REMOVAL OF THE Uterine Appendages NINE CONSECUTIVE CASES BY MARY A. DIXON JONES, M.D. GYNECOLOGIST TO WOMAN’S HOSPITAL OF BROOKLYN, N. Y. Reprinted from Thk Medical RKC0'Ra^J4jti?ust 21, 1886 NEW YORK TROW’S PRINTING AND BOOKBINDING COMPANY 201-213 East Twelfth Street 1886 ERRATA. Read menstruation for menstrual, page i, 6th line. Omit terms, page i, 6th line. Feeble for full, page i, 12th line. Depth for width, page I, 15th line. Madame Y$oW\x\for McBurney, page 27, 8th line. Version for fusion, page 29, 14th line. Help for helps, page 29, 5th line of note. Ovaries for organs, page 30, 20th line. Read mothers’ daughters for mothers, daughters, page 31, 20th line. REMOVAL OF THE UTERINE APPENDAGES. NINE CONSECUTIVE CASES. BY MARY A. DIXON JONES, GYNECOLOGIST TO WOMAN’S HOSPITAL OF BROOKLYN, N. Y. Reprinted from. The Medical Record, August 21, 1886. Case I. Fibromyomata ; chronic salpingitis ; enlarged and cystic ovaries.—Y. D , aged thirty-five ; married thirteen years ; two children, youngest seven years of age ; no miscarriages. Menstruation commenced at the age of thirteen ; menorrhagia. When eighteen years of age, menstrual more frequent, lasting longer terms, and ac- companied with pain ; sometimes only one week in the four was free from the flow. Her general health began to suffer, for which she was given various tonics. I was called to see the patient March, 1885. She was then very anaemic, weak, and prostrated, and there was mental depression ; pulse full, and a temperature varying from 990 to F. On examination I found two sub- peritoneal uterine fibroids ; uterus measured four inches in width, and its hard, irregular surface left no doubt that there were intramural growths. The cervix was lacerated, perineum ruptured, and the uterus had a tendency to 2 sink down into the lower part of the pelvis, thereby inter- fering, to some extent, with the functions of the rectum and bladder. This condition of the uterus, with the accompanying hemorrhages, was no doubt the cause of her suffering and ill-health, and though fibromyomata may be regarded by some as harmless and seldom fatal,1 yet the complications in this case would certainly lead to some disastrous re- sult.3 Her cachectic appearance and the low grade of constitutional disturbance suggested the possibility of some inflammatory action, or even the possibility of car- cinomatous or sarcomatous degeneration.8 But whatever were the conditions of the patient, she must be relieved if possible. Her system seemed now on the limits of its capability of endurance, the tumors were evidently increasing in size, and might at any time cause dangerous pressure or fatal hemorrhage. The ques- tion was, what was best to be done. Should we commence using-ergot, with the vague hope of somehow having good results ? Would the sub-serous tumors and the inter- stitial fibroids be favorably affected thereby ? Could we be justified in placing her for months under the influence of ergot, risking the dangers of abscesses and ergotism ? Would she live to stand the long and uncertain expeii- rnent ? And were we not equally uncertain of any good result ? * Should we try the various “ sorbefacients,” iodides, 1 “ Relatively few of them are fatal ” (Pepper’s System of Medicine, vol. iv.). a "Fatal results by no means infrequent” (Meadows, llrit. Gyn. Journal), “ Uterine myoma is fatal in a much larger number of instances than is generally supposed (Tait, lirit. Gyn. Journal). “ The growing tumors create exhausting hemorrhages, mental depression and anxiety, and disturbance of the functions of nutrition and excretion, which usually drag the patient down to the grave (Thomas, p. 533). a “ I have had several instances under observation where the tumor of a simple fibroid rapidly underwent the metamorphosis into sarcoma” (Emmet, p. S4f). “The weighty authority of Virchow is cast into the scale favoring the possibility of sarcomatous degeneration ” (Thomas). 4 “ Much harm has resulted from the injurious use of ergot ” (Emmet). Thomas says he has known many fatal cases of sloughing when the rigidly con- tracted os prevented a resort to surgical procedures. “ The moment the treatment ceases the hemorrhages come back as violently as ever ” (Lawson 1'ait). 3 bromides, and chlorides, which are said to have the power of removing these neoplasms ? 1 I could not be- lieve this would be of the least efficacy, and their long- continued use would only derange an already enfeebled stomach, and still more impoverish an already impover- ished system. Should we try etectrolysis, piercing the tumors with long electrolytic needles? Such a proceeding in this case would be attended with grave and unusual dangers.2 Should we remove the sub serous tumors, according to Schroeder’s method of partial hysterectomy ? The opera- tion is extremely dangerous, and, even if successful; there would still be the interstitial fibroids, which probably were .making most of the trouble. Enucleation and trac- tion have had brilliant results in the hands of two of our eminent American gynecologists, yet, with our present advance in surgery and improved methods of operating, hysterectomy seemed less appalling and less hazardous, and would more fully meet all the indications in this case,3 1 “ It is not possible by therapeutical means to obtain a sensible diminution in the volume ofa real fibrous tumor ” (Scanzom). “ We have never obtained any sen- sible results from the internal exhibition of iodine ” (Scanzoni). “Medical treat- ment is worse than useless, it is a mere waste of time ; I would say, scarcely hon- est ” (Meadows, Brit. Gyn. Journal). “ I very much fear that no remedy exists that will exert any influence on the growth of these tumors, or cause their absorp- tion” (West and Duncan). “We know of no means whet eby they can be made to disappear short of a surgical operation” (Hewitt, op. cit., p. 569). “ No such effect can be looked for with any confidence ” (Thomas). “We are to-day igno- rant of any means, other than extiraption, by which a hard fibroid can be removed from the uterine tissue ” (Emmet, op. cit., p. 566). “ I have never seen a single instance, nor an approach to one” (Tait, May 27, 1885). “The medical treat- ment of uterine fibroma is a myth ” (Lawson Tait). 3 “ I have seen several deaths occur from it in this city” (Emmet). “The pro- fession has not generally consented to the adoption of this measure as safe and efficacious ” (Pepper’s System of Medicine, p. 270, vol. iv.). 