her the absolute necessity for rest and quiet. He should have insisted upon her remaining in bed, Avith 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 Avithout any untoAvard symptoms. But he did nothing of the kind, and the consequence Avas that she became very ill, and, Avorst of all, Avas subjected in turn to the tender mercies of several other incompetent in effects of wrong diag- doctors. One said that she had enteritis, nosis. ' another neuralgia of the liver (!), a third hypertrophy of the womb, and a fourth dyspepsia. Their diagno- sis Avas wrong, and hence their treatment could not be right. She grew worse instead of better. This brings us to the practical lesson that I Avish to draAv 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. • -l 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 Avhether this or that class of symptoms of which Avomen 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 dysmenorrhcea, and by the possibility that the patient, if so disposed, may deceive us, by leading us to believe that she has miscarried Avhen she has not, or vice versa. Add to this that in many cases the diseases of the Avomb and of the ovaries Avhich folloAv abortion run a latent course ; or they may partake of just enough of the hystericallt mimicry " to counter- feit other diseases, as for example peritonitis, enteritis, cystitis, etc. A recent writer* has published the following table upon the * Dr. A'an de Warker, in the Journal of the Gynaecological Society of Boston, vol. IV, pp. 297-8. 336 THE DISEASES OF AVO-A1EX. differential diagnosis between spontaneous and induced abor- tion :— Accidental and Spontaneous Abor- tion, to the Third Month. r. 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. a history of uterine displace- 4. Often ment. 5 As a rule the pulse rarely reaches ioo. 6. As a rule, there are no symptoms of inflammatory complications of the uterus or the abdominal viscera. Instrumental Abortion, to the Third Month. l. 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. 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. Evidence of history. Previous good health. Evidence of habitual abortion absent, or doubtful. 5. As a rule pulse from 100 to 120. 6. 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, hoAvever, delivery is inevitable, you must conduct it to a safe termination for the moth- er. But your interest in the case Avill 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 Avith the operation of cutting off a leg, or stitching up a Avound. Suc- cess may depend Avholly upon the after-treatment. First, then, as in surgical feA'er folloAving bodily injuries and surgical operations, rest is the great remedy. A Avoman, the lin- ing membrane of Avhose Avomb has been forcibly Rest. «? • torn off in an early abortion, perhaps, by the use and abuse of instruments, or Avhose placenta has been pre- maturely detached in miscarriage, is as unfit for exercise as the man Avho 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. THE DISEASES OF PREGNANCY. 337 I knoAV there are Avomen 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 Avay. And some of you knoAV from experience Avhat it is to have such patients come to you from a neighboring toAvn 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, Avhile, despite your best efforts, the ride and the excitement may cost the mother her life. The analogy betAveen 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 Avater, and applied by means of compresses over the hypogastrium and pudenda. If the patient Aoavs freely, or is particularly addicted to haemorrhage, the water should be cold; othei'Avise, if she prefers, it may be tepid or even warm. You can advise Avhatever 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 efficacious in warding off the incidental fever 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 Avas 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- Beiiadonna. nation of blood to the pelvic viscera without haemorrhage, excessive perturbation, unrest, and nervous irritabil- 22 338 THE DISEASES OF AVOMEN. ity, Avith more or less acute pain, local or general, I know of no remedy so useful as belladonna. Atropine in the third decimal trituration aauII 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 Avill become more serious, and you Avill need to study Aery 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 Avrapped in flannels, Local treatment. or haAe the abdomen coArered Avith 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 folioav 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 Avhile she is suffering, and let all her clothing, and that of the bed, be Avarm and dry. The chamber should be well ventilated, but do not alloAv 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 Avoman 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 Avhich Ave 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. Xature. — 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, Ave 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 Avriters incline to the opinion that this catalogue embraces only the crude outline of its causes and consequences, Avhile 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. 339 340 THE DISEASES OF AVOMEN. 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 Avhich 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 ahvays to Avomen during the term of utero-gestation, or at some iaaLTiond t0 gestat'°n and period of lactation. A feAV writers, indeed, claim to haAe Avitnessed 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 Avhat folloAvs, Ave 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 Peculiar lesion. . „ approach, hoAveA^er, is as follows: I he patient calls attention to a burning or scalding sensation in the mouth, Avhich sensation is greatly aggravated by the taking of Avarm, 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, Avhich redness is found to exist in patches, or diffused more or less continuously over the Avhole 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 cloilar, 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 T ., , equally characteristic. Among these there will Incidental symptoms. ' ° be found a marked pallor of the surface, 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 Aoav of saliva; the tongue is red and smooth ; cutting and colicky pains from the simplest ingesta; alternations of constipation and diarrhoea ; strangury, Avith 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 Avithout any sensible perspiration ; and, if during lactation, a decided sympathy betAveen 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 AA'hich 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 Avhich it occa- sions in every ease, as because of its intractable nature, as shown in its alternating Avith the mouth symptoms, being better Avhen they are Avorse, 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 Avhole alimentary tract, as Avell 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 Avhich marks the invasion of this disease upon local surfaces, interferes very materially Avith the healthy condition and requirements of those organs Avhich 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 Avhich classification, practically speaking, there would appear to be no real necessity. We shall, however, consider a few of them separately. 342 THE DISEASES OF AVOMEN. 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. , . n phenomena are symptomatic ot a more pro- found disturbance of the general organism ; and that, properly speaking, Ave are to regard them as the certain evidence of some such original disorder. Examples are not Avanting in Avhich this disease is believed to have pursued a latent course in the system, during Avhich 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 Avhile 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 Avill hold good that it is only through a close and careful study that Ave 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 Avriters, which vesicles ultimately degenerate into more or less troublesome centers of infection, each shoAving at its base a hardened and Avhitish 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 \"esicles burst, they develop into ulcers, which are either superficial or deep-seated. If the system has been very much depraved, and the vitality runs Ioav, The local ulceration. these ulcers may be very numerous and of 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 loAver 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 raAv surface Avhich is exposed, and to the depth of the ulceration. In exceptional instances these ulcera- tions have dipped doAvn to the bone beneath. It is not unusual for these characteristic lesions to disappear suddenly, leaving the patient in apparent health. After a brief interval, hoAvever, they reappear, and may thus ^Capricious nature of 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 ahvays accompany those peculiar to this variety of sore-mouth. They may precede, folloAv or alternate Avith 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, Avhich Avas not accompanied by epigastric uneasiness, anorexia, or pyrosis. Instances in Avhich this disease runs its course Avithout a more or less decided implication of the stomach and boAvels are believed to be very rare. In this respect the stomatitis materna resembles the aphthae of infants Avhich, as you are aAvare, 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 Avhich are the imper- fect mastication of food; an improper and Causes of the digestive unAvholesome diet: the actual transfer, or the derangement. ' continuation, of the local lesion to the gastric und enteric mucous membrane ; to a depraved nutrition from other vauses, 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 Avhich 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 AVOMEN. is this class of subjects Avhich is most liable to be seized with it after labor. When complicated Avith stomatitis the diarrhoea may either anticipate or folloAv 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 Avill occasion you no little anxiety. You should bear in mind, hoAvever, 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, Avith smarting or scalding sensa- tions during, or immediately after urinating. tomsnal and veslcal symp~ Occasionally these symptoms precede those already enumerated. Sooner or later they are almost certain to be present, and Avhen they are not mentioned voluntarily, you Avill 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 Avill vary from 1024 to 1030. For the most part, the general symptoms are such as imply a debility Avhich may be extreme. If the disease has existed for any considerable time, the patient is usually anaemic. The anaemia. , J She is pallid and exhausted, and the face ap- pears puffy and bloated. Her complexion is less Avaxy and clear than in chlorosis, but has a sallo\v and cadaverous shade in it, which is not common in other diseases. These symptoms are likely to be accompanied by an irritative fever Avhich 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 ahvays recurs during pregnancy or lying-in. a. he 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- Is it cause or effect ? . r_. . -, r> i -, • • i ,i tion. the simple fact that it is limited to the periods of gestation and lactation, Avhen 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 haA^e preceded the local lesion. And such is the case. The Avoman 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. Aveakly and sickly persons, as Avell as of those Avhose systems ha\'e 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 Avhere, 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 Avithout 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 of 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 Avhich she is found — either pregnant, or in one or another of the stages of recovery from her confinement,—Avith the local symptoms already detailed, Avill enable you to diagnosticate it readily. It It may be latent. . , , , . . ,. ■, -i is only Avhen this disease is obscure and. runs a latent course, being limited to the gastric, alimentary, or urinary 346 THE DISEASES OF AVOMEN. 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 Avith the original strength of the patient's constitution; her age, habits and surroundings; the co-existence of tuberculosis of the lungs, or Qualifying circumstances. „. . ,-, ,-, • i r ,i of 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 anaemia 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 ahvays 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, }ou Avill 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 feAver the chances of a speedy and certain recovery. It is sometimes quite impos- sible to eradicate this disease in the case of women avIio have had it in several successive pregnancies. Although recovery fre- quently folloAvs the Aveaning 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 done is to select a suitable diet. This consists of a proper admixture of vegetable and animal food, for you will observe that in many The diet. . . . 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, which is closely allied to scorbutus, and which may sometimes be cured by merely regulating the diet. Even in to\vns 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 Avhich are juiey and nutritious, may be prescribed Avith good effect. She may also have milk, eggs, oysters, game, plain custards, animal jellies, cracked Avheat, 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 alloAving the patient to drink freely of butter-milk. Other acidulated drinks are almost specific. Lemonade, orange- ade, and jelly-Avater, are most available. They may be taken either Avarm or cold, as the patient prefers, and Acidulated drinks. • i • i • • are not contra-indicated m most cases of indi- gestion and diarrhoea. Nor Avill 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. . . , Ihe same is true Avith respect to the diet. As a rule, you may let her have Avhatever she longs for in the Avay of food or drink, providing it is not Avholly 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 Avhich are sometimes successful, Expedients for arresting are fae induction of premature labor, the Avean- this disease. J- ing of the child, and a change of climate. The induction of premature labor is justifiable only in those extreme cases of stomatitis in Avhich it is morally certain that the patient must die unless pregnancy is terminated Premature labor. n , . .-.[.. T-, and the Avomb emptied ot its contents, bortu- 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 AVOMEN. Because taking the child from the breast of the mother who has stomatitis Avill sometimes be of immediate and lasting benefit to her, physicians have inferred that Aveaning Weaning the child. , . - „.. . , Avas the best remedy. Ihe custom Avith 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 Avill not ahvays 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 draAving her life aAvay to keep her child alive, that she is so anaemic and emaciated as to be totally unfit both on her oavii and the infant's account to nurse it any longer, Ave prefer not to interrupt this very important func- tion. A change of climate, especially if the patient leaA'es a mias- matic district, will sometimes cause the symptoms of this disease to disappear promptly and permanently. In Change of climate. „ „ ... 1 exceptional cases a removal of a te\v miles only will work almost as marked a change in her feelings as it does in certain cases of asthma and of intermittent feArer. This expe- dient is particularly applicable if the stomatitis is complicated Avith chronic boAvel affections. Railway travel is indicated if there is an inveterate diarrhoea, and residence in an equable cli- mate for those mothers avIio are consumptive. Hysterical sub- jects, with the nursing sore-mouth, may sometimes be sent aAvay from home Avith the greatest relief to themselves and all con- cerned. The medical treatment of this disorder is constitutional and local. Of internal remedies, the various acids are in the best repute. The nitric acid has been given in the The medical treatment. . ° loAver 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 AA'hich tAvo prominent physicians had treated a lady for stomatitis materna for tAvo Avhole months. She The various acids. greAv worse and Avorse. -Finally they told her that she must Avean 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 Case. . four times daily. She continued the remedy for the space of a fortnight. A radical cure folloAved, Avithout weaning the child, or the employment of any local application Avhatever. 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 Avhich tAvo teaspoonfuls are to be taken once in from three to six hours. Arsenicum is generally suitable for cases of this form of stoma- titis Avhich are to be met Avith in malarious districts. If there is burning in the mouth, Avith frequent desire for Arsenicum album. cold drmks ; if the Avater which the patient drinks habitually is stagnant or impregnated Avith decomposing matter of various kinds ; if there is great prostration of strength, anorexia, Avith chronic disorder of digestion and painless diarrhoea ; if the system has been poisoned Avith cpiinine in large doses, or if the accompanying symptoms are analogous to those of typhoid fever, it may prove of excellent service. The same indications Avill call for natrum muriaticum. Dr. Murch Avas in the habit in these cases of alternating the arsenicum Avith small doses of Bel- locq's charcoal. If the disease is complicated Avith glandular dis- ease of a scrofulous or syphilitic character, the arsenicum jodatum might be preferable. Dr. D. T. BroAvn* has Avitnessed the best effects from preceding the employment of arsenicum Avith a fe\v doses of carbo vegetabilis. Dr. W. C. Barker extols the use of "arsenicum (ith in alternation Avith sulphur 6th, repeated once in four hours, in those cases of nursing sore-mouth Avhich are char- acterized by a very slight and almost imperceptible odor of the breath, Avith 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 Avhich mercurius is best adapted is that in Avhich the ulceration of the tissues is very marked. The ulcers are corroding, the breath offensive, the Mercurius. . „ „ . . - secretion ot saliva profuse, in short, the symp- toms are those of the stomatitis ulcerosa of the old writers. If * A'ide Tj-ansactions of American Institute of Horn., for i860, p. 78. 350 THE DISEASES OF AVOMEN. there is no syphilitic taint, the mercurius corrosivus is preferable, otherAvise the mercurius jodatus, 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 Avho are predisposed to scrofula or phthisis, the calcarea Calcarea carbonica. . in n • rr>i carbonica may be of excellent service. Ihe symptoms which indicate it are dryness of the mouth and tongue, Avith a sense of roughness and stinging; a dry, bitter, sour, or metallic taste ; great aAersion 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, Avith acid eructa- tions ; A'omiting 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, Avith burning in the urethra during micturition. There are some examples of this disease Avhich it would be very difficult, if not indeed impossible, to cure Avithout this remedy. Dr. Helmuth reports* that ammonium carbonicum cured a case of long standing in which there was great prostration, IioIIoav cough, and burning in the tongue — the Avhole Ammonium carb. , , .,. nn i .,1 •■> , buccal cavity being filled Avith Aesicles 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 Avhich remedy the chief indication Avas 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. . ^ with ague, natrum muriaticum 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 Veronica beccabunga. . . r, 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 (einpirically it is true, for I have but a Aery feAV provings of it,) almost exclusively, and Avith 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 tAvo fluid-ounces of soft Avater. When they are indicated, I use other remedies in alternation Avith 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 Avith saccharum lactis, in the proportion of one berry to ten grains of the sugar, and applies the poAvcler, moistened, through the medium of a thin linen cloth. Other remedies Avhich 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, AAashes and gar- gles, composed of borax, or borax and honey, The local treatment. . . . „ , „ sage and borax, a mixture ot 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 Aveak solution of the carbolic acid. And yet others are in the habit of prescribing the topical use of hydrastin in Avater, or glycerine, or both. In cases Avhere the buccal and faucial mucous membrane is badly ulcerated and the breath is fetid and offensive, a drachm of the mother tincture of baptisia maybe added to four fluid-ounces of Avater 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 Avith simple cold Avater. There are those avIio, in exceptional cases, think it necessary to touch the ulcers AA'ith 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, hoAvever, are of secondary importance compared with the good effects of an appropriate diet, 352 THE DISEASES OF AVOMEN. 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. Iu the milder cases they are all that is necessary, and Ave can save our medicines for those Avho really need them. And, let me tell you in this connection, that there is more of reputation, as Avell as of good sense and satisfaction, in curing some of our patients by means that are Avithin the reach of every- body, than there is in the use of those Avhich are more .scientific and fanciful. " The best physician is he Avho knows Avhen to Avith- 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 primiparae 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, uraemia, 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 Avhich, Avhile they do not come under our care dur- ing the lying-in period, are yet necessarily related to labor. Being a sequence of delivery, Avhether at term or prematurely, they "are sometimes styled post-partum affections. Their common and cardinal peculiarity is that they depend upon lesions Avithin and about the post-gravid uterus, and are therefore limited to those avIio have been pregnant. Such of them, hoAvever, as require surgical treatment Avill be considered further on. In our obstetrical and puerperal clinics you are being taught at the bed-side Avhatever pertains to the clinical history of labor and of child-bed disorders. My own special course on the puerperal afieetions Avill acquaint you Avith the most interesting and practical part of this very important subject, Avhile it excuses me from their consideration in my general course upon the diseases of Avomen. Manifestly the list of post-partum lesions should include the remote sequehe of abortion, of miscarriage and of premature deliv- ery, as Avell 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 knoAV how to treat them intelligently until we take their common and iiiA'ariable cause into account. 23 '*% 354 THE DISEASES OF AVOMEN. It is especially incumbent upon us to consider this and kindred questions very carefully; for Ave, of all others, should discriminate betAveen those diseases Avhich are idiopathic and such as are sympto- matic, or between the primary and the secondary affections that avc are expected to cure. When a mother consults us for the relief of an intra-pelvic disorder, we should, if possible, satisfy ourselves Avhether the lesion that Ave find does not date from her delivery, no matter how long since her baby Avas born, or from some mishap or neglect Avhich interfered at that time Avith her puerperal coiiAralescence. This subject is so very important, and concerns the Avelfarc and comfort of so large a class of our patients, that I must beg you to give it your especial attention just hoav, Avhile 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 Avell since her last confinement, Avhich Avas six years ago. After die birth of the child, the labor being rapid and very painful, but quite natural, she Avas taken Avith uterine haemorrhage, Avhich Avas very active and copious at first, but finally became passive. This haemorrhage did not and avouIcI not yield to remedies. The doctors could not cure it, and it ceased only Avhen she had Aveaned the child. Sub- sequently her menstruation Avas resumed, but it Avas too profuse and long continued. Sometimes she continues to flow for three Aveeks, constantly, and has only one Aveek's interval before the period comes around again. But the discharge ahvays 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 haAre dropsi- cal symptoms. Her face, hands and feet, and finally the Avhole general integument, became puffy and oedematous. Then she had palpitation of the heart, and dyspnoea after slight exertion, as in A\7alking up stairs. Sometimes she would Avaken out of sleep Avith impending suffocation, and in order to breathe freely avouIcI be compelled to jump out of the bed, and to Avalk 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 ahvays been normal in quantity and quality. She has had six physicians, five of Avhom 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 Aveek, 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 Avrong Avith the Avomb. 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 Avith 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 Avithout difficulty, and passed to the The depth of the fundus of the organ Avithout the least obstruc- uterus. ~ . . tion. My first impression on finding the uterine cavity of such an increased size, was that its enlargement Avas probably clue 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 oriran Avas 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 Avomb. To the " touch" the cervix feels swollen and enlarged; and on examination through the abdominal parietes, by conjoined man- ipulation, in this manner, an oblonc tumor is Negative symptoms. ^^ ^.^ ^^ ^ ^^ Thug examined> betAveen the two hands, the mobility of the tumor is consentane- ous with that of the womb. We 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 elate 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. i00ke(j. 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 AVOMEN. at term. Those mothers avIio 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 tAvin-delivery, and also of an ex- cessive accumulation of the amniotic fluid. Rapid labors, especially if they are not folloAved by after-pains, are more likely to be fol- loAved 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 Avhen 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' vieAv is too sweeping and exclusive. This interruption is Avhat physiologists style the " retrogressive metamorphosis" of the uterine tissues after delivery, and is intimate- ly associated Avith the clinical history of uterine Imprudence. . displacements. We cannot reasonably suppose that the extraordinary growth of these tissues, Avhich has been going on for months, Avill be resolved aAvay and removed in a few days after the Avomb 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, Aveight, 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 Avonderful process. Haemorrhage after delivery bears so important a relation to the contraction of the Avomb that its occurrence and persistence in this case leads us to suppose that, folloAvino: the Haemorrhage etc, . . ." labor, the involution ot this organ Avas incom- plete. And the uterine tissues must have remained in this relaxed state. The subsequent development of menorrhagia, Avith too frequent as Avell as too copious menstruation, confirms this vieAv. So also do the dragging sensations, Avhich she has experienced so constantly in the intra-pelvic and sacral regions, and the abnormal depth of the uterus But Iioav shall Ave explain the cardiac complication, and Avhy did it folloAv the third instead of the first attack of menorrhagia? Manifestly, because of the excessive and continued loss of blood, SUB-INVOLUTION OF THE UTERUS. rVW or of the anaemia Avhich 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 ease. In real cardiac disease Ave 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 Avhich implicate the nervous system especially. And although tli<" 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 ahvays folloAv. I have made a careful phy- sical examination of this Avomaits heart, but failed to find any evidence of a structural lesion. And avo may reasonably infer that, if she has nothing of the kind iioav, after having been treated for " disease of the heart" by five doctors in succession, she Avill prob- ably be exempt from it in the future. Treatment.—I am glad of the opportunity to sIioav you this case, for it is a typical one, and its treatment involves certain questions Avhich cannot be regarded as settled. Practical deductions. T,.„ i ., • 1 • -i ' <» i 111 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, Avithout reference to Avhat Simpson very properly stvled a sub-involution of the uterus. And secondly, a practical application of our knoAvledge of the relation of certain remedies to this particular lesion avouIcI not only enable us the more promptly to cure the original disease, but likeAvise also, Avhatever might come of it, or be complicated Avith it. Here the defective involution of the uterus is the prime cause of ill-health. . That cause is still at work. Manifestly, the first indication is, if possible to remove it. But Iioav The prime indication. ,,,.,, t .-, t j.i i l shall it be clone.'' Is there any knoAvn remedy for this relaxation of the uterine muscular fibre? There are well- known remedies Avhich affect this organ, just as there are those which decidedly and certainly afiect 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 ahvays accompanied by a determination 358 THE DISEASES OF AVOMEN. of blood to the internal generative organs, and if the uterine muscular fibre is at all developed, as during The physiological pregnancy, labor, or lying-in, by expulsive con- action of ergot. i © J '_ J © - i tractions of the Avomb. Under the latter condi- tions, ergot excites the peristaltic movements of that organ Avith the same certainty that opium congests the brain, and that verat- rum viricle lessens the force and frequency of the pulse. Its poAver to facilitate delivery at term, and to arrest post-partum haemor- rhage is established. This poAver depends upon an intimate physiological relation or affinity betAveen the fully developed muscular fibre of the uterus and the spurred rye. But you should remember that the similarity of the womb Avith the other IioIIoav viscera is exceptional, and by no means constant. Within the limits of health there is no condition in Avhich the muscular coat of the heait, the stomach, or the bladder is Avanting. Yet in the non-gravid uterus, and more especially in those avIio have never been pregnant, this coat has no real, but only a rudi- mentary existence; and in those Avomen avIio have conceived, and even carried their children to term, the normal involution of the organ after labor has restored it as nearly as possible to its ante- muscular state. So, therefore, Ave say, that there is a period in the history of most Avomen, Avhich is characterized by an extraordinary evolution of the uterine muscular fibre, and that the various disease-producing contingencies Avhich beset its groAvth and decline have their thera- peutical counterpart in remedies of Avhich secale is the type. The ergot 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 Avill 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 Avhich 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 Avomb avouIcI 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 Avomb remained flaccid, and did not fold upon itself; the blood ceased floAving temporarily, Avhen there Avas little more to lose, but commenced again Avith 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 folloAved her last confinement, six years ago, and Avith every men- strual return since that time, there being a similar engorgement of the uterus, and the same relaxed condition of its Avails, she has passed through a similar experience. In so far as the loss of blood is concerned, and if it Avere possible, she might as Avell have borne twelve children each year. And can you see any reason Avhy 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, Avith re- current haemorrhage, as Ave avouIcI treat the same train of symp- toms, minus the (edema and the dyspnoea, if she Indications for secale. . . . " . Avere still in the lying-in chamber. I he first indication is to secure the proper uterine contraction. The object of this is three-fold viz.: to stop the excessive Aoav, to stimulate the absorption of the redundant muscular structure,and to relieve her of the pain, and soreness, and dragging sensation to Avhich 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 Avith 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 eases like this, that the medium and higher potencies might be as useful; I cannot say. Of this one thing, hoAvever,you may be assured, that in all such cases, Avhether they are directly or indirectly dependent upon a defect, interruption, or irregularity in the organic changes proper to the Avomb during pregnancy or parturition, you Avill do Avell to seek for therapeutical indications in the history of that abnor- mality, Avhether it be of antepartum or post-partum origin. And, if the other incidental indications correspond Avith these, Avhich 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 Avide and essential difference between a case of men- orrhagia Avhich depends upon a defective involution ot the Avomb, 360 THE DISEASES OF AVOMEN. Avhether it be chronic or acute, and one of excessive menstruation, caused by uterine polypi, fibroids, cancer, caulifioAver excresence, ovarian disease, chronic metritis, or an impoverished condition of the blood. This case is typical of a certain kind of menorrhagia, and I am speaking only of this particular variety. The reason Avhy our best practitioners give comparatively feAV remedies, is that they learn to classify their cases in this practical Avay, 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, Avhen 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 sIioavii in the recent experiment in which 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, Avhether 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 Avhich 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 Avomb, is also shown in those cases ot tardy labor, in which a feAV closes 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, likeAvise, of sabina, ustilago, trillin, and ipecacuanha, Avhich are so often and so unAvittingly prescribed for the relief and remoAral of this identical condition. Doubt- indications for other 1 .1 v t -, ., remedies. les*' these 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 Aoav has entirely ceased, they should keep the recumbent, or, better still, the horizontal posture. SUB-INVOLUTION OF THE UTERI.-, ETC. 361 For, no matter Iioav appropriate the remedy that is chosen, an opposite course avouIcI induce a hypostatic congestion, and subse- quent haemorrhage, with uterine prolapse or procidentia, and a perpetuation of the puerperal hypertrophy. This woman Avill 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 first at four months, the second at three and one-half months, and the third at three months. Prior to this experience she Avas ahvays avcII ; she used to Aveigh two hundred and five pounds, now her Aveight is one hundred and forty-eight pounds. The first abortion Avas caused by a fall upon her back. ^he kept around for a Aveek after the fall, had no pain or especial inconvenience, and at the end of a Aveek miscarried without pain. The Aoav lasted about three days; she remained in bed for nine days, and then got up, but, as she did not feel very Avell, she took to her bed again and kept it for four clays more. Then she felt Avell and returned to her duties. The second abortion Avas caused by stooping and lifting a Avash- tub. This Avas done in the morning. She began to Aow at once, and at nine in the evening the foetus Avas discharged. She had no real pain, but kept her bed three clays. The third came on after putting up the clothes line, and hanging some heavy Avet clothes upon it. This time she Avas in her bed for nine days. The last abortion occurred six Aveeks ago. She had no physician in either case. Last Aveek, or Ave Aveeks after the third " mishap," she had her menses, the Aoav continuing for six days. At'that time she had more pain than usual with the discharge. This, she says, Avas 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 give an account of her experience; and (2,) because she did not have a doctor, either before, during, or after her "mishap." For once, therefore, Ave 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 Avoman 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- It d t fuH inustrate what has been styled tlons. J iTi the "habit" of aborting, else it avouIcI 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 elate. When abortion occurs repeatedly, it may assume a regular type, in Avhich case it most frequently happens at the month. Or, as in intermittent fever, the type may change, and Types of abortion. ., ... t >, 1 i it may anticipate, or come earlier, as it has clone in this instance. Sometimes the type is retarding, and a woman avIio began by aborting at the fourth month, Avill end by miscarry- ing at the sixth, or at the seventh month. And, Avhether the subsequent "mishaps" are earlier or later than the Arst, 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 Avay betAveen the periods. You Avill observe that each time this Avoman has aborted since the first attack, her pregnancy has been shortened just tAvo Aveeks. My oavii observation leads me to conclude that the more removed the date of miscarriage from the time in the month at Avhich men- struation Avould have occurred, the less the probability that a . diseased state of the ovaries has had anything to do Avith causing the trouble. Exceptionally, however, as in inter-menstrual dysmen- orrhcea, 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,Avhen this Avoman aborted at the fourth month, it Avas not in consequence of metritis; because she had no pain from first to last, neither after the fall, nor Aet Peculiar cause of. . ' Avith the expulsion ot the embryo. And what Avas 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 Avhich 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 Avomb has been emptied of its con- tents, Avhether 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 Avhat has caused it. But in 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 Avith 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 Avhat 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 healthy-looking, vigorous woman like our Peculiar susceptibility. *-; ° patient. But it only proves that she was sus- ceptible to the action of this class of causes, Avhich, in Avomen avIio are differently constituted, might have had no such effect. There are those avIio can undergo almost any kind of physical exercise or fatigue Avithout the risk of abortion. Some Avomen work hard throughout their pregnancy, and others travel and incur the greatest risks by sea and land Avithout any mischievous results. But there are those in Avhoma misstep, a fit 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 Ave prescribe for this poor Avoman? Is my duty discharged to her and to you Avhen I have ordered a feAV poAvders, and told her to come again? A moment's reflection assures me that, under the present conditions, she avouIcI probably abort as often as she conceived. Her predisposition to abortion is partly original, and partly acquired. If Ave suppose that her fall Avas severe enough to have caused a perfectly healthy woman to mis- carry, Ave 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 Avhich is at the bottom of the difficulty, is Avhat Ave A\rant to cover with our prescription. In fifteen months she has had her menses but once. Three times The importance of • th t jntelvaj jn consequence of a fruitful rest. ' * conception, the Avomb has begun and continued to develop until it Avas suddenly and forcibly emptied of its con- 364 THE DISEASES OF AVOMEN. 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 Avas half finished, before menstruation Avas 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 avouIcI continue to resent such a disregard other hiAvs. The Avomb must rest, and recover its tone, as Avell 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, Avhen Avith proper care meaiiAvhile, she might be able to reach her term without any acci- dent. She Avill take calcarea phos. 3d trituration, tAvice daily for one Aveek, and then arnica 3, one close every alternate night. [One year later this Avoman became the happy mother of a healthy and Adgorous 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 Avhich is eighteen years old. She has had no mis- carriages. She has not been Avell during the long interval, but has suffered from articular rheumatism, menorrhagia and prolapsus. She has had much local treatment by escharotics, for an alleged uterine ulceration. There is great weight Avithin the pelvis, especially in advance of the monthly Aoav, at Avhich 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 Avas very prolonged, and finally Avas instrumental. It sometimes happens that the post-partum involution of the uterus is interrupted even Avhen the patient has suckled her child. If the menses return prematurely, and recur Causation. \ J frequently, the flow aviII be menorrhagic and the conditions will be very similar to those in Avhich 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 knoAvledge 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- 0fTnamrtiohn.reSUlt crimiuately, as it it were always the result of an inflammation. You should bear in mind the clinical rule that, unless a Avoman 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-invo- lution and metritis at the same time. The case before us is, hoAvever, an exceptional one. We can- not learn her puerperal history, neither can Ave estimate the mis- chief that has been done in her case by cauteri- zation. The menorrhagia and the pain at the month, as Avell as the inflamed condition of the cervix, Avhich you observe in the field of the speculum, are so many evidences of metritis. The depth of the uterus, Avhich, 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 Avhich must have occurred at the time of her delivery. It is a question Avhether Emmets' operation should properly be the first step in the cure; or if Ave should fry to fulfill the physi- ological indication of securing the contraction of the uterus as a means of putting an end to the menorrhagia, the metritis and the prolapsus. For the present she Avill take the secale cornutum 2, four times a day. SUB-INVOLUTION, CHRONIC METRITIS, MENORRHAGIA, AND PROLAPSUS. Case.—Mrs. S., aged tAve;ity-six,had a miscarriage at the fourth month of her first pregnancy, five months ago, in consequence of which she Avas confined to her bed for six weeks. The menses Avere very irregular and copious, Avith bearing-doAvn pains Avhen standingd* Avalking, with great Aveight in the pelvis. During the monthly Aoav, this weight and pressure are so increased, that she is obliged to keep herbed 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 sIioav you that sub-involution does not ahvays depend upon a laceration of 366 THE DISEASES OF AVOMEN. the cervix uteri. The depth of the womb is four and one-half a practical lesson. inches' aild the ,lterillc epistaxis and the pro- lapsus are the natural and necessary conse- quence of its non-involution. It Avas about as stupid to cauterize the Avcmb 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 Avith 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 Avere 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 Avas discharged cured.] SUB-INVOLUTION AND RETRO-DISPLACEMENT OF THE WOMB. These two lesions not unfrequently 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. LECTURE XXIII. PELA'I-PERITONITIS. Pelvi-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 effeot upon the mens?s, the chill and thirst, the stage of effusion, the fixity of th j uterus, the peritoneal t umor, the reflex disorders ■ —Causes. Cast;.—Prognosis—Treatment both local and general. Case*. Clinical History.—Although pelvi-peritonitis is much the more frequent Avith those avIio have borne children, or avIio 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 Avhich are non-puerperal. ( bniparecl Avith inflammation of the uterus proper, it is relatively about as frequent as pleurisy Avhen compared Avith pneumonia. Indeed, if the truth Avere known, I have no doubt that there are more eases 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 Avas 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 raihvay train. She had labor pains for twelve hours before the ovum Avas extruded, and Avas confined to her bed for three Aveeks afterward, during Avhich 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 ot 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 Hoav has ceased. At first the monthly discharge begins Avith- out pain, and geneially Avithout her knowledge, but in a period varying from half an hour to tAvo hours, the suffering begins and does not cease entirely until the Aoav stops. The character of the Aow is natural. These intra-pelvic pains are very much aggravated by riding in a 368 THE DISEASES OF AVOMEN. 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 dowiiAvarcls of the right lateral cul-de-sac, Avith great tenderness and an inclination of the body of the uterus toAvards the left side. The tenderness extends forAvard to the region of the bladder and is so marked that, after being introduced, fhe most careful separation of the blades of a Cusco speculum causes an unbearable pain, especially in the right half ot the pelvis, Ihe passage of the sound, Avhich avus also very painful, shoAved 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 Ave have the stages ot con- gestion, effusion, adhesion, resolution, and of Different stages of. "- r_. suppuration, lhey are not all present m every case, for if the trouble is arrested Avith adhesion, that will be the end of it, unless there is a relapse; and so also Avith the other modes of termination. Many cases, hoAvever, pass into the chronic form and develop a sort of cachexia that is really incurable. The Arst, or the congestive stage is accompanied by pain Avhich is usually, but not ahvays, preceded by a chill. The pain is sharp, darting and lancinating in character, like that The pain. . ° ' of ordinary peritonitis. Exceptionally it comes on Avithout any prodroma; and still more rarely the pain is lack- ing altogether. The pain is located at the base of the abdomen, Ioav doAvn over the superior strait, but it usually inclines toward one hip more than the other. Its grand characteristic is that it is Special characteristic . -, i ,. , , of. aggravated by motion, by pressure, by increased rapidity of respiration, by standing, and by the effort to urinate, or to evacuate the boAvels. On account of this PELVI-PERITONITIS. 369 pain there is a marked and decided intolerance of the touch, Avhether 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 Ave cannot use the speculum to any advantage, or even, perhaps, succeed in passing it at all. This is especially true in case of the 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, Avith a feeling as if the Avomb would be expelled, and Avith more or less tenesmus of the bladder and the rectum. Another symptom Avhich is seldom lacking is abdominal tym- panitis. This may be local or general, and it may come on abruptly a't the onset of the disease. The cause of the The tympanitis. . . meteonsm, the colicky pains, and ot 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 Avomen Avho have tympanitis, menstrual colic and vomit- ing at the " month," are really ill Avith 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 copramiia. When it folloAvs abortion, especially if there has been a great The facial expression. deal ot 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 Aery high. It ranges from 101° to 103°, rarelv reaching lot0. But the pulse has The temperature and . . . . . ,. . . . thepuise. the characteristic frequency ot 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. . . . hoAvever, this posture may be assumed only at the monthly period, or after exercise, as in riding or Avalking. Sometimes the patient finds great relief from having the hips raisecb 24 370 THE DISEASES OE AVOMEN. 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 , . . . . 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 Aoav is sometimes diminished, sometimes suppres- sed, and at other times is very much increased in quantity. When this form of peritonitis occurs in those avIio have Effect upon the never been pregnant, it is likely to induce either menses. i o » j amenorrhcea or dysmenorrhcea; 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 pyamiic complications, or extensive suppuration Avith relapses, the initiatory chill does not repeat itself. There may, hoAveArer, be inordinate The chill and thirst. 2. . .__. .,/ J J . . , thirst, Avith or without tolerance ot 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. ... 1.11-1 has taken place the local symptoms, as revealed by the " touch," are entirely changed. Noav three things are to be especially noted; (1) the diminution of the Three points to be ob- served in local exam- local pain on pressure, (2) the fixation of the inations. 7 uterus, and (3) the presence of a tumor at some portion of the roof of the vagina. This diagram Avill give 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 loAver down, especially upon the left side. The more extensive the circum-uterine i nflammation, and the more prolonged the first stage of the attack, the greater the liability of the uterus to become anchored by adhesions. If ut^rusflXlty°ft G the case is complicated Avith cellulitis, or Avith tuberculous or cancerous infiltration, you may find the uterus quite immovable. Fixity of this organ is very apt PELArl-PERITONITIS. 371 to folloAv 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- orrhcea, 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 swellino- formecl by the accumulation Avill 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 throAv a kind of collar about the cervix Avhich 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 beloAV the level of the posterior lip of the cervix, it does not drop very far cIoavii- Avards, 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 ahvavs painful on pressure. Like the tumor of pelvic hematocele, the 372 THE DISEASES OF AVOMEN. 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 Avhen the tumor is as large as an orange, or the foetal head. This is the class of tumors Avhich are sometimes mistaken for ovarian tumors, and Avhich 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 lhat, the more the uterus and its appendages are bound doavii bv the false Menstrual relapses in. ; membranes Avhich have resulted, from previous inflammation, the more intolerant it is of the monthly nisus. Eor this reason the worst cases of dysmenorrhcea, Avhich develop into menorrhagia and drag a patient cIoavii, are dependent upon this variety of peri-uterine inflammation. The bands avhich fasten the uterus to the Fallopian tubes and the ovaries, the bladder, and the rectum sometimes interfere very decidedly Avith their functions. The extension otSrfl"»rSSI!,Ve'and of the inflammation to the peritoneal coat of the intestines may result in more or less of strangu- lation and agglutination and thus interfere very materially Avith the nutritive function. From these causes, chronic pelvic peri- tonitis is almost ahvays accompanied by a series of reflex disorders, such as spinal irritation, headache, hysteria, and paralysis. There is a form of pelvi-peritonitis Avhich results from Menor- rhagia, and Avhich, besides being accompanied by sterility, is very difficult of cure. It is very likely to occur in the penTnnfs06"1 PeM" wives of those men who lwve bee11 dissipated in their early years, or avIio, because of absence from home and other circumstances, are led to the practice of Avrong habits. These cases originate in a gonorrhceal 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 Avriters concerning pelvic peritonitis is attributable to the fact that A source of confusion. most of them, and the best of them, have insisted that it Avas ahvays consecutive upon metritis. Bernutz, whose excellent clinics I attended in Paris, is the leader of this PELVI-PERITONITIS. 373 party. ' Jousset and others, however, recognize a A'ariety of causes Avhich may or may not be connected Avith any form of metritis, Avhether 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- hpematoeele, uterine and ovarian tumors, the extension of entero- peritonitis, cystitis, rectus, uterine deviations, coitus and the use of injections during menstruation; and the traumatic effects of operations about and Avithin 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, and the Avearing 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 Avorst examples that I have ever From rheumatism. seen, belonged to this ekns, and have occurred in women avIio have never been pregnant, and in Avhom 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 Avas sent to me by Dr. C. C. Brace, of Boulder Colorado, and which is still under my treatment. Case.—Mrs.----, aged thirty-eight years, Avas married fourteen years ago, but has never been pregnant. She has been ill for four years. She Avas 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 Avhile the spinal suffering Avas entirely substi- tuted by the pelvic pain and distress. Five years before, she had been operated upon for vaginism us; but iioav a similar spas- modic condition of the vagina came on again, arcl 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 Avhich occurred at the month, and at other times also in consequence of the least fatigue or avoitv. Alter the second operation she returned to Nebraska in January, Avhere she remained tAvo months on a visit; but Avhile 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 Avhich time the spinal symptoms ♦Lectures on Clinical Medicine, translated by Ludlam, Chicigo, j age 263. 374 THE DISEASES OF AVOMEN. 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 iioav been subject for Cavo years, and Avhich my friend Dr. B., and myself also, have frequently relieved by repositing the Avomb. The menses return regularly every four Aveeks, being sometimes a day or tAvo in advance. The Aoav 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 Avhich the attack Avas induced in a young girl, by swinging. My friend Dr. W. A. Sheppard, of Dundee, 111., called me in consultation a feAV months ago to a Avoman avIio had had a severe attack of pelvi- peritonitis Avith a sudden anteversion of the uterus, that Avas caused by her being SAvung 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 Avill From pelvic cellulitis. be best to deter my remarks upon the cbAerential diagnosis of these tAvo afieetions, 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- ceie.0mPU 1C aemat0_ tonitis is hard at first, and becomes 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 \Tery 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 Guerin :* " In both these affections the invasion of the disease may be announced by a matou^ metritis^* chill; both are accompanied by acute pain, and Ave may find in the case of metritis a tumor which, reaching above the pubis, may lead us to believe that it is due to *Lecona cliniques sur les maladies des organes gSnitaux internes de la femme, par Alphonse Gu6nn, etc., Paris, 1879, page 366. PELVI-PERITONITIS. 375 pelvi-peritonitis. But the vaginal touch Avill soon dissipate our doubts on that question, hi metritis Ave shall recognize that the tumor is movable, Avhilst in peritonitis it is fixed by adhesions as firmly as it it Avere nailed. In this form of peritonitis the culs-de- sac are filled by the tumor, Avhile 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 pelvi-peritonitis." Jousset differentiates betAveen pelvic peritonitis and abscess of the iliac fossa as follows: *" In abscesses in the iliac fossa*, if they are superficial, the tumor is not perceptible by iiiac°fossaSC & ^he vagma> 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 deep-seated sAvelling in the external portion of the iliac fossa, Avhich afterwards is felt in the lateral Avails 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 Aveeks; but more serious cases Avill require more time and In the adhesive j both and jn all forms of pehi-peri- variety. ' L l 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 Avill be very careful in promising to cure this affection, or in claiming that he has ever succeeded in doing 7 o ~ 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 gonorrhoea! and the rheumatic. Do the best Ave can, some of these cases will continue for years without any permanent improvement. * Op. citat. p. 275. 37U THE DISEASES OF AVOMEN. Ill attacks of pelvi-peritonitis Avhich arc secondary upon puer-1 peral metritis, salpingitis, and ovaritis, as Avell as in those Avhich folloAv a prolonged course of local treatment by In the puerperal and oschatic and t, harmful expedients of secondary forms. i uterine surgery, the result Avill vary Avith 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 Avell and to digest her food, if she has had menorrhagia, or repeated abortions, the ten- dency of the tumor to develop into an abscess Avill be a ery much increased. Pelvi-peritonitis is comparatively frequent in delicate women avIio are predisposed to tuberculosis. Thiscom- ^tubereuloussub- plicatj011> or the possibilitv 0f it, should lead you to qualify your prognosis. Treatment.—The treatment is local and general. The uterus is so sAvung in the folds of the peritoneum, that a moment's reflection Avill convince you ot the importance of rest e rest for the patient Avhen that membrane is in- flamed. If a Avoman cannot Avink Avithout changing the position of the womb in its relation to other organs, or Avithout tightening and stretching its ligaments; and if these PELAT-PERITON'ITIS. 377 means of support are composed most largely of peritoneum, it is evident that bodily rest is indispensable to the cure of peh'i-peri- tonitis. Xo advice is more harmful in these cases than to insist that the poor victim must get up and go about, must exercise vigorously,and Avalk or ride, perhaps on horseback, or travel about as if she Avere Avell. 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, Ave cannot expect that the inflamed surfaces will ever be restored to their ante-morbum state. A mode of exercise including the proper postural treatment for some of these cases has recently been suggested by Dr. Van de AVar- 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 avc examine the matter avc 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 Iioav, the pehis elevated. The natural etlect 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 sedati\e etlect seems to be clue to the motion. We all knoAv how seductive and soothing is the sense of langour that steals over the senses, Avhile gently oscillating in a hammock. There is no doubt but the Lotus-like tendency has its force doubled in the case of a Avoman Avhose power of nervous resistance is Aveakened 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 Avater. or vaginal injections of the same, the topical application of the bran poultice and Local treatment. ^^ emollient,5 ancl the pai„ting of the lower portion of the abdominal integument Avith Latour's oleaginous collodion. If the womb is out of place it should be carefully repositecl, but Transactions of the American Gyna^cological Society. Vol. 3,1878, page 342. 378 THE DISEASES OF AVOMEN. pessaries of all kinds are harmful, and cannot be borne. There h scarcely a Aveek that passes in Avhich I am not obliged to removo a pessary that is persecuting some poor Avoman in this Avay. In very exceptional cases, hoAvever, an instrument with a perineal support may not only be tolerated, but of real service. All those Avhich put the vagina upon the stretch, are mischievrous, even m the milder forms of pelvi-peritonitis. Of late, excepting in local peritonitis Avith pelvic hsematocele, we never find it necessary to resort to opiates in these cases. There is an expedient Avhich has the double merit of 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 back Avith the hips raised. She should be undressed and go regularly to bed. Then hotwaterinTections.116 place^n old-fashioned English bed-pan beneath the hips, or bring them to the edge of the bed, and so arrange the rubber cloth beneath them that the Avater may Aoav into a basin or bucket upon the floor. The stream can be throAvn by a syphon of plain rubber tubing, or by a syringe Avith a constant current. See Figs. 36 and 37. The temperature of the Avater, of Avhich from tAvo quarts to tAvo gallons may be used at one time, may be gradually increased from d#~ to lU8°. Tiie 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 Avith the mixture of aconite, hamamelis, calendula, conium or chloroform, and glycerine, may be For the induration. . . n J J. passed Avithin the vagina, or pressed gently into the posterior cul-de-sac,and left there for some hours. It tlie case is rheumatic, the hamamelis used in this Avay will give the most relief. Whatever may be said to tiie contrary, it is of the utmost im- portance in these cases to keep the boAvels in a soluble condition. With avomen of sedentary habits especially, the ^Obviate the constipa- begt chosen remedies in the world will not bring about the desired result Avhile they continue to suffer from constipation, Avith the passage of hard, dry, scybalous stools. The same is true of the co-existence of haemorrhoids. I have seen cases of pelvi-peritonitis upon Avhich no positive curative impression could be made by the resources of gynaecology, until they had been relieved of a harrassing cough. Every fit of coughing induced a fresh attack of the intra-pelvic pain and distress, and sent the patient to her couch or her bed. Sometimes such a cough may depend upon a coincident pleurisy, and the remedies that are suited to one aviII ansAver for both of these affections. The general treatment consists in the appropriate use of remedies. But Jousset is quite right when he says, that the General treatment. . , . . .-. ' , . . _, special pathology ot pelvi-peritonitis is so re- cently knoAvn, that Ave have no clinical and classical treatment 380 THE DISEASES OF AVOMEN. for it. He, hoAvever, recommends three remedies as being the most useful in the acute stage. These are aconite, colocynth, and cantharis. I must refer you to his work on Clinical Medicine for the special indications Avhich he has given for their use. He has great confidence in the employment of the mother tincture of aconite, of Avhich he says: " In very acute and severe cases Ave do not hesitate to prescribe tAventy to thirty drops of the mother tincture, to be taken Avithin tAventy-four hours; but Avhere the attack is milder and not so threatening,the loAver dilutions (the first, second and third) have ahvays been suffi- cient. Whatever the close or the dilution, the aconite should be continued Avhile the fever continues to be violent.'' The indica- tions for this remedy are draAvn from the character of the fever, and from the serous inflammation. I have long ago learned to have confidence in colocynth in some cases of pelvi-peritonitis. Dr. Richard Hughes relates that, in a case of poisoning by colocynth, the autopsy showed that the intestines Avere glued together by a recent exudation of lymph;* and it has seemed to me that this remedy Avas especially adapted to those cases in Avhich the disease had shown a disposition to involve the peritoneal coat of some portion of the boAvel, or of the ovary. The symptoms which indicate it are colicky, cutting, tearing pains in the abdomen, and diarrhoea Avith rectal and vesical tenesmus. Where there is much tympanitis, Avith diffuse tenderness, neu- ralgic pains, nervousness, insomnia, flushing of the face, Avith dilated pupils and delirium, belladonna A\i 11 be Belladonna and atro- f servi(.e j 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 Avell to substi- tute a feAV 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 OA'erlooked in this connection. What Baehr says of it (Science of Tlterapeutics, translated by *A Manual of Pharmacodynamics. Bv Richard Hughes, L. R. C. P. Ed. Third Edition 1876, page 315. PELVI-PERITONITIS. 381 Hempel, Vol. I, p. 515) is certainly true. " Hartman's assertion that peritonitis cannot be cured Avithout acon- Rryonia. . ite, seems to us more applicable to bryonia. ft conies into play at the most decisive period in the development ot the disease, namely Avhen avc desire to remove the effused fluid as soon as possible .... In comparing the second stage of peritonitis Avith the pathogenesis of bryonia, Ave 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 Avithout caus- ing any further derangement; hence, that no suppuration Avill take place. But the medicine should be used consistently ; Ave 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 Ave desire to abort the tendency to all forms of pelvic abscess. If the effusion is lodged in the meshes Apis mellifica. ... . . . . ' .,-, . ■,-, ot the areolar tissue, the apis aviII do all tnat is claimed for bryonia Avhen 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 likeAvisealso in post-puerperal pelvic peritonitis. Terebinth. r . Ll. ,. . . . , -. Ill 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 hemorrhagic states as are met Avith in typhlitis and dysentery ; and is useful in peri-cystitis also. In the form of pelvic peritonitis Avhich is more or less complicated with cellulitis, occur- ing in Aveakand 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 bv brvonia, belladonna, rhus tox., The salicylate of soda. ^'^^ colocyiith, and macrotin. Of late I have given the first, and sometimes the second decimal trituration 382 THE DISEASES OF AVOMEN. of the salicylate of soda in some of these cases Avith 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 dispositionto implicate the spinal muscles and ligaments indirectly, and (3) the nervous, and mental symptoms. This remedy has been extolled in a loose Avay 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- . . . ^ . . itouitis. greater relative frequency ot pelvi-peritonitis, 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 ahvays easy to distinguish spinal irritation from a pain- ful condition of the spinal muscles that is very generally knoAvn as myalgia; but, it is necessary to do so, in or- Do. in peritonitis with -,,",,. , .,..,. . . spinal myalgia. der to obtain a clear indication for macrotin in pelvi-peritonitis. For this remedy is not called for in the former case, Avhile 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 poAver of macro- tin to control the mental symptoms that sometimes accompany this disease than to cite the principal details of sympJmUn? ""^ a case which I have already published in Jous- set's Clinical Medicine. This is one of a num- ber of similar cases in Avhich this remedy has benefited my patients and brought me no little reputation. Case.—Mrs.----. came to me from Baltimore in 187G. 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. 383 were regular, but scanty; there Avas much intra-pelvic pain and dis- tress, spinal myalgia, and sleeplessness Avith a complete lo-s of appetite. Mentally she Avas on the verge of insanity; nothing on earth interested her; her lovely boy, her sister, her friends, society, and the church Avere all very distasteful. She could not read or think Avithany diversion or satisfaction, and she became emaciated and Avretched. She had treatment from both and from all schools of medical practice; had avoiti pessaries, and had passed through the purga- tory of leeching and blistering, staiwation and hydropathy, but Avithout being benefitted in the least. Locally there Avas an exten- sive abrasion of the cervix uteri to which I applied the oleagin- ous collodion. She Avras of a rheumatic diathesis, which, Avith 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 feAV Aveeks Avas quite Avell again. Three years have iioav 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 Avhich Avere in some respects remarkable. In the first of these, Case the patient, aged 35 years, the mother of five children, the youngest of Avhich Avas five years old, complained of severe pelvic pains Avhich she has had since her last labor. Her puerperal history Avas 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 doAvn. In search- ing tor 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 Avords, upon the so-called uterine ligaments, consequently the inflamed mem- brane is put upon the stretch. But, Avhen she lies upon her back, as Avas demonstrated to the class, the Avomb recedes of itself and its ligaments are relaxed. Besides, Avhen she stands erect, sits, or walks about, there Is a hernial protrusion at the umbilicus, Avhich causes the pain in that locality. AVhen she lies upon her back, the hernia being a small one disappears of itself, and the pain along Avith it. In the second case, there Avas a clinical history of partial steno- sis of the cervix uteri and consequent dysmenorrhcea, for which 384 THE DISEASES OF AVOMEN. the patient had been treated surgically by incision three years before. After this operation she had suffered from an attack of peri-uterine inflammation from Avhich she has never entirely recovered. For two years she has had a form of menstrual peritonitis. Of late, hoAvever, her symptoms have changed and she iioav complains of a burning pain in the vagina Avith great tenderness, Avhich prevents the in- troduction of the speculum. On visual inspection the vagina Avas 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 Avas consecutive upon the pelvic peritonitis, and that she had never had it before. In the third case there Avas an evident complication of pelvic cellulitis and a laceration of the cervix Avith the pelvic peritonitis. The patient also had rheumatism of the left Case. ankle-joint. The case had been under careful observation for some Aveeks, and there Avas no doubt about the diagnosis. The form of the laceration, Avhich Avas shoAvn to the class, is very Avell illustrated in the accompanying figure. Fig. 35. Difld laceration of the cervix. Prof. L. said that the chief obstacle to the cure in this case Avas that, Avhile the circum-uterine inflammation, more especially the peritonitis continued, an operation for the laceration of the cervix was contra-indicated.] LECTUEE XXIV. PELVIC CELLULITIS.—PELVIC ABSCESS. Pelvic cellulitis. Cose.-The congestive stage—the stage of effusion-ditto of resolution- ditto of suppuration. Causes. Coincident diseases. Diagnosis. Sequela?. Of late years the physiology and pathology of the pelvic areolar tissue has attained a great and merited degree of importance. The Avhole theory of uterine displacements and of uterine inflam- mation is concerned in its clinical history. From the day in Avhich Dr. Priestly's researches and dissections Avere published (1854), until Dr. Emmett's book Avas issued last year (1879), uterine pathology has undergone a complete revolution, and Avhat Avas vaguely styled the " loose cellular tissue" has received such con- sideration as has not been bestoAved upon any other tissue Avithin the pelvis. I shall therefore, take especial pains to give you as correct an idea as possible of the subject of pelvic cellulitis, of 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 with sequela? that are Aery peculiar and persistent. Another characteristic Avhich complicates the study, and the treatment of pelvic cellulitis is the tendency to the formation of abscesses. PELVIC CELLULITIS.—PERI-METRITIS.—PELVIC ABSCESS. Case.—Mrs. S----, set, 30, Avas delivered by forceps of a dead child tAvelve Aveeks ago. FolloAving this her physician said that she had puerperal fever. When she entered the hospital she complained of acute pain in the right iliac region, AVhich Avas ag- gravated by touch and motion. There was a tumor (for which she had been blistered) in the right iliac fossa, Avhich Avas of 25 385 386 THE DISEASES OF AVOMEN. irregular outline, and could be very plainly felt above the brim of the pelvis. The corresponding limb Avas 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 Aveak. Tongue coated. Yesterday she commenced to haA'e a pretty free discharge of pus from the uterus, and her symptoms are already someAvhat relieved. Until then the vagina Avas 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 Avhich 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 sequelse of uterine disease or accident, is perhaps least objectionable. You are aAvare that the pelvis is lined Avith a fascia Avhich is re- flected over the muscles contained within it, and over the pelvic organs also, and Avhich serves to shield, to The pelvic cellular tissue. strengthen and to separate them. Now be- tween the layers of this pelvic fascia, Avhen they come into con- tact Avith each other, and also betAveen the fascia and the oro-an 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 Avorth 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. o87 sometimes seated in the areolar tissue about the uterus. For this form of the disease is especially incident to the An important suggestion. puerperal state. And Avhen Ave 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 groAvth and development of its cellular tissue also. Authors haAre not, in so far as I am aAvare, said anything on this subject. Nevertheless it may be true that this particular tissue, like the muscular coat of the Avomb, is pro- duced and then remoAed to ansAver 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, Avhether 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 Avithin the pebvis. ' As I have said, Avhen it is not traumatic, it rarely occurs Frequency of. except as a sequel or contingent of lymg-m. Gestation and labor are, therefore, its most poAverful preclispo- 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 of suppuration. I add the stage of resolution. because I believe that appropriate treatment Avill 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 Symptoms of. . . -. . „., " come on insidiously, the symptoms are such as mark the onset of inflammatory fever. There is a more or less decided chill, A\diich may or may not be repeated. If the chill is lacking, it Avill 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 AVOMEN. rapid, or, in Aveak 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 folloAved almost immedi- ately, by 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 aauII 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 Avill be in the upper part of the A-agina, and contact with this organ, even by the exercise of the most delicate " touch," Avill be insupportable. If the peritoneum is also inflamed, the pain will be acute and lancinating in character. Most of the pain experienced, hoAvever, is ascribed to the pressure of the effused fluid (Avhich 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, Avhich 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 folloAvs in pretty rapid suc- . , , cession. The serum escapes from the capilla- Formation of the tumor. . . nes into the meshes of the areolar-tissue, infil- trates it, and solidifies as if it Avere out of the body, or just as it does in the pulmonary air-cells Avhen it causes a hepatized state of the lung in pneumonia. The resulting tumor varies in ifo shape and size according to circumstances. If the space betAveer the fasciae is limited and of a particular shape, the " SAvelling :: cannot be larger, and must be of the same configuration. It groAvs 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 clotAvill 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 of 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. BetAveen the tAvo the size, shape and consistence of the tumor, whether it be above the pelvic brim or beloAV 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 Avails of the Avomb as are Avithin reach may also be examined. As a rule the uterus is fixed, or but slightly movable. One of the first symptoms indicative of this effusion is a local heat, swelling and tenderness of the vagina, Avhich is apt to be felt at one side of the canal, and limited to one Symptoms. • i -n spot. Later the vaginal Avail 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 Avill usually, but not ahvays, be flexed. This retraction of the thigh relieves the pain by relaxing the muscles in the imme< diate ATicinity of the tumor. It is involuntary, and more or less complaint Avill be made Avhen the leg is distended. In puerperal women the milk and lochia are usually suppressed. This complicates the case, and implicates the nervous system more especially. Delirium, insomnia, unrest, spasms, Incidental symptoms. . convulsions, and even mania have toffOAved from 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-r exists. This stage of effusion, Avith its resulting tumor, may continue unchanged for a variable period ranging from one Aveek to a 390 THE DISEASES OF AVOMEN month. There is no fixed limit to its duration. Sometimes, in con- sequence of a relapse, the congestion is again Course and duration. ,-,.-, -. -i ,, i , • ro • jy n established, and the resulting effusion toffoAv- 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 Avhen some considerable time has elapsed, commence to groAV and finally attain a marked deA^elopment 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 Avhich the tumor may remain for some time at a stancl-still, and finally pass aAvay Maybe wanting. ,. . . . Avithout ending m suppuration. As you aviII 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 sAvelling would be impossible, and suppuration Avould almost inevitably folloAv. Under the circumstances, therefore, in Avhich Ave are likely to find these patients, this third stage of the disease Avill frequently be lacking altogether. But Avhen her strength has previously been good, her gestation and labor have been accomplished without too great a draught upon her nutritive and nervous resources; Conditions that promote 1 l "L l, n it i resolution. when she has been well nursed and properly fed, medicated and otherAvise cared for; and above all when there is no prevalent epidemic erysipelas, or puer- peral disorder, Ave may observe the tumor gradually and quietly resolving itself away under appropriate treatment. If the SAvell- 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. . L s- ration. With the commencement of this pro- cess the symptoms vary as in the case of abscesses located else- Avhere. 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 PELVIC cellulitis. 391 to stand upon the feet, to urinate, or Avhile 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. p p . . —,., fever, of a remittent type, sets in. There are rigors alternating Avith 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 someAvhere in the body, and is aAvaiting its discharge. The pulse continues rapid, although it has lost in strength. There is anorexia and great debility, Avith or Avithout diarrhoea. Even although the tumor may have been firm and like fibro- cartilage, or almost like scirrhus, to the touch, it iioav begins to soften. This softening may be recognized either Seat of the fluctuation. • i -i • 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 Aagina at one side of, or directly behind the cervix uteri, in the posterior cul-de-sac. lt From some peculiar arrangement of the layers of the pelvic fas- cke, Avhen 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 ahvays to point in this direction and to find an exit for itself, either at the loAver 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 fasciallayer 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, ^agnosis of the presence and been atten(ied 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. V. Simpson. D. Appleton & Co., New York, 1872, page 72. 392 THE diseases of avomen. Concerning the means of escape for the pus, Avhen 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. . T„ . „ . the vagina, or the rectum. 11 it forms 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 backAvards 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 betAveen 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, tAvo 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 tAvo 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, ceUuSHdsdalnatureofpelvic its epidemic prevalence, and its special thera- peutics, correspond with those of erysipelas, more closely than Avith 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 sip1esiaPs.obablyalliedtoery" 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 folloAv in conse- quence of injuries sustained in natural unassist- Parturition. "! . 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. pf.latc 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 Avay. Puerperal cellulitis is one of the sequelae of instrumental deliv- ery, more especially Avhen the resort to the forceps and other in- struments has been uiiAvarrantably 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 mtra- suryr7tingentofuterine uterine pessaries, even the best of them, is very apt to induce it. Incision of the cervix uteri, wrhether 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 folloAved amputation of the cervix, ovariotomy, the ligation of polypi, the excision of hemorr- hoidal tumors, the operation for Aesico- and recto-vaginal fistulse, and also that for ruptured perineum. It has also resulted from the use of very seA'ere 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 betAveen the layers of the broad ligaments. Coincident Diseases. — Peri-uterine cellulitis rarely runs its whole course Avithout 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 eiseases of avomen. pelvi-peritonitis, ovaritis, and endometritis, in Avhich 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 Avill sometimes be puz- zled to differentiate betAveen pelvic peritonitis, Sometimes very difficult. . pelvic haemotocele, uterine fibroids and pelvic cellulitis. Let "me beg your earnest attention therefore, Avhile I tell you how you may knoAV them apart. The pelvic areolar tissue being betAveen 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. . r toneum, it may be supposed that in case of 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 folloAved by a mitigation, if not by an entire remission of pain ; Avhich 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 fossae. The same is true of puerperal ovaritis, in Avhich 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 Avhich symptoms are proper to ovaritis occurring in puerperal Avomen. I have copied Dr. Thomas' table, giving the differential signs betAveen peri-uterine cellulitis and pelvi-peritonitis, upon the blackboard :* PERI-UTERIXE CELLULITIS. PELVIC PERITONITIS. i. 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., stc. Third edition, 1872, page 461. pelvic cellulitis. 395 PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 4- Tumefaction generally noticed later-ally in the pelvis ; • 4- Generally noticed near or upon the median line ; 5- Tendency to monthly relapses not marked ; 5- Tendency to relapse every month 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 S. Facies not much altered ; S. Facies very anxious ; 9- Nausea and vomiting not excessive ; 9- Nausea and vomiting often excessive ; 10. Does not necessarily displace the uterus ; 10. Displaces the uterus as a rule ; 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, for example, the inflammation in cellulitis was ahvays limited to the broad ligament on either side, the tumor could invariably be reached Avithout difficulty by downAvard 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 Avomb, or about the cervix uteri, shall be inflamed, Avhile that Avhich separates the layers of the broad liga- ment escapes altogether. In this case Ave 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, Avill generally enable you to separate this disease from pelvic cellulitis. OAving to the extension of the inflammation in this form of peritonitis, the induration, if there is any, is not ahvays located in the median line, as the pain Avas at the beginning of the attack. When gonorrheal, 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 Avith non-puerperal Avomen, pelvic cellulitis almost never occurs excepting among those who have recently been confined. It must be acknoAvledged, hoAvever, that the lines which sepa- 396 THE DISEASES OF AVOMEN. rate these two diseases are not ahvays distinct. For, whether *t be due to the fact that the textures involved 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 Avithout our knowing it, and that Ave 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 Avhich they are From pelvic haematocele. ,. „« ,-p,. , prone to occur are very different. I hus, pefvic hsematocele takes place in consequence of a weak, adynamic state in Avhich the blood has become of bad quality by extreme losses, as in uterine haemorrhage, 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 hsematocele 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 haematocele 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 groAvs older. The opposite change occurs in the hsemato- 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 adia- From uterine fibroids. cent parts. If sub-mucous, or interstitial, they are characterized by the frequent occurrence of metrorrhagia, and inter-periodic hsemorrhage, Avhich 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 of 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 Avill 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 Avell as of your oavii reputation, Avill depend upon your skill in diagnosis. Se, -i i i ,1 • enng the tumor has softened and become thm ; 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 AVOMEN. ,wi%. tion of the ligament outwards, in order to shun the sheath of th<> 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 Avail 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 Avouncling some of the pelvic viscera. But when there is a point of fluctuation, you may puncture very carefully and evacuate it as you avouIc! 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 ot the tumor, beciuse 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. Fio. 37. A vaginal syphon. In suitable cases the abdomen may be opened, the abcess emptied, its margins stitched into the incision, 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. Laparotomy and drain age in. LECTUKE XXVI. PELVIC HEMATOCELE. Pelvic hematocele, 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 tiesVr"1* °n En varle" blood tumor that has been formed within the pelvis, and Avhich, both from its origin and loca- tion is connected Avith the internal oenerative organs. Various qualifying terms have been applied to these tumors, as for example, they are called peri-uterine, because they are outside of the womb, but in its immediate vicinity; retro-uterine Avhen they are in the Douglas' space; vesico-uterine Avhen they are located anteriorly, between the uterus and the bladder; intra-peritoneal Avhen the blood of which they are composed has been poured into the peri- toneal sac; and extra-peritoneal Avhen 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 pseuclo, the non-encysted and extra-peritoneal hematocele. Some Avriters call the latter a thrombus. By drawing a parallel between the recto-vaginal fold of the peritoneum, in Avomen, and the tunica vaginalis testis in men, Bernutz concludes and insists that true hematocele can only take place Avithin the peritoneum. But these qualifying terms only serve to indicate the accidental location and anatomical relations of the tumor. Neither of them is sufficiently comprehensive to include the Avhole subject, nor do they represent so many A'arieties of the same affection. For this reason Ave 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 exaim.de, of amenorrhcea from cervical occlusion, menorrhagia and 417 418 THE DISEASES OF WOMEN. metrorrhagia, abortion, extra uterine pregnancy, and pachy-pcri- Not a disease perm. tonitis- lt is alwa.Ys 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, unci 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 Avil.1 depend upon the nature and severity of the its clinical history is disease or ^q [niUTy upon which it is secondary. not constant. j j i j 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, Avith a tendency to a profuse and prolonged menstrua- Predisposing causes. , -a r .1 tion precedes the attack. A copious Hoav ot the menses predisposes to hematocele Avhen that Aoav is intermittent and very irregular. Sometimes those women avIio for some cause are anemic, or in a state of chloro-anemia, are Catamenial disorders. . . , , xiable to the formation ot these pen-utenne 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. Age has its influence, for Ave find that attacks of this disease are comparatively more frequent among those whose sexual vigor is most pronounced, and at a period ot life Avhen it Age and sexual vigor. . L „,. . , is most active. 