SYNOPSIS OF GYNECOLOGICAL CASES TREATED IN THE BOSTON CITY HOSPITAL FOR FIVE YEARS PRECEDING JANUARY 1, 1881. REPORTED BY G. H. LYMAN, M.IV Reprint from Medical and Surgical Reports of City Hospital, Third Series. BOSTON: PRESS OF ROCKWELL AND CHURCHILL, No. 39 ARCH STREET. 1 8 8 2 . SYNOPSIS OF GYNECOLOGICAL CASES TREATED IN THE BOSTON CITY HOSPITAL FOR FIVE YEARS PRECEDING JANUARY 1, 1881. 1 REPORTED BY L«'~ G. H. LYMAN, M.D. Reprint from Medical and Surgical Reports of City Hospital, Third Series. BOSTON: PRESS OF ROCKWELL AND CHURCHILL, No. 39 ARCH STREET. 1 8 8 2 . SYNOPSIS OF GYNECOLOGICAL CASES TREATED IN THE BOSTON CITY HOSPITAL FOR FIVE YEARS PRECEDING JAN. 1, 1881. Reported by G. H. Lyman, M.D. As the service devoted in this hospital to diseases peculiar to women has been rapidly increasing since 1875, with a manifest tendency to future development, it is worth while, for the information of the Trustees of the institution and for the profession, that the published Hospital Records should contain a concise report of the work of the past five years. This service having no separate staff, but being participated in by all the regular visiting physicians, the records are more or less perfect in proportion as they have been interested in gynecological matters, some devoting more of their time and others less, to this particular class of patients. As the ser- vice becomes more systematized, the records, doubtless, will become more detailed, more reliable, and more useful. In this paper only such of the cases will be summarized as were distinctly gynecological, that is to say, only those in which this element was manifestly the "fons et origo ” of the disorder for which the patient sought relief. Were all the cases of pelvic derangement which have been treated, incidentally as it were, to be included, the narrative would require more time and space than are at my command. In this connection it is also to be noted that this report deals only with such cases as were admitted to the hospital, the progress and treatment being under daily supervision. The larger number treated in the out-patient department, applying irregularly, the conduct and treatment being com- paratively under little control, are of less value for profes- sional record. SYNOPSIS OF GYNECOLOGICAL CASES. 3 Few women enter a public hospital for acute diseases, and fewer still with chronic ailments, in whom functional disturb- ance of the pelvic viscera is not an important factor in the problem presented; but such cases are more properly reckoned with the diseases of which they are merely symp- toms, more or less important, as the case may be. The men- strual derangements, for instance, accompanying inflamma- tory disease, and due to deranged circulation, are excluded ; while the inflammatory and reflex disorders of the circulatory and nervous systems, directly excited by local pelvic disturb- ance, are, properly speaking, gynecological, in the sense in which that term is here used. No one familiar with the rapid development of this branch of general practice can fail to recognize its grave importance in connection with the diseases of a large half of the human race ; and if our hospitals are to do their work intelligently and economically, and, above all, with the greatest ultimate benefit to the usefulness of our sick female poor, this consideration should have its full influence upon all governing bodies of such charities. The prime motive, doubtless, is that the patients shall be so treated, if possible, as to enable them to attend to their domestic or other employments, to earn their own living. It is of little use, for instance, to admit a woman suffering from chronic endometritis, and give her only that temporary relief to her leucorrhcea, irritable bladder, and general pelvic distress, which mere rest alone will often afford, and then send her back to her daily work, with the certainty that she will soon relapse and be as helpless as ever. To treat such cases, economically for the public charity, and usefully for its re- cipients, the cause must be removed, the pelvic organs must be restored to their normal condition, if such restoration be practicable. This, of course, requires not only the proper appliances and the separate arrangements of a distinct gynecological ward, but a larger consumption of the time which can be daily afforded from other patients on the part of the visiting staff. The first steps to some organization in this direction were undertaken, timidly and reluctantly at first, by our late energetic superintendent, Dr. Cowles, under direction of the 4 SYNOPSIS OF GYNECOLOGICAL CASES. Trustees, and before his resignation, with a degree of good will and assistance which was a constant encouragement, as results became more and more manifest. It is far yet from being all that it is capable of being, and should be, made ; but enough certainly has been done to show that the Boston City Hospital intends to be always in the