3 “The results of enucleation (interstitial fibroids) are by no means encourag- ing. We class the operation among the most hazardous in surgery ” (Diseases of Women, West and Duncan). “ It really deserves, as far as I am concerned, the appellation of the word butchery” (Lawson Tait, Brit. Gyn. Journal). Emmet says : “ In this city alone three deaths have occurred from perforation by the hand of three different operators when dexterity could not be questioned ” (op. cit., p. 607). Dr. More Madden, before the British Gynecological Society, speaks of the “ less heroic measures, such as enucleation and removal by traction,” and says : “ I think the operation of enucleation, which is teally a very simple operation, and which has been very successful in my practice, is preferable in suitable cases. By this operation I have removed not only large submucous fibro-myomas, but also inter- stitial, and in some instances partly sub-serous, tumors.” One case he reports : 4 There was left for consideration either hysterectomy or removal of the uterine appendages. In the present state of the patient, a necessity for the former operation would be unfortunate, and the uterine appendages were so diseased that their removal was a necessity. I decided to do either hysterectomy or Tail’s opera- tion, as would be best for the patient. May 19, 1885, the patient was received into my private hospital, and on May 23d I performed the latter, assisted by I)r. C. C. Lee, Dr. C. N. Jones, Dr. S. King, and Dr. J. C. Minard. The condition of the uterus was well ex- amined, and it was deemed advisable to remove only the appendages. There was considerable difficulty in secur- ing a pedicle. The ovaries were three times their normal size, and projecting from each one was a cyst the size of a hen’s egg. It seemed almost aqu istion whether we were operating for cystic ovaries or for a fibroma. The patient slept well the night after the operation ; next day took some nourishment; sixth day ate solid food with relish. Temperature, 98$° ; pulse, 70. Eighth day, stitches removed ; abdominal wound entirely healed, On the twenty-fifth day after the operation she was dis- charged from the hospital well, and walked four blocks that morning without any discomfort. She has continued to grow strong, and has been in excellent health ever “ Uterus retroflexed, hollow of the sacrum occupied by a large globular interstitial tumor, as large as a foetal head at the seventh month.” The uterine cavity was laid open and the uncertain instruments were plunged in, pulling forth the tumor. “ A large coil of intestines followed,” as if to know whether he so unkindly knocked or no. The instruments were in the peritoneal cavity ! Not able to see what was the injury, how to repair it, or how to clean the cavity. The patient was in col- lapse, but fortunately recovered. The second case he reports: "Uterus com- pletely retroverted, a considerable-sized tumor was found bulging into the uterine cavity. The most prominent portion of the tumor was firmly grasped by the vul- sellum and forcibly dragged down through the os, and as tar as possible into the vagina; and the growth was thus cut away. In this 'way we had removed more than two-thirds of the growth when the patient became collapsed. On the second night after the operation she again became collapsed, sank and died." As I see it, a carefully and well-arranged hysterectomy is less dangerous, and gives a more intelligent chance of saving life. About the time of my operation, or just before, I had the pleasure of w itnessing Dr. C. C. I.ee perform hysterectomy, at the New York Woman’s Hospital, for an immense cystic fibroid of the uterus. 'Ilie operation progressed pleasantly, and the patient made an excellent recovery 5 since, has gained in flesh, is active and vigorous, and says she has not been as comfortable or as well since she was a girl. The size of the tumors are gradually dimin- ishing. Macroscopical examination : The tubes are long and tortuous, the ovaries are enormously enlarged, and on their surface exhibit numerous cicatrices. On section the structure is dense and fibrous, and enclosing numer- ous cyst cavities. Fig. i.—Sub acute Ovaritis. 15 L, Longitudinal bundles of dense fibrous con- nective tissue ; 15 T, transverse bundles of such cicatricial tissue ; I, groups of in- flammatory corpuscles of recent date (acute inflammation) ; O, ovum,. coarsely granular ; E, ovum split up into epithelia ; O I, ovuin split up into epithelia and inflammatory corpuscles, x 500. Microscopical examination : 1 Both ovaries are in a state of chronic ovaritis. All the special ovarian tissue is replaced by dense fibrous connective tissue, coarse fibres interlacing. The left ovary in its cortical portion exhibits nests of inflammatory corpuscles, which shows 1 The microscopical examinations were made in Dr. Heitzman’s laboratory, part.of them by Dr. Mary D. Jones and part by Dr. C. N. D. Jones. 6 that the morbid process in portions of the ovary is sub- acute. In the cortical substance of the ovary are still left a few small ova, and it is interesting to trace out under the microscope the manner in which the ova are destroyed. We could also see groups of epithelia, when an ovum had been split up into its constitutional ele- ments ; still other groups gave a cluster of partly epithe- lial and partly inflammatory corpuscles, which latter had arisen from thetepithelia. Such inflammatory corpuscles mixed with those arising from the connective tissue and the smooth muscle-fibres, showed the formation of cicatri- cial fibrous connective tissue. Case II. Chronic ovaritis ; encysted sarcoma of left ovary ; salpingitis.—Miss L. M , single; thirty-five years of age. Menstruation commenced at the age of thirteen ; severe pain the first time, and she has never passed a period since without great suffering, the pain always commencing three or four days before the flow. The flow now lasts four or five days, not as long as for- merly, nor is the flow as great, but the pain is constant and unremitting, so severe at times she can neither walk nor stand. She also states that her first attack of seri- ous illness was fifteen years ago, when she was taken with a hard aching pain in the left side of the pelvis, which increased gradually year by year, ofttimes prevent- ing her from sleeping, and frequently so sharp and lanci- nating that she had to scream with the agony. For this suffering she consulted many physicians, and had a great variety of treatment ; some prescribed fly-blisters to be repeatedly placed over the lower part of the abdo- men, and leeching at intervals; some used pessaries which she said “ always made her worse; ” for nine months she was treated for “ inflammation and misplace- ment,” with no relief; a year she was treated for ‘ul- ceration,” no better results ; for five years she was treated for “uterine congestion.” The next physician, after at- tending her for some time, said he could do nothing more, and relieved by hypodermatic injections of morphia. 