1ms 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 Aveak and varicose con- dition of the veins, not only in the lower ex- diIthheS.m0rrba8rIC tremities and in the external parts, but also of the internal organs and surfaces. Clinically there is very little difference betAveen a varicose condition of the hemorrhoidal vreins and that of the utero-OArarian vessels. And, Avhen 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, variola, diphtheria, malig- nant jaundice, or purpura, as to incur the risk Vitiated blood. •' . l l ' ot its effusion or transudation from the free sur- face of the inflamed peritoneum. For in this class of cases Ave may have a hemorrhagic peritonitis as Avell as a hemorrhagic pleurisy. Pelvic peritonitis may predispose to pelvic hematocele by reason of the adhesions and false membranes Avhich have been formed during its course. These sequele are not directly, Pachyperitonitis. ° .. _ . ^ . , J or necessarily, ot a serious character: but, as VirchoAV and Bernutz have shown, there is a possibility that the delicate vessels which ramify upon these neo-membranes may be ruptured, and a hemorrhage result. This is Avhat is understood by pachy-pelvi-peritonitis as a predisponant of hematocele. Those of you who are interested in the study of this peculiar sub- ject Avill find the remarkable monograph by Bernutz in the Ar- chives de ToGologie, des Maladies des Eemmes, etc., for March, April and May, 1880. The exciting causes include Ararious traumatic injuries, as for example, blows upon the abdomen, falls upon the buttocks, the effects of jumping and of being throAvn from a The exciting oauses. . , ^. . ,. i~ 1 i carriage, and rough riding on horseback, especi- ally Avhen these are applied during the menstrual epoch. Voisin reports several cases that were due to the indulgence of coitus during menstruation, and other Avriters 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 Avhich it was caused by the use of cold 4:20 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 Aoav. Whatever is capable of arresting this periodical discharge very abruptly may precipitate this form of internal hemorrhage. The resort to vaginal and intra-uterine injections for the relief of men- orrhagia, or to stop the Aoav 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, Avhen the uterus may fill Avith 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 Avith the peritoneum. Pure, healthy blood, it is said avouIc! not induce peritonitis; but, if the blood was depraved, either in the general circulation, or Avhen it came into the peritoneal cavity from some special source, it would be very likely to cause septic infection, as Avell as a serious inflammation. There are exceptional cases in which hematocele evidently results from a partial or complete stenosis of From cervical the cervix ^teri. We have had one of these under our observation for three years past. The facts were as folloAvs: Case.—Mrs. —,aged twenty-eight, a slender, delicate woman avIio had been married for six years, but Avithout offspring, and Avith 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 some twelve or twenty-four hours, and being ahvays someAvhat 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 hemorrhoids. I gave her remedies for some time, but Avithout 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 somethingquite wrong an 1 unusual within the pelvis. I felt the conical cervix croAvded forAvard toAvards the symphysis pubis by a rvtro-uterine tumor, that Avas of irregular form and*doughy to the touch. Around its outline the tissues Avere very tender. * Unfor- tunately, I could not know Iioav long this state of things had existed. The tumor Avas bi-lobular, with a kind of sulcus betAveen the lobes that could easily be felt by the rectal touch. This sulcus, indeed, corresponded in shape, size and direction Avith the rectum itself. She had had a great deal of sacral pain, and of dragging in the hips and the loins, but the boAvels Avere regular. The sacral distress Avas usually very severe at the month. There Avas an almost complete stenosis of the uterineceiwix, 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 Avas diagnosticated as one of menstrual hematocele, due to a reflux of blood from the uterine cavity. A careful dilatation of the uterine canal Avas begun and continued throughout the inter-menstrual period. When the month came around, the flow Avas much more free, and she had very little head- ache. The strictest quarantine and rest Avere enjoined for a Aveek during the period, and then the careful dilatation ot the cervix Avas resumed. In three months the menstrual trouble and the headache had Aanished, and, by a free coffee-ground discharge from the rectum, the tumor had almost entirely passed aAvay also. For the last two years she has been quite Avell. The intra-peritoneal hemorrhage in hematocele has been attrib- uted to various sources. Thus, Bernutz ascribes it to menorrhagia Avitha regurgitant Aoav of the menses through the ^source of the h^mor-ovidiict^ Xelatoilj to the ruptlire of a Graafian follicle, and the gravitation of blood into the retro-uterine pouch: VirchoAv, 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 (Tenouville insist that it conies from the o\rary; Trousseau and Tardieu, to a sanguineous exhal- ation from the peritoneum; Tyler Smith, to an OArarian or Fallo- pian menstruation,Avhich is Aucarious in character; and Gallard to the escape or dropping of the ovum into the peritoneal cavity, or in other Avords, to the detachment of the ovum in extra-uterine gest it ion. 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 AVOMEN. 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 sloAver and more scanty extravasa- tion Avithin the peritoneum is almost certain to excite an adhesive peritonitis, in consequence of which, the walls of the hematic 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 Avhich is located at some por- tion of the roof of the vagina. The physical Local symptoms. „ . . , ° . . , characters ot 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 Fig. 38. Clover-leaf form of hematocele. or complete fixity, and elasticity Avith a sense of fluctuation which soon gives place to an unequal density, (like the tumor of pelvic celbditis.) 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 Signs per vaginam. ' \ . '-. c the base and inferior outline ot the tumor; the dislocation of the cervix, forwards, backAvads, 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 of the tumor and of the uterus. The largest tumors are almost ahvays 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 shalloAv 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 tu^or™ ^ °f ^ 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 hematomata. Voisin's* description of the mode of formation of these tumors is very graphic: " When blood escapes from the ovaries, the tubes, or the uterus, it falls naturally behind the broad ligaments thetumofr.f°rmatl0n0f into 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 Avith the rest of the abdominal cavity. In some rare cases the blood is earned in part into the vesico-uterine space, but in a very small proportion compared Avith 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 betAveen all the pelvic organs, or rather betAveen their peritoneal coverings. The coils of intestine are pushed upwards by the extravasated fluid, or lise upAvard 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 bv the rectum and peritoneum, below by the recto-uterine cul-de sac, aboAe, by the coils of intestines Avhich, by their adhesions to the fundus uteri, the broad ligaments, the ovaries, the tubes, the round ligaments, and the peritoneum Avhich 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 ot 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 AVOMEN. behind or above the pubis, and the rectum obliterated. If the ante-uterine tumor is large enough, the fundus and body of the Avomb may be retroverted. If the effusion has Fixation of the t j j ^ R j -j {th uterus that or£?an uterus. i ' o may be fixed as in a mould or cast Avhen the tumor begins to harden. Retro-uterine hematomata 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 hematic tumors in the same patient. (See Figs. 39 and 40.) In some cases these tumors diminish in size from time to time. If Ave can prevent a repetition of the flow, especially in menor- rhagia, they Avill shrink as they become more Changes in the tumor. ' ' i i i solid, until finally they are removed by absorp- tion, or 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. Fig. 39. Intra and extra-peritoneal haematocele. If the hemorrhage happens to occur Avhen the rectum is loaded with feces, 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, Avhich 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 hwariably Jain upon her back. Pelvic hematocele is so often related to menstrual disorders Lhat the first symptoms are generally connected Avith amenorrhoea, menorrhagia or dysmenorrhcea. If a copious General symptoms. in- \ menstral Aoav is suddenly arrested, and a hema- tocele results, its onset Avill be very abrupt; but if the menstrual Aoav escapes very sIoavIv, drop by drop, the tumor may develop gradually, and the general symptoms Avill come on imperceptibly. In the former case the sudden shock as avcII as the loss of blood, may induce fainting and prostration. In both conditions, Avhen the hematic tumor is formed, the external Aoav ceases. Fie 40. Intra-peritoneal hasmatoeelc. The larger the size of the tumor, the greater the amount of blood effused, and the more sudden the atbick, unless in very exceptional cases, the less marked are the signs The coincident peri- f eoinciclei^t peritonitis. And hence, at the ton;tis. 1 very beginning, the pain is not ahvays a criterion of the gravity of the case. If the attack has come on sIoavIv, or 42(5 THE DISEASES OF AVOMEN. the extravasated blood has been poured into the connective tissue, or into the peritoneal sac, Avhen those parts are already inflamed, the suffering Avill be very sevrere. Large accumulations give rise to great suffering, how- ever, when they have existed for a little time. The pain, Avhich is perhaps more agonizing than even a Avoman is called upon to endure, under other circumstances, is located about and within the pelvis and the loAver 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 o ~ 7 rectum, Avhere 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, Avith a feeling as if the intra-pelvic tissues Avere 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, Avith coldness and pallor Other symptoms. . of 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 overAvhelming as not to be followed by reac- tion. Their suddenness and gravity are like those which are due to perforation of the boAvel in typhoid fever. A very remarkable case of this kind Avas reported to the Clinical Society of our Hospi- tal last year by Dr. R. F. Baker, of Davenport. In milder cases the suffering is mitigated after a few hours, but, in consequence of increased effusion or of an extension ot the peritoneal inflammation, it is likely to return. case- aD reapsm? Exceptionally there is a relapse at ^ach 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 Avithout 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, ch'sentery, or a dysenteric diarrhoea, JeTsCTs!iD *he is likely t0 he developed. The fever varies ac- cording to circumstances. If the pain and the peritonitis are marked, the temperature and the pulse will be increased; but, if the hemorrhage has been great and sudden, the temperature Avill be low and the pulse feeble. When the duration of the disease is prolonged, a marked and persistent anemia 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 hematic cyst. The accompanying symptoms Avill include the signs of the suppurative form in addition to those of hematocele. Diagnosis.—In a differential Avay it is more difficult to distin- guish betAveen a pelvic abscess, or pelvic cellulitis and pelvic hematocele, than between hematomata and any From pelvic cellu- th(,r ^ss of jyic tumorS- In my lectures Oil litis. g L J pelvic cellulitis, I have already given you the signs by Avhich Ave separate these two diseases. This is a very import- ant subject and one that merits your careful attention. The great Nclaton, mistaking a pelvic abscess for a pelvic hematocele, punc- tured the tumor through the posterior Avail of the vagina, and discharged an immense quantity of pus instead of blood. Nor is it ahvays easy to avoid confounding this disease Avith uterine fibroids. The chief points to remember are that in hema- tocele the tumor forms and groAvs rapidly ; that From uterine fibroids. .. ,. • ^1 l x-x its formation is accompanied by grave constitu- tional symptoms; that the tumor is regular in its outline, and soft to the touch, groAving more dense as time goes on; that its presence causes the most intense suffering Avhich 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 sIoav and gradual growth, Avithout any special or dangerous constitutional symptoms; the tumor is more or less irregular in outline, and hard from the first; its presence is tolerated Avithout severe pain, and it does not displace the Avomb 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 betAveen these tAvo 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 Avith the intention of enucleating the tumor; and Stoltz, Avas 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 ot the hematocele Avas not dis- covered until the autopsy Avas made. Bernutz and Goupil could not decide, in a case at the Hotel Dieu, Avhether it Avas an hematic tumor or a uterine fibroid; and several cases are on record in which a large hematocele Avas mistaken for an ovarian cyst. Indeed, in one case, recorded in the Transactions of the Lon- don Obstetrical Society, the operation for ovariotomy was actually begun under a misapprehension of this sort. If Ave except the very rare cases of ovarian tumor in Avhich there is a hemorrhage Avithin the cyst, there should be no danger of mistaking a case of pelvic hematocele From ovarian dropsy. ° " . . for one of ovarian dropsy, lhe 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 Avill enable us to decide between them. Extra-uterine gestation is al ways accompanied by some of the signs of pregnancy; the tumor is of sIoav growth,andis generally painless. If the vascular attachments of the ovum are not pregnanoytraUtenne broken, there are no grave constitutional symp- toms ; but if they are ruptured, Ave shall have symptoms of pelvic hematocele superadded to those of extra-uterine pregnancy. Case.—In a very remarkable case of this kind to Avhich I Avas called in consultation in December 1879, by my friend Dr. Thomas Fig. 41. The aspirator. PELVIC HEMATOCELE. 429 Fio « nrawing of an haematic tumor resulting from a rupture of the sac containing the ovum in ovarian nregnancy. This tumor was shown to the College and Hospital Class 1 or 1879-80 the day after its removal. The facts as illustrated were a.so confirmed1 by Drs. Rowscy, Lungren, Parmellee. and others, who were present and who assisted in the operation. PELVIC HEMATOCELE. 431 Rowsey, of Toledo, Ohio, the pregnancy Avas ovarian, and the sac and its attachments had been ruptured at the eighth Aveek, Avith a resulting hematocele of the right broad ligament. Even at so earl}- a period, Dr. Roavscv had very skilfully recognized the case as one of extra-uterine gestation, and when the rupture took place and his patient Avas in great peril, I was sent for to decide upon the expsdiency of an operation for the remoAral of the tumor. We determined upon gastrotomy, and found the right broad ligament to be the seat of an hematic tumor larger than my fist, at the upper and inner angle of Avhich the dark blood Avas oozing into the peritoneal cavity. The sac upon the right ovary had been ruptured and Avas filled Avith soft blood-clots, and the embryo Avith its rudimentary cord Avas immersed in fibrinous clots, and fluid blood. The Avhole mass Avas carefully removed by the ecra- seur, taking the broad ligament along Avith it. The patient re- acted Avell, but for some unknown reason, since a post-mortem avus 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 • u tumor. the absence of the agonizing ot the uterus. .. » ' n e peritoneal pain, and of the A'omiting 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 Avith a good degree of certainty. 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 Avith the The aspirator and the test care and not indiscriminately. They exploring needle in. fri ' J 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 Avhen it is soft the fluid may be t^>o thick to run through the canula of so small a trocar. If upon the withdnuval of the instrument a feAV drops of pus are brought aAvay Ave shall knoAV that the case is one of abscess Avith or Avithout an hematocele. I have already sIioavii 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 AVOMEN. 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 hematic 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 Avere pronounced and the reaction intense; if the tumor continues soft and flabby, the pulse Aveak and feeble and the appetite poor; if the anemia continues, and the chlorotic hue does not give place to the florid complexion; if the attack Avas menstrual, and there is a probability of a relapse at the next or subsequent periods; if the rupture Avas tubal, ovarian, uteriiie, or the consequence of an extra-uterine pregnancy; if the case is complicated Avith 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 Avhere these hematomata empty their contents into the rectum there is danger that the hemorrhage may be reneAved and become so excessive as to be beyond control. I ought, hoAvever, to say that of late, unless they are over-whelm- ingly fatal in the first stage, cases of pelvic hematocele are more readily controlled than in former times. This result depends upon our having a more correct idea of their special pathology than Avas possible tAventy years ago. And, consequently, upon our know- ing enough to avoid the added dangers of a mischievous interfer- ence Avith Avhat Ave 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. x the best means of preventing an increased effu- sion of blood, or a relapse. The patient will choose the position Avhich is most easy, and she should be permitted to keep it. It may be necessary to insist that she shall remain in bed through tAvo or more consecutive menstrual periods. And not only should she be kept quiet, but the bowels should be at rest, and not Avor- ried by cathartics, or even by enemata. I have knoAvn a case in which a relapse of an hematocele Avas induced by strangury. For PELATC HEMATOCELE. 433 a long time after an attack of this disease sexual intercourse should be strictly forbidden. In serious cases it becomes a question Avhether our dislike of opiates should not yield to our desire to relieve the terrible suffer- ing that is incident to the hematic 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 Avere 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 Avithout it if you can, but, the fact is that in very bad cases you Avill 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 Avater injections per-rectum, or per-vaginam. You may add tAvo tablespoonfuls of the mother tincture of hamamelis to a pint of very warm water, and throAv it into the rectum or the vagina. Or compresses Avet with the same solution may be applied over the pubis and the vulva Avith good etlect. Some authors prefer cold instead of Avarm applications aud injections. In this case cold Avater, and even ice Avater may be thrown into the rectum as a means of arresting the hemor- 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 Avhisky or brandy, milk punch, or egg-nog, Avith inhalations of camphor, or ammonia may be servicable. If at the same time the pain is very severe, a feAV whiffs of the nitrite of amyl may bring relief and the much needed repose. The medical The medical treat- . . L i i t • • * i i • meot treatment, as stated by Jousset, is included m three principal indications, viz., (1) to limit and OArercome the serous inflammation, (2) to faAror the absorption of the effused blood, and (3) to prevent a repetition of the hemor- rhage. The first of these indications is to be met by the remedies of Avhich I have spoken in my lecture on pelvi-peritonitis. They are aconite, belladonna, colocynth, rhus tox., and terebinth, to Avhich may be added china, ipecacuanha, secale cor., arsenicum, thlaspi burse, hamamelis and digitalis. Here are the notes of an interesting case to Avhich I Avas called in consultation some Aveeks ago by my friend Dr. E. G. H. Miessler, of this city. 28 434 THE DISEASES OF AVOMEN. Case.—Mrs. G., aged 33 years, of bilious temperament and of a AAreak constitution, enjoyed good health until she was married, which was ten years ago. From a continued exposure to Avet 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. A.t the end of the second year of her married life she gave birth to a premature child, Avhich labor occurred in the eighth month. From want of proper care and assistance this accident gave rise to some severe pelvic trouble, Avhich 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 Avas not able to move about. All of her symptoms Avere of a rheumatic character, for which I found bryonia 3, was Avell indi- cated. The pains AvereAvorse oh motion, and better at rest, Avith thirst for cold drinks, and constipation. Sept. 19 was called again. The folloAving statement Avas given by the patient herself. She felt greatly relieved from her pain and lameness—was able to move about and do her Avork. On a cold rainy day, and Avhile 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 Avere given in alternation, and hot bran- ,poultices were ordered to be applied locally. There Avas but slight fever. The next day the ovarian pains were someAvhat relieved, but the pain in the back Avas more severe. It was not a constant pain, but paroxysmal, and seemingly aggravated by flatulency. There Avas nausea and vomiting, Avith a yelloAV-coated tongue, loss of appetite, thirst, restlessness and headache, tenes- mus, constipation of the bowels. A Araginal examination revealed some swelling along the posterior Avail of the vagina, which Avas 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 Avorse. Pulse 120—tempera- ture 102°—more SAvelling, 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 Avas 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 Avhich I Avillingly consented, and Dr. R. Ludlam was sent for. He made a careful examination and approved my diagnosis, that it Avas a genuine case of retro- uterine hematocele. It Avas 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 Avater injections, which Avere 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. Ave re successively given. After Iavo days more of suffering, a very offensive matter of a dark broAvn color escaped by the rectum, which gave decided relief. Then for a day the discharge Avas 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 recoveiw. 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 Avhen the tumor The surgical treat- j golid and [{ accessible. The l.ltter ig the ment. •> common method of discharging the cyst. In our day these tumors can be tapped Avith the aspirator much more safely than was possible Avith the old-fashioned trocar. But still the operation is not devoid of danger, and is strongly contra- indicated in certain conditions. Thus it avouIcI Contra-indicationSforuot } gafe ^ expedient while the effused blood tapping. l continues in the fluid state, Avithout being encysted, nor Avhile the size of the tumor continues gradually to diminish and the patients condition to improve, nor if the source of the hemorrhage, being catamenial and dysmenorrhoeal 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 hemorrhage in such cases is no indications for tap- lon„er in operation; if there is a very large accumulation, which is not too recent, but Avhich causes great pain and pressure, Avith 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, Avith a hyperthermic condition, there should be no delay in evacu- ating the tumor. I am opposed to putting it off very long, for Avhen 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. AVe select the most dependent part of the pouch, and discharge it with a large-sized aspirator trocar. I Fig. 43. The aspirator. A safer resource in the hands of an experienced gynecologist is to open the abdomen, empty out the accumula- k^and^magfin1.^ 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 shoAV you upon the table, and my remarks upon this form of inflam- mation in my general clinic Avill give you a practical idea of this very important subject. For, as there will be no lack of these cases in your private practice, Avherever 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 Avhich is six years old, relates the folloAving story: Eight days ago, at the proper time, the menses made their appear- ance Avithout any unusual symptoms. On the same morning she commenced a five days' job of Avork upon the sewing machine. At the close of the first days' labor the Aoav ceased for some hours, and then, after a foot-bath and a night's rest, it returned. On the third day there Avas another intermission in the menstrual discharge, and on the fourth day it ceased entirely—tAvo days sooner than usual. She iioav complains of headache, Avith slight vertigo, the face is flushed, the pupils are somewhat dilated, noise Avorries 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 Avhile standing upon the feet. She also has a burning, bearing-doavii 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 SAvollen, hot, dry, and exquisitely tender. She cannot bear the least pres- sure upon it. The Avomb lies very Ioav in the pelvis, so much so that Avhen she stands upon her feet it rests upon the perineum. Examination Avith the speculum shows the tumefied and tender 43; 438 THE DISEASES OF WOMEN. cervix to be congested and more than twice as large as natural, 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 tAvo varieties of cervicitis — one in Avhich the substance, or parenchyma of the uterine cervix is the seat of the inflammation (cervical metri- 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 Avomen Avho have not given birth to one or more children, either prematurely or at term. Indeed the most powerful predisponent of this Rare in nulliparae. . , . n . . . , . . 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 Avhich is proper to the virginal cervix, and thenceforth we find it liable to diseases from Avhich 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 pJd'ispoTent11^ cyde a about the time of the menstrual return. It is possible that this Avoman 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 Avith patients as Avell as with their physicians — and therefore, she set to work the very clay 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 Avorks the mischief in those Avho run it. The trouble is that, Avith most utfrbendis™cehsmes 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 Aveeks, and perhaps even for months. Then they go to Avork for days and nights consecutively, in order to despatch it, and to tk 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 Avorking Avith it, continuously for hours and days together, that does the harm. If the same Avork were properly distributed, as our wives and daughters kt practice " upon the piano — not as a business, but as a recreation and diversion, the result Avould doubtless be very different. In the case of those Avomen, Iioav- ever, Avho are obliged to sit at the seAving-machine from morning until night each day in the Aveek, in order to obtain a livelihood, it is almost impossible for them to escape certain functional and organic diseases of the Avomb. Whatever tends to Avound, bruise, or irritate the neck of this organ may, in those avIio are predisposed to it, give rise to cervi- cal metritis. Too violent exercise, as horseback m«ritisS°f acute cerv'cal 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 Aoav ; 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 Iioav it is possible for either of these causes to develop this form of metritis by conA*erting the physio- logical injection of its structures, which is nec- res^fts6 °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 AVOMEN. result of this engorgement will be Ave 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 ceiwical metritis is more likely to be confounded Avith cer- vical endo-metritis than with any other disease. In the former, the neck of the Avomb is sAvollen and tender, Differential diagnosis. . . . .. not only to a light touch, but also to pressure upon it from Avithin the A^agina, 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- rhoeal 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 ahvays pain in the head, photophobia, a flushed face, and such nervous symptoms as those of Avhich this patient complains. Fortunately the organic changes in the cervix, which are the sequelse 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 Avill have passed before the physician is consulted. Doubtless the frequent return of the menses serves to perpetuate the liability of the neck of the Avomb, AA'hich has once been inflamed, to repeated attacks, that may finally end in estab- lishing the chronic form of the disease in it. In those Avomen in whom the cervix is unusually long, as Avell as in those avIio are of a relaxed fibre, cervical metritis is very apt to become chronic and intractable. The same is true if the disease occurs in Avomen 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 Avoman experi- ences Avhen she is upon her feet, suggests that she should not be alloAved to walk about. The horizontal posture Postural treatment. x is the first thing you should prescribe for 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. 441 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 aA'oid 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 ha\ing 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 remo\red. And you should act promptly. Remove the cause. x .. . . . . . . . Learn the source ot the mischief 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, Avill 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- Prevention better than vention is better than cure." Hygiene should cure. " ° go hand in hand Avith Therapeutics. It would not be sufficient to give this Avoman belladonna, or any other rem- edy, and dismiss her Avithout 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 Avill 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, SAveeping, 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 be prohibited. Pessaries and every species of artificial support, 442 THE DISEASES OF AVOMEN. 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 Avill be no harm in prescribing a vaginal injection, consisting of the tincture of arnica, glycerine, and tepid Local measures. ' . . . Avater. In. case she has hemorrhoids, 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 AA'ater, 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 Avith it. In one of my cases it certainly brought away half a teacupful of serum with Avhich the swollen and pen- dulous cervix had previously been engorged. It may be possible by some such simple and harmless expedient to prevent Avhat might otherAvise develop into chronic cervical metritis. The internal treatment should be regulated by the obvious symptoms peculiar to the individual case for the cure of Avhich you . . are consulted. This Avoman will take of bella- Prescription, donna £d, a dose every three hours. When her symptoms are somewhat improved, it may be repeated once in six hours. Let her come again next Aveek. In some of these cases, Avhether complicated Avith other forms „. . , . . . . of pelvic inflammation or not, and Avhere the The hot rectal douche. . suffering is very acute, the hot rectal douche recommended by Dr. Chad wick, of Boston, is an excellent means of relief. The Avater 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 Avith its palmer surface toward the cocyx. As soon as you begin to feel the loAver pouch filling up, you should Avait a little, but without withdrawing1 the nozzle of the syringe. In this way from one to four pints of water may be injected Avith- out exciting an immediate action of the boAvels. The patient CORrOREAL CERVICITIS, ETC. 443 should keep quiet for half an hour, and it is possible that the water may not pass aAvay again for an hour or tAvo. CHRONIC CORPOREAL CERVICITIS. — CHRONIC CERVICAL METRITIS. Case. — Mrs. Emma H. ----, aged 26, Irish, is of sanguine temperament, has had three children and tAvo miscarriages, the last of which she induced herself six months ago. The menses have always been profuse, and accompanied Avith 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 Avomb. 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 SAvollen 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 Avas first placed on belladonna3 once in tAvo hours. The cotton tampon saturated Avith pure glycerine, was to be intro- duced every evening and Avorn through the night. This treat- ment, local and general, promptly relieved the engorgement and tumefaction of the uterine cervix, and her general condition Avas very much improved. Since that time, however, she has treated herself and our clinical assistants, to a series of hysterical mani- festations, of Avhich the following is a list: 1st. Gastralgia. Avhich continued at intervals for three da3*s. '2d. Retention of urine—Avhich she passed easily enough Avhen left to herself—lasted one Aveek. 3d. Paralysis of the right arm for three days, and 4th. Pseudo-pleuritic pains that continued for tAventy-four hours. Our patient Avas brought into this institution from a neighbor- ing hospital Avhere, she says, her case Avas 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 unAvorthy of trust as that which patients bring us concerning the views of other physicians, and the treatment to Avhich they have already been subjected. 444 THE DISEASES OF AVOMEN. Symptoms — This is a case of chronic cervicitis, or of cervical hyperplasia. For some reason, most probably on account of the abortions Avhich she has suffered, such inter- Mechanical symptoms. .... n . . .... 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, Avithin 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- corrhceal Hoav. 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 Avoman complains of, are almost ahvays present. Menstrual disorders are frequent. Some of these patients have amenorrhcea. In many cases there is unusual pain and difficulty in the commencement of the " period,*' which Menstrual disorders. . x is occasioned by a partial closure of the cervico- uterine canal. But Avhen 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, Avhkh you will meet with in private Contact. . ^ r 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 Avails 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. Post-puerperal. „ . lhomas prefers to style it, almost ne\Ter 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. . „ 1 1 , i i • 1 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 Avill be on the alert for this condi- tion of things among multiparse in malarious districts. Diagnosis.—A few symptoms, carefully considered, will gener- ally enable us to differentiate betAveen this disease and cancer of the uterine neck, which is usually of the scir- From uterine cancer. - . _ „ . . rhous variety. 1 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 Avere cancerous, the outline Avould be irregu- lar, nodulated, and bosselated, and it would feel hard and carti- laginous. Cervical metritis is almost ahvays a sequel to preg- nancy and to labor. It bears no especial relation to the climacteric. Cervical cancer is not at all infrequent in nullipara, 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 44(1 THE DISEASES OF AVOMEN. tissue and haemorrhage ; in cancer, such a tendenc}7- is very marked. But, even with the greatest care, it is not always possible to distinguish between these t\vo 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 Avas 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, hoAvever, the SAvollen 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 wrould 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- m£rftfsn°sis 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 Avith 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- Fostural treatment. . . „ ing posture, and off their feet, at the month especially. Shopping, visiting, party-going are as injurious as a CORPOREAL CEl.VICITIS; 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 dysmenorrhcea, remove the cause and relieve the consequent engorgement of the cervix. If she has intermenstrual dysmenorrhoea, cure it. If the General indications. a • now 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 Avhen these conditions are set aside. She should be especially careful not to do anything before, during or directly after the Aoav 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 the rem- edy or remedies. Podophyllin, mercurius, chamomilla, bryonia, nux 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 aftd apis mellifica. Some of the Bell., lach. and apis. best cures that I have ever made have been performed Avith 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 Avith glyc- Local adjuvants. . . t ° " erine can do no possible harm, Avill not interfere Avith 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 Hoav, the menses are regular but scanty. The trouble began two years after the birth of her child, which Avas 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 Avill 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 AVOMEN. On local examination, the os A\ras found much SAvollen and of a purplish hue, Avith a Avell defined vesicle on the anterior lip Avhich Avas filled Avith serum. The cervix Avas elongated, red, and of sugar-loaf form, but there Avas 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 Avoman 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 avIio saAv it in the field of the speculum Avill remem- ber hoAv 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 Avas impossible for her to have either chronic metritis, or sub-involution of the Avomb. And you remember that when I introduced the sound it passed to the depth of tAvo and a half inches only, which fact confirmed my statement. But, hoAV can corporeal cervicitis occasion a scanty Aoav of the menses? Manifestly by narrmving 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 Avhen it entered the womb, and which it afterAvards 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 boAvels regular, and the bladder from becoming distended; the avoidance of excessive sexual excitement, tight lacing, or too prolono-ed Query. Treatment. Fig. 44. Hall's Syringe. CORPOREAL CERVICITIS, ETC. 44S standing, and the passage of the sound, or the trial of slight and careful dilatation of the cervical canal almost directly in advance of the floAV, are measures. 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 Avoman are as real as those of pneumonia or of rheumatism, but they depend upon a mechanical cause, and Avill persist Avhile that cause con- tinues to be applied. The structural lesion furnishes the chief indications for the treatment, because, Avithout this lesion, there would be no symptoms that were sufficiently distinctive to tell us what the trouble was, neither Avhat the remedy should be. I pre- scribed tartar emetic being fully satisfied of its Tartar emetic. , , ,. , ... .. . . poAver 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 Avill 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 Aveek in the presence of theclass. All local treatment Avhatever Avas Avithheld, 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 Avas so perceptible that e\cry member of the class, as Avell as a number of physicians avIio Avere present from time to time, was satisfied with the result. 29 450 THE DISEASES OF WOMEN. Where this inflammation is benign, and the infiltration of tho cervix Avith serum that is loosely organized, constitutes the Avhole of the local difficulty, the case is in some sort the counterpart of the hepatized lung in pneumonia. This was Avhat Spiegelberg recognized Avhen he recommended the sponge tent as a means of diagnosticating simple corporeal cervicitis from cancerous infiltra- tion of the cervix, and this Avas my idea in advising the internal use of tartar emetic for the resolution of the hypertrophied cervix, Avhen it was traceable to a non-specific inflammation. I have iioav 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 Uterine hyperplasia and ■, 1 ,. , . , . J sub-invoiution. 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. LECTUEE XXVIII. CHRONIC CERVICAL ENDO-METRITIS, OR ENDO-CERVICITIS.—UTER- INE LEUCORRHCEA. 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 Aveeks ago. She is noAV 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 shoAving you that the simplest reme- dies are sometimes the most efficacious. Her clinical history, as recorded on her admission, is as folloAvs: — Case.— Mrs.----, 28 years of age, the mother of two chil- dren, has been an invalid for tAvo years past. Her ill health dates from her last accouchement, which Avas normal in all respects. She, hoAvever, -'got up" very sIoavIv, and was Aveakly 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, Avhich extends to the thighs, and bearing doAvn pains and pressure Avithin the pelvis, "as if everything Avould be forced from her." This latter symptom is Avorse Avhen she rises to her feet from the chair or couch. She also has a leucorrhceal dis- charge, Avhich is thick, creamy, and sometimes more Avatery and copious. The freer this Aoav 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 feAV minutes at a time, and can not Avalk but a short distance Avithout 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 Avhich, she thinks, is in the 451 452 THE DISEASES OF AVOMEN. mouth of the Avomb. Intercourse is almost intolerable. The bowels are badly constipated; the appetite poor and capricious, Avith more or less of nausea and loathing of food, especially in the morning. Her eyes are so weak that she can not read or seAV more than five or ten minutes at a time Avithout pain, indistinct vision, and lachrymation. The touch reveals a tumefaction and tenderness of the cervix uteri. The Avomb lies very low in the pelvis. The external os uteri is patulous, and its lining membrane everted. A thick, albu- minous mucus Avas taken directly from the canal 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 Avhich 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, Avhich is found Avithin the cavity of the Avomb. For Avhile you Avould naturally suppose that these two affections Avould 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 Avho are not practically familiar Avith this disease may be disposed to question Avhether such a limited extent of in- flammation could really induce very serious or m.fcotusntmembrhaene.cervical persistent symptoms and ill health. The ute- 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 doAvn into each of the little glands Avithin the cervix, of Avhich, according to Dr. Tyler Smith, there are as many as from tAvo to three thousand. In an ordinary case of endo-cer- vicitis, therefore, a larger extent of mucous membrane is inflamed than you avouIcI 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 Avhich depletes from the patient's general A glandular lesion. A a o strength, complicates the case, adds to the suf- CEVRICAL ENDO-METRITIS, ETC. 453 feting and retards the cure. EA'erv 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 Avomb, 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 Cervical leucorrhoea is i i ,1 l p ,1 n • , not uterine catarrh. between the character ot the Aoav in true ute- rine catarrh, and in proper cervical leucorrhcea, as there is betAveen the rusty sputa of pneumonia and the mucoso- puriform secretion Avhich is stained Avith 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- Predisposing causes. . . 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 within 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 Avhich are the counterpart of those of Avhich Mrs.----complained, you will have a strong presumptive sign of her disorder. A careful examination locally Avill either confirm or disprove your suspicions. The scrofulous cachexia also predisposes to this form of uterine inflammation. It could not be otherAvise, Avhen so important a part of the secretory apparatus is implicated. The same is true of the return of the menstrual cycle. The physiological afflux of blood to the uterine cervix, and especially to the vascular membrane lining Menstruation. . . , , . , . , n , its cavity, may develop into a state ot hyperse- mia, and so derange the process of nutrition as to establish a gen- uine inflammation. Dysmenorrhcea, too frequent, tardy, scanty, or irregular menstruation, tend in the same direction. 454 THE DISEASES OF WOMEN. The tuberculous diathesis is also a powerful predisponent of cer- vical endo-metritis. Depraved nutrition, from Avhatever cause, too prolonged lactation, rapid child-bearing, hereditary feebleness of constitution, and habit- ual strain of the mental faculties, if it is of a depressing character, belong to the same list of causes. My observation leads me to remark that there is still another cause which should be included in this category. I allude to the influence of what is known as a " bilious cli- Biliary disorders. ,, TTT1 ■, • t 1 -i ± mate. Wherever hepatic drsorders prevail to any considerable extent, as in malarious districts, we find a strong tendency to this variety of uterine inflammation. Organic and functional diseases of the liver embarrass the circulation of venous blood through the pelvic viscera. In a climate in which every kind of morbid state is stamped Avith the impress of "biliousness," this cause is constantly at work, and the step from congestion to inflammation of the cervix uteri is so short a step that it is very easily taken. Multitudes of women have cervical endo-metritis from this indirect cause alone. In confirmation of this view we find that, next to the large class of scrofulous subjects who suffer from it, Avomen with dark hair and complexion, and black eyes, that is to say, avIio are of a bilious temperament, have this disease most frequently, and in its most intractable form. This is an item Avhich those of you who are to locate in the South and West Avill do Avell to bear in mind. The exciting causes of this disease are very similar to those Avhich often give rise to cervical metritis. A sudden arrest of the menstrual Aoav, dvsmenorrhoea, cold Avet feet Exciting causes. -it- "••,■,• and damp clothing, tight lacing and the Avear- ing of heavy skirts that are hung at the Avaist, violent exercise at the month, too forcible and intemperate coitus, the retention of a portion of the secundines after a miscarriage, the use of harsh injections to prevent impregnation, or of harmful instru- ments to induce abortion, ungratified sexual desire, as in nym- phomania ; uterine displacements; obstinate constipation with paralysis or stricture of the rectum ; ovaritis ; gonorrhoea : rough travel in a carriage, the cars, or upon horseback, prolonged stand- ing upon the feet, and the Avearing of ill-adjusted pessaries, are the CERVICAL ENDO-METRITIS, ETC. 455 most common of these causes. Exceptionally, in corporeal endo- metritis, there is an extension of the inflammation from the cavity of the Avomb dowmvards into the canal of the cervix. This almost never occurs, unless it be in the puerperal state, in which case the endo-cervicitis is a sequel of the endo-metritis proper. In vulvo-vaginitis, Avhether it be specific or not, the inflammation may finally invade the cervical canal and extend as far as the internal os uteri. But these cases are comparatively rare. A mild, and in many instances a self-limited form of cervical endo-metritis, is sometimes met Avith during the prevalence of an epidemic influenza. You have seen seA'eral From Epidemic Influenza. . . . . cases of this kind in our Clinique during the present winter. Such attacks may be either primary or secondary. They sometimes alternate with catarrhal inflammation of other mucous passages, as, for example, the nares, the throat, and the bronchial tubes, and perhaps also of the alimentary mucous mem- brane. In Avomen of a scrofulous, or tuberculous cachexia, as Avell as in those who are greatly debilitated from other causes, an incidental cervicitis of this kind is Aery likely to become chronic. The most prominent and persistent symptom (in a Avell marked case of this disease) is the leucorrhcea. It is the first abnormal- ity to attract the patient's attention, and the one above all others Avhich a majority of prac- titioners are most anxious to relieve and to remedy. It usually begins Avith a slight increase of the normal healthy mucus from the cervix, which is observed to be most abundant a day or two in advance of the menstrual Aoav. Or it may folloAv menstruation, and continue for some days after the cessation of the catamenial discharge. Sometimes it is intermitting in character, being brought on by violent exercise or excitement at any time during the infra-menstrual period. The more chronic its nature, the more copious and exhausting it becomes. It may be creamy, viscid, highly albuminous, and inspissated in character. After a longer or shorter period, Avhich varies in different individuals, the dis- charge becomes habitual and constant. Whenever the patient assumes the upright posture there is a sensible escape of this secretion from the cervix uteri. When she arises in the morning, after lying in bed all night, this Aoav may even be profuse, as it was a little Avhile ago in the case before you. If it is bloody you 456 THE DISEASES OF AVOMEN. will remark that the blood is not thoroughly mingled, or incor- porated with the mucus—as it Avould be in case of a muco- sanguineous discharge from the uterine cavity. When the follicular inflammation Avithin the cervix uteri is become deep-seated and chronic, more especially if it occurs in scrofulous subjects, the hyper-secretion is altered in character. Examination Avith the speculum discloses a string of tenacious, transparent, ropy mucus, hanging from the external os uteri into the Aragina, and in exceptional cases, even from betAveen the labia majora. Dr. W. Tyler Smith compares the appearance of this secretion from the cerATix to that of soft soap. " It seems as if the alkali of the discharge combined Avith the fatty and albumin- ous element, to form a saponaceous compound."* Farther on in the course of the disease, and even although there may be no abrasion of the os uteri, and no ulceration, pus-corpuscles are added, and the discharge becomes muco-purulent. In most cases, however, it is puriform instead of purulent. It The puriform discharge. . _ .. in • • 1 l • is seldom that the Aow is acrid and excoriating in character, unless she has ulceration of the Avomb ; or the in- flammation is specifiers, for example, diphtheritic, or syphilitic, in its nature ; or the tone of her general health is very Ioav, by reason of debilitating diseases, such as stomatitis materna, haem- orrhage, inanition, and a consequent deterioration in the quality of the blood. All of which leads to the inference that this form of leucorrhcea should properly be regarded as a symptom, and not as a disease per se. In this respect it ranks Avith a cough, symptomUCOrrhcEa merely a a haemorrhage, a dropsy, or a diarrhoea. When you take the discharge directly from the os uteri, and examine it in the field of the microscope, it presents the appearance shoAvn in this diagram. Here are cylindrical epithelial cells, mucus-corpuscles, pus-corpuscles, blood globules, and fatty particles. These are found floating in an alkaline plasma, Avhich A'ehicle is furnished by the cer- fl varying characters of the vlcal glands. Dr. Tyler Smith observed that 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., etc., Philadelphia, 1855, page 64. CERVICAL ENDO-METRITIS, 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 Auid 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 Avill not understand me to say that all cases of this form of leucorrhcea depend upon cervicitis. By no means. There are other causes, such as obliquities of the uterus, Cervical leucorrhcea from j^q presence 0f foreign glOAVtllS, ulceration of other causes. J- o o the os uteri, granular degeneration, ovaritis and kindred affections even more remote, and Avhich operate in a reflex Avay, that sometimes originate and perpetuate this discharge by stimulating an undue activity of the glands Avithin the cervix. For the present I must defer their consideration. The dragging sensations about and Avithin the pelvis are not ahvays so marked and seAere in this form of cervical inflammation as they are in cenical metritis. For in endo- Pelvic pains and suffering. ..*.., , /> , i i • cervicitis the neck ot the Avomb 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 Avith the size of the cervix. Something depends, hoAvever, 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 A'ery apt to complain of bearing doAvn sensations, symptoms of prolapse, forcing of the pelvic A'iscera towards the vulva, and not infrequently or rectal aching and tenesmus Avhenever 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, Avhich are located either Avithin the vagina, at the mouth of the womb, or in the ovarian region. Sometimes Burning sensations. , .. ti i -ij-iii the cerA'ix is so displaced and tender that inter- course is very painful. More rarely, hoAvever, the unnatural con- dition of the parts causes an increased sexual desire, Avhich the 458 THE DISEASES OF AVOMEN. patient feels must be gratified, even though it be at the cost of subsequent suffering. Straining at stool, or in urination, may cause a Aoav of mucus from the cervix, and even from the vagina. The bowels are almost ahvays 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 doAvn. Among the loAver 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 of inAammation of 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- tAveen the inferior segment of the womb and the eyes. I have treated a case of incipient amaurosis Avhich Avas entirely and promptly relieved by the removal of a small mucous polypus that Avas 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 folloAv 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 inAammation have been relieved in her case, has the Aveakness of vision and its attendant symptoms improved. My friend Prof. Vilas, the oculist, informs me, however, that such symptomatic derangements of vision are apt to remain after the primary trouble Avith the uterus has been cured. Upon making an examination with the speculum in a case of endo-cervicitis, if the Avoman has ever been pregnant, you will almost certainly find the cervix uteri someAvhat sAvollen, the os CERVICAL ENDO-METRITIS, ETC. 459 patulous, and, if the leucorrhceal Aow has been copious or long continued, the mucous lining of the canal of Examination with the ,1 • , , t 11 i speculum. the cervix everted. In the virgin, hoAvever, and in those avIio have never conceived, as Avell as in very mild and recent cases, the tumefaction, the relaxed and open os uteri, and the hernia of the ceiwical 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 Avords, the inAammation in this case is limited to the cervical canal, bounded above by the internal os, and beloAv by the exter- nal os uteri. I am convinced that endo-ceivicitis is much more common among young unmarried Avomen than it is generally sup- posed to be. In the latter class the vaginal portion of the cervix is rarely inAamed. Its investing membrane is not congested, neither is it hot, dry, or especially tender. But in confirmed cases, occurring in Avomen who have borne children, 3-011 will observe that the mucous membrane about and within the os uteri is in a state of hypersemia and of evident inAammation. The nearer the men- strual period the more these parts Avill be congested, and the more open and dilatable the os tincse. In considering the diagnosis of this disease Ave are led to remark that the most mischievous results have folloAved the confounding of inAammation Avith ulceration and induration Diagnosis. itxt-» ot the neck of the Avomb. 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 folloAved by harmful conse- quences. For they always reAect the treatment that will be adopted. If I Avere to teach you that inAammation, induration and ulceration are essentially one and the same disorder, my indi- vidual error as a teacher avouIc! react against the Avelfare of your patients and of the community, through you, because it would set you upon the Avrong 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 AVOMEN. 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 OA~er, thus, very gently, and you will wind up and remove A practical hint. . " . . . - , the etrmgy 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 Avill see at a glance Avhether you have a case of simple inAamma- tion or of ulceration to deal Avith. 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 Avill 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. Noav a simple abrasion of the os-uteri may be, and most fre- quently is, merely incidental to the endo-cervicitis. The leucor- rhoeal discharge does not come from the denuded The flow not from anul- n "I j_ • "I • i jy ■,! • ,1 i p cerated surface. surface, but is derived from within the canal of the cervix. If, hoAvever, 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 Avill 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 r , i • , j> i -i /. metritis. by the existence ot a leucorrhcea, 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 clyscrasise. 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 ; Pro nosis for they are by nature chronic and tedious. And there are so many causes Avhich, directly and indirectly, modify the vascularity of the part that is infiamed, and derange and damage its glandular function, that your best inten- CERVICAL ENDO-METRITIS, 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 wmen it has apparently been cured. Treatment. — Nothing is more common than for young physi- cians to claim that a feAV doses of this or that remedy have sufficed to cure a case of cervical leucorrhoea. And this independently of sexual excitement, the monthly exacerbation, and all the drawbacks which are but so many obsta- cles in the Avay 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 Aoav, 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 Avhich 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 endo-cervicitis are avoidable. It will be necessary to remove your patient from under their influ- ence. You Avill see to it that there shall be no Remove the cause. i -i • , , • 1 r „ „ sudden interruption or derangement ot men- struation ; that her clothing is suitable and sufficient; that her feet are warmly 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. dally at or near the month), of uterine displacements, constipa- tion, dysmenorrhcea, dysuria, ovaritis, blennorrhagia, rough riding, Avearisome exercise, or the wearing of an abominable (not abdomi- nal) supporter or pessary. Both Avith 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. _„ . in stant attention. It your experience shaft cor- respond with my OAvn, you will find that the prime indication Avith 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, Avhich 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, foAvl,. game, soups and broths of different kinds, if not too greasy, the Avhites 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 nathre Avine, or the extract of malt, may be alloAved. Condiments and coffee are often injurious, while acid drinks are not only grateful but useful also. Some of these patients Avill never get Avell while they remain Avithin doors. Others need a change of scenery and surround- ings, and they must travel. And yet another Travel and exercise. m . class must be kept in a passive state. But Iioav 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 'k half cured," and you will be prepared to study its special therapeutics. CERVICAL ENDO-METRITIS, 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. l-n-i-iii also inflamed, or ulcerated, they do not reach the diseased part. And yet you Avill 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 Aarious kinds. With a view to clear the Aagina of the unnatural discharges Avhich 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 Avith the poisonous Aoav, Ave may prescribe injections of Castile suds, or of glycerine and tepid Avater. A better means of relief, hoAveA-er, consists in the direct appli- cation of pure glycerine to the inAamed cervix. This substance has the poAver of causing a free discharge of The topical use of giy- serum fr0m its engorged capillaries, and thus of cenne. o o i remoA'ing 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 Ave relieve this local embarrassment of the circulation, it is like extracting a splinter from the Aesh in a case of irritative feA^er. 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 reAex 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 Avith pure glycerine, and introduce it into the vagina after the patient has retired for the night. It should be pushed up against the cervix and left there until morning, AA'hen it can be withdrawn. The removal of this tampon will be folloAved by a more or less copious discharge of a thin serum, Avhich is the pro- How to apply it. 464 THE DISEASES OF AVOMEN. duct of the g" insalivation," as it has been termed. This little operation may be repeated, according to circumstances, from one to three times each Aveek during the inter-menstrual period. Another, and a more direct means of applying this substance is to take such an instrument as this, Avhich is a flat uterine probe, armed with a bit of cotton-wool or soft sponge, Another method. . . -i ■, ■, • ■ ., i • saturate it with the glycerine, introduce it into the cavity of the ceiwix and pass it as far as the internal os uteri. Turn it about gently, and after a feAV seconds it may be Avith- draAvn, 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 meaiis 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 ahvays 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 tAvo ounces each of glycerine and Calendula, hydrastis, etc. ■...-.■.-■ distilled water, and applied locally. Or the hyclrastis, hamamelis, arnica, or baptisia, may be used in the same Avay. 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 tAvo ounces of glycerine, and applied Avith a camel's hair pencil to the canal of the cervix. I have sometimes used the oleaginous collodion Avith 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 [ntra-cervical injections. n safe to resort to injections throAvn into the cer- vix, lest the fiuid 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. _ •-' ■L chanical support is more likely to do harm than good. The only pessary that I ever employ in these cases is the CERA'ICAL ENDO-METRITIS, ETC. 465 saturated tampon, of which I have just spoken, Avhich some of my patients wear whenever they are upon their feet. Exceptionally the perineal strap or pad is palliative, and Avill 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 endo-metritis. In very tedious cases compression of the inAamecl mucous membrane exerts a salutary inAuence, not only in lessening the copiousness of the Aow, but in curing the Compression. . . lesion upon AA'hich it depends. Jbor 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 ansAver equally well. Medicated bougies and suppositories are not of any especial value in endo-cervicitis. Compression would, hoAvever, be harmful, excepting in chronic cases of this disease, and should ahvays be used Avith caution. Concerning the employment of caustics in the management of this disease, they certainly are no better indicated than they avouIc! be in nasal catarrh, inAuenza, catarrhal ophthalmia, or a '* cold in the head."' It Avould 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 Avithout the topical use of alum, the acetate of lead, or even of carbolic acid, and why should they claim that a similar inAammation 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 Avrong in their deductions ; practically, I believe, they are Avorking more mischief (uiiAvittingly, to be sure) than any equal number of physicians, of AA'hatever denomination, the Avorld over. For Avhat excuse can there be for converting a case of simple enclo-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 ? 30 466 THE DISEASES OF AVOMEN. I have long been of the opinion that, in the selection' of the constitutional remedies for this form of leucorrhcea especially, the physical characters of the flow, as it is ordi- A fallacious practice. . • -i i narrly obtained, have been considered more im- portant and suggestive than the facts of the case will Avarrant. 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 Aow should become white, watery, milky, opaque, cheesy, curdy., yelloAvish, brownish, flesh-colored, or even greenish. And, since the conditions which give rise to the varying qualities of the ieucorrhceal Aoav (in endo-cervicitis, or uterine catarrh), are purely accidental, and contingent upon the passage of that Aoav 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 afterAvards 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 ? Noav, I propose, that in order to obtain a correct idea of the secretion Avhich is poured out by the cervical glands in uterine leucorrhcea, Ave should not trust to the patient's Rule for examination of . /> , . the flow in cervical leu- version ot the matter, neither to our own exam- corrhoea, . „ mation ot the Aoav, Avhen it has been mingled with the vaginal mucus, but that, in order to examine it properly, Ave should take the discharge directly from the cervix uteri itself, as well for curative as for diagnostic reasons. Then, as in nasal catarrh, Ave Avould have the original product unchanged, and what- ever we could learn from it that Avould help us to differentiate be- tween remedies would be much more satisfactory and trustworthy CERVICAL ENDO-METRITIS, 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, abnormal1 discharge"5. 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 Avhich, like the sputa, diarrhceic discharges, and the cervico-leucorrhceal Aoav, 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 Aoav in cervical leucorrhcea are many of them too fickle and varying to be possessed of the prac- tical significance Avhich 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 haAe), when remedies for cervical leucorrhcea haAre been pre- scribed on these shadoAvy 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 Avhen we can not do better. In vaginal leucorrhcea, hoAvever, 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 Avomb, as in medullary cancer, caulifioAver excrescence, and the like, this kind of Aoav never comes from the cervix uteri. Where both these varieties of leu- corrhcea co-exist, as they sometimes do, you Avill generally succeed in curing the vaginal form first, and that Avhich depends upon endo-cervicitis afterAvards. If you can trace the origin of an attack of cervical endo-metri- tis to " taking cold," or to an epidemic infiuenza, no matter Avhat length of time has elapsed since the disease set in, you Avill do Avell 468 THE DISEASES OF AVOMEN. to prescribe the remedy or remedies that Avould have been suited to the primary disorder. Whatever remedy Avould have cured the "cold," the inAuenza, 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, likeAvise, 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 trustAvorthy 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 Avill adhere closely to this method of selecting the remedy in this class of cases, it Avill 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, inAammation, or derangement, they might indicate belladonna, atropine, apis mel., colo- For reflex ovarian disease. , . cynth, phosphorus, alumina, platina, chma, 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 stamp, or character, to the symptoms, it may be indispens- able for you to study the pathogenesis, and the For contingent disorders itii • /• , 1 n • • ,i of menstruation. published experience ot the profession Avith 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 complications the more For utero-digestive com- ■.. . plications. common remedies are nux vomica, chamomilla, arsenicum alb., mercurius, graphites, lycopod- ium, colocynth, veratrum alb., aloes, opium, sepia, carbo veo\, CERVICAL ENDO-METRITIS, ETC. 469 collinsonia can., china, sulphur, hydrastis can., the citrate of iron and strychnia, kreasotum, plumbum, pulsatilla, alumina, natrum mur., podophyllin, sesculus hip., nitric acid, and nux moschata. For those Avhich implicate respiration: phosphorus, bryonia, sanguinaria, calcarea phos., calcarea carb., sili- In utero-pectoral and re- i -i. , , . spiratory ailments. cea, iycopoaium, stannum, tartar emetic, lache- sis, hyoscyamus, drosera or dulcamara. For symptoms connected Avith the local and general circulation: veratrum vir., bryonia alb., stannum, apis mel., In coincident disorders j • •■_ -i • -i ., , of the circulation. digitalis, cactus grand., aconite, gelseminum, veratrum alb., naja trip., or belladonna. For the nervous symptoms, especially in those Avho are liable to Hysteria, almost any remedy in the Materia Medica might be re- quired. Most likely, however, you will find Bervourcromp^cltion1s.and what you Avant 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, hyoscyamus, camphora, ferrum, chimaphila umb., and the eupatoreum purpureum. When the rectal troubles predominate, Ave have aloes, podo- phyllin, nux vomica, sulphur, hamamelis, col- tom°r' euter°"recta symp" linsonia can., and the sesculus hippocasta- num. Do not understand me as recommending that these remedies shall be given consecutively, or Avithout 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 symptoms which, in the treatment of this A'exatious disorder, do really afford the most trustAvorthy 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 AVOMEN. 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 Avas obliged to again take her bed, because of prolapsus of the womb. Previous to the birth of her child she had some spinal trouble, Avhich was much aggravated after confinement,and her physicians diagnosed an abscess on the back over the right hip—for Avhich the hot iron was used and this Avas kept open for one year, for three years fol- lowing she Avas confined to her bed. She iioav complains of con- stant back-ache, and bearing cIoavii pain for a week previous to the Aoav, 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 SAvollen, red, and very tender, she has no leucorrhcea. The sound passes Avithout 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 Avomb; the scanty menstruation; the enlargement of the body of the cervix as a complication; the expulsive uterine pains in advance of the Aoav ; 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 Avomb and to the rent in the perineum. If the laceration ot the cervix played an important part in this case there must have been subinvolution Avith chronic metritis, and possibly cellulitis, and menorrhagia. Part Sixth. 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 Avhich I slmll 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 Avhich is co-incident Avith menstruation, sub-acute and chronic abscess of the mammary gland, and excoriated nipples. It happens that Ave can show you a number of such cases this morning. The first on the list is one of burroAving abscess of the mammary gland Avith a sinus. This is a very unfortunate condi- tio:., and one that Avill 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 Avhich is three months old. She complains of a " gathered breast,'' Avhich began to trouble her seven Aveeks ago, or Avhen the babe Avas five Aveeks old. She first noticed Avhat appeared to be a small "cat-boil" on the right breast, Avhich Avas not very painful and did not in the least interfere Avith nursing. It, however, contin- ued gradually to increase in size, and to become more tender. Three Aveeks ago her physician advised that it should be poulticed and afterwards freely lanced. The former part of the prescrip- tion was tried, but she avouIcI not consent to its being opened. As a consequence, the abscess broke at the end of another Aveek, and although it seemed but a small affair, discharged a large quantity of healthy pus. The orifice through which this fluid escaped has 471 472 THE DISEASES OF AVOMEN. continued to enlarge until it is noAV about the size of the nail of my index finger, and, only yesterday, she was startled by discoA'- ering that Avhenever the child nurses, or she sAvalloAvs anything, and sometimes when she moves the right arm, the milk escapes quite freely from it. Tavo days since, another "boil" made its appearance at the loAverand outer margin of the same breast, and noAV, 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 Aveak and feeble, Avith slight hectic, unrest, anorexia, and is Avithal very much discouraged. Unless it be located in the loose cellular tissue about the nipple, the mammary abscess Avhich 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 loAver 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 tAvo 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 revieAv, the extravasation and escape of milk is caused by a rupture of one or more of the proper lactiferous ducts, Avhieh are compressed during suckling, deglutition, and also Avhen 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 Avill succeed more frequently Avith the former than with the latter. They should be given in the sixth, or a higher potency, and the dose repeated eArery three to six hours. It has been claimed that the local application of the tincture of phoshorus in tepid or cool Avater is very serviceable also. The phosphorated oil of the shops Avill sometimes ansAver an excellent purpose as an external application. My practice has been, in most cases of this kind, to resort to the topical use of granulated sugar, Avhich is a simple and unobjection- able domestic remech'. Applied directly to the A domestic expedient. r , -i ,/»,• surface of the ulcer at the mouth of the sinus, whence the pus or milk, or both these escape, it stimulates fresh, healthy granulations, and closes the unnatural outlet. It oper- ates kindly and speedily, is a good antiseptic, and is always avail- able. It may be insinuated into the canal Avithout doing any pos- sible harm, or causing severe pam. If this simple expedient fails, you may inject a Aveak solution of tincture of calendula into the sinus by means of a clean ureth- ral syringe. And the same solution may also be applied over the ulcer at the site of the abscess. Calendula is sometimes wonder- fully efficacious Avhere there is considerable loss of the integu- ment, and Avhere an extravagant quantity of pus is formed. The old plan of slitting up these sinuses Avith a knife Avas cruel, barbarous and unnecessary. It is undoubtedly true that, in a majority of cases, these deep-seated abscesses once formed Avould seldom become sinuous and fistulous if they Avere promptly and properly opened, but this fault does not justify the subsequent slashing and hacking of these delicate organs. There is a proper time for all things, including the lancet. And the same is true of the caustic and astringent 471 1HE DISEASES OF AVOMEN. injections Avhich have been thrown into these passages hereto- fore. As in other abscesses that involve a considerable drain upon f he patient's strength, Ave must counteract the loss and fortify against it. This woman should have a good, nourish- ing diet of eggs and lean meat. Beef is prefer- able, and may generally be taken in the solid form. Of all vege- table substances Avhich are appropriate to cases of this kind, oat- meal is best. Bread made from unbolted wheat flour; — thus securing the phosphorus Avhich is contained in the hull of the grain, — is also advisable. According to Agassiz's theory con- cerning the large relative proportion of the same element in fish, we may sometimes select from this class of food. The fish should also be lean. Fresh air and sunlight, with freedom of the mind from all harrassing cares, are excellent and available tonics. Mrs.----will take of phosphorus 6th, a dose every four hours during the day. The granulated sugar to be applied tAvice daily, The diet to consist of broAvn bread and butter, and rare roast beef, Avith dry, mealy potatoes. She must nurse her babe from the left breast exclusively. The right one should, however, be well draAvn by means of a breast-pump each morning and even- ing, and then kept soft and Avarm. Let her report at the end of a week. ON AVEANING A CHILD, AND THE SUBSEQUENT TREATMENT OF THE MAMMARY GLANDS— GALACTOKRHCEA. Case. — Mrs. Z----, aged 30, applies for advice concerning the propriety of weaning her child, and likeAvise for instructions rela- tive to the best method of procedure if this expedient is deemed proper. The baby is eleven months old, and healthy in every respect, not having had a clay's sickness from its liirth. The mother's health is also excellent. The milk is furnished in good amount and quality, and although she really dreads to Avean the little one, she will nevertheless do so if it is thought best. By the advice of her former physician she nursed an elder child, uoav four years of age, until it Avas eighteen months old. Her infant feeds Avell, and, if it Avere allowed, would eat almost anything. It has a mouthful of teeth. She fears that Avhen she takes It from the breast altogether, she may have trouble with the glands them- ABSCESS OF THE MAMMARY GLAND. 475 selves. For she is somewhat peculiar in this respect, that Avith her the milk continues to be secreted for a long time after it has ceased to be regularly draAvn off. Thus Avhen she Aveaned her little girl, tAvo years and a half ago, the milk " continued to come into the breast," as she says, for four or five months longer, her menstruation being quite regular meanAvhile. And folloAving an abortion, that she once experienced at the fourth month, she had a considerable Aoav of milk for the space of nearly six months. For this reason she feels exceedingly anxious to knoAV Avhat course is the proper one. In the practice of your profession you Avill be frequently con- sulted in cases similar to this. You Avill observe that some mothers apply for professional sanction to Avean their Fashionable pretexts for ,.11 -, -1 • -1 -1 , the indiscriminate weaning children early, and, indeed, that many of them of infants. . prefer not to nurse their babies at all. These most unnatural and baneful practices are, unfortunately, becom- ing more frequent. In all our cities and toAvns — and in these days of railways and telegraphs there are no more country A'illages — 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 Avill 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, Avhile a fourth is uiiAvilling 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 Avhat is both natural and necessary for the Avelfare 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 SAveeten 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 OAvn children. They are never quite ready and willing to Avean them. If your future observation accords Avith my OAvn, you Avill have reason to conclude that, Avith many members of this 476 THE DISEASES OF AVOMEN. 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 Avomen to prolong the period of lactation. As a rule, menstruation is suspended until the iii effects of too prolonged c]^}^ js taken from the breast. This they all lactation. know as well as we do. They are also aware that, while the nursing Avoman 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 Avill 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 The proper time for wean- casem?— a physiological reason Avhy 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 Avill be little risk in weaning it. It "will, hoAvever, be more safe for the child to cease nursing in cool or cold weather, as in the fall or Avinter, 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 Avait 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 coav's milk for the infant, may afford another valid reason for prolonging lactation eAen beyond the twelfth month. Statistics prove that after the ninth month, Aveaning is more apt to be folloAved by mammary abscess than at any period betAveen the second and ninth months. In the case in which Ave 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 Aveaned. Treatment. — And noAV 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 Avhich the breast is draAvn, or emptied; the more it is nursed, the greater the yield. But in this case a profuse Aoav 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 Avill avert such a calamity. For it is a species of martyrdom for any Avoman to suffer from an abscess or abscesses of the mammary gland, and Ave should use our best endeaA'ors to spare her such an infliction. Where, as in this instance, the flow of milk is A'ery profuse, and especially if the child is several months old, I think the wiser course is to Avean it gradually — say to nurse it only at night for a time, and to feed it dur- ing the day. This plan Avill prevent the accumulation of a very large quantity of milk in the breasts, and also alloAv the general organism to accommodate itself to the neAV 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, Avhich 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. AfterAvard, 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 Avhich are believed to have the poAver of lessening the quantity of milk secreted are termed Anti- galactlcs. They are used both internally and externally. Of those Avhich are adapted to internal use the more 478 THE DISEASES OF AVOMEN. prominent are belladonna, bryonia, calcarea carbonica, and phos- phorus. Besides these, other remedies are suited to lessen a redun- dancy of this Aoav, when it is attended by peculiar symptoms, all of Avhich 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 you in the lecture-room. In general, the younger the child the greater the danger of mammary abscess from Aveaning it. There are, hoAvever, 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 Avithout incurring the risk of this accident. When, a physician tells you that he has ahvays 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- T , ,. . pose. Cloths may be Avet with the common Local applications. tincture and applied directly to the breast. Or it may be anointed with a mixture of camphor and SAveet 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 Avater, as a preventive against mammitis and mammary abscess in cases of this kind. I have no experience thereAvith. They recom- mend to apply a Avet compress directly over the gland, and to pro- tect the clothing by a dry one outside. This is to be reneAved 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 coArering the breast Avith one or more layers of flannel, and then applying a bladder which is partly filled with broken ice. Persistent rigors and chilliness, hoAvever, contra-indicate the use of cold applications of all kinds. A stimulating lotion may also be made of black pepper {Piper nigrum'), by permitting it to stand for a considerable time in good brandy. The pepper should, hoAveArer, be in the grain and not ground, or pulverized, otherAvise, 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 Avill 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 Avhich 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 Avith the extract of belladonna.* He has em- ployed this treatment for the prevention of mammary abscess Avith almost uniform success in 44 cases, in Avhich 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-Avork supporter, or by strips of adhesive plaster properly applied. Means of support for the These plaster-strips are sometimes used to breasts. r 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 Avould not be best for her to drink largely of any fluid Avhatever, more especially of water or malt liquors. She will take a dose of the calcarea carbonica every nioht, and apply the camphorated oil externally. * Transactions of the Obs. Society of London. A'ol. I., p. 31. 480 THE DISEASES OF AVOMEN. EXCORIATED NIPPLES. The next case on the list this morning is one Avhich has corneas an inheritance from the puerperal state, and Avhich will have its counterpart to y i 1 j sterility. which is sometimes profuse, and has continued for tAvo years, came from the uterine cervix, in all probability she Avould have remained sterile; for, as I shall doubtless have occasion to show you, this form of leucorrhcea is a frequent cause of barrenness. And, besides, had it been uter- ine, and not vaginal, there would surely have been a partial or complete arrest thereof during pregnancy. Sometimes, hoAveArer, both varieties may exist conjointly, or they may even alternate in the same patient. Treatment. — In all cases of leucorrhcea Avhich are incident to gestation and lactation, you should bear in mind that the blood is being drained of its assimilable material for the groAvth of the offspring. For this reason it is sometimes quite impossible to cure the affection radically until these functions have ceased by limita- tion. In either case, indeed, the leucorrhcea may be critical, and it might therefore be injurious either to mother or child to arrest it while these processes are going on. This is a forcible argument against the use of astringents which are designed to seal up this Aoav, and to close a species of safety-valve to the general economy. There are two reasons that may justify, and eA'en necessitate, the weaning of the child for the cure of a leucorrhcea Avhich is incident to the nursing period. If the draught Weaning the child. , to upon the mother s resources Avhile nursing, undermines her strength, it furnishes a cause for this disease which is constant in its operation, and which can only be removed by putting the child aAvay from the breast. And Aveaning is still more strongly indicated if the child Avas large and plump at its birth, and the leucorrhcea continued during pregnancy also. Be- sides, the safety and welfare of the infant may require that it shall be brought up artificially, rather than upon the unhealthy milk that is furnished by the mother. Not unfrequently the cure is half performed Avhen you have prevented a Avaste Avhich only Aveakens the mother and injures the child. Stop the leak, and her strength may soon return. For it is a condition of healthy glandular activity, that the blood must be nourishing and stimulating to the glands as well as to other bodily organs. LEUCORRHCEA AND THE LACTEAL SECRETION. 493 It is no less important to select a suitable diet for this patient, than to decide upon the appropriate remedy for the symptoms presented. Indeed, the rational method of pro- cedure would be, first, to supply the physio- logical conditions that are requisite to health, in order that our curative agents may afterAvards act more promptly and efficiently. Granted that, in the case before us, the function of the mesenteric glands is so impaired that they fail to effect the proper changes in the peptones brought to them from the boAvel. The indication is to choose such an aliment as by their aid may be assimilated. The Avhites of eggs, lean meat, sea-food, as oysters or other shell-fish, or good fresh milk, are more easily digested and disposed of, and also more nourishing, than a mixed diet largely composed of fatty substances, soups, and the like. It is quite as necessary to dis- criminate carefully in this class of diseases, and to alloAV only such food as Avill be kindly received and appropriated, as it is in the case of the infant, Avhose digestion is very weak, and Avhose ali- mentary system is easily deranged. Sometimes the vegetable acids are not only grateful, but really beneficial. The patient may eat grapes, oranges, tomatoes, or baked apples, or she may drink a mild Avine, or an occasional glass of lemonade. Noav and then the most excellent results are obtained from travel, partly because of the change of scene and surroundings, but also, as the phrase is, "from change of pasture." The same food, cooked differently, may be more acceptable to the stomach of an invalid, and less harmful in every Avay, than if she had remained at home and eaten it from the same dish and table as before. But let us inquire if there is any means whereby the important function of lymphosis may be stimulated and encouraged. The salts of potassa, soda, lime, alumina, baryta, Lymphatic stimulants. . • t • i i i , i iron, iodine, ammonia, phosphorus, and other earths and metals, are all more or less intimately related there- with. As prepared by the pharmaceutist, or in the form of mineral Avaters in the great laboratory of Nature, they have long been employed for the cure of all the principal disorders of nutri- tion. And the almost universal record of the good results so frequently obtained from them, leads us to conclude that empirical observation cannot have gone A-ery far astray in this matter. The hint, at least, is significant. Clinical experience confirms their 494 THE DISEASES OF AVOMEN. value in the treatment of leucorrhcea. A majority of the reliable remedies for this disease are of mineral origin. And each of them has a specific, pathogenetic, and curative relation to the lymphatic glands. It is for this reason, doubtless, that they are most serviceable in the treatment of scrofulous and catarrhal affec- tions of almost every kind. Although these clinical generalities are both analytical and suggestive, they should not be allowed to substitute a more care- ful selection of the appropriate remedy or remedies. We must choose from among all those named, and many more beside, the proper simillimum for the more prominent symptoms complained of. If you will turn to the pathogenesis of calcarea carbonica you will find it. The indications for this most excellent remedy are so positive and almost mathematically exact, that we need look no further. It is called for by the milky leucorrhcea, with aching in the vagina, and itching in the pudenda, with increased flow after exercise, and also in the case of a woman Avho is subject to a too copious and oft-recurring menstruation. In prescribing the calcarea carbonica in similar cases, and in- deed ordinarily, my own preference is for the third decimal tritu- ration. And, while I do not question the efficacy of the medium and higher preparations thereof, my experience is certainly opposed to the theory which holds that no curative effect can be obtained from this remedy unless it be given in the sixth or a higher potency. Mrs.