fore-front in every improvement in economical administration, consistent with the scientific treatment of the sick poor, for whose benefit it was established, and for whose comfort and relief the city has always cheerfully dealt with a bounteous hand. So pressing has the'need for special treatment of this class of cases become, and so necessary for every hospital which claims to be more than an almshouse infirmary, that all the largest and most important of the hospitals in Great Britain, and many of those in this country, have established separate wards for the purpose, and many of them a distinctly sepa- rate service, — a result which all will doubtless sooner or later achieve. In the short period covered by this report nearly eleven hundred cases, distinctly gynecological, have been treated ; that is to say, cases in which the local lesion wras the direct cause of the disability and suffering, excluding a larger number in which the local lesion was symptomatic and of secondary importance in the treatment, such as pulmonary, cardiac, gastric, and rheumatic affections, diseases of the nervous centres, and the whole category of febrile affections. Of primary importance are the puerperal affections, such as labor, pregnancy, miscarriages, etc., as being the originat- ing cause of a very large number of those disorders which will be comprised in this summary. PUERPERAL AFFECTIONS. CASES OF LABOR. As it is not the purpose of the hospital to admit cases for 'confinement, the number of labors has not been large; but, notwithstanding the restrictions, seventy cases of emergency have occurred, in which humanity forbade a refusal. As illustrative of these emergencies, one was taken sud- denly w’hile riding in a carriage, and was delivered before SYNOPSIS OF GYNECOLOGICAL CASES. 5 she could reach the hospital; in one, labor came on without warning, and she was delivered in the street; one was delivered of a seven months’ child, unexpectedly, in the water-closet of a store, having but a single pain ; several were brought by the police either during or immediately after labor; one was admitted for other injuries caused by a drunken husband, and soon resulting in labor; others for convulsions or post-partum hemorrhage ; and still others for lacerations or other injuries resulting from labor just com- pleted. Of the whole number, four resulted fatally, of whom one was admitted with fever a week before delivery ; one, a single woman, was admitted with symptoms of paraly- sis before her full term ; one, a single woman, was brought by the police three hours after delivery; and one, delivered a week previously, had rupture of the uterus. Among the recoveries seven had puerperal septicaemia, and were treated with intra-uterine douches, quinine, etc. ; all of these septi- caemic cases were delivered in the hospital, but with such antecedents as to make it very doubtful, to say the least, whether the development of the disease could be fairly attributed to the hospital atmosphere. The forceps were required in but two cases, and version in one. Twenty-six were single, and two, twenty-one and twenty-three years respectively, " claimed ” to be widows. One, a school girl of fifteen, who had never menstruated, had an easy though prolonged labor of nineteen and one-half hours. Nine of the cases had rupture of the perinseum ; six were sutured successfully, and one failed of union. One of those not sutured had septicaemia. PUERPERAL SEPTICAEMIA. Sixteen eases of puerperal septicaemia, the patients having been previously delivered at or near full time, are recorded: one of these was admitted delirious, only a few hours after her delivery of a seven months’ child, which, in her delirium, she subsequently killed. Though thoroughly poisoned by the disease, she eventually recovered under quinine, intra-uterine injections, etc. ; another, delivered twenty-four hours before admission, had complete rupture of the perinaeum. This 6 SYNOPSIS OF GYNECOLOGICAL CASES. case resulted fatally, and the autopsy by Dr. Cutler revealed gangrene of the uterine mucosa, with a "thin, false, grayish membrane, suggestive of a diphtheritic process.” From the records, it is doubtful if the injections, which were used in this case, ever penetrated the uterus. The other cases had all been delivered from five days to four weeks before admission. Of the whole number, five died, — one complicated with phlegmasia alba dolens; one, a single girl of seventeen, had, after delivery, been turned into the streets by her father, where, after long exposure in the snow, she was rescued by the police. Several of the recoveries, also, were desperate cases; and the favorable result, as would appear from the records, was undoubtedly greatly influenced by the free use of intra- uterine injections. Other cases, of septicaemia following abortion will be found recorded under that head. ABORTION. The cases of abortion are seventy-six in number. Seven- teen of these were single, live