7 Her last physician treated her for valvular disease of the heart ; said the uterus was misplaced and bound down by adhesions. He also attempted to introduce pessaries, which, as before, “gave great distress.” The patient first called to see me May 5, 1885. I found the uterus acutely anteflexed, not adherent, ova- ries small, tender, and exceedingly sensitive. The pa- tient was extremely nervous, hysterical, and her mental condition somewhat disturbed. Many of her friends said “she was not exactly right in her mind.” But I considered all these abnormal nerve symptoms due to reflex irritation from the condition of the ovaries, and in- formed the patient that an operation for their removal might be necessary. I did not see her again for more than a month, and on examination found the same conditions I had pre- viously diagnosed. The patient informed me that she had made efforts to get into a hospital, but had not suc- ceeded. First applied to the Homoeopathic Hospital in New York, was examined by the visiting surgeon, but not admitted. Next applied to a hospital in Brooklyn ; after a consultation of the staff, she was informed that she was incurable, and the hospital did not receive “ in- curables.” I told her I would admit her into my private hospital, give her any necessary treatment, and perform for her any operation that might be necessary for her re- covery. The next day, June 18th, she entered. I had her immediately put in bed, kept quiet, good nourish- ment. Massage twice daily, bowels freely open, hot douches daily, and the skin kept active by warm baths and rubbings. June 25, 1885, I performed laparotomy, assisted by Professor Wylie and Dr. C. N. D. Jones. Dr. S. King gave the ether ; the ovaries and tubes from each side were removed. The next day her temperature was 101°, pulse, 98. On the fifth day she asked for beefsteak and toast for breakfast, and on the eighth day the sutures were removed from the abdominal walls, when the wound 8 was found entirely healed, and on August ist she was discharged from the hospital apparently well. Fio. 2.—C, coarse fibrous connective tissue, with large blood vessels ; V, mainly venous in character; S, septum, or prolongation of connective tissue into a closed space filled with globular and angular corpuscles in rows. Between the rows there are fat-globules and empty slits. A, cellular elements. Macroscopical appearance of specimens : Both tubes are dilated ; the left at one portion is dilated into a sac 9 2 ctm. in diameter, and at the fimbriated extremity the lumen is obliterated by inflammation. Both ovaries are smaller than normal, and contain numerous small cysts. Microscopical examination : Section from left ovary gave a rather startling appearance ; there were numerous comparatively large alveoli, or closed places, filled with a tissue endothelial in nature ; the alveoli were sur- rounded by and closed with coarse fibrous connective tissue, richly supplied with blood-vessels. This connec- tive tissue penetrated the alveoli, remaining fibrous in character, and produced elevations which were surrounded by endothelial tissue. The boundary line between the connective tissue and the endothelium in most places was sharply marked, in other places the two tissues blended without any definite line of demarcation. The endothe- lial tissue consisted of globular and polyhedral corpuscles, mainly arranged in rows, and freely intermixed with dark brown fat- and pigment-globules. The rows of corpuscles are in many places interrupted by light gaps, probably caused by a liquefaction of these corpuscles. This tu- mor we would have to term either an endothelioma or an alveolar sarcoma. Right ovary contains cysts filled with an albuminous liquid. The arteries of the medullary portion are tortu- ous in a high degree, and their middle coat in a marked waxy degeneration ; the stroma everywhere is trans- formed into dense interlacing connective tissue, the re- sult of chronic ovaritis. Many persons thought the patient could not survive the operation ; but since it was performed she has been constantly gaining in strength and vigor. She looks well, and her nerve conditions are improvirg. October io, 1885, she called to see me, and said she had gone to church three times the previous Sunday—walking. Case II. Chronic pelvic peritonitis; pyo-salpinx; ovaritis.—H. J , a frail little woman, aged twenty- three years, weight seventy-five pounds, called to see me August 18, 1885. She has been married two years and 10 eight months. Menstruation appeared at the age of twelve; no pain at first, but soon after she had dysmenor- rhuea, which gradually grew more and more severe, and the menstrual flow more profuse, continuing eight or nine days. A year after marriage she gave birth to a premature child, seven and one-half months, which lived only a few days. After childbirth she had a severe attack of septic peritonitis, which lasted eleven weeks, since which time she has not been able to go around, constantly in bed, says the slightest exertion prostrates her, that she “ suffers constantly with pain and soreness in the pelvis ; sharp piercing pains darting and shooting up through the rectum, not a day that she does not feel these piercing pains, frequently many times during the day; that for seven years she has suffered thus, had every thing put on to draw the inflammation out ; ” now, she says, “ she is willing to go through anything for the sake of being well.” Her temperature and pulse were and ico respectively. 