----Avill take one-and-a-half grains of the third trituration of the calcarea morning and evening, and report at the end of a week. LOSS OF THE NIPPLES FROM ERYSIPELATOUS INFLAMMATION. The notes of the folloAving remarkable case were sent to me by one of our cleverest graduates, Dr. E. E. Holman, of Warren, Illinois, in June 1880. Case.—Mrs. H., a primipara avIio was confined two months ago by a midwife, seemed at first to do Avell; but in a fcAv days the nipples became perfectly raAv from nursing. The midwife did nothing for them. The application of the child to the breast, caused the mother so much pain that her husband Avas obliged to hold her Avhile it nursed. This process Avas continued until both nipples came off", after Avhich the milk flowed constantly. Ery- sipelatous inflammation set in which spread over both breasts and AN.EMIA FROM LACTATION, ETC. 495 down to the hips, Avherever the milk kept the clothes Avet. The baby had been Aveaned. The inflammation Avas almost entirely subdued by the internal use of belladonna. 'The patient had a good appetite and her gen- eral health Avas fair, although she is of a scrofulous diathesis, and her lungs are not very strong. Glass nipple-shields Avere used to protect the breasts from the constant flow of milk. They Avere kept in place by a closely fitting waist, Avhich was avoiti day and night. The local application of camphorated oil Avas persisted in until there Avas no further secre- tion from the glands. At first, hoAvever, plain cosmoline Avaa used until the surface had healed over. The nipples—or rather Avhat remained to tell that they had once existed—bathed as they Avere in the milk, did not heal until lacta- tion had ceased, Avhen they healed rapidly under the topical appli- cation of pulverized gum arabic. (I have never failed Avith this as an application for sore nipples, even Avhen other means have been ineffectual.) After the erysipelatous inflammation had been controlled by the employment of belladonna, calcarea carb. 6, four times per clay Avas the only remedy given. The menses came at the proper time, and the patient enjoyed as good health as ever before. AN.EMIA FROM CONJOINED LACTATION AND MENSTRUATION. Case.—Mrs. M., aged twenty-six, has been ill for ten months, or since her only child Avas tAvo months old. She complains of pain in her chest, and of a copious leucorrhceal Aoav Avhich is Avorse in the inter-menstrual period, and is aggravated by the least exercise. Her menses are regular, not too copious, but have con- tinued to recur since the babe Avas two months old, she nursing the child until its death, at six months. China 3, four times a day. May. 19. She is feeling better, but has some chilly, creeping sensations. The leucorrhcea is less free. China 3. May 2(5. On local examination in presence of the sub-class, Ave find the uterus measuring four inches in depth, and a slight endo- cervicitis. China 3. June 2. She presents herself Avith a good report having, " nothing to complain of." She feels strong and Avell again. Her color is very much improved, and she is advised to report for another local examination after the next monthly period. It is practically burning the candle at both ends for a mother to persist in nursing her child Avhile she is menstruating. This woman's menses returned before the involution of the uterus was completed. When they came, the natural and necessary effect 49G THE DISEASES OF AVOMEN. of lactation to divert the blood from the pelvis, and to stimulate the uterine contraction, like a battery, was suspended; besides, the double drain in the flow of the milk and the menses, reduced her strength and impoverished her blood, if it did not actually poison her child. The increased depth of the uterus Avhich you all can verify, is the result of these combined causes. You have seen that, in this case at least, it does not depend upon a laceration of the cervix. UNILATERAL NEURALGIA FROM PROLONGED LACTATION. Case.—Mrs. C, aged tAventy-eight years, has had tAvo children, t he youngest of Avhich is a large, strong boy, uoav eighteen months old/ She still nurses this child, but only on the left breast, the milk having disappeared from the right breast only because the child Avas ahvays applied to the other one, a habit Avhich greAv out of his lying and dragging at the nipple all night. The patient is very weak, and,'in the morning especially, sometimes leels so exhausted that she can scarcely get up. When her baby was four months old she began to menstruate, and this function has repeated itself, at first irregularly, but of late the Aoav has been regular, although more copious than it Avas formerly. Her chief complaint is of a pain in the left chest passing beneath the breast and extending through the thorax to a point below the corresponding scapula. It also passes cIoavii the left arm, Avhich sometimes feels so Aveak that she can scarcely lift it. This pain, Avhich she has had for six months, is sharp, catching and spasmodic in character, unaffected by respiration, not at- tended by cough, palpitation or dyspnoea, but is ahvays aggra- vated by the child's nursing, especially at night. She is pale, salloAv and dragged out, Avith the appearance of having been ill for a long time. Here Ave have an illustration of the fact that one condition of secretory activity in the mammary gland consists in the applica- tion of the child to the breast. • This Avoman nursed her baby exclusively on the left side because it avus more coiwenient, as it ahvays is, and because the little youngster could lie there and pull at it all night long. It also confirms Avhat I have so often told you of the ill effect of nursing and menstruating at the same time. The evil conse- quenccs are not ahvays identical, but they are inevitable. In the case which has just left us, there Avas a decided anaemia; but here EXTRAORDINAR Y LACTATION. 497 we have a local and persistent neuralgia that is directly referable to prolonged lactation under peculiar circumstances. The points that I Avant to make for you are these: (1), that a little reflection Avill prevent you from confounding such a case as this with pulmonary or cardiac difficulties; (2), that the exercise of a little good sense in the regulation of the patient's habits is indispensable to a cure: (3), that since Ave cannot arrest the menstrual function at will, Ave must wean the child to stop a further waste; and (4), the affiliation of the remedy is an affair of secondary importance, for Avhen the proper conditions for the Avoman's health are supplied, the neuralgia will usually disappear of itself. I Avill close this lecture by citing the following case Avhich was reported in the ^V. E. Medical Gazette for April 15, 1867, by Dr. Wm. Pearson, of Mass.: EXTRAORDINARY LACTATION. Case.—Mrs. D., residing in Vermont, aged twenty-eight, had been married ten years, and enjoyed good health, but had never borne children, or had any signs of pregnancy. She began to have morning sickness in August, 18.34, and menstruation gradually ceased three months later. In January following, the morning sickness subsided; but she had a feeling of general languor, and soreness in the region of the right ovary. She had " motion plainly to be felt and seen," she said. About this time the mam- mary glands began to have more than the usual tenderness and fullness, and in February the breasts Avere full of milk to over- AoAving; and in fact, she had all the usual signs of pregnancy in the last stage. About the first of March, she Avas " taken Avith slight flowing," which continued a Aveek or more attended Avith pains like those of labor; and a physician Avas called to attend to her case, Avhich he thought very peculiar. These symptoms gradually passed off; and, in about three Aveeks, she had a similar attack of pain and flowing. The secretion of milk continued as before; but she had no expulsion of any substance from the uterus, either this time or ever afterAvards. Subsequently her usual monthly periods became established; but she continued to have a large Aoav of milk, and was obliged to have it draAvn by some means. In the course of a feAV Aveeks, a child Avas presented to her by a gentleman who had the misfortune to lose his Avife in confine- 32 498 THE DISEASES OF AVOMEN. ment. She nursed the child from month to month, and gradually diminished in size, and recovered her usual health and strength. The lady is still living, in good health, with the exception of occasional attacks of colic, and severe spasms in the region of the liver, probably from biliary calculi. In a practice of more than thirty years, I have never happened to see another such case, and how to account for this I know not. This was evidently a remarkable, and a very unusual freak of Nature, for Avhich, since the function of ovulation was intact meanwhile, no valid reason can be assigned. If the uterus had contained a foreign body, the delivery of which had been brought about as in natural labor, there would have been a physiological reason for it; but the circumstances as related cannot be ex- plained in any such way. Part Seventh. THE DISEASES OF THE CLIMACTERIC. LECTURE XXXI. THE CLIMACTERIC PERIOD. The Menopause ; the disorders of,—the diseases that tre cured by it. Symptoms; Case, diagnosis ; prognosis; treatment. Hysteria at the climacteric. Hysteria in a woman aged sixty. The period at which the menses cease is sometimes styled the " change of life," the " grand climacteric," the " critical age," the " turn of life," and the menopause. It indicates the close ot a woman's menstrual, and therefore of her sexual life. When that life has continued for thirty years or more, Avith its monthly vicissitudes, Avhich have been interrupted only by pregnancy, lacta- tion or disease, it is natural to suppose that its final arrest will be beset by contingencies of a peculiar kind. The diseases of the cli- macteric possess a peculiar interest for the physician, more especially because they are intricate and difficult of cure, and because they concern a very important class of his patients. If it is important to tide a patient over the difficulties that are proper to the crises of which we have spoken, it is none the less so to protect her at the climacteric. The clinical interest Avhich centres in her as a sexual being culminates at this period, and there is no better evidence of our civilization, and of our professional capacity than is to be found in the care Avhich Ave bestoAv upon Avomen at this time, and under these circumstances. The age at Avhich this period arrives in woman Araries as much in different individuals as does that Avhich dates the advent of puberty. Indeed it bears such a general rela- tion to the early or late establishment of the menstrual function that Ave ordinarily estimate from puberty to 49r 500 THE DISEASES OF WOMEN. determine Avhen the catamenia should naturally cease. Thus, the usual duration of menstrual life is thirty years. If our patient Avas " unAvell" for the first time Avhen she Avas Duration of menstrual jjUt thirteen years old, and Ave add thirty to that number, we shall have forty-three years as the most natural limit for the return of the monthly cycle. If, instead of beginning at thirteen the function had failed until she Avas fifteen, then she would most naturally continue to menstruate until she had reached the age of forty-five years. But this calculation is approximative, and not exact. We must make alloAvance for modifying, circumstances of various kinds, among which hereditary peculiarities are, per- haps, the most marked. There are families in which all the women cease to menstruate prematurely at as early an age as thirty, others at thirty-five, and still others in whom the menopause is adjourned until fifty, or even to the 60th year, Avhen it degenerates into a species of sexual haemorrhage. In these cases the advent of the change of life bears no particular relation to the age of the individual at the time that puberty was estab- lished. It not unfrequently happens that those avIio begin to menstruate the earliest continue to do so for a longer period than those who began later in life. Physiologically considered, the " change "' which closes and terminates a most important function of the female economy, is truly an eventful and a marvelous one. It must Importance of the change. , work such a complete revolution as to invest this crisis with numerous contingencies. For this function, Avhich represents the maternal instinct and relation, which made it pos- sible for the Avoman to become a mother, Avhich Avas suspended Avhile the child was being developed in utero, and Avhile she nourished it at the breast; and Avhich Avas restored again in due season, is not one that can be begun, continued for so many years, and then stopped, Avithout great expense and risk to the general organism. Hence Ave find that the approach of the climacteric predisposes Avomen to various diseases Avhich are of a more thfsrperiod'ition incident *° or less serious nature. And, what is very strange, it not unfrequently happens that the disease from Avhich they may have suffered at puberty re- THE CLIMACTERIC PERIOD. 501 turns. It is so in the case before us. The class of affections which are most likely to recur in this manner are eruptive and nervous disorders, and haemorrhages from certain mucous mem- branes. In cases of this kind, it may happen bertymi^retum"1t0 P"~ ^m^ man)' years have elapsed Avithout any sign of the difficulty, but Avhen this change begins to take place the first symptom noticed is the reappearance of the old enemy. Very nervous and plethoric women are more likely to suffer in this manner, and indeed to be ill, at the change of life, than those Avho are of a lymphatic temperament. But in this respect the menopause is not absolutely or always in relation with puberty. Very often the experiences that have intervened since the Avoman first began to men- New disorders induced. .. . n .. , i i struate have so changed her nature that she has acquired a predisposition to other and different diseases. Preg- nancy, labor, and lactation, leave their impress upon her organi- zation, and it is as impossible for her youthful susceptibilities ahvays to return, as it would be for her to become the same in feeling after the change of life that she was in her girlhood. Another peculiarity worthy of note is that many diseases are cured, or disappear in consequence of the climacteric. The ova- rian atrophy and paralysis removes a constantly Old diseases cured by. . „ ,. „., . . recurring source ot disease. 1 he monthfy cycle and its attendant excitement of the nervous, vascular, and glandular systems is withdrawn. A season of continued quiet, and comparative tranquillity supplies a favorable condition for the restoration of health. And when the critical period has passed it is found to have been the scape-goat of a thousand ills. Slender women may become corpulent and even obese, bed-ridden invalids get up and Avalk, and an entire and radical change of physical condition is the consequence in those who escape the perils of this period. They enter upon a new phase of life, with new hopes and relations towards the present and the future. Symptoms. — The manner of approach of the critical period varies in different individuals. With some women the change is abrupt, but with the majority it is more prolonged and gradual. Not infrequently the flow becomes intermittent, or, rather, the periods become irregular. One, two, three, or perhaps six months, and sometimes a year or more, may elapse between them. 502 THE DISEASES OF WOMEN. In many cases they are too frequent, as well as too profuse, for a season, and afterwards are more tardy and abnormal in this respect. In a considerable proportion of cases the amount of the flow lessens gradually, so that it may finally come aAvay 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 obserA'ed that 208 had haemorrhages of various kinds. Of these, 138 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, haem- atemesis, haematuria, bursting of varicose \eins, 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, Avhen the change comes on abruptly, and more especially in those Avho are in good health, is often the occasion of alarm Avith such Simulates pregnancy. persons lest they be pregnant. This 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. 503 attacks are self-limited, and subside of themselves when the crisis has finally passed. In a few they supplement the catamenial Aoav, 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 circuia- coldness, tingling and numbness of the ex- 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. 111/^1 , o j 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 folloAv 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, Avhich is most difficult of cure. The ganglionic nervous system is always impli- cated. There is a form of epilepsy AA'hich is not unusual at this period. I have seen several cases of the kind that Avere in no Avay connected Avith the hereditary form of this disease. Only yesterday I Avas consulted by my friend, Dr. W. R. McLaren, for the relief of the folloAving Case. — Mrs.----, aged forty-five, is iioav passing through the grand climacteric. The menses recur every four to six months. They are quite profuse. About every seven Aveeks 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, Avith 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 Avith her one year ago, at Avhich 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 Disorders of the special ^he skin are among the more common of these senses. ' o affections. These complications are most apt to occur in weakly, nervous, debilitated women in Avhom, for some reason, the climacteric is Aery much prolonged or exhaustive. The respiratory system comes in for its share of the contingent ailments. Those Avomen especially who are predisposed to pecto- ral complaints, who inherit this bias, and Avho sy^temasesoftherespiratory'naYe 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 Aveeks. In others they subside of themselves when the first cause is removed, and the menstrual crisis is safely OArer. In not a feAV 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 wrould 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. tiv°systeem.°f thegenera~ Thus Dr. Tilt* found that of 500 women at the 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, leucorrhoea, 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. chat., p. 82. THE CLIMACTERIC PERIOD. 505 abscess, and haematocele. And still another disease of the generative system, properlv speaking, is cancer Incidental diseases. ' ** , 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 Avhich worries them exceedingly, and may perhaps Avear aAvaA' their remaining strength very Rheumatism and neuralgia. . t i rapidly. Again these affections are combined, and either or both of them may be located Avithin the pelvis. The arrival of the critical period may act as an exciting cause, and really occasion an attack of rheumatism in one avIio not only has never had it before, but Avho Avas 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 folloAv it almost immediately, you Avill be puzzled in your prog- nosis. Eminent authorities are of opinion that The general health the ^g 0Variaii 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 Avill be a safe criterion upon Avhich to base an opinion if Ave 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 alloAvance for previous ill health, and to qualify our prognosis; for it is a crisis through which the woman must pass, and Avhether she will survive it or not, will depend very largely upon the stock of strength that she has in reserve to be°'in Avith. 506 THE DISEASES OF AVOMEN. 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. , ,. . -. , n need to be eliminated, but because of an over- whelming afflux of blood to a delicate tissue or organ, Avhich may 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. . of the alimentary disorders, of wrhich I 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 ot 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 Avears upon a Avoman avIio has reached the turn of life like a Avant of sleep, of rest, and of freedom from the petty cares and annoyances Avhich she could once overcome by her OAvn strength of will. She should be encouraged and stimulated by cheerful society, and pleasant intercourse Avith a feAV friends. Her thoughts should not be introverted. She should not be permit- ted to brood over such reflections as Avill make her nervous and Avretched, 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 Avhich she is predisposed. If she is liable to haemor- rhagic attacks from plethora, let her diet be pre^sposmons5.1 herediury V^n an(l unstimulatiiig, her habits as active as possible Avithin 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 of nitric acid, china, arsenicum alb., secale cor., sabina, crocus, trillium, erechthites, pulsatilla, ferrum met., and carbo A'egetabilis. Cool acidulated drinks ought ahvays 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 ahvays alarm- ing and frequently dangerous, especially at this time of life, the possibility that the patient may pass almost Piuhisishe tendency t0 insidiously into a decline from tuberculosis in some of its forms, renders it necessary to antidote this predisposition Avhenever 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 Avet, to go out in a storm, to wear insufficient clothing, no matter hoAV 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 Avomen are in the habit of doing. Such a patient should not be removed from her old home into a neAV house, for example, in Avhich the Avails are not dry. In brief, Avithout being fussy, she should take unusual care of her health at this period, for a slight indiscretion, or an otherAvise 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 avIio 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, ahvays giving pref- For the digestive disorders. , . .. , ,, erence, however, Avhen possible, to those reme- dies that have a curative relation to the generative, as well as 508 THE DISEASES OF AVOMEN. to the alimentary function. Nux vomica, colocynth, arsenicum alb., mercurius, pulsatilla, natrum mur., bryonia, calcarea carb., cocculus, A'eratrum alb. and veratrum vir., chamomilla, sulphur and belladonna belong to this class. The diet should be regulated with the greatest care. The Avonderful 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 cir^uiat'ioendisorders °f the remedy. Other available remedies of this sort are veratrum viride, gelseminum, and bella- donna. They are not only indicated physiologically and patho- genetically 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, Avhich 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 demand such remedies under almost the same identical indications, as Avould be prescribed for them if they were incident to the more com- For the nervous symptoms. mon menstrual disorders, as for example, dys- menorrhcea, amenorrhcea or menorrhagia. Belladonna, ignatia, hyoscyamus, coffea, chamomilla, moschus, pulsatilla, caulophyl- lin, macrotin and senecin, are most freely indicated. And so likeAvise of diseases of the generative organs that are incident to the critical period. The rules which I have so fre- quently repeated Avith reference to their medi- generadveedssy°srtdernrs °f the cal and surgical management should be carried out in practice Avith even more than ordinary care and skill. Whatever can possibly interfere Avith 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 PF.R10D. 509 is passing, quite as decidedly as the cessation of the Aoav 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 begun, to cure it and remove its consequences as speedily as possible. For the rheumatic and neuralgic complication, macrotin, rhus For rheumatism and tox" atropine, the valerinate of zinc, mercurius, neuralgia. anc\ 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 dniAvn from my clinic, illustrating the date of the menopause and showing the relative frequency of the diseases that accompany and folloAv it. Of these fifty cases, it will be observed that the age at Avhich menstruation ceased, Avas beloAv forty in two cases; between forty and forty-five, in fifteen cases; betAveen fortv- Age at decline. ~ , ' . * five and fifty, in twenty eases: betAveen 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 Avhich the patients Avere suffering Avhen they came to the clinic, and Avhich Ave re post-cliuu cteric, there Avere seven cases of dyspepsia, six of apoplexy, Relative frequency fi f rheumatism four 0f procidentia of the of disease. ' l uterus, three of headache, tAvo of anasarca, tAvo of gastritis, tAvo of epithelioma of the cervix, tAvo of prolapsus uteri, and one each of asthma, epistaxis, bronchocele, Bright's disease, dyspnoea, papular eruption, incipient paralysis, hemiplegia, haemorrhoids, 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 Avill 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 Avould be by puerperality if they occurred after child-birth. ANALYSIS OF FIFTY CASES, TAKEN FROM PROF. LUDLAM'S CLINIC, ITS SEQUELAE. POST-CLIMACTERIC DISORDERS. 1 2 3 4 5 6 7 8 9 10 11 12 n 14 15 16 17 18 19 20 21 22 23 24 25 6109 6113 6155 6279 6298 6309 6367 6439 6475 6468 6512 6513 6554 6599 6629 6937 6721 7118 8213 7276 7379 7423 7501 7540 7607 Epithelioma ot the cervix Dyspepsia................ Chronic gastritis......... Atonic dyspepsia......... Chronic dyspepsia....... Anasarca................. Procidentia uteri......... Hemiplegia............... Metrorrhagia............. Procidentia uteri......... Papular eruption......... Asthma.................. Headache............... Uterine fibroid........... Apoplectic tendency...... Uterine epistaxis........ Apoplectic tendency...... Ovarian dropsy........... Apoplectic tendency...... Articular rheumatism___ Dyspepsia................ Hemorrhoids............. Incipient paralysis....... Epithelioma of cervix..... Dyspnoea................. 46 26 48 42 27 28 47 29 46 30 51 31 50 32 48 33 43 34 43 35 43 36 47 37 50 38 46 39 ,S6 40 48 41 47 42 55 43 41 44 51 45 52 46 38 47 48 48 30 49 47 50 SHOWING THE DATE OF THE MENOPAUSE POST-CLIMACTERIC DISORDERS. Hemoptisis, Post-Menstrual headache......... Rheumatism................... Rheumatism.................... Rheumatism.................... Prolapsus, vviih vesical irritation Epistaxis......................... Apoplexy......................... Tuberculosis..................... Anasarca........................ Chronic vaginitis................. St anal irrilation.................. Procidentia for seventeen years.. Gastritis.......................... Prolapsus uteri.................... Dyspepsia........................ Congestive headache............ Apoplectic tendency............. Dyspepsia........................ Bronchocele...................... Procidentia for nineteen years... Bright's disease.................. Rheumatism..................... Dyspepsia........................ Apoplectic tendency.............. THE CLIMACTERIC PERIOD. 511 HYSTERIA AT THE CLIMACTERIC. Case.—Mrs. S----, a strong, healthy-looking woman of 50 relates the following history: She Avas taken ill while pregnant Avith her sixth and last child, fourteen years ago. This illness she attributes to neglect and unkind treatment on the part of her hus- band. Despite much trouble, suffering and anxiety, she Avent to term, and her child is still living. Her chief symptoms Avere a feeling as if she Avere dying, Avith great prostration, sinking, chok- ing at the throat, and partial unconsciousness. She would Aveep and sob for hours together, and her gloomy feelings could not be dissipated. These attacks came irregularly, but increased in severity toAvards the close of gestation. Two years later an eruption resembling " salt rheum " made its appearance on the riffht arm, above the elbow, and on the same side of the neck. The cropping out of this eruption, which is Averse in cold weather, Avas folloAved by manifest relief of the ner- vous symptoms. She soon remarked that when it Avas out most frequently, she felt best in other respects, and vice versa. This alternation has continued for tAvelve years. Whenever the erup- tion disappears, the nervous symptoms are very distressing. Menstruation continued regularly until four years ago, the patient at that time being forty-six years old. It then began to be irregular, sometimes being absent for two, three, or even four months, and Avhen it returned, it Avas liable to be profuse and long- continued. Twice she Avent only two Aveeks between her periods. Once, as they did not return from October to the following July, she supposed that they had entirely ceased. I have brought this patient before you to illustrate the possible relation betAveen a cutaneous eruption and the existence of hys- terical symptoms. For tAvelve years this erup- skm disease and ti(m hag alternated with intractable nervous hysteria. symptoms, more alarming than serious. She has been questioned very thorougl}', but Ave cannot learn that she ever had any eruption which had been repelled prior to the date of her present illness. Nevertheless, the evident relation betAveen the disease of the skin and the other symptoms complained of Avill not be doubted. Repelled eruptions are, in general, more likely to produce some structural disorder of the mucous membranes than to give rise to functional or organic lesions of the nervous system. But instances are not Avanting in which'serious neuroses, as, for example, insan- ity, epileps}', paralysis, and neuralgia, have been due to this cause. 512 THE DISEASES OF WOMEN. And so, a'so, Avith hysteria. I have seen the most obstinate cases refuse to yield to the best affiliated remedies, because they origin- ated in the repercussion of some apparently trifling eruption. If you Avill take this clinical hint at its proper value, it may be of great service to you bye and bye. These cases are exceptional, it is true, but such a one may be the very first on the list of your private patients. The menstrual irregularity in this case is referable to the critical period through Avhich the patient has been passing during the last four years. Treatment.—We should, so far as is possible, ascertain the especial nature of the eruption Avhich has caused, or is so nearly .related to, the disorder for which Ave are to Character of the erup- . T . . , - . tion may indicate the prescribe. Is it vesicular, papular, pustular remedy. A or squamous? Has it ahvays preserved the same character? Does it itch, or burn, or Avhat are its peculiar sensations? What accidental circumstance is likely to bring it out, or aggravate it? These and similar inquiries may influence the choice of the remedy, "especially in chronic cases. The key to the cure may be found through them. The increase of duty in the enunctory function of the skin, and the increased determination of blood to the cutaneous surface at the climacteric, tends to reproduce such latent eruptions and humors as may have disappeared and been forgotten during men- strual life. It is not an uncommon thing for women to suffer from rashes and eruptions instead of the flushes of heat, the per- spirations, or the coldness of the surface of Avhich the majority of 1 hem complain at Avhat is often called the " doclging-time." If these eruptions are generally distributed they may be critical and salutary, in Avhich case they should be treated kindly, and not repelled by the use of harsh, or astringent applications; but, if they are limited to the external genitals, more especially if they persist, and are accompanied by an intractable vaginitis, there is reason to fear that they are either of a specific or of a malignant character. In this case the eruption Avas originally vesicular. Each time it reappears a crop of vesicles forms. They soon break and dis- charge, and the serum dries and forms a yellowish crust. This is followed by slight itching, especially Avhen the part is exposed to the air. THE CLIMACTERIC PERIOD. 513 These symptom indicate rhus tox., and it alone may be suffi- cient for the cure, not only of the eruption, but of the incidental affection also. I prefer the thirtieth attenuation of this remedy for chronic cases. In exceptional cases, it ansAvers very Avell to alternate two potencies of this remedy, as for example, the third and the thirtieth. If the rhus fails, we may give sulphur in a similar manner. Mrs. S. Avill take a dose of the rhus tox. 30th, every morning and night, and report intAvo Aveeks. She must be careful to avoid pastry, spices, fats and indigestible food of all kinds. And also to forbear applying any Avash or ointment that might repel this eruption and increase the difficulty. HYSTERIA IN A AVOMAN AGED SIXTY. Case.—I Avas called, during the night of August 20, 1857, to visit Mrs.----, aged GO. She Avas in a semi-conscious state. At intervals of from two to five minutes she had spasms Avhich affected chiefly the neck and superior extremities. During these spasms both the fingers and the Avrists were very much flexed. The arms and hands trembled constantly. The pulse continued quite regular and uniform, both during the paroxysm and in the interval. The eyes were slightly suffused, but otherwise natural; the pupil being neither dilated nor contracted. When the parox- ysm subsided, she became very restless, and moaned and Avept immoderately. I observed that by directing the conversation to other matters, leaving her condition and surroundings for foreign topics, the duration of the interval between the fits could be con- siderably prolonged. She had been very much exercised and ex- cited over the proposed marriage of a daughter, to which she was opposed, and for three days had neither slept nor eaten. I ordered a cup of strong coffee—for I knew that she could not drink this beverage, in health Avithout becoming exceedingly nervous and Avakeful. Of this she took tAvo teaspoonfuls once in ten minutes. She had only a slight spasm after the first dose, and in half an hour had fallen quietly asleep. The next morning she felt greatly refreshed by her night's rest, but Avas still somewhat Aveak and exhausted. She had an indis- tinct recollection of my having been in her chamber the night pre- vious, but knew nothing of having taken the coffee. I ordered tea instead of coffee, a generous diet, and for the future less excite- ment and fatigue. She recovered promptly Avithout meclizine. As a rule hysteria occurs only in those women who have not 33 514 THE DISEASES OF WOMEN. ceased to menstruate. Occasionally, however, Ave meet Avith well- marked examples thereof before puberty, and Hysteria incident to men-after the climacteric. It is rare to find an strual life. example of this strange affection in one avIio is more than fifty years of age. I Avill not detail the clinical history of this disease at the present time, but direct your attention to one or tAvo points of practical interest in the case before you. We make a distinction between spasms and convulsions, which it Avill be well for you to bear in mind. Spasms are not necessa- rily, or even generally, accompanied by an entire Spasms or convulsions ? „ . „,. . . „ . loss of consciousness, lheir manifestation is local and temporary. They leave the patient quite decidedly, and she becomes almost, if not altogether, rational in the interval. Convulsions, on the contrary, are soon, if not from the outset, characterized by a complete obliteration or suspension of the per- ceptive faculties. The patient knows nothing of Avhat is going on around her. She may remain as oblivious during the interval as in the paroxysm. Convulsions are accompanied by a more general derangement of muscular action. The spasmodic move- ments are less apt to be local, and more frequently implicate the different sets of voluntary muscles in succession, beginning Avith those of the head, neck, and superior extremities. If you examine the eye of an hysterical subject, you may find that it is not changed in its appearance. The pupil is neither dilated nor contracted. Sometimes the eye is The pupil in hysteria. J suffused, and the ball may be rolled upwards. Noav and then there Avill be a marked difference in the size of the pupils, but this may or may not be pathognomonic. I am not aAvare that any author has observed this as a symptom of hysteria, but I am inclined to think that it is possessed of some significance as a diagnostic sign. Add to this that you may sometimes detect the patient looking at you askant, or slyly listening to what you say, breathing more The patient manner. regularl7 and freely, or having her spasms at longer intervals, Avhen she discovers that you are quietly busying yourself with other topics of conversation. A little tact Avill sometimes enable you to cut the Gordian knot of diagnosis in the most complicated cases of this kind. If the pulse is not perturbed, but keeps the even tenor of its THE CLIMACTERIC PERIOD. 515 way, during both the paroxysm and the interval, it is an almost Tu , positive sign of hysteria. If the attack is refer- The pulse . " able to emotional causes, acting upon a too sus- ceptible organism, the nervous symptoms that follow will almost certainly be tinted Avith some peculiarities. Loss of sleep is a powerful predisponent of this disease. Treatment. — Tact is no less important in the treatment than in the differential diagnosis of hysteria. In no other disease is it of more practical moment to be personally ac- Valueoftact. x i. J quainted Avith your patient. If you knoAV her peculiarities beforehand, the case may be said to be half cured at the outset. There are a thousand little items which the physician who is observant gathers up and stores away against a time of need. And it often happens that Avhat would appear trivial, turns out in the end to be most significant and useful. For, in this manner, he may not only interpret the meaning of certain extra- ordinary and alarming symptoms, Avhen they are present, but may be led at once to the selection of the remedy proper to the case. However much Ave may pride ourselves upon our scientific attainments, I assure you that our patients are prone to estimate our professional capacity and skill, by our abil- solrce"! °f impromtu re~ ity to turn all sorts of expedients to the best account, at the shortest possible notice. They Avill think more of you, if you can effect a cure Avith some simple and harmless domestic remedy Avhich they have overlooked, like the coffee in this case, than if you go through the labor and take the time and pains to select the appropriate simillimum. Keep your quiver full of arroAvs, and be ready for any emergency. I knoAv of no remedy so Avell adapted to the relief of nervous symptoms, caused by mental fret and friction, and accompanied by insomnia, or Avakefulness, as coffee. A charac- teristic indication for it is found Avhen the patient "cannot sleep for thinking." The mind will not rest. The mental faculties are more than usually and incessantly active. The fact that coffee disagrees with a person when she is well, may afford you a clinical hint Avhich will be available in prescribing for her Avhen ill. The coffee may be administered in the crude form, in the loAver, medium, or even the higher potencies, Avith equally good results, as in the case I have cited. In some forms of hys- 516 1HE DISEASES OF AVOMEN. terical neuralgia, you may effect a prompt cure Avith caffeine in the third decimal trituration. In one form or another, coffea has appeared to me to be very Avell adapted to many of the nervous affections of old people, and of old ladies especially. Of late years I have often prescribed caulophyllin for nervous conditions that Avere post-climacteric, with ex- cellent results. One of my private patients who is an estimable old lady, and Avho has had a great deal of mental care and anxiety on account of her children, suffers from attacks that border very closely upon hysteria. They are characterized by great nervous tension and unrest, Avith Avakefulness and a propensity to Avork and worry over little things Avhich she Avould not notice at other times. The caulophyllin has such a soothing and delightful effect upon her that she calls it my hasheesh, and she avouIcI not be Avithout it for any consideration. She takes it in the third decimal trituration. DIABETES AT THE CLIMACTERIC. The occurrence of diabetes at the menopause is not infrequent, and should be thought of in case of eczema of the vulva and pru- ritus. (See pages 512 and 528.) The affection may be chronic, in which case it is symptomatic of tuberculosis, or acute and tran- sient, as it sometimes is during pregnancy. Its chief constitu- tional symptoms are insomnia, flushings that are folloAvedby chills and rigors, irritability of temper, hypochondria, anorexia and emaciation, with or without a cough. We have elsewhere con- sidered this subject very carefully and extensively. (Clinique Vol. V, pages 16 and 148, and Yol. VII, page 181). One of the most interesting monographs upon any medical topic that has recently appeared is that of Lecorche upon saccharine diabetes in women.* *Du Diabete Sucre chez la Femme par le Doeteur Lecorche, etc., etc., Paris, 1886, pp. 403. LECTURE XXXII. INCIPIENT PARALYSIS AT THE CLIMACTERIC. Incipient paralysis at the climacteric. Post-climacteric neurosis. Climacteric rheuma- tism. Bilious colic at the climacteric. Prolapsus uteri, with dropsy, dating from the climacteric. Post-climacteric anasarca. Case.—Mrs.----, aged 4S, has had eight children. The last tAvo labors Avere very difficult, from a fall which she received during her sixth pregnancy. She iioav complains of pain " low cIoavii " on the lett side of the spine. This is Avorse before the Aoav, which is very scanty. She also has some pain, of a pricking char- acter and numbness in the right arm, there is vertigo, and she cannot sleep after 4 o'clock in the morning. Belladonna 3, four times a day. April 10. The numbness in the arm, is better, but she com- plains of pain in the vertex, and vertigo. Her feet get cold, and she has cold creepings folloAved by hot flashes, sometimes she gets blind for a time. She ahvays feels better Avhen lying cIoavii, but is very apprehensive of danger. Aconite 3. April 24. She is very much better; her back does not ache so much, the headache and vertigo are better, but the numbness of the arm is about the same. The menses have returned, but Avere less free than before. She has a good deal of pain before the flow comes on, and after it ceases there is a profuse leucorrhceal dis- charge, Avhich is acrid and accompanied ny bearing-doAvn pains. Sometimes this discharge is thin and Avatery and lasts about tAvo Aveeks. Kreosotum 3, four times a day. May 15. Better in every respect. Same remedy. June 5. Is not so Avell, menses are groAving more scanty, and the thin excoriating discharge is more profuse, but the headache and numbness are relieved. Nitric acid 6. June ID. Better in all respects, except the pain in the back. Same remedy. July 3. The arm and head are Aery much better, she sleeps Avell iioav. Same remedy. July 17. Her backache is very troublesome, and is worse in the left lumbar region. The pain in the head and arm are still improving. Merc. sol. 3, four times a day. July 31. The pain in the back continues, but she is much better in other respects. More. sol. 3. Aug. 2S. She is improving someAvhat, but the hand feels numb, 517 518 THE DISEASES OF AVOMEN. and there are darting pains in the arm, and cramps in the right limb. Rhus tox., 3. Sept. 11. Tiie right arm is well, and the pain has gone to the left one which cracks in every joint Avhenever she moves it. The arm and hand burn, there is still pain in the back, and she has frightful dreams. Rhus tox., 3, four times a day. Jan. 8. The patient after an absence of several months of com- parative freedom from suffering returned, complaining of the old pain in her back, arm and shoulder. The menses have been very irregular and scant. Bryonia 3. March 12. She has pains in her arms and Avrists, and hot flushes of the face. Bell. 3. April 23. The pain iioav extends the Avhole length of the right arm, Avhich is hot and feels as if it Avas swollen, and is worse at night. She has chills, folloAved by headache and if she stands long her feet SAvell. She has an eruption at times on the loAver limbs. Apis 3, three times a day. May 28. Her arm is still painful, and is Avorse on lying cloAvn, and at night. She still has some pain in her head, Avith attacks of vertigo. At times she is cold all over and is only relieved by being rubbed. Merc. sol. 6, four times a clay. June 4. She is much better. Continue same remedy. Sept. 24. Her chief complaint is of a pain in her right shoulder, Avhich becomes cold and is Avorse at night, so that she cannot sleep, and she is unable to use it. The eruption still annoys her, and is iioav on the arms also. Nux 3, three times a day. [She continued to report from time to time, and Avith the final cessation of the menses the symptoms of incipient paralysis dis- appeared. The eruption, hoAveArer, lingered for some weeks, being limited exclusively to the extremities, both upper and loAver. The cold creepings and the hot flashes disappeared Avhen the erup- tion came, and did not return. The best remedy Avas sulphur 30.] You are not to suppose that the diseases of the climacteric include those affections only Avhich folloAv the final arrest of the menses. For it may happen that they shall precea^h?aTiesStmay anticipate that period, just as a child may be ill from teething some Aveeks or even some months before the teeth can be seen. This crisis often forecasts itself in the diseases to Avhich most Avomen are subject, at and after the age of forty; and there are certain classes of patients in Avhom you Avill find that this influence is quite peculiar. Most Avomen who are of a plethoric habit, and especially those avIio have grown PARALYSIS AT THE CLIMACTi RIC. 519 stout and fleshy as they have grown older, find themselves men- struating more scantily, and little by little the Aoav ceases until it finally stops. In proportion as it diminishes a series of nervous derangements are developed, which depend upon a congestion of the cerebro-spinal centres, and apoplectic and paralytic symptoms creep on insidiously. Under these circumstances it may be of the utmost importance to recognize the significance of these symptoms, and to be able to tide the patient over her difficulty. If Ave can Prophylaxis of the hi ld h f impending paralysis, and menopause. L » i j ' keep her from being a physical Avreck for the balance of her life, Ave shall have done a good deed, and one that will bring a grateful after-glow to our oavii experience. There is nothing very striking in the recital of tins poor Avoman's case, or in the choice of remedies for its cure, but the result was all that could have been desired. It serves to Points in this case. . . ,. illustrate the fact that in our practical lives as gynaecologists Ave must not ahvays expect very prompt and im- mediate results from our treatment. For Avhere a slowly coming crisis like the climacteric is concerned, Ave may need to persevere for many months before our object is finally accomplished. I ought to tell you that it is not an infrequent occurrence for the uterine discharges to become thin, Avatery, and more or less acrid and excoriating as the change of life cSlTZechl^c!S' aPVro^ches' and that» 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 malignant. 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 Avhile the discharge continues to be corrosive in character. It is for the relief of this kind of a discharge, in connection Avith the menses at the menopause, that I prefer the use of nitric acid, and sometimes of kreosotum, either of Avhich Remedies for the } > jn the third Qr the gixth dilution. acrid now. .. .-> When the menses are scanty Avith 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 AVOMEN. to the head and to the spine, Avhich threaten to end in paralysis, glonoine is a better remedy than lachesis. POST-CLIMACTERIC NEUROSIS. Case.—Mrs.----, German, aged sixty, michvife, has been an invalid for eight years past. Her menses ceased Avithout any othei ill eflect than that, Avhen they stopped, she became subject to dis- tention of the stomach and abdomen, Avith 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 SAVollen 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 Aveeks 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 Aoav has ceased. My first prescription Avas the citrate of iron und 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 Avhen 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 iioav complains of pains in her shoulders and chest, Avhich she thinks Avere caused by taking cold about a year ago. At that time, an abscess formed in her left breast, Avhich Avas lanced and discharged freely. She Avas not nursing at the time. Her menstruation Avas established at eighteen, and still continues. For six months previous to the Aoav, she had been afflicted Avith blindness, Avhich came in paroxysms in the afternoon, and continued until the next morning. The Aoav iioav lasts a week, and is copious, causing great exhaustion. There is a cold BILIOUS COLIC AT THE CLIMACTERIC 521 sensation extending from the knees cIoavii to the feet, Avhich are ahvays cold. Silicea 3, four times a clay. May 12. Is feeling much better; has some pains across her shoulders, but is gaining strength. Silicea 3. May 19. The patient Ava-improving until, being 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, Avhich 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 Avhich she took macrotin Avith the best efl'eet. The menses came less frequently, and finally ceased alto- gether, after Avhich the rheumatism soon disappeared.] Rheumatism at the climacteric is quite as much of an outhiAv as it is under other and Aery different conditions. This case Avas cured by macrotin 3, under indications which have cqnie to be regarded as reliable. A little Avhile ago, you remember, Ave cured another case with nux vomica 3, Avhen, along Avith the rheumatic pain in the right arm, there Avas formication, or a feeling as if ants Avere craAvling beneath the skin. Other cases have been cured Avith 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 Avhat her physician said Avere attacks of bilious colic that were clue 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, Avhen she applied to this clinic six Aveeks ago. She has been forced to be very careful in her diet, and has observed that Avhen the fit ccmes on, if she lies cIoavu and keeps very quiet it is less severe and passes off 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 Avere that, Avhile she avus menstruating, Avord Avas brought to her that her child Avas dead. He Avas soon brought home from school in a horrible fit, after Avhich he Avasill for a long time and she nursed him. AY hen this happened she had already had some Avarning of the approach 522 THE DISEASES OF AVOMEN. 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, Avith the effect to lessen the severity of the paroxysms, but they still continued to return as before. She Avas then put upon chamomilla 3, and improved in every way. In a little Avhile she observed that a single close of this remedy Avould 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, Ave should be better able complications at the tQ estjmate \ts effects in a clinical Avay, and C'liinuctcric also to prescribe for them intelligently. But Avhen a Avoman has been out of health for tAvo years in anticipation of this epoch, and Avhen during that period she has been exposed to an exciting cause that avouIcI certainly have made her ill at any other time, the morbid conditions are so complicated that it is very difficult to solve them. If Ave add to this, as in the case under revieAV, a manifest predisposition to a disease,, or a dyscrasia like that of cancer, Ave shall be very chary of promising to cure the patient, or even to make her comfortable for any considerable length of time. You have Avitnessed the remarkable effect of chamomilla in this case, and the delight Avith Avhich our patient A qualified p-rognosis. -i -i *i ii x 4.1 i i, ^ t * ascribed the result to the remedy; but 1 must Avarn you not to conclude that her disease is radically cured. PROLAPSUS UTERI AVITH DROPSY, DATING FROM THE CLIMACTERIC PERIOD. Case.—Mrs.----, aged 52, has had four children, the youngest of which is iioav 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 tAvelve years, and it ceased at forty, that is to say tAvelve years ago. She says that her mother met Avith her " change " at the same age. The first symptom of ill health that this Avoman remarked in her oavii case, Avas a bloated feeling in the abdomen, which Avas sometimes quite full and distended, and again Avould 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 IHE CLIMACTERIC. 523 ing is notably increased by exercise, and is accompanied by bloat- ing and puffiness of the limbs, the feet, and the face. The boAvels 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 (piite positive that the Avomb 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. AYhen she liesAvith 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 Avell Parturition a cause of for you, in every case, to inquire Avhether the uterine deviations, and t; t has receiltlv passed through the piDCCSS the climacteric period A •< l 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 Avas not noticed until three years later. The prolapsus came on Avith the "change," or the advent of the grand climacteric, Avhich, 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 Avhy she, at her time of life, has a prolapsus so decided, and Avhich is only remotely, if at all, related to pregnancy, is the co-existence of dropsy, to Bropsy at the climac- i c - ' _ i J ' ^ teric, and constipation, Avhich many women are liable at the climacteric. causes of prolapsus. Th ascites and general anasarca are indicative of a weakened and relaxed fibre, Avhich strongly predisposes to uterine displacements. Add to this the direct pressure imposed upon the Avomb, also the semi-paralyzed condition of the rectum, and of the perineum (Avhich has lost its resiliency), and the dis- placement doAviiAvards, even to the extent of procidentia, is readily explained. The only support that the uterus has from beloAv, is from the contractile Avail of the vagina, Avhich rests like a column upon the perineum ; and the chief muscles of the latter are con- 524 THE DISEASES OF AVOMEN. nccted Avith the rectum and the anus. In the constipation Avhich 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 folloAv upon the heels of labor, either premature or at term; but it also occurs in those avIio, like this patient, have borne numerous children, and avIio 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, ft happens that the displaced uterilS will and the perineal pad. * l | gravitate into its proper position, if the patient can keep off her feet. But it is not ahvays possible, nor avouIc! it be best, for women Avith this infirmity to go to bed and remain there. Those of the poorer classes must Avork, and they all need exercise. And thus it may become necessary to supply a means of support Avhich 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 Avomen somewhat achanced in life, avIio are ill in other respects, and constitutionally Aveak, and Avithal obliged to Avalkand to work daily, that I am accustomed to recom- mend the Avearing 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 Avith the proper internal remedies, its effect is to tone up the parts Avhich afford the natural support for the uterus, and at the same time to alloAv the patient to move about Avith 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^emedieT0"11008' fmiu 1Vom llU violeilt exercise, more especially from lilting heavy Aveights, and from scrub- bing, SAveeping 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 cpialitv 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 nux Aromica and apis mellifica. And, since neither of them Avill cover the tAvo sets of svtr.p. Internal remedies. . L toms Avhich are present, I recommend them to be given in alternation, the former at evening, and the latter in the morning and at noon of each day. The nux 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 once or tAvice daily, hi similar cases, lycopodium, or sepia, Avill 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 Avith 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. Case.—Mrs.----, is (>(> years old. She is married, has borne sixteen living children, and has had two miscarriages. Ten of the sixteen children died before they Avere one year old. She lias been constantly ill for six or seven years. Tiie menses apparently ceased at the age of fifty-two, but avc re intermittent and irreg- ular during the three following years. She had always floAved copiously at the month, and suffered much from exhaustion. There is iioav a general anasarca. The urine is scant; there is pain in the kidneys, and her limbs " burn like fire." There are also varicose A'cins of the lower extremities. She has some vertigo, but the appetite and the sleep are good. Hamamelis 3. May 2l>. She thinks there is some improvement, but the urine is stiil 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 Avith that all 526 THE DISEASES OF AVOMEN. the symptoms are improved. Continue the hamamelis 3, three times a day. The tAvo prominent factors in this case Avere such as often co- exist, viz. (1) a tardy venous circulation, and (2) anaemia. mu ^ . Both these conditions are incident to the lnemor- The hemorrhagic diathesis at the rhagic diathesis. AYe know that this patient menopause. wag a hemorrhagic subject because she flowed so freely at the month, and because she was the victim not onlyot varicose veins, but of dropsy from a sluggishness of the general circulation. I have often verified the indications for hamamelis in cases like this, and I urge you not to forget that, although it is not classed among the remedies Avhich are especially suited to the climacteric, it is nevertheless, of great service under these peculiar conditions. I cannot refrain from expressing the opinion that the slight tenure of life of ten of this poor Avoman's children, Avho died before they Avere a year old, Avas chargable to the impoverished condition of her blood, made Avorse by pregnancy and lactation, just as it has been by the climacteric. Part Eighth. DISEASES THAT MAY' OCCUR IN MORE THAN ONE OF THE CRITICAL PERIODS TO AArHICH AA'OMEN ARE SUBJECT. LECTURE XXXIII. AFFECTIONS OF THE EXTERNAL GENERATIVE ORGANS. Pruritus of the vulva. .Abscess of the labia and of the vulvo-vaginal gland. Vulvo- vaginitis. Prurigenous vulvitis. Infantile leucorrhcea. Although, as Ave have seen, some of the diseases of Avomen are limited to a single crisis, in Avhich case Ave can classify and study them separately, yet A*ery often tAvo or more of these periods may merge and be involved in their clinical history. The etiology of this class of cases is therefore complicated, and their special pathology and treatment difficult. Some of them date from puberty, but all of them are more or less intimately related to the allied functions of menstruation and reproduction. The diseases Avhich naturally come under this section of our subject are those an Inch affect the external and internal generative organs, the bladder, and the rectum. They are chiefly local in character, and have this peculiarity in common, that, Avhile they may occur in either or all of the periods of Avhich Ave haveypoken, their treatment is partly medical and partly surgical. This gives a remarkable interest to their clinical study, for physicians are not agreed upon the relative merits of these tAvo methods of treat- ment; nor are Ave ahAavs prepared to say where one should end and the other should begin, Avhere one is better than the other, or Avhere they should be used conjointly. 527 52b THE DISEASES OF AVOMEN. PRURITUS OF THE VULVA. Case. — Mrs.----, a healthy looking Avoman, has an infant of three months, Avhich is her third child. She says that when the " babe was a month old she began to suffer from an itching of the external genitals. At times this itching is almost insupportable. ahd she really feels as if she might become insane in consequence of it. She describes it as Avorse at evening, after being much up- on her feet during the day. There is a mucous secretion from the vagina Avhich is sometimes quite copious, but generally scanty, and Avhich she has observed is very apt to dry upon the parts exposed to the air, where it forms into scales that are easily de- tached by rubbing. Urination is sometimes followed by scalding and burning sensations, Avhich are referred to the vulva rather than to the urethra. Coitus is painful, and apt to be succeeded by a pinkish discharge from the vuhro-vaginal canal. She had this local trouble while nursing both her former children, Avith the last of Avhich it continued for more than a year. Her skin is fair, and to her knoAvledge she has never had any eruption. The babe is Avell, and thrives upon the breast exclusively. This form of prurigo usually depends upon inflammation of some portion of the mucous membrane lining the vulva. It is in- cident both to the purulent and the follicular Various causes. forms of vulvitis, of which pruritus is the most distressing symptom. Among the causes Avhich may induce it are, a lack of cleanliness ; the contact of acrid vaginal secretions, as in leucorrhcea, uterine cancer, etc.; masturbation ; gonorrhoea ; syphilis ; vegetative growths ; ascarides , indigestion ; diabetes ; and the use of alcoholic drinks or highly seasoned food. Some- times it is caused by acrid vaginal discharges poured out during pregnancy, and may result in abortion. Again, it is developed during lactation, and Avill not cease entirely until the child is Aveanecc In little girls it may accompany the exanthemata, and disappear with them. In women, it sometimes alternates Avith a chronic eruption to Avhich they have been subject, hi very nerv- ous persons, it may possibly arise from simple hyperesthesia of the mucous membrane. There may be aphthous ulceration, or perhaps an herpetic or eczematous eruption, or an abrasion at the junction of the mucous membrane Avith the skin, Avhich shall be sufficient to account for the suffering. Not unfrequently the sur- PRURITUS OF THE VULVA. 529 face is so heated and inflamed that the mucus secreted is dried upon the parts, and this causes such intolerable itching that, no matter Avhere she is, or what her surroundings, the patient can- not refrain from rubbing or scratching. Another cause of this troublesome affection in certain cases is disease of the uterine cer- vix. Some attacks of pruritus pudendi have been attributed to a varicose condition of the veins of the vagina. Others are known to arise from the presence either of a peculiar parasite (pediculus pubis), or of the itch insect (acarus scabiei), in the hairy portion of the mons veneris. Dr. Meigs reports the following case :* " I Avas consulted for a young lady about tAventy years of age, who suffered from an intolerable pruritus and uneasiness of the vulva. Her physician had prescribed many and ^ Pruntus from trichiasis, various remedies in vain. He had examined, by inspection, the privities, but could not dis- cover the cause ; Avhich, hoAvever, Avas not dissipated by his appli- cation of nitrate of silver and other medicines. When I was called to give my opinion of the case, I Avas much surprised to find it attributable to a real trichiasis of the vulva. The hairs that groAV usually on the derma, and then not very close to the epithe- lial surface, had sprung from the very margin of the mucous mem- brane of each labium. They Avere straight, like eyelashes, and pointed inAvards. It was from the tickling and pricking of the points of these hairs that her distress arose. They Avere all re- moved by her nurse, with tweezers, and the complaint disap- peared." The itching, burning or stinging sensation, Avhichever it may be, is not always constant, but remits and intermits. It may be aggravated by exercise, fatigue, excessive heat of the weather, standing before a fire, by the warmth of the bed, by mental emotion, passional excitement, or urination. It may be worse at evening and at night, thus pre- venting rest and sleep. Sometimes the patient is compelled to leave her bed and Avalk about the room in order to obtain the least respite from her suffering. It worries her into a nervous state, rendering her unhappy, petulant and ill. The paroxysms may be so severe as almost to drive her crazy. Sometimes * Woman : her Diseases and Remedies, etc. Phila., 1859 ; p. 96. 530 THE DISEASES OF AVOMEN, they give rise to local spasm in the form of vaginismus, or in a more general way to an hysterical fit. In the mildest variety the cutaneous surface of the larger labia is the seat of formication, or craAvling sensations, which torture the patient exceedingly. In this case she will insist that multitudes of little insects are run- ning over the external generative organs. When the mucous membrane reflected over the clitoris is the seat of the itching, the case develops into one of nymphomania. The scratching and rubbing of the parts really affords but little permanent relief, and yet it is impossible for the poor victim to resist such a propensity. In this manner the Lesions from self-inflicted surface is sometimes so severely wounded that wounds. «/ extensive injury is done to the soft tissues. In case there is an eruption, the vesiculse are broken and the nails may cause extensive abrasions and ulceration. Sometimes the sen- sation of heat in the parts affected is even worse than the itching. In some women the attack precedes the menstrual flow. The physiological determination of blood to the pelvic viscera, and the irritable condition of the vulvo-vaginal str^aiVeriod^themen" glands and nerves, which usher in the "pe- riod," seem sufficient to account for this result. These persons become exceedingly nerArous, and suffer greatly at such times. They are on the eve of an hysterical paroxysm, it may be for hours together; fitful, capricious, disheartened, and sometimes almost demoralized. When the flow commences the crisis is soon past, and the pruritus may not return during the month. In such cases the proper menstrual Aoav is often supple- mented by a copious leucorrhceal discharge. The most intract- able examples of neuralgic and spasmodic rharaUandSamenodrrhSanor" dysmenorrhea may originate in this form of pruritus. Sometimes the pruritus comes on for a few nights after the cessation of the Aoav at each period. Or it may be due to menstrual suppression, constituting the prurigo latens of Alibert. The liability to this painful teric""1"3 at the climac" disorder appears to increase Avith advancing age. Not unfrequently it occurs at the climac- teric. A considerable proportion of women suffer more or less from it about the time the menses cease. This itching of the genitals is also one of the contingents of PRURITUS OF THE VULVA. 531 pregnancy. It is more apt to come on after than before the third month, and may either cause abortion, or con- nancy"tusduringpreg" tinue to term. Some women ahvays have it Avhen they are pregnant. Here is a striking instance of general and local pruritus in a pregnant Avoman, pub- lished by M. Maslieurat-Lage'mard.* " Mrs.----, aged 32, first became pregnant Avhen twenty-one years old. Prior to the sixth month she suffered but little from Case the disorders incident to gestation ; but after that time, and without any apparent cause, she was attacked with intense pruritus, Avhich extended over the whole body. The legs, thighs and genitals were first seized, but at the eighth month the itching extended even to the palms of the hands and the soles of the feet. The rubbing and scratching, Avhich she could not resist or avoid, caused premature labor, im- mediately following which the irritation ceased. She became pregnant again, and, as before, continued well until the sixth month. Then the pruritus returned, and continued until the seventh month, when she miscarried. This experience Avas re- peated six times in succession ; so that in all she had eight pre- mature labors Avhich wene due to excessive pruritus." Diseases about and within the uterine cervix are sometimes accompanied by an inveterate pruritus, which may exist for years, and defy all ordinary modes of treatment. It dis(earephcated wkh uterine may be due to simple induration, or ulceration of the cervix, endo-metritis, hydatids, polypi, or fibroids. A very painful form of it may arise from inoculation and irritation caused by contact of matters Avith cauliflower ex- crescence; and some authors believe that pruritus of the vufva is, under peculiar circumstances, a suspicious eign of uterine cancer in its earliest stages. (?) In other cases, uterine disease is caused by an extension of the inflammation, which is attendant upon the pruritus, from the A'uh'a to the uterine cavity. As in this case, this troublesome affection may torment the Avoman only during the nursing period. Under laai'tion'110 the pe"od °f these circumstances, weaning Avifl generally cure it with as much certainty and promptness as did the emptying of the womb in the example just quoted. * Gazette Medicale, 15 Mars, 1848. p. 204. 532 THE DISEASES OF AVOMEN. The danger from pruritus of the vulva is that it may persist until it has so exhausted the nervous energies as to leave the sys- tem an easy prey to organic disease. Inveterate cases are likely to be accompanied by digestive disorders of the most serious nature. The prognosis will there- fore vary with the clinical history, the cause, the complications, and the duration of the disease, as well as with the temperament, time of life, dyscrasia, and the original strength and vigor of the patient. Treatment. — This is local and general. It would be cruel to deny our patient the use of such palliatives as will mitigate her sufferings without in the least interfering with the cure of her complaint. And, since the local expedients to Avhich you will be obliged to resort must vary in different cases, you should possess an ample stock of them in the outset. First of all is cleanliness, which can be secured by having the parts frequently bathed with suds from castile soap. The honey and juniper tar soaps answer equally well. Pledgets of old, soft linen may be wet either with cold or warm water, as the patient prefers, and applied fre- quently. Or wheat-bran water may be used in the same Avay, and, in some cases, injected per vaginum. If there is a vesicular eruption, Avith a ra\v surface, or the burning in the urethra and dysuria are very marked, water, or glycerine, or both, may be medicated with the tincture of cantharis, and applied to the vulva by means of compresses. The urtica urens is appropriate to the erythematous form, Avith a scarlet surface of the mucous mem- brane, and where there is complaint of burning and stinging as from nettles. In case of aphthous ulceration, you should not forget the com- mon borax, and the hydrastis, both of which are in excellent re- pute as palliatives in this form of pruritus. An" emulsion of olive oil and lime water is sometimes of excellent service. Or a roll of lint dipped in almond oil may be introduced into the vagina. Colombat recommends a lotion composed of a tablespoonful of cologne water to a teacupful of Avarm water. Lisfranc prefers a mixture of starch five parts, and camphor one part, to be applied once daily to the inflamed surface, the latter having been AAashed before the preparation is used. Scanzoni extols a liniment com- PRURITUS OF THE VULVA. 533 posed of chloroform t\vo parts and almond oil thirty parts. HeAvitt prefers them in the proportion of one part of the former to six of the latter. In extreme cases, others prescribe a mixture of melted lard and chloroform. Or the rhigolene, ether, or chloroform spray may be used exceptionally. If there is considerable local inflammation, I am in the habit of prescribing a poultice of ground slippery elm, or of linseed meal. If the case is chronic, and very obstinate, more othe0rrwVisevitis,sy^hi'iticor especially if it is syphilitic, the surface may be painted over with a solution of the nitrate of silver, composed of one grain to the ounce of distilled water. In other inveterate examples the chromic and hydrocyanic acids are permissible and useful. If the itching is due to the presence of pediculi, a mixture con- sisting of the ointment of the yelloAV nitrate of mercury one part, and lard three parts, may be smeared over the For pediculi. ascarides, etc. ^ pudenda. Or an infusion of tobacco may be applied locally with a view to disgust and destroy the parasite. In trichiasis of the vulva you may follow the treatment prescribed by Dr. Meigs, as quoted above. If the irritation is due to the presence of ascarides in the rectum or vagina, or both, injections of common salt and water, olive oil, or of a decoction of garlic, may be ordered. It is very important to enjoin quiet. The fresh air is, hoAvever, requisite. Sexual intercourse should generally, Rest, diet, etc. * . . ° J but not invariably, be forbidden. A proper, unstimulating diet should be chosen, and every form of alcoholic drink denied. I Avill not detain you with detailed indications for remedies that may require to be given internally. Let it suffice that the utmost importance must attach to the special cause and Internal remedies. , • t • i i • i . history ot each individual case in which you are consulted. For there is no single specific for this affection, any more than there is for hysteria. Natrum muriaticum, sepia, silicea, sulphur, arsenicum, calcarea carb., conium, mercurius, and the various acids, are most frequently given. Dr. AA"m. Hunter found that the introduction of the female catheter avouIc! sometimes afford immediate and complete relief. 534 THE DISEASES OF AVOMEN. Others have recommended the application of a Avater-proof cloth made of rubber, or gold-beaters' skin. The lo- Other expedients. , .... .. . . .,-. cal use ot the essence of peppermint aviu answer in some cases. The use of agaricus muscarius has been advised; and my friend Dr. D. S. Smith of this city, and also Jousset and Baehr praise the tincture of conium in a Ioav dilution for Additional remedies. . , , , -, -^ -m,- TX TT , n internal and external use. Dr. W.H. Holcombe, of NeAv Orleans, Avrifes:* " AVhen sympathetic with ovarian or uterine trouble, platina 6, internally, and caladium scguinum externally have rarely failed me. When vesicles or excoriations accompany the itching, graphites, internally and externally, is truly specific, but I give it Ioav—the first decimal trituration for the wash, and the third decimal three times a clay by the mouth. For the pruritus ot young girls, Avith leucorrhcea, and associated Avith ascarius vermicularis, nightly injections ot a strong decoction of garlic Avith an internal close of ignatia are promptly curative." In his Hom.Therapie., Vol. II, Kafka advises: " for itching of the external labia, mercurius 3, or kreosotum 3; for itching of the mons veneris, natrum muriaticum 6, or 30, or carbo vegetabilis 6 ; for itching of the vagina, if the sexual instinct is not increased, sulphur 30, graphites 6 or 30, natrum mur. 6-30, belladonna 6; ditto Avith erotismus and nisus sexualis excedens, nux vomica 6, cannabis indicus 3, calcarea carb. 6, zincum metallicum 6; Avith nymphomania, bartya carb. 6, mix vomica 3-6, ignatia 3-6, platim 6, zincum metal. 6. In all cases of pruritus pudenda lukeAvarm sitz-baths and full baths are to be recommended." ABSCESS OF THE LABIA MAJORA AND OF THE VULVO-VAGINAL GLAND. All abscess of the labia is the result of an inflammation of its cellular tissue, or of the vulvo-vaginal (Bartholin's) gland. For some unaccountable reason it is more frequent. on the left than on the right side. AA7hen the first symptom observed is a hard tumor in the centre of the labium, Avithout any superficial inflammation, the affection is glandular, and may be gonorrhceal or not. AA'hen the inflammation is specific, it has travelled along the duct before invading the gland; but the non-specific form may arise from simple obstruction of the ♦The U. S. Medical and Surgical Journal, Vol. 8, p. 49. ABSCESSS OF THE LABIA, ETC. 535 duct. In both cases the abscess Avill discharge a verv nauseous and offensive matter. This form of abscess is most frequent betAveen seventeen and thirty years of age. It is caused, in most cases, by traumatism of n , the genitals as in rape, and excessive coitus, Causes of. - l ' and also by gonorrhceal vulvitis and vaginitis. Martineau reports the folloAving cases: * " The first Avas that of a young Avoman of 22, avIio, meeting her lover, from Avhom she had been separated during the siege of Paris Cage during the commune in 1870-71, submitted to his embraces nine times in one night. There followed from it an abscess of the left vulvo-vagmal gland, for Oct7 Avhich she sought my advice. The cure Avas completed at the end of eight days. " The second case Avas that of a young Avoman of 25 Avho lived with her parents and only saAV her lover evenings. One evening betAveen the hours of* 8 and 11 coitus Avas re- Case. . pea ted seven times. Two clays after there Avas a slight itching of the labium majus, then smarting and swelling; the patient entered the hospital and I found an abscess of the left vulva-vaginal gland, Avhich healed at the end of eight days. " These are not isolated cases. The gynaecologists mention sev- eral and I doubt not physicians have occasion to see them in their practice, especially in young brides, Avhere to excessive coitus must be added, difficulty of defloration and the fatigue of the bridal trip. Tarclieu observed a case as the result of a rape; he cites a case in a girl of sixteen avIio Avas obliged to submit to the repeated assults of her ravi.slier at least tAventy times in less than eight days.-' It is sometimes connected Avith tardy menstruation. One of my patients has had tAvelve of these abscesses Avhich in every instance has been connected Avith the menstrual period. More rarely it occurs during pregnancy, or as a result of the traumatism of the soft parts during labor. The symptoms are pain in Avalking or sitting, a mild puritus and unusual moisture of the parts, sAvelling of the affected side, the formation of a small hot tumor, Avhich is pear-shaped and Avhich closes the vulvar orifice. *La France Medicate, July 21, 1880. 536 THE DISEASES OF AVOMEN. Diagnosis. The mucous membrane covering the vaginal side of the tumor is congested and purplish, and the tumor soon becomes fluctuating. In from four to eight or ten days the abscess breaks and discharges its contents, but only perhaps to refill at the next monthly period, or to develop a fistula which may continue to discharge. Martineau in his clinical lecture says: " The diagnosis is generally easy. This pyriform tumor, situ- ated at the entrance of the vulvar ring, betAveen the labium majus, Avhich it pushes outAvarcl, and the labium minus, Avhich it flattens Avith- in, clearly detached from the neigh- boring parts and leaving intact the superior segment of the vulva, can- not be confounded Avith a stercoral abscess, with a presecto-vuhar ab- scess, nor with a purulent collection, proceeding from caries of the isch- Om, „ , , . Fig. 46. Abscess of the labia lie Will not COllfouild tills majora. abscess Avith abscess of the labium majus. In fact, phlegmon of the greater lip is seated at the external portion of the vulva; it projects outward, not iiiAvard, like abscess of the vulvo-vaginal gland; finally, Avhile the latter is habitually circumscribed and uni- lateral, phlegmon often becomes general, extending to the labia minora, the clitoris, and even ac- cording to Huguier, to the mons veneris." It is more difficult to diagnose betAveen abscess and a cyst of the excretory duct. In both cases Ave find, on one side of the Fig. 47. Cyst of the duct of the vulvo-vulva, a globular tumor, oflim- vaginal gland. •, -, . ited extent, springing from the interior of the vulvar ring, and pushing the large lipoutAvard: but incase of the cyst, it is smaller, indolent, Avithout reactionary ABSCESS OF THE LABIA. 537 and inflammatory phenomena; its greater diameter is directed according to the transverse direction of the excretory duct, and pressure causes the escape of a colorless fluid, slightly viscous but not purulent. It is very important not to confound an abscess of the labia Avith vulvar enterocele, lest you might plump a lancet into a hernial sac. The possibility of reducing the tumor by taxis, or of its disappearance in the recumbent posture, the impulse given to the tumor by coughing, and the absence of constitutional symptoms, are the signs by which you AvouldknoAV that a knuckle of intestine had been forced into the labium. Either Avith or Avithout our help, these abscesses must be dis- charged of their contents. It is a question Avhether more harm than good is not done by opening them too early. Guerin and Martineau have observed that fistula? are often caused in this way. The latter advises to Avait for such an abscess to open itself through the mucous membrane or through the excretory duct of the gland. It generally breaks through the nympho-labial furiOAv, and the cure is speedy. If, however, the pain is very severe and the fluctua- tion is marked, it may be lanced in a direction that is per- pendicular with the labium. In some cases it is best to keep the Avound open Avitha cloth tent or a bit of charpiethat has been Avet with a solution of hydrate of chloral or of carbolic acid. AA^hen a fistula is formed, and the case becomes chronic, Ave need to dis- sect out the entire gland, Avhich should be done very carefully on account of the haemorrhage. In the beginning such an abscess should be poulticed A\rith slippery-elm or oat-meal. Flax-seed is objectionable in this case especially, because it becomes rancid. Dry heat applied by hot-Avatcr bags will give relief and hasten the suppurative process. For a simple, non-specific abscess of this gland the best internal remedy is phytolacca. AVhen it is blenorrhagic, mercurius, or kali jodatus, is preferable. If the process of suppuration is very slow, you may give hepar sulphur, or perhaps nux vomica, as has been recommended for anthrax. If the discharge is copious and too protracted, silicea will be indicated. If there is great debility and prostration, with a depraved condition of the blood which tends toAvards sloughing and gangrene, arsenicum, lachesis, and the mineral acids are called for. The early constitutional symp- 538 THE DISEASES OF AVOMEN. toms, the fever and chilliness will respond to the usual remedies such as aconite, belladonna and bryonia. ECZEMA OF THE VULVA. Case.—Miss— age 23, came to the sub-clinic for the cure of an eruption about the anus and along the vulva, from Avhich she had suffered for about four Aveeks. The attack Avas preceded by a dys- enteric diarrhoea with acrid and irritating discharges. The stools were very frequent but not very copious. AVhen the eruption be- gan the bowel complaint ceased, and it has not returned, but in- stead she has had haemorrhoids. The vulvar and anal irritation are very much increased during the monthly periods. She has never suffered from any other eruption. A local examination revealed the existence of a patch of eczema which had evidently begun about the anus and extended over and beyound the labia majora. At some points there were vesicles, at others there were the dry scales of eczema. There Avas no vaginitis. Rhus tox., 3, internally, and Latour's collodian locally. She continued to report, and the treatment was not changed except temporarily to substitute Cantharis 3. for the rhus toxicodendron. But as the eruption declined a new set of symptoms appeared, and she began to sIioav signs of exfoliative endometritis, or a form of membranous dysmenorrhcea. This lat- ter condition Avas preceded by an evident extension of the irrita- tion, and possibly of the eruption also, along the vagina and to- Avards the uterus. In Lecture XIV I have spoken of this class of causes for mem- branous dysmenorrhcea. The case before you shows the possi- bility of the direct extension of the vulvar eruption along the vagina to the uterine cavity, and also of a lesion of the uterine mucous membrane which shall result in its being moulted at the return of the menstrual period. VULVO-VAGIN'ITIS.—PRURIGENOUS VULVITIS. Case.—Mrs. T----, aged 45, English, married and the mother of eight children, Avas admitted to the hospital yesterday. She has never had a miscarriage. Three years ago she Avas troubled with a sudden arrest of the menses,'which "continued for eight months. They finally came on again spontaneously, and in the usual quantity, but the Aoav Avas subsequently attended with considerable pain. The climacteric Avas passed without any untoward symptoms one year ago. VULAO-VAGINITIS. 539 During the period of arrest of the catamenia, this patient was treated for ulceration of the Avomb, which, she says, Avas accom- panied by considerable discharge. At one time she remembers a sudden Aoav of " matter " Avhich, she thinks, amounted in all to nearly or quite a tea-cup full. This discharge came suddenly tklike the Avaters." There has been no trouble in micturition. The bowels have been constipated, and she has been annoyed with internal haemorrhoids Avhich occasionally bleed. At present she complains of intense itching of the genitals, and says that pimples sometimes form on the labia and then burst. There is heat in the vagina, especially after exercise, and occa- sionally a slight, but never a copious, leucorrhcea. She also has considerable pain in the right leg, which extends from the right iliac region in front, around, and over the hip, and doAvn the limb to the inner malleolus and the inside of the foot. This pain is not affected by changes of Aveather, but is aggravated by motion. The right knee-joint is enlarged, as in chronic synovitis. On physical examination the uterus Avas found in position, and of normal size. Examination Avith the speculum re\Tealed the mucous membrane lining the vagina and reflected o\Ter the vaginal portion of the cervix to be studded Avith a papulous eruption resembling prurigo. The same eruption extends over the vulva and the adjacent integuments. This, gentlemen, is one of the old-fashioned women, whose maternal record is in every respect a creditable one. She has borne eight children, and has never suffered a An exceptional case. . . T„ . ... T 1-1,1 miscarriage. It it Avere possible, 1 Avould take occasion to name all the physical and moral exemptions that she has enjoyed in consequence. Not the least among them is that she has escaped any serious illness at the climacteric. Three years ago, at the age of 42, she had suppression of the menses for eight months. Meanwhile she received treatment for ulceration of the Avomb, but Avhether she ever intermittent menstrua- ha(i fT^ disease, we do not knoAv. It is very tion before the change. ^ probable that her physician mistook the sup- pression for a sign of ulceration, and proceeded to cauterize her with a view to restore the catamenial Aoav. It is equally proba- ble that the menstrual arrest Avas due to a physiological and not to a morbific cause, or in other words, that it Avas a sign of the approach of the '* change of life ;" for, as I have already said, such intermissions in the performance of this function are by no 540 THE DISEASES OF WOMEN. means rare in women who haAre reached their fortieth year, and in whom the period for its entire cessation can not be very dis- tant. The probable cause for such a temporary arrest, and Avhich is apt to be overlooked, is a failure in the ripening of the ovule, and in the dehiscence of the Graafian follicle. Defective ovulation. . . „ . „ ... , By-ancl-by the function of ovulation is resumed and the menstrual Aoav re-appears. The muco-purulent discharge of Avhich she speaks may have been due to a vicarious accumulation and retention Avithin the uterine cavity, Avhich finally found vent Avith the suddenness of a rupture of 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, Avho 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 ahvays 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. , -111 the torment sometimes occasioned by Avalking, 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 papulae 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. it as is located upon the cutaneous surface of 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 VULVO-VAGINITIS. 