widows, tifty-two married, and two not recorded. There is reason to suppose that a much larger proportion were unmarried, but not willing to acknowledge it, and the same doubt is probably justified as to the causes given by them ; although, as will be seen, eigh- teen of the number had no hesitation in confessing criminal intent, giving details, not only of the crime, but often of the criminal, — a striking evidence, if any were needed, of the laxity of the law as to irregular practitioners; for, so far as appears, but one, whose victim was a school girl of sixteen, was ever convicted. Of the eighteen alluded to seven were single, two widows, and nine married. Still, a large proportion could undoubtedly be traced to overwork, falls, lifting, and other accidental causes. There were seven fatal cases to sixty-nine recoveries. Of the seven fatal cases one was delirious, and collapsed when admitted, abortion at four months and fatal from sepsis ; one delivered at seven months, after four months of vomiting; one of sepsis, the placenta having been retained three months; two of peritonitis, and SYNOPSIS OF GYNECOLOGICAL CASES. 7 two of sepsis, admitted with the disease well advanced, the autopsies revealing lymphangitis. Of the recoveries, nine- teen were admitted with retained placenta, seven with exces- sive hemorrhage, three with septicaemia, and three with peritonitis. Of the eases of retained placenta, in several a considerable time had elapsed since the abortion ; in one case, already mentioned, three months, and fatal from sepsis ; in others, one retained ten weeks, five six weeks, one seven weeks, two four weeks, two three weeks, and two two weeks, —all of which eventually recovered. The fatal case was admitted in a state of collapse, with offensive placental tissue protruding from the os. In nothing has the improvement in the management of post-puerperal diseases, of late years, been more obvious than in the use of intra-uterine injections. Cases formerly hopeless are now managed with confidence and success. Septic absorption from unhealthy conditions of the uterine mucosa, from abrasions and lacerations of the cervix, vagina, and perinoeum, is forestalled, or kept in subjection; and, though not so successful when lymphangitis or peritonitis has already supervened, this form of antiseptic treatment is an invaluable resource against further absorption, as the system will often tolerate and recover from a certain amount, if the supply be cut off. Two cases of phlegmasia dolens were admitted two weeks after labor, in one developed on the second, in the other on the ninth day, after confinement. In neither were pelvic complications noted, being probably so obscure as to be overlooked. Other cases developing in the course of septi- caemia are noted under that head. PHLEGMASIA DOLEXS. DISORDERS INCIDENT TO PREGNANCY. For disorders " incident to pregnancy ” tifty-two cases were admitted, — five with albuminuria, of whom one died soon after entrance of convulsions, at nearly her full term. Nine had hemorrhage, threatening abortion, none of whom so far as discovered had placenta previa ; nineteen sought re- 8 SYNOPSIS OF GYNECOLOGICAL CASES. lief for excessive vomiting; one had paralysis supervening at the eighth month; two had acute chorea; two had neu- ralgia ; one, single, age twenty-three, was salivated by medi- cine taken unsuccessfully to induce abortion; two had accidental injuries threatening abortion, and others entered for pruritus, vulvitis, etc. All but the fatal case of convulsions were discharged relieved, to await their confinement elsewhere. ACUTE CHOREA. Of acute chorea there were thirteen cases, eleven dis- charged well, and two relieved. Of these, eight were school girls, from six to sixteen years of age. Two were attributed to over-study ; one to fright; one to tape-worm ; one to indi- gestion ; one, twenty years of age, to "irregular habits ; ” and one each to previous attacks of rheumatic fever and cerebro- spinal meningitis ; a considerable proportion of which only are to be reckoned, strictly speaking, as "gynecological.” HYSTERIA. Of hysteria there were eighty-three cases, forty-eight single, nine widows. In twenty-four the catamenia were irregular; one, single, was due to excessive coitus; four to suppression from cold while menstruating; three traced to previous induced abortions; fifteen, all single, to futile attempts to induce abortion, and one to fright. A large number are doubtless reported as hysteria as a matter of convenience, being cases of irregular nervous action, depend- ing more or less upon pelvic disorder, though without any very definite or positive symptoms, and requiring merely temporary treatment and rest with tonics. VAGINISMUS. Of vaginismus one case only is given, a young married woman, who had been twice operated on elsewhere without relief. Some benefit followed gradual dilatation with glass plugs, but she left before the treatment was completed. SYNOPSIS OF GYNECOLOGICAL CASES. 