1 examined the pelvic organs, and found the cervix lac- erated, excessive tenderness in the region of the ovaries, tubes enlarged and evidently fixed by firm adhesions. At once, there seemed to be no other way of relieving her sufferings or curing her than by the removal of the uterine appendages. Still, while preparing her for the operation, I determined to see if treatment could not, according to the statement of some, cure her, and so supersede the necessity of an operation ; for if anyone should be saved the dangers of an operation it was this frail, feeble little woman. One of our most distinguished gynecologists says some cases of tubal and ovarian disease can be cured by repeated applications of Churchill’s tinct- ure of iodine, hot douches, etc. I tried faithfully these, and, as I thought, all other recognized and approved means. The patient was in my private hospital, and everything was constantly done to improve her special and general con- dition. Her health grew better, and she seemed much improved in many respects, there was less peritoneal in- 11 flammation, the adhesions stretched and softened, yet, after all these three months of persistent and careful treat- ment, there seemed to be just as much soreness and ten- derness about the ovaries, the tubes seemed to be even more enlarged and prominent, the darting pains just as severe and frequent, the movement of the bowels just as painful, and the patient no more able to be out of bed. There was now as much necessity for the operation as there was three months previously. Her life was in peril without it. The patient was anxious and impatient for it to be performed ; many times when other patients were to undergo operations she would wish it was her; often said, “she wanted her ovaries taken out.” October 29th we commenced to prepare her especially for the opera- tion, and on the 31st it was performed. I made the usual incision of two and one-half inches, the abdominal walls bled freely, and there was great difficulty in getting out the appendages on account of strong adhesions. Both tubes were firmly adherent by their extremities, and throughout their whole extent to the ovaries, and were very much dilated and filled with fluid. Their trans- parent attenuated walls seemed ready to burst. The pedicle on each side was firmly secured, appendages re- moved, and the peritoneal cavity washed out, but there was so much, and such continued oozing that a drainage- tube was put in. At 9.30 same evening, temperature ioi°, pulse 130; fifth day, temperature pulse 100. The tube was repeatedly washed out and the dressings changed, considerable bloody serum oozed out. On sixth day glass tube was removed and a small rubber tube in- serted in its place. Eighth day, sutures removed ; the patient seemed well, temperature and pulse almost nor- mal, appetite good, and she relieved of the pain from which she had long suffered, yet the fistulous tract did not heal; there continued to be a small sinus from which constantly issued a slight discharge. One day, some two months after the operation, as I was pressing the sides of this fistulous canal to see the 12 quantity and nature of the discharge, there burst out a small white mass, which, upon examination, proved to be the ligature of one of the stumps—there was the Stafford- shire knot exactly ! The lower end of the drainage-tube had in some way become displaced toward the right side ; probably in this way the ligature had become infected and was consequently expelled. Soon after the passage of this ligature the fistulous tract healed, and there was no further trouble.1 Fig. 3.—Representation of the structures after they had laid in Chromic acid three months. (), ovary with deep cicatricial furrows ; F, Fallopian lube with marked convolutions and cystic enlargements; FE, fimbriated extremity of ttic tube firmly attached to the ovary. May 20, 1886, her husband writes that she is feeling splendidly; that he could not have imagined that she ever could be as well. May 30th, she wrote : “ Doctor, you have given me my life, and what is more, an interest in life.” 1 I.ast October McBurney, of New York, performed the radical operation for hernia, using six silk ligatures ; there remained two sinuses. On April 9th, in cutting down he found the ligatures had not been absorbed. March 26, 1886, Dr. C. N. D. Jones performed same operation for an enormous hernia. A small fistula remained. May 20th the wound was opened in the line of the old cicatrix and the unabsorbed ligature removed, after which the wound healed rapidly. 13 Microscopical section of the left ovary revealed the presence of rather dense fibrous connective tissue, inter- laced with small bundles of smooth muscle-fibres ; folli- cles scanty. Ovary has the appearance of senile involu- tion (M. I.). Microscopical section from the right ovary exhibits acute inflammation, arteries dilated and extreme- ly tortuous (C). The tubes were in a state of chronic pyo-salpingitis. Fig. 4. When we examine these structures we see how com- pletely their physiological functions were destroyed. Even if we had aspirated the tubes, and so drawn off the pus, ovaries were so diseased, the lining membrane of the tubes so changed, and there was such a desqua- mation of the epithelii. that there could not possibly have been any true functionating power. And the aspirating or opening and draining would have been as dangerous as the operation for removal, and there would still have been left the diseased structures to give trouble and dis- tress, and be a cause of serious complications. By this operation (Tait’s) many cases can be restored to health who must otherwise suffer and die. I can now look back upon a practice of years, and remember many 14 whom I could have cured if I had known of this opera- tion at the time. Case IV. Chronic ovaritis; Abscess of left ovary; Pyo-sa/pingitis—Mrs. D . a delicate young woman, twenty-one years of age, married two years, no children ; menstruation commenced at the age of thirteen, from the first it was accompanied with great pain, the pain commencing two or three days before the flow. After marriage dysmenorrhoea was much increased ; she had an attack of gonorrhoea, which inflammation and infection extended through the tubes, causing inflammation so se- vere that she had to keep her bed the most of the time. When first seen by the writer she had been confined to her bed for some weeks, the whole pelvis was sore and tender, on each side of the uterus was a mass low down and extremely sensitive. In appearance the patient was small and imperfectly developed, there was no breadth or depth to the pelvis, and an apparent lack of vigor in every organ. She was removed to my private hospital, November n, 1885, not able to sit up, had a quick, feeble pulse and a high temperature. She was placed immediately in bed, and had constant care day and night. By treatment the size of the mass was reduced, adhesions softened, and much of the sensitiveness relieved. The patient in every respect seemed in a very much better condition, had a good appetite, was able to be around, and was feeling comfortable. Some would have pro- nounced her “cured without an operation,” but we knew the causes were still existing, ready to give trouble at any time. The patient was very anxious that the diseased struct- ures should be removed, though in some way she be- came fully impressed with the idea that she would not live. January 23, 1886, I performed the operation for the removal of the appendages, assisted by l)r. W. G. Wylie and Dr. C. N. D. Jones. Dr. lngals administered the ether. The