541 the case of elderly women in Avhom there is no diffuse vaginitis, and Avhose vaginal mucous membrane has not The color of. . . ^. recently been discolored either by pregnancy or menstruation. But, in younger persons, in Avhom 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 unAvholesome food, and Causes. liit. 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 Avith chronic skin disease. There is a form of granular vaginitis from Avhich pregnant women sometimes suffer that should not be confounded Avith this. In it the eruption, or rather the pin-head pim- piagnosis from granular pies consists of myriads of little granulations vaginitis. -T jo Avhich give rise to pain, heat, and sometimes to considerable discharge. It is self-limited, is not accompanied by vulvar prurigo, and terminates Avith delivery. 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 Avhich are From follicular vulvitis. „ . ,, , ,. ... . ,, found upon the vulva, and just Avithin the ostium vaginae. 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 amount of the leucorrhoeal discharge is not in proportion with the local suffering. Mrs. T. has but little Aoav of this kind. AAliere, hoAvever. the eruption and the inAammation extend Avithin the cervix uteri, and possibly into the uterine cav- 542 THE DISEASES OF AVOMEN. 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 papulae (as in case of other Aegetatiye groAvths within the vulva), may excite a very troublesome leucorrhcea. 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 leucorrhcea, Avhen in fact they are deceived and the discharge is disposed of in this Avay. In rare instances the eruption inA'ades 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 Arariety of uterine devia- ceming uterine displace- tion. For this reason I felt almost confident ments- that her womb Avas 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 Avhen a Avoman 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 Avomb 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 Avill vary according to circumstances. Such cases recover more readily in Avinter than in summer, in cool Prognosis. than in warm climates, and in young than in old patients. Scrofulous persons, and those avIio are predisposed to aphthous conditions, or to chronic cutaneous eruptions of Avhat- ever kind, get well very slowly. The syphilitic taint may retard the cure. If it folioavs the climacteric very closely, or co-exists, as in the case before us, Avith rheumatism, we shall not be Avar- 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 Avater, and the application of a Topical treatment. i i -i -i , bland demulcent, as bran-Avater, glycerine, almond oil with or without chloroform, or of the muriate of hydrastin with glycerine, Avill ansAver an excellent purpose. ^loths 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 dyscrasia, 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 vuh'o-A-aginitis to Avhich 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, AA-hich also creates a sense of scalding and itching. This is accompanied by dryness, redness, and heat of the inflamed surfaces. Soon, hoAvever, the parts become moist from the exu- 544 THE DISEASES OF AVOMEN. 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 Avell as Avith the duration of the disease. In scrofulous children, more espe- cially if they have been alloAved improper food and have not been kept in a cleanly, healthful condition, the leu- corrhceal Aoav 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. AATien 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 Aoav 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 Avinter along Avith a more or less severe influenza. I have knoAvn 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 Avorms that ha\Te escaped at the anus, and craAvled Avithin 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 LEUCORRHCEA. 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. t °° selves, and which are most useful, are calcarea carb., hepar sulph., and mercurius. A majority of cases may be cured Avith pulsatilla, or calcarea carb. If the passage of the urine occasions great suffering, give can- tharis, and have cloths that have been dipped in Avarm water applied over the vulva. If there is ulceration, or aphthous in- flammation, add hydrastin or calendula to the water. If ascarides 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 boAvel, 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 Avashed Avith the same towels as those Avho are healthy. For Isolation. , although the disease is not ahvays easy ot com- munication, yet it might happen that it Avould spread through a Avhole 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, r.iet 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 Avel- 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 Avell since. Prior to that date her menstruation had ahvays been regular ; but since that sudden check of the flow, the periods have returned every three weefcs. 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 Avas 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 a very little bloody. The only real pain experienced is after the flow of urine, or rather, while the last drops are running aAvay. This induces a burning, stinging pain, Avhich 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 Avho treated her for this difficulty made an examination aa ith the speculum, and after analyzing all the symp- toms that Avere 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 Avith the speculum. But it was denied, and he continued to treat her for " disease of the Avomb." The physical examination just made discloses a vascular tumor Avhich is nearly the size of my thumb-nail, at and Avithin 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 someAvhat 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 1 • , , i i j i l and Avithin its canal, being attached thereto by a pedicle, like a polypus. They consist of a hypertrophy of the mucous papillae, and are very vascular. Sometimes the tumor is lobulated ; more rarely there are tAvo instead of one. The pedicle may be so slender as to break very readily Avhen you seize the growth with a pair of small forceps ; or it may be firm and un- yielding. The symptoms accompanying such a case have already been detailed in this report. Painful and frequent micturition, espe- cially after exercise upon the feet; pain upon 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 AVOMEN. tinue until the patient is very 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 ej^n^nadoynfor physical s^e flight have been relieved in as many minutes. But two things were in the Avay 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." Hoav thEbcasaedes to recovery in this instrument could aid in the diagnosis of renal disease, and Avhat particular affection of the kidneys she Avas thought to have, I do not knoAV. The second obstacle was her OAvn 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 Avait a reasonable length of time, providing the symptoms are not very urgent. Give the to^hysicXxpiofation!°rt appropriate remedies meanwhile, and place the patient under such hygienic regulations as Avill favor her recovery. But if the symptoms do not yield as they should, or if they shoAV 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 feAV 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 Avhen 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 wdll 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 URINARIUS. 549 are connected Avith urination, Avhere the quality of the urine is unaltered, as it is in cases of chronic and invet- Especially requisite . in diseases of the erate uterine disease. For you mav be morally female urethra. . ^ J certain Avhen you have given cantharis, mer- curius, aconite, apis mel., cannabis, hyoscyamus, and kindred remedies, under appropriate indications, and relief has not fol- loAved, 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 off with a pair of sharp scissors, or the bistoury. Or ligation, or as- Excislon. . J. ?? > tringents and cauterization may answer; but they are more slow and painful. The stump, or point of attach- ment may be touched Avith the per-chloride of iron, or with a stick of the nitrate of silver, in case of haemorrhage. In order to prevent the subsequent groAvth of the tumor it may be necessary to repeat the application of the caustic after a feAV days. I have recently treated a case in Avhich 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 reCommeiid 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 tAvo years old, consulted me for the relief of urinary symptoms from which she said she had been suffering for a tAvelve month. Her physician had treated her constantly for nine months for uterine prolapsus. She hid had applications of some sort made to the womb through a speculum, had Avorn a pessary, taken sitz baths, and tried electricity, both Avet and dry, but Avithout 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 Avas no leucorrhceal 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 Avho Avill feel very badly over it, if he ever learns hoAV the case has turned out. My mode of operating AA'as to seize the groAvth sIoavIv but firmly with this pair of Pean's artery forceps. 550 THE DISEASES OF AVOMEN. When the blood had been thoroughly pressed out of the growth, 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 Avhere I Avanted it, no blood was lost, and the growth soon sloughed off. In a feAV cases, Avhere the groAvth was so attached upon all sides of the meatus that it would have been very difficult to remove the whole of it Avithout 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 Avithout cutting it off. If the tumor is very large, a needle armed Avith 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 from 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 After-treatment. . . . -,.,., urethritis, it should then be treated as if the case Avas an idiopathic one. NON-SPECIFIC URETHRITIS. 551 NON-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 months, 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 Aveeks. She is the mother of tAvo children, the youngest of Avhich is one year old. The babe was weaned at six months, since Avhich time she has menstruated regularly. On the eve of the regular " period " she Avas seized with a strong desire to urinate, but, being " down tGAvn on a shopping expedition," she could not conveniently re- spond. Although suffering great pain in consequence, micturition Avas deferred for more than an hour, during Avhich 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 Aoav 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, Avhich are referred to the meatus and the course of the urethra. She says the pain is most acute and burning during the Aoav. 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, Avhich continued for three Aveeks and appeared to subside of itself. Although her at- tention had not been called to the fact before, she now remembers that it folloAved 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 Avomb 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 Avriters upon the diseases of women have said little or nothing of this painful affection. We cannot attribute this oversight to its infrequency, for, in the female subject, urethritis is much more common than stone in the bladder or cystitis, both of Avhich diseases have received a due share of attention at the hands of the gynaecologist. Nor is it an insignifi- cant complaint. For Avhatever 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 Causes. -i -i • i •• • -i • 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 vvomb ; 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 Avhen the bladder should be emptied. A spurious form of this disease is sometimes met with in hysterical Avomen. In the sub-acute variety the attack may recur Avith 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 burning sensation Symptoms. ^ ° is continuous, being aggravated by the flow of urine. In others it commences Avhen 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. , • t from it upon either side Avithout increasing the difficulty. Sometimes the erect position is intolerable. It is par- ticularly so if the case is complicated Avith prolapse of the Avomb, 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. "1 . , „ . " . cording to the duration and gravity ot the attack. It varies, also, with the individual constitution, scrofulous persons being more apt to have a copious Aoav of mucus than others. The mucus is mixed with the urine Avhen 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 Aoav of pale, limpid urine, such as frequently folioavs a hysterical fit. When you visit such patients and inquire in general terms con- cerning their ailments, you Avill most likely be told that they have disease of the kidneys. For, hoAvever intelli- A domestic fallacy. ,, ,, gent in other matters, most Avomen suppose that anything wrong Avith urination implies that the kidneys, and not the bladder or urethra, or both, are at fault. A diligent inquiry into the especial symptoms Avill 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 554 THE DISEASES OF AVOMEN. increased suffering and strangury from moAung around during the day, and the frequent, scanty, interrupted flow Diagnosis—from stone. „ i "i /v • t-» of urme, are common to both affections. 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 Avhich Mrs.----complains. In stone, the urine is more or less bloody ; its chemical reaction varies Avith 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, Avhich is referred to the pubic region, From cystitis. ••in 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 Avorse 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 Avhether a given case of urethritis is or is not compli- cated Avith gonorrhoea. If the inAammation is From gonorrhoea. . specific, the attack is more likely to be accom- panied by marked constitutional symptoms, by more intense suf- fering Avhen the urine is passed, by a more copious discharge ol mucus, and, Avhat is still more characteristic, the more acute symp- toms subside spontaneously in from tAvo 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 speciAc inAammation in the urethra. Let me recommend, hoAvever, that, whenever it is possible, you shall give all parties concerned the beneAt 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 Avhich to say a Avord concerning the length of time required for this and similar diseases to recover under proper treat- Rapid cures exceptional. 1 . - ment. In some of our books and journals you will And it reported that a single dose has cured such a patient almost instantly. The inference is that if Ave prescribe carefully and accurately, the relief Avill be certain and speedy. The truth it often quite the reverse. Such a case as this, one in Avhich a poor Avoman has been ill Avith marked and decided local inAamma- tion for many Aveeks, must, in the nature of things, convalesce sloAvly. And so is it Avith the majority of diseases that the physi- cian is required to treat. The ill effects of motion are so manifest in urethritis that the Arst condition prescribed should be rest in the recumbent position. The patient may be alloAved to lie on the back, Rest in the recumbent or upon either side, as she prefers, but should position. -t A not be permitted to stand, sit, or walk about. Riding Avould be equally injurious. She should as much as possi- ble refrain from doing anything which Avould 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 Tive diet and drinks. . ^ ^^.^^ The mealg ghould 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 Aaxseed 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. ^^ ^ & polypug in the canal; rem0ve 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 inAammation 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 AVOMEN. is incident to leucorrhcea or any form of menstrual derangement. In gonorrhaeal urethritis, especially if there is considerable inflammation and heat in the vagina also, I knoAV of no remedy so well adapted to the relief of acute symp- For gonorrhoeai t ag atropine 3. Besides this we have urethritis. l aconite, cantharis, cannabis sativa, and mercu- rius, wrhich may be given under appropriate indications. Simple, uncomplicated cases may require cantharis, cannabis, conium, belladonna, nux 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- Localtreatment. .. .. , • -1 p 1 -1 .• m line, or vaseline as a vehicle tor hydrastin. lo apply it you may wrap a long and slender dressing forcep tightly with cotton, smear it with the cosmoline and, 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.) Fig. 49. The uterine-and urethral syringe. In case the attack of urethritis is complicated Avith inflamma- tion and induration of the cellular tissue about the passage, or if it is gonorrhaeal and relapsing, the hot water The urethral douche. -,,.,. ,. , "-,.._ douche is ot exceeding value. 1\ ater as hot as the patient can bear it may be thrown through a catheter like this. (Fig. 50.) Fig. 50. Skene's reflux catheter. You should not forget, hoAvever, 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 Ave Aveeks. At this time the kidneys Avere somewhat involved and she began to have nerv- ous chills, which came regularly twice a day for a while, gradu- ally increasing to four or five in number daily. The chills continued in this Avay 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 SAveat 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 boAvels are habitually constipated. She has nevci had haemorrhoids, and can lie upon either side. Ignatia 3 four times a clay. Oet. 21. 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 yaAvn, and the feet become cold. She says that of late, during the menses she has pain in the back and clown 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. 21. 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 Aveek, she has been awakened Avith a sensa- tion of coldness between the shoulders, and she cannot get Avarm. 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 hoav Avhen passing the urine. Some days she must void it every half hour, and must get up quite often at night to urinate. She lias 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 THE DISEASES OF AVOMEN. Dec. 1. The chills still continue. Straining to urinate, as she sometimes must, Avill 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 SAvel- ling and tenderness along the course of the urethra. The meatus Avas 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 Avas 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. * \ ' * inAammation 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 sIioavs that the adaptation of the remedy to the epi-phenomena is not ahvays easy or successful; and that a slight local inflammation Avhich 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. Treatment. / i -i , , , Some ot these cases can be cured by the regular practice of drawing off the urine Avith the catheter. In others relief Avill come Avith allowing a Sims' catheter to remain in situ. "When these cannot be borne it may be Ay ell to order the Avarm hip-bath, Avhich can be continued for several minutes and repeated four or Ave times daily. It is not a bad rule to advise that such a bath shall be taken as often Sitz-baths in. as the chill returns, or in anticipation of it. For this chill is a kind of outlaAv, or a spurious aAair 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 rena[compiicaCtionand eveiT such ca*e Ave should look for the presence of mucus, pus, epithelium, blood cells, alkalinity, and the absence of urea, and Avhen 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 Avithin the meatus, Avhich lacera- tions are likely to develop into linear ulcers u^thrrratl0n80f ^ that are very 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 Avound Avill give the greatest relief. Nitric acid 2, hyclrastis 2, or, if there is suppuration, calendula, may be mixed with glycerine and used in this way. Dr. Shears, ojr 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 (Avhich, Avhen mixed in equal parts with the oil of SAveet almonds, has no bad odor). This can be used in emulsion Avith the oil, or by means of a slender gelatinous sup- Fl°- 51- Duncan's suppository. pository, Avhich can be passed into the urethra and alloAved to dissolve. (Fig 51.) I have given you the details of this case until the present, just as they Avere recorded by Mr. Doav, our clinical clerk, and they will serve to sIioav you that one of your teachers at least, cannot treat these cases properly Avithout a little time and thought, and without an analysis of the symptoms and conditions that are pre- sented. This patient should have had mercnrius cerrosivus 6, a month ago. LECTURE XXXV. CYSTOCELE.—HERNIA OF THE BLADDER.—VAGINAL CYSTOCELE. VESICOCELE. Cystocele. Symptoms. Case.—Varieties of; treatment, mechanical, and surgical. On dila- tation as a means of di ignosis 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 tAvo children, the eldest of which is Ave and the youngest is three years. About six months ago she began to have a discharge from the vagina, Avith severe bearing doAvn pains. At Arst she thought she had falling of the womb, but iioav she thinks the bladder comes down, because Avhen the swelling is the largest so as to protrude a little from the vuha, 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 inAammation 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 Avhich it remains for tAvo or three days and then may disap- pear of itself. She is very nervous and restless, and does not sleep Avell. Dec. 3. A local examination in the presence of the sub-class shoAvecl vaginitis Avith swelling and deformity of the urethra. The p«.rts are very sensitive. A female catheter Avas introduced and its point passed dowiiAvard toAvard the IioIIoav of the Sacrum. The touch showed that the bladder and the uterus Avere 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 iioav in our elinic, which shoAvs that the aAection is not a very rare one. This is not g 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 shoAvs 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 shoAvs 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 tAvo latter celeariet,es ° cyst0" only in Avomen. Perineal cystocele is sometimes 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 Avith those avIio have borne a number of children, but it may happen in young girls, and in those avIio have been married Avithout becoming cystocele vaffma mothers. The pathognomonic signs of this affec- tion are the formation of a tumor at the anterior and upper portion of the vulva, Avhich is largest Avhen the patient stands erect; Avhieh disappears or is easily reduced Avhen she lies down; which is covered Avith transverse Avrinkles Avhen the blad- der is empty, and smooth Avhen it is full, Avhich interferes Avith urination until it has been reposited, and in Avhich the urine may accumulate until it has become ammoniacal, or even until calculi have been formed therein, and the change in the direction of the urethra, so that Avhen 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 ot the uterus and of the vagina, or if it has preceded it, cannot ahvays be knoAvn; nor is it of very great practical im- portance to speculate upon it. It is enough to knoAv 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 Avhere they belong. The treatment is either mechan- Treatment. ical OT Surgical. With a view of supporting these parts, various pessaries have been devised, of FlG-5^ Skene's pessary for cystocele. Avhich Dr. Skene's is in more general use than any other. 36 562 THE DISEASES OF AVOMEN. Case. My friend Mr. George E. Halsey, of Halsey Brothers, pharma- ceutists in this city, has devised a modiAcation of the Shannon supporter, Avhich is very simple and at the same time very useful in cystocele. If}ouever 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 Avhich time she had used various expedients to keep the bladder in position. She then began to Avear Haisey's pessary for prolapsus of the bladder, and she told me only a feAV days ago that she has hoav Avorn it for two years with entire relief, and I know that she is a truthful Avitness. In the American Journal of Obstet- rics for July, 1880, you "will And an illustrated description of Gehrung's ante-version pessary as adapted to the treatment of cystocele and procidentia uteri. The paper gives the details ot Haisey's pessary for cys-6^1*- casei of cystocele that have been tocele- cured by it in the hands of different physicians. Here is the instrument, Avhich 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 Avhich, en passant, are ce?ePanatr0ectofc0eieVSt°" equally applicable in recto- cele. Huguier's method consisted in dilating the urethra Avith the sponge-tent, so as to permit the introduction ot the index Anger of the left hand into the fig. 54. Gehrung's ante- bladder. The anterior Avail of the vagina version pessary. Avas then seized Avith the Museux forceps and dragged down Fig. 53 CYSTOCELE. 563 wards and forwards so as to separate it as far as possible from the corresponding Avails of the bladder, after Avhich several long pins Avere passed so as to cross each other be- Huguier's operation. neath the vaginal fold, and through the cel- lular tissue Avhich separates the vaginal and vesical walls. Care Avas taken not to pierce the bladder, by means of the Anger Avhich Avas retained Avithin it, after Avhich a Avire loop Avas throAvn about and beloAv the pins, and the A*aginal fold Avas tight- ened. The Anal step consisted in applying the ecraseur so as to remove the redundent tissue. The same operation, but Avith the finger in the rectum as a guide tor the pins, Avas made for recto- cele. Jobert (de Lamballe) removed several longitudinal bands of the mucous membrane from the anterior Avail of the vagina and stitched the incisions together, taking the pre- Jobert's operation. . . .. l ... , caution to leave a flexible catheter in situ in order to prevent the contractions of the bladder Avhile the healing process Avas going on. Vidal (de Cassis) advised to form a cica- trix by means of applying a number of serra-Anes, Avhich may Vidal's operation. . ,, , he allowed to remain until the parts of the vaginal mucous membrane included have sloughed away. fig. 55 serre-flnes The operation Avhich I prefer, both for cystocele and rectocele,is that Arst practised by Professor Stoltz, of Nancy, Stoltz's operation. \ . "L. . . ■" 1 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 0 ^ystoceief 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 Ane 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. Fig. 56. Stolz's Method. Most cases of rectocele are accompanied by perineal laceration, and can be disposed of by the operation of colpo- rectoceie. 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 Arm, 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, tAvo 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 UEETHKA, 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 ~,.% 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, AVis.,for relief from what proved to be a rectocele. The tumor was as big as a very large orange, and protruded from the Arulva. 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 Auids 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 satisAed 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 Aat 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 AVOMEN. 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 Anger. You have seen me perform this operation by means of the dressing forceps, Atlee's uterine dilator, and the sponge- 566 THE DISEASES OF AVOMEN. 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 Avish you to examine carefully. Ten minutes ago it Avas removed from the urethra of one of my lady patients, and it presents some appearances sp^nge-IenT f°r ^ which [t is (luite 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 Aveeks with a violent, non- specific urethritis. Under the appropriate treatment, which I have already detailed to you the inflammation of the urethra Avas 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 Avas 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 Avas Arst done by means of the instruments Earned, and afterAvards by the introduction of a series of long sponge-tents at intervals of three days. Each time that I have removed the tent it has presented the appearance so Avell sIioavii in this specimen. The use of the tent in this case enables me to locate the seat of the ulceration very definitely. I knoAV by the appearance of the sponge that the urethra is in a healthy state, and that the pus Avhich has been discharged with the urine came from some portion of the bladder. Having stretched the vesical sphincter Avith the dilator, so that the urine escaped freely, and aftenA^ards intro- duced the tent to the same distance, by actual measurement, I am confident that its tip Avas applied to and Avithin the neck of the bladder. The thick, creamy pus, Avhich has been brought away by the sponge, Avas not sufficiently Auicl to have run cIoavii from the cavity of the bladder, but Avas 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 conAclent 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 female urethra quite rapidly. For this reason, and because it lessens the duration ot suffering, Ave choose a freshly-made tent, one that will Mode of applying. soften and expand very readily. 1 he patient should be placed upon the back, Avith 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 Avere intending to apply the obstetric for- ceps. Then take Atlee's uterine dilator, or the long dressing for- ceps, have them Avell oiled, or anointed Avith glycerine, or Avith 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 doAviiAvards. 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 feAV 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. You may leave it Ayithin the urethra for from half an hour to one or tAvo hours, but not longer. For it Avill soften and dilate much more rapidly than if it Avere 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 Avere alloAved to remain for any considerable time. It need not be carbolized. If the passage is very narroAV, or has been infiamed, it is better to begin Avith a small-sized tent, and afterAvards 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 Avhen Arst introduced, and because it does not need to be 0 568 THE DISEASES OF AVOMEN. retained so long in the urethra. The bladder should be emptied before beginning the operation. I have used the tent also in very obstinate inAammation of the urethra, and ha\re thus been enabled to recognize, locate, and treat, an ulceration of its mucous membrane The tent in urethritis. much more directly .md successfully than I COuld otherwise have clone. The topical employment of remedies to the inAamecl 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 Avith the neck of the bladder, and Avith 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, Avhile 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, Avhen 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 ot the bladder by the eye and the touch. The late Dr. Gustav Simon devised vesical specula?, of various sizes, the largest being about an inch in diameter, Avhich 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, tha urethra is stretched as already described, and DILATATION OF THE URETHRA, ETC. 569 the speculum is passed slowly and carefully. Only Ave to ten minutes are required to dilate the urethra in this Avay. A better instrument, hoAvever, is Dr. Skenes', endoscope, which can be applied more easily, Avhich you can And in the instrument shops, and Avhich can be used with the sunlight or Avith a strong artiAcial 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 organ. For visual inspection of the urethra only, you may use a cylin- drical speculum like this. (Fig. 61); or, if you Avant to look jus Avithin the meatus, a common ear-spec- ulum Avill sometimes ansAver the pur- pose. Vesical palpation is not difficult es- pecially after dilatation ot the urethra Fio.ei. 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 betAveen them. The object of Object of intra-vesical ^ t()uch ftg appjied to the inner Sl]rface 0f the palpation. x 1 bladder is to recognize the hypertrophy of the organ in chronic cystitis, the presence of vegetative growths and 570 THE DISEASES OF AVOMEN. of foreign bodies Avithin it, for the diagnosis of defects in the vesico-vaginal septum Avhen 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 BGr. tie IV. TrZ Fig. 63. 7i BW., Posterior wall of bladder; B Gr„ Fundus; Tr. L, Trigonum Lieu- taudii: bb, 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 Avill 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. HVSTERICAL ISCHURIA. 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 Avas carried out by us repeatedly in one sitting and by several of our medical brethren, avIio happened to be in our clinique at the time, yet, as I stated above, no serious consequence Avas ever witnessed. By so great a number of palpations of the bladder, every scruple which might have been brought forAvard against it ought iioav to be put aside, and this method of exploration, Avhich was formerly only permitted in some rare cases and by specialists, should become the common property of every medical man." In my judgment, 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 Avails; and Em- A clinical caution. *~ . . met and others have knoAvn dilatation to be fol- loAved by incontinence. It is ahvays 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 ot cystitis, the question of forming an artificial fistula between the bladder and the vagina (kolpocystot- omy) for the purpose of diagnosis and for drainage Avill be con- sidered. HVSTERICAL ISCHURIA. I shall not detain you Avith any extended remarks upon the sub- ject of retention and suppression of the urine. There are several varieties of ischuria Avhich take their name from Varieties of ischuria. . , , , ,. ,, -.. -■ m the local seat and cause ot the disorder. Ihus we have the calculous ischuria, in which the disorder depends upon the presence of stone, either in the pelvic of the kidney, the ureter, the bladder, or the urethra; and the renal, the vesical, theureteric, and the urethral, which are clue to disease or obstruction in either of the parts just mentioned. All of these affections are as likely to occur in Avomen as in men. But there is one form of ischuria, or of anuria, why it may be which is almost entirely limited to women, and Svstcricftl* Avhich is knoAvn as the hysterical ischuria. There are tAvo reasons Avhy this affection is called hysterical (1), because 572 THE DISEASES OF WOMEN. it occurs ill 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 Avith 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 degree of suppression, Avith scanty urination, or perhaps, under strong 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 Avater for tAvo, three, or four days 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 knoAvledge of physiology Avill serve you a good purpose. You knoAV that a sudden and complete arrest of the secretion of urine is a much more serious Physiologicalcompii- affai than itg o.radual and partjal suppression. cations in. c x l l And you also knoAV that in the latter case there may be 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 Aveighed from day to day, shows the clinical and necessary connection betAveen them. There is an essential difference betAveen this form of ischuria and the suppression, with uraemia, Avhich is incident to malignant jaundice; between it and the uraemia Avith 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 iimneSdmPleCaSeSiSSelf"whichofteu accompanies the hysterical parox- ysm, and Avhich usually ends Avith a copious Aoav of clear, limpid urine. Such attacks are due to a temporary con- dition in Avhich the renal sympathies are unhinged, and they sub- side Avhen 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, hoAvever, this affection is associated Avith the graver forms of paralysis, and of renal or hepatic disease, the case is more serious, and Ave shall need to qualify our prognosis. ^rhe secondly form But, even in this secondary form the ischuria may sometimes be relieved by a feAV inhalations of chloroform, or of ether, by the passage of the catheter, as Avas 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 Avhich,! am indebted to our house physician, Dr. G. F. Shears: Case.—Miss A., aged 21 years, of a very nervous temperament was s uttering Avith Bright's disease and from very painful men- struation. The act of urination av;is quite painful and often per- formed Avith 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 AAras not passed in Ave or six hours. Promptly at the expiration of the six hours I Avas informed that she Avas in great pain and still un- able to urinate. The catheter was again used, being passed Avith difficulty on account of the sensitive condition of the parts. Every remedy Avhich seemed appropriate to this condition was tried, but Avithout avail. The catheter Avas the only r^al means of relief, and, although its passage caused the most exquisite pain the patient begged for its use and it Avas applied four times a clay for ten days before I determined that there Avas no real need of it. For some days my suspicions had been aroused as I noticed the varying character ot the urine Avhich Avas sometimes dark and scanty, sometimes nearly normal in appearance, and again as clear as the clearest spring Avater. Still I hesitated to act upon my suspicions. There Avas certainly a lesion of the uiinaiy apparatus and it appeared incredible that anyone Avould undergo the pain the patient seemed to suffer during the introduction of the instru- ment unless it Avas to relieve greater pain. At length being firmly impressed with the idea that the demand Avas 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 Avas 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 AvhateA^er it had done in the past it Avould not be necessary to use it again. My Avords were prophetic, tor although the case remained in my hands some 574 THE DISEASES OF AVOMEN. four months longer, during Avhich time the same symptoms Avere often present, the catheter was never again necessary. You are not to suppose that all of these case» are to be cured so promptly by the same, or by any other Internal remedies. ™ . , ™ ,., , . -, ~ means. The best effects are often derived from Atly-chosen remedies, among Avhich are apis mel., mere, cor., causticum, belladonna, hyoscyamus, and nux vomica. The most important clinical indications for these remedies will generally be found in the lesions of function or of structure upon Avhich the ischuria is engrafted; and you will therefore give clue prominence to the coincident symptoms of cystitis, urethritis, nephritis, Bright's disease, and especially of neuralgia, hysteria, and spinal irritation. LECTURE XXXVI. CYSTITIS. Cystitis. Causes. Symptoms. Diagnosis. Prognosis. Treatment, local, general, surgi- cal, and dietetic,—washing out the bladder,—reine-lies f >.r—cystotomy, mode of per- forming, the after-treatment. Objections to, results of, the artificial eversion of the bladder, drainage.—the milk diet in,—the Clysmic spring water in. The irritable bladder. Cace.—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 inAammation, the mucous membrane is more prone to it than any other. It is the sub-acute and chronic forms of mucous cystitis Avhich are commonly knoAvn as catarrh of the bladder. Acute cys- titis is rarely an idiopathic affection; and Ave do not Aery often meet Avith it unless in the puerperal state. Causes.—Cystitis may arise from exposure to cold and Avet; 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 OA'cr-clistention of the bladder; from the sudden arrest of leucorrhceal and gonorrhceal 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 hemorrhoids, as Avell as from ulcers, Assures, and foreign bodies in the rectum. Symptoms.—The symptoms which are most prominent, and Avhich are ahvays 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 ata time. 576 THE DISEASES OF AVOMEN. In the milder and more chronic cases the pain and tenesmus are very much aggravated by standing, riding, or Avalking about; while sitting or lying cIoavii may afford comparative ease. If, hoAvever, the constitutional symptoms are very marked, there may be a nightly aggravation Avhich interferes Avith rest in the recum- bent posture. The urine is hot and highly colored, and in a little Avhile be- comes alkaline in its reaction. At Arst it is cloudy, but soon con- tains mucus and blood; then it becomes more thick and glairy, and Anally deposits a viscid, ropy, or purulent sediment. Its passage is often accompanied by pains Avhich radiate along the ureters to- Avards the kidneys, along the urethra down the loAver extremities, toAvard the spine, the sacrum, or the perineum. If there is any considerable uterine disease or deviation, all the symptoms will be Avorse 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 surfice 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. Xor will 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 Avomen, Avithout a physical examination by palpation, percussion, by the touch through the Anger 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 sameAvay that Ave 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, Avhich 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 Assure 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 Avhich the patient has already been subjected. Treatment.—The treatment is local, general, surgical and die- tetic. In the acute form, local applications of hot Avater by means of compresses to the pubic region, poultices of The local treatment. l L . . Aax-seed or of oat-meal, or Avarm sitz-baths are of the greatest service. Sometimes the hot-water irrigation of the A-ao-ina Avill mitigate the suffering and relieve the congestion. If the case is complicated Avith prolapse of the bladder, Avith dys- menorrhcea, or Avith pelvic congestion from any cause, the patient should be advised to lie with the hips eleA^ated, 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 WOMENT. Iii chronic cases Avith copious discharges of mucus and pus, great relief may be obtained and a source of ^ washing out the biad-infection removeci5 by washing out the bladder once or tAvice daily Avith Avarm water. This may be done by means of a closely Atting 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 Aushing the bladder, and for Fig. 67. Nott's double-current catheter. medicating its inner surface afterAvards, is such an one as this, Avhich 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, Avith Topical medication of + i ^ __• T ■ . . , . , m the bladder. the urine, I have certainly had good effects from the local use of calendula. In rheumatic and hemorrhoidal subiects you may substitute the hamamelis for calendula; Avhile, if the trouble is of traumatic origin, arnica is CYSTITIS. 57$ best. In all cases, hoAvever, only a feAV 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 The medical treat- i • i , .,. . . . . , ment. burning and tenesmus Avith violent pains in the bladder, the passage of scalding urine Avhich issues drop by drop and is scanty, turbid, and sanguineous. When these symptoms are accompanied by prolapse of the uterus and of cantharis. the rectum» witn Pams along the ureters and in 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 gonorrhoeal vaginitis or urethritis. And so like- Avise of sub-acute cystitis Avhich has resulted in atony of the blad- der Avith retention of urine. There is another indication for cantharis Avhich it Avill be Avorth your Avhile to remember, Avhich is that it is adapted to cystitis occurring in those avIio are subject to erysipelas, more especially of the face and of the external genitals. It is just as true in the case of vuhTar erysipelas, Avith vesical irritation, occurring in lit- tle girls, as it is Avith Avomen. Belladonna is called for when the region of the bladder is very sensitive to the touch, Avith shooting pains in the loins, and paralysis of the neck of the blad- der, Avith involuntary discharges of urine. It is especially adapted to those nervous and delicate subjects Avho cannot sleep, and-who greatly exaggerate their suffering. In very acute cases, and especially if they are of gonorrhoeal 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. „,. , n . , ,. . , . " There are, hoAvever, a feAV practicaf clinical in- dications Avhich 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 icith paralysis of the bladder, hyoscyamus, causticum, carbo veg., 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- liAca, or camphora. The surgical treatment consists in devising a means for the thorough and constant evacuation of the blad- der. There are tAvo methods of Ailing this in- dication; (l) 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 ereat- ing a vesico-vaginal Astula, Avhich establishes a continuous drainage of the organ. It consists in passing a grooved staff into the triangular space, the apex ot Avhich is at the com- mencement of the urethra and its base at a line draAvn trans- versely from the oriAce of one ureter to the other. While this is held firmly, the perineum being retracted Avith a Sims' speculum, and the patient anaesthetized, 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 Avith the forceps, everted, and about one-fourth of an inch of tissue on either side is snipped off Avith the scissors. The haemorrhage, Avhich is not troublesome, if Ave have kept to the median line, may be controlled by torsion, by Pean's forceps, or by serre-Anes. CYSTITIS. 581 In lieu of the incision, Dr. Pallen has proposed to make the opening Avith the thermo-cautery, which obviates the risk of venous haemorrhage, and prevents the premature contraction and closure of the Astula. The subsequent local treatment consists in Avashing out the bladder daily, and thoroughly, Avith starchy and demulcent fluids, such as flax-seed Avater, etc. When tiie cystitis The after-treatment. . . . is cured, the artiflcial opening may be closed as in ordinary cases of vesico-vaginal Astula. The chief objections to this vesicovaginal section are that the operation is not devoid of danger from consecutive cellulitis, for although in most cases at the point of the incision cystboteomrtOVaKinal there i. 1. Rectum. 2. Uterus. 3. Bladder. 4. Vagina. are slight and self-limited forms of uterine deviation which are of no consequence in a clinical point of view, except A clinical rule. . . . 7 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) Avill give you a correct idea of the normal position of the uterus as it lies betAveen the bladder in front and the rectum behind. Observe that even Avith the bladder distended, its axis inclines forAvard at an obtuse angle Avith the axis of the vagina; and that its fundus and body are raised above the bladder in such a Avay as greatly to be inAuencecl by its vary- ing form. This fact, together Avith the intimate union existing UTERINE DEVIATIONS AND DISPLACEMENTS. 591 betAveen the lower segment of the uterus and that of the bladder, shoAvs Avhy one of these organs cannot be displaced Avithout in- volving the other. The uterus is sustained by folds of the peritoneum with inter- lacing fibres and areolar cellular tissue. The utero-vesical liga- ments in front of the Avomb, the utero-sacral mentesu £ ligaments behind it, and the broad ligaments on either side of it, are the moorings by Avhich it is attached. BcIoav, its only support is derived from the vaginal column, Avhich rests upon the perineum. Etiology.—The causes of uterine displacement are predisposing and exciting. Among the former the most prominent is preg- ¥> _,. nan?v, Avhich, by increasing the size and Aveight Predisposing causes. . ~ c of the uterus; by changing its form and its vascularity as Avell as its relation to other organs; by straining its dgaments 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 poAverful predisponant of uterine displace-: ments.* The monthly congestion of the ovaries and their append- ages, the risks of interruption to the Aoav, 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 arc unknoAvn 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 Avearing of heavy skirts and dresses Avhich are Avoidable causes. '. " 1 i *■ .,1 1 it , not properly suspended from the shoulders, and of high heeled shoes, Avhich change the relation of the organs Avithin the pelvis and place the centre of gravity Avhere it does not belong, are all of them, in a greater or less degree mischievous. Skating, dancing, riding on horseback, Avithout regard to the menstrual period, and especially the neAV method of cultivating •See pages 132 and 160. 592 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 Avhich lie within the uterus itself; (2) the extrinsic, or those which are Avithin the Xh© Gxcitins* C3.US6S. 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 1 • t i i • i uterine groAvths, 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 avouIcI no more think of trying to cure a chronic case of prolapsus Avithout Arst measuring the depth of the uterus with a graduated sound like this, (Fig. 71) than I Avould of giving Fig. 71. Jenks' elastic graduated sound. a diagnosis of whooping cough Avithout looking at the fragnum lingua?. When you have no graduated one, an ordinary sound will ansAver the purpose. Each and all of the afieetions named are characterized by an increased depth of the uterus, Avhen Ave meas- ure from the os to tiie 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 Avomb, although in a very different way. The extrinsic causes are the inclination or bias Avhich the uterus has received during pregnancy; the pressure of extra-uterine flbroicls, of ovarian, abdominal, and pelvic tu- The extrinsic causes. , ,. . , .. , ,. , . mors, and ot the abdominal viscera; the 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, hemorrhoids, prolapse UTERINE DEVIATIONS AND DISPLACEMENTS. 593 of the boAvel 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 Avith the tolerance which the uterus has for them. The accidental causes are chieAy mechanical, and include the mischievous effects of falls, bloAvs, and injuries from lumping, or straining The accidental causes. , , , ° ° the body severely. The extreme or spasmodic action of the diaphragm in coughing, convulsions, in running, or rapid breathing from any other cause, may also put the Avomb out of place. Here Ave 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 Avhich I have already spoken. (Lectures IV and V.) They vary Avith the kind and degree of the displacement, and Avill therefore be treated of Avhen Ave come to speak of the several varieties of this general disorder. The remote symptoms are of two kinds (1) those Avhich arise from a derangement of the intra-pelvic circulation, and (2) those Avhich depend upon disorders of the nervous system, both ganglionic and cerebro- spinal. The former class of causes accounts for most of the troubles Avith the liver, the kidneys, and the digestive organs Avhich 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 Avhichare so common in these disorders of place, Fi as well as in uterine affections generally. Diagnosis.—The diagnosis Avill be considered Avhen Ave 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 abso'lutely impossible without a physical examination. iG. 72. Gid- den's uterine sound. 38 594 THE DISEASES OF AVOMEN. Treatment.—The general therapeutics of uterine displacements involves several important questions: (1) the significance and clinical value of the subjective symptoms in the tics^f™ therapeu" choice of the remedy, or remedies to be em- 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 tAvo first of these inquiries, it has always seemed to me that, in a given case, if the subjective symptoms are common The scope and value to two or more kinds of uteri ne deviations; if or internal remedies they are not to be depended upon exclusively, exclusively. •J.i-i • i • -,. 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, Avhich cause and complicate these displacements, are of so varied a character; and if the hysterical epi-phenomena are most prom- inent and least significant, Ave ought not to rely Avholly 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- wmcn are given upon pathogenetic indications liable indications of an are always inefficient. For these subjective kinds. i i • 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 em- placement, by clinical experience, and by physiological reasoning also. Hence I have said that the reports of cases in Avhich it has been claimed that deviations and displacements of the womb are easily cured by the affiliated remedy are faulty, because they have not told the whole story; am\ 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 Avon- clers in this Avay, 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 oavii 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 Avhich a poor felloAv is on trial for his life for having murdered a man in an out-of-the-Avay place. The evidence is all in, and the case is about to be closed Avith the result of liberating the prisoner, when a travelling daguerreotypist rushes into court Avith 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 Avas convicted by this proof and by the plea of this providential Avitness avIio 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 Arst 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 eAridence that the uterine sound can furnish is brought into court, Ave shall have the facts in the case, for " the apparatus can't lie." Bear in mind, therefore, that the symptoms upon Avhich you are to rely for the choice of your remedies in this class of cases are the cardinal signs that are coupled Avith some struc- The cardinal symP- t } functional disorder of the generative toms. & 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 Avith menstruation, the symptoms will have a peculiar significance. You Avill have an ample illustration of this mode of prescribing in my clinic, but let me quote a case Avhich 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 tAvo years old, and no miscarriages. Her labor lasted only half an hour, her lying-in Avas tedious, but so far as Ave can learn, she had no especial illness. Her health has, hoAvever, been Avretched from that time until the 596 THE DISEASES OF AVOMEN. present. She nursed the baby for fourteen months. The menses returned Avhen the child was nine months old, and have come regularly and copiously every three to four Aveeks since that time. She complains sorely of bearing cIoavii pains, and dragging in the hips and loins, Avhich almost entirely prevents her from being upon her feet. At times there is so much doAviiAvard 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 Avas 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 Avas four and one-half inches. She took secale cornutum 2, three times a day for two Aveeks; and then secale 3, as often for another fortnight. She received no local treatment Avhatever, and took no other remedy. At the end of one month the uterus Avas measured again in the presence of the sub-class, and its depth Avas found to have been reduced to three and one-half inches. Meamvhile her general health and spirits had improved in a corresponding degree. The dilapidated, dragging sensations had almost entirely disappeared, the pressure Avas 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 Avas of mocleiate quantity. Secale 3, Avas continued as before. I AArill not repeat what has already been said concerning subinvo- lution of the uterus, but Avill remind you that, in the case just cited, the cause of the prolapsus, as Avell as of the menorrhagia, Avas recog- nized by physical exploration. The curative indications Avere partly physiological, and partly clinical. If the secale Avould finish the work of uterine involution, Avhich for some unknown reason had been interrupted during the lying-in, it Avas exactly Avhat Avas 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 avIio saAv the case Avith me. " It runs Avithout 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- tj.ii 1 1 ,, saries an old story. new' for there have always been those who were 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 for intermittent fever, blooms peren- nially in our medical societies. Nor is it likely to be settled until physicians have learned to discriminate betAveen cases of displace- ment that are primary and those which are secondary. This is the first step toAvards the correction of extreme vieAvs on both sides; for Avhere both parties hold to a half-truth neither has the benefit of the Avhole truth. A pessary is a crutch, era 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 Avorn Avithout regard to the month; and from a lack of cleanliness, Avhich is often consequent upon Avearing 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 beloAv the organ. If the cervix is capped Avith a cup that is either too large or too small, its protecting epithelium Avill soon be destroyed, and abrasion and ulceration Avill fol- Ioav. All kinds of stem-sup- ports are likely to induce cellu- litis, or peritonitis Avhich may Fig. 71. Curved stem pessaries. result fatally. (Fig. 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 fistulse. A case of this kind Avas reported to our National Society a feAV years ago by my friend Dr. S. S. Lungren, of Toledo, in which he found the fragments of a glass tumbler that had been introduced bottom side up to sustain 598 THE DISEASES OF AVOMEN. the uterus. Similar cases are on record in our medical works, and, although it may seem strange to you that a Avoman should have forgotten the introduction of such an instrument, you may perhaps stumble upon such things in your oavii exper- ience. A case is recorded in the Ohio Medical and Surgical Journal for 1852, in Avhich a Avooden pessary Avas 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 there . 8ub_invollltion 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 Avith- out hsematocele. They are more especially indicated in displacements Avith vaginal relaxation and prolapse, procidentia, Avith cystocele and rectocele oc- curring in avo- Indications for. men of a very lax fibre, Avith muscular atony, avIio have borne their children rap- idly, and avIio 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 loAver segment of the Avomb, pessaries are of great temporary benefit. The Same is true when, as ill old Fio.76. Coxeter stem pessary. ladies, Ave are not warranted in operating for the radical cure of these displacements. Fig. ts. Mcintosh's uterine pessary. Case. UTERINE DEVIATIONS AND DISPLACEMNTS. 599 Briefly, I think it is Avrong to abuse these instruments, or to insist upon dispensing Avith them altogether, until avc have some- thing better to fill their place and to answer ^ Argument lor their their purpose> If you discard them entirely, and refuse to apply them under any condition, a certain share of your patients Avill be compelled to consult those Avho Avill use them for their relief. And, after all, since they do not interfere Avith the action of fitly-chosen remedies, Ave 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 Ave have ansAvered is that of resorting to external, or abdominal supports for the relief of certain forms of uterine displace- ments. There are two sides to this question also. The objections urged against these belts, binders or corsets, as a class are that, Avhen snugly applied they Aveaken Abdominal suppor- ters. Fig. 77. Mathieu's abdominal supporter. the abdominal muscles by their steady pressure; that they force the intestines doAvnAvarcls upon the displaced uterus and thus increase the difficulty; that they interfere Avith objections to. the freedom of action of the diaphragm, and so embarrass respiration; and that, sooner than Avith any other form 600 THE DISEASES OF AVOMEN. of support, a woman becomes a slave to them, and must continue to Avear 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 Advantages of. .^ gome cageg qj_. peri_uterine inflammation; their adaptation to cases in Avhich 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 fact 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 ahvays 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 Avill need a more complicated binder Avith elastic straps and adjustable pads, which can be shifted like those upon a truss. Here are three kinds of bells which in many cases will answer a good purpose. (Figs. 78, 79 and 80.) Other forms ot 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. TAventy years ago one who had had more experience than any other physician in America, in the treatment of uterine displace- ments Avrote 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 oigan to its proper position; but, on the contrary, that the Avhole tendency of the abdominal brace is to aggravate the pressure on the uterus, and increase its deviations. Hence Fjg 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 Avhich 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." * Fio. 80 a. Fig. 80 b. Shannon Self Adjusting Supporter. 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., I860, page 299. LECTURE XXXVIII. PROLAPSUS UTERI AND PROCIDENTIA. Pseudo-prolapse of the uterus. Prolapsu3 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 Avas summoned in haste to visit Mrs.----, Avho, the husband Avrote me, Avas "almost dead Avith prolapse of the Avomb." In his note he requested me to bring the necessary instruments for replacing that organ. The patient, aged 52, had been ill one Aveet, under the care of two physicians avIio had diagnosticated the case as one of prolapsus uteri, and avIio, I Avas told, had several times restored the Avomb to its normal position. These operations had caused her great pain, and she had a mortal dread lest I should think it necessary to repeat them. The clay previous, the doctor had succeeded in introducing a Hodge's lever pessary, Avhich, 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 Avas retching and bilious vomiting, and, although she had taken cathar- tics, the boAvels had not been opened for four days. There Avas much ineffectual tenesmus, and with each effort at stool she com- plained of feeling as it the uterus and neighboring organs Avould be expelled from the body. She Avas exceedingly nervous, and at intervals of five to fifteen minutes suffered acute pains across the inferior portion of the abdomen. These pains Avere 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 Avas 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, Avere to be taken in hourly alternation until the symptoms improved, after Avhich they Avere to be repeated every tAvo hours. It 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 Avater. I made no examination per Araginam. 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 Avere repeated only at 603 PROLAPSUS UTERI AND PROCIDENTIA. 603 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 Avas very pain- ful, and she Avas much exhausted in consequence. The tenesmus and vomiting Avere relieved, and she declared herself Avell. Con- tinued the same remedies once in four hours. The " touch" re- vealed the uterus in situ. The husband and family Avere delighted Avith the promptness of the relief afforded. Tavo clays later this patient Avas able to attend to her household duties. Nothing is more common than a temporary prolapse of the womb. Some Avomen have it at each menstrual period; others after any extraordinary fatigue, as in Avalking proIapsUeenCy°f Ul6rine or ridinS; some from ll fit of mental anxiety or of coughing; others after a stool; and others again after coitus. When induced by these causes it is a self- limited affection, and may pass aAvay Avith 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 Avould 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 Avrong diagnosis in cases of this kind. Either the slight and temporary displacement may be converted into a permanent one, Avith all its Consequences of in- ■,/*»• i t i 1 l- correctdiagnosis. consequent suffering and disorder, by reason ot 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 Avhatever kind. Nothing could be more cruel, harmful and unnecessary, than to resort to manual treatment in such a case as Unnecessary manipu-thj ■ ^ t jQ wMch j f()Und jt> Wj latlon. ' n . J explore and Avorry such a sensitive Avomb Avith the sound? Probing will not relieve these acute symptoms, and a pessary avouIc! be about as useful as a fracture box in inflamma- tory rheumatism. Opiates might deaden the sensibilities, but they are possessed 604 THE DISEASES OF AVOMEN. of no curative relation to the symptoms detailed, and avouIcI indi- rectly unhinge the nervous sympathies more Harmful medicat.on. " f? . .. and more. It 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 oavii 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 avIio have preceded us. On the other hand, the fact that such cases may get Avell of themselves, providing Ave do nothing to interfere therewith, is too frequently lost sight of by our physicians. anCa™ia?mT E™7 ki»d of remedy has thus been given and extolled as a specific for uterine deviations. You will find the most incredible stories of cures Avith this or that dilution detailed in our books and journals. Perhaps a single dose has Avorked the most marvelous results, the womb being replaced, according to the report, almost as soon as the medicine was swallowed, no alloAvance 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 Avhat might otherwise develop into a troublesome case of do^nproh^sus?8may "terine prolapse. We may sometimes avert 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 Avhat avouIcI 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 Avas adapted to the relief of the peculiar incidental symptoms of which this patient complained. Nux vomica will not go to Avork like an intelligent agent to re- store the fallen Avomb 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. We must select the remedy according PROLAPSUS UTERI AVITH ULCERATION. 605 to the symptoms that are present, just as in a case of 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 oavii observation must help you to de- cide. It avouIc! be very Avrong to claim that Alternation of reme n_____ 1 , i a- i • ±-\ • dies cures nave not been effected in this manner, and equally at variance Avith 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, AVITH SUPERFICIAL ULCERATION OF THE CERVIX. Case.—Mrs.----, aged tAventy-four, began to menstruate at twelve, from which period she dates her illness. The catamenia are irregular, sometimes appearing once in three Aveeks, again in four, and, occasionally, with an interval of five Aveeks. 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 clays, and is normal in quantity and quality. During the inter-menstrual period she complains of a bearing clown sensation Avithin the pelvis. There is great Aveakness of the back in the lumbar and sacral regions. Standing for any length of time, or Avalking a short d/stance, fatigues her exceed- ingly. When Aveary, 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 folloAved by a faint feeling, and sometimes by actual syncope. At other times, and especially if she is in a room in Avhich 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 doAvn upon the knees." At such times the lower limbs feel numb, insensible, and semi-paralvzed, but the knees are especially Aveak and poAverless. Another symptom Avhich she has remarked is a sense ot coldness on the top of the head, which, Avhenever she swallows either cold or Avarm drinks, is curiously changed into a sensation as ot "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 outs a cup or glass to her lips. For some years past (she does not know Iioav long) she has had leucorrlKea." The discharge is habitually more profuse immediately before, but ceases during menstruation. In character she de- scribes it as "catarrhal," creamy, bland and unirritating. 606 THE DISEASES OF AVOMEN. The touch reveals the uterus prolapsed, the neck of the Avomb tender and tumefied. When she stands, the anterior lip of the cervix rests upon tiie posterior vaginal Avail, directly over the perineum. Upon examination Avith the speculum, a large, irreg- ular, suppurating ulcer Avas found to extend Avithin the external os uteri, and over a considerable portion of the anterior lip of the cervix. Uterine deviations not unfrequently date from puberty. They are the more likely to IoIIoav if menstruation begins at a very early uterine luxations or a Aery late age. With this patient the flow may begin at puberty. first appeared Avhen she Avas 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 Avhich are contingent upon that process in older women. In the case before you, the afflux of blood to the internal generative organs, the increased Aveight of the Avomb, the requisite dilatation and relax- ation of the uterine cervix and of the vagina, the contractile effort of the Avomb to expel its contents, supplied the identical conditions Avhich predispose to uterine displacements folloAving 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- irregular menst™- exist- Itis unusual to meet with a chronic case ationacauscof proiap- of prolapsus, or of retro-version, iii 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 Aveight has borne it down upon the structures that Ave re designed to sustain it, until they have given Avay, and it has become displaced. For if the uterine ligaments are not fortified against this increase of Aveight in the Avomb, 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 betAveen 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 Avhieh 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 sacral pains are modified according to circumstances. Pains- As a rule, they are more acute and tormenting in nervous, hysterical, and delicate Avomen than in those avIio are of a different temperament and organization. Among the more robust and energetic there is sometimes a remarkable tolerance ot uterine displacements, Avhich may exist for years Avith 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 Avalking, and some- times by bending forAvards and then rising suddenly to an upright position. The back feels very weak, and perhaps as though it Avere 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 Avomb, these several diseases are almost ahvays 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, „ , . of the sympathetic, is sufficient to account tor Prolapus and par- ■ i ' . atysis the sudden, partial, and temporary paraplegia, or powerlessness in the loAver limbs. She falls upon the knees irresistibly. There is numbness and semi-paralysis, Avhich are self-limited. The nervous currents between the spinal center and these parts are interrupted, and the consequence is manifest. Rest, Avith change from the upright to the horizontal position, causes the womb 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 faintness, 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 SAvalloAving cold or warm drinks, Avhich act produces a "crawling" sensation beneath the scalp, as Avell as the sense of suffocation Avhen 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, hoAvever, that these symptoms are none the less real because Ave style them "nervous," and because it is only The reality of " ner- through our knowledge of the reflex nervous vous' symptoms. system that Ave are competent to explain their existence. In truth, this Avoman 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 other other symptoms. For, although the element of exaggera- tion enters largely into the hysterical constitution, Ave cannot doubt that persons Avith 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 Avill tell you that prolapsus, leucorrhcea, 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 vieAv is correct; but symptoms, like quarrels, do not come Avithout cause. When it is possible, Ave must 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, Avhich it is most desirable and necessary for the physician to knoAV. Our patient has a chronic prolapse of the womb, Avhich in all . , probability OAves its origin to causes already Leucorrhcea and ul- i -J ^ J ceration from proiap- named. FolloAving this displacement, and con-. 8US' sequent upon it, she also has leucorrhcea and uterine ulceration. Which of these two contingent affections came PROLAPSUS UTERI AVITH ULCERATION. 609 first, Ave do not know. Nothing is more common than a leucor- rhceal Aoav 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 Ioav upon the perineum, its friction against the poste- rior vaginal wall is pretty certain, sooner or Llceration from ' . " . . . abrasion. later, to cause an abrasion of 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 Avill 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 mation ahvavs imperils the proper nutrition of inflammation. * * >■ i the organ or tissue in which it is seated. Its chief danger lies in this Aery fact. But there are many disorders of nutrition, and some of them of a most serious character, Avhich certainly are not in any manner dependent upon the inflammatory process. It is probable that a large proportion of cases of uterine ulcer- •>',ion commence Avith simple abrasion of the mucous surface. The Avearing of an ill-adjusted pessary, or of one Cause of uterine which is made of improper material, the careless abrasion. L l ' 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 throAvn into the vagina, especially after coitus or during menstruation; the contact of corrosive discharges from the uterine cervix, and of vitiated semen, as Avell as friction from the various uterine dis- placements, may be sufficient to produce it. Superficial ulceration of the os folloAving abrasion of its epithe- lium differs from other varieties of uterine ulceration. It consists 39 610 THE DISEASES OF AVOMEN. 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 Ave shall fail. Any attempt to cure the leucorrhcea Avithout Therapeutical refiec- reco„.nizing or relieving the ulceration of the os tions. » ft .-> uteri, or to remedy this lesion Avithout doing anything for the displacement of the womb, avouIc! reflect upon our skill and experience. And so also if we Avere to elevate some of the incidental, irrelevant, hysterical symptoms of Avhich our patient complains, to the dignity of characteristic symptoms, when they do not deserve such distinction, and afterAvards busy our- sehes Avith 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 Avhich is the reverse of that in Avhieh they came Rule deducible from _t{ j t fi t d b;lck t tj startin? the order of symptoms. ' » point. But Avhen 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 Avoman 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, it necessary, she should persevere in this for some Aveeks, or even for months. For you will not cure these cases so promptly as sonic enthusiasts avouIcI 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 seAving machine than she is to run with a fire engine. And, if she Avere my pri- Dressing the hair, etc. ^- J l vate patient, I should forbid her dressing her oavii hair—Avhich is really one of the most tiresome and injurious kinds of exercise for a woman avIio is suffering from uterine dis- ease. Her clothing should be Avorn loosely about the waist. No matter Avhat the kind and degree of the uterine displace- ment, if the os uteri is abraded or ulcerated, it is Avrong to apply PROLAPSUS UTERI AVITH ULCERATION. 611 any pessary Avhatever: tor, by direct pressure upon, and contact with, the denuded surface, these instruments Contra-indications __.,. 1 • • i • £.• tt i i • for the pessary. may wolk serious mischief. Under such circum- stances, they have been knoAvn to increase the sufferings, to extend the lesion of the cervix, to multiply the reflex symptoms, and to augment the leucorrhceal Aoav. 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 Avoman's recovery, of Avhich I have forborne to speak in her presence, is the prohibition of sexual con- gress. OtherAvise it is next to impossible to <:onrg°relbs!ti0n0f S6XUaI cure some of thsse cases* Her separation from her husband Avill insure against the undue determination of blood to the internal generative organs, wdiich 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 Avomb. If Ave overlook or ignore this item, a cause Avhich may counterbalance all our efforts at cure, Avill be constantly at work, and avc 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. WJ ,. . And so, also, of similar cures Avhich are ascribed Modus operandi of causiics, etc., incer- to the use of cold Avater in the various hydro- tain cases, pathic establishments. Without saying a Avord against this system of treatment, it is quite probable that the ben- efit derived m many of these cases is clue 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 tiie strong tincture of calendula acid Calendula topically. , ,. J , ,. ,, 1 two ounces eachot glycerine and distilled Avater. Of this mixture a tablespoonful may be put into a teacupful of tepid Avater for an injection per vaginam. This injection, Avhich 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 SAvelling and tenderness of the cervix, Avhich are so marked in the case under review. In not a feAV instances it may suffice to arrest the leucorrhceal flow. Or a mixture of glycerine and Avater 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°tsher!0Cal eXP6di" the hydratis 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 Avonderfully efficacious in healing these simple abrasions of the utero-vaginal mucous membrane. The preparation of collodion Avith castor oil, recently extolled by M. La tour, in his method of treating diseases by isolation, has been of great service to some of my private patients, in Avhose cases it Avas 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 Avill study the symp- toms carefully, excluding those Avhich 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 Avhich 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, Avith obstinate constipation. The boAvels 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 Avould be forced from her." All the unpleasant symptoms are increased during and for some time after the menstrual period. At times she experiences severe cramping pains in the right thigh, Avhich 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 from the latter paroxysms is obtained by lying doAvn immediately upon the PROLAPSUS UTERI AVITH RIGHT LATER0-AVERSION. 613 left or opposite side of the body. By keeping quiet in this posi- tion for a little Avhile, the cramp-like pain subsides and soon Iea\'es entirely. She has not been able to lie Avith any degree ot com- fort upon her right side since her ill-health began. And if she rolls upon that side Avhile sleeping, the cramps in the right thigh Avill aAvaken her at once. She has an almost constant headache in the region of the temples. During and after the menses, Iioav- ever, it is apt to be located in the occipital region. The flow is too profuse. It continues a Avhole Aveek, instead of four days as heretofore. It is also too frequent, returning as often as every three Aveeks at the farthest. You have doubtless observed the relative frequency of consti- pation as an attendant upon the diseases of Avomen. One of its most common causes is a paralysis of the rec- constipation from t j j^ examined this patient per vagi- rectal paralysis. •- i o 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 Avomb against the boAvel 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 Avas 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 ahvays depends upon pressure applied to the side of its boclv 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 Latero-version from dispiacec} ejther toward the right or the left an over-loaded rectum. L ° side of the pelvis. When, hoAvever, it depends upon the pressure of a tumor caused by impacted feces contained Avithin the rectum, the fundus will, as in the case before us, ahvays be thrown toward the right acetabulum and the cervix toAvard the tuberosity ot 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 Avhich Mrs.----complains are referable to pressure of the corpus uteri upon the anterior The cramping pains. ■,,/?,! 1 1T'i 1 v branches of the sacral nerves. v\ hen she lies upon the right side, the Avomb falls upon those nerves, or is 614 THE DISEASES OF AVOMEN. pressed by the distended rectum against them. When she turns upon the left side, it drops away, and the cramp ceases. When she Avalks 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 toAvard 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 avouIc! be forced through the vulva. These cramp-like pains are1 very similar to those Avhich 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 Avomb is retroverted suddenly, as from a fall or other impulse, one or both the loAver extremities may be violently cramped and even paralyzed. In this poor Avoman'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 loAver 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 bv the displacement of the uterine cervix, or The vesical symptoms. " j?.i ±1 , by pressure ot the uterus against the neck of the bladder and the urethra. The uterine cervix is so joined Avith the inferior portion of the bladder that it cannot be very decid- edly displaced Avithout 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, luid, because they suppose that all de- rangements of the urinary function are due to renal disorder, patients not iwifrequently consult their physician tor the cure of disease of the kidneys, Avhen they are really suffering from some form of displacement ot the womb. Such slight degrees of prolapsus, as are incident to the men- PROLAPSUS AVITH RIGHT LATERO-VERSION. 615 strual period and to the early Aveeks of pregnancy, are sometimes the cause of frequent and painful micturition. These sufferings are, hoAvever, 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 *;he other. In chronic prolapsus all these symptoms are made to vanish, at least temporarily, by lifting the Avomb into its proper position. This case illustrates the possibility of uterine displacements disconnected Avith abortion or Avith labor at teim. The frequent return of menstruation, and the excess of the Aoav, indicate a primary disorder of this very important function. Treatment.—There are tAvo reasons Avhy this Avoman is not Avell. The first is, that her rectum is paralyzed ; Leading indications. 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 neo-lect of the patient to attend to the calls of To remedy ti-e con- n!lture, or to go to stool regularly everyday, stipation. . ° , T,, this bad habit should be corrected. Lnemata containing olive oil, or castor oil, may be given for temporary relief, with the vieAv of softening and removing the impacted fa?ces. Laxative food is of more service in constipation depend- ing upon causes Avhich affect the upper portion of the intestine. Some of these patients with paralysis of the rectum might eat broAvn-bread, oatmeal, figs, prunes, or baked apples until dooms- day Avithout 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- ^ jacj. Qf resilieucv ill the rectlllll, tllC pi'C'S- restore the uterus. . ence of hecal matter Avithin 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 THE DISEASES OF WOMEX. with its incidental uterine displacement, are alumina, nux vom- ica, natrum mur., plumbum, opium, belladonna, sulphur, zincum and lycopodium. Among those Avhich 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 nux vomica 3d at night, and calcarea carb. 3d in the morning, one close of each daily. She must keep off her feet as much as possible, particularly at the catamenial season. PROLAPSUS AVITH ANTERIOR INCLINATION OF THE FUNDUS UTERI. Case.—Mrs. S----, aged 27 years, has never been pregnant. She has had prolapsus and has Avorn a ring pessary for a year past. Local examination discloses a doAvnwarcl displacement, with a slight inclination of the fundus of the uterus toAvards the bladder. The menses are regular, but the prolapsus is much Avorse during the floAv. 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 might have resulted. But, awkAvard as it is, I think a Hodge's pessary (Fig. 83) Avould 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 Fto. 8i. these cases. As a rule, Hornby's instrument, Avhich is cheap, durable, easily adjusted, Avith a spring-stem, and a per- ineal support, is the one that I prefer. PROCIDENTIA UTERI. Case.—Mrs.----, aged forty-seven, Avho 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 ceased tAvo 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 clone for her A fortnight ago I shoAvedyou a patient Avho had suffered from procidentia of the uterus for sixteen years. Youwill Case. remember that in her case, the tumor was very large, and that she told us it had been carried externally for a num- ber of years Avithout being replaced. The sur- fig.82. zwanke's penary. face of the tumor was excoriated in large patches, and the cervix was SAVollen and discolored almost beyond recognition. The tumor was the form and size of an egg- plant, and, from venous congestion its loAver portion had very much the same color. (Fig. 88.) In the case Avhich is noAV on the table, although the tumor is not so large, the Fro. 83. Hodge'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 tAvo 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 knoAV 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? loAver portion, and by the possibility of pass fig. so. Hornby's pessary. jna-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 iioav Avithdraw it and sIioav you the depth ot the Avomb, Avhich is exactly four inches. Fig. 81. Fraser's pessary. Diagnosis. 618 THE LISEASES OF AVOMEN. Case. Fig. 86. Hornby's pessary. There is very little doubt that this displacement of the uterus folloAved childbirth, and that the escape of the organ from the pelvis Avas 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 Avoman 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 in a perpendicular direc- tion Avith the cervix looking dowiiAvard. I passed the sound and shoAved the class that its depth Avas seven inches, careful examination of its textures satis- fied us that it was the puerperal uterus Avhich had thus been extruded. The case Avas 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 ^H>; say, by the adjustment of a pessary Avhich Avould keep the Avomb Avhere 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 remoAr- 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 narroAV the vagina and prevent the extrusion of the Avomb. This is styled elytrorrhaphy, and in making it, I prefer Thomas' operation Avhich I have already described under the head Episio-perineor- of Cystocele. rhaphy' The third, consists in freshening the edges of the labia and bringing them together by suture so as to close Elytrorrhaphy. Fio. 87. Incisions and sutures in Elytrorrhaphy. PROCIDENTIA FROM PERTUSSIS. 619 the vulvar orifice, excepting only a small opening Avhich is left for the discharge of the urine. This operation is termed \pisio- perineorrhaphy. PROCIDENTIA UTERI FROM PERTUSSIS. Case.—At the eighth month of pregnancy, Mrs.----, aged 32, Avas seized Avith a violent attack of Avhooping cough. The par- oxysms ot coughing Avere so frequent and severe as to threaten premature labor; but by careful management she Avas finally brought to term Avithout any serious mishap. After delivery she got up Avell, 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 (Avhich she always has Avhile nursing), she felt herself Avell. At the end of the third month, and Avhile taking her usual afternoon drive, she took cold, and the consecpience Avas, a recurrence of the Avhooping cough. The fits returned Avith 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 Avas summoned, and arrived shortly. The Avomb had been forced entirely out of the pelvis, and Avas lying betAveen the thighs. It Avas easily reduced by appropriate taxis and the proper treatment Avas 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 make a few clinical points particularly clear to Antagonism of tho l v 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 Avomb are not ahvays 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 beloAv. This state of things predisposes to downward displacements of the Avomb after delivery. If the patient is upon her feet too early and too frequently, if the Avomb folds upon itself very 620 THE DISEASES OF AVOMEN. sloAvly, and its involution is imperfectly accomplished, such mis- haps are more likely to folloAv. Constipation in some lying-in Avomen, and diarrhoea in others, are predisponents of prolapsus and procidentia uteri. Among the exciting causes of these particular displacements in lying-in Avomen, and in those Avho have recently been delivered, a violent cough is, perhaps, the most serious. cough a cause of jjcnce we may have prolapsus in a slight or utennj displacement. J L L „ . 