9 MASTITIS. Of mastitis eight cases are given ; three relieved by strap- ping, the rest, advanced to suppuration when admitted, were relieved by incisions. CYSTITIS. Cystitis, so frequent an accompaniment of pelvic disorders, has been of course a common occurrence, but there were six cases not reported under other heads, in which it was the chief factor. One had a history of old pelvic cellulitis and retroversion, the only fatal case ; one dated from an induced abortion, eighteen months before; one, due to calculus, was relieved by extraction of the stone through the urethra; and in one the inflammation followed the removal of a hydroceph- alic child, ten months previously, the child weighing nine- teen pounds thirteen ounces, and requiring decapitation. VAGINITIS. Of vaginitis twenty-four acute and sixteen chronic cases were treated; of the acute sixteen were single, six married, and two widows. Two were caused by felonious assaults (one of them being in a child of eight years of age), and one resulted from a "stickpenetrating the vagina while coasting,” some time previous to entrance. CARUNCLE, PRURITUS, VULVITIS. Caruncle of the urethra, relieved by operation, and prUritus of the vulva, are each represented by a single case, and simple vulvitis by four cases only. ABSCESS OF LABIUM AND VAGINA. Of abscess of the labium we find seven cases, one resulting 7 O from recent parturition; the remainder due probably to coition. Of abscess of the vagina (within the sphincter) one case was received, a recently married woman of twenty-two, note- worthy as having a double uterus, with single cervix. 10 SYNOPSIS OF GYNECOLOGICAL CASES. ENDO—CERVICITIS. Among the most frequent of the affections of the pelvic organs which the physician is called upon to treat in private practice, as well as in hospitals, must be reckoned endo- cervicitis. Of this disease one hundred and one cases were admitted, in which it was the chief cause of disability. This does not include the larger number of cases treated only inci- dentally, as symptomatic of graver trouble, such as lacerations, endometritis, subinvolution, cellulitis, and pelvic peritonitis. The direct cause is not always easy to trace. General ill- health, the use of sewing-machines, constipation, the practice of abortion, over-work, chill during menstruation, excessive coition, in a word, any cause of disturbed pelvic circulation may induce it. Among the laboring poor, who are unable to favor themselves at the catamenial period, who can spare little or no time from their duties for child-birth, few escape it. Although coition is a common cause, injustice no doubt is often done by unfounded suspicions of impure connection. This remark is especially applicable to the large number who support themselves as sempstresses; women compelled to sit in a cramped position for long periods, who resist the inclina- tion, or are deprived of the opportunity, for attention to the bowels and bladder ; or shop-girls, who are compelled to stand with little intermission throughout the day, in a close, furnace or steam-heated atmosphere. Under such conditions, exag- gerated local congestions can hardly be avoided, for one week at least out of every four. For such, hospital treatment, with its facilities for rest and local applications, becomes essentially necessary ; and we may add, where they can give the requisite time for treatment, it is very successful. Few have the means, or the necessary privacy in their confined lodgings, for its proper management, and must either have such provision made for them, or drag along in weariness and discomfort until they become a public burden, or something worse. These cases are, as a rule, discharged from the hospital well; although, occasionally, impatient of the delay and relieved of the more urgent symp- toms, they are discharged at their own request. SYNOPSIS OF GYNECOLOGICAL CASES. 11 OVARIAN DISEASES. The ovaries were the principal seat of disease in twenty- five cases. Of these, nineteen were cases of ovaritis, of which six were traced directly to chill during the menses, and four to sexual excesses. Two cysts, supposed to be in the broad ligament, were cured by tapping through the vagina. One, with an ovarian cyst, died of pyelo-nephritis five days after entrance. One, with a dermoid cyst, twelve ounces of " fatty fluid ” mixed with hair being drawn by tapping, left before farther treatment. One case of prolapsus of the ovary was entirely relieved by a thick pessary, and one case only of colloid cancer of the ovary is reported. This last had every characteristic of a multiple fibroid when admitted, and the admission of the sound four and one-half inches determined an erroneous diagnosis. The autopsy revealed the body of the uterus of normal size and length, the apparent elongation consisting of the supra- vaginal portion of the cervix. For this error the present reporter alone is accountable, and calls special attention to the cause