ovaries were large and adherent. Right ovary was first removed, it measured 2k inches ; the left 15 one measured inches. In lifting the left ovary an abscess in the ovary burst, discharging a thick, greenish-yellow pus, some of which escaped into the peritoneal cavity. The cavity was well washed out, but the continual ooz ing from the broken adhesions made it necessary to put in a drainage-tube. For a long time after being placed in bed the patient seemed to be in a condition of ex- treme surgical shock, which lasted some hours. Her external surface was cold and clammy. Two attendants continued rubbing her for more than an hour before re- action was fully established. Her pulse continued to go up, and by next morning it was 170 per minute, and soon grew so rapid that it could not be counted ; tem- perature, ioi|°. By 11 p.m. the day after the operation her pulse was again 170 per minute ; temperature, ioi|°. Tube was washed out. On third day at 8.30 a.m. her pulse was 160 ; temperature, Pancreatized milk was given by the rectum. Fourth day—pulse, 120; temperature, i o 11°. Nausea and vomiting still continued ; at 9 a.m. vomited dark fluid ; gave seidlitz powders ; washed out the tube, no vomiting after. Up to this time she had taken ten seidlitz powders. They had pro- duced no operation on the bowels, yet in some way they seemed to have the power of destroying or carrying off the microbes, and so preventing any septicaemia.’ From this time the patient began to improve rapidly, and Sat- urday morning, a week after the operation, she looked brighter, better, and stronger than she had looked for months. Seventh day the glass drainage-tube was re- moved and a small rubber tube inserted in its place, which was removed at the end of another week, and be- fore the end of the third week the opening was entirely closed and the wound healed. Twenty-second day after the operation the patient left the hospital, rode three miles to another part of the city, stepped lightly from the 1 On the slightest indication of peritonitis after an ovariotomy we give a rapidly acting purgative, it matters not what (Tail, in Hritish Medical Journal, May 15, x836). 16 carriage, ran up high steps to the front door, then up a high flight of stairs to the second1 floor ; said ‘‘she felt perfectly well ; had not a pain or an ache.” March 2, 1886, she wrote: “I am feeling perfectly well, never felt better in my life ; have an excellent appetite, and am gaining in flesh.” The cause of suffering was removed, which, if allowed to remain, would doubtless have caused her death before many months. Fig. 5.—F, F, follicles ; A, abscess crfvity ; FE, fimbriated extremity of Fallopian tube. Macroscopical examination : Left ovary very much en- larged, upper surface exhibiting an opening with jagged edges, which led into a pus-cavity three centimetres in diameter, fimbriated extremity of Fallopian tube dilated into a pus-sack. A vertical section through the ovary exhibits two follicles, and in the centre an abscess cavity, with irregular walls. In its vicinity and toward the outer periphery the tissue is discolored, soft, and friable, in- dicative of beginning suppuration. Microscopical examination : A section from the vicin- ity of the abscess exhibits a marked infiltration of the tis- sue with inflammatory corpuscles. Both the myxomatous and fibrous connective tissue are transformed into inflam- matory corpuscles to a considerable extent. The smooth 17 muscle-fibres likewise are transformed into such corpus- cles, and in many places rows of the corpuscles indicate their origin from smooth muscle-fibres. This transforma- tion also invades the endothelium and the smooth muscle- fibres of the middle coat of the arteries, which near the apices appear to be completely destroyed. The corti- cal substance of the ovary not invaded by inflammation is of a marked myxomatous character. The right ovary is in a condition of sub acute inflam- mation. Portions of the medullary substance being trans- formed into dense fibrous connective tissue, other por- tions are crowded with inflammatory corpuscles. Kig. 6.—Suppurative ovaritis. M, rows of inflammatory corpuscles originating from smooth muscle-fibres; A, artery whose endothelial and muscle-coat toward the lower extremity is completely transformed into inflammatory corpuscles; P, beginning formation of an abscess, x 500. Left Fallopian tube exhibits a marked inflammation and infiltration both in the mucosa and in the muscle-tis- sue. Right Fallopian tube is in a state of acute inflam- mation, both in the mucosa and muscle-coat. Comparatively few cases of abscess of the ovaries are reported. In Scanzoni’s work, p. 398, is recorded a case of abscess of the ovary ; woman died suddenly from rupture of abscess into the peritoneal cavity. Emmet, in the last edition of his work, p. 651, says: “I have 18 seen but one instance of this kind of ovary. A mass, the size of a hen’s egg, was felt on left side. February 16th application of pure carbolic acid was made to the fun- dus daily by means of an applicator ; 23d, sponge-tent introduced, canal dilated, granulations removed, and equal parts of carbolic acid and glycerine applied freely throughout the canal. March 25th, canal partially di- lated to facilitate the application of carbolic acid. On 30th, when half awake, she turned suddenly in bed, when she felt something move inside of her, went into collapse, and died.” From the autopsy, made five hours after death, the author says : “ It was evident the ovary had long been the seat of an abscess.” Thomas, p. 667, quotes a similar case of collapse and death : “ A blister had been applied on the hypogas- trium, and opium given in large doses, five days after became collasped and died. Autopsy eighteen hours after death ; between the organs a great deal of puriform serum ; left ovary size of hen’s egg ; in its removal several ounces of pus escaped. No evidence of cellulitis.” Lawson Tail says, in his work on “ Diseases of the Ovaries”: “Abscess of the ovaries is a condition of extreme rarity, and in the majority of instances probably death occurs from the rupture of the abscess into the peritoneum. The only cases of abscesses of the ovary, in clinical experience of which I have been certain, are two.” F'irsl case, op. cit., 61 : “ Left ovary contained two ounces of pus ; both ovaries and tubes removed ; patient recovered without a bad symptom.” The second case, op. cit., 125: “Patient had suffered many years with great ovarian pain ; much increased at the menstrual period ; the left ovary contained two drachms of pus and appeared to be on the point of bursting into the abdom- inal