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 Avith causing the displacement. The cough alone is responsible for it. It acts through the spasmodic and forcible contractions of the diaphragm, Avhich it necessarily induces. And the more violent the coughing fit, the greater the danger of this unfortunate result. During the fit of Avhooping cough the convulsive action of the diaphragm is sometimes prolonged and painful. In children it is very apt to be folloAved by retching and vomit- ing, and sometimes by severe and intractable tenesmus of the boAvel. In the case of my patient, avIio had just been straining at stool, its effect Avas to overcome the slight re- sistance offered by the sphincter vagina? and the perineal muscles, and to empty the pelvis of the Avomb itself. Of course, this Labor a predisponent. PROCIDENTIA FROM PERTUSSIS. 621 accident would be much more likely to happen at the second or third month after confinement than after the Aagina and peri- neum, as Avell 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 Rest 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 alloAvecl 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 Avomb 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, Tans and reduction. . , , . , n tit raise the hips and loAver the head. Then, hav- ing anointed the hand, grasp the tumor firmly, and insinuate it gently Avithin 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 Aveeks, even after the patient has left her bed. There is no more natural and enectual 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 Avhooping cough, the effects of the paroxysm being so disastrous and prejudicial to permanent recovery. Cure the cough, and its indirect consequences Avill cease. Stop the convulsive action of the diaphragm, and the uterine displacement may not return. LECTURE 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. Latero-version, the rarity of. In- version, the clinical history and modern surgical treatment of. General llemarks.—In order that you may have a clear idea of the nature of uterine flexions, tAvo facts should be borne in mind: (1) that, in this kind of displacement the shape Two peculiarities of. . . -1/-.1 ot the uterus is always changed, and (2) that the flexure occurs at the junction of the neck Avith the body of the organ. Properly speaking, therefore, these deviations are char- acterized by a change, or curve in the axis of the Avomb, Avhich 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, Avhile the body of the uterus has a greater latitude of motion. It is The anatomical j-U* , „ „ „ j_ i • 1 it predisponent of. tms arrangement which permits a bending or tAvisting of the organ backAvards, fonvards, or laterally, Avhile its neck is in situ, or very nearly so. These flexions are facilitated by the peculiardisposition 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 Avhatever kind. Varieties.—There are three kinds of uterine flexion, (1) retro- flexion, (2) ante-flexion, and (3) right or left latero-flexion. RETRO-FLEXION OF THE UTERUS. We have already considered the relations of retro-flexion to obstructive dysmenorrhcea, (page 202), but something remains to be said upon this subject. This form of flexion is more common 622 RETRO-FLEXION 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, Avith or Avithout 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. Fig. Retru-tiexion of the uterus. Oiagnosis. 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 Avhen 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 fingei The touch. 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, Ave must appeal to the uterine sound as a means of settling the diagnosis. I The uterine sound. ^ ^ ^ ^.^ ^^ ^^ th& taWe jn 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 hvo 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 SHARP &. SMITH 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- organ?81tIon ° * e 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-FLEXION OF THE UTERUS. 625 Keeping it in place. per week, to replace it a few hours in advance of the monthly flow, and to keep the patient lying on the abdomen until the period has passed. This is a trying expedient, but it may ansAver 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, Avhich have Pessaries in retro- 1 • j_i n flexioa oeen m vogue since the days of old Dr. Macintosh. In some cases the plain hard-rubber stem Avill be sufficient (Fig. 92.) At first it maybe too straight to pass the internal os, in Avhich 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), Avhich can be readily introduced and which expands in such a way as not to be easily displaced. Fig. 92. Hard rubber stem. Fig. 93. Chamber's stem pessary. When the case has almost developed into one of retro-version, and the cervix is thrown forAvards, 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 sterns is by passing The retro-uterine through the canal tampon. ° . Of 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, Avhich has been anointed with carbol- izecl cosmoline, into the Douglas' space, Avhereitmay beAvorn 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- FlG. 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 qu^nTo'r^ *"" very decidedlJ forwards; neither should we lose sight of the fact that this position of the organ may continue during menstrual life, Avithout being in reality abnormal. It is only Avhen the Avomb 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, are 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 avouIcI 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 liter- The touch and the ine gmmd wjU be mQre thorouo:ll and satisfactory. sound in. n J 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 ahvays 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 Ui)0n her back for some hours, in order that the sound in extreme . . it cases. urine might accumulate, and that the distention of the bladder, together Avith the effects of grav- ity, might carry the fundus of the uterus toAvard the rectum, and so straighten its axis that the sound Avould pass quite readily. The urine can then be draAvn Avith 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- aSSoumnd.reP°8it0r 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, Ave 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 forAvards, and the blad- der may become tolerant ot its own proper contents. In the milder cases, where the symptoms are worse at the monthly period and almost Avholly disappear in the interval, a menstrual quaran- tine, Avith keeping the patient constantly upon her back until the Aoav has ceased Avill sometimes be sufficient for the cure. This is especially true if Ave 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 stem pessaries in. already been advised in retro-flexion are equally 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 UTERES. Case.—Mrs.----, aged 51, of nervo-bilious temperament, was admitted to the hospital one month ago. She has been suffering more or less for ten years Avith 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 leucorrhcea, 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 boAvels 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 Avas corrected by means of the sound, Avhich, together Avith 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 o Relative frequency the orgJm the cervjx ig ^ slightl y> if at aU djs. 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 Cause8 these cases it is possible that the involution of the Avomb 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 avIio, 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, Avhich pains are severe and protracted, and exte id more or less 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 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 AVOMEN. when she turns over and lies for a little on the opposite side, the displacement is not a very serious affair. I have iioav passed the sound to the fundus uteri. You will ob- serve that the roughened surface of the handle, which corresponds to the tip of the instrument, and its anterior Passin? the sound. l , curve, looks toAvard the right thigh ot 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 Avith 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. Noav the organ is in situ, and the sound has served the double purpose of acquainting us with the precise ganepDk nature of the displacement, and of 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. ^Xie should lie on the opposite side, in order to keep the Avomb from gravitating into its unnatural position. This Avoman had right latero-flexion, in Avhich the fundus uteri had toppled over against the right side of the pelvis. She must there- fore lie upon her left side, if she Avants to get Avell of this diffi- culty. There Avill 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 Avill be a difficult prescription to tike. For the first feAV days especially, it Avill 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 glad of her good resolution. These cases are more readily and radically cured than what is known as latero-version, a condition in which the uterus is directly across the vagina, Avith the fundus at one acetabulum, and the cervix uteri at another. VERSIONS OF THE UTERUS. 631' If the uterus has been flexed laterally for a considerable time, it may be so bound cIoavii by unnatural adhesions that its reposition will be followed by more or less of peritoneal Bes°ntmgeDt 1Sea* inflammation. Again it Avill be folloAved by a species of sciatica, Avhich is persistent and troublesome. For the former, such remedies as rhus toxicoden- dron, belladonna, or bryonia, may be required. For the latter, I knoAV of nothing to compare Avith colocynth. » VERSIONS OF THE UTERUS. General Remarks.—The chief characteristic of this kind of dis- placement consists in the cross-position of the uterus. In con- firmed cases of version the Avomb lies transversely ZZZZIT™ ™ the I»l™.. or « its fan** is very much depressed, it lies diagonally across the vagina. Versions are more serious and difficult of cure than flexions. As a class they are more frequent Avith those avIio have borne children, while the opposite is true of flexions of the uterus. Versions are less likely to be accompanied by painful, delayed, and difficult men- struation than are flexions; but the vesical and rectal complications are almost ahvays more marked and inveterate in versions, than they are in flexions of the avoirb. In many cases the slighter degree of flexions are self limited, and get Avell spontaneously; but Avhere they persist, the case may develop into a corresponding version, and then become chronic. My oavii idea is that most cases of uterine version really begin with flexion, and that, either in consequence of neglect, or of im- proper treatment, Avhich is Avorse, they finally versions as the result mero.e mt0 a deviation which involves the neck of flexions. n as Avell as the body and fundus of the womb, and finish by throwing the Avhole organ across the pelvis. Varieties.—There are three kinds of version, Avhich take their name from the direction assumed by the displaced fundus. Thus Ave have (1) retro-version, (2) ante-version, and (3) latero-version, of which there are the right and the left. retro-version of the uterus. In retro-version the fundus uteri is thrown backward against the rectum, and the cervix forAvard against or upon the bladder, 632 THE DISEASES OF WOMEN. while the body of the womb lies across the vagina. In extreme cases the fundus may fall upon the coccyx, or the perineum, while the cervix may mount so high that the uterus shall be upside down. The predisposing causes of retroversion are pregnancy, puer- perality, abortion, the abuse of coitus, atony of the rectum, constipation, haemorrhoids, chronic dysentery, Causes- ischuria, obstructive dysmenorrhcea, and certain deformities of the pelvis, more especially if it is too capacious, or Fig. 97. Retroversion of the uteius. if the promontory of the sacrum projects very far forwards. The exciting causes are the lifting or carrying of heavy weights, a IiIoav or fall upon the abdomen, jumping, running, a sudden jar from a mistep, or a violent paroxysm of coughing. The symptoms are more abrupt Avhen this deviation occurs during early pregnancy than at other times, although as in one of our hospital cases it may happen suddenly from lifting- a bucket of coal, or of water. In most cases, hoAvever, the symptoms come sloAvly, and gradually. There is pain in the sacral and lumbar region, Aveight and pressure in the region of the cervix, Avith epigastric uneasiness and distress. The rectum is more or less irritated by the pressure of the tumor, and there are mucous discharges Avith more or less tenesmus and in- effectual urging to stool. Sometimes there is a complete obstruc- tion ot the rectum, in Avhich case the patient's complexion ma}r soon show the dirty gray tint of coprsemia, with a very disagree- able odor of the perspiration. RETRO-A'ERSION OF THE UTERUS. 633 The bladder symptoms are usually less marked than in the anterior displacements, but the intimate union betAveen the neck of the uterus and the bladder anteriorly, makes Jhe vesical symptoms ^ ^^ impoasible to displace the Olie without disturbing the other. According to Rigby this form of version may produce engorgement and chronic inflamma- tion of the ovaries. "When it occurs in early pregnancy there may be symptoms of a threatening abortion. If it has come on very abruptly, the loA\rer extremities may be partially or wholly par- alyzed. The reflex nervous symptoms are very troublesome. Next to the gastric disturbance, Avhich is almost never lacking, the occipital headache, and the pain on the top of the head or toms?nerV°US SymP~ about the vertex, 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 Avhen 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 loAverdoAvn than natural, for confirmed cases of version are almost ahvays complicated Avith more or less of prolapsus. By the finger, the outline of the body and neck of the womb can be readily felt. The rectal touch is often essential to a correct diagnosis, for in no other Avay can the nature of this retro-uterine tumor be so thoroughly knoAvn. AY hen this form of touch is combined Avith the skilful use of the sound Ave 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, espechlly if the Avails of the abdomen are not too thick. But sounding the uterus in these transverse positions is not ahvays an easy matter, and hence its reposition by internal means is sometimes very difficult. The directions that The new mode of are usuapv o-iven for performing this operation, reduction. - s x ° A 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 AVOMEN. they are often sufficient to lift the organ into place. The expedient of applying atmospheric pressure Avithin the vagina for this pur- pose, is another result that rightfully dates from the discovery ot the Sims' speculum, by the use ot Avhich, with the patient in the knee-chest position, it is best applied. The mode of applying pneumatic vaginal pressure, Avith gravi- tation, to the reduction of retro-displacements has been carefully and skilfully elaborated by Dr. Henry F. Camp- How to apply this b n f Augusta, (hi* The posture chosen is method. ' o ' a the same that Avas adopted by Deventer in 1701, in the treatment of prolapse of the funis. The patient is placed upon her knees Avith the chest thrown forward upon the bed or couch, the hips being raised at an angle of about forty-five degrees. This is Avhat is known as the genu-pectoral, or semi-prone position. The vagina is then expanded, by the introduction of the speculum, the best of Avhich 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 Aveight 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 Avhich consists in the frequent resort to this position, and the separation of the labia Avith the patients atient36 US6d b * ° own fing"ers' or ^v 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 Elevator. J T . . ,, -, , the rectum. (Fig. 99.). It is especially adapted to retro-version occurring in virgins and during pregnancy. In some cases direct pressure may be 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 Fie. 103. Armstrong's uterine repositor. under the theory that their reposition Avas 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. Fio. 101. f towe'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. 636 THE DISEASES OF WOMEN. Eio. 102. Woodward's retroversion pessary. Fig. 103. Woodward's pessary for retroversion. In a day or tAvo the effects of mal-position, and the strangulation of the Avomb will have passed away, after Avhich the organ may be reposited as Ave have already di- rected. The next thing to be clone 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 Avas all that was necessary, and it may be in recent cases, the Avearing of an abdominal supporter Avould 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 organ in situ. Something more Avill need to be done 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 Avhich provides for the admission of air, as in the mode of reposition Avhich has just been described. Such a dilatation is maintained by the Fig. 104. Graily Hewitt's re- various p e S S aT i e S troversion pessary. 4.1 x- i 1 that have been used for retro-version, the most popular of Avhich 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 Avay or another they are all modified from the old ring pessary which Avas 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 AYood ward's pessaries (Figs. 102 and 103) Graily Hewitt's (Fig. 104) and Thomas' (Fig. 105) retro-version pessaries unite the double principle of Fig. 105. Thomas' sion pessary. retro-vcr- RETRO-VERSION OF THE UTERUS. 637 leverage and vaginal distension, and are therefore profitable in many cases. Sometimes Ave 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 Cutters pessary for retro- version (Fig. 107) puts a crutch behind the organ and keeps it forAvard. In a few cases, hoAvever, I have found that Cutters' original pes- sary for retro-version Fig. 106. Buttle's pessary. (Fig. 26) could be Avorn when Thomas' modifica- 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 Avill 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-VERSION OF THE UTERUS. This draAving (Fig. 108) Avill give you a good idea of the relative position of the uterus Avhen its fundus is throAvn forAvard upon the bladder, and its cervix upAvards against the rectum, the axis of the organ being across the pelvis. Fig. 108. Ante-versiun 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. AY hen 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 Avhen the patient is standing or walking, and sometimes there is such an absolute inability to walk, or to stand, that those Avho have 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 ahvays present. In bad cases the cervix may retreat so far into the IioUoav ot the sacrum as to obstruct the passage of faecal matter and occasion tenesmus, and diarrhoeic or dysenteric symptoms. If there is any difference be- tAveen ante-version and retro-version in so far as these peculiar symptoms are concerned, it is that, Avhile in the former, lying on the back mitigates the tenesmus, or the constipation, it is not so in retro-version. Courty says: "AYith several patients Avho had retro-version it has seemed tome that, Avhether applied Avith the hand, temporarily, or constantly Avith the abdominal belt, pressure upon the hypogastrium tended to increase instead of to lessen the suffering; while the contrary Avas 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 the cervix, its being carried in the direction of Avhat the old doctor called the "premonitory"' of the sacrum, Avill help us to decide the question. If to this we add the conjoined palpation, through the vagina and around ^a^MB^^^. the symphysis pubis, the case may almost al- yp^^'^^Sk ways be clearly made out. Even therec-||P ^^^k |H tal touch has a negative value Avhen the ^jPk^ 1^ Jw fundus uteri cannot be found posteriorly. ^^^gggai Mr AY hen the sound or the probe can be passed, . ,. ,. ~ .. ., i 'lii Fig. 109. Hitchcock's ante- the direction of its point and curve will be version pessary. almost if not quite as distincti\Te as in ante-flexion; and the effect of the dorsal decubitus Avith 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 Reduction of the become filled, after which the hips may be raised displacement. . . . " 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 Trompes, par A. Courty. Pro.essor, etc., deuxienne Edition, Paris 1872. page 863. 640 THE DISEASES OF AVOMEN. in. anterior wall with a Sims' speculum, or with the depressor. AYith 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 Avhich is suited to ante-version. Beside that, there are modifications of the ring, and of Hodge's pessary, Avhich are suited to these Means of support. © x - ' cases, more especially because they serve the pur- pose of separating the vaginal Avails 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 in ante-version than in retro-version. The Fig. 110. Kinlock's ante-ver- , , .. .. sion pessary. dorsal position, at least lor a portion ot the time, is almost indispensable for the cure of these cases, some of which are very much benefitted by cultivating Rest and remedies the habit Q± re"tainino. 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 Avhich is exceedingly rare is almost ahvays due to a fall upon one hip or the other, to lesions that have been acquired during the lying-in, or to the nres- Peculiarities of. l. j e i ence ot tumors or of dropsical and other accu- mulations Avhich force the Avomb out of place. This version is also characterized by a transverse position of the uterus, but, instead of lying across the pelvis in an antero-posterior 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 Avhich are persistent, Avhich radiate through the pelvis and the abdomen, and Avhich Subjective symp- „,„ vi i a> , i , toms. aie hkely to afiect the sacral nerves in their distribution to the loAver 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 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 Ave 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 Avill 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. INAERSION 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. Ill. 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 sIioavii in the diagram. (Fig. 111.) 642 THE DISEASES OF WOMEN. Ill the chronic form, 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 Cuuscs *~* placenta or the umbilical cord; rapid labors; rigidity of the uterine cervix Avith 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 Avhen 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 ahvays 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 Avith 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 uheasiness and distress, with a feeling of pelvic strangulation that arises from the presence of 'the tumor. The same cause mayjiroduce 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 leucorrhcea, and is largest at its loAver The tumor. ° 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 tAventy 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 Avhen months or years have elapsed since the inversion took place, great careAvill be Diagnosis. . i o required. You would know such a case from one of procidentia, by failure to find the os-uteri, and one or both lips of the cervix at the lower end of the tumor; From procidentia. . 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. The sound in utero gives precisely the same indications, and the diagnosis fibroid1 a SU "mucou8 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 Avhile the uterine surface of a tumor is sensitive, you may pinch, or push a needle into a polypus or a fibroid 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- Til6 cruci&l test 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 it it were congenitally lacking. The greatest care should be exercised in the diagnosis for it has happened that the in\rerted Avomb has been amputated, under the supposition that it Avas 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 Ioav 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 displacement is beset with pecu- liar difficulties. The first indication is to reduce, or to re-invert 644 THE DISEASES OF AVOMEN. the organ by forcing its body and fundus through the constricted cervix. If the tumor is large from age or expo- Treatment. , J , t , . n sure, and the utero-cervical orifice is narroAV, as it almost always is, this operation may be impracticable. For it is this orifice, Avhich Maurieeau compared to the neck of a phial, that interferes with the ready replacement of the womb, and the constriction of Avhich it is sometimes cpiite impossible to overcome. In recent cases of inversion occurring in obstetric practice, the parts are in such a condition that prompt and immediate action will generally be successful. If the placenta remains attached, strip it off carefully, and then apply steady pressure Avith the tumor in one hand, Avhile the other hand is placed for counter-pressure above the symphysis pubis. Be careful, hoAveArer, 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, ot Albany, *; Dr. A. R, Thomas, of Philadelphia, t; Dr. Mary Safford Blake, J; and Dr. C. G. Higbee, of St. Paul, Minn., \. AY hen inversion folloAvs abortion, Avhich is very rare, and of very doubtful diagnosis, the reduction is usually spontaneous. But in confirmed cases of inversion that have After abortion. . , _ existed tor 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 ..,.„... . ,„ ._ l 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 boAvel 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 Romceopathy, Twenty-fifth session, 1862, p. 36& t. Do, do. do. do. for 1873, page 503. §. The United States Med. and Surg. Journal. Vol. IV. p. 216. INVERSION OF THE UTERUS. 64J method, with proper precautions, is better than the instrumental one. In the attempt at reduction by the hand, tAvo 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 ot the index finger of the left hand into the bladder, aucl the index of the other hand Dr. Tate's vesico- into tbe rectunii Then the fingers approach rectal method. *- * each other and are in position to stretch the cer- vical ring, Avhile both thumbs are made to press the fundus upAvards and toAvards 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 Avitha tallow candle that Avas Avrapped in a rag. The external os was closed by a silver suture, Avhich Avas removed on the third day, and the patient recovered Avithout 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 right hand into the rectum, and above courty's rectal the uterus> anj then by curving the fingers for- Avard 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. AYatt's method is really the same as Cour- ty"8 Another means of manual reduction is known as ^soeggerath's, which consists in the usual counter-pressure over the pubis, and in direct pressure upon the cornua of the uterus thoTggerathS ^ with the filleer 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 AVOMEN 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 Avhen 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 Avithdrawn, and for the present, at least, it may be necessary to relinquish any further attempt at reduction. In this case Dr. Emmet advises to stitch the os uteri Avith a ^Emmet's expedi- s[lyQV 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 of wood, or even Avith a talloAv candle if you can find one. Drs. Sims and Barnes have advised that, where Sim's and Barnes- the cervieal orifice will not yield and the reduc- method. ... tion is otherAvise 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 Avater 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 Avas INVERSION OF THE UTERUS. 647 reported to one of our journals some years ago, by Dr. E. R. Ellis, of Detroit. The case Avas 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 is most popular just now is knoAvn as that of Dr. J. P. AYhite, of Buffalo. It is sim- ple, rapid, efficacious, and quite safe, if properly Dr. White's method. , . . ' . , , ,, used. A glance at the repositor, ana at tiie accompanying cut, Avill explain its modus operandi. (Fig 113) Fia. 113. White's repositor for inversion. In all cases in which an attempt is made at immediate instrumen- tal reduction the effort, if unsuccessful at first, should not be con- tinued for more than one or two hours, other- Frecautions. wige fatal peritonitis or cellulitis may result. Nor should it be repeated in less than thirty-six to forty-eight hours afterAvards. Several fatal cases are recorded in Avhich this rule aa;is not followed. AA'here judicious taxis and elastic pressure have failed and it becomes a question Avhether the uterus should be odDr- Tbomas' melh- amputated, Prof. Thomas' method of opening the cervical ring so as to reposit the organs should be carefully considered. This method, Avhich is one of the 648 THE DISEASES OF WOMEN. boldest achievements of American surgery, consists "in abdominal section over the cervical ring, dilatation Avith 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, avIio surrounds the neck of Amputation. . , .. . . the organ Avitn a rubber ligature, that may bo tightened on the second day, and which secures a complete separa- tion of the Avomb in a fortnight or-less. AYhen the knife or the ecraseur are used, the tumor should first be ligated 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, dowm 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 Koeberle 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 AVOMB. 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 neAv interest of late. A feAV years ago ulceration, Avith or Avithout induration of the cervix, Avas ^en- ln?T^l^Tra erallv thought to be the essential and fuiida- views on ulceration. - c? mental lesion in most of the diseases of Avomen. For thirty years, indeed, this idea domiuated, and the practice Avas to rely upon local treatment, exclusively. But, iioav that Ave can differentiate more closely, Ave knoAV that ulceration of the cervix uteri is really infrequent, and that the appliances of the Bennet school of gynaecologists Avere often brought to bear upon a lesion Avhich had no existence until it Avas 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 Avomen are to be spared the suffering and the harm that have been unwittingly and unnecessarily inflicted upon the sex for a Avhole generation. Uterine ulceration may be a local or a constitutional disease. The forms of this ulceration that are purely local are abrasion Avith simple and irritable ulceration. The 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 vieAv. AYe shall consider some of them separ- ately, reserving to a future occasion Avhat Ave have to say of can- cerous ulceration. 619 650 THE DISEASES OF AVOMEN. SIMPLE ULCER OF THE UTERINE CERVIX. Case.—Mrs. T-----, aged 28, mother of one child, has been ill for six months. She complains of Aveakness and debility, Avhich incapacitate her for her daily duties. There is a great deal of pain in the sacral region, dragging in the loins, and bearing-clown sensations Avhen she is upon her feet for any considerable time. Internally she feels a sense of swelling and fullness Avithin the vagina, and of burning at its upper portion. At times there is quite a free leucorrhoeal Aoav, Avhich is of a bland unirritating character. Examination Avith 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 Avithin 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 Aveight and fullness, of weakness and bearing-doAvn in the region of the Avomb. 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 unfrequently there is an aversion to sexual congress, and Avhen complicated Avith vaginitis, the act is likely to be folloAved by a bloody discharge. The reflex hysterical symptoms are numerous and varied. Such patients are prone to be hypochondriacal, and sometimes exhibit strong tendencies toAvards insanity. The objective local symptoms revealed by the " touch" and the uterine speculum are peculiar, and Ave must rely upon them as . . diagnostic. The ulcer, the shape of Avhich Objective local symptoms. . L 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 UTERINE CERVIX. 6,51 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, eAuncing 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 ahvays covered Avitli a muco-purulent secre- tion, Avhich must be Aviped off carefully. In an acute case the part looks as if a corresponding extent of its inA*esting 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 SAVollen, congested and sensitive. AA'hen 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 Avhich Ave shall haAre more to say hereafter. The most common causes are painful, forcible and too frequent intercourse ; coitus during or directly after menstruation, wdiile the uterovaginal mucous membrane is very vas- 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 Avalking 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 AVOMEN. Smith is of opinion that the corrosive properties of the leucorrhosal discharge may occasion this form of ulceration, Avhen brought into contact Avith the surface. This form of uterine ulceration is especially apt to occur soon after marriage ; or it may be caused by too prolorged nursing. According to eminent authorities, among whom are Churchill, Bennett and AA7hiteheacl, 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 acid, belladonna, arnica, ignatia, aurum mur., nux 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 leucorrhceal discharge, 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 leucorrhcea is purulent, or muco-purulent, it may be better to substitute calendula for the arnica. Other topical expedients are injectipns of an infusion of flax-seed, or of dilute glycerine, Avhich does not become rancid; the direct application to the ulcer of a Avatery solution of gum tragacanth, or of a solution of loaf- sugar ; painting the ulcer Avith collodion, or Avith 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 Avhich commend it as an external application in abrasion and in superficial ulceration of the cervix. It is flexible and Avater-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 Avith the cotton brush the surface of the ulcer should be dried very carefully. The coating that forms Avill re- main for from tAvo 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. Ricini, " 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 Avhich are peculiar or valuable, in so far as the differential diagnosis and the treatment are concerned. AYithout a local inspection of the lesion, its recognition avouIcI be as impossible as it Avould be to identify the eruption of scarlatina Avithout seeing it; nor could Ave knoAV Avhat we have cured, if avc are successful, Avithout a careful visual examination of the cervix to begin with. For this is a local affection of constitutional ori- gin. Case.—Airs. S----, forty years of age, the mother of four children, has been ill for eighteen months past. She is pale, and has the Avorn look of one Avhose 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 Avomb. This is aggravated by standing a long time, or by riding. It is also apt to be Avorse in the evening. Sometimes there is strangury, but it is of brief duration and not very severe. Theie 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, »' 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 tAvice the size of the thumb nail. The only treatment she has had Avas a four months' course of bi-Aveekly cauterizations, from Avhich her health became so bad that she Avas 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, Avhich are as delicate as those of vari- The eruptive stage. ^^ ^^ ^^ ^ epitllelium beCOmeS de- tached, and small curd-like spots appear. AYith 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. Noav 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, hoAvever, are its shallowness, its being preceded and accompanied usually by the herpetic eruption on the cervix uteri, and the Symptoms. . 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, Avhich 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 yvith which this is liable to be confounded are the diphtheritic and the syphi- litic. From the diphtheritic ulcer it may be knoAvn 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 yelloAv, 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, Causes. , . tabes mesentenca, 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, I reatment. ~ •/ ' and neither the doctor nor the patient knoAvs what has been done. More frequently, hoAvever, 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 Avith 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 Avhich sometimes prompts and permits the physician to diagnosticate and to pretend to cure the most serious uterine diseases Avhen they have no real existence. Patients not unfrequently declare them- selves ill Avith some particular "Aveakness," and, whether they are mistaken or not, Avill 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 Avomen have thus been cauterized for uterine ulceration Avhich, before the application of the escharotic, had no existence. Multitudes of them have done Reprehensible practice. . 1 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 Aveakness 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 Avere, 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 AVOMEN. af the profession who have a bias towards dishonesty, and who seize upon every opportunity to make the most out of a class of cases Avhich are often obscure, intricate and tedious at the best. Bennett and a nost of lesser lights have decreed the uterine cervix to be the center of pathological interest in Avoman. 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 knoAvledge. Here is a poor Avoman 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 feAV little A constitutional and not • i ill j.1. 1 C "U jnereiy a local disease. vesicles Avere developed upon the neck ot her womb. Their investing tunic was ruptured, and an aphthous ulcer Avas 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 Avould in a case of stomatitis he!ahhrove 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 Avhites 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 ahvays grateful, and, I believe, useful in such cases. AArhere 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 „ , . , Avhere 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 tio^?r the aphthous condI" necessary to prescribe arsenicum alb., hydrastin, nux 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. • -i -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 Avill 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, AvhateA^er 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 Avith numerous holes of the size of a large shot. For the herpetic form of this disease, Leadam recommends the injection of a Aveak solution of the thuja oc, to be repeated tAvo 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, cifically. curative relation to 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. AAre will give Airs. S-----arsenicum alb. 3, a dose three times daily. Her diet Avill consist of bread and milk with beef, potatoes and tomatoes, for dinner. Once each day she Prescription. ^ ^.^ ^ ^^ qJ, ^^ ^^ lemonacle . ancl 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 glycerine every night and morning.* *In four weeks this patient was well. She took no other remedies. 43 658 THE DISEASES OF AVOMENT. 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 in the utero-vao> 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 Avhich 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, Avhich 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 boAvels 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 ahvays menstruated regularly, but, for some months past, has observed that the Aoav is less free than formerly. She has no pelvic pain or distress of any kind, but is at times annoyed with a copious leucorrhoea, 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 betAveen andesfltomrach!ionsofuterus the uterine cervix and the stomach. This poor Avoman is the A'ictim of utero-gastric irritation which is so decided as to make her Avretched 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 Avould not be led to suspect any uterine com- plication. Even the leucorrhcea would not necessarily be due to IRRITABLE ULCER OF THE UTERINE CERVIX. 659 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 ne!ehsLSrPy.CUUmn°talwayS remember these reflex relations, and to try if possible to cure the patient Avithout 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 Avell-chosen remedies, you Avill be justified in proposing to search for the remote cause within the pelvis. And not unfrequently you Avill discoArer a latent and unsuspected lesion of some kind Avhich Avill 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 Arery extensive and serious disease of the pelvic organs, without a corresponding degree of suffering, indeed Avith- out the patient or her physician having sus- i,eTiaLnterine lesion 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 noAV, has existed from the commencement of this Avoman'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 Avithout 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 Avith pus, or Avith a bland, somewhat gelatinous 1veRmuc0usalofthepr°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 ortAvo 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. -ii-ipi i below the level ot the mucous membrane covering the uterine cervix. This mucous membrane is some- times red, inflamed, and even oedematous, 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 Avith 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 uittr"8n °f 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 vieAv. They have a pearly, exsanguine look, and her tongue has the ragged appear- ance of one wdiich 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, Avhich, Avith 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. J the most marked examples of this disease ore sometimes met with among those who have "lived too well,"' IRRITABLE ULCER OF THE UTERINE CERVIX. 661 as the phrase is. These persons haA-e brought on indigestion, and a depraved state of the nutritive function by eating irregu- larly and immoderately, by drinking too much Avine and spirits and developing an irritable, nervous temperament that has predisposed to this species of cachexia. It sometimes folloAvs excessive loss of blood, as in haemorrhage from abortion, and may be due to too prolonged lactation. Treatment.—AVhen there is reason to believe that uterine ulceration proceeds from, or is perpetuated by some digestive derangement, it is of the first importance to Die^etc!16 indigestion _ correct that disorder, Avhatever 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 Avhite 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 AA'hich may be exhausting her little stop any drain. gtock ^ strengtu. Haemorrhage, too excessive or prolonged lactation, diarrhoea, leucorrhcea, 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 elseAvhere. The class of remedies most frequently indicated are arsenicum alb., nitric, muriatic or sulphuric acids, sulphur, rhus toxicoden- dron, baptisia tinctoria, hydrastin, and arseni- intemai remedies. cm jQ(L 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. ,■. -i /. i • t* i i^j 1 called for, and may, if property 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 ahvays sufficiently protective to prevent the contact of the atmosphere and of acrid discharges, Avhich 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 Ave 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. AVhere the leucorrhoeal 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 someAvhat with a prompt and radical cure of the ulceration. For, although all forms of uterine ulceration heal more sloAvly and less certainly at the change of life, you Avill 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 Avhich permits the absorption into the pelvic circulation of certain fiecal matters. This induces the form of blood-poisoning that has been described by Dr. Barnes under the head of coprsenio, Avhich has the effect to interrupt the healing process in cases of irritable ulcer especi- ally. To overcome this condition Ave must correct the habit of constipation, and, if necessary, have the rectum cleansed every day. DIPHTHERITIC 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 foreign growth, which, in 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 Avhich covers the diphtheritic ulcer, or patch, is at first very adherent, and cannot be detached Avithout more or less injury and consequent haemorrhage. After a little while, however, the friction of the parts during the motion of the body, as in Avalking or sitting upright, or a careless introduction of the finger, or of the specu- lum, may separate them. Their removal leaves a raAv, bleeding, painful, intractable, suppurating ulcer, which may, or may not, extemporize another Avash-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 The depth of the ulcer, sma]Jer 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 661 THE DISEASES OF WOMEN. nasal diphtheria especially, it destroys, or perhaps inoculates the adjacent tissues. This discharge is ahvays 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, Aagina and neck of the A secondary disease. . . . ........ . , Avomb. As in 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- riola, 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 Avere 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 Avhich 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. necessary that the specific cause should be at work. For this specific agency, Avhatever 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 Avhich I have seen have occurred in the persons of those women who, from watching and taking care of those who yvere 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. 665 of diphtheria you should examine this class of patients very care- fully Avith 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. Treatment. 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 hyclrastis, or calendula, or of any of the aforenamed remedies, diluted Avith 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 Aveak 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 Avater, " as an injection for ulcerated os uteri, and even for leucorrhcea, with good 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 Avho may hap- pen to be under treatment for various uterine affections. There is also the same need for isolation in diphtheritic ulceration of the Avomb as in diphtheritic sore throat. POST-PARTUM ULCERATION OF THE WOMB. Although ulceration of the womb is not usually classed among the sequelas of labor, there is little doubt but that it sometimes occurs in this connection. Case.—Mrs.----, aged 2$, has an infant five months old. She nurses the child, Avhich is thrifty, and lives exclusively upon the 666 THE DISEASES OF AVOMEN. breast. The mother is not Avell. 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, Avith inability to lie upon her left side, malaise, anorexia, frequent headache, occasional strangury, and a leucorrhcea Avhich at times Aveakens her very much and increases the old pain in the back. These symptoms began during her lying-in, and have continued until noAV. An examination Avith 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 unknoAvn reason she has a lingering con- valescence. At first there may have been a considerable degree of puerperal inflammation, and folloAving this a state of things analogous fo Avhat Trousseau styles "colliquative suppuration." Lactation, is, perhaps, normal, and the other functions are intact, but she is extremely Aveak 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. Meamvhile 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 Avill be charged to some other cause than the ulceration, Avhich 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 tion.sequel °f inflamma" often, but not ahvays, of such a Ioav 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 Avhich our patient complains. If there were anything distinctive in these symptoms, they would be more easily and generally recognized. But, in a given case, Ave cannot knoAV positively that a lesion of the cervix exists without ocular examination. Here the speculum is as requisite a FOST-PARTUM ULCERATION OF THE WOMB. 667 means of diagnosis as if the disease were idiopathic, and did not folioav parturition. There are tAvo 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 bioodpaired quality of the upon the mother's blood during gestation , and the second, a similar drain through the mam- mary glands Avhile she is nursing. By impairing the quality of the blood, and thus loAvering 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 Avhich I have just given you concerning the relation between the depraved and impoverished condition of the blood and the symptoms complained of, is Weaning the child „ , . .„ . . of great practical significance. Acting upon it, you would prescribe the proper hygienic regulations. If you are satisfied that there is too much of Avaste 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 Avhere the quality of the milk is such that the child is finally poisoned by it. The diet should be as nourishing as possible. AHoav milk, lean meats, eggs, game, fruits, and good bread and butter, instead of the sick-room teas, slops and kindred abomina- tions. Fresh air and sunlight should also be ingredients in the prescription. But let me caution you to re- member that Avalking may be very harmful, in case of uterine ulceration, and for this reason, the Avomb being pendulous Avhen the patient Avalks, 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. 668 THE DISEASES OF AVOMEN. Riding is less objectionable, but I have observed that many patients with uterine ulceration complain seriously of Riding. , the street-cars, the stopping and starting, as Avell as the roughness of Avhich, worry them more than riding in the stages on the avenue, or in a private conveyance, if it be carefully driven. You Avould not send such patients to ride in a rough country Avagon, 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- andwhc°mparatively easy' emption of the menstrual return, Avhich so much retards the cure under different circumstances. Here is no periodical determination of blood to the Avomb. 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 Avaning strength. It may signify that the mother's force tadoennstruationdurinslac" 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 Avho 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 exdu-from ^he Sphere 0f influence of internal reme- sive local treatment. 1 dies. They argue, and with some sIioav of rea- son, that there is a lack of responsiveness on the part of the tis- sues which 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-PARTUM ULCERATION OF THE AVOMB. 6($ 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 ; Avhile, in the latter, it Avould 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 Ave may facilitate the ment. . < " 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 — Avhen there is no specific reason, either in the nature of the lesion, or in its cause and symptoms, Avhy some specific remedy, as for example the nitrate of silver, or iodine, or Avhat 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 Avas impossible, because of the frequent Arguments pro and con. _ return and concomitants ot the menstrual IIoav, the dependent position of the uterus, and the evil consequences of sexual excitement. But it does not folloAv 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 Avomb does not so strongly predispose to its vascular derangement, or to the perpetua- Interdiction of coitus. , . „ , , , ., tion of 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 Avorst 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, Avhich 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 Avill not understand me as objecting to every variety of local application in simple ulceration of the os uteri. Such an ex- treme vieAv Avould be as untenable as that Avhich Allowable local treatment. - - . . ' . . . holds that such means, and only such, are abso- lutely requisite and curathre. There is no Aralid objection to the topical employment of diluted glycerine, Avith or Avithout the cal- endula, of SAveet 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 leucorrhoeal discharge, and Avill also stimulate the reparative process Avhereby the lesion can be healed. The calendula is especially useful Avhere the purulent or muco-purulent Aoav, 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. LEUCORRHCEA WITH CHRONIC OVARITIS. General remarks on leucorrhcea. Leucorrhcea with chronic* ovaritis. Chronic leucor- rhoea and the scrofulous dyscrasia. Irritable uterus or hysteralgia. Although leucorrhcea 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. Leucorrhcea may also be a critical and therefore a salutary affection, and for this reason it is not ahvays best to seal it, Avhether by local or general means. If a Aoav of this kind folloAvs 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 leucorrhcea 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 leucorrhcea for the last ten years. The discharge is of a yelloAvish Avhite color, sometimes thick and creamy, and again thin, copious, and quite fluid. After having been upon her feet for a long time, the Aoav becomes more profuse. She is certain that the quantity discharged frequently amounts to three or four ounces in a day. When the matter Avhich is most liquid escapes, she feels most exhausted. She complains, at such times especially, of a sense of Aveariness, and of dragging pains in the loins and hips. For a long time, she remarked the leucorrhceal discharge Avas 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 Aveeks, but the proper flow is oraclually 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, Avhich is located just within the anterior 671 672 THE DISEASES OF AVOMEN superior spinous process of the left ilium and above the groin, or in other words, in the region of the left ovary. This pain, Avhich is sometimes very severe, ahvays extends doAvn 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 Avalking increase its severity. Examination by the speculum discloses a scrofulous suppurat- ing ulcer at the os externum, extending into the canal of the cerAnx. 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 Avhom cauterized the cervix severely, but without any benefit to the patient. Indeed, she steadily continued to grow Avorse, and, as you see, her general health is noAV 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 Burnipg.pain in ovaritis. Ovulation sometimes a that Ave are forced to conclude that the ovarian constant cause of ovaritis. 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 Avith 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, Avith 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 Avith 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 Avhich 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 lungs, the mammary glands, the uterine mucous membrane, the nerve centeis of animal life, and especially with LEUCORRHCEA AVTTH CHRONIC OVARITIS. 673 the uterine cervix and its secretory apparatus. The neck of the uterus is not more intimately associated with the Avomb itself, of which it is the natural outlet, than it is Avith the ovaries. These little organs, although remotely located, have really as much to do Avith the active dilatation of the os uteri, and the escape of the menstrual Aoav 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 of serious and pro- ovanes. -1- _ *■ tracted disease — nothing is more certain than the eonsequent, although indirect, implication of the other. It Avould 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, Avhether from the uterus or the vagina, or both to- gether, are ahvays indicative of structural disease someAvhere. The lesions which produce them may be idiopathic or secondary. They may depend upon causes which are purely local, upon those Avhich 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 AA'hich we have been consulted. The gradual diminution of the menses is significant and sug- gestive. When ovaritis is accompanied by uterine ulceration, Avhich is not cancerous or phagedenic, there is Leucorrhcea may substi- almost always a tendency in the menstrual tute menstruation. ■■' . 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, Avithout ulceration of the cervix, and • , AA'hether it comes from the uterus or the vagina, Uterine and vaginal ca- # tarrh from ovaritis. ^e clischarge is usually increased either before or directly after the catamenial flow. Here the ovarian sympa- 43 674 THE DISEASES OF AVOMEN. 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, Avhich le^corrWa55 caused 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^tholo0"'3"06 °f spec" embrace so favorable an opportunity to say a few Avords 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. HoAvever 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 Ave 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 knoAvledge 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 AVITH 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- tAveen the cervix and the ovaries is such that Avhatever harms one will almost certainly implicate and injure the other. Your preceptors are fully aAvare 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 OAvn zatinonofritIhenoseuteCHUteri" future experience will one day confirm the 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 haAre 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 Avhich pertain to the leucorrhceal discharge. The proper plan is, therefore, first to treat the disease of the left ovary, and afterAvards, 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 pain in the left ovary, 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 folloAved by leucorrhcea. The appropriate remedy is thuja oc, of which she Avill 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- signed to relieve suffering Avhile 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 AVOMEN. gradual, improvement in our patient's health. In addition to the internal remedy, she should syringe out the vagina twice daily Avith 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 Avater injected into the Aragina. But it should be an indict- able offense, for the physician to prescribe or apply astringent Avashes and escharotics, for the relief of such a case of leucorrhcea as that to which your attention has noAV 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 Avhich 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, Avhich she continues to nurse, is thirteen months old. The quantity of the leucorrhceal flow is large, and has always been so, excepting Avhile she suckled her children. She ahvays 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 leucorrhceal 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 Avell to divide the varieties of leucor- rhcea into the acute and the chronic forms. xVcute leucorrhcea may be physiological, critical, and even salutary, as crmcaT"11068^ ™ay b6 spermatorrhoea may exist Avithout being, in a proper sense, pathological. A leucorrhceal Aoav sometimes affords a means of escape for an excess of serum that has accumulated Avithin 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 LEUCORRHCEA, ETC., 677 Such a Aow 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 Avould be mischievous if they were retained. Or it may be 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 Ave do nothing to increase the difficulty or to prolong its duration, it Avill cease of itself as soon as its transient exciting cause has been removed. When, hoAvever, as in this case, a leucorrhcea becomes chronic or habitual, when it has persisted, without cessation, for Aveeks or months, draining aAvay the patient's strength, Local and general makin~ her wretched", one of three things is causes. ° B 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, Avhich perpetuates it; or (3) these tAvo 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 Avere of the acute, or self- limited kind; another third Avere intimately connected Avith the history of some local lesion, or lesions, of the generative apparatus; while the remaining third Avere essentially of a constitutional character. But the physician who is engaged in a general prac- tice Avill 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 toAvns, Avhere 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 varying influences smDuld draw a Avrong 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 Homceo- pathy, page 490. 678 THE DISEASES OF AVOMEN. relied exclusively upon internal medication, basing the choice of the remedy upon the indications Avhich 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, Avho sees a much larger pro- portion of cases of leucorrhcea Avhich belong to the second group, is almost certain to adopt the current theory that there is ahvays a local lesion at the bottom of the difficulty. To him a leu- corrhceal Aow is synonymous Avith inAammation 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 an excep- tional case, and he is sufficiently discriminating to exclude these lesions as the cause of the trouble, it is altogether improbable that he Avould 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 Avhich he has employed. It is not difficult to discern, therefore, that, while these parties may be equally 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 Avhole circuit of the question at issue. Generally speaking so little is thought of the constitutional causes or modifications of this aAection that they are regarded as of little consequence in its treatment. Especi- Constitutional causes. ,,..,. /.,, i • i . , -, ally is this true ot those dyscrasia? 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 inAuence Avhich one of these morbid states of the constitution exerts upon the clinical history of leu- corrhoea. 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 Scrofulosis in. ,, ^ general health which often predisposes to, and alters the clinical history of other diseases. Its modifying in- CHRONIC LEUCORRHCEA, ETC. 673 fluence over afieetions of the skin, and ot 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 leucorrhoea, its practical lessons are scarcely recog- nized by the profession. This fact may be verified by reference to the Avorks of the most distinguished Avriters of all schools, Avho say little or nothing on the subject; and also by a consultation Avith experienced physicians, avIio either know nothing of it, or avIio, taking an exceptional advantage thereof, have perhaps been enabled to make some remarkable cures. Noav this case is a typical one. When you are consulted for the cure of a leucorrhceal discharge and find the patient Avith a rough, dry skin, a pasty, unhealthy look, an indolent habit of body, Avith swelling of the lymphatic glands, deficient in stamina, impaired digestion, and a tendency in the leucorrhcea-to alternate Avith 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 Avill 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 Aoav of milk Avhen suckling, as nearly all scrofulous Avomen do, the modifying inAuence of this dyscrasia is the more pronounced and positive. Here then, is a constitutional cause Avhich 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, Avhen those remedies are selected by the usual method. For there are not a feAV cases of this kind in Avhich, in order to be successful, you must direct your attention to the underlying dyscrasia. You cannot cure this leucorrhcea by local applications. Merely to seal the Aoav by astringents, or by the use of any kind of caustic, avouIcI 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- 680 THE DISEASES OF WOMEN. litic cachexia, I very much doubt. And it follows that, if Ave cannot do so, we should be very careful about promising to cure a chronic case of scrofulous leucorrhcea like this one. Treatment.—AVomen are generally better economists than men, but in the matter of wasting their oavii physical resources, they are sometimes very prodigal. Here Ave are in Economy of strength. . , . ., , . the middle of winter. 11ns 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 leucorrhceal Aoav. She will never get Avell in this way. Ablactation, or weaning, is therefore the first remedy. The second is to put her upon a good diet. Milk, fooTningandg°°d 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 given 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 Avill remember the case of M----, a sewing-girl 23 years ot age avIio came to our clinic a martyr to a constant and copious uterine discharge. When she Avas not menstru- Case. . ° ating, she had the leucorrhceal Aoav, and this double drain had induced the most unmistakable symptoms of chloro-aneemia. She had palpitation, Avith cardiac irritability on exercise, and very decided symptoms of cerebral and spinal anaemia. Once she had a partial paralysis of sensation in the Avhole of the left half of the body, and Avhich responded to the internal use of rhus tox. 3. For the leucorrhcea 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 especially adapted to the scrofu- lous constitution. It is an aliment merely, and not a medicine, and we may use it as Ave do the vegetable acids in stomatitis, or milk in Bright's disease, Avithout any risk of interference Avith the action of appropriate internal remedies. IRRITABLE UTERUS.—HYSTERALGIA. Case.—Mrs. J----, 27 years old, married, Avith three children the youngest of which is tAvo years of age, has been an invalid for nine years. She is naturally delicate and sensitive. She Avas mar- ried at eighteen, and left home directly for a wedding trip, Avhich 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 Avas very much shattered. She attributes this result to a Avant 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, after fourteen, she suffered a great deal at her monthly periods, more especially for the first ten or tAvelve hours. For this she usually took hot teas, and gin, and kept to the bed. Since the birth of her children this dysmenorrhcea has not returned, but she has not been well for a moment. Her chief complaints are of a fugitive character. She is Avretched when she goes out, and Avhen she comes in; in the morning and at night. The only pains that she has are shooting, shifting and transient, mostly in the loAver part of the back and of the abdomen. At intervals she has spells of lying in bed Avith these pains tor several days. Sometimes there is strangury, particularly after coitus, Avhich ahvays Avorries 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 * visit. Her nights are wakeful, and she dreams of every event, Avhether pleasant or painful, in her past life. Her feet are ahvays 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 Avith it she says it produces 682 THE DISEASES OF AVOMEN. 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 Avhich 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. - . . . ., T 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. „ , • , • i •, ., . of the Avomb, 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, Avhich 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 Avho 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 avIio 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 haAung 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 be natural Exciting causes. 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 thereAvith. Under their influence the Avomb 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 ahvays 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 Avoman over "the month " as it is to carry a popular patient, who is very ill, over the Sabbath, or through a holiday, Avithout 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, Avithout 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 boAvels, of the ovaries, or of some pelvic or abdominal tumor against the Avomb ; spasmodic and me- chanical obstructions of the cervix uteri; ulceration of the vagina or\rulva; nymphomania; \raginismus, 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 Avomen who, having been married for several years, From an early abortion. -i-ii t pi ha\re had no children. In many ot 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 Avas 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 Avho has suffered Avith this trying disease, whose health has been ruined, Avho has remained childless, and who avouIc! give the world if, when she was the bride of a few Aveeks, she had not SAvalloAved somebody's "never-failing pills," or taken the Avretched advice of a neighbor in this respect. Another fertile source of this uterine irritability is the reckless cauterization of the cervix of Avhich I have already spoken so fre- quently. There are certain subiects upon From escharotics. " , , , Avhose delicate organisms this species of refined cruelty reacts Avith a most damaging effect. And it is a singular fact that those physicians Avho resort to it habitually become blinded to these results and indifferent of the consequences. Let me cite you a case to which I Avas called yesterday : Case. — Mrs.----, an intelligent, active woman of twenty-two, of nervous temperament, mother of one child t\vo years old, has not been well for six months. Her household cares, and the Avorry with servants, the heat of the weather, and having to entertain an IRRITABLE UTERUS. 685 avalanche of friends, had worn her down, and she Avas 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 Avhich she Avas accustomed) than usual. For some Aveeks she tried to cure herself by means of domestic remedies from her OAvn 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 OAvn shopping and marketing, and, as usual, -went to church and to Sabbath-school. Finally, through the advice of a neighbor, she consulted a lady physician, Avho cauterized the neck of the womb, and continued to do so tAvice each Aveek, excepting the menstrual Aveek, for six Aveeks. From the first application, she felt 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 Avalked 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 Aveek, 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 Aveek, 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, 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 legion> It varies in 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 iennrth of time. They can not stand or sit more motion. ° * than a few minutes without great suffering, and going up and doAvn 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 Avhich is apt to be folloAved by extreme pain, exhaustion or faint- ness. Sometimes there is an irresistible desire to pass water, especially Avhen she lies doAvn ; again the urging to stool is equally tormenting Avhenever she sits up. And still the urine may be unchanged in quality, and the boAvels remain costive. To these symptoms Ave must add those which simulate certain local disorders, as in the mimicry of Hysteria. The most common of these are dyspnoea, aphonia, palpitation of May simulate other dis- ^he 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 of temper, loss of self-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 c_symptoms may be capri- acided. In brief, the symptoms are subject to the same variations, and are many of them as inexplicable as they are in hysteria, to Avhich 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 fortliAvith the symptoms van- ish. The family are horrified at her going out so soon ; and the doctor, Avho left her an hour before at home, may meet her miles aAvay 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 contradictory nature of. in a half-reclining posture, ride by the hour, or all the day long, Avithout the least sign of fatigue or suffering. Or she Avillmanage the affairs of her household, of the church, or of some charitable enterprise, Avithall the exec- utive ability of one who is well and able to Avithstand 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 AA*omb. The cervix is ^ . . . tender to the touch, and if you push the oraan Physical examination. ~ toAvard 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 vieAv to intro- duce the sound or the speculum occasions more of suffering than usual. Sometimes the uterus feels SAVollen and slightly enlarged. Occasionally it is more or less prolapsed, and in \rery rare instances it is either retroflexed or retroverted. Diagnosis. — This disease is sometimes confounded Avith coccy- odynia. But, in coccyodynia, Avhether from an injury sustained dur- ing labor, or from a fall or a bloAV, the patient From coccyodynia. . can not sit doAvn squarely, or rise again Avithout immediate and most excruciating pain, Avhich is ahvays referred to the point of the coccyx. In irritable uterus the pain is not ahvays 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 Avhile at stool, and pressure Avith 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 boAvels, and pressure upon the coccyx does not cause any very distinctive or extreme pain. 688 THE'DISEASES OF AVOMEN. You Avould 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 From organic disease.- not fog confounded with dysmenorrhcea, for in Dysmenorrhcea. " irritable uterus, although it is apt to be Avorse at the month, the pain recurs Avithout 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. • ,i 01 i c ,1 . -, -, -. ciently. So also ot the avoidable causes, pro- viding you can determine Avhat 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 Avill 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 Aveak, debilitated, and badly nourished. If they take a sufficient quantity of food, it does not build them up as it Build uP the general should. Their vital force is low, and their strength strength. ' o 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, 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- eadn6 mode and time °f stea(l 0I" mincing their meals and eating under 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. - -ip.-ni the greater the need ot 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 Avill 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 Aveak exercise. J and too ill to take active exercise, regardless of its cost or consequences. The best rule Avith A\drich I am acquaint- ed is to observe carefully hoAV each one is influenced by the effort of going to ride or to Avalk, and thus to learn Avhat she can bear and take Avithin the limits of actual fatigue. She may be able to ride three squares not only Avith impunity, but Avith 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 Avere 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 Avater. 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. ^^ ^.^ ^ ^ ^^ yQ^ 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 ahvays, 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. 44 * 6v'0 THE DISEASES OF AVOMEN. A A'ery common error in the treatment of the irritable uterus is to suppose that uterine surgery, as it is technically styled, and ordinarily practiced, Avill help to cure it. For 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 Avhatever variety, are so many instruments of torture. They invariably aggravate the disease. It is only Avhen 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 with salt-water, dry frictions along the spine from above doAvmvards, hot or cold water locally, the shoAver bath, pediluvia, wearing a thick layer of cotton batting along the back, the wearing of silk undervests and Avrappers 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, Avhen my friend sug- gested that something, and the simpler the Why we should use them. i-iii •, -i p better, should be prescribed for external use, chiefly in order to keep the nurse and Avatchers busy with that which would do no positive harm, even if it did but Aery 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 Avill " 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 tho IRRITABLE UTERUS. 691 choice of remedies when speaking of the treatment of hysteria. M ., There is no specific for the relief and cure of No specific treatment. *- the irritable uterus. If the proper conditions are supplied and secured, medicines will achieve the most marked results. OtherAvise they are poAverless. 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. Avill take a dose of macrotin three times daily, and have electricity applied along the spine tAvice per Aveek — every Tues- day and Friday evening. I think it best in 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 surgical. 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 Avell as its treatment are not fully understood. Varieties.—For practical purposes Ave 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 knoAvn among authors as the chronic form of the disease, and one in which the uterine tissue becomes hard, of a Avhite or greyish Avhite color, Avith such an absence of moist- ure as causes it to creak when it is cut Avith the scalpel. In the encephaloid cancer the surface is of a pinkish Avhite, or rose color, Avith 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 irree reflex symptoms. J 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 Avill vary Avith the location of the tumor, Physical signs of. ....... -. i • i x- i i its size, its texture, its age and period ot develop- ment. Its sensibility, its immobility, the ease Avith Avhich it is made to bleed, and the odor of the discharge upon the finger after direct palpation. In cancer of the Avomb especially, the touch Avill indicate the degree of phagaclenic ulceration, the friability of the granulations, the extent to Avhich 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 si oris that have been revealed by the finger. But it is only in the case of limited, or incipient cancerous ulceration, or of cancroid o-roAvths upon the cervix that Ave shall find Avhat is distinctive in the field of the instrument. The irregular, fungous, or bleeding surface, Avhich is of a greenish or broAvnish 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- The proper speculum ated surface. 1101. jn case the disease has involved for. . 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 iioav 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 Avith the fingers. I have known great harm to be clone 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, Avhen 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 Aarieties of uterine cancer are difficult of recognition. Fortunately it is most frequently located in the vaginal portion of the cervix, Avhich is readily accessible to phys- In the early stage. . , , , • ~rn c i . i ical exploration. It 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, you Avill not give a Avrong diagnosis. In cervical hyperplasia, or corporeal cervicitis, the use of the sponge-tent, according to Speigelberg, dilates ^rrom corporealcervi-the j;art and distinguishes the'lesion from the fibrous, or scirrhous cancer of the cervix, upon which it Avould fail to make an impression. An intra-uterine fibroid might be attended with copious watery discharges that Avere offensive and bloody, but the sound and the conjoined manipulation would detect a tumor From uterine fibroids. . 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; „_ , Avhich are not sensitive Avhen a needle is thrust From uterine polypi. . into them; Avhich increase in size at the month, and which occasion expulsive pains like those of labor. There is hoAvever, 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 Ave may say that a woman avIio has a uterine fibroid is in no danger of dying from cancer, Ave 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 From syphilitic • ... ,. , n , ,. . ulceration. varying constitutional symptoms, and the clini- cal history of the case will enable us to discrim- inate betAveen 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 Avithout very serious impairment of the general health; or it may develop rapidly and run its course in a very feAV Aveeks or months. In all cases very much depends upon the period at Avhich 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 folloAving case, for the notes of Avhich I am indebted to the husband of the patient, Dr. P. B. Hoyt, late of Paris, Illinois: Case.—I positively knoAV that there .Avas 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, Avhich continued Avith 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 cornutum and sabina, controlled the hiemorrhage so Avell, that Ave Avere certain she Avould 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 doAvn the left thigh. Sometimes these pains Avere very distressing but Pulsatilla, and gelsemium, relieved her. Some days she passed as many as from twenty to forty of these clots. There Avere strong contractions of the 'womb Avhich caused the most excruciating 698 THE DISEASES OF AVOMEN. pains. On the 18th of Nov. she Avas suddenly taken Avith bearing down sensations attended with shooting, stitching, burning pains, which she compared to hot needles run up into the abdomen, causing her to bend forAvard, and support the abdomen with both hands. She laid cIoavii 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 the 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 Avas at least tAvo and a half inches in diam- eter, and it and the Avhole cervix Avas covered with nodules, like little Avarts. After carefully noting her symptoms, I commenced treatment Avith calcarea carb. every tAvo hours, Avashing the parts with 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 avouIcI reduce the induration, but it failed 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, Ave 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 watery 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 Aveeks previous to this Ave had visited Chicago, to consult Dr. Ludlam, Avho made a careful examination, and gave me his valuable advice for which I shall ever feel grateful, but his prog- nosis Avas 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 Avas increas- ing in size and depth, and the parts were very tender to the touch, Avith a continual bearing-doAvn pain. Indeed there Avas a decided prolapsus. At this time, the hips, back, thighs, and abdomen Avere veiy painful and tender, and the left thigh near the groin Avas much swollen, f iioav used the extract of hamamelis very freely, Avhich mitigated the pain. A severe peritonitis uoav set in, Avhicis came near terminating her life, but by the local application of linseed- meal poultices, with the use of belladonna and aconite internally, Ave succeeded in reducing the inflammation, and she seemed better. There was, hoAvever,a great accumulation of fluid in the abdomen, Avhich finally degenerated into pus, and Avas discharged per rectum the night before hvr death. After the peritonitis had subsided, we found the left ovary enlarged and very sensitive, and this condition continued until she died. Her strength iioav failed, and I could see that she Avas 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 green color, almost black, and of an indiscribable odor. ToAvards the last, nothing Avas retained on the stomach for more than five or ten minutes, and finally after taking three or four spoonfuls of tea, she began to vomit Avorse than ever, and so rapidly that she could not raise it, and choked to death, at eight o'clock a. m., March 2.3, 1880. When the course of this disease is rapid it may carry the patient off before the symptoms that attend upon chronic ca-cs have developed themselves. But Avhen it has con- The cancerous tiim :d for months or years, and h is extended to the neighboring organs, Avith ulceration and sloughing, fetid and ichorous dischirges, severe haemorrhage and intolerable suffering, the nutritive functions become impaired, there follows a species of sIoav poisoning, and the development of what is termed the cancerous cachexia. This cachexia is recognized by a peculiar earthy, or waxy, or talloAv complexion of the skin, n ith a tendency to dropsical infiltration of the integument. 700 THE DISEASES OF AVOMEN. You must be careful however, not to confound itAvith copraemia, which is a form of blood poisoning that depends upon the reten- tion and absorption of faecal elements from the The copnemic and jntestine anc] which produces a salloAV, dirty, cancerous complexion. ' l . hue, Avith unpleasant exhalations from the skin. I have knoAvn 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 fecal matter. The case Avas afterwards cured by rectal injection thai softened the mass and brought it aAvay. 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 influence of preg- ^ interfere with delivery, or resulting nancy and labor upon. J *- ' e 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 off 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 Avhere the lesion is most decidedly local, and Ave 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 Avoman whose mother or sister may have died frcm cancer of the Avomb, or of the breast, has su.'h a dread of this disease that we must not declare Carcinophobia. . our diagnosis too early, or too decidedly. For a lack of cai'e 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 same circumstances Avith respect to heredity, a Avoman's mental and neivous condition may be such that she will not be satisfied unless you tell her she has cancer of the Avomb. It is not a fortnight since I Avas 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 saAv upon my table recently the case of a poor shop Avoman avIio 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 tAvo dol- lars for each local application, Avhich Avas repeated tAvice in each and every Aveek, for more than a year. And yet, as you Avill Avitness, there Avas not a trace of cancer to be found anyAvheie. One mode of death from uterine carcinoma is sIioavii in the case that 1 have just cited. Others die from fatty degeneration of the heart, from the supervention of cellulitis, septic Causes of death from. . „ A. . , i i •.,• 1 i 1 •*• infection, uraemia, phlebitis, and lymphangitis, Avith plegmatia alba dolens, and others still from inanition Avith 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 question Avhether the use of astringents, caustics, and stimulating Avashes, in cases Avhere there Avas a suspicion of 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 groAvths, and it is not impossible that the radical change in uterine thera- peutics, Avhich 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 ot 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- haps of other varieties of cancer, is true or not, ce^anruterine if this method of treating these lacerations is cancer. o-enerally adopted, the uterus will soon be exempted from injuries that have been inflicted blindly, and Avith- out regard to their ultimate effects. If " prevention is better than ciire,"°and his discovery really climini-hes the proportion of cases of this terrible disease, Dr. Emmet will have builcled better than he knew. The objects to be met by local treatment in indications for local a(jvanced cases of uterine cancer are, (1) to treatment. ^.^ ^ intm_pelvic pain? (2) to COlltrol the haemorrhage, and (3) to disinfect the discharges. 702 THE DISEASES OF AVOMEN. The best means of filling the tAvo first of these indications is the resort to hot Avater 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 Avith almond oil, or Avith laid, one drachm to the ounce, may be applied by means ot a cotton tampon; or a mixture of chloroform, glycerine, and SAveet oil may be used in the same Avay. Occasion- ally Ave may take advantage of the anaesthetic properties of very cold applications, and Aran's expedient of passing a cylindrical speculum and filling it Avith 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 Aveak solution of the iodide of 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 poAvdered 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 Avill 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 in- menteme 1Ca "^ ternal remedies, I believe that such a result has never really been accomplished. As you may suppose, the lesion being seated in an orgaji with a Avide 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 atfiliate the remedy, or remedies, to the case in point, as nearly as possible. There are a few remedies, however, Avhich seem possessed of a ^clinical, if not of a curative relation to the cancerous diathesis. These are arsenicum jodatus, hyclrastis can., conium, juglans tin., 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 Avhen 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 tAventy-five years ago. While lifting a heavy weight she felt something give Avay Avithin 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 corrosh'e 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 seAere 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 wThen 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 Avhole body, as if needles were sticking into every pore of the skin. Then red bunches, Avhich vary from the size of a grain of Avheat, to that of an egg, 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 Avorn 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 " 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 Avas knobby, SAvollen, and irregu- lar. By the touch the cervix Avas found to be fixed and immov- able, and very great distress folloAved the introduction of the finger into the Douglas pouch. The vagina was very narrow and exceedingly sensitive, although its walls Avere indurated, even down to the vulva. This condition had rendered it impossible to pass any but the smallest speculum. This Avoman remained in the hospital for three months under treatment, Avhich 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 of that time her health Avas so much im- proved, that she Avent to the country Avhere 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 Avas 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 Avhich is nearly gone, is ulcer- ated, tunneled, and excavated, Avith 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 ment. surglcal treat" uterus, revives the old idea that in some forms 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 uterus7n.tKm °f ^ not be undertaken in ordinary cases. Its risks are fearful, and thus lar at least, the results scarcely Avarrant 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, if 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 Avhole 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, Avith its removal in the case of an interstitial, or of a sub-peritoneal fibroid. " The first extirpation of the carcinomatous uterus Avas made by rVndreas a Cruce, in 1650. In 1812, Gutberlet operated through the abdominal Avails. Langenbeck and Delpech operated by this method, the latter successfully. Langenbeck and Sauter in 1822 operated through the vagina. Saiiter's operation Avas successful. [n 1828 Blundell operated successfully per vaginam. Recamier, in 1829, modified the operation per vaginam by ligature en masse of the lower part of the broad ligament by means of a curved needle. Delpech, in lNoO, proposed a combination of the vaginal and abdominal extirpation. In 1876, Hering operated successfully Avithout ligating the broad ligaments. Freund's operation, 1877, differs from all previous operations. He Avas the first to close the 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 Avith than is generallj „ ... .. supposed. The history of menstrual disorders Sterility from ovaritis. . . and irregularities, just alluded to, confirms this idea. Indeed, whatever imperils the integrity of the catamenial function may also implicate fecundity. When lesions of the ova- OVARITIS. 