of it, as one not commonly alluded to in the differential diagnosis. HEMATOCELE. Six cases were admitted with hematocele, and resulted favorably. Four of them were opened, of which one had also a spontaneous opening into the rectum. In the aspirated cases suppuration had occurred, and the constitutional irrita- tion was only allayed by removal of the sanious contents, and injections of iodine or carbolic acid. Beside the above-mentioned six cases, it is quite probable that others were recorded as pelvic peritonitis or cellulitis, as many of the cases so recorded entered the hospital after suf- fering for long periods .with pelvic effusions, and unable to describe their earlier symptoms with sufficient clearness to render an exact differential diagnosis possible. 12 SYNOPSIS OF GYNECOLOGICAL CASES. PELVIC EFFUSIONS. One hundred and forty cases were admitted with other pelvic effusions. Unfortunately, an exact differential diag- nosis is wanting in many of them. This, doubtless, was some- times unavoidable ; but, after careful scrutiny of the records of each case, the following summary is thought to be sub- stantially correct; that is to say, of pelvic peritonitis, one hundred and five; of pelvic cellulitis, thirty-five. Of fhe first a large number had simple effusion into Douglas’s pouch, or into the lateral parts of the pelvis, resulting from cold, over-exertion, excessive coitus, bathing during the menstrual period, induced abortion, and arrested involution from various causes after delivery. The most common causes noted ap- pear to have been chill during menstruation and excessive coitus. Of the one hundred and five cases of pelvic peritonitis seventy-two recovered, and thirty left before entire recovery, generally convalescent. Among the recoveries eighteen had resulted in abscess, twelve of which were aspirated, and five opened spontaneously in the vagina, rectum, or groin. Of the three fatal cases one died of septico-pyaemia, the even- ing of her admittance, the autopsy revealing, besides the peritonitis, a laceration of the vagina; one was admitted much exhausted, with extensive effusions and an abscess in the groin; and of the third death there are no particulars, far- ther than that she was aspirated through the vagina. Of the thirty-five cases of pelvic cellulitis sixteen recov- ered entirely, two died, and the remainder left before entire recovery, so far relieved as to be impatient of longer confine- ment. Of those discharged well, or relieved, resolution took place in seventeen, and eighteen resulted in abscess, of which eleven were aspirated, and seven opened spontaneously before or immediately after entrance, two of them into the rectum, one into rectum and vagina, one into rectum and groin, one into the groin, one into the vagina, and one into the bladder. Of the two fatal cases one entered exhausted, with sup- puration in the groin and into the rectum, and the other SYNOPSIS OF GYNECOLOGICAL CASES. 13 revealed at the autopsy an extensive parametritis of long standing; aspiration was too late to be effectual. As a rule, the local treatment of all these cases resulting in actual pelvic abscess, whether originating in hematocele, peritonitis, or cellulitis, was (in cases accompanied by offen- sive discharge or showing a tendency to reaccumulate)— by re- peated injections of the sac with dilute carbolic acid or iodine, with due provision for proper drainage. No doubt many fatal cases occur from not opening sufficiently early. Aspira- tion should be resorted to as soon as it is reasonably certain that suppuration has occurred, and especially when the local tension is accompanied by severe constitutional irritation, and cystitis or rectitis. The relief is usually immediate, and in a large proportion of cases the result successful. The following, as among the probable causes recorded, are worth notice : in one, the recent use of the sound for restor- ing an anteflexed uterus; in one, the free use of a sound in the treatment of sterility some time previous ; in three, lacer- ated cervix; in two, recently induced abortion; and in one, there were suspicions of extra-uterine pregnancy. It is wor- thy of note, as a matter of prognosis, that out of this large number of pelvic effusions, either from hematocele, cellulitis, or peritonitis, so small a number should have terminated in suppuration. So far as concerns peritonitis and cellulitis, no doubt that effusion is even more common in general practice than these figures would indicate, but escapes observation from want of careful attention to the symptoms and the neg- lect of vaginal examination. The remarks made above as to the differential diagnosis be- tween hematocele, pelvic peritonitis, and pelvic cellulitis, are equally applicable to the cases of chronic metritis, endome- tritis, and hyperplasia of the uterine mucosa ; but an analysis of the records would divide them with probable accuracy into twenty cases of chronic metritis, and forty of