cavity. Had it done so she doubtless would have died. Both appendages were removed, and she made a perfect recovery.” In the same work he quotes two cases that were re- ported in The Lancet, 1877. “One had an exploratory 19 incision, patient died a few hours after ; the other had an exploratory puncture, symptoms grew worse, and she died some months after.” Tait remarks, “ It is impossible to resist the conclusion that abdominal section, performed soon after the onset of serious symptoms, would have enabled the surgeon to have relieved his patient.” July, 1885, before the British Gynecological Society, Lawson Tait reported two cases of double pyo-salpinx together with abscess of right ovary. “ The lives of both patients had been for months in jeopardy ; the operations were of extreme difficulty; abscesses bursted ; and very great care had to be taken in cleansing the peritoneum. The patients recovered ” {Brit. Gyn. Journal). April, 1886, Tait reports before the same society an- other case of abscess of the ovary : “ Operation extremely difficult and the hemorrhage severe ” {Brit. Med. Journal, May 8, 1886). Edis reported before the same society a successful operation for abscess of ovary. As far as I have seen the reports, the only patients with abscess of the ovaries who have recovered are those for whom Tait’s operation was performed. Case V.—Chronic ovaritis ; pyo-salpingitis.—Miss A. Y , a young woman, twenty years of age, has suffered with constant pain in the pelvis for seven years, greatly increased at the menstrual periods, and at times ex- tremely severe. But the most serious consideration in her case was the unhappy and abnormal manifestations of the nervous system, depression of spirits, and at times the contemplation of suicide. All of which symptoms I believe were largely due to reflex irritation from the thoroughly diseased condition of the ovaries and tubes. When first called to see her I found on examination uterus completely retroflexed and retroverted, both ova- ries enlarged, sensitive, and dislocated down into the recto-uterine cul-de-sac. I made known to her her con- dition and the necessity for an operation. She at once accepted the idea and was impatient for the operation to 20 be performed, frequently saying, “1 want both ovaries and both tubes removed said that “for years she had suffered such distress and agonizing pain that she could stand it no longer.” She was by special and general treatment prepared for the operation. I removed the appendages from both sides of the uterus. She made an excellent recovery, and month by month she is growing stronger and more vigorous, her nervous system more and more normal, and she is enabled to enjoy life and attend to her ordinary duties. Microscopical examination showed chronic ovaritis and pyo-salpingitis. Case VI. Hystero-epilefisy ; cirrhosis of the ovaries ; salpingitis.—Mrs. M. K , aged thirty-six years. After the birth of the fourth child her health began to fail; great prostration, and suffering much with her back, con- stant pain and distress in the pelvis ; and there was a history of gonorrhoeal infection. The attacks of hystero- epilepsy were gradually growing more serious, her mind was becoming less active, and her perceptions more ob- tuse. Already her face had the dull, heavy expression of an epileptic. These epileptic attacks recurred at every monthly period ; sometimes during the day she would have a continued succession of convulsions, with inter- vals of only a few minutes, struggling and throwing her- self in all conceivable positions; frequently opistho- tonus, and showing “ le pied hysterique.” It was evident that these spasms or convulsions were caused by some internal irritation ; and unless the cause was removed it was impossible for any medical treatment or appliances to help her, or prevent the recurrence of the spasms. Such cases usually tend to idiocy and death. When I presented to her the hope of possibly relieving her by removing the diseased ovaries, she cordially ac- cepted the idea, and on December io, 1885, 1 performed the operation, in my private hospital, assisted by Dr. C. N. D. Jones. Dr. Cary gave the ether. Dr. J. L. Mi- 21 nard was present. The patient recovered well from the ether, and seemed scarcely sick during the whole con- valescence from the operation ; was up and around at the end of the second week. She has since done well in every respect, showing greatly improved nervous condi- tion, and up to the present time, June 5th, has not had a return of the spasms, and the dull epileptic look is giving way to a more intelligent countenance. Macroscopical examination : Ovaries small, hard, and nodular. When cut open they were markedly cirrhotic, composed entirely of coarse fibrous tissue, interlacing. Almost the whole gland-structure was replaced by cicatri- cial tissue. In the left ovary was seen the remains of only one follicle ; in the right there were three, all of them located near the outer end of the ovary. The tubes were dilated into three cyst cavities and there were sev- eral small parovarian cysts. Microscopical examination : Left ovary almost entirely transformed into dense fibrous connective tissue; no healthy gland-structure left. Right ovary, especially in its medullary portion shows, in some places, inflammatory infiltration, crowded with inflammatory corpuscles, while in other parts the ovarian tissue is transformed into dense fibrous connective tissue. The condition is sub-acute ovaritis. There is a marked dilatation and tortuosity of the blood-vessels, most of the arteries showing hyper- plasia of the middle coat with marked waxy degeneration. The tubes are in a condition of well-pronounced sal- pingitis, both in the mucous and muscular portion. The tubal arteries show hyperplasia of the muscle-coat. I conceive that nothing else would have relieved the spasms. No amount of bromides or massage—nothing but the removal of these diseased organs—organs which had organically changed in structure, which could no longer perform their functions, and hence were a source of irritation. Case VII. Salpingitis; ovaritis.