749 ries are sufficient to prevent the completion of the process of ovu- lation, they also preA'ent 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, Avhile one of them escapes, other things equal, the poAver 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, Avhen 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 Avith the uterine cavity ; and if the ovum Avere furnished by the follicle, it could not be conveyed to the Avomb. 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 preA'ent conception, in some such manner as an excessive deposit of fat in the omentum some- times preA^ents Avomen, 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 Barrenness from gonor- both ovaries at the same time than any other, rhoeal ovaritis. >> 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, Avhich 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 Avho, 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 luwe been wild and profligate in youth, and whose bad habits may haAre perpetuated themsefves. Careful inquiry into the history of such a case, may disclose that the patient has had one or more attacks of gonorrhoeal 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 gonorrhoeal taint, hoAvever 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- ovant?sphoman'a from ease ^s to diminish rather than increase the 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 noAV 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. , , of 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 Ave 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, Avhen 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 ovIrhastmentofpuerperaI 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 Avith 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 upon abortion. I 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 boAvels, 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 AVOMEN. 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, Avhen 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 Avith belladonna. The symptoms, mostly abdominal and symptomatic, Avhich 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- Hamamelis virginica. -n • i • • -i n edy, locally and internally, in orchitis, led me to infer that it avouIcI 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 poAver, in some instances, to prevent abortion, where such a mishap threatens in consequence of ovarian irritation and inflammation. In the latter, it allays the pain and averts the menstrual derangement Avhich is so liable to folloAv. 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 Avhich 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 subiects, suggest that it might Gelseminum. tip also be useful m 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 leucorrhoea, and menstrual de- rangement incident to the critical period. When Lachesis. . . # xr conjoined Avith metritis, in sub-acute and chronic cases, this remedy is sometimes very useful. It is recommends See Medical Investigator, Vol. Ill, p. 62. OVARITIS. 753 by Hering in chronic enlargement with induration or abscess of the ovaries. The following cases Avere kindly furnished by my friend, Dr. A. H. Botsford, of Grand Rapids, Michigan: u Miss M----had suffered many months from dysmenorrhcea, 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, Avhen felt through the abdominal walls. She Avas so lame and sore that she could not Avalk. 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 ne\rer 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 tAventy-eight years of age, and had no further trouble of the kind. She died at thirty-five, of pulmonary congestion. u 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 SAvelling in the region of the ovaries. I3 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 Avith 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 noAV 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 ovenvorks 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 Avell adapted to inflammation of the peritoneum as to that of some other serous tissues —as, for example, the pleura and synovial membranes. Bryonia aiba. ^ far ag we are aware? it kas n0 specific 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 macrotys. The ovular theory of menstruation is confirmed by clinical experience. Excepting those already named, and a few others Avhich are given for specific reasons, all the The menstrual disorder . . 1 aids m choice of the rem- remedies of considerable repute, m 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 Avith 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, dysmenorrhcea, 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 Avill 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, atSh^dSnluraaoT and diet> travel and 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. 755 the menstrual process. Conception folloAved, and the ovarian lesion disappeared. When there is reason to suspect that either the gonorrhoeal or syphilitic taint is present, the mercurius solubil- oVJJEt?tmentfor8°norrhoeal is, mercurius jodatus, nitric acid, thuja, kali jodatum, or aurum metallicum, may be indicated. The curative virtue of calendula Avould be available in case of fistulous opening and discharge of the ovarian Calendula. L ° & abscess through the abdominal walls, or into the bowel, bladder, uterus, or vagina. In puerperal ovaritis, AA'hen the inflammation and tenderness become diffuse and very acute, I knoAv of no local expedient so grateful and beneficial, in a majority of cases, Local treatment. ... as the application ot dry, hot bran to the abdo- men. It should be sewed up in bags, heated as hot as can be borne, applied, and then reneAved frequently. This application possesses the merit of availability and lightness ; it is inodorous, and medically unobjectionable. After the acute symptoms have yielded someAvhat, and the patient is able to lie upon her side, dry heat may still be used, by means of a heated dinner plate, which is wrapt in flannel and kept in constant contact with the abdominal parietes. Cloths dipped in hot water soon become cold, and the patient may be chilled there1.)}'. Hops are sometimes prescribed in extreme cases, in which it is impossible for the patient to sleep, and Avhere nerv- ous symptoms predominate. Emollient cataplasms of various kinds have been resorted to, and sometimes Avith good results. In acute ovaritis, Avhere the pain is more circumscribed and very severe, arising, propably, as M. Yelpeau suggests is the case in orchitis, from strangulation of the organ by its Hamamelis virginica. , , t r i .ccij'l.lI envelop, great relief may be afforded by the external use of the hamamelis virginica. I prefer Haisey's fluid extract of this drug, Avhich may be mixed with hot water, in the proportion of one part to three, and applied locally, by means of cloths or flannels that have been dipped therein. In case the SAvollen and sensitive organ is prolapsed along the Avail of the vagina, a weaker solution of the hamamelis, containing glycerine, may be used as a vaginal injection, or applied by means of cotton wool or charpie saturated Avith the same, and introduced into the 756 THE DISEASES OF AVOMEN. vagina. This application is sometimes remarkably efficacious. It may also be injected into the rectum. If the Arnica—Aconite. . . . . . inflammation is of traumatic origin, arnica may be used in the same manner as recommended for the hamamelis. The local and general employment of aconite is recommended in case of a rheumatic complication, Avhich sometimes involves the most extreme suffering. Vicissitudes of Aveather and temperature sometimes affect this class of cases so unfavorably, that it is Avell to protect and insulate the ovaries from their harmful influence. For dampness from cold and this purpose a layer of cotton batting, flannel, or silk, should be Avorn next the abdomen. In very susceptible subjects, Avhere, from taking cold, mild attacks of ovaritis frequently accompany menstruation, this expedient is also serviceable. Warm baths are better than cold, and the hip bath is preferable to any other. The cold hip bath is sometimes useful, but should be taken quickly, in order to insure reaction. Baths, etc. tit i ,.,... . „ lhey should not be used indiscriminately, hor the relief of pelvic pains incident to severe attacks of ovaritis and ovarian neuralgia, Dr. Aran recommends the expedient of packing the speculum, in vagina, with coarsely powdered ice. Such ex- treme measures are rarely, if ever, justifiable. Little attention need be paid to restoring the displaced ovary. Remove the inflammation, and the structural changes consequent upon it, and the dislocated ovary Avill take care of itself. Any attempt to reduce the luxation, farther than by placing the patient in a favorable position, Avould probably result in more of harm than of good. As one of the most trying obstacles in the way of a cure is found in the recurrent menstrual congestion ; so it is quite impossible, in many cases of ovaritis, to effect a cure while cours°eCribe sexual inter" the patient yields to sexual indulgence. She must live absque marito. I have found that those patients with ovaritis Avho come to this city for treatment, and who are thus removed for a time from the stimulus of sexual excitement, recover more rapidly and permanently than others of my patients, Avho, while being treated, are obliged to remain at home. There are, however, a few exceptions to this rule. LECTURE XLVI. OVARIAN NEURALGIA--OVARALGIA. Ovaralgia. Etiology. Clinical history of. Diagnosis. Prognosis. Treatment. Ovarian Irritation. Case.—Causes, nature of. Case.—Remedies. An eminent author has insisted that the ovarian stroma is the sexual center of the female organization. Whether or not this theory is true, it is certain that this spongy structure is erectile, and therefore subject to extreme vicissitudes in respect of its cir- culation and innervation. For the ovaries are well furnished Avith blood vessels and nerves. This is a necessary condition of their functional activity which, as in the case of other delicate organs, implies the possibilities of diseased states that shall arise from a derangement in their nutritive and nervous supply. In health the ovaries are not sensitive. Enclosed in their fibrous capsule (tunica albuginea,) they float out of harm's way. But, under some peculiar or periodical excitement of Peculiar predisponentsof ^he generative SA'stem, as, for example, in coitus, ovarian irritation. o ■■ *■ menstruation, pregnancy, or parturition, they are liable to become irritated, congested, inflamed, or the seat of severe neuralgic pain. And since " women are always about to menstruate, or menstruating, or ceasing to menstruate ; or the womb is gravid or going to become so, or it is recovering from the parturient state ; these organs have never an even, steady tenor of life." Hence the frequency of ovarian diseases, one of the most interesting and troublesome of Avhich is the theme of my lecture this morning. Etiology. — The neuralgic diathesis is the most powerful predis- ponent of ovaralgia. Women Avho are subject to neuralgia of the face, head, teeth, and other parts, sometimes The neuralgic diathesis. ^^ ^^ frQm ^ affection. In such persons, if anything is Avrong in the pelvic region, the pain is very liable to become neuralgic, in Avhich case the rectum, the uterus, the neck of the bladder, or either of the ovaries, may be the seat 75i 758 THE DISEASES OF AVOMEN. of suffering. In this class of subjects the nervous system may have been originally Aveak and subject to painful disorders, or that con- dition has, perhaps, been acquired by habits of life, and the sur- roundings to Avhich the patient has been subjected. We find examples of this kind among seamstresses, avIio lead lives of toil and anxiety, and Avho subsist upon tea, Avith insufficient and improper food, as Avell as among those who are buffeted by emotional excitement at the expense of their happiness and general good health. Such persons are almost invariably anaemic or chlorotic. This neuralgic predisposition may be complicated with a rheu- matic diathesis. I have treated several patients for neuralgia of the pelvic organs in wTiom the suffering was The rheumatic diathesis. *.. „ , ,. directly chargeable to a metastasis ot the disease from some other part of the body. My oavii observation leads me to conclude that the daughters of rheumatic fathers, especially if the parent Avas of intemperate habits, are particularly liable to this complication. The rheumatic element may be masked, but it cer- tainly modifies the nature of the attack, and should not be over- looked in its treatment. So also of hysteria. Very few hysterical Avomen are exempt from neuralgia. Indeed, it is one of the many peculiarities of hysteria, that the slightest causes implicate the The hysterical diathesis. . . nerve filaments and involve suffering. A focal congestion Avhich is temporary, incidental, and self-limited, and Avhich in other persons Avould be an insignificant affair, in Avomen of this temperament will sometimes give rise to extreme suffering of a neuralgic character. It is true that such patients are prone to exaggerate their sufferings, but still the fact remains, that in hysterical Avomen the peripheral nerve filaments are peculiarly sensitive to causes Avhich induce pain. The excitement of the generative system to Avhich this class of persons is especially subject, is a fertile source of OA^arian neural- gia. Excessive or fraudulent intercourse ; un- Sexual excitement. . gratified sexual desire; menstrual derange- ments ; emotional influences, as, for example, too much of thea- tre-going, of novel-reading, of dancing, or of the worry and Avear of fashionable society ; carrying too much or too little Aveight in life, and exemption from proper household cares ; may cause such OVARIAN NEURALGIA. 75 The hysteric condition is characterized by irritability, sui gen- eris, of the nervous system as a Avhole, or sometimes more partic- ularly as connected Avith certain organs ; and although this condi- tion can not probably be originated in the individual by modes of living, and other external circumstances, it may be aggravated by them." In what this hysterical predisposition really consists we do not knoAv. Hoav it is that it reverses the finer traits and characteristics of Avomanhood, Avhether temporarily or perma- Its real nature is unknown. ^^ ^ .g ^^^ t() comprehend. That such are among its effects is a thing of every-day observation. It is at the bottom of half the disease and the unhappiness of the sex. It may turn the Avife against her husband, the sister against her brother, the daughter against her father, the mother against her child, and friend against friend the Avorld over. Its strange characters may be traced upon every page of human history. In the affairs of church and of state, in medicine and morals, in soci- ety at large and in the sick-chamber, its influence is certain to be felt. It does not destroy life directly, but indirectly it has slain its thousaiHls. In brief, it is the most mischievous and the most enigmatical and elusive of all those elements Avhich enter into the formation of " poor, weak, human nature." Prognosis. — Uncomplicated hysteria is not a fatal disorder. It may, hoAvever, serve to conceal the graver symptoms of disease * Essays and Notes on the Physiology and Diseases of Women. London, .1851. p. 237- 796 THE DISEASES OF AVOMEN. under cover of such as are not serious, and in this manner tends to destroy life by causing the real lesion to be overlooked. Let me illustrate: A delicate, nervous Avoman is seized Avith a sharp attack of pleuro-pneumonia. In the emergency of her sudden illness arr officious neighbor is called in. This impromptu nurse has a voice and manner that serve only to excite the patient more and more, and, despite her bundle of expedients, some of which, if properly applied, might have been efficacious, the symptoms are aggravated. The reflex effect of that Avoman's presence and performances upon the sen- sibilities of such a subject is so to shock and derange them, that it may be quite impossible for the doctor when he arrives, to discrim- inate properly betAveen the symptoms that are presented. He can not tell which of them are genuine and Avhich are spurious, for the former are masked, while the latter are lashed into undue prominence. All the symptoms that are chargeable to the nurse's lack of tact, to her incompatibility and to surrounding circum- stances generally, rather than to internal conditions of the patient's organism, Avill be likely to deceive and mislead the physician. Vesical or rectal tenesmus, globus or clavus hystericus, fugitive and excruciating local pains and spasms, a temporary diabetes in- sipidus, aphonia, hysterical vomiting, amenorrhoea, or a host of other irrelevant symptoms, not one of Avhich has any characteristic relation to the original disease, are so magnified, and stand out so clearly and prominently, as to divert his mind into the Avrong channel. Under these circumstances, and especially if he is inexperienced, the physician may feel himself called to prognosticate a fatal issue. Taking the wrong cue, adding to the alarm instead of arresting it, and causing matters to become Avorse in compound ratio — for doctors are either helpful or harmful — the patient may finally die, not indeed of hysteria, but of the pneumonia Avhich has been per- mitted to run its course Avithout interruption, because it has been overlooked. Or, if the physician in charge has had sufficient experience, and has tact enough to enable him to recognize the hysterical out- growth in such a case, but is Avithal A'ery much occupied, and weary with this class of patients especially, he may hastily con- clude that she has a fit of hysteria and prescribe accordingly. HYSTERIA. 797 Meanwhile the real disease is making rapid progress, and before his next visit it may have become incurable. Noav it is this deceptive exaggeration that is likely to mislead, and to cause us to misjudge, to overrate, or to underrate the dan- ger in cases of hysteria complicated Avith other forms of disease. Some of the verbal and objective signs are untruthful. They in- troduce the lying element into the record, and hence the difficulty in detecting them and in assigning their proper diagnostic and prognostic value. Treatment.— Before we proceed to the special therapeutics of this affection, there are some considerations General remarks. which demand our notice, and which are essen- tial to its proper and successful treatment. This disorder being chiefly emotional in its origin, and indeed in its very nature, it is vitally important to obtain such an in- fluence over the mind of the patient as will Mental remedies. ^^ .^ ^ meagure to Control the Symptoms, 01* at least to place her in a state in which our remedies will act more promptly and efficiently. There can be no doubt that very many cases of hysteria, in some of its protean forms, have been unAvittingly cured by means that were suited to occupy, divert, overAvhelm, or control the emotional faculties. Such expedients are to be regarded only as auxiliaries to proper treatment, but as such they are so useful, and sometimes so necessary, that they should not be overlooked. For it has often happened that the manner and bearing of the nurse, or of some kind-hearted neigh- bor who has been called in, has clone a thousand times more to cure these patients than the physician's prescription. The intan- gible, but no less potent influences of fear, faith, hope, confidence, will, reason, diversion, management, occupation of the mmd, ar- gument, concession, opposition, sympathy, indulgence of caprice, helping her to bear her burdens-whether real or imaginary- change of diet, air and scenery, are sometimes indispensable And unless we can use them appropriately, or the patient shall happen to be accidentally brought under their influence, the best chosen remedies Avill utterly fail of effect. Herein lies the difficulty in controlling and curing the various forms of hysteria. The most inexperienced among you might match a great many of the symptoms mechanically, and prescribe 798 THE DISEASES OF AVOMEN. for them secundum artem. But, unless you are able to recognize Avhich of them are genuine and which are The real problem. l l r> i not; unless you can separate the real from the spurious; unless you can refer those Avhich are hysterical to their proper source, and succeed in reducing the emotional disturbance of the patient to order, you Avill fail to cure this disease. Now, there are many ways of accomplishing this object. You knoAv that hysterical patients are eccentric. For this reason it requires a large measure of tact (which can only be acquired through observation and experience) to manage them properly, and to cure them most certainly and promptly. I can no more tell you what to do in each particular case of hysteria than I could define the odor of small-pox or of measles. But it is pos- sible to give you some general directions that shall be useful. In the first place, if you desire to be most successful in treating this class of diseases, you should maintain your distinctive char- acter as physicians. For there is a species of Something depends upon , i i i • i i i i the doctor's habits. mutual reserve and respect Avhich should sepa- rate the physician from his patients, and which invest him with a peculiar influence over them. If this is prop- erly maintained, it need not subtract from the social character and position upon AA'hich so much of his general reputation de- pends. But it will give him an immense advantage in the man- agement of every kind of hysterical disorder, to which so many of his lady patients are subject. Nor is a highly-Avrought, delicate, impressible, nervous woman likely to be benefited by the advice of a physician Avhose personal habits and manners are repulsive to her, and Also his personal ad- i i n l i . 1 ,1 , i dress, etc. whom she is compelled to tolerate rather than esteem. In this, as in other matters, trifles have great Aveight. I have knoAvn a brother practitioner, who Avas skillful and competent, to be discharged by such a patient for the reason that " he never Avore a decent cravat." His slovenly habit more than counterbalanced the effect of his remedies, and, while he continued to visit her, his patient greAv Avorse instead of better. The good influence of one physician may be crippled by his loquacity, another is too taciturn; a third asks too many, and a fourth too feAV questions of the patient; one brings too full a budget of news from a neighbor; another is eternally canvassing HYSTERIA. 799 for his school of medical practice, his church, his club, or his political party; one is too cross, Avhile it is alleged that another is " altogether too kind." This is but a scanty list of personalities, any one of which may serve, in this class of diseases especially, to neutralize the curative effect of his remedies. You are not to suppose The smallest items not ,i ,, ...,-, . . always trivial. that they are insignificant merely because they are not alluded to in your text-books. What- ever can by any possibility constitute an obstacle to recovery is important and worthy of your attention. Fortunately most of these vexations are avoidable. You will not all excel in obtain- ing the confidence of your patients, and in bringing them into that passive state in Avhich they can be most readily cured. But each of you can by education acquire such a measure of tact and of adaptation to caprice and circumstance as Avill multiply your resources and render you many times more useful to them. I am so confident that a lack of sympathy, a dearth of feeling, a real incompatibility of temper and taste betAveen the physician and his hysterical patient may cause his treat- phys'cS^SSr611 ment to result in more of harm than of good, that, in case this obstacle can not be otherwise removed, I think it better to withdraw and to let another phy- sician be called. Indeed, I have sometimes voluntarily discharged myself, after having frankly told the patient and her family that, for some unknoAvn reason, my remedies had failed to cure her; and that, in my judgment, such a change Avas what she most needed. Under similar circum- stances we would not hesitate to discharge the nurse Avhose every movement was annoying to the patient and antagonistic to her comfort and welfare. And I do not know Avhy the same rule should not also apply to the doctor. If a new face and a new method of prescription will Avork the desired change in her feel- ings and her symptoms, by all means let them be tried. For these things can operate through the emotions, and may entirely super- sede the necessity for remedies of Avhatever kind. And by fol- lowing this rule, although you lose the credit of curing one such patient, you will gain the reputation of saving another ; for, when the wheel turns around, your face and your manner may be the 800 THE DISEASES OF AVOMEN. one thing needful in a similar case which your professional neigh- bor has failed to relieve. In lieu of controlling the emotional outbreaks and suffering in hysteria, by the personal tact, character and magnetism of which I have spoken, these subjects are often brought Narcotics and Anti-spas- uncier the quieting influence of narcotics and modics. x. o anti-spasmoclics of various kinds. But such medicines are mischievous, and should be given under protest and exceptionally, or rather not at all. One reason Avhy there are so many nervous women in our clay is, that the habit of taking such drugs is almost universal. And eArery feAV months a neAv one is added to the list. Thousands of Avomen, Avho should be Avell and healthy, are just now uncier the slavish domin- ion of the hydrate of chloral and the bromide of potassium. The taking of these substances habitually begets a predisposition to nervous disorders Avhich grows apace. So that if there were no other reason for withholding them from our prescriptions, Ave should not gh'ethem freely and indiscriminately, lest the habit be formed in consequence. There are, however, exceptional cases in which this means of temporary relief can not be rationally excluded. When from excess of pain, fatigue, or excitement, it is ab- Sometimes permissible. solutely impossible otherwise to procure the needful rest, they are perhaps permissible. But these are excep- tional cases in Avhich we must choose between tAvo evils. It may be better to compel sleep, to overwhelm the nervous centers, and to run the risk of the secondary consequences of such an expedi- ent, rather than let the patient wear herself out Avith unrest, extreme pain, or protracted insomnia. Concerning the propriety and advisability of alcoholic stimula- tion in the weakened conditions of the neiwous system, which Al . ,. . , . predispose to, and attend upon hysterical dis- Alcoholic stimulation. x j orders, physicians are not agreed. One class, of which Dr. Skey is the modern representative,* considers them indispensable, and insists that they should be given freely and promiscuously. On the contrary, what might be called the de- nunciatory school is equally positive that in all forms alcohol is always injurious. * Skey on Hysteria. A. Simpson & Co., N. Y., 1867. HYSTERIA. 801 This involves a question which can not be settled for you in the lecture-room. If you are satisfied that these agents can be utilized in correcting the mal-nutrition and depraved vitality from which this class of patients often suffers preeminently, it Avill be your duty to prescribe their sparing and transient use. If you need to husband the vital resources of one avIio is exceedingly weak, and almost bankrupt in strength, and are satisfied that alcohol, or tea, or coffee Avill diminish disassimilation, and prove a veritable '• savings bank to the tissues,"' as Moleschott so quaintly terms it, you should not Avithhold them. Under certain circumstances it may be quite as necessary to furnish a rapidly oxydizable material to the organism, as in other „ „ r j . . conditions it is to supply oxygen itself. I might Folly of dogmatizing. ... . " ^ ° insist that Avine, brandy or whiskey have never been of the least service in any case of hysteria. But that Avould not alter the facts. Individual observation is too limited to justify such assertions. Indeed, these arbitrary rules have very little to vecommend them. I have knoAvn Aveak, nervous, delicate Avomen to be disabled and bed-ridden for months and years because their physician obstinately denied them the little stimulus Avhich they craved, and the temporary use of Avhich Avould have set them vipon their feet again, Avithout doing any possible harm. So far as my oavii experience extends, I have found it best to discriminate carefully, and to prescribe one or another of the dif- ferent preparations of alcohol only Avhen I could Qualified use of stimulants. 1 _ ■ . . . . not do better, and when there Avas no especial langer of reviving an old habit, or of forming a neAV one Avhich ivrould result in intemperance. There is an essential difference betAveen giving AA'ine or brandy to the extent of complete narcot- ism, or endorsing its persistent use until one's patient is in a state of chronic alcoholism, and the judicious and temporary employment of it as an available stimulus in an emergency. And let me tell you that there is not one-hundreth part the danger of our making drunkards of Avomen that there is of making topers of men. The exercise should be regulated most carefully. Many Avomen become fatigued almost beyond measure Avho, strictly speaking, take little or no exercise. With the majority Proper exercise. q£ th^ pergons the fault is not that their time is not occupied, but that they lack the stimulus and benefit of 51 802 THE DISEASES OF AVOMEN. variety of occupation. Their house-life is a species of tread-mil] round of Avork and Avorry, Avith little or no change Avhatever, What this class needs is diversion, a combination of mental and physical exercise that shall keep all their faculties in healthful play. If a Avoman Avears out her nervous energies in household drudgery, you must prescribe a change of habit, and season her cares with a little of the spice of the outside Avorld. Fresh air and sunlight, society, travel, music, literature, or an additional servant may be useful ingredients in your prescription. Among Avhat are called the "better classes," Avith Avhom life is a listless, perpetual holiday, a predisposition to hysteria is fre- quently nurtured or acquired. With many " beuerrdasses!"ng ' e women the seeds of this disorder have been soAvn in boarding-school. Boarding-house life and hotel life, in America, are nurseries of hysteria. This kind of life subjects its A'ictims, Avho are Avithout proper and constant employment of their time, to vicissitudes of excitement, and of personal experience that are inimical to health. The nervous systems of these Avomen suffer most severely. Their life is an aimless, artificial one, Avith a large margin of leisure Avhich is apt to be Avrongly appropriated. It is almost impossible for a gifted and attractive young or middle-aged lady to escape the perils of such a home, if indeed it deserves the name. And, since it will not always be possible for you to locate these patients just as you could Avish, any more than to mate them pro- perly, you Avill be forced to counteract such Domestic occupation. influences in the most practicable manner. If they haA'e the means and the disposition, persuade them, if pos- sible, to settle in homes of their OAvn, Avhere proper domestic cares may occupy a share of their time and attention. Thousands of Avomen Avould be cured of the hysterical tendency if they were blessed with comfortable homes, and removed permanently from the corrupting influences to Avhich they are otherAvise sub- jected. It is sometimes absolutely essential to remove them from a house in which everybody knoAvs everybody's business, and in which no woman has any business. You can also accomplish a great deal by the exercise of a little tact in keeping these patients busy with something useful, instructive and profitable. One may perhaps become interested in a course of reading which you HYSTERIA. 803 shall map out for her. Another might be made to forget her com- plaints if she Avere to resume her music, her Cultivation of proper i^ i 1 r* , • • . mental habits. i"1 rench, or her German; or to participate in one or another of the charitable objects and missions, in which some of the best Avomen of our day are so much engrossed. One should see more of society, and another less. All need some kind of diversion, some mental occupation, some change which shall dh'ert their thoughts from themselves, and especially from a morbid stimulation and gratification of the sexual appetite. You will sometimes haA'e to counteract such domestic infelicities as, by the constant fret and friction which they induce, serve to keep those who are predisposed to hysteria, ^Removedomesticinfeiici-always on the sick list. This woman may be cured by getting her out of sight of her OAvn servants; and that one, if she can escape the neighborhood in which she is certain to see or hear something of others, men or women, against Avhom she has conceived an inveterate dislike. The hysterical irritability is very apt to accompany, or to be engrafted upon a jealous and unhappy disposition. It certainly is much easier to prescribe than to furnish con- tentment to such persons, but example and pre- cept will accomplish wonders, even although, like the third party who attempts to make peace betAveen man and wife, Ave some- times incur considerable risk in giving our advice. In all this you will be compelled to take a leading character in the old play of Tact versus Talent. And I am anxious that you shall not appear upon the stage of practical life as physicians Avithout ever having had a rehearsal. For, in the cure of hysteria especially, the largest share of the work to be done may depend upon these common-place matters. LECTURE XLIX. TREATMENT OF HYSTERIA.--CONCLUDED. Treatment during the fit. Do. for the hysterical diathesis; do. for the accompanying lesions and complications. Case.—The utero-gastric and cardiac disorders. Case.— Hysterical hemiplegia. The hysterical mimicry. Treatment. From the time of the Greek midwives, Avho, according to Galen, were the first to employ the Avorcl Hysteria, its treatment has been divided into that proper for the paroxysm and that for the interval. When you are called to relieve a woman who is in " a fit of hysterics," you must knoAV what to do. First, you should be self- possessed, and not in a flutter. AIIoav nothing Treatment during the fit. . ° to surprise you. Be cool and collected. Look upon the most startling developments as matters of course. Do not give a hasty opinion as to the result. Qualify your prognosis, and above all things do not be in a gloomy, despondent state of mind yourself. Have the patient placed in a comfortable position upon the bed or sofa. Let the head be slightly raised, and if need be, held by an assistant. HaAre the forehead and face bathed Avith cool or cold water, or cold compresses laid across the fore- head and temples. Let her have a plentiful supply of fresh air. If it bloAvs from the AvindoAV directly into her face, so much the better ; or she may be fanned by the nurse. All ligatures in the form of corsets and garters, etc., should be removed. The dress should be thrown open at the throat especially, and only enough force applied to keep her from inflicting bodily injury upon herself and others. The usual restoratives consist in allowing her to smell of ordi- nary spirits of camphor, ammonia, musk, cologne water, chloro- form, ether, alcohol, vinegar, the fumes of a Available expedients. . burning feather, or ot a lighted match. Sina- pisms and the warm foot or sitz-bath, vigorous rubbing by a strong, healthy person, dashing cold water upon the head or spine, the application of heat, electricity, and the use of brandy, coffee, cam- 04 HYSTERIA. 805 phor, sulphuric ether, ice water, or a solution of some salt of vale- rian by injection into the rectum, are among the available expedients, which may be tried before the patient is able to swalloAV. Some- times the paroxysm will be relieved almost immediately by firm pressure upon the hypogastrium. More frequently it will pass away insensibly uncier the influence of delicate attention and quiet, and proper sympathy which tend to soothe and calm the excited feel- ings. Or it may terminate by your sending out of the room some person aa'Iio is well enough disposed, but Avho is especially obnox- ious to the patient. If the fit has been induced by anger, or some fancied slight, or disappointment, or by mental anxiety or grief, no allusion to the cause or to the possible consequences of the Precaution—Tact. *- attack should be permitted Avithin hearing of the patient. Indeed, the greatest care should be taken to turn the current of conversation, if there is any in the room, into quite another channel, else it may prolong the disorder. Whatever is said should be calculated to divert her attention from herself, and thus indirectly to restore the Avill to its supremacy over the emo- tions, for when the Avill of the patient is in league Avith the emo- tions it adds fuel to the flame to persist in telling her how very ill she is. The better plan is to speak of something quite foreign to her present condition and surroundings, and to try to interest those avIio are present in the subject matter of conversation. This Avill be a mild means of counter-irritation, or diversion, Avhich will serve to benefit the patient, who is unwittingly being toned down by your tact. It is the habit of some physicians to scold such a patient, or to declare contemptuously that she has " nothing but hysterics," and to refuse to do anything for her. This is posi- tively and unprofessionally cruel, for, Avhile it lasts, the suffering is as real as in any other disease, and the patient as deserving of sympathy and relief. Doctors are servants. And whether you are sent for in the middle of the night, or while at church, or at a social party, to visit an hysterical patient, you should carry with you as large a measure of good-nature as if you Avere going to a case of puerperal peritonitis, or of some other serious disease. Most frequently, however, the paroxysm will have ended before 806 THE DISEASES OF AVOMEN. your arrival. If she remains obstinately silent and refuses to an- SAver your questions, give her the medicine, For her taciturnity. and Avait until she gets ready to speak. This let-alone species of indifference on your part Avill hasten the crisis, and after a fit of Aveeping, she will be communicative enough. Concerning the treatment betAveen the paroxysms, I Avish in the first place to insist that you shall not be misled by the inci- dental and irrelevant symptoms Avhich are so common in all forms of hysteria. I have often thought that if it Treatment in the interval. Avere possible to treat our hysterical patients just as we are compelled to treat infants when they are ill, that is, Avithout regard to their subjective sensations, the special treat- ment of this disease Avould be greatly simplified and much more successful. For it is the peculiar rendering, the exaggerated esti- mate, the misinterpretation of the sufferings experienced, that Avill sometimes lead you to Avish that such a patient was as mute as a child that is only a month old. I knoAV that it is very difficult to discard Avorthless symptoms Avithout at the same time eliminating some Avhich are really valu- able and important, and yet, I tell you frankly Necessity for caution in , i , • • n ... « , , the exclusion of symptoms, that, in my judgment, a majority ot the symp- toms, more especially those derived from the tongue of an hysterical patient, are of no practical significance whatever. You cannot depend upon them. They are compounded of shrewdness, cunning, trickery, deceit, a mor- to^caLVe«dbyany0ringiebicl Pagination, real suffering, and reflex irri- remedy- tions of all kinds, which confuse and confound us at every turn. One of my medical friends says that a hysterical patient is " apathological kaleidoscope." It is so ab- solutely impossible to prescribe for the totality of the symptoms that, in many cases of hysteria, you will be compelled to abandon the idea ; for when they change like the hues of the chameleon, and are as irreconcilable, incompatible, and contradictory, as they often are, you avouIc! need as many remedies as there are single, individual symptoms, and these might have to be changed several times daily. As a prospective improvement upon the ordinary unsatisfactory and unsuccessful method of combating hysterical symptoms, let me counsel you to direct your treatment, 1st, Against the hysteri- HYSTERIA. 807 cal diathesis, and 2d, Against the symptoms which properly belong to the lesion, of which the hysterical attack is General rules. , " either the consecpience or the concomitant. Physi- cians recognize the practical significance of the rheumatic, the gouty, the tuberculous, and the syphilitic diatheses. In the treat- ment of almost every variety of disease of Avhich their existence can possibly complicate or modify the symptoms, they receive clue consideration Avhen Ave make our prescriptions. The hysterical predisposition is equally pronounced and equally deserving of at- tention. Its treatment is more decidedly hygi- For the hysterical dia- • j i i , • ,-t t • 1 tj_ thesis. enic and prophylactic, than medicinal. It pre- scribes the removal, if possible, of all the causes which might originate or perpetuate this disorder. It regulates the mental and physical exercise of the patient, her habits of eat- ing and sleeping, her social and domestic life, and everything, in short, Avhich can influence the functional operations of her ner- vous system. It places particular stress upon these matters in her case because of her constitutional bias towards hysteria. It recog- nizes that health cannot be restored unless the proper physiologi- cal conditions for its restoration and maintenance are supplied. A knoAvledge of this diathesis Avill sometimes aid in the selec- tion of our remedies. The relations of belladonna, ignatia, caulophyllin, agaricus, hyoscyamus, lilium tig., Remedies to counteract it. . * - . . gelseminum, ether, moschus and Aaferian to this peculiar predisposition are Avell knoAvn to the profession. They ctre sometimes given Avith excellent effect as hysterical prophylac- tics, and may finally eradicate the disease altogether. As inter- current remedies they may be equally useful. The choice betAveen them Avill depend upon a few " characteristic," objective, cardinal symptoms. The diseases of the generative system are the most usual con- comitants of hysteria. Disorders of menstruation underlie a large proportion of the cases of this disease. Dys- prce°risncidentmenstrualdis- menorrhcea, amenorrhcea, too scanty, too copi- ous, irregular and too frequent menstruation may need to be cured before the symptoms of hysteria will disappear. For each of these affections you should therefore prescribe as care- fully as possible,'taking only such note of the hysterical outgrowth as Avill enable you to counteract the predisposition of which I have 808 THE DISEASES OF AVOMEN. spoken. The chief thing is to cure the menstrual irregularity, after which the contingent symptoms will disappear of themselves. Remove the cause and the effect Avill cease. Cure the idiopathic lesion, and the sympathetic, nervous, accidental symptoms Avill A'anish. This method of procedure will enable you to discriminate be- tAveen the legitimate symptoms, AA'hich are reliable, and those Avhich are not. It Avill not, hoAvever, do away iegitimat'eesymSpttodms0f the with the necessity for close and careful study of those symptoms, and a proper adaptation of the remedy to the cure of the menstrual difficulty. You will proceed to remedy that disorder, Avhatever it may be, with little or no regard to the hysterical phenomena, hoAvever noisy and clamorous they are. The same rule applies to organic disease of the ovaries, and of the uterus, to uterine displacements and ulceration, to hypertro- phy and neoplasms of the Avomb, to leucorrhcea, uteruT^ovarie's^etc.50^116 abortion and its consequences, to vesical and rectal irritation, inflammation and ulceration, which so frequently exist in connection Avith hysteria. The symp- toms that properly belong to these several affections are those which are most significant, and Avhich Avill afford the real indica- tions for the cure of the case. There is no objection to an inter- current remedy for the relief and removal of a contingent delirium, globus or clavus hystericus, the hysterical stitch in the side, or the infra-mammary pain ; but your chief concern will be to recog- nize and cure the lesion from which so many of the symptoms are proliferated, but upon which they are in a sense supernumerary. So, also, with the gastro-alimentary, hepatic, cardiac, cerebral. spinal and renal difficulties Avhich sometimes attend upon hysteria. r L These complications render it still more difficult Also of other organs, onhdarare themseIves sec~ to cure- For they may be, and often are, them- selves secondary upon some inter-pelvic disor- der. Under these circumstances you Avill 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. SOU the symptoms that are referable to the pelvic viscera may afford a more reliable guide in the treatment than the Utero-gastric and utero- „ . ■ ,1 i • , , cardiac derangements. gastric or the cardiac symptoms, separately con- sidered. One of my patients had an intractable tmesis Avhich the best chosen internal remedies failed to relieve. Case 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 Avas located Avithin the pelvis, I proposed a vaginal examination. The touch revealed the uterus badly pro- lapsed. It AAas 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, Avalking, 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 Avhole 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 Avithin the last three years. These cases are exceptional, but they Avill 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, dit?onser complicating con" will 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 AVOMEN. 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 Avere distinctly referable to a state of permanent congestion of the pelvic organs, Avith 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 ^he ^oss °^ ^l00(^ at the month, and by the Aveakened 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, Avomb-tire, Aveari- ness and physical dilapidation are the result. Sometimes, and especially toAvard the climacteric, and in women of a highly intellectual cast, these conditions of local hyperaemia and anaemia are reversed. The cerebro-spinal axis is surcharged with blood, Avhile 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, Avith friction, kneading, tapping and percussion; of the motion ot 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. Tavo Aveeks ago she was suddenly seized during the night Avith a violent fit of hysteria. The spasms of the voluntary muscles were very severe. She talked foolishly of her little HYSTERICAL HEMIPLEGIA. 811 love affairs, of church matters, and upon all kinds of topics. In about half an hour the paroxysm passed off Avith 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 Avere paralyzed. The muscles Ave re relaxed. She could move the leg a little, but only Avith the greatest effort. The arm Avas quite poAverless. Her consciousness Avas 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 Avhen she protruded it; her speech Avas unimpaired, but it Avas sometimes difficult for her to SAvallow. She complained of frontal headache and inability to sleep. The right pupil Avas considera- bly enlarged, but the left one remained unaltered. The boAvels were obstinately constipated. The menstrual Aoav, Avhich had begun only a feAV hours before the hysterical attack set in, Avas arrested, and did not return. She has been subject to amenorrhoea, 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 Avhich I have already spoken. One avouIcI say, at first thought, that Hysterical mimicry. ., . , , ., . ., , r ... 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 Avhich the right half of the body is poAver- less. This poor girl had to be carried into the amphitheatre, for she cannot stand alone. When she attempts to Avalk, the right limb, Avhich seems a little stronger than it Avas at first, SAvings with a pendulum-like motion, directly forAvards and backAvards, 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 tAvo forms of palsy have no necessary relation to each other. a practical test. Observe that when I stuck the pin into her arm, to test this question, it was done Avithout her knowledge. If 1 had told you in her hearing what I intended to do, and she had seen the point of the pin coming towards her, she Avould 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 812 THE DISEASES OF WOMEN. a clicking noise, Avhich exactly resembled that caused by the striking of a metallic instrument against a calculus, a\ hich disease she Avas supposed to have. Having AvithdraAvn the instrument, I Avas about to declare that my patient had stone in the bladder, Avhen, upon turning its handle, I discovered that it had become loosened and gave forth precisely the same click that I had heard before. This shoAvs the impor- tance of being ahvays on our guard, lest Ave arrive at Avrong con- clusions in diagnosis. Naturally enough you would like to know Avhat variety of unilateral paralysis it is from Avhich this patient is suffering. I haA^e no doubt but that it is hysterical, and my Diagnosis. ", judgment is based upon the folloAving 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 Points. J J i • • i • 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 moA'e the palsied extremity under sudden and poAverful emotional impulse. Such Other differential signs. . . a patient may sometimes be so shocked or start- led as to use the limb automatically, and Avithout thinking of Avhat she is doing. One of my neighbors, who had not Avalked 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 Avhen she stoops forAvard she keeps it close to her side. In absolute paralysis of that member it Position of the arm. -, -i 1 • -i i r> i , l _c l would be impossible for her to do so, tor, hav- ing no voluntary control over it, it would fall forAvard Avhen 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. , „ , i , 1 • • • x useless for months, their size is not so apt to be diminished as in ordinary palsy. The limb does not become shrunken and attenuated, but remains as plump and fleshy as the soun~ v>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 hystericus 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- May occur in males. ^ ^ ^ ^ one> Bemg lftrgely 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 "laving 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 AVOMEN. and persistent use of the proper means Avill 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- :ricitv, animal magnetism, the movement cure, Adjuvants. 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 Avhate\rer may cause her to become impa- tient and irritable, or that can in any Avay disturb her mental equi- librium. Ignatia, gelseminum, belladonna, secale cornutum, cuprum, plumbum, rhus tox., cocculus. causticum, baryta Internal remedies. carb., caulophyllin, 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 pedCiagno^snt 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, back ache. Case.-Causes, predisposing and exciting, traumatic and nervous. Symptoms, reflex and direct. Spinal irritation and uterine disease. Diag- nosis in post-traumatic case?, difficulties of, from myelitis. Prognosis. Treatment for the menstrual, rheumatic and neuralgic, complications, local treatment. Faradiza- tion. Physometra. Case.-Causes. Diagnosis. Treatment. Some of the more adA^anced members of the class have fre- quently consulted me with regard to the treatment of spinal irri- tation. This Avoman 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 ofa table. The Woav was upon the most prominent of the loAver cervical vertebrse, (vertebra prominens}. In consequence of this injury she Avas for six weeks very ill in bed, and so extremely Aveak and sensitive that they had to move her on a sheet. Several months elapsed before she could Avear 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.----, Avhile visiting her mother one day, touched the spot Avhere the bloAV Avas received upon the neck, and she suddenly fainted away. Then followed a thorough course of blisters, Avith tartar emetic dressings, cups, leeches, and four years of barbarous treatment, Avhich to think of, makes her "shudder to this day.*' With this treatment, there Avas much sloughing of flesh from the back, Avhich is all scarred up noAV. It was a regular field-day Avhen these sores were 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 Avorse." 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 AA'hich position it remains. She did not menstruate until she had reached her eighteenth year, and then only once. She "never saAv anything again" until after she Avas nineteen years old. From the time that menstrua- tion Avas really established, she began to improve, and kept toler- 815 816 THE DISEASES OF AVOMEN. 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 Aveek she began to Aoav 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. AYith this mass many gallons of water were also discharged. The mass consisted of small bodies, Avhich "varied from the size of a pea to that of a Avalnut, and which Avere strung together like grapes upon a stem." Two months elapsed before she could sit up. The lower limbs became poAverless, 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 Avhole summer. They were excruciating, and so severe that "it seemed as if she would go crazy with them." In eighteen months more her first child, a son, Avas born. In two years from his birth she had another child, Avhich 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 Avere normal in all respects. The labor Avas 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 Avalking on an icy place doAvn 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 tAvisted backwards. She ax as lifted upright, and, with a woman's courage, walked home again. When she got up her head was fixed backAvards, the muscles of the neck Avere rigid and spasmodically contracted, so that she could not turn the head or straighten it Avithout taking hold, as she did, Avith her hands upon either side, and forcibly bringing it into position. AArhen 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 Avith her hands. In consequence of this second accident she Avas 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 IRRITATION, 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 doAvn the body and extremities, the pain in the head Avould 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- fering. Even if one should point the finger toAvards the back it would make her " scringe." _ The loAver 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 Avith menstruation. AATith this exception, she has never had dysmenorrhea, or indeed any " female Aveakness " of any kind. The spine is not as straight as it should be, but is curved posteriorly at a point michvay 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 dowiiAvarcls toAvard the body. It is impossible for her to sit upright Avithout something to lean her head against. She can use her hands from the Avrists 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 Avhich Avas the sAvallowing of a tea-spoonful of the strong tincture of iodine, which a druggist's clerk had put up for Indian hemp ! Opium throAvs her into violent, frightful spasms, Avhich 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 Avarm weather. Her Avorst attacks of prostration ahvays occur in the Avinter and spring, generally in the months of February and March. The menstruation is becoming scantier, the Aoav is very debili- tating and very irregular. As she approaches the climacteric her general health is someAvhat improA'ed. Here is a ease that avouIcI puzzle a clairvoyant. A spinal in- jury of a very serious nature is received at the impressible age of 818 THE DISEASES OF AVOMEN. eleven years. Its effect is to delay the establishment of the menstrual function. AYhile the system is suffer- ing, not only from the traumatic lesion of the spinal nerves and muscles, but also from retarded puberty, she is placed uncier such treatment as would undermine and ruin the health of the strongest person. This voluntary martyrdom Avas continued for four long years. And yet she lived. At eighteen, when she had discontinued these barbarities, Nature renewed the attempt to establish the catamenia. The Hoav 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, AA'hile 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 Avoman. 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. • p 1 some portion of the spinal column, or from a railway jar, or contusion. Of course men and Avomen are alike subject to such accidents. But in women, who are more deli- cately organized, whose spinal muscles and PrSonenrgar'ization a nerves 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 Avhich she is ahvays passing, or is about to pass, and we find there are especial reasons Avhy 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 D . .. . this kind of martyrdom, but that a large nieas- rractical inference. •* ° ure of their consequent suffering and mal-treat- ment is due to ignorance thereof. AA'liat a woman Avants 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 Iioav a slight fall, bloAV 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 throAv off this incubus, and develop strength by the use of it. As a rule, the stronger they are, and the more muscular, the less their sympathy Avith this class of patients. This, of course, reacts upon the victim, and she can not accomplish Avhat might be possible under different circum- stances. A similar misjudgment 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 ot Mrs. M. \Y hue her nervous sym- pathies and susceptibilities Avere at their utmost tension, she Avas put upon the rack and tortured afresh. Her physician made no alloAvance for sexual impressibility and excitability, and hence the means employed Avere fitted to increase her suffering rather than to alleviate it. There can be no doubt that the doctor did the best that he .jould "with the light he had;" but it Avas the dark lantern of empiricism that he carried. He evidently mistook the case for one of spinal meningitis Avith effusion. But in this he was in error; for Avhatever 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 Avas 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 paralysis. 820 THE DISEASES OF AVOMEN. The very fact that puberty was arrested, Avithout any intra- pelvic lesion, and that menstruation came on spontaneously Avhen the treatment was suspended, shows that the disorder was mainly, if 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, 01 jumping, lying, sitting or standing habitually in such a posture as to keep the spinal muscles on the stretch, and Exciting causes. .. -i i , t-»i thus to weaken and paralyze them. Kheuma- 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 Avearing 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 Ave 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 Avill be dull, aching and heaA-y in character, with complaint reFio°nminjuryinthesacral °f great weariness, exhaustion, and perhaps of numbness also. The patient Avishes 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 pilloAV or her shaAvl, 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 doAvn and distress, as if the Avomb 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 AA^hen 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- reFrom injury in the dorsal cesges of ^ fo^ Yertebr8B. 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 Avhich the pain produced in this Avay Avas compared to that from stabbing with a very sharp knife. The dorsal vertebras are most frequently affected. If the bloAV has been received, or the injury done to the spine, in the cervical region, the pain and soreness will vary according to circumstances. The suffering is apt to be viMi0reg!CJnUry in the cer" very severe. Sometimes the arms become poAv- erless from injury of the neix-es which consti- tute the brachial plexus. Other branches of the cervical nerves being injured by the bloAV or the shock, the muscles of the back part of the neck are more or less implicated. These muscles, Avhich you knoAV 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 AA'hich 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 Avrist. 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. ,,'.. ,. r j.1 l 1 It may be located in any portion of the back from the occiput to the point of the coccyx. Light pressure on the spinous processes of the tender vertebra produces consider- able pain, while firm pressure may be borne Avithout flinching. This shoAvs its neuralgic character. Now, from Avhat I have said you will infer that the causes of spinal irritation act either centrically or ec- Their centric and eccen- centricalh'. In the former case a mechanical trie action. - . . 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 AVOMEN. 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 Avay, 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 boAvels, 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 utfrfnTd^ease'.0"and witn uterine disease. And there are other cases in Avhich, for sexual reasons, and on account of the perturbing influence of the menstrual molimen, or of maternal contingencies, the Avomb 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 feAV 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 Avomb, arise from Reflex symptoms. . ... . uterine irritation Avhich 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. AAre may refer the occipital headache of menstruation to a similar cause. The point Avhich I Avish 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 Avomen, 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 IRRITATION. 823 most troublesome cases of spinal irritation that I have ever treated originated in OA^aralgia. The contingencies that From ovarian implication. . ° beset ovulation even Avhen 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 maybe cases in Avhich the converse is true, and Avherein the ovarian disease is sec- ondary upon the spinal lesion. Indeed, it is sometimes extremely difficult to decide betAveen the cause and its effect, and to say positively whether the ovarian lesion is idiopathic, or vice versa. As a rule, hoAvever, I think you will find that the other coinci- dent disorders Avhich sometimes attend upon spinal irritation are almost ahvays 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. AYe 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 hoAV long a In post-tiaumatic cases. - , -. , . . period may have elapsed since the injury Avas 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 Avhether such a patient has ever fallen, Qr received a bloAV upon any part of her back. It is possible that so long a time has elapsed since the accident occurred, or that the mischief itself Avas attended by so little pain and immediate illness, that it may have been for- gotten. She may have tumbled doAvn stairs, fallen upon the ice, from her horse Avhile riding, or from a chair upon Avhich she Avas 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 AVOMEN. been induced. In a Avord, Avhenever you can refer the lesion to a traumatic injury, hoAvever 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 Aery different. AA7hen neither the patient nor her friends can recall such a misfor- tune, and there is no reason to believe that any Difficulties in the way of portion of the vertebral column has ever been diagnosis. X directly injured, it Avill 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 Avomb, there is manifest spinal irritation of a reflex nature. Sometimes this exacerbation of pain and super-sensithe- ness in the spine alternates Avith the sexual infirmity or excitement, and this fact Avill 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 AA'hich is almost invariably due to uterine or ovarian disease. Spinal irritation should not, and need not be confounded Avith inflammation of the spinal cord or of its membranes. Its advent is not characterized by a chill, rigors or fever. tio^o!theco^tc^"1"11" The Pain 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 ahvays 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 Avith serous effusion into the spinal canal. This disease may be distinguished from true neuralgia by the diffuseness of the pain which does not folloAv 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. S9q close resemblance to neuralgia, however, in such cases as Ave have had uncier review this morning. For where the cervical vertebra 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 clone 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 Avill depend upon one of tAvo things , (1), the curability of the uterine or of the OArarian disease, Avhatever 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 Avho travel from one physi- cian to another. By the time you have them fairly in hand you Avill find that they are experienced itinerants. Itinerant patients. . , . „ . . f hey have 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 Ave re in this case, at a time Avhen the menstrual function is about to be established, or when the Guard the menstrual func-c]ianLres that are incident to puberty have tion. ^ x ^ already begun, you should take the greatest possible care to do nothing that can interrupt this process, or pre- 826 THE DISEASES OF AVOMEN. 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 amenorrhcea, a similar indication Avill in amenorrhoea and at exist. And if they come on Avith the climac- the climacteric. J # . i i t • i * teric period, you will bear in mind what I said in my last lecture concerning their treatment under these circum- stances. Incidentally, Avhatever disease may drain the patient's strength or exhaust her energies, should be remedied as speedily as possible. A quarter of a century ago, Avhen this poor Remove any dangerous Woman suffered for tAvo consecutive months condition. Avith 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 floAv. For the sponge-tent Avas unknoAvn, and 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 Avill need Tact and sympathy. . to exercise a great deal ot tact and a large measure of sympathy and discretion. Rough treatment may sometimes be tolerated in other cases (although it is inexcusable), but in this disease it Avill not be borne. The patient's perceptions are too acute, and she is too susceptible and sensitive to be treated in such a Avay. 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 Avith the tenderness and delicacy of her organization on the one hand, and Avith 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 Avorse 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 spFnliinj^15 °f the perf., will be indicated. I have great 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, rargksym7oams.and neu" veratrum alb., veratrum vir., colocynth, lachesis, caulophyllum, nux A'omica, colchicum, and gel- seminum, with the leading indications for Avhich 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 icliopathically. But rian0sytmptUomsi!,e and °va" wnen tnese 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, Avhich 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 Avhich are secondary upon the spinal trouble, Avill usually yield to treatment that is addressed to the cure For contingent disorders. 1-1,1 1 1 , ot 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- plaint. They are not only grateful and useful on account of the relief Avhich they afford, but do really assist in 828 THE DISEASES OF AVOMEN. 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 OAvn preference for these local expedi- ents has been based upon the folloAving 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. . rubbed over the painiul 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 lelief to coat the surface Avith the oleaginous collodion. If the disease has resulted from a mechanical cause, you Avill not forget the local use of arnica, hypericum, calendula and hamamelis. I believe these topical applications Topical expedients. . , . ,7 have the best effect, in this disease especially, Avhen 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 Avere, by a layer of cotton batting, or of oiled silk, worn next the skin. The cotton may be seAved into the clothing and kept constantly Domestic expedients. t i i 1 -r i it applied, day and night. It should extend from the neck throughout the Avhole length of the back. In many cases, more particularly in those who are predisposed to rheu- matism, the patient should Avear a silk vest, or under-Avrapper, to protect her from sudden vicissitudes of the Aveather, and from electrical changes. Sponging the back from above doAvnAvards with warm, or hot water, may help, to remove the extreme sensitiveness of the integu- . ., ,, . ment. It should be done very carefully Iioav- Available expedients. , ever, and, if possible, by a person who is in sympathy Avith the patient, and toAvards whom she has no feeling SPINAL IRRITATION. 829 of antagonism. In chronic cases, Avith marked debility, salt- Avater spongings along the spine are sometimes very beneficial. In certain cases, the shoAver-bath, electricity, and animal magnet- ism may also be useful. They should, hoAvever, be administered with care and discrimination, else they may only serve to increase the difficulty. The electrical bath ansAvers as an available tonic, Avhen the general strength is very much reduced, and the patient's nervous system needs a ready means of support of some kind. A recent Avriter says: "There is one special phase, however, of spinal irritation Avhich is very amenable to a direct treatment, viz., cutaneous and mucous tenderness. AYhen- Faradization. . . . . , . ever the 'hypersestheuc part is Avithm reach, so that Ave can apply Faradization, Ave 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 dry metal, and the negative one, Avhich is to be applied to the painful surface, should be in the form of the Avire-brush. The positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backAA^ard or forward over the sensitive skin, a pretty strong current being employed. The process is painful, so much so that it Avill often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the Faradization. Avery feAV daily sittings of four or five min- utes length, Avill generally remove the morbid tenderness com- pletely. AYhen 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 clays ago. Case__Mrs____ a^ed 27, living in AYisconsin, is the mother of tAvo'children, the youngest of which is eighteen months old. From her marriage at eighteen, until the birth ot her child in the twentv-firstvearTshe Avas subject to uterine catarrh, and was m wretched health in consequence. But alter the bahv was born she recovered entirely, and was well until theTmth 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 AVOMEN. so adherent that the doctor had great difficulty in removing it. For four years she has not soon a avoII 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 Avomb 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 Avas almost killed by an instrument that Avas forced into the vagina! It really Avas unnecessary to use a speculum, for Avith the perineum laid open and the vagina almost everted, the uterus fell readily into vieAv by the mere separation of the labia. It seems incredible that so many physicians could have prescribed for her Avithout having 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 Avreck, Avhen the pelvic organs Avere 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 tAvo children. She Avas delivered of the youngest ot these, one year ago,— during the riots in the city of NeAv York. She says she had a short and easy labor, after Avhich she did Avell until the third day, when, the report having been circulated that the house in Avhich she Avas living Avould be fired or destroyed, she Avas obliged to remove to another. The distance being only tAvo 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 Avhole year. There is a circumscribed enlargement of the abdomen, situated in the mesian line, and extending from the pubis toAvards 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. AY hen she reclines the tumor gravitates or rolls toAvard the side upon which she is lying, but without any change in its form, and PHYSOMETRA. 831 without borborygmus. It is still circumscribed, and ahvays tym- panitic. The neighboring parts yield their normal sounds on per- cussion. The only pain she has had is a species of soreness from outAvard 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 SAvelling feels as if it Avere 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 Avoman, 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 Avas 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 Ave have here this morning. Indeed, owing to its rarity, many physicians of large experience have neArer seen a case of this kind. If you observe the physical characters of this phantom tumor, you will note that its outline is as Avell-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 Avhen 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 Avhen she lies upon her back, as in ascites. Physometra, or the collection of flatus in the Avomb, is almost ahvays, 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 ahvays pres- ent in these cases, as in other forms of tympanites to Avhich 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 AVOMEN. portion of the secundines after delivery ; or similar changes in fragments of intra-uterine groAvths Avhich 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, reJafned11505'''011 °f ma"er an{^ 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 Avhich 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 poAverful Avhen conjoined, as in this case, Avith apprehension and anxiety, as Avell as Avith 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, Avhich is either draAvn into that organ by a species of suction, or passes w0Smbtion °f a'r int° the mt° it when the os uteri is open and other mat- ters have so escaped as to leave a vacuum, into Avhich 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 Avomb. 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 Avhy 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 Avill not detain you Avith further remarks on this subject. The diagnosis is much easier than it Avas a few years ao-o. You have only to put the patient under the influ- Diagnosis. ' 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. PIIYSOMKTRA. -sOO 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 boAvel, by passing a small canula, or a male cathether, through the os uteri. Then, by placing the outer extremity of the in- strument uncier Avater 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 Treatment. 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 Avorries> her, it may be evacuated a feAV times for her com- fort during the day.* In case the uterine tympanitis depends upon the retention and decomposition of Avater Avithin the Avomb [hy- lterus' drometra], of blood Avithin the same cavity [hasmatometra], 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 Avomb and the escape of the decomposing fluid is not all that Avould be required. For putrid or purulent changes avouIcI only be hastened by insuring its contact Avith 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 Avhen they are necessary, both ^ intra-uterine injec- -n th(J puerpcral and the non-puerperal state, my oavii preference is for a solution of the chloride of lime, Avhich is a better disinfectant, and quite as 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 of glycerine and calendula. If the odor is extremely offen- sive, the proportion of the lime-water and the glycerine may be doubled. In a very interesting case of physometra that was brought to me by Dr. A. J. Howe, of California, there Avas a marked increase in the gaseous accumulation whenever the patient had an excess of mental work or worry, and her greatest relief Avas 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. Vagin- ismus. The line of demarcation betAveen 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 at hat upon medicinal influences in curing them, is an unsettled question. There are those avIio insist that, in this specialty, surgery is almost omnipotent, and per contra those also avIio claim that constitutional remedies alone are adequate to the end in vieAv. The attentive student of gynaecology is aAvare that Avithin the last quarter of a century, Uterine Surgery has developed from a rudimentary to an almost perfect branch of Value of uterine surgery. ." t. i c • l i -^i ake it thoroughly 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 Avith the greatest accuracy; (4), to drain the bladder while VESICO-VAGINAL FISTULTE. 881 the wound is healing; and (5), to remove the sutures very cautiously in due time. The first of these indications is met by plating the patient in the Sims', or the prone position upon a proper wound.™ table or chair, and in a good 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 Avhich 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. If the rent is high in the anterior Fig. 144. Sims' depressor. cul-cle-sac, or lateral, and not readily accessible, it may be best to seize the uterine cervix and bring the Avomb 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 clone as ^Vivifying the mar- freely Rnd ag thorouffhly as possible, but from the vaginal side only. The vesical mucous mem- brane should not be cut, or pricked, or injured in any Avay. 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 Ave can reasonably hope for a o-ood result. The plan which I have found most convenient is to secure one lip of the rent at a time Avith a Sims seizing for- ceps (Fig. 149) and then to pare the edges with the curved scissors, 882 THE DISEASES OF AVOMEN. (Figs. 145, 146, 147) or Avith the knife (Fig. 148). The art ot vivifying the margins and bevelling them properly is acquired Avith practice and care, and Avhen 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 Ave proceed, is the correct one. If there is considerable haemorrhage, the hot-water irrigation, as in trachelorrhaphy, will arrest it. The insertion of the sutures. Fig. 147. Emmet's curved scissors. The next step is the insertion of the sutures, which should ahvays be of silver wire. The Avhole secret of 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. *a j^ Fig. 148. Sims' rotary knife. Taking a Sims' neecllc-holder, (Fig. 151,) and one of Sims', of Emmet's, or of Hodgen's needles, its point is introduced at a third VESICO-VAGINAL FISTULTE. 883 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 draAvn through, the border being steadied by this little fork (Fig. 152), and cut off 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 doAviiAvards, until all are in position. Then, before tAvisting them c1oavii and closing the Avound, the bladder and the vagina should be carefully washed and cleansed of blood-clots and ot all foreign substances. Fig. 150 Tubular needles. Here is an expensive case of tubular needles which I brought from Mathieu, in 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 56 884 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 Avith the fingers and by the manipulation of the sutures. It must be done slowly and cau- Adjustment of the .• 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 onlv brings the scarified surfaces into close contact, but it makes a ridge Avithin the bladder that turns the Avater like the peak of a roof. It is be- cause this bit of tailoring must be Avater-tio-ht that you should take the greatest care so to tAvist the sutures as to bring the parts into exact apposition, and not to close the mouth of either of the ureters. As a rule Ave always begin by twisting those sutures which are nearest to the vulvar outlet, but they must not be draAvn 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 Avith the Avound, as you have seen me do after an ovariotomy. Some prefer to pass a per- ^ Tightening the sut- foratec| ghot oyer the wjre an(j then tQ CQm_ press it firmly; and others use a thin disk of perforated lead, Avhich 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, Avhich Avould strain VESICO-VAGINAL FISTUL.E. 885 1 the Avound, interfere with its union, and give rise to pain and vesical drainage. suffering, the bladder must be drained, at least for the first forty-eight hours. If the urethra Avill tolerate it therefore, a Sims improved, or a Skene's self-retain- ing catheter (Fig. 69) may be passed and allowed to remain in position. Unfortunately, the cases in Avhich the lesion is at the bas-fond ot the blad- der, are those in Avhich the instrument is not very Avell borne, and you will need to remove it occa- sionally, or perhaps to take it aAvay 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 Avith Avhich this may be accomplished will depend upon circum-Fl0 152. Thewiread- stances. If the rent is high, or the parts are fi„nYtaook.ield' aQd tumefied and the sutures are buried out of sight, it may be very difficult. It is sometimes necessary to seize the neck of the Avomb and draAV it cIoavii again. If the Avire 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 ot the scissors through it as shoAvn in Fig. 156. 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 futures there is a slight leakage of urine into the vagina. In very bad cises this is likely to happen, and may be only temporary. But sometimes a small orifice may remain, and this will need to be tieated by a subsequent operation. It is commonly supposed that the operation which I have just Removal of the su- tures . Caution, and encour- agement, Fig. 153. The sutures ,i position. 886 THE DISEASES OF AVOMEN. The dangers of the operation. Fig. 154. Bozeman's button sutures. described is free from clanger, even where it is not successful. Our American authors are almost silent upon this point. The 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 Gynecologic for January 1877, Doctor Venieuil treats this subject very thoroughly. He says: "I am pursuadecl that the neAver methods of operating are less dangerous than the old, first, because ot their usual success at the first trial, the repeated operations that Avere 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 ot all this however, at least it I may judge by my oavii 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 Avomen in about eighty operations! Tavo others have threatened to die, one of erysipelas, and the other of embol- ism! and several have been very ill Avith 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 folloAving month, page 129, M. le Dr. Puech gives the statistics of 229 cases Avhich 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 Avithout qualifying our prognosis Avith reference to a possibly fatal result. Beside the operation Avhich Ave have consid- ered there is a form of vesicovaginal anaplasty that is very rarely practised in our day, Avhich consists in closing Bozeman's suture applied. Elytroplasty VESICO-VAGINAL FISTULA. 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. Episiorrhaphy. Another expedient consists in the closure of the vagina, as in the extreme cases of procidentia of the uterus spoken of in Lecture XXXVIII. Fig. 156. Introduction of the sutures. KECTO-VAGINAL FISTUL.E. In this form of fistula the recto-vaginal septum is open and permits the escape of gas and of faeces 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 AVOMEN. the sphincter ani and the perineum. In some cases it is so high as to be found Avith difficulty, but oftener it is Avithin 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 uiiAvarrantable 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-holder. misapplied cauterization, the ulceration caused by hardened faeces, 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 fecal matter and of flatus 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 of the table, and a Sims speculum passed in a reverse way from RECTO-VAGINAL FISTULA. 88J that in which it is usually employed. "With this the anterior mi. ,. . , wall of the vagina is lifted, and the rectovaginal The physical exam- ." n ination. septum falls into vieAv. The 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 case of Aresico-vaginal fistuhe. Prognosis.—Contrary to Avhat you may have supposed a larger proportion of cases of vesico-vaginal fistulae 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 Avhen Ave 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 Avork, 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 draAving them together accurately by interrupted silver sutures, in twisting these sutures, in passing the perfor- ated shot and compressing them, the same as in vesico-vaginal fistula?. 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 Avith a pair of straight scissors (Fig. 157). If the fistula is far away, hoAvever, you may need to use a Sims knife-holder and adjustable blade, (Fig. 158) 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 Avell 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 tAvist- ing the sutures closely in some cases of recto-vaginal fistulae and I much prefer to secure the wires Avith perforated shot that can be compressed Avith these forceps. (Fig. 163). Fig. 163. Shot compressor. In the after-treatment, it is really a question whether the old mi_ M x practice of keeping the boAvels bound does not The after-treatment. ° 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 Avas very likely to interfere Avith a good result; and I consequently adopted the practice of keeping the boAvels 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 Avater with the tincture of calendula may be used daily. The sutures may be removed in eight or ten clays, and the patient allowed to take moderate exercise after the second Aveek. To RECTO-VAGINAL FISTUL.E. 891 r? admit of the escape of flatus, and to prevent tenesmus a rectal tube should be avoiti for some days. . Another mode of operation is to bevel the edges of the fistula, and to scav the Avound on the rectal instead of Newer modes of ope- ,-\ • i , mi • ■ -i ■>. ration. trie vaginal surface. 