endome- tritis, including those of hyperplasia. The cases of acute metritis are reported under the various heads of abortion, septicaemia, etc. The supposed causes were chiefly suppression of the menses, displacements, lacerations of the cervix and peri- 14 SYNOPSIS OF GYNECOLOGICAL CASES. nseum, the sequehe of induced abortion and subinvolution following labor, and of more or less remote origin. None of the sixty cases terminated fatally, the local treatment con- sisting generally of scarifications, glycerine tampons and hot douches, dilatation by tents, the free use of the curette in the hypertrophic and hyperplastic cases; and, when neces- sary, applications to the cavity of strong solutions of carbolic acid in glycerine, subsulphate of iron, iodine, or nitric acid. Many of the cases tabulated under the head of endo-cervicitis were also more or l'ess complicated with uterine enlargement of secondary importance. LACERATION OF THE CERVIX AND PERINEUM. No systematic record has been kept of the number of these injuries, observed in the various disorders included in this report. They have, however, been of extreme frequency, and, as elsewhere noted, are an important factor in the causa- tion of pelvic derangements; the former from the continued irritation of the everted and inflamed cervical mucous mem- brane, and the latter from the inevitable disturbance in the pelvic circulation arising from diminished support of the viscera, and consequent relaxation and prolapsus of the vaginal walls. For laceration of the cervix, with eversion and abrasion of the mucous membrane, forty-eight cases were admitted. Twelve of these were operated on ; two were found to be pregnant, and in a large number either the injury was of so recent date that they refused operation, or were satisfied with the temporary relief afforded by douches, scarifications, tampons, or nitric acid. One of the operations was followed by a sharp febrile attack, with chills, but terminated favorably with perfect union. Minor lacerations, which are so common, and for which no operative interference was required, are not included in the above. Seventeen cases are recorded in which laceration of the perinseum was the reason for admission. Seven of these were restored ; three refused operation ; one was pregnant; one was attacked with dysentery; and one had vesico-vaginal fistula SYNOPSIS OF GYNECOLOGICAL CASES 15 and atresia of the vagina from cicatricial bands, which de- manded primary attention. In the others, recently confined, the time had passed for primary, and had not arrived for secondary, operation. Three of the operations involved both sphincter and septum. FISTULJE. Of recto-vaginal fistula but one case was admitted; it originated in rectal abscess, the pus burrowing into the peri- naeum and labia, in a very unhealthy subject, and who left the hospital with but little improvement. Of vesico-vaginal fistulee there were three cases. One, resulting from recent instrumental labor, refused operation ; one, before alluded to as complicated with rupture of peri- naium and vaginal atresia,— a very large one, — was nearly closed by operation, a minute opening remaining. There were also in this case cicatricial vaginal bands, and the operation was to be repeated later, when these bands should have been soft- ened down by the use of glass plugs, etc. The remaining case, of seventeen years’ standing, having undergone repeated operations in a foreign hospital, was finally successful. Fissure of the anus was noticed in but one case. It was of recent origin, and cured by stretching the sphincter. Atresia of the vagina, from dense cieatricial bands, oc- curred in but one ease, already spoken of. It resulted from labor, supervised by a midwife, eleven weeks before en- trance. The placenta was retained eight days, its expulsion being followed by incontinence of urine. On vaginal exam- ination, a large transverse fistula, admitting the finger, was found close to the urethra, the vagina being entirely occluded beyond that point. This band was dilated, after incision, and a second one found near the cervix, through which no probe could be passed. After a month’s use of a large glass plug the lower band was so far softened as to admit of operation for the fistula. As the existence of a small valvular opening in the upper band was revealed by the appearance of the menses, it was not disturbed, experience proving that, should ATRESIA OF VAGINA. 