—M. S , twenty- six years of age ; married six years ; two children, the 22 youngest fifteen months old. She complained of great pain in her back, in her pelvis, and down her thighs, and so much bearing down, heaviness, and distress that she could not rest night or day ; could not attend to her du- ties ; was always tormented with this constant suffering. She had done everything to find relief. The cervix had been twice sewed up, the perineum had been restored, and lately the patient had spent seven months in a hos- pital, and the womb had been treated ad nauseam. Still her sufferings were just as great, as constant, and as con- tinued. On examination I found the uterus completely retroverted, lips of the cervix gaping wide apart and covered with hard cicatricial tissue, the ovaries very ten- der and dislocated down into Douglas’ cul-de-sac. She entered my private hospital January 20, 1886. I sewed up the lacerated cervix for the third time, in hopes possibly of relieving some of her nervous symptoms, and as a little recreation to her while she should be prepared for the more serious operation. Such was her nervous excitability that she had to be chained by some thought. I informed her that this operation would not relieve the great distress, and eight days after she pretty clearly in- formed me of the same fact; but the operation was an entire success, the wayward walls of the cervix were brought into perfect and easy coaptation, and there they will stay, a specimen of good workmanship ! Wound healed by first intention. The operation for the removal of the appendages took place February 10th. Present, Dr. C. N. 1). Jones and Dr. Ingalls. Before the operation the husband informed me that “ the desire for a family was nothing compared to the distress of seeing her constantly suffer.” I know the mild-mannered man had groaned under her tantrums, and felt that he could not live with her and her two ova- ries, too. The appendages were removed from both sides. The ovaries were atrophied, and had evidently been the seat of long-standing inflammation. Third day after the operation the patient was singing, and said she 23 felt well enough to get up. As days passed on she per- ceived she was free from the old distress that had fol- lowed her for years. At the end of sixteen days she was discharged from the hospital, well. I saw the patient May 6th. She was the picture of health ; happy, cheerful, and active in her household du- ties ; said she felt perfectly well, had no pain or distress. Many suppose this operation renders a woman sterile, but we must bear in mind that she is already completely sterilized by disease. The operation takes away the cause of suffering, and enables the patient to lead a life of usefulness and activity, instead of suffering long years of invalidism. Macroscopical examinations of specimens: Both tubes present an anomalous appearance. Each is bifid from the central portion outward, having two distinct sets of fimbriae ; the lumina of the twin tubes remain separate to the point at which they were severed from the uterus, and probably continued so until they communicated with the uterine cavity. The walls of the tube are much thickened, together with the meso-salpinx ; in the latter there are numerous small cysts. The ovaries are small and atrophied. Nearly the whole portion of the left ovary is occupied by a large cyst. Microscopical examination : Both ovaries are in a state of acute and subacute ovaritis, groups of inflamma- tory corpuscles mainly in the cortical portion. The arteries of the left ovary are in a state of waxy degener- ation, and the stroma contains a large number of amy- laceous corpuscles. Both tubes are in a state of acute salpingitis; both in the mucosa and muscle-coat there are groups of inflammatory corpuscles. Case VIII. Salpingitis; ovaritis; ovarian hcerna- toma.—Miss L. S , aged twenty-three, has been suf- fering with pain in the'pelvis for the last five years, very much increased at thejnenstrual period. Menstruation commenced at the age of thirteen. She suffered agonies, not only during the period, but for three or four days be- 24 fore ; and for the last two years has been unable to attend to her ordinary duties. She called to see me February 20th. On examination I found the uterus anteflexed and bound down by adhe- sions, and a large inflammatory mass low down on each side of the uterus. By treatment the conditions were very much ameliorated, and on March 27th she entered my private hospital, and on the 31st 1 performed the operation for removing the uterine appendages, assisted by Dr. C. N. I). Jones. Dr. Ingalls administered the ether. The abdominal walls bled profusely, and there was great difficulty in getting out the ovaries on account of dense and firm adhesions and extreme shortening of the broad ligament. She recovered nicely, with no draw- back except unusual nausea and vomiting, probably due to chronic dyspepsia and an enlarged liver. Macroscopical examination : The right ovary on one surface presents a ragged opening leading into a cavity three centimetres in diameter, which contains a large clot of blood, and is therefore the seat of a hamatoma sacca- turn. The other portion is in a state of cystic degeneration. In the left ovary there is not the least vestige of normal ovarian tissue, nor is there a single Graafian follicle, or normal corpus lutea ; the whole is occupied by an in finite number of small cysts, the larger of which is about one centimetre in diameter. In the right ovary, stroma transformed into fibrous con- nective tissue to some extent, other portions occupied by inflammatory corpuscles; sub-acute ovaritis; waxy de- generation of the arteries ; corpora atnylacea. Case IX. Ovaritis ; abscess of right ovary ; chronic salpingitis ; endo arteritis {syphilitic t). — M. B , twenty-four years of age, unmarried. Menstruated at fifteen; before the appearance of menstrualin was sub- ject to attacks of dizziness. The last five years she has suffered with almost constant pain in the pelvis, very much increased at the menstrual periods, and for the last three years the intense pain has commenced a week be- 25 fore the flow, and continued during the period, being so sharp and severe that she has had to keep her bed lately most of the time. She was sent February to, 1886, by one of the con- sultants to the Woman’s Hospital clinic. On examination I found the whole pelvis exceedingly tender, the slightest pressure from the outside causing pain ; the uterus was acutely anteflexed and the appendages drawn up by ad- hesive inflammation. While in the Woman’s Hospital she was treated, the uterus dilated, etc., but the menstrual pain continued just as severe, and her sufferings just as constant. April 3d she was admitted into my private hospital, and on the 6th I removed the uterine append- ages. There was great difficulty in the operation, on ac- count of many and firm adhesions, and during the opera- tion an abscess in the right ovary burst. The peritoneum was carefully washed out and the patient made an excel- lent recovery, and is now relieved of that almost con- stant pain and suffering which was exhausting her strength and making an invalid of an otherwise healthy woman. Macroscopical examination : The ovaries and tubes are much enlarged ; in the right ovary there is a large cavity, 1.5 ctm. in diameter, the contents of which escaped dur- ing removal. In the left ovary, at the distal extremity, there is a cystic protuberance, which, on section, is found to contain a grumous fluid, which being placed under the microscope shows pus-cells and debris. Microscopical examination : Left ovary—The whole stroma is transformed into fibrous connective tissue, the bundles of which are freely interlacing. Some portions of the tissue are in a state of high waxy degeneration. The arteries in the middle coat are also in a state of waxy degeneration, the calibres of which are much narrowed, or nearly obliterated, owing to an outgrowth of the endo- thelia, which is the characteristic feature of chronic endo- arteritis. The tissue is crowded with amylaceous cor- puscles. Diagnosis, chronic ovaritis ; waxy degeneration 26 of the newly formed connective tissue and of the arteries ; corpora amylacea. Right ovary contained a small abscess, with character- istic appearances. Left Fallopian tube—The epithelium is preserved to a large extent, but is mostly destitute of cilia. The con- nective tissue is slightly augmented and of a delicate fi- brous structure, in some portions with a waxy gloss, in other portions crowded with inflammatory corpuscles, also slightly waxy. Most of the arteries in their middle coats are enlarged and in a high degree of waxy degen- eration. The calibre of some arteries is crowded with inflammatory corpuscles, a feature of endo-arteritis. Both in the epithelial and connective-tissue layers numerous highly refractory structureless corpuscles are scattered— so called corpora amylacea. Right tube—The features clearly resemble those of the left; arteries dilated and tortuous ; waxy degenera- tion ; corpora amylacea. Each of these patients had metrostaxis, and no ap- pearance of menstruation since. The microscopical examination of the appendages shows that each patient had ovaritis in some stage; some of them probably commenced menstrual life with ovarian congestion. The first case had hyperaemia of the ovaries when very young, which soon passed into acute ovaritis, then into a more chronic condition, then into cystic degeneration. The second case, an unmarried woman, suffered for years with acute and chronic ovaritis, long before the sarcoma was developed. The fifth case, also a young unmarried woman, had for years an inflam- matory condition of the ovaries. The third case had evidence of acute and chronic ovaritis long before the complications of puerperal peritonitis. The fourth case, a young married woman of twenty-two, probably had ovaritis for nearly half of her life. The ovaries of Case VI. show in some portions chronic ovaritis, in others subacute, and in other portions a cirrhosed condition, 27 which was the outcome of long-standing inflammation. In the seventh case the ovaries were cirrhotic and atrophied. The eighth and ninth cases, both single women, had ovaries organically diseased ; in one there is not the least trace of normal ovarian tissue left, while in the other the whole stroma is transformed into fibrous con- nective tissue. McBurney is often quoted as having said, “ That it would be difficult to point out a single well-authenticated case of acute ovaritis out of the condition of pregnancy.” The same idea seems to be repeated in most of our standard gynecological works. “The ovary is seldom the seat of inflammation except as the result of child- birth ” (Emmet). “ Acute inflammation of an unimpreg- nated ovary is of such rare occurrence that no case has come under my care” (West and Duncan). “Acute inflammation and abscess of the ovary is a condition rarely met with in practice ” (Hewitt). “ We have had but a single opportunity of studying non-puerperal acute ovaritis upon the cadaver” (Scanzoni). “ Acute ovaritis is quite rare, except as a complication of peritonitis and cellulitis ” (Thomas). The first-named author further says : “In attacks of peritonitis and cellulitis the ovary may have been only scorched in the general conflagra- tion ; ” that “ the ovary is scantily supplied with nerves, and the pain that is so frequently experienced in the neighborhood of the ovaries has no direct connection with the ovaries.” So even our classical “ ovarian irri- tation ” is a delusion ! Bennett says : “ In nineteen cases out of twenty in which the ovarian region is the seat of a dull, aching pain, and apparently tender and swollen, there is no actual ovarian disease ; the symptoms are almost invariably the result of some uterine lesion.” Another English writer says : “ In many cases the symp- toms are purely neuralgic in character, independent of any local lesion ; ” that “ pain is the patient’s ailment,” —“just like the back-ache which bears so large a part among the minor ills of women ; and any treatment that 28 directs the patient’s attention to the seat of suffering is apt to perpetuate the evil instead of removing it.” “Pain is the patient’s ailment ! ”—thus this eminent author speaks of this formidable disease, which is so little under- stood. Yet it remains just as much a fact that there are unnumbered instances of both acute and chronic ovaritis, a countless number of women suffering years of martyr- dom from disease of the organs, wearing out their lives, and the cause of suffering, never recognized, remains a secret which the grave finally covers, unless, perhaps, discovered at some post-mortem, and then not very much to the advantage of the patient. Scanzoni tells of a woman who died of pneumonia ; at the autopsy it was discovered that “ the ovaries were enlarged, effusion into the follicles, and in the parenchyma small abscesses of various sizes, all containing sanious pus.” These con- ditions were not suspected before death. West and Dun- can tell of a similar case. A woman died of bronchitis and emphysema ; at the autopsy “ the appendages were found matted together by firm adhesions, one ovary atrophied and the other enlarged by a cyst filled with grumous blood.” The medical attendant imagined no trouble in this direction. The same author gives other similar cases. Hennig states that out of eighty-one post-mortems, a diseased condition of the ovaries was found in fifty- three, not only showing how frequent is the disease, but how infrequently it is recognized. Another author states that out of sixty-six post-mortems, in twenty one the ovaries presented changes due to inflammatory action. In Dr. Wylie’s clinic at the Polyclinic one-twelfth of the cases were diagnosed as