1 his is easily accomplished by stretching the sphincter Avith the tAvo thumbs (as should be done 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 afterAvards uniting them by tAvo sets of sutures, one of which is in the ATtgina and the other in the rectum. In another plan of operation, which is hio-hly recommended by Dr. Gooclell, " A shallow cut is made around the vaginal mouth of the fistula, about half an inch aAvay 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, Avhich is iioav closed by rectal and vaginal stitches—the former uniting the raAV surfaces of the frill, the latter the raAV 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 folloAving manner: Before the mu- cous frill has been inverted, metallic sutures are passed through its edges, each end of each one entering the raAV surface and emerging on the mu- cous surface. The free ends of the Avires are next secured temporarily by tAvisting 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 shot are then run up one by one to the rectal Avound and clamped, and the operation is completed by seAving up the vasfinal avouiicI." LECTUEE 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 perin um. The peiineal 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 if Ave are careful not to confound those of the perineum proper with those of the vulvar or- These lacerations often ifice> F 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- Anfttomy of the vul- „ . . . . var oriaee. flon °f ^ne sphincter vaginae muscle, Avhich sur- rounds the external orifice of the vagina, and which is attached posteriorly to the central portion of the perin- eum, where it mixes Avith the transversal is and the sphincter ani muscles. These structures guard the vaginal orifice and permit of its distensibility and dilatability, Avhich qualities are essential to a safe and natural labor. The sphincter vagina? is an orbicular muscle, which is more easily broken than you Avould 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, throuo-h the anterior commissure of the vulva or the nymphee, where it 892 LACERATION OF THE PERINEUM. 893 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 fourS!™ of 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 laceratiou of the cervix uteri. The fact is that the co-existence of rigidity of the os uteri Avith what is usually styled a ruptured perineum in labor is a mistake; a practical hint ^or ^ie eternal 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 Avhat Anatomy of the per- ^ag keen aptly 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. , . ." n , , margin is along the posterior Avail ot 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 boAvel into the vagina, as Avell 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 Avhich take place The physiology of j th perineal body during o-estation, and after the perineum. * © ^ delivery are as pronounced in their way as are those Avhich are proper to the mammary gland, the heart, the liver, or even to the uterus. "Whatever interferes Avith the devel- opment of this inverted keystone during pregnancy will predis- pose it to traumatic injuries during labor; and Avhatever arrests its puerperal involution Avill 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, Avhich, strictly speaking, are due to an organic defect, for Avhich no one is to blame, and for Avhich there is no known prophylaxis. Observe that, in order that Ave 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 Avhen it has involved the recto-vaginal septum, the case is complicated Avith a recto-vairiual 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 fcetal head, puer- peral convulsions, the delivery ot 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 Avomen avIio have their first children late in 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 Avhich the patient Avas brought before the class for the removal of an enormous fibroid Avhich had escaped from the os uteri, and Avhich filled the pelvis completely. It Avas severed by a strong copper wire i i the ecraseur, but the wire broke twice before it Avas 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 Avay doAvn to its cutaneous border! The tumor, Avhich afterwards Aveighed six pounds, Avas 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 Avas forced to desist. My only re- maining resource Avas to cut it in pieces and to take it aAvay in sections, Avhich was carefully and successfully done. The patient had been so long under the influence of the anaesthetic, and Avas so very Aveak and anaemic from the fearful menorrhagia tc Avhich she had been subject, that it Avas 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 Ay as a farmer's Avife in AYisconsin, 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 boAvel. 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 Avhich often heal spon- taneously. Frequency.—What I have said of the relative frequency of lacerations of the cervix uteri is quite as true we must look for Qx- vl]]var anc| perineal lacerations. The mere fact that physicians and obstetricians have often overlooked them, does not disprove their existence. In recent 896 THE DISEASES OF AVOMEN. 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 Avarm water, and by means of a candle or a lamp. For the touch alone, no matter Iioav educated or experienced, cannot decide this question. It is not ahvays practicable or expedient to inspect the tegu- mentary perineum at the close of labor; but the fact remains that these lesions Avithin 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 Ave should look for them very carefully. For the sake of your oavii reputation, as Avell as for the cure of your patients, I recommend you to examine these cases for yourselves, and not to trust to the ip>se dixit of the nurse, or to your OAvn 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 ahvays be avoided. But, since Ave cannot vouch for the integrity of the perineal and vulvar tissues, and cannot ahvays control the direction or the degree of the forces that are necessary to effect delivery, this claim is iwi Avar ran ted. 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 Avill 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 Avill be cicatrized, and this condition of the surfaces may be a source of general ill health. For, Avhile this Effects of cicatriza- 1 , , ,. ~ , , tion of the rent. Heterologous tissue is often harmless, its pres> ence in delicate, slender and nervous Avomen 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 Avhich not more than ten or twelve hours have The immediate treat- t • ,, . t , , „ ment in recent cases, passed since the accident, and before the mar- gins of the wound have healed over, it will be a question as to Avhether you shall stitch it up or not. Some au- thorities will tell you that you ought ahvays to resort to the suture, and others will insist that it is never necessary. Both are right and both are Avrong in their extreme vieAvs. 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 Avith warm calendula Avater, carefully removing- all clots, bits of fat and shreds, and then to mould the edges as carefully as possible so as to bring the tegumentary perineum into its proper position. Then I place a firm compress that has been moistened .vith a mixture of equal parts of calendula or of hamamelis, glycerine and Avarm Avater, against the perineum, and Avhile the limbs are flexed, put tAvo 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 tAvo or three times in tAventy-tour hours, and Aveak injections of calendula Avater may be given per rao-inam once or tAvice daily until the avouiic! is healed. The knees should be tied together, but not tightly, for the first forty- eio-ht 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^eofserre-flnes.^^ ^ of S(>n.e.rines> Avhich? if they are of ihe 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 AVOMEN. have been applied, and the compress can be used at the same time. The primary operation is not difficult unless the Avound has passed through the sphincter ani, or involved the recto-Aaginal septum, in Avhich case it will be necessary to The primary operation. . . , " administer an anaesthetic and to proceed as Ave 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 Avound. When, hoAvever, the degree of the laceration does not include the sphincter ani, or the septum above the apex of the perineal body, the Avire sutures may be passed from the cutaneous surface and tAvisted 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 Jhe secondary opera- mogt ^^ The ok] rule ^ to ^^ ^^ ^ child Avas weaned. The preparatory treatment for perineorrhaphy is to allay any existing local inflammation of the parts, to have the boAvels thoroughly opened a day or t\vo 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 Avith 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 ce^.0 freshenin8 pro" of the sutures. The vivifying process is the same as that described for vesico- and recto-va- ginal fistula?, 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 draAvn to the edge of the table in a strong light, and the anterior vagina lifted Avith a Sims' speculum, it is Avell 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 Avith the scissors, and no portion of it is alloAved to re- LACERATION OF THE PERINEUM. {<9«J 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 perineal rupture and first two sutures in posi- tion (Thomas). as in recto-vaginal fistula. Fig. 166 represents the outline of this neAvly-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 Avater, or, if there are spouting arteries, by Pean's haemostatic 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 Avhich separates the two halves of the perineal body. The second step of the operation concerns the introduction of the interrupted sutures. Most authors prefer The passage of the ^q silver Avire, but they are not agreed upon sutures. . ^ '" 1 • i <. 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. 1-2. Fig. 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 Aveakened 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 Avith a holder which is very useful m this and kindred operations is Pveverdin'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 Avire is preferable. The mode of securing the silver wire in these cases 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 Removal of sutures. ., », ,-. ,. « the same manner as after the operation tor ves- ico-vaginal 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 reparati\re forces, and providing the operation has been 902 THE DISEASES OF AVOMEN. 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 Avound 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 uncier 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 Avho had suffered a complete laceration of the perineum for more than thirty years. Case.—Mrs.----, aged fifty-five, was sent to the Hahnemann Hospifal by Dr. W. H. Gibbon, of Chariton, Iowa. She had had eight children, the eldest of Avhich Avas 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 micbvife. During the last two days of this prolonged labor the patient Avas in an unconscious condition. The delivery was finally accom- plished by pulling the child forcibly aAvay. The consequence Avas 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 tAvo to three days and nights. In the whole thirty-three years she had had absolutely no control over the escape of the faBces, or of flatus from the boAvel. The operation was set for October 6, 1881. The patient was put uncier the influence of ether, and Class No. 2 was admitted to the operating room. There Avere 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 Avas no surface Avhich could be freshened as in the usual mode of making the operation of perineorrhaphy; and the retraction"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; fhe 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 Avater, containing a little carbolic acid and cal- endula. The diet Avas laxative but nourishing, and no effort was made to lock the boAvels. 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 draAvn Avith a flexible catheter. The sutures were remoArecl 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. LECTUEE LV. THE PATHOLOGY OF OVARIAN TUMORo. Varieties. 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 cysls of the ovary: Morbid Anatomy of; Etiology of; Diagnosis aud 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, Avhose 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-Avail 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 clanger 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. 90a 906 THE DISEASES OF AVOMEN. The vascular supply to these groAvths is furnished through the fibrous capsule of the cyst. Only their external surface is sup- plied Avith blood vessels. This is a fact of Avhich 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 Avhich 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 OVARIAN TUMORS. 907 chemical properties and the true clinical import of this cell are not yet fully determined. It is spherical, some- The ovarian ceil, 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, hoAvever, 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 Drysclale'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 LaAvson 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 AVOMEN. is no other bodily organ Avhich 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 Avomen of all classes of society, but are most frequent among those whose surroundings are unhealthy, whose diet is meagre, and Avho 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 Avas standing. Another was jammed and injured in the abdomen by a runaway horse; and a third Avas 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 deA^eloped Avithin 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 Avill 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 pam 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 toAvard 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 ahvays 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 AVOMEN 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 facies ovariana which was once thought to be pathognomonic of this affection. The tumor groAvs 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 SAvelling 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 *0n 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 upon the integu- ment. In oligocysts, Avhere 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 forAvard, 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 Avay, 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 Arariety when they are numerous, and of the canine when not numerous), of bits of alveolar processes with teeth in them, of rudimentary teeth Avhich 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 Avomen, 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 foetal inclusion, a foetus icithin 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 Avords,that a dermoid cyst of the ovary was of necessity the result of an extra-uterine pregnancy. A third Avas 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's System of Medicine, vol. II, page 365. 911 THE DISEASES OF AVOMEN. inseparably linked Avith 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 Avithout 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 feAV 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 groAvth; 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 plating 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 AA'hen it should have been prevented. Since a dermal growth may be composite, and may have one or more cysts, Avhich 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 OArarian 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, Ave may, as a general rule, decide it to be uterine." The aversion to cutting doAvn upon a fibroid, and the tradition that while cystic growths were removable with comparative safety, the excision of fibroids, whether of the 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"% 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. +The American Journal of Obstetrics, etc., May, 1887, page 451. Jlbid, Vol. XV., 1882, page 876. THE PATHOLOGY OF OVARIAN TUMORS. 917 result 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 ufTne nbroids 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 ot secondary formation, and result from changes in previously solid tumors. 3. Diagnosis.—Tf 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- Laparotomy as a diag- \n^e diagnosis of an ovarian fibroma without a re- nostic resource. ° ... ... 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.) LECTURE LVI. THE PATHOLOGY OF OVARIAN TUMORS.—Continued. Malignant tumors of the ovary.—1. Cystd-sabooma. Case. Physical signs. Rupture of the sac. The rule for tapping. Aspiration. Differential diagnosis. Ovariotomy. 2. Cysto- uabctnoma. Clinical history; Symptoms; Diagnosis. 3. Soierhtts of the ovary; His- tory and symptoms. 4. Colloid or Myxoma; not always cancerous. Tait on malignancy of. 5. Papilloma, epithelioma and oaulifloweb degeneration of the ovaby. Case. 6. Encephaloid of the ovary. Case. IV. MALIGNANT TUMORS OF 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 filled; 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 OVARIAN TUMORS. 919 received ai 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 Aveakness for a few days. 1 ollowmg 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 Avithin 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 cliag- 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 groAvth. I Avill mark it Avith 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 ahvays 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 aAvare that the womb is usually drawn upward and forAvard 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- Rupture 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 Avhen 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, Avhich 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 comes 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 Avhy repeated tapping increases the risks of a subsequent ovariotomy. Providing death does not folloAv from shock, or peritonitis, or hemorrhage, or from all these, an early or a repeated rupture of the cyst-Avail Avill 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 aDother 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 Avhen 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 us 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 darkf 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 careful 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-sarcoma 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, Avhat 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 Avhen 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-CARCINOMA 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 Avail 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 Avhich 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 PMt 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." (Eustache.) The differential diagnosis between the cysto-carcinoma and cysto-sarcoma ha\'e just been given you. (See page 924.) 3. £CIRRHUS 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. L 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 svas 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 Avhich 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 ^"Tfthfovary"110"8 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 OArary 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 Tail.) 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 fluid. 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 Avhich 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 groAv 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 Avear 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 OVARIAN 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 Avomb. 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 clown carefully on what seemed to be a cyst-wall, a separation was made for an iuch or two in order to determine if we were really within the peritoneum. This could not be decided until the fluid was Avithdrawn 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 Avas 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 Avas 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 Avas 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 aAvay. Very 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 Kceberle. 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 Avas 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 aAvay 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 Avho 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 Avas 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, which 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 Avere forty pounds of ascitic fluid, Avhile 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. LECTUKE LVII. THE DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. I. From Ascites. 2. From encys'ed peritoneal dropsy. Case. 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 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 iioav I propose to teach you hoAV to diagnosticate that disease from those with Avhich it is often confounded. In tAvo of these cases my diagnosis has been already confirmed, for the tu- mors which Aveighed 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 Avith her knees draAvn 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, hoAvever, 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 Avhich is quite clear and charac- teristic, and which assures us that the intestines lie behind a cir- cumscribed sac, Avhatever its contents may be. This is so well DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 933 sIioavii in the chart (Fig. 18) that I 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 "touch." theaccumulation 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 fossa?. When it exists, ex- treme dropsy of the abdominal Avails is almost ahvays conjoined Avith 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 accumulation about an ovarian cyst the more suspicious the character of the tumor. Tapping is a useful means of diagnosticating betAveen these tAvo affections. Having Avithdrawn the serum in case of ovarian dropsy, avc find that the solid or semi-solid tumor does Tapping. 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 Avell made out that avc need not confound it Avith 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 cone during the menstrual period, neither directly after a meal, nor yet in your office. I once" tapped a very Care in time and ^ 'Q (.yst ^^ R smaU trocar ancj very carefull V, place for tapping. J~ _ J t " in my office, and my patient sank almost imme- diately into a state of collapse from Avhich it took me t\vo hours to rescue her. Dr. Peaslee lost a case from tapping Avith 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 eATacuatecl. Beside its diagnostic value, tapping is sometimes of the great- 931 THE DISEASES OF AVOMEN. est service in helping us to decide upon the propriety, and indeed the necessity of an early operation. When you The prognostic value succeed in draAving off a considerable quantity of tapping. n . x of fluid, Avhich 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 oil tapping one sac Avhile the rest of the tumor is grow- ing, but that the Avhole 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 Avhich, 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 saAv that poor Avoman on the table; you heard me give an unfavorable prognosis; you Avitnessed that I declined to operate, unless the husband and the patient took the Avhole risk; you saw her feeble condition, her courage, her cheerfulness, and her deter- mination not to leave this hospital until that tumor Avas removed. One of the sub-classes Avitnessed the operation, in Avhich, through the most formidable and universal adhesions that I have ever seen, the tumor, Aveighing forty pounds and consisting of five large lobes, Avas removed. The next day it Avas examined before the Avhole class, and you saAv 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 Avith the others. The patient lived only seven hours; but the legacy left us was the conviction that if, Avhen the trocar had told its story, the tu- mor had been removed, she might have gotten Avell ao-ain. It is important to remember that in ascites, after paracentesis, the re-accumulation of water is usually slow, Avhile after the evacuation of an ovarian cyst, it is much more rapid and persis- DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 935 tent. Iii one of my patients Avho had ovarian dropsy, from whom I withdrew many gallons of water, the abdom- Refilling of the sac • i , , . orcyst. nial tumor Avas quite as large as evrer at the end of the first Aveek. 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 betAveen them May co-exist. . * is more difficult m 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 drop) sy.—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, Avhich may occur in men as Avellas in Avomen, may he traumatic, or it may be cancerous, or tubercu- lous; and it may follow an attack ot pelvi-peritonitis, or of hematocele. It is not of very frequent occurrence, but Ave haAre had three cases of the kind in the hospital in as many years. One of them Avas brought here by Dr. II. C. Thole, of Dwight, 111., a description of which you Avill find in The U. S. 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 Avhen 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, Avhen such a sac has been tapped, it almost never re- fills. This, indeed, is the kind of an " ovarian tumor" Avhich 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 oases of this kind have been cut down upon Avith the Case- intention of performing ovariotomy, Avhen there really Avas no other tumor than such as had resulted from this sac- culated form of peritonitis. On the fourth day ot September, 936 THE DISEASES OF AVOMEN. 1S74, I took my friends Drs. Dorion and Foster, and my brother, Dr. F. M. P. Ludlam, to a case which four physicians, tAvo of Avhom Ave re gynecologists, had pronounced to be one of ovarian dropsy. The diagnosis Avas masked, and the patient Avas aAvare of the fact. We Avere prepared to operate in case it should be war- ranted after the exploratory incision Avas 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 iioav, Avhen 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 Avell defined that you might suppose there Avould be little risk of confounding it Avith ovarian foun°dedently C°D~ dropsy; but experience proves otherAvise, for it has frequently- happened to the surgeon to declare the patient ill Avith ovarian dropsy, when, in reality, she Avas pregnant, and upon making an abdominal section to find the fcetus in utero, instead of an ovarian cyst Avithin the cavity of the peritoneum. So frequent is this error in diagnosis, that it Avould not perhaps be extravagant to say that at least one-third of the cases of so-called ovarian dropsy, in Avhich gynecologists are con- sulted, prove to be cases of pregnancy. In ovarian dropsy menstruation is sometimes arrested. The reflex ovarian sympathies, Avhich involve other organs, may simu- late those proper to gestation. The digestive Parallel symptoms. . . L ° ~ 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 Avith milk, and even the areole may become quite distinct. Usually, hoAvever, in ova- rian dropsy, unless both OA-aries are diseased, the menses return irregularly, or are too frequent and copious. Last year I Avas consulted in a case of ovarian dronsv occurring A rare case. . L - « m a worian 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, Ave say that in pregnancy the abdominal tumor has some peculiarities of situation and irroAvth which may perhaps serve to distinguish it from an ovarian enlargen\.-^t. For exam- DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 937 pie, it has originally been intra-pelvic; it ascends gradually or Location and growth. "10re mPkUy, as tl™ CUSe 111:1V be, at about tllC 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 Ave must not forget that both these affections may escape observation or suspicion until Aveeks or even months have elapsed before our advice is sought. Under these circumstances, Ave 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, Changes in the cervix n i •, -, i ,, . , in both states. 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 Avould 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 toAvard the affected side in ovarian dropsy, still its location Avill in most casus not differ materially from that of the unimpregnated uterus. If the internal os uteri Avas open, and the finger did not come into direct contact Avith the mem- branes, the placenta, or Avith some part of the foetus, the Avoman could not be pregnant. The easy introduction of the uterine sound, and its ready passage to the fundus uteri, Avoulclalso 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 ijs pregnant, her " term" is very near. The uterine souffle is so equivocal a sign of pregnancy that, except as confirmatory, Ave cannot place much dependence upon it; for it has been found that it does not arise, The uterine souffle ,ls was once SUpp0Sed, from an 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 OF AVOMEN. culation. It may be present in fibroids, in uterine cancer and hypertrophy, in tumors within the broad ligament, in aneurism ot the abdomi-al aorta, in case of a tumor pressing upon the iliac arteries, in sub-involution of the womb after delivery, and also in ovarian enlargement Avith or Avithout dropsy. If you are fortunate enough to detect the fcetal heart-sounds, all dcubt Avill be at an end. But, although this will afford you an unequivocal sign of pregnancy, if you can rec- Thefcetal heart-sound ize it it won]d n0t, llOAVever, 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 avouIcI not knoAV 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 Avails are thin, it is sometimes possible to recog- nize the head, or the extremities of the foetus, by palpation. Quickening, if it Avere 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 avouIcI 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 otherAvise determine the diagnosis, it will be best for you to proceed as in other cases Avhere pregnancy is possible, id est, to Avait until the proper limit for that of diagnosis!1 element condition has passed, for, ordinarily, there need be no haste in deciding. If the Avoman is preg- nant, the tumor Avill not sensibly increase in size, or develop in an upAvarcl direction, after eight and a half months. When ten or tAvelve months have elapsed since the SAvelling Avas first noticed, it is tolerably certain that there is some kind of a tumor present Avhich avouIc! be found in case of extra-uterine pregnancy, in Avhich the foetus might be indefinitely retained. But this form of ges- tation is so rare as scarcely to deserve notice in this connection. In Avomen, as you knoAV, the natural limit for pregnancy is nine DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 939 months, Avhile the average duration of ovarian dropsy is about three years. IV. Irom 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 42S). 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 encapsulecl,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 Avill 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 Avhich are extended in this Avay are almost ahvays 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 Avith 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 Avails of the sac will not collapse and close Avhen that instrument is AvithdraAvn.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 afterAvards, 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 Avhen it is most likely to be confounded Avith ovarian dropsy. V. "From uteriiv fibroids.—Although ovarian dropsy may be accompanied by irregular menstruation, in which the Aoav may be 940 THE DISEASES OF AVOMEN. either too frequent or too copious, or both, ne\ertheless Ave can not properly say that patients having this form Haemorrhage. " . ^. T ot dropsy are prone to uterine hemorrhage. 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 Avomb, AA'hich is pathological and not physiological, or Avhich, in other words, does not pertain to the development of the gravid uterus, but which folloAvs 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 hemorrhage; Avhile 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 hemor- rhage avouIcI be impossible. Whenever, therefore, you have a patient avIio is subject to con- siderable or continuous flooding, which begins and ceases Avithout 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 Avill have reason to suspect that she has one or more uterine fibroids. In that case the tumor Avill most probably be due to hypertrophy of the uterine muscular tissue, while the hemorrhage 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 by a bloAV from the finger upon the of the uterus and the posterior Avail 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, hoAA^ever, it may happen in this form of neoplastic groAvth that the Avomb may be immovable, as it is in scirrhus ol that organ. The distance to Avhich the sound will enter the Avomb 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 Length of the uterine 1 -p ,i . . cavity. uiepsy, it the Avomb ;s 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 Avhich are present in a case of fibroids, do not properly belong to the clinical history of ovarian dropsy. Fibroids are of sIoav 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 Relative rapidity of . /i i 11,1 growth, tor some months and groAvn 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. Irom fibro-cystic growths—Those fibroids Avhich are attached to the exterior surface of the womb, and Avhich lie be- neath its peritoneal investment, sometimes undergo cystic de- generation. In this case the tumor, Avhich may include a number of these degenerate fibroids, is likely to become Difficulty of diagnosis. . £l, ,, 13 ., ., , of such size as to fill the abdominal cavity, and to be mistaken for ovarian drops}*, 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, hoAvever, this species of fibroid is compar- atively rare. Dr. Routh's statistics shoAV that in only three out of eighteen cases of fibro-cystic tumor Avas there any menorrhagia. Spencer Wells has several times diagnosticated thepres- Menorrhagia absent inence 0f t]iese fibro-cysts of the uterus by the es- this form of fibroids. . cape through the trocar on paracentesis, ot a thin serum containing from five to fifteen per cent, of blood, Avith Avhich 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 groAvths, I will refer you to a valuable classification of the more prominent 942 THE DISEASES OF WOMEN. symptoms arranged by Dr. Charles C. Lee, and published in the "V. Y. Medical Journal;' Vol. XIV., p. 474. IN OVARIAN CYSTS. IN FIBROCYSTS OF THE UTERUS. 1. Disease may occur at any period, even 1. Scarcely ever orcursunder thirty —gen- before puberty. erally from forty to fifty. 2. Development rapid — usua:iy 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 c onfined 1o certain regions face of the tumor. —generally to upp< r jortion, while the lower is hard and dull. 5. Vaginal examination shows little dis- 5. A'ai'inal ox; minat 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 c r 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. aiihesions 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 muddy ; 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 Avith gas is not very likely to be confounded with ovarian dropsy. If the abdominal enlargement, upon Avhich I place my hand, is due to such a cause, the SAvelling will be tympanitic on percussion over its Avhole 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 feAV moments. Physometra is ahvays attended by more or less troublesome hysterical manifestations, Avhich do not pertain to ovarian dropsy, and Avhich 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 OVARIAN DROPSY. 943 ease of that viscus. The form of dropsy that attends it is ab- dominal. When effusion has taken place into Physical exploration. . A the peritoneal sac, you will recognize the phys- ical signs of ascites. The margin of the enlarged liver, Avhich is Avell defined, the absence ot uterine complication, which is suggestive, the digestive and constitutional disorder, Avhich are significant from the outset, and the general contour of the tumor, will help you to differentiate betAveen enlargement of the liver and the presence of one or more o\ arian cysts. In October, 1879, I was called by my friend, Dr. A. W. Burn- side, of Belviclere, 111., to a patient Avhose former physician had declared that she had an ovarian tumor. Dr. B. g-ave no opinion, but desired my diagnosis and my vieAv 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. Burnsicle's pupil, Dr. W. A. McDowell, A\ras sIioavii to the class. The record of her case is as follows: Case. Mrs. —, a?t 52, is the mother of tAvo children, the youngest of Avhich is tAventy-tAvo years of age. Tavo years ago she began to be troubled Avith indigestion, and although she Avas under con- stant treatment, it gradually greAv Avorse. About four months before her death she became unable to retain any food upon her stomach. In the early part of August there Avas observed a small abnormal growth near the umbilicus, Avhich greAv slowly until about three Aveeks before her death, when it greAv very rapidly, Avith an aggravation of all her other symptoms. At times she suffered very severe burning pains Avhich she referred to the stomach. Her feet and limbs became very dropsical, and her com- plexion finally became highly jaundiced. Almost the Avhole abdo- men Avas filled with the tumor, Avhich, at the post-mortem, Aveighecl eleven and a half pounds. The gall-bladder Avas full of gall stones, three of which Avere as large as a hickory-nut. There Avere extensive adhesions to the transverse colon, and also to the stomach. So, also, Avith an abnormal development of the spleen. The constitutional symptoms which accompany it are characteristic. One or another of the forms of ague, and im- pairment of the quality of the blood, Avith leu- kaemia and perhaps anaemia also, Avill 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 fa?cal matter.—The former avouIc! 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 Avomb by some flexion or deviation of the organ, or by some foreign groAvth Avhich served to block up its outlet. In either case the "touch," and the introduction of the uterine sound, Avould discharge the menstrual deposit and remove the tumor. Such an expedient avouIcI be useless in real ovarian dropsy. If there Avas excessive frecal accumulation, the previous history of the case, and, more than all besides, a careful examination of the tumor, would disclose the difference betAveen it and the dis- ease Ave 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 encmata of oil, castile-suds, or of a similar soWent, would settle the cpiestion 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 neAV 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 ihe 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 adopted 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 you 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 troubb 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 -DOBSEtf STORES 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 and 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 Cases to which it is by anv other means whether the tumor is uter- suited. j j _ ^ 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 all 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 dysmenorrhoea 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 (Avhere 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 Avere 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: "1 never knoAV exactly Avhat I am going to find Avhen 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,' Avhile 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 ahvays 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 Avriting, and without preAuous warning, she suddenly felt Avhat 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 Aveight 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 groAv!" When she had lost in all about eighty pounds in weight, Dr. Van Voorhis 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 Avere bad and the digestion was very much im- paired. She gained strength slowly, and finally determined, with all of a good, brave Avoman'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 Avas opened. This disclosed a cancerous mesentery which Avas 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 Avhich 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 Avhom 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 ah 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 Avith an ovariotomy, or a hysterectomy, or Avhatever else should be required, when 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 weU again. EXPLORATIVE METHODS OF DIAGNOSIS. 951 relief with little comparative risk, even where it does not promise anything in the way of a radical cure. I had such a case a Aveek 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, Avith 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 Avhich 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 Avere 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 clays. She suffered no inconvenience from these repeated tappings. She would keep her bed one clay before the operation and then would be about her house the folloAving 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 Avere taken aAvay. 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 Avas lying at the left lateral cul-cle-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-sicled 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, haAre the effect to arrest the rapid ascitic effusion. With the assistance of Dr. Olds and Dr. N. G. Kieff, of Albion, Ind., 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 Aveighed 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 Aralued 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 Ave 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 Avhat 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 patient 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, 6he 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 haATe been re- quired, both in hospital and consulting practice, Practical results. I haATe f ouncl 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 noAV 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 Avas the means of saAung life. With few exceptions, and Avhen 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 affairs 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,^ 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, 18*3. JThe 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.-OVARIOCENTESIS. 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. J 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." (Thorburn). 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 shoAvn, 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 Avhatever. 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 Chirnrgicale, 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 Avhich it is to be introduced. Selecting a spot along the mesian line of the abdo- men, Avhich 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 Avithout 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 Aoav 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-Avail 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 tAventy-nine pounds, I had to cut through four inches of fat and integument before coming down upon the peri- toneum. 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. 1^1, 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 clays. It is not well to decide too hastily as to the significance of the fluid that has been draAvn. 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 paroA'arian 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 mennlfter"tapfpinegabdo" ^ ^ *s a *aT8e one> x9 worthy of note. The scaph- 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 Avhile it relieves suffering, the removal of the contained fluid EXPLORATIVE METHODS OF DIAGNOSIS. 957 facilitates Avhatever 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 paUiative. it is permissible 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 Tapping a dangerous {jie 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 sac was then inserted 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 refiU- ng to thesame extent as before. This tuck had reaUy taken in four inches of the circumfer- ence of the cyst-wall. (The Clinique, A ol. Ill, page 112.) 958 THE DISEASES OF AVOMEN. 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 first ovariotomy; nor that Ave have often knoAvn those who had been tapped by our confreres, to die Avithin tAventy-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 Avhich came under my oavii experience: Case.—Mrs. R., 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 Avithout any word of caution as to the risks of the operation; Avithout 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 Avas twenty-six pounds; the fluid was of the chocolate ATariety; and the growth Avas composed of four endogen- ous cysts. The large outer sac Avas adherent through eArery 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 Avell and recovered without a single bad symptom. The sources of clanger from exploratory tapping are various. There is a possibility that the puncture of the frome 8°urces °f danger cyst-wall may develop into a rupture, with extra- vasation of its contents and a fatal collapse. In old cases in which the coats of the sac have become very thin *Op. cibat., Vol. IV, page 1179. EXPLORATIVE METHODS OF DIAGNOSIS. 959 because of distention, or from the corrosiATe 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 h 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 ihe contained fluid* In five minutes after the needle Avas wfthdraAvn 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- it increases the risks tis, as in the case just cited; by draining aAvay after ovariotomy. ' J . . . " 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., LECTURE 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 feAV 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 in 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 Avas, 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 iioav there is not an organ that is covered with the peritoneum Avhich 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 folloAving 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- b An early operation is ciple of gudl deky ig & 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, Avhich 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 Avith 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 otomyablecase8forovari" 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 noAV 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, Avith loss of appetite, insom- owiotomy118 for early n*a' gasri'ic 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 AVOMEN. case of a rupture of an ovarian cyst, with a discharge of its con- tents into the cavity of the abdomen. The pos- oPSon.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 Avas up and about her room. Two clays 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 folloAving case in Avhich I successfully removed a hemorrhagic cyst, Avith a solid tumor weighing thirty- eight pounds, illustrates the importance of operating promptly. Dr. Frederic Stevens, our former houst-surgeon, had the care of it after the operation, and has kindly furnished the following notes: A multilocular ovarian cyst weighing thirty-eight pounds— abundant hemorrhage 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. Ludlam in May, and an immediate operation advised by him. During August the tumor again grew rapidly, causing dyspnoea^ constipation and general malaise. The emaciation Avas marked and rapid. On September 15, Dr. Ludlam was again consulted, and the elate 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 fainting 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- Plate III. Ovarian tumor with hemorrhage into the cyst. 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 Avas made the next morning, September 20, 1886. There Avere 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 Avhich 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 tAvo 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, Avhich Avas 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, Avith blood, pus, or tube-casts in the urine, the presence of albumin in that fluid would not interfere Avith the operation, except- ov 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, seSfn.^ and the or to the autunm months. With the proper precautions it may be safely done at any season, excepting in the very hot Aveather, 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 Avind 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 roomnperature °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 Avhich the operation is to be made should be thoroughly scrubbed, Avhitewashed, cleared of its carpets and rugs, disinfected and afterwards opened to the fresh Surgical cleanliness of . m, .. . , . ., .. , .. the room, instruments, air. Ihe 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 Avater 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 avouIcI 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 AVOMEN. 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 Avith warm soap and water, after which it may be 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 Avith 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 loAvering 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 Avhile 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. OVARIOTOMY. 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 Avill ansAver. 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. pi , i n n i i , i most; ot Avhom 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 Avoman 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, Avhen 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 avIio has been thus exposed, or who has very recently performed or assisted in an autopsy, should not be alloAved 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 The necessary instm- forcepS (Fig. 176), and three ditto with gold- Avashed handles; a No. 7 or 8 steel sound; a Pean's trocar; two blunt tenaculae; two pedicle forceps; a Baker Brown's cautery clamp; a Pacquelin, or some other form of cautery; *'Ttis 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 has put 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 enonX=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. 2(5) ; six fine surgeon's sponges, and one flat one; a small ecraseur; Avith 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 Avithin 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. i- , i • i i t» • . ■, . n an expedient practised by Kecamier m 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 and not a rude 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 longer 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 to2ePnm.Dg 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 clone 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 The length of 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. uigite not to rupture the Cysts, and liot 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 mp ymg e c ^e vessels that ramify 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 Avarm, 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 Avater 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 The adhesions. x x, j? x i e t x i • n separate them in front before disturbing those Avhich 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 Avithout putting the hand into the abdomen. Stringy, vascular, fibrous, and especially omental adhesions should be ligated twice Avith 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 abclo- oas^esions.mdanBer" 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 Aveighed 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 hiSOTrhage^rom! the temperature of 103° to 105° or even to 115° are the best means for arresting the haemorrhage from the torn adhesions. Wylie's expedient of clamping the pedicle before the adhesions are disturbed may answer the same *The United States Medical Investigator, April, 1878. fZTie U. S. Medical and Surgical Journal, vol. IX., p. 225. 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 ahvays malignant. The possibility that adhesions may have formed Ioav 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. Hoav 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, ped?ciegemeilt °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 Avith warm toAvels 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 AVOMEN. 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 The two general method; or it must be ligated, or cauterized, or both, and then dropped back into the abdomen, which is the intra-peritoneal 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 down and the forceps removed. The pedicle The clamp. .g ^^ 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 WeUs' clamp for the pedicle. peritoneal cavity, as first practised by Dr. Nathan Smith, of Con- necticut, in 1821, the course to be pursued is The ligature. very differeni 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 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 seAved Avith 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 ATessels. 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 a 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 The actual cautery. ^.^ ^ 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 aStoTelxtra! and without the clamp, the elder Keith and peritoneal method. Lawson Tait have put the profession and our 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. ., . ., liilii i 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 Avithout 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 haemorrhagic 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 Avarm 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 Avhich 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. Apropos 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 8hoc°ktwaterflu8hingfor 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 Avith the use of other restoratives. The indications for drainage are identical with those which require that the abdomen should be thoroughly cleansed, Avith the added risk of haemorrhagic 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 OArarian cachexia is often so Ioav 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 doav 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 Txi© sutures 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 Avound 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 Avill 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 any discomfort arising from the Avound. 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, Avith 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 Avhen 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 continuous peri- ^ie 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. Qne in whioll the wap,8 oJ| foe abdomen are 984 THE DISEASES OF AVOMEN. 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 aSaeinedCcystuturefor 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 Avith iodoform. Then a compress of iodoform, mercurial, or carbolic gauze two or three inches Avide, is laid along the wound, and adhe- woundfir8tdressingofthe slYe 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 drSagi'taoe8 °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 at 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 bPuttingthe patient to middle? nor shouia the head be raised. Warm blankets should be placed about her legs and bottles pf 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. LECTURE 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 haemorrhage; 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 Avithout 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, oi- lier 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 beo-in 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 Quiet, and absence awav and as q uietlv as possible. From the of visitors. J' mi i 11 i very outset she aviII need the same general treatment as if she had passed through a perilous childbirth. No noise, or stir, or flurry, or Avhispering 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 nermitted to turn upon either side. 985 986 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 thehroommperatare °f ror lllis purpose 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 windoAvs 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. » ■ t> x •£ \ i i xi i x fresh air. But 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 Avas 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. ,, -, , ,, •, « , • affow it unless the necessity tor rest is lmpera- tiAre, 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 closes 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 The uise 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 momeeter!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 •> xi £ x x u closed. Leave it there tor tAvo 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 clay or tAvo 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 over the past record of a case, as it is to forecast its future. The Value of the record. clinical hintgj 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 Avay. 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 Thirst and appropri- SOmethinp- to drink. Sometimes the craving for pfp drinks ^ • 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 Ave usually begin with hot, instead of cold drinks. Hot Avater, 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 988 THE DISEASES OF AVOMEN. 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 Aveek, the best is good cow's milk; but, for fear of inducing colic, it should be diluted and taken very Avarm. 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 clone with safety. One of the most annoying and rebellious symptoms is flatu- lency. It may be due to the dyspeptic habit; to a superficial Flatulence 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 Avhen 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 mav Nausea and vomiting. -ill J\ xv x T£ xi • i possibly have a good effect. If 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 Dr. Jenks' expedient Pf^ be tUrlied toWard ODe side OT the °thei' for tympanites from in- slowly and gradually, and propped in that testinal obstruction. ... T-P , ,J' - ,L ff 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, Avhich caused the clamp to be torn loose, the loAvest suture to be also torn out, and the loAver angle of the abdominal wound to yawn, through Avhich gap the serum from the abdominal cavity exuded for tAvo 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 Avith a force more remarkable than anything of the kind I ever before witnessed. The patient, as she began to experience relief, instead of being passiATe in our hands, complained in no mild terms of the unkind and ungentlemanly treatment she Avas receiA'ing. From this time there Avas 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 Avound 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 haATe taken firm hold of a case, Ave may make up our minds for a Nausea and vomiting. ~ , . % • A , , m. tierce struggfe before they can be ousted. Ihe 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 Aveapons 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 Avound 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 A'omiting do not promptly yield to the appropriate treatment. It has been observed that vomiting is more apt to occur in cases in Avhich 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 closes 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 Avater, 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 Avhether a persistent A'omiting, or one that occurs after the first few days or a week, is not clue to some form of sepsis, or to peritonitis, or to both t With sepsis and peri- thege conditiong> jf {x ^ ^ mogfc ^^ 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 of 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 inters^ai1u\ceration.and °f *ne cyst-contents, an irrepressible vomiting with dilatation of the stomach will depend upon ulceration of its lining membrane. The following is a case in point, the lesion being confirmed by an autopsy. The patient was brought to me by Prof. C. W. Eaton, of the University of Iowa. Case—Mrs.----, of Des Moines, was forty-eight years old, mar- ried, and the mother of four children, the youngest being four years old. All of her labors had been difficult. She A\ras a woman of intellectual tastes and of nervous temperament. She first observed an enlargement in the epigastric region about one year ago, and the most unpleasant symptoms attending it were referred to the stomach. The paroxysms of pain and indigestion which Avere fol- loAved by Aromiting, soon became so frequent that she was forced to diet herself very strictly to prevent them. She had also been subject to haemorrhoids and to inveterate constipation, and at times the urine had been very copious. The abdominal distention finally became so great that her phy- sician thought it advisable to relieve it by tapping, which he did about two months ago, Avhen seven and one-half quarts of reddish brown fluid were withdrawn. In six weeks, she was again tapped, 992 THE DISEASES OF AVOMEN. 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 fiA^e and a half quarts of a dirty broAvn fluid were removed. At each tapping the fluid Avas highly albuminous. Her menstruation had been normal in every respect, and she had not reached the climacteric, although there Avere signs of its near approach. I made the operation in the hospital, NoA^ember 6, 1880, with the assistance of Drs. Shears, Crawford, Eaton, Beynolds and Paul. The patient bore the anaesthetic very well, and the operation lasted one hour and a quarter. There Avas 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 Avhich 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 clay. The post-mortem Avas 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 Avas 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 Avas no effusion of lymph upon the intestines, no blood, or bloody serum, or clots, anyAvhere, nor was there a drop of pus to be found Avithin 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 Avhatever. The stomach was found to be greatly dilated. Its external THE AFTER TREATMENT IN OVARIOTOMY. 993 appearance was healthy. It contained about three pints of dirty ochre-colored water. On being opened along the Avhole 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 toav of dark-colored spots Avhich 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 polycyst from a patient, for my friend Dr. C. W. Crary, now of Kenwood, 111. The Avoman was 62 years old, a theomaniac, and therefore a confirmed dyspeptic, who did not care 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 aud anxiety by rolliDg 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 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, Avhen 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 AVOMEN- 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 septicaema 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 Avarm 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 boTwheeisCon and may be le£t there until thege fluidg are thoroughly drained off. The outer end of the rubber tube which can be pierced and fastened to the binder Avith a safety- pin, must be carefully covered to preA'ent the admission of air into the peritoneal cavity. The object of plating the superficial sutures with catgut is that the Avound need not be disturbed until the time has arrived for removing the deeper ones. That time varies The removal or the from a Aveek to ten clays. If the Avound is dry and sweet, and the line of union is perfect, 998 THE DISEASES OF AVOMEN. and especially if the tumor Avas 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. Noav that the rule is for recovery to follow without suppuration, I prefer to leave the sutures a few days longer than Avas 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 tAvo 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 thl &-sCt°getting upM and 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 Rochelle, 111., the patient of Dr. W. A. McDowell. The tumor Avas 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, Avhile 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 Avas 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 Avho are predisposed to respiratory affections are likely „ . a x. to have trouble during their convalescence from Contingent affections: . , t-u i i bronchitis and pneumo- ovariotomy. JUderly women are more subject to bronchitis, broncho-pneumonia, and catarr- THE AFTER TREATMENT IN OVARIOTOMY. 999 hal affections of the air passages than those who are uncier 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 Avoman 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 11 years old, cleaned, scrubbed, and helped to whiteAvash 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 clay she had pains in the left chest and shoulder and a harassing cough. The case developed into a serious attack of broncho-pneumonia,Avhich was not fully overcome until after the fifteenth clay. 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 pyaemic, and sometimes the periosteum of the inferior maxilla is involved. Warm applications and 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 folloAv 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- thrSbus.8' phIegmasia' 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 deArelops into a confirmed phlegmasia, and extends to the thigh, from Avhich 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; Avrapping 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 ■ e , ■ , even m death, as m one of 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 Avhich 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 health9 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 will render her recovery next to imjwssible.— A month ago I showed you an ovarian cystoma Avhich I had just removed from a patient of the Drs. Dunn, of Centralia, 111. The Avoman was 5S 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 Avas tap- ped and but once. AfterAvards it greAv steadily and at the opera- tion Aveighed 02 pounds. She is now Avell 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 that 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 Avas a double ovariotomy in a patient of Dr. L. W. Jordan, of Bucyrus, O. The largest tumor Avould have exceeded ninety pounds in weight if she had not been tapped for temporary relief just one Aveek 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, Avith repeated attacks of vomiting and purg- ing, and to be confirmed at post-mortem by signs of gastric or enteric ulceration. 1. 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 aub> infection. 5. That the cardiac degeneration and involvement which are incident to this form of abdominal growths, as shown by Dr. FenAvick, may be ascribed to a pernicious anaemia that is of septic origin, and Avhich 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 Avait 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 OATariotomist, 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 Ioav 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 Avho 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. LECTURE LXI. OA'AEIOTOMY 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. Vuginal ovariotomy. Cases adapted to. Alode of operating. A new hint. The after-treatment. There are other modes of performing ovariotomy Avhich remain to be described and illustrated before Ave dismiss the subject. One of these is Avhat is called ovariotomy by enucleation, Avhich Avas first proposed and practised by Prof. J. F. Miner, oiSrmeth0d°f enU"ot" B"ffa!o. ^- Y-»* and which has been variously modified for the purpose of adapting it to a Avider 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. FolloAving this mode of separation there Avas 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 ovrarian tumor has a dense firm covering, and the vessels Avhich 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 avouIcI suspect avIio has not attempted its separation in the manner described. The same efforts Avhich are made to separate the adhesions elseAvhere if extended to the pedicle, Avill be found equally successful. The finger should be introduced under the central portions of the pedicle, fully down 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 Avhich 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 Avhatever; 'The American Journal of the Medical Sciences for Oct. 187:2, p. 391. 103? 101)1 THE DISEASES OF AVOMEN. and those cases in Avhich the anterior Avail of the cyst is covered by a sub-peritoneal vascular membrane, Avhich makes it imprac- ticable to finish the operation in the usual Avav, bieafSoer.thatareSUita" but in which U is expedient to cut through this membrane very carefully, and afterAvards 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, Avhich adds a neAV resource to the management of cases in Avhich the adhesions are so general and so formidable as Ludiam-s method of th j t force one to relinquish the removal enucleation. i of the tumor. This plan, which i had never heard of before, consisted in the separation ot the coats of the cyst Avail, in removing its lining membrane entire, and in leaving the matrix Avithout disturbing any of the peri-cystic adhesions or visceral attachments. The records of this remarkable case Ave re carefully preserved, and read as folloAvs: Case.— Mrs. H., of this city, aged 22, is the mother of one child, Avhich is tAvo 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 cIoavii the left leg. For some time the side had been weak and the pain not very severe, Avhen 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 Avhich lasted a whole Aveek. She first observed an enlargement in the left iliac and ovarian region four months after her marriage. This Avas accompanied by a general bloating of the abdomen, which Avould subside and at times almost disappear. Then she became pregnant, and toAvards "term" her size was " enormous." She had a natural labor, and got up well, Aveaning the child wlien it Avas 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 Avhich caused the growth to diminish someAvhat in size. Durino; tAvo weeks of this time she took a "treatment" of this kind every day on the doctor's theory that the enlargement Avas due to dyspepsia, Avhich he told her arose from drinking coffee! In all she has had fourteen physicians, each of Avhich has given a different diagnosis. One said she had dropsy and an ovarian tumor. Another decided that the ascites Avas'so pronounced as ' to prevent a recognition of the ovarian tumor, if there Avas one. OVARIOTOMY BY ENUCLEATION. 1005 A third treated her for about thre^ months for a " fattenino- of the apron " (omentum?) which " fattening," it Avas said, " pre- vented the escape of the Avind and so caused the abdomen to become enlarged!" During the past tAvo years she has had repeated attacks of Avhat, from her description of the symptoms, appears to have been sub-acute peritouitis. These Avere generally induced In- active exercise Avhile on the feet, as for example by ironing, or by standing for a long time Avhile cutting out garments. Not unfrequently these fits of illness avouIc! either accompany or fol- Ioav the menstrual period. The menses had been and continue quite regular. In former years the Aoav Avas very free, but of* late it is becoming more scanty. The general health is good, the appetite fair, but at times she cannot lie clown and sleep, owing to the dyspnoea caused by the mechanical pressure of the tumor against the diaphragm. The measurements (Aug. 2, 1873), Avere as folloAvs: The cir- cumference of the body over the umbilicus Avas 37 inches; from the ensiform cartilage to the pubes, 14^inches; from the ensiform cartilage to the umbilicus, 8 inches ; from the umbilicus to the pubes, 6^ 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| inches; and from the left ditto to the point of the last floating rib on the right side, 16h inches; depth of the uterus, 2f inches. The operation Avas 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 Avere present Dis. W. Danforth, C. X. Dorion, and R. K. Paine, of the Hahnemann Hospital, and Messrs. C. D. Stanhope, H. \Y~. Roberts and G. R. Parsons, of the college class. Dr. Paine administered the ether, and my colleague, Dr. Dorion, Avas my chief assistant. Although none of us had ever Avitnessed the removal of an ovarian tumor by any form of enucleation, I had previously determined upon this mode of procedure, more especially because it Avas evident that the cyst Avas bound on all sides by adhesions, resulting from the frequent and severe attacks of peritonitis to Avhich my patient had been subject. I made the incision, as usual, along the linea alba. At first it Avas only four inches in length, but it Avas afterAvards enlarged to five inches. There Avas but little hemorrhage. Anteriorly the adhesions Avere so intimate and firm that it Avas only by the escape 1006 THE DISEASES OF AVOMEN. of the abdominal fluid at the loAver end of the incision, and the application of Atlee's test that Ave 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 Avere very compact and very vascular. This fact Avas so obvious that all the physicians present expressed themselves as satisfied that the operation must be abandoned, or the patient's lifeAvould be put in great peril by completing it after the old method. And this state of things caused me to reneAv my resolution to test the expedient of enucleation. At a glance it Avas evident, hoAvever, 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 Avere in the Avay of getting at the pedicle. Therefore, in order to separate the cyst, Ave could not begin " under the central portion of the pedicle," but had to content ourselves Avith first detaching it at a point opposite the abdominal incision. Noav this, as you may suppose, was a very delicate matter. The peritoneal layer being very thin, and the cyst-Avail likewise, the greatest care had to be exercised in beginning and in com- pleting their dissection and detachment. A very slight incision Avas first made, and then the handle of the scalpel A\ras used to carry on the separation until it Avas sufficiently extended to uIIoav ot the fingers being employed in the same Avay. It Avas only Avith extreme care and patience that this part of the operation Avas performed, for the cyst required to be separated in this manner throughout its Avhole 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 hemorrhage. The diagram on the black-board Avill give you a pretty correct idea of the pathological anatomy of the tumor, and also ot the relative position of the tissues Avhich Avere separated during the operation. OVARIOTOMY BY ENUCLEATION. 1007 Laving finally removed the cyst, we were prepared to appre- ciate Dr. Miner's remark: " No surgeon in the Avorld Avas ever more surprised at what he had done than myself, Avhen I found that I had removed a large ovarian tumor Avithout ligating a single vessel, and Avithout any haemorrhage Avorthy of notice." Here Ave had taken out this large sac Avithout having applied a ligature, or resorted to torsion, or anything of the kind: and Avhat Avas equally remarkable, Avithout having seen the intestines, the uterus, the opposite ovary, or eAren 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 Avhich had oozed from the capillaries. After waiting a quarter of an hour, in order to be certain that hemorrage would not set in, the abdominal incision Avas closed Avith silver sutures in the usual way. The cut was dressed Avith a compress moistened Avith a mixture consisting of the tincture of calendula, glycerine and warm water, in equal parts. The Avhole Avas secured Avith adhe- sive straps and a binder, and the patient put to bed again. The entire operation lasted tAvo hours. The cyst and its contents Avere estimated to Aveigh thirty pounds. She rallied Avell, and the anesthesia passed Avithout 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 Avas harassed Avith a nervous cough, Avhich Avas 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, Avith dyspnoea, which continued for half an hour. Re-action Avas induced bv friction, the application of dry heat, and by the internal use of stimulants. The usual precautions Avere taken each day thereaf- ter to prevent the recurrence of the chill, and Avith success, but the dyspnoea came at 4 p. m. every day for a week. On the fifth day she took mercurius sol. 3 and bryonia alb. 3 every tAvo hours alternately for the white pasty tongue and the cough. In the afternoon two of the deep sutures Avere removed, and she was turned upon her side for the first time. On the sixth day, from 7 to 10 p. m. she av;is very restless, and was troubled with a nervous cough, for Avhich she took spongia 1008 THt" DISEASES OF WOMEN. instead of bryonia, with arsenicun: alb. 3. She had also a fre The flow? which ig very free,is usually, but not ahvays painful, and very debilitating, If it has continued long, the patient becomes anaemic, bloodless. and perhaps dropsical also, it returns every fortnight, or three 1036 THE DISEASES OF WOMEN. weeks; she does not recover from one attack before another is upon her. It is astonishing Iioav small a fibroid may serve to per- petuate such a haemorrhage. For it may happen that a little body of this sort, which is not larger than a grape, may cause as great a loss of blood as sometimes does the fragment of placenta which is left in the Avomb after an abortion. Leucorrhcea, serous discharges and obstructive dysmenorrhcea are often due to the presence of uterine fibroids. More rarely the tumor blocks up the outlet, and there is complete retention of the menses. Incidental symptoms of uterine de\riation are ahvays present. The larger the tumor the greater the displacement. Being at- tached more frequently to the posterior Avail of Uterine displacements. - n • the Avomb, retroversion and retroflexion are very common. If, hoAA'ever, as sometimes happens, the point of attach- ment is to the fundus, and the tumor is a very large one, the organ may be inverted. Anteversion, anteflexion and prolapsus are not infrequent. Latero-version, a state of things in Avhich the body of the Avomb is forced toAvards one side of the pelvic basin, is some- times caused by the presence of an intra-uterine fibroid. Beside the morning sickness, anorexia and caprices of appetite, the development of the mammary glands, of the areolae, and of the abdomen, there are other signs simulating Changes in the cervix. those of pregnancy, that are caused by the growth of a fibroid in utero. The cervix is shortened, and may become flaccid and patulous. More frequently, hoAvever, after some months, it forms a ring Avhich is resistant and sometimes very sen- sitive to the touch. Auscultation through the abdominal pari- etes (providing the tumor has passed above the The uterine souffle. pelvic brim) reveals the uterine souffle, which you remember was once regarded as a positive sign of pregnancy. In exceptional cases there is a singular tolerance of the pres- ence of these tumors. Some Avomen carry them for years and become so accustomed to them that they make Tolerance of the tumor. , " very little if any complaint of them. It is only in consequence of the haemorrhage, or the pressure they occasion, that they are led to take measures for their removal. They do not ahvays interfere with pregnancy, although they groAV more rapidly in the gravid than in the non-gravid uterus. They some- times cause abortion. FIBROID TUMORS OF THE UTERUS. 1037 These tumors, as they groAV, lead to an enlargement of the uterus and an increased size of its cavity. Hence, if the oreanis not quite filled Avith the fibroid, the sound Avill Increased size of the uterus. . pass quite readily, and perhaps farther thanyou Avould have supposed. For the depth of the uterus may be as great as it is at term. In order to get the best idea of the size, and the point and mode of attachment of the groAvth, you should select a flexible sound, which Avill adapt itself to the contour of the tumor Avithout force, and, therefore, Avithout inducing pain or haemorrhage. As felt through the abdominal parietes, the outline of the tumor can usually be very Avell recognized. There is dullness on percussion over the Avhole anterior surface of Physical signs. the womb, ft is not unusual for the patient to complain that one particular spot is and has ahvays been painful and tender to the touch ; but there is no diffuse soreness. The uterus is hard and resistant to external palpation. These tumors, being invariably attached to the body and fun- dus of the womb, a vaginal examination by the touch is of little use unless the groAvth is large enough to be Ihe touch. „ -.. . felt, or so to displace the uterus that it can be reached. In case the tumor is very large, the AAhole organ may be displaced upAvards, above the brim of the pelvis and the " touch " reveal nothing. In some cases the Bi-manual examination. . . , . , . "touch maybe conjoined Avith pressure Avith the tips of the fingers of the free hand over the uterus and just above the pubes, as in Sims' bi-manual exploration. Causes. — The causes are not Avell knoAvn. That the groAvth of these tumors bears a certain relation to the menstrual function, and to that of procreation also, is e\"ident from Menstruation and child- t]ie fact ^hat thev are most frequently devel- bearing. <- x j oped at a period Avhen these functions are most active. But precisely Avhat that relation is has not been deter- mined. In a certain class of cases it is probable that the fibroid is a sequel, or a consequence, of the incomplete involution, or fold- ing upon itself, of the uterus after delivery. It has happened that a clot has been found to form the nucleus of a uterine fibroid. Diagnosis. — The diagnosis is difficult. I have already told you 1038 THE DISEASES OF WOMEN. hoAV to diagnosticate a case of intra-uterine fibroids from one of o\rarian dropsy.* The hardness and mobility of From an ovarian cyst. . „ n . ,-. the tumor ; the absence of fluctuation ; the depth of the Avomb, asshoAvn oy the distance to Avhich the sound Avill enter ; the co-existence of lnemorrhage, Avhich may be men- strual, but is often inter-periodic ; the pain and uterine tenesmus ; the uterine souffle in either groin ; the uterine displacement and leucorrhcea; and the comparatively sIoav rate of the groAvth of ihese fibroids, are sufficiently characteristic. The occurrence of uterine fibroids and of ovarian dropsy are not very frequent in those avIio haAre neArer been pregnant. The incidental haemorrhage, Avith its tendency in most cases to return at or near the month Avith tolerable regularity ; the tardy and protracted groAvth of the tumor; the absence of quickening and of the foetal heart sounds; the rounded outline and hardness of the tumor as felt through the abdominal Avails : the patulous state of the os uteri; and the persistent displacement of the Avomb, are so many signs Avhich will help you to differentiate this variety of uterine fibroids from pregnancy. The altered and peculiar shape and consistence of the cervix in case of placenta praevia, would be as different from that Avhich is proper to uterine fibroids, as it is from that of ordinary pregnancy. You should not forget that it is possible for a woman with any variety of uterine fibroid to become pregnant, although, in case of the intra-uterine variety especially, they sel- dom reach term Avithout aborting. It is therefore best not to pass the sound in all cases indiscriminately, and Avithout thought of the possible consequences. Perhaps, in a majority of eases the large fibroid becomes impacted in the pelvis and does not rise into the abdominal cavity, as the gravid uterus does, at or about the fourth month. In the case of uterine hydatids the abdominal tumor is larger, grows more rapidly, is characterized by smoothness, fluctuation and decided distention, which subsides sorae- From hydatids. what Avith occasional discharges of serum and blood. Sometimes small portions of the mass are detached and extruded, from Avhich specimens it is possible to recognize the nature of the growth. AVhen there is copious or continued haem- * See page 369. FIBROID TUMORS OF THE UTERUS. 1039 orrhage, the diagnosis from a uterine fibroid is more difficult. In this case a decision can be reached by dilatationof the cervix and an exploration of the uterine cavity by means of the finger or the uterine -sound. It is quite impossible, in most cases, to distinguish an intra- uterine fibroid from a fibrous polypus, without artificial dilatation of the cervix and careful exploration, unless the polypus is large enough, and its pedicle suffi- ciently long to enable it to drop into the canal of the cervix, or into the vagina. Their differential diagnosis is, however, not a matter of very great importance. The only real difference betAveen them is that the fibroid is enclosed in a proper capsule, which really disconnects it from the surrounding tissue ; while the polypus is a true out-growth, Avhich is continuous Avith the sub- stance of the uterus and C0Arered only by its lining membrane. These differences are not observable, hoAvever, until the growth has been removed. These fibroids have sometimes been confounded with the tumor formed by inversion of the Avomb. They have many symptoms in common. But inversion folloAvs the evacuation From inversion of the 0f the uterus. Either the Avoman has recently womb. been delivered, in abortus or at term, or the organ has first been distended and developed by a contained tumor, and finally turned inside out during or in consequence of its deliv- ery. The best test between these tumors, however, is a very simple one. In inversion the tumor is sensitive, and if you stick a pin into it the patient feels it; but not so in case of the fibroid. By means of the uterine sound or probe alone you can diag- From.retroversion and nosticate retroversion and retroflexion of the retroflexion. uterus from a sub-mucous fibroid. Prognosis.— There are several sources of danger in this disease. The haemorrhage may drain aAvay the strength, and so undermine the health as finally to destroy life. Sometimes such patients die very suddenly from excessive loss of blood. In consequence of the mechanical pressure of the tumor upon the pelvic viscera, or upon the ureters, serious disease may be caused in the bladder, the boAvels, or the kidneys. The reflex disorders occasioned by the same cause are harassing and 1040 THE DISEASES OF WOMEN. exhausting. The impairment of digestion, respiration, and espec- ially of the circulation are sometimes very serious. In some cases the symptoms are very deceptive, and give no reliable criterion of the gravity of the disease. Women who have carried these tumors about with them for years Symptoms deceptive. ^.^ ^^ ^ ^^.^ ftnd at kst find them. selves ill, are apt to drop off very suddenly; while those who complain most bitterly are often in a less dangerous condition. The risk of operative interference is less than in either of the other varieties of uterine fibroids. There are two reasons for this fact: (1) because the tumor is more readily 10n' reached and removed, and (2) because the clan- ger of consequent inflammation is in proportion with the liability of wounding or cutting into the peritoneal surface of the womb. Treatment. — The treatment is medical and surgical, or pallia- tive and radical. Whatever contingencies beset the case must first be removed. The haemorrhage is the source of danger and must be controlled. For this purpose such remedies as ipecacuanha, china, arsenicum alb., hamamelis, erechthites, crocus sat., cinnamonum, trillium, secale cor., sabina, belladonna, nitric acid, or ferrum met., may be given each under its appropriate indications. The suitable remedy will generally suffice to relieve the pain as well as the excessive flow. If the haemorrhage is copious and continuous, and it becomes necessary to stop it at once, in order to husband the patient's strength and to save her life, and internal remedies act slowly or fail altogether, recourse must be had to such local treatment as Avas recommended in my lecture on uterine haemorrhage.* You doubtless remember what I then said of such available expedients as cold Avater locally and by injection, ice, ice-Avater, pouring cold water from a height upon the abdomen, colpeurysis, and the tampon. In some cases the sponge tent makes an excellent tampon for the cervix ; and Palfreyf recommends to introduce the speculum, to draw down the anterior lip of the cervix, and then, with the uterine sound to pack its canal Avith a long and narrow strip of lint. The lint. which may have been soaked in carbolized Avater, should be * See page 8o. f Medical Press and Circular, Vol. VII, p, 516. FIBROID TUMORS OF THE UTERUS. 1041 alloAved to remain for about twenty-four hours before it is re- moved. Among the improved methods of haemostasis, which also in- clude a more or less permanent exemption from the Aoav, there is no simple expedient that is more valuable The sponge-tent as a + k , ±1 • . i .,• .1 t hemostatic. than the introduction ot the sponge tent. I have known it alone to prevent the return of the menorrhagia, and to secure a natural flow for months in suc- cession. In obstinate cases nicking, slitting, or incising the os uteri Avith a curved, blunt-pointed bistoury, a pair of scissors, or the hys- terotome, has also been practised with marked Incision of the cervix. success. \\ hether these latter means are effi- cacious because they unload the engorged vessels, or because by dilating the os uteri, they empty the Avomb of its more fluid and distensible contents, and thus remedy the difficulty, I am not pre- pared to say. But that they certainly present a valuable means ot relief, Avhich is ahvays available, and which, until quite re- cently, Avas unknown, I am Avell assured. If this treatment fails to bring the desired relief, Dr. Atlee* recommends to folloAv up the section of the os uteri Avith a free division of the capsule of the fibroid in utero. Dr. Atlee's operation. __,. . .. , , . c , This is accomplished by means ot a long- handlecl, curved and probe-pointed bistoury, Avhich is to be passed into the uterus as far as the guiding finger Avill reach, and then drawn firmly down over the tumor so as to cut through its capsule and into its substance to the depth of half an inch. This opera- tion not only lessens the haemorrhage, but so impairs the nutri- tive vitality of the fibroid that its destructive metamorphosis is soon established, and it will be either enucleated spontaneously, or thrown off Avith a kind of 'leucorrhceal discharge. This prac- tice seems to me to be especially adapted to tumors with a broad base and margin of attachment. There is a certain proportion of cases of uterine fibroids, more especially of the sub-mucous and the intersti- Hypodermic iujec- tiai val.jctjes in which the haemorrhage can tions of ergot. be controlled and the growth ot the tumor held in check by the sub-cutaneous injection of ergot. I could cite •Transactions of the American Medical Association, 1858, p. 558. 1012 THE DISEASES OF WOMEN. you many cases in Avhich I have been successful by this means; in a feAV of Avhich the growth has disappeared entirely. Occa- sionally there is such a susceptibility to the action of this poison that ergotism is readily induced, and avc have to desist from its use. I prefer Squibbs' solution of ergot, Avhich can be prepared by any responsible druggist, Avhich ought to be fresh, and which contains a grain to the minim. Of this solution from three to six drops may be thrown into the integument in the hypogastric region (but not perpendicularly into the tumor), two or three times per week. Bartholow's solution also ansAvers very well. A good result from the-ergot is that uterine contractions which tend to force an interstitial fibroid into its cavity, and a sub- mucous fibroid into the vagina, Avhere they are accessible, is pretty sure to folloAv. The taking of ergot by the mouth will almost never do any good in these cases. Another expedient for the control of the haemorrhage is a re- sort to the removal of both the ovaries, as Battey's operation in. already described uncier the head of normal ovariotomy. The effect of this operation is to arrest the monthly floAv and to precipitate the menopause. As a natural consequence the periodical afflux of blood to the womb is arrested and that organ with Avhatever is nourished by its vessels undergoes the same atrophy as if the change of life had come about in the natural Avay. Very much has been claimed for electricity in the cure of these tumors, but I knoAV of very little that is to be Electricity and elec- . J troiysisin. relied upon in the support of that claim. It is so serious a matter to puncture these growths, and such fearful consequences have sometimes folloAved their per- foration, that I confess to a dread of running the electrical, or any other kind of needle into them. Dr. Cutter puts the case very Avell when he says that galvanism is a means, but not the means of treatment for sub-serous uterine fibroids. The same authority* quotes a number of cases toshoAv that the . . .. _ growth and development of some of these An animal diet in. L *<-ov. fibromata may be largely if not Avholly con- trolled by an exclusively animal diet. I have not tested this * Cutter : Food as a Medicine in cases of Uterine Fibroids, American Journal of Ob- stetrics, etc., Vol. X., page 562. 62 FIBROID TUMORS OF THE UTERUS. 1013 matter except in a case which Avas brought to me by the late Dr. Von Tagen, in Avhich it had no perceptible effect. But unless Dr. Atlee's operation shall result in the extrusion of the fibroid, either as a whole or in fragments; or it shall be Excision of the tumor. Sp°ntaneouf^ ^fc^ed and expelled, as it sometimes is, by strong uterine contractions; or unless it shall undergo some form of degeneration, and thereby escape or cease to be troublesome; a radical cure will only be possible by its excision and removal. This is to be effected by a „. . n , ligation of the tumor. And two obstacles are First obstacle. . in the way of its accomplishment. The first of these is the narroAv state of the cervix uteri. To overcome it Ave must resort to free dilatation. If the tumor is quite large, and the cervix is shortened and softened, as in the later months of pregnancy, two or three sponge tents of various sizes may be introduced successively. These Avill expand the neck so that the fingers can be passed within the Avomb, the exact site of the tumor ascertained, its mode of attachment also, and the instru- ment adjusted. For this must be done by the sense of touch, and not by sight. In the more rigid and unyielding states of the cervix, the sea- tangle tents are preferable. Of these quite a number are to be passed through the internal os uteri one after Dilatation the fli st step. . /.. . . .. . another, until it contains from three to seA'en or eight of them. The longer these tents are the better. They should be alloAved to remain for from tAvelve to twenty-four hours. On their removal, it the dilatation is not sufficient, one of Barnes' rubber dilators may be inserted through the cervical canal, in- flated, and left in situ tor some hours longer. These expedients will provide a mode of entrance that Avill make the further steps of the operation possible. To secure a free expansion of the cer- vix, it may perhaps be necessary to incise it at the same time that you dilate it. The second obstacle in the way of operating in some of these cases is the difficulty of adjusting the ligature, or rather, the chain or wire of the ecraseur. If the tumor is The second obstacle. in the vagma? and is not very large, there will be no trouble in this respect; but if it is in the uterus, and more than all, if it is attached to the fundus, and has a broad base, in- 1044 THE DISEASES OF WOMEN. stead of a pedicle, you will find that it :s not so easily done as you might have supposed. Indeed, it may require repeated trials Fig. 195. Greenhalgh's tumor forceps. before you succeed in carrying the loop of the ligature over and beyond the tumor. A few authors insist that, to facilitate this Fig. 196. Sims' volsellum hook. object, the uterus should be dragged doAvn to the vulva. But, unless in very exceptional cases, this proceeding is barbarous and unnecessary. See case given on page 893. Fig. 197. Steele's volsellum forceps. It is quite a different thing hoAvever, to sieze the tumor and draw it doAvn. This expedient is so necessary in most cases that a volsellum of some kind should be at hand, and it is best to be Fig. 198. Byrne's volsellum forceps. provided with two or three of them. Greenhalgh's tumor forceps (Fig. 195), Sims' volsellum hook (Fig. 196), Steele's (Fig. 197), FIBROID TUMORS OF THE UTERUS. I01o or Byrne's volsellum forceps (Fig. 198), or the simpler tenacuhe (Figs. 199, 200) are excellent in suitable cases. This manipulation, if successfully made, facilitates the adjust- ment of the ecraseur, with Avhich we intend to excise the tumor. Fig. 199. A volsellum forceps. And here again there is a choice of instruments. The texture of the groAvth is so firm that a delicate instrument would soon be Fig. 200. The old volsellum. broken; and therefore the ecraseur must be strong enough for the purpose. If the tumor is really Avithin the uterine cavity the instrument should not have a straight shank, as in (Fig. 201), but should be curved like the uterine sound, (Fig. 202). Fig. 201. A straight ecraseur. Whether the ecraseur shall carry a Avire or a chain, or if they shall be united as in Thompson's instrument, (Fig. 203), will de- pend upon circumstances. Braxton Hicks' wire-rope, as well as the copper Avire, are apt to get into a snarl, or to break from a strain. In tAvo ot my operations the strongest copper Avire that I could find broke when the tumor was about half cut through. If you can succeed in adjusting the chain, I think you will feel most confident of a good result. 1010 THE DISEASES OF WOMEN. Ill order to ensnare the tumor most readily, let me give you a hint which I have found of great service. First ascertain as accurately as possible the precise site of the tumor, and its point of attachment to the uterine Avail. Then place the patient in such a position that it will drop Fig. 202. Tiemann's chain ecraseur. away from its pedicle, or base, toAvards the opposite side of the Avomb. If it happens to be centrally located the position of the patient is less important. Fortunately a majority of these intra- uterine fibroids, and fibrous polypi also, grow from the posterior wall of the Avomb; and therefore the patient is usually placed in what is now knoAvn as the left lateral position. When the instrument is finally adjusted, all that remains is to tighten it sloAvly and steadily until the tumor is cut off. This should be done very gradually, lest the wire Cauton. tit • .„ Y , break. Iron Avire aviII not stand the strain; but the Avire-rope or steti Avire are more trustworthy. If the tumor Fig. 203. Thompson's ecraseur. is a very large one, it may need to be delivered with the obstetric or other forceps, or perhaps to be cut into pieces before it can be brought aAvay through the os uteri. Fortunately, in ecrasement, there is an exemption both from immediate hemorrhage and from the clanger of subsequent inflammation. In rare cases, where the tumor is very large and pedunculated, and occupies the vagina, it is so difficult to excise it in the ordi- FIBROID TUMORS OF THE UTERUS. 1017 nary way, that it has been recommended first to seize it Avith the obstetric forceps, and then todraw it out at the &.u exceptional case. vulva, after which the ecraseur may be applied. This operation causes a temporary inversion of the Avomb; but Fig. 204. Sims' enucleator. the os having been stretched so Avidely by the tumor, and para- lyzed by pressure upon it, is not likely to contract so firmly as to interfere Avith the reposition of the organ afterAvards. If there is much haemorrhage, the, stump, or pedicle, may be seared with an iron at a Avhite heat, or painted with the per-chloricle of iron, before the uterus is replaced. Fig. 205. Sims' blunt hook enucleator. When the intra-uterine fibroid is attached by a broad base, its removal must be affected in a different Avay. The old plan was to make a deep gash into the tumor and then to insert a Avad of cotton which had been dipped in oil, or a bit of caustic, and leave Fig. 206. Clark's tooth-edged scissors. it there so as to induce a slough. Another method consisted in seizing the growth Avith a forceps and twisting and tearing it forcibly out of its bed; this was called the process of avulsion, and is discarded iioav. Since many if not all of these sessile fibroids are encapsuled, Dr. Sims and others have practised their enucleation. After cutting through the investing tunic, a Sims' enucleator (Fig. 204), or his blunt hook (Fig. 205), may be introduced, and by careful and forcible manipulation the tumor may be rolled out of its bed. 1048 THE DISEASES OF WOMEN. In exceptional cases, according to Dr. Emmet, the tumor Avill cause the uterus to expel it in imitation of labor; and this pro- cess may be aided by cutting off the accessible portions, either with a curved scissors, or with a pair of tooth-edged scissors like these, (Fig. 206). Fig. 207. Thomas' spoon-saw. Dr. Thomas' method consists in seizing the tumor at its most dependent and accessible point Avith strong volsellum forceps, passing up along its sides the spoon-saw or serrated scoop depicted in Fig. 207, and by a gentle, pendulum motion from side to side sawing through the attachments of the tumor and freeing it en- tirely from its connections Avith the uterus." He says: "The advantages which experience teaches me attach to this instrument are the folloAving: (1) the attachments of the tumor are separated by a saAv, Avhich greatly limits haemorrhage; (2) the slope of the spoon, convex Avithout and concave Avithin, causes it to folloAv of itself the contour of the tumor unless this be very lobulated, and protect the enveloping tissues from injury; (3) the highest points of attachment of the tumor are as readily reached as the lowest, the freed growth descending under traction as the saw severs its adhesions in successive sweeps around it; (4) the saAv action gives to the process of separation, Avhether the groAvth be interstitial or submucous, sessile or pediculated, rapidity or certainty; and (5) and last, though by no means least, the nature of the spoon-saw secures separation of a growth at the highest point of its attachment, leaving no peduncle to decompose." II.—SUB-PERITONEAL FIBROIDS. These growths, which are located on the exterior surface of the womb, and beneath the peritoneum, are also knoAv as sub-serous, extra-mural and extra-uterine fibroids. They sizFere^ncy'number' are less frequent than either of the other vari- eties, but Avhen they do exist, are almost ahvays multiple. They groAV more rapidly, are of various sizes, and may be very numerous. Not unfrequently the abdomen Avill be filled SUB-PERITONEAL FIBROIDS. 1049 Avith one Avhich is very large, Avhile the exterior of the uterus is studded Avith a number of smaller ones that are undeveloped. Sometimes, hoAvever, two or more of these tumors mav groAV together and not differ materially in their size and form. Symptons.—Since they have no necessary connection with the cavity of the uterus, neither Avith its mucous membrane, nor indeed with the generative intestine in any Avay, the disorders of menstruation Avhich are almost invariably present in the case of sub-mucous fibroids, are lacking in the sub-peritoneal variety. There is no especial liability to haemorrhage, or to serous dis- charges from the uterine cavity. The haemorrhage that accompanies this form of fibroids is in proportion Avith the breadth of the attachment of the tumor. The longer and more narroAv the pedicle the more decided is the exemption from menorrhagia. It is because these sub-peritoneal tumors usually begin as sessile growths and gradually become pedunculated that the monthly haemorrhage in these cases is apt to diminish and finally disappear as time goes on. When this symptom continues, in case the tumor has a slender neck and is freely movable, then there may be good reason to suspect that other groAvths of the same kind have begun to develop upon the surface of the uterus. Here is a Avet specimen in Avhich you will find that there are thirteen of these extra-uterine fibroids of various sizes, Avith a varying breadth of attachment, upon a single uterus. The symptoms are, hoAvever, chiefly mechanical. Small tumors of this kind occasion very little inconvenience, and may exist for years Avithout symptoms. Larger ones drop Chiefly mechanical. ^ ^ ^^.^i^ spacG) gainst the bladder anteriorly, or press laterally in such a way as to cause pain Avith- in the pelvis or in the corresponding hip and thigh. If it becomes pedunculated, as it frequently does, the length of the pedicle may permit the tumor to float, as it Avere, and to change its position with reference to the pelvic organs, so as not permanently to dis- place the uterus. But, Avhen ttiere is no pedicle, and the groAvth has a broad base, the womb is almost certain to be dislocated and more or less fixed in an unnatural position. 'Pressure on the bladder, even without co-existing anteflexion, may become so considerable as to compress it betAveen the sym- 1050 THE DISEASES OF WOMEN. physis and the tumor, giving rise, in consequence, to second- ary phenomena in the uro-poietic system. The hypersemia of the pelvic blood vessels, occasioned by fibroid tumors, is frequently manifested in the mucous membrane of the bladder as a varicose distention of its veins, especially of those situated at the neck of the bladder; and Rokitansky even observed a case of rupture of a submucous cystic vein, Avith haemorrhage into the bladder. Thomson relates a case in which a perforation occurred in the Avail of the above organ from pressure of a large fibroid tumor, Avith adhesion of half of the periphery of the tumor to the borders of said per- foration. " On the other side pressure affects the rectum, and defecation may be completely prevented by fibroids impacted in Douglas' space. They may also cause varicose distention of the liaemor- rhoidal veins, and hyperaemia of the rectal mucous membrane in the same Avay as in that of the bladder."* Hypostatic hyperaemia, or engorgement, of the utero-Aaginal mucous membrane is a very common result of the pressure from these tumors. And hence they are likely to be Coincident disorders. 1 . attended, not only Avith uterine deviations, but with a coincident cervicitis, endo-cervicitis, endo-metritis, and vaginitis. Such local derangements of the circulation sometimes find vent in a critical haemorrhage Avhich is inter-periodic, and sometimes (though rarely in this form of fibroid) in copious or prolonged menstruation. In these extra-mural fibroids there is a marked and character- istic tendency to peritoneal inflammation. In many cases this lesion is latent and circumscribed, and as a con- Liability to peritonitis. sequence adhesions are formed Avhich glue the tumor more or less firmly and generally to the neighboring parts or organs. At other times patients suffer from acute lancinating pains, are sick a feAV days, Avith a sharp attack of peritonitis, and then recover. All the suffering and all the sequelae, however, are usually, but improperly, referred to the tumor itself. These are the adhesions which are encountered on section in gastrotomy. Diagnosis. — The frequency with which this class of fibroids is * Pathological Anatomy of the Female Sexual Organs, by Julius M. Klob, M D etc N. Y. 1868. p. 175. SUB-PERITONEAL FIBROIDS. 1051 located at the posterior cul-de-sac increases the liability of their being mistaken for retroversion or retroflexion r.?ro°fl,e1xioent.roversion and of the womb. But the physical signs will enable you to distinguish them. Perhaps the "touch" reveals a tumor Avhich lies in the IioUoav of the sacrum, but it alone is insufficient as a means of diagnosis. The bi-manual examination Avill help you to decide A\diether the upper and ante- rior portions of the uterus are enlarged or the seat of an abnormal groAvth. But it will not serve to differentiate betAveen a fibroid tumor in the posterior part of the pelvis and a retroverted or retroflexed uterus. To settle this question, therefore, Ave must pass the uterine sound. If the point of the instrument looks toAvards the superior strait, as it should, Avhen it has reached the fundus, the tumor is a fibroid, and the uterus is not displaced backAvards. I should not forget to remind you, however, that, in certain cases, these two disorders co-exist. Having already detailed the signs by Avhich you Avould diagnos- ticate an extra-uterine fibroid from an ovarian From ovarian dropsy. tumor or cyst, it is unnecessary to repeat my remarks upon that subject. So much depends upon the length and size of the pedicle in these cases that it is difficult to establish a rule of diagnosis betAveen this form of fibroids and pregnancy. The uterus Avill be increased in its dimensions if the pedicle is short, and if the Avomb should groAV and develop, the presumptive signs of pregnancy Avill be all the more promi- nent. There is, hoAvever, some considerable difference in the form and general character of the abdominal tumor in the two cases. In fibroids, if there is more than one, the outline of each can be recognized through the abdominal parietes. If these Avails are thin, and not inordinately deA^eloped, the fibroid is felt to be a hard, firm, resistant mass, Avhich imparts an entirely different sen- sation to the fingers from that of the elastic fluctuating sensation of the gravid uterus. Sometimes it is possible to feel the rounded, knob-like masses caused by smaller fibroids Avhich are attached to the exterior of the uterus. The uterine souffle will be very similar in both; but the possi- bility of hearing the fcetal heart-sounds Avill sometimes enable 1032 TEE DISEASES OF WOMEN. you to decide betAveen them. In fibroids the tumor deArelops very sloAvly, Avhile in pregnancy the relative rapidity of its growth is much more marked. By Avithholding an opinion for a few Aveeks you may sometimes be able to settle the question of diagnosis very positively, on account of the size of the tumor having very much increased meamvhile, providing she is pregnant. Unmistakable quickening would also be diagnostic, but it must be real and not imaginary. In the later months, the condition of the os and cervix uteri, the more or less regular return of the menstrual Aoav, the inability to feel the movements of the foetus, the depth of the uterus as disclosed by the sound (Avhich should not be passed if the signs of pregnancy are at all prominent, or unless in very extreme cases), will generally enable you to determine the diagnosis cor- rectly. Time is, hoAvever, an important element in this respect. It may require that you make seA^eral examinations before your final decision is given. If so, and the patient is not in extremis, it Avill be Avell to alloAV the intervals betAveen these several exam- inations to be someAvhat prolonged. When pregnancy occurs in the case of a woman who already has one of these sub-serous fibroids, it is more likely to extend to term Avithout accident than in case of the sub-mucous abon'o?6 immunity from tumors of which I have spoken, probably for the reason that in the former the uterine cavity and its mucous membrane are nearly or quite normal. In these fibroids the previous history of the case; the absence of grave constitutional symptoms, chill, fever, and a tendency to suppuration ; the fact that the tumor has been From pelvic cellulitis. groAvmg for months or years, and has no neces- sary connection Avith parturition, Avhether premature or not; neither Avith any traumatic or surgical injury; Avould serve to distinguish this affection from pelvic cellulitis. Add to this that in cellulitis the uterus is almost ahvays fixed and immovable, Avhile in fibroids it is not so, and you can have no difficulty. The tumor that is sometimes formed by impaction of the faeces is in no manner connected Avith the uterus, is posterior to it, does From impaction of the not move Avith it, is doughy to the feel and can be indented on pressure, is accompanied by symptoms of paralysis of the rectum, obstinate constipation, rec- tai tenesmus, and more or less of intestinal irritation. SUB-PERITONEAL FIBROIDS. 1053 Course and Termination. — Having free space, Avithin the pelvis at first, and then Avithin the abdomen, in Avhich to grow, these tumors mav reach a considerable size, and exist Toleration of. - in a dormant state for years before they are observed or detected. And being, in most cases, unaccompanied by alarming or dangerous symptoms, harmless in themselves, and benign in their tendencies, their presence may be tolerated for many years more. Extra-uterine fibroids tend to develop into fibro-cysts, such as you saAv in the case of Mrs. C. D----, in this clinic, some Aveeks ago This cystic degeneration is one in Avhich Cystic degeneration. " . i • i _/» the tumor becomes composite, and instead of being made up exclusively of fibro-cellular tissue, as it was origi- nally, is composed of compartments, or cysts, Avhich contain a quantity of serum, blood, or pus, or of all these commingled. It is only in case of the larger fibroids that this particular degeneration takes place ; and you should remember that, although it is by no means very frequent in the sub-peritoneal fibroids, yet it is much more rarely met Avith in either of the other varieties of this dis- ease. Prognosis. — Concerning ultimate recovery from this kind of a fibroid you had better promise nothing. Nature may extemporise a means of palliation and relief, through an Nature's attempts to cure. . ,, " - ,, ., arrest of the development of the tumor, or even amputate it spontaneously by attenuation or rupture of its pedicle, so that it shall float around like a loose cartilage in the knee-joint, causing little pain or inconvenience; but it is not probable that she will remove it entirely. Pregnancy is not so serious a com- plication in extra- as it is in intra-uterine fibroids. Although such a tumor may possibly co-exist with carcinoma uteri, yet it is a settled fact that uterine No risk of cancer. fibroids have no malignant tendencies, and do not, therefore, develop into cancer. Treatment. — Physicians are agreed that, more especially in the early stages of these groAvths, internal medica- shon-comings of internal ^on s]Wyld suffice for their removal and cure. treatment. , , •■ . But to say that it ever has cured them is to claim too much for our skill. In the present state of our knowledge, the 1051 THE DISEASES OF WOMEN. most that avc can expect to accomplish Avith our remedies is the relief of contingent disorders and complications. And Avhether we shall ever improve upon this is largely a matter of "faith and Avorks." If these tumors result from a simple hypertrophy of tissue, the resolvent poAvers of our medicines, locally and inter- nally used, should be sufficient to arrest their development, if not indeed to cure them radically. Perhaps in the future Ave may be more successful Avith these means than Ave have been in the past. One grand difficulty in the Avay of this result, hoAvever, is the impossibility of placing such patients under proper treatment in the early staire of the disease, Avhen the tumor Reasons therefor. ...... or tumors are m their mcipiency, and Avhen specific means avouIcI act more promptly and perhaps successfully. Another is that the differential diagnosis is so difficult; and a third, that Icav Avomen Avith these adventitious groAvths, or Avith uterine tumors of any kind (especially in these days of prize-surgery), are Avilling to take sufficient time to test the merits of internal treatment. The only surgical resource in case of the extra-uterine fibroid is gastrotomy. If the tumor has a Avell-detined pedicle, and its at- tachments are not very extensive or vascular, Surgical treatment. ' it may be removed, and the pedicle ligated, as in ovariotomy. A similar operation may suffice in case its stem or stalk is broken, and it is floating in the ab- Gastrotomy. . . ° dommal cavity. But, even after the abdominal incision has been made, if it is found that the groAvth is glued on all sides, and thoroughly amalgamated with the uterus and the neighboring parts, it is thought to be best to relinquish the oper- ation, to close up the Avound and alloAv the tumor to remain. This course is deemed proper because of the danger that Avould almost necessarily folloAv from the final extirpation of the groAvth under such adverse circumstances. These dangers include the possi- bility of the shock or collapse, haemorrhage, fatal peritonitis and septicaemia. Hysterectomy, or the removal of the uterus itself, either wholly or in part, has sometimes been successfully practised for the rad- ical cure for these fibroids. I have already described Avhat is knoAvn as Freund's operation (page 705), and the more recent SUB-PERITONEAL FIBROIDS. 1055 method of ablation devised by Dr. Lane (page 706). You will find that, although this operation, like that of JfHptahtion(,ttbeute'ovariotomvwas almost always fatal a few years rus and the ovaries. " J •' ago, its statistics are much more favorable noAV. During thirteen years ending Avith the first of January, 1878, Pean, of Paris, performed hysterectomy 21 times, Avith 16 recoveries and 8 deaths, or Avith a loss of one third of his cases.* I knoAV of no one in America avIio has had a more remarkable experience in the operation for the removal of the uterus than my ofood friend Dr. C. Ormes, of Jamestown, NeAV Dr. Ormes' cases of york> y m find [t detailed jn the Clinique uterine extirpation. L for May 15, 1881, from Avhich paper avc gather that out of five cases, three were folloAved by complete recovery. In one ot these cases he reports that ten years after the operation the woman Avas Avell and hearty. In one of his fatal cases the fibroma was complicated with a colloid tumor ot the ovaries, the Avhole mass weighing 51 pounds, the patient's Aveight in health being only 93 pounds. *Lecons de Clinique Chirurgicale, etc., par M. le Dr. Pean, etc., Paris, 1879, page 832. LECTURE LXIV. FIBROID TUMORS OF THE UTERUS.—(CONTINUED.) 3. Interstitial Fibroids. Symptoms. Dysmenorrhcea, menorrhapria, abortion, sterility. Diagnosis. The tenaculum, the sound and dilatation. Treatment, medical and sur- gical. Trillin»in menorrhagia from fibromata. Case.—Uterine polypi. Case.—Pathology and treatment of. Having discussed the special pathology and treatment of those fibroids which are denominated intra-uteniie and extra-uterine, we iioav come to speak of such as are located Avithin the Avail of the Avomb, midAvay between its mucous and serous coats. These tumors, Avhich are not in the uterine, nor yet in the abdominal cavity, are commonly knoavii as 3.--INTERSTITIAL FIBROIDS. They also have various synonyms such as intra-mural, intra- stromal, parietal, and intermediate. These are the round tumors proper, for no matter what their size, unless they are forced into the uterine or the abdominal cavity, and thereby become oval or perhaps pedunculated, their shape is unchanged. They are al- ways enclosed Avithin a proper capsule, and, like the other varieties, are most frequently located posteriorly Avith reference to the Avomb. In very rare cases they are met Avith at the loAver segment ot the uterus, and even in the cervix. But, wherever they are found, the neighboring portion of the womb is hypertrophied, and all of its tissues are preternaturally developed. Symptoms.—The symptoms are more or less grave and trouble- some accordino- to the size of the tumor and the tendency to inflammation Avithin or about the Avomb If Uterine deviations. , the groAvth is large, and fixed in the posterior Avail of the uterus, that organ Avill necessarily be displaced pos- teriorly. For this reason retroversion and retroflexion are almost invariably present in these cases. But if the tumor is attached to the side of the Avomb, the latter will, of course, be draoo-ed, or made to incline laterally. 1056. FIBROID TUMORS OF THE UTERUS. 1057 In a considerable proportion of cases there is dysmenorrhcea. The difficulty of menstruation is clue either to the partial closure Dysmenorrhcea. or the tortu°sity of the cervico-uterine canal, which is caused by the flexion of the uterus and the presence of the tumor; or to the fact that this foreign body almost necessarily excites painful contractions of the Avomb Avhenever anything is to be extruded. In other cases, I think there can be no question that the obstruc- tion to the ready exit of the flow in dysmenorrhcea may indirectly cause such a tumor to be developed. It is reasonable to suppose that such a derangement in the uterine circulation as almost necessarily accompanies very painful and tardy menstruation, would beget a vice of nutrition that might result in local hypertrophy. And thus, in exceptional cases, it might be very difficult, and perhaps impossible, to determine Avhether the dysmenorrhcea Avas the cause or the consequence of the interstitial deposit. On account of their nearness to and intimate relations Avith the uterine mucous membrane, there is almost as great a liability to . . menorrhagia in the interstitial as in the sub- Menorrhagia. ° ■*>«" mucous fibroid. The menstrual discharge is always too free, and the return of the periods is apt to be more frequent than natural. In many cases the flow is prolonged and continuous, the blood oozing away constantly. Or the haemor- rhage may be sudden and alarming, accompanied by violent pains and contractions like those of labor. Not unfrequently this condition of things is mistaken for abortion, more especially if shreds of membrane and coagula are expelled. The tendency to abortion is somewhat less marked than it is in the case of intra-uterine fibroids, but this accident occurs more ., . frequently in this than in the extra-uterine Abortion. . variety. We can account for this clinical fact upon the theory that this adventitious groAvth diverts the nutri- tive supplies which are needed by the developing embryo. Perhaps a better explanation is that the tumor, or fibroid, excites such peristaltic contractions as are likely to empty the womb of its contents. The unequal development of the uterine wall is not Avithout its influence also. I have noAV under treatment tAvo cases of sterility, which are due to the presence of parietal fibroids. In both of them the 1058 THE DISEASES OF WOMEN. growths are so situated as to cause violent dysmenorrhcea, and so decided a retro-flexion of the Avomb as ab- solutely to prevent the ingress of the semen masculinum. Under these circumstances insemination is impos- sible. In order to cure these women it will be necessary to remedy the displacement. But if conception were attained, they would almost certainly abort afterAvards, unless the fibroid had been disposed of. Other incidental disorders are endometritis, cervicitis, leucorr- hcea, cystitis, proctitis, rectal ulceration and paralysis, inveterate .constipation, haemorrhoids, pelvic cellulitis, and pelvi-peritonitis. Diagnosis. — In separating these from other foreign groAvths Ave rare obliged to depend mainly upon physical signs. Examination is to be made with the finger per vaginam, and per rectum, and with instruments also, of the cervical and uterine cavities. The tumor must first be located, and afterAvards identified. These .steps are less difficult, perhaps, than in other fibroids, because inmost •cases the tumor is pelvic and not abdominal, and because it is so located in the hollow of the sacrum as to be more accessible. The bi-manual method facilitates the examination by the "' touch." The patient should be placed upon her back, the limbs flexed, and the abdominal parietes relax- ^ The bi-manual examina- e(j. ^he left hand is then to be placed upon the hypogastrium and pressure made upon the uterus over the pubes, so as to cause it to descend as far as pos- sible into the excavation, toward the ostium vaginae ; the index finger of the right hand being at the same time within the vagina, or the rectum, is made to explore the lateral Depressing the uterus. . /.,-.■,. and posterior surfaces ot the Avomb in such a manner as to recognize any increased or abnormal development of its wall. Or, if the woman is corpulent, it may be necessary to draw doAvn the uterus with a Sims' or Nott's tenacu- T"he uterine tenaculum. . .. . mm, in order to examine it more thoroughly fhrongh the retro-uterine space. The probe may suffice to indicate the presence of a tumor which presses toAvards the uterine cavity : but The sound. . x . . J in generat it wil 1 not diagnosticate an intra-mural ifibroid, excepting upon the principle of exclusion. Thus, if the FIBROID TUMORS OF THE UTERUS. 1059 sound is passed without difficulty or obstruction, and takes the direc- tion of the proper uterine axis, the inference is that, if there is a fib- roid in the Avail of the womb, it cannot be of any considerable size. For one of these tumors must almost necessarily displace the organ. A sub-peritoneal growth Avith a pedicle might fill the hollow of the sacrum without changing the axis of the womb, but not so with an interstitial fibroid. HoAvever, if you can not satisfy yourselves of the existence of an intra-mural tumor, by the conjoined methods of Avhich I have spoken, it will be necessary to proceed to clila- Dilatation. r . . J r tation, in order to be able to explore the cavity of the womb with the finger or other instrument. This may be done in the manner indicated in my last lecture. It should be done cautiously, however, lest you induce a severe haemorrhage. The differential signs between an interstitial fibroid and pelvic cellulitis, pelvi-peritonitis, and kindred affections, with Avhich it is sometimes complicated, and for which it has been mistaken, are the same as those by which you Avould distinguish these dis- eases and other sequelae from sub-mucous and sub-serous fibroids. Prognosis. — My own experience leads me to conclude that this variety of the myo-hbromata is more amenable to treatment than either of the others. Unless it be excessively developed, or attended by unusual haemorrhage, or other dangerous complications, from which this class of fibroids is not exempted, you should not despair of curing your patient. A favorable change is likely to folio av the menopause. This crisis once passed, the chances are that with the subsequent atrophy, or senile involution of the uterus and influence of the change ^e ovaries, such a growth may also undergo a retrograde metamorphosis, and never occasion any more trouble. Sometimes, however, these fibroids cause the climacteric to be delayed, and the menstrual flux to be substi- tuted by prolonged and dangerous haemorrhages, which have a fatal tendency. In bad cases, where the cervix is long and narrow, as well as dense and undilatable. occurring in Avomen who The condition of the have never been pregnant, the prognosis is generally unfavorable. Indeed, the texture, consistency and other physical characters of the neck of the 1060 THE DISEASES OF WOMEN. womb, have more to do than almost anything else with the possi- bility and probability of cure, whether by surgical or medical means. Other things equal, multiparae are more likely to recover than nulliparae. While the fatty, calcareous, cartilaginous, and even the osseous degenerations which these fibroids sometimes undergo, are to be considered as salutary in their tendencies, other various forms of degen- varieties of textural change may imply increased eration. ° " x " danger. Suppuration, sloughing, oedema, and interstitial haemorrhage are critical processes that will cause you the greatest anxiety, and which you will learn are beset with. extreme peril. The spontaneous enucleation of the tumor is alto- gether favorable. An evident inclination in the fibroid to develop in the direction of the uterine cavity, and especially to become pedunculated, is not of necessity a bad sign, for it may facilitate its removal by surgical means, or otherAvise. When complicated Avith other diseases, the danger varies Avith the grade and character of the contingent disorder. In women of a haemorrhagic diathesis the chances of recovery are not the most promising. Treatment. — I am aware that there is a sort of histological difference between a simple hypertrophy of the uterine wall and an interstitial fibroid ensconced in its capsule. Curable in their incipi- gu^ ^jg difference is more apparent than real. ency. ■"• x The early clinical history of these fibroids is so closely related and allied to those changes which take place within the same tissues during utero-gestation, and their post- partum involution, as to convey a therapeutical hint which prom- ises to be of especial service. And I am persuaded, as the result of experience, that, in their early stages, these tumors are often curable by the use of internal remedies conjoined Avith very simple local means. It is therefore a most fortunate circumstance that these pari- etal fibroids are more likely to be recognized, and to come under our care at an earlier period of their existence than either of the other varieties of this affection. It is for this as well as for diagnostic reasons, that I have chosen to treat of them separately. Manifestly, the first duty of the practitioner is, if possible, to FIBROID TUMORS OF THE UTERUS. 1061 prevent their recurrence. This may sometimes be accomplished through the adoption of means that are calcu- Prophylaxis. lated to ensure the complete and uniform \nvo- lution of the uterus after delivery ; the free and ready exit of the menstrual flow; to prevent such habitual or permanent deAiations of the womb, particularly retroA*ersion and retroflexion, as would result in its disproportionate development; the prevention of abortion, and its consequent arrest of the organic changes proper to pregnancy; the interdiction of intemperate and fraudulent intercourse; and of the wearing of pessaries, stays, abdominal supporters, and of Avhatever might interfere with a free and unin- terrupted distribution of blood through the pelvic and abdominal viscera. This preventiA'e treatment is very important. And so likewise is the medicinal treatment. The haemorrhage and the serous discharges, as well as the symptoms Avhich are attendant upon the local inflammation and the Medicinal treatment. . menstrual disorder, afford a series ot definite indications for our remedies. We make requisition upon the materia medica for secale cornutum, sabina, sepia, belladonna, lachesis, crocus, calcarea carb., staphisagria, arsenicum alb., sili- cea, phosphorus, lycopodium, china, thuja, carbo vegetabilis, sul- phur, or nitric acid. One of these is given upon specific indica- tions— which should be as definite and accurate as possible — and its use is persisted in until the symptoms for which it Avas pre- scribed have disappeared. Then another may be chosen. 1 could detail a number of cases in Avhich the careful and per- sistent employment of belladonna has removed a limited hypertrophy of the Avonib Avhich, but for it, would undoubtedly have developed into a fibroid. It was given in the third decimal attenuation. Lachesis is equally efficacious in certain cases. It seems pos- sessed of remarkable virtues as a resolvent, particularly Avhere there is a defective inA'olution of the Avomb. I am not aAvare that any author has mentioned this fact, and you will therefore take my individual estimate of its \ralue for no more than it is Avorth. No class of facts needs such abundant confirmation as those AAdiich are clinical. In my hands the best effects have been derived from lachesis in the sixth and the twelfth attenuations. 1062 THE DISEASES OF WOMEN. In claiming that these tumors are curable in their incipiency by means that are so mild and available, I do not forget that there are many sources of fallacy which might lead to Sources of fallacy. * . ,. ,, », n a wrong inference respecting the efficacy ot 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 Avay. The climacteric may arrest their development; and other changes may cut off their nutrition and cause them to Avither. 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 clue alloAvance 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- T , erine, or with glycerine containing- a few Local means. in drops of the strong tincture of calendula, of hamamelis, hyclrastis, 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 r , . incisions into the tumor and through its cap- Lnucleation. or sule, from the interior surface of 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- Avhile to aA-oid pyaemia 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 ot 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 Bioavii's plan of coring or "gouging" out a piece from the middle of the tumor and filling- the Drs. Atlee's and •, -xii .1^,11 i 1 '^ ■,■ Brown's operations. cavity Avith lint that had been dipped in olive- 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 uten, both on account of the J.i a. haemorrhage that may folloAv, and of directly Danger in dilatation. J ' -T fatal results, that the greatest possible care is requisite in the preparation of the patient for the removal of the tumor. Dr. Thomas reports tAvo cases of sudden death from the use of the sponge-tent preparatory to enucleation, and sums up the dangers of this Avhole 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 Avill in all proba- bility fail. The prospect of success is, for these reasons, much better in multiparous than in nulliparous Avomen."* 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 loAver part of the abdomen eight years ago. This tumor greAv slowly, Was not sensitive, was larger at the month than directly after the flow, and finally caused symp- toms of prolapse of the Avomb Avhen she was 011 her feet. When she first came to the Clinic she Avas very Aveak from the loss of blood, from an impaired digestion, improper nutrition, and from a depressed mental condition. At one time 111 the early history of the case, and Avithout any apparent cause the menses Avere 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,pag-e 103. 1061 THE DISEASES OF WOMEN. of trillin with the effect to dispose of the menorrhagia, to remove all of the symptoms that Avere 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. MeaiiAvhile, hoAvever, the growth of the neoplasm has extended to the neck of the Avomb, 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 Avhich are almost always present in cases of interstitial and intra-uterine fibroids. For like secale it is of little effect in uterine haemorrhage unless from pregnancy or otherAvise 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. AV. C. Barker, of AVaukegan, it not only con- trolled the alarming haemorrhage but it also relieved a severe neuralgia, and put an end to a tedious and harrassing cough that had worried and Aveakened 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 Avhich 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 iioav. She a'lso complained ot a full pressing headache which \yas worse at the monthly cycle, although the flow did not appear. She had taken various remedies to torce the Aoav but Avithout the least effect. An examination of the os uteri in the field of the speculum showed that it Avas plugged Avith a polypus, Avhich Avas examined by the class, and then carefully tAvisted off in their presence by the use of a Sims' polypus forceps. The next Aveek she reported that the monthly Aoav folloAved directly after the removal of the growth; that it Avas normal in quantity, quality, and duration; and that with its advent all of her pelvic distress and headache had disappeared. This Avas a small mucous polypus that Avas attached, as most of Mucous polypi. them are' within the canal of the cervix, about the internal os uteri. From being very vascu- lar, these mucous growths are sometimes styled sanguineous; UTERINE POLYPI. 10G5 and, Avhen 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 Avithin the uterine cavity, as well as in the canal of the cervix, Avhere they sometimes exist in considerable numbers. (Fig. 208). FtG 203. Multiple mucous polypi. (Beigel). It is Avell to remember that, Avhether single or multiple, these polypi may not only give rise to copious hemorrhage at the month, but that they may and do sometimes cause the most in- tractable form of uterine leucorrhcea. So that, as in the case Avhich you have just seen, a polypus may cause Common characteris- . i • •- ,.r „.„_.,i,,,,„ ticsoruiennepo.vpi. :l menstrual suppression, or it may produce either menorrhagia, metiorrhagia, or a leucor- rhcea. This is true of each and all the varieties of uterine polypi, whether they are mucous, cellular, glandular, or fibrous in their character. AATien these bodies are accessible to the touch, and can be brought into the field of the speculum, their Diagnosis. ,. '.. t n. 1 -r» 1 1 i- diagnosis is not difficult. But Avhen they lie above the internal os, before the cervix has been developed by their presence or pressure, avc need to explore for them, and to dilate the neck of the womb so that avc may find them. For this purpose Ave begin with a sponge-tent, or a Nott's dilator 10G6 UTERINE POLYPI. (Fig. 22), or Atlee's dilator (Fig. 24), and, if necessary, folloAv it up Avith the careful use of Hunter's uterine dilator (Fig. <>2), 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, Avithout really drag- ging it down, and to be more readily accessible. Fig.ZIU. Forceps for uterine polypi. AA'hen the growth is reached the question of its removal may be decided upon. If it is not very large or Treatment. . l J f fibrous, it may be tAvisted Avith 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 (Fio-s. 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 Avithout pain or hemorrhage. But if the polypus is too firm in its texture to be taken in this way, UTERINE POLYPI. 1007 it may be drawn down with a volsellum, and snared with a wire through Gooch's old canula (Fig. 212), or by means of a wire ecraseur, of which the curved ones are the best. (Fig. 213). Fig. 212. Gooch's canula. Fig. 213. Wire ecraseur 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. 211.; 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. 2. helonias in, 110. menses should not be forced, 111. spasmodic dysmenorrnoea inci- dent in, 111. the diet in, 112. exercise and travel in, 112. Chorea during pregnancy, 318. may arise lrom 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 leucorrhcea, 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 leucorrhcea a symptom in, 456. varying character of the flow in, 456 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, 404. 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, 50©. 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, 506. remedies for 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 and 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 haemorrhagic 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- orrhcea, 227. hints in treatment of pelviocellu- litis, 402. Clysmic spring Avater, 5S3. Coccyodynia and irritable uterus. 687. Colocynth in ovarian neuralgia, 765. pelvi-peritonitis, 3o0. Colic Fallopian, 1021. Collodion oleaginous, formula, G53. Combined touch in uterine flexions, 027. Congenital defects cause of delayed 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. Copraemic 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. 5(50. varieties of, 561. pathognomonic signs in, 561. treatment for, 561. operation for, 562. Huguier's, 563. Jobert's, 563. Vidal's 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 haematocele, 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- terna, 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 dysmenorrhcea, 215. Diphtheritic ulceration of the os uteri, 663. constitutionahsym'ptoms 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 pelvi-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 Dysmenorrhcea, 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. Elytroplastv for vesico-vaginal fls- tuhe, 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 amenorrhcea, 124. Encysted peritoneal dropsy, diagno- sis of, 935. 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 amenorrhcea. 169. inter-menstrual, 170. non-sexual causes of, 171. prognosis in, 172. treatment of, 173. belladonna in, 174. nux vomica in, 174. hyoscyamus 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-perineorrhaphv, operation of, 618. Episiorrhaphv for vesico-vaginal fis- tulas, 887. Epithelioma of the uterus, 70S. 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, 713. qualifying indications for remov- al of, 721. local treatment for. 722. Ergot in sub-involution, 358. Eruption, in dysmenorrhcea, 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 haematocele, 420. Excoriated nipples, 480. most frequent in primiparae, 481. local and general causes of, 481. symptoms of, 481. may become ulcerated, 4S2. may result in abscess, 483. treatment of, 483. 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 endo-metritis and mem- branous dysmenorrhcea. 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. FAHNESTOCK. 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 menorrhagia, 265. trillin in menorrhagia 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 in, • 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. Fistulae, vesico-vaginal, 872. recto-vaginal, 887. the surgical treatment for, 889. Fixity of the uterus m 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, fa23. 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 toucli 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 amenorrhoea, 115. Fothergill, on ovarian dyspepsia.767. Frequency of pelvi-peritonitis in rheumatic subjects, 373. Freund's operation for extirpation of the uterus, 705. p AL ACTORRHCEA, 474. VJ Gastrotomy in fibroids, 1054. Gelsemium in amenorrhcea, 140 menstrual headache, 159. dysmenorrhcea, 215, 217. INDEX. 1077 Gelsemium, membranous dysmenor- rhcea, 246. pelvi-peritonitis, 380. ovaritis, 752. General pathology, 33. Genitals, external, the inspection of, 67. Girlhood, 35. Gonorrhoeal ovaritis, 735. treatment for, 755. and sterility, 749. Goodell's operation for recto-vaginal fistula, 891. Guernsey's elevator in retro-flexion, 634. HAMAMELIS VIRG. in ovaritis, 752, 755. Hammond on arsenic and strychnia m 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 m chlorosis, 110. Haematogehesis and chlorosis, 102. Haematocele, pelvic, diagnosis of, from pelvi-peritonitis, 374. (See Felvic haematocele, 418.) Hemiplegia Avith menorrhagia, 265. hysterical. 810. Haemorrhagic tendency, influence of the, 43. diathesis in pelvic haematocele, 420. ' remedies in, 260. -----,----- Haemorrhage, post-menstrual, 253. post-dysmenorrhoeal, 254. at the climacteric, 254, 502. in uterine cancer, 693. Hereditary amenorrhoea, 100. Hereditary amenorrhoea, 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. DEX. 107S Hysteria, general rules in the treat- ment Of, 807. coincident lesions of the uterus and ovaries in, 808. caused by utero-gastric and utero- 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, vaginal, 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 Iguatiain 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 leucorrhcea, 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 eversion, 74. Inter-menstrual epilepsy, 1-70. Interstitial fibroids of the uterus, 1056. Intestinal resonance, 94. Intra-uterine astringents in menor- 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 fibroid, 643. the crucial test for, 643. prognosis in, 643 treatment of, 644. following abortion, 644. manual treatment of, 614. Tate's vesico-rectal method for reducing, 645. Courty's rectal do., 645. Noeggerath's 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, 5S4. hysteria a factor in, 585. three points in the diagnosis of, 585. treatment of, 5S5. 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 definite lesion, 682. a species of hyperaesthesia, 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, 686, nervous symptoms in, 686. physical examination of, 687. diagnosis of, from coccydynia, 687. from dysmenorrhcea, 688. 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 MA'JORA 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, 86t. 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. prima; y operation for, 898. secondary operation for, 898. freshening process in, 898. closing the Avound 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, 041. treatment for, 641. Leucorrhcea, 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, t>77. local and general causes of 677. constitutional causes of, 678. scrofulosis in, 678. remedies for, 68<>. in uterine cancer, 693. Leucocytosis, 943. Listerism in ovariotomy, 937. and drainage, 9S1. Lithotripsy and vaginal cystotomy, 587. Lithotomy, supra-pubic, by Helmuth, 587. Local svmptoms of pelvic haemato- cele, 423. Ludlam's method of enucleation, 1004. ITACROTIN in pelvi-peritonitis, M 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 haematocele, 433. )EX. 1080 in Medical treatment for vaginismus, 850. and mechanical causes of ovari- tis, 725. Membranous dysmenorrhcea. 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, 23t, 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. conbra-toidications 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 Avith 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. Menorrhoea—cervical epistaxis, 255< i-ts 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 examina' tion in, 258. may persist Avithout 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 hyernorrhagif diathesis in. 260. scrofulous diathesis in, 260. syphilitic diathesis in, 261. ovarian complication in, 261- the exercise mostimportantin the cure of, 261. change of climate may aid the cure of, 271. Menses, should not be forced in chk> 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. haemorrliagio 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, 1H8. intermission common, 269. irregularities in chlorosis, 100. complications in chlorosis, 104. suppression and retention not the same, 117. suppression may be hereditary, IIS. 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. Me suration, 74. Mental state in chlorosis, 101. Mercurius in stomatitis materna 319. viv. in ovaritis, 752. Metritis, acute cervical 437 varieties of. 438. rare in multiparae, 438. the monthly cycle a predisponent Of, 43S. 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, 416. 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. Multiparae effects of parturition in, 56. NAJA in ovarian neuralgia, 765. Narcotics and anti-spasmodics in hysteria, 800. Natrum 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 iu amenor- rhoea, 121. 1082 INDEX. Nervous exhaustion, theory of chlor- osis, 103. and menstrual functions, 270. symptoms at the climacteric, 503. in prolapsus uteri, 608. of irritaole uterus. 686. Neuralgia, menstrual, varieties of,143. cutaneous of pregnancy, 301. symptoms of,'301. unilateral, from prolonged lacta- tion, 496. Neuralgic dysmenorrhcea. 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, 1025. 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 ^unesions in ovarian tumors, 975. Operation for vesico-vaginal fistulae, 880. recto-vaginal fistulae, 887-9. laceration of the perineum, 897. removal of ovarian cysts, 960. Oophorectomy, 1025. Opiates in spasmodic dysmenorrhcea, 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 dysmenorrhcea, 245. irritation and chronic cervical endometritis, 468. tumors during pregnancy, 53. resolution of, 746. Ovarian dysmenorrhcea, atrophy and induration, treatment for, 754. neuralgia, ovaralgia, 756. peculiar predisponents of, 757. the neuralgic diathesis and, 757. rheumatic diathesis and, 758. hysterical diathesis and, 758. organic disease ot 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 .,i. 762. for „ne rheumatic com- plications in, 762. topical, 702. valerianate of zinc in, 764. atropine in, 764. colocynth in, 765. naja in, 7(3-5. ammonium carb in, 765. cimicifuga in, 766. irritation, case of, 766. dyspepsia, by Dr. Fothergill, 767. irritation at the climacteric, 768. a pathognomonic s»ign of, 763. exciting causes of, 769. Dr. Woodward's case of, 769. remedies for, 770. Ovarian dropsy, area of dullness in, 95. diagnosis of, from pelvic haemato- 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 mavity in, 937. rapidity of growth of, 937. difficulty of diagnosis of, from fibro-cystic growths, 941. from enlargement of liver and spleen, 942. Ovario-pectoral sympathies, 120. Ovaritis, 724. INDEX. 1083 Ovaritis and menor-rhagia, 248. chronic, Avith leucorrhcea, 671. the burning pain of, 672. ovulation sometimes a constant cause of, 672. may cause uterine and vaginal catarrh, 673. sub-acute form of. most frequent 724. generally symptomatic. 724. from dysmenorrhcea, 725. from medical and mechanical causes, 725. epidemic form of. 726. peculiar pain in, 727. traumatic, 727. peritoneal form in, 728. vaginal touch in. 730. characteristic pains of, 730. rectal touch in, 731. the "double touch" applied in, 731. prolapse of the ovary and, 730. sometimes produces a feeling of strangulation, 732. vesical symptoms in, 732. and menstrual disorders, 733. and menorrhagia, 734. gonorrhoeal, 735. pathological anatomy of, 738. the lesion of, varies, 738. the discoloration and clot in, 739. haemorrhage into the ovary from, 740. dropsy as a sequel of, 740. is liable to terminate in suppura- tion. 741. character of the pus in, 741. extemporized outlets for pus in, 742. variolus, 744. diagnosis of, 744. characteristic symptoms of. 744. danger of. after abortion, 745. as a contingent of lving-in, 745. danger from suppuration in, 745. Kiswiscb says of, and pelvic tu- mors, 746. and ovarian tumors, 746. drain from excessive discharge following suppuration in, 747. consequence of structural change from, 747. menstrual sequelae incident to, 747. may implicate the uterine mucous membrane, 748. sterility from, 748. gonorrhoed, and sterility, 749. may induce nymphomania,750. general treatment of, 750. belladonna in, 751. colocynth in, 751. Ovaritis, veratrum viride in, 752. mercurius vivus in, 752. hamamelis virg. in, 752, 755. gelsemium in. 753. lachesis in,752. bryonia alb. in, 752. gonorrhoea], treatment for, 755. calendula in. 755. puerperal, 755. arnica and aconite in, 756. proscribe sexual intercourse in, 756. Ovarian tumors, 905, varieties of, 905. cysts, normal anatomy of, 905. cysts, contents of, 906. cysts, clinical history of, 909. cysts, physical signs in, 910. cysts, dermoid, morbid anatomy of, 912. cysts, dermoid, diagnosis of, 914. fibroids, clinical history of, 915. fibroids, laparotomy in, 917. malignant tumors, 918. cysto-sarcoma, 918. cysto-sarcoma, aspiration in, 922. cysto-sarcoma, case of, 923. cysto-carcinoma, 925. cysto-carcinoma, clinical history of, 925. schirrhus, history and symptoms of, 926. colloid, or myxoma, 926. colloid, not always cancerous, 926. papilloma, and epithelioma, 927. cauliflower degeneration, 927. cauliflower degeneration, case of, 928. eucephaloid, case of, 930. Ovariotomy, abdominal, 960. suitable cases for, 961. early indications for, 961. immediate indications for, 962. contra-indications for, 963. double, case of, 964. , preparatory treatment, 966. asepsis and anti-septics in, 967. day and season for, 968. anaesthesia in, 970. instruments for, 971. preparing the patient for. 972. ' opening the peritoneum, 973. the adhesions in, 975. steps of the operation, 970. treatment of the pedicle, 977. peritoneal toilet in, 980. drainage in, 981. after-treatment of, 985. importance of, 985. temperature of the room, 986. 1084 INDEX. Ovariotomy, after-treatment, 985. shock and reaction, 986. pain and restlessness, 986. the pulse, 986. the clinical thermometer, 987. nausea and vomiting, 990. sepsis and peritonitis, 991. gastric and enteric ulceration, 991. the urine, 993. salines in peritonitis, 994. care of the drainage tube, 995. dressing of the wound, 995. Reopening of the wound, 996. secondary haemorrhage in, 996. contingent affections, 998. results in, 1000. by enucleation, 1003. Miner's method of, 1003. Ludlam's method of, 1004. by partial inucleation, 1009. vaginal, 1013. Ovary, prolapse of the. 728, 730. ar excellence the organ of men- struation, 732. Ovulation sometimes the cause of ovaritis, 672. PAGE, Dr. M. F. on gelsemium in dysmenorrhcea, 215. veratrum vir. in dysmenorrhcea, 215. Pain and discharge in epithelioma of the uterus. 712. Palpation, abdominal, 75. vaginal, 75. Paralysis and procidentia uteri, 607. Parturition, 55. effects of, on the nervous svstem, 55. in primiparae. 55. effects of, in multiparae. 56. traumatic lesions during, 56. Pathognomonic signs of vesico-vagi- nal fistulae. 874. Pectoral complications of amenor- rhcea, 124. Pedicle, treatment of, in ovariotomy, 977. Pelvic cellulitis, 4v». 385. synonyms of, 386. frequency of. 387. four stages of, 387 intra-pelvic pain in, 388. formation of the tumor in. 388. location of the tumor in. 389. symptoms of second stage, or the effusion in, 385. incidental symptoms of, 389. the third stage may be wanting in, 390. Pelvic cellulitis, conditions that pro- mote resolution in, 390. fourth, or suppurative stage of, 390. accompanying hectic of, 391. seat of fluctuation in the tumor of, 391. diagnosis of the presence of pus in. 391. varied means of escape for pus in the tumor of, 392. essential nature of, 392. is probably allied to erysipelas, 392. one of the contingencies of lying- in, 392. is a sequel to dystocia, 393. a contingent of uterine surgery, 393. may be complicated with other diseases, 393. diagnosis of, sometimes difficult. 394. diagnosis of, from pelvi-peritoni- tis, 394. and pelvi-peritonitis mav co-ex- ist, 396. and pelvic haematocele, 396. diagnosis of, from uterine fibroids 396. sequelae of. 397. prognosis of, 397. epidemic, tendency of. 398. traumatic causes of, 399. in paludal districts. 400. prognosis of. will vary according to the complicating disease, 400. the complicating lesions of, 400. a new version of an old fact con- cerning, 401. condition of the menstrual func- tion in, 401. sometimes accompanied by men- orrhagia, 402. and the treatment to which the patient has been subjected, 402. a clinical hint in the treatment of, 402. usually the result of pyaemia in the puerperal state, 403. may be complicated with abscess of the broad ligament, 403. may be associated with vesical lesions, 404. and the dyscrasia upon which it has been engrafted. 404. and the cancerous cachexia, 405. and pelvi-peritonitis usually fol- lowed by tuberculosis, 405. treatment of, 409. pathological deductions from, 410. INDEX. 1085 Pelvic cellulitis, general indications for the treatment of, 410. aconite in. 411. arnica in, 41*1. belladonna in, 411. veratrum viride in, 411. local adjuvants in, 413. remedies tor the stage of effusion in, 413. | apis mellifica in, 413. demands a good diet, 414. alcohol very beneficial in some cases of, 414. emollients in the treatment of, 416. best treatment for the suppura- tive stage in, 416. how to open the abscess in, 416. after-treatment of, 417. Pelvic Haematocele, 418. definition and varieties of, 418. not constant in its clinical his- tory, 419. causes are predisposing and ex- citing, 419. may arise from sexual excess, 419. influence of age and sexual vigor in the production of, 419. most frequent in the haemorrhagic diathesis, 420. one of the sequelae of pelvic peri- tonitis, 420. pachy-pelvi-peritonitis a predis- ponent of, 420. exciting causes of, 420. may arise from cervical stenosis, 421. source of, 422. local symptoms of. 423. signs of, per vaginam, 423. Voisin's description of formation of the tumor in, 424. fixation of the uterus in, 425. general svmptoms of, 426. the coincident peritonitis in, 426. pain and other symptoms in, 427. the anaemia in, 428. diagnosis of. from pelvic celluli- tis, 428. from uterine fibroids, 428. from ovarian dropsy, 429. from extra-uterine pregnan- cv, 429. from retro-version of the uterus,431. the aspirator and exploring needle in, 431. prognosis in, 431. treatment of, may be palliative, medical and surgical, 432, 433, 435. indications for tapping in, 436. Pelvic haematocele, contra-indica- tions for tapping in, 435. Pelvi-peritonitis, 367. clinical History of, 367. varieties of, 368. symptoms of, 368. different stages of, 368. origin of, 49. stenosis of the cervix and dys- menorrhcea. 201. the pain in, 368. special characteristics of, 368. tympanitis seldom lacking in, 369. facial expression in. 369. the temperature and pulse in, 369. the posture most common in, 369. nausea and vomiting most fre- quent in, 370. and its effects upon the menses, 370. the chill and thirst in, 370. stage of effusion in, 370. three points to be observed in local examination of, 370. fixity of the uterus often follows, 370. the tumor in, 371. menstrual relapses the rule in, 372. tends to digestive and reflex dis- orders, 372. may result from blenorrhagia, 372, causes of, a source of confusion, 372. most frequent in rheumatic pa- tients. 373. diagnosis of, 374. from pelvic cellulitis, S74. from pelvic haematocele, 374. from parenchymatous metri- tis, 374. from abscess of the iliac fossa, 375. prognosis of, 375. in the adhesive variety, 375. in the puerperal and second- ary forms, 276. in tuberculous subjects, 376. treatment of, 376. importance of rest in cases of, 376. local treatment of, 377. a substitute for opium in, 378. mode of applying hot-water injec- tions in, 379. with induration, treatment for, 379. obviate the constipation in. 379. a clinical hint in cases of. 379. Jousset on general treatment of, 379. aconite in, 380. 1086 INDEX. Pelvi-peritonitis, colocynth in, 380. belladonna and atropine in, 3S0. gelsemium in. 380. bryonia in, 381. apis mellifica in, 381. terebinth in, 38*1. the salicylate of soda in, 381. macrotin in, 382. rheumatic, macrotin in, 382. with spinal myalgia, macrotin in, 382. mental symptoms in, 382. Percussion, posture of the patient during, 95. in uterine tumors. 96. Perineum laceration of, 892. anatomy of the, 893. physiology of, 894. perineorrhaphy, 898. primary and secondary, 898. Tait's method, 902. Peritonitis, pelvic, 367. varieties of, 368. temperature and pulse in, 369. diagnosis of. 374. treatment of, 376. Jousset on the general treatment, of, 379. remedies most useful in. 380, 381, 382. Pessaries in uterine displacements, 596. when indicated in prolapsus uteri, 611. contra-indicated, 244. Phosphorus and calc. phos. in chloro- sis, 109. Physical diagnosis in gynaecology. 66. exploration in obstructive dys- menorrhcea, 212. examination in menorrhagia. 258. signs of epithelial cancer. 715. exploration in diagnosis, 943. Physometra, 830. the tumor in, 831. decomposition of organic matter a cause of, 832. diagnosis of, 832. treatment for, 833. and ovarian dropsy, 942. Position of the patient in using the uterine sound, 89. Post-climacteric affections, 65. dysmenorrhceal haemorrhage, 254. Post-partum ulceration of the womb, 665. likely to be overlooked, 666. a sequel of inflammation, 666. due to an impaired quality of the blood, 667, treatment for, 667. topical applications in, 668. Post-partum-ulceration of the womb, interdiction of coitus in, 669. allowable local treatment irn, 670. Post-puerperal atresia, a cause of dys- menorrhcea, 197. diseases, 353. Post-surgical peritonitis, 202. Predisposing.causes of chronic endo- metritis, 453. of disease at the climacteric, 506. Pregnancy, 45. the physiology of, 45. the diseases caused by, 46. uterine displacements in, 46. irregular development of uterus in, 46. twisting of the womb during. 46. effects of, upon the uterine liga- ments, 47. cervical inflammation and ulcer- ation during, 47. effects of, upon the cervix, 47. changes of the endometrium in, 47. peritoneal changes during, 48. common diseases of, 49. the rheumatism of, 51. disorders of digestion in, 52. of urinary organs in, 52. of pulmonary system in, 52. diseases cured bv, 53. diseases that co-exist with. 53. ' the vis medicatrix of, 53. effects of phthisis upon, 53. influence of, upon coincident dis ease, 53. of, upon ovarian tumors, 53 the uterine tumor in, 94. chlorosis in. 101. diagnosis of, from amenorrhcea, 122. diseases of, 279. differential diagnosis of, 279. uterine obliquities in, 282. changes in the breast in, 282. the foetal heart-sound an unmis- takable sign of, 283. changes in the cervix during, 283. the uterine souffle not diagnos- tic of, 283. molar, 284. the morbid anatomy of, 284. influence of age upon. 285. retention of the embryo in, 286. and menstruation, 286. probable signs of, 280. cause of the delivery in, 287. excessive abdominal development in, 288. size of the abdomen as a sign of, 289. INDEX. 10S7 X, Pregnancy, diagnosis of, 289. the induction of premature labor in, 292. Pulsatilla in mal-presentations during, 292. bilious colic during, 293. vascular relation between the uterus and liver during, 293. vascular changes in the uterus during, 294. bilious symptoms in early, 294. cholestraemia contingent upon, 295. albuminuria in, 297. prophylaxis of bilious colic of, 297. mercurius cor. in albuminuria —" Ouring, 298.__ abdominal cramps in, 299. spurious peritonitis during, 300. diagnosis of spurious peritonitis from cutaneous neuralgia dur- ing, 301. uterine colic during. 302. gastro-intestinal disorders inci- dent to. 302. gastro-intestinal disorders, treat- mp^nf ana.------_...... jsea and vomiting of, 304^) nausea and vomiting off4«-^ome- —-times fatal, 304. significance of a coincident jaun- dice during, 305. morning sickness of, may depend upon uterine deviations, 305. no specific for the nausea of, 305. special indications for remedies in morning sickness of, 307. remedies for nausea and vomit- —'Hng of, 307, 308. '---------- " stretching the cervix in morning sickness of, 308. the expediency of abortion in morning sickness of, 398. dangers arising from morniDg sickness of, 309. varicose veins during, 310. morning sickness and retrover- sion of, 311,312. reflex gastric symptoms in early, 312. morning sickness of, if not exces- sive, may be salutary, 313. uterine sound in retroversion during, 315. postural treatment for retrover- sion during, 315. chorea during, 318. rheumatism a predisponent of chorea during, 319. effects of, upon uterine cancer, 700. Procidentia, pessaries for, 61S. elytrorrhaphy for, 618. episio perineorrhaphy for, 618. from pertussis, 619. labor a predisponent of, 620. treatment for, 62.. taxis and reduction in, 621. Prolapsus uteri and procidentia. 602. obstinate vomiting with, 132. frequency of, 603. with dropsy at the climacteric, 522. consequences of incorrrect diag- nosis of, 603. unnecessary manipulation in, 603. spontaneous cures of,and quack- ish claims, 604. internal remedies in, 604. with superficial ulceration of the cervix, 605. irregular menstruation a cause of, 606. lumbar and sacral pains in, 607. and paralysis, 607. hysterical complications of, 608. reality of the nervous symptoms in, 608. leucorrhcea and ulceration in, 60s. ulceration from the abrasion of, 609. treatment for, 610. contra-indications for pessaries in, 611. caustics in ulceration with, 611. with ulceration, calendula in, 611. with right latero-version, 611. and constipation from rectal par- alysis, 613. cramping pains in, 613. vesical symptoms in, 614. leading indications for treatment in, 615. with anterior inclination of the fundus uteri, 616. Prolapse of the ovary and ovaritis, 728, 730. Pruritus of the vulva, 528 causes of. 528. from trichiasis, 529. clinical history of, 529. may arise from self-inflicted wounds, 530. may precede menstruation, 530. with dysmenorrhcea and amenor- rhoea", 530. at the climacteric, 530. during pregnancy, 531. may be complicated with uterine disease, 531. may be limited to the period of lactation, 531. prognosis of, 532. 1088 INDEX. Pruritus of the vulva, topical pallia- tives, 532. with vulvitis, 533. if due to pediculi, etc., 533. internal remedies for, 533. Dr. Holcombe's treatment for, 534. other remedies for, 534. Pseudo-membrane in diphtheritic ulceration of the os uteri, 663. Puberty 35. and nubility not the same, 36. delayed, causes of, 37, 113,114. impoverished blood at, 37. nervous exhaustion at, 38. effects of the tuberculous habit in, 38. delayed, and bronchocele, 39. diseases cured by, 39. hysteria at, 39. the diseases of, 97. emmenagogues at, 268. Puerperality, 57. diseases of, self-limited, 57. Puerperal cachexia, 60. ovaritis, 755. Pulsatilla in mal-presentations, 292. Pyaemia and pelvic cellulitis, 403. "DECTAL touch, 78. XL in ovaritis, 731. Recto-abdominal touch, 79. vesical touch, 79. vaginal touch, 79. Recto-vaginal fistulae, 887. causes of, 888. physical signs of, 888. prognosis in, 889. surgical treatment for, 889. after treatment in, 890. Dr. Goodell's operation for, 891. Rectocele, operation for, 562. Rectum, inspection by forcible ever- sion of, 74. manual exploration of, 80. Recurrent abortion from mal-lacta- tion, 487. Reflex relations of the uterine cervix and stomach, 658. do. of the ovary, 672. Repelled eruptions, cause of mem- branous dysmenorrhcea, 231, 234. Reposition of a retroverted gravid uterus, 314. Results in the operation for lacera- tion of the perineum. 901. Retention of the menses, 128. accidental causes of, 129. and uterine displacements, 160. treatment of, 162. Retro-flexion of the uterus, a cause of dysmenorrhcea, 202. most common, 622. Retro-version, pessaries for, 316. and morning sickness of preg- nancy, 311, 312. uterine sound in, 315. symptoms of, 632. vesical disorders in, 633. nervous disorders in, 633. new mode of reduction in. 633. Guernsey's elevator in. 634. preparatory treatment for the re- duction of, 637. Rheumatism during pregnancy, 51. and menorrhagia, 263. a predisponent of chorea, 318. and neuralgia at the climacteric, 505, 520. Rheumatic diathesis in ovarian neu- ralgia, 758. Rhus tox. in menstrual epilepsy, 174. in stomatitis materna, 351. Rouget, theory of metro-peritonitis, 48. SALICYLATE of soda in pelvi- peritonitis, 381. Salpingitis, 1019. varieties of, 1019. Salpingotomy, 1028. Battey-Tait operation, 1028. Scrofulosis a predisponent of chronic cervical endo-metritis, 453. Secale in sub-involution, 359. Sepia in chlorosis, 110. Sequelae of abortion, 334. » of pelviocellulitis. 397. Serre-fines in laceration of the perin- eum, 897. Sexual excesses and pelvic haemato- cele, 419. Simon's manual exploration of the rectum, 80. method of cystotomy, 581. Sims' elevator in fibroids, 92. repositor in anti-flexion, 627. method for reducing inversion, 646. operation in epithelioma of the uterus,718. for vaginismus, 853. Sound, the uterine, in diagnosis, 84. in diseases of the cervix, 84. to test the mobility of the uterus, 85. in tumors of the uterus, 86. in deviations of the organ, 86. mode of introduction of, 91. time for use of, 87. difficulty of introducing, 88. INDEX. 1089 Sound, choice of, 91. versus the tenaculum, 93. use of in obstructive dysmenor- rhcea, 206. Spanaemia in chlorosis, 103. Spasmodic dysmenorrhcea in chlorosis 111. adjuvants in, 111. dysmenorrhcea, 215. Special pathology, importance of, 674. Speculum, the best uterine, 69. Sims' 70. mode of passing the, 73. painless withdrawal of, 73. and sound conjoined, 90. Spinal irritation and hysteria, 793. notalgia, 815. causes of, 818. errors in the treatment of, 819. is of nervous origin, 820. exciting causes of, 820. symptoms of, 820. and uterine disease, 822. reflex symptoms in, 822. from ovarian implication, 823. diagnosis of, 823. may arise from coccyodynia, 824. diagnosis of, from inflammation of the cord, 824. prognosis of, 825. treatment of, 825. in amenorrhoea and at the climac- teric, 826. remedies for effects of the spinal injury in, 827. remedies for rheumatic and neu- ralgic symptoms in, 827. remedies for uterine and ovarian symptoms in, 827. local adjuvants for, 828. domestic expedients in, 828. faradization in, 829. prolapsus uteri, and laceration ot the perineum, 830. Sponge tent in membranous dysmen- orrhcea, 232. in dilating the urethra, 566. mode of applying, 567. in urethritis, 568. a practical hint in the use of, 568. Spontaneous discharge of a renal cal- culus^. . cures of prolapsus uteri, 604. Stage of effusion in pelvi-peritonitis, 370 Stem dilators in obstructive dysmen- orrhcea, 208. . pessaries in ante-flexion, 628. Stenosis of the cervix in dysmenor- rhcea, 201. Sterility from dysmenorrhcea, I8y. SteriMty, a sequel of membranous dys- menorrhea, 233. from menorrhagia, 259, from a profuse leucorrhcea, 492, 674. from ovaritis, 748. Stomatitis materna, 339. limited to gestation, 340. the peculiar lesion in, 340. incidental symptoms in, 341. a constitutional disease, 342. a local ulceration, 342. incidental gastrin disorders of, 343. causes of the digestive derange- ment in, 343. diarrhoea a contingent of, 343. renal and vesical symptoms in, 344. the anaemia in, 344. date of onset, 345. diagnosis of, 345. prognosis of, 345. treatment of, 346. acidulated drinks in, 347. expedients for arresting, 347. weaning the child not specific in, 348. may disappear with change of climate, 348. medical treatment for, 348. arsenicum alb. in, 349. mercurius in, 349. calcarea carb. in,350. ammonium carb. in, 350. baryta carb. natrum mur. in, 350. veronica beccabunga in, 350. rhus tox. in, 351. local treatment of, 351. Stone-in the bladder and urethra, 585. relative frequency of, in women, 586. causes of, 586. prognosis in, 586. treatment of, 587. lithotripsy and vaginal cystot- omy for, 587. supra-pubic lithotomy for, 587. spontaneous discharge of, 587. Study, diagnosis, and pathology, 842. pathogenesis and symptomatol- ogy, 843. Sub-involution of the uterus, 353. depth of the uterus in, 355. various causes of, 355. negative symptoms in, 355. relation of post-partum haemor- rhage to, 356. treatment of, 357. prime indication for treatment of, 357. 1090 INDEX. Sub-involution, physiological action of ergot in, 358. indication for secale in, 359. china, etc., in, 360. and recurrent abortion,361. and chronic metritis of eighteen years' duration, 364. a source of disease, 58. and laceration of the cervix uteri, 58, 862. and puerperal endo-metritis, 58. nursing a valuable prophylactic in, 61. cause of, 364. not always the result of in- flammation, 365. physical signs of, 365. chronic metritis, menorrhagia, and prolapsus, 365. a practical lesson in the diagnosis of, 366. Sub-peritoneal fibroids, 1048. Super-involution of the uterus, 121. Suppressed menstruation, 117. and retention not the same, 117, 137. Suppression of the menses, hereditary tendency to, 118. incident to acute disease, 119. caused by change of climate, 119. from an idiosyncrasy, 119. from chronic disease, 119. essentially a glandular disease, 120. ovario-pectoral sympathies in, 120. super-involution of the uterus, cause of, 121. symptoms of, 121. derangement of nervous and vas- cular system in, 121. treatment of, 123. Surgery and therapeutics, 840. Surgical treatment of retention of the menses, 130. menorrhagia, 251. of pelvic haematocele,435. of uterine cancer, 704. of vaginismus, 815. Sympathy between the generative organs and the heart, 98. uterine cervix and ovaries, 673. Symptoms, digestive, in chlorosis, 98. cerebral, in chlorosis, 98. cardiac, in chlorosis, 98. in amenorrhoea, 114. menstrual retention, 129. of uterine disorders may be re- motely located, 296. the effusion in pelvic cellulitis, 389. versus disease, 608. Synonyms of pelvic cellulitis, 386. Syphilitic cachexia in menorrhagia, 260. System, circulatory, in diseases of pregnancy, 50. nervous in, 50. digestive in,50. TAPPING in pelvic haematocele, 435. for diagnosis, 954. Tait's perineorrhaphy, 902. operation, 1028. Temperature and pulse in pelvi-peri- tonitis, 369. Terebinthina in pelvi-peritonitis, 381. Therapeutics and surgery in diseases of women, 840. Thomas' operation for cystocele, 563. for inversion, 647. Three points in the local examination of pelvi-peritonitis, 370. Tilt's operation for vaginismus, 852. Totality of the symptoms, 135. " Touch " the rectal, 78. the recto-abdominal, 79. the vesical, 79. the vaginal, 79. applied to the bladder, 83. the vesico-vaginal and recto-ves- ical, 83. by the uterine sound, 84. in diagnosis, 84. Trachelorrhaphy in laceration of the cervix, 866. Traditional fallacy of parturition, 56. Traumatic lesions of parturition, 56. Treatment of pelvi-peritbnitis, 376. Tuberculous subjects most liable to pelvi-peritonitis, 376. diathesis and cervical endo-me- tritis, 454. Tuberculosis, pelvi-peritonitis and pelvic cellulitis, 405. Tumor the, in pelvi-peritonitis, 371. formation of, in pelvic cellulitis, 388. Tympanites seldom lacking in pelvi- peritonitis, 369. ULCERATION sans inflammation, 609. cause of abrasion, 609. of cervix with prolapsus, 605. of the womb, 649. Ulcer of the uterine cervix, 650. subjective symptoms of, 650. objective, local, 650. treatment for, 652. INDEX. 1091 Unilateral neuralgia from prolonged lactation, 496. Uraemia, apocynum in, 309. Urethra, dilatation of, 565. Urethral tever and fissure of the urethra,557. pathology of, 558. treatment for, 558. vesical and renal complications of, 559. may depend upon lacerations of the urethra, 559. Urethritis, non-specific, 551. causes of, 552. symptoms of, 553. character of the urine in, 553. diagnosis of, from stone, 554. from cystitis, 554. from gonorrhoea, 554. treatment of, 555. the urethral douche in, 556. Urinary organs, disorders of, in preg- nancy, 52. Uterine appendages, diseases of, 1016. women most subject to, 1016. from imperfect development, 1016. from acute dysmenorrhcea, 1016. from puerperal affections, 1017. from gonorrhoeal infection, 1017. from membranous dysmenorrhcea, 1018. from tubal and ovarian phthisis, 1018. in scrofulous subjects, 1018. forms of ovarian degeneration, 1019. varieties of salpingitis, 1019. subjective symptoms of, 1021. objective symptoms of, 1022. physical signs of, 1022. confusing elements of diagnosis, 1023. Explorative laparotomy in, 1023. the serious nature of, 1024. Battey's and Hegar's operation, 1025. cases adapted for, 1025. indications for, 1025. in neuroses, 1026. in mania, 1027. recurrence of menstruation, 1027. Tait's operation, 1028. Battey-Tait operation, 1028. difficulties and dangers of, 1030. Uterine colic, 164. caused by vaginal injections, 164. symptoms of, 165. duration of, 165. incident to dysmenorrhcea, 165. incident to hysteria, 165. may precede menstruation, 166. Uterine colic frequent in intellectual women, 166. frequent in neuralgic women, 166. treatment for, 166. disorders not always easy of cure, 263. fibroids, 1032,1048,1056. fibroids, menorrhagia from, 265. diagnosis of, from pelvic cel- lulitis, 396. diagnosis of, from haemato- cele, 428. diagnosis of, from ovarian dropsy, 940. diagnosis of, from uterine cancer, 696. cancer, diagnosis of, from syphi- litic ulceration, 697. epithelioma, 708. leucorrhcea, 451. souffle not diagnostic of pregnan- cy, 283, 907. cervix, stretching of the, in morning sickness, 308. surgery versus uterine therapeu- tics, 835. surgery, value of, 835. often followed by pelvic cel- lulitis, 396. therapeutics practically ignored, 836. therapeutics ought not to be neglected, 838. cervix, irritable ulcer of, 658. laceration of, 855. and stomach, reflex relations of, 658. and vaginal catarrh from ovaritis, 673. polypi, menorrhagia from, 274. polypi, diagnosis of, from cancer, 696. polypi, 1064. common characteristics of, 1065. diagnosis of, 1065. treatment of, 1066. recurrent fibrous, 1067. Uterine deviations and displace- ments, 589. geieral considerations upon, 589. a clinical rule regarding, 590. causes of. are predisposing, avoid- able and exciting, 591. exciting causes of, three kinds, 592. intrinsic causes of, 592. extrinsic causes of, 592. accidental causes of, 593. often cause of morning sickness of pregnancy, 305. symptoms of, 593. 1092 INDEX. Uterine deviations and displace- ments, diagnosis of, 593. general therapeutics of, 594. necessity for reliable indications of, 594. cardinal symptoms in, 595. opposition to pessaries in. an old story, 596. causes of mischief from pessaries in, 597. indications for pessaries in, 598. contra-indications for pessaries in, 598. argument for pessaries in, 599, abdominal supporters in, 599,600. with obstructive dysmenorrhcea, 186.| may date from puberty, 604. and digestive disorders, 607. Utero-gastric and utero-cardiac de- rangements in hysteria, 809. Uterus, irregular development in,46. twisting of the, during preg- nancy, 46. super-involution of, 121. retro-version of, from pelvic haematocele, 431. natural position of, 589. physiological changes in, 589. extirpation of, Freund's opera- tion for, 705. extirpation of, Lane's operation for, 706. extirpation of, Ormes' operation for, 707. fibro-cystic growths of, 901. VAGINAL palpation. 75. touch in ovaritis, 730. Vaginismus, 846. symptoms of, 847. local hyperaesthesia a distinctive symptom of, 848. causes of, 849. diagnosis of, 850. medical treatment for, 850. surgical treatment for. 851. cured by excision of irritable tu- mors, 852. Dr. Tilts operation for, 852. Dr. Sims operation for, 853. other expedients for cure of, 854. Valerianate of zinc in ovarian neural- gia, 764. Varicose veins, 310. Variolus ovaritis, 744. Vascular tumor of the meatus urina- rius, 546. nature and location of, 547. necessity for physical examina- tion in, 548. Vascular tumor of the meatus urin- arius, symptoms of 547. obstacles to recovery from, 548. treatment for, 549. excision of, 549. a new mode of operating for, 549. after-treatment in. 550. Veratrum viride in dysmenorrhcea. 215. in pelvic cellulitis, 411. in ovaritis, 752. Veronica bee. in stomatitis materna, 350. Versions of the uterus, 631. compared with flexions, 631. the result of flexions, 631. retro—of the uterus, 632. Vesical lesions in pelvic cellulitis, 404. inspection and palpation in dis- eases of the urethra, 568. value of ,569. a clinical caution concerning, 571. symptoms in ovaritis, 732. in prolapsus uteri, 602. Vesico - vaginal and recto - vesical touch, 83. Vesico-vaginal fistulas, 872. varieties of, 872. causes of, 873. its origin often in child-birth, 874. the pathognomonic signs of, 874. Dr. Holcombe's case of, 875. prognosis of, favorable, 877. treatment of, during lying-in, 878. in the post-puerperal cases, 878. by cauterization, 878. special surgical indications for the operation in, 880. vivifying the margins of the wound in, 881. insertion of the sutures in, 882. vesical drainage after the opera- tion for, 885. removal of sutures in, 885. dangers of the operation for, 886. Electroplasty for, 886. Episiorrhaphy for, 887. Vicarious menstruation, 275. Vidal's operation for cystocele, 563. Voisin's description of the tumor in pelvic haematocele, 424. Vomiting, prolapsus uteri the excit- ing cause of, 134. relieved by repositing the uterus, 134. Vulva, pruritus of the, 528. causes of, 528. eczema of the. 538. Vulvo-vaginal gland, abscess of, 534. INDEX. 1093 Vaginitis, 538. symptoms of, 540. the eruption in, 540. causes of, 541. diagnosis of from granular vagin- itis, 541. follicular vulvitis, 541. treatment, topical and constitu- tional, 543. Vaginitis, prognosis in, 542. WEANING maybe harmful, 61. necessary, 62. fashionable pretexts for, 475. proper time for, 476. White's manner of reducing inver- sion, 647. Womanhood 36. the clinical history of, 36,38. $ d V -v '•• • ;'^A:.Kn% 5. i * .■- .