16 SYNOPSIS OF GYNECOLOGICAL CASES. conception ever unfortunately occur, the constriction of itself need be no obstacle to delivery, or, proving such, may be di- vided at the time of the labor.1 POLYPI OF CERVIX. Of polypi of the cervix six were removed, four mucous, and two fibroid. One of the fibroids completely occluded the cervix in a young married woman (a private patient), causing distressing dysmenorrhcea. Its removal gave entire relief, and a baby in ten months. UTERINE FIBROIDS. Of uterine fibroids there were thirty-two cases, three of which, developed within the cervix, were removed; fifteen were subperitoneal; seven intramural; four were multiple, and of two no exact diagnosis was made. One, sub-mucous, and weighing sixteen and one-half ounces, was removed. Of the whole number four died while in the hospital, viz. : one, a multiple, with sloughing of the mucous surface, died of exhaustion ; one, a multiple, sub-peritoneal, died suddenly of acute gastro-enteritis; one, a multiple, intramural, was complicated with cardiac dilatation, and died of cardiac embo- lus ; and one, aspirated through the abdominal parietes, pre- sumably for diagnosis, died of pain and hemorrhage, the autopsy revealing an intramural fibroid localized in the pos- terior wall. In several cases hemorrhage was arrested by tents; while the free and long-continued use of ergot was of service in a large number of cases, by the relief of pain, and diminution in size of the tumor; though the ultimate result cannot be given, as such cases are not retained in hospital for any length of time, and they rarely return to report prog- ress. The reporter, however, is able to give the subse- quent history of one such case, which occurred during his service, three years ago. She entered for profuse hemorrhage 1 Atresia of the Vagina, by Dr. Isaac E. Taylor, in Transactions of the American Gynecological Society, Vol. 4, p. 404. For the contrary view see article by Dr. Trask on Rupture of the Uterus, Am. Journal of Med. Sciences, July, 1856, p. 104, where out of four hundred and seventeen, six cases were attributed to this cause. SYNOPSIS OF GYNECOLOGICAL CASES. 17 and pain, disabling her from any exertion. The fibroid was multiple, and after the os was largely dilated one of the most prominent growths was removed, and she was put upon the free use of ergot. A sharp inflammatory attack ensued, of short duration; the hemorrhage eeased, the pain was re- lieved, the catamenia became regular, and the tumor is now so far diminished as to enable her to do her housework easily and comfortably. Another case, worth noting, entered with a large tumor closely adherent to the abdominal parietes, which had been subjected to electrolysis by an irregular prac- titioner. Besides the internal adhesions, his proceedings were followed by two proliferating masses as large as an orange, protruding externally. The exuberant granulating masses were removed by ligature, and the surfaces healed kindly before her discharge. CANCER. Epithelioma of the vagina, not involving the cervix, occurred in two cases. One had opened its way into the bladder; the other, extending from a short distance below the cervix, posteriorly, presented a large oval mass, like an egg, separated from the rectum only by a thin layer of mucous membrane, so thin as to render operative interference imprac- ticable. Of cancer of the uterus sixty cases are recorded, thirty- one of them epithelioma, mostly of the cervix, and, in four instances, extending to the vaginal walls. When epithelial, and confined to the cervix, the rule has been to remove the mass, using the curette freely, followed by acids, iodine, bromine, or subsulphate of iron, and, though marked temporary relief to the pain, foul discharges, hemorrhages, and dysuria was obtained, the subsequent history of those leaving the hos- pital, though not doubtful, is not positively known. Eighteen, admitted in advanced stages, died in the hospital. In one case of scirrhus the hymen was found entire, though the patient had been married thirty-seven years; and in another, of similar character, both breasts had been removed twenty- seven years before, for "cancer.” In another case of epithe- lioma, the uterus was entirely prolapsed between the thighs ; 18 SYNOPSIS OF GYNECOLOGICAL CASES. and the whole organ was excised by Dr. Blake, the patient dying of " shock.” UTERINE DISPLACEMENTS. Uterine displacements are reported under the three heads of prolapsus, anteversion and retroversion. Of prolapsus, two were complete, and in two the cervix only was visible at the vulva. Two cases were due apparently to post-puerperal complications interfering with involution. One (complete) was caused by lifting, and was easily relieved by intra-vagi- nal support. One of the cases, the cervix only protruding externally, rugose and dry, and of one year’s duration, was, strictly speaking, due to supra-vaginal elongation of the cer- vix, the sound passing four and three-quarters inches. A portion of the vaginal cervix was amputated, with the elfect of diminishing the elongation above, either by contraction or by stimulating absorption, and with the result of so far relieving the patient as to keep the cervix within the vagina. Of anteversion and flexion twenty-six cases are found. A few of these, of recent origin, due apparently to strains, falls, or other injuries, were entirely relieved by replacement and rest, and some by the use of stem pessaries or tents ; but the majority obtained only the usual result of partial relief. Retroversion or retroflexion existed in one hundred and one cases, with the usual accompaniment of excessive or painful menstruation, vesical and rectal irritation, reflex ner- vous disorder, ovarian, gastric, or cardiac, and lumbago. One notable case, aged twenty, was blind, unmarried, and the mother of a child four years of age. Excepting a few cases, in which the organ was glued down by old adhesions, a suitable pessary was effectual in giving relief; and in many of recent origin replacement and rest alone were needed, with only temporary artificial support. About one-half the cases were in unmarried women, as semp- tresses, servants, and factory operatives. It is much to be regretted that the records, especially the earlier ones, have not always made the important distinction which exists between version and flexion. As these terms are in many cases evidently used as synonymous, I am obliged SYNOPSIS OF GYNECOLOGICAL CASES. 19 to report them as versions. The normal anterior inclination of the uterus may often be mistaken for a version, but, unless accompanied by vesical or other symptoms, is hardly worth attention as such; and the same is true of slight retrover- sions, which often exist without causing any pelvic disturb- ance, or requiring treatment. A true flexion, however, can hardly exist without such an interference with the circulation, with the vesical functions, or with the menstrual flow, as to cause symptoms demanding relief. So far as my own expe- rience is of any value, I should say that anterior displace- ments were greatly less frequent than posterior displacements ; that anterior flexions were much more common than anterior versions ; and that retroversions very far outnumbered retro- flexions. The importance of the distinction pathologically and with reference to treatment need not be insisted on here.1 MENSTRUAL DERANGEMENTS. Menstrual derangements uncomplicated with displacements are recorded under the heads of suppression, dy smenorrhoea, menorrhagia,, and metrorrhagia. Of suppression there were twenty cases. In two of these there was suspicion of pregnancy; in two it was attributed to a sea-voyage, six and eight months previously, a not un- common cause among emigrants ; in two there was probable incipient phthisis, and six originated in exposure and chill while menstruating. One, twenty years of age, had never menstruated, examination revealing imperfect development of breasts and vulva, the uterus measuring but two inches. Of dy smenorrhoea, nineteen cases. Ten of these were due directly to stenosis, and were treated by dilatation or incision. One was associated with membranous exudation. Of the remainder some refused local examination, and in others the cause was not positively determined. Of menorrhagia and metrorrhagia twenty-nine cases are recorded in which the flow was not accounted for by some definite lesion, and so reported. One of these was due to 1 Sec the excellent remarks of Dr. Bantock and others on this subject in the Trans- actions of the Loudon Obstetrical Society for 1880, p. 188. 20 SYNOPSIS OF GYNECOLOGICAL CASES. excessive coitus, four to chill while menstruating, five to overwork, and nine were the sequence of previous miscar- riages, and subinvolution. Under the head of menopause three cases are recorded of indefinite pain, disordered circulation, and nervous dis- turbance. Vicarious menstruation is reported in one case, a laundress, aged 55, who had suffered from epistaxis every six weeks, since the cessation of regular catamenia, fifteen years previously. (See also Absence of Uterus below.) ABSENCE OF UTERUS. Finally, absence of the uterus is represented by one case, of which the following details are given : — F. R., aged 20, widow, was married at 14. The cata- menia never appeared. Always in good health until three months before admission, since which time she has suffered from headache, pains in bones, and a sharp, piercing pain in the lower abdomen, which had increased during the previous two weeks. Has some cough and dyspnoea, and suffers from palpitation and swollen feet. Appetite good, bowels regular, micturition normal. Upon examination, the vagina was found fairly developed, but terminating superiorly in a cul- de-sac, where a small nodule could be felt, both by vagina and rectum. She says that formerly epistaxis occurred every month. Has never had any preference for the com- pany of men, and has taken no pleasure in sexual inter- course. Headache is now her chief trouble. Three weeks after entrance she had two attacks of epistaxis, with relief, not only to her headache, but also to an extreme flatulence, which latter she says occurs every month. She remained three months and a half in the hospital, during which time she had, besides the epistaxis, one attack of haemoptysis and one of haematemesis. Among other means, electricity was resorted to, with the hope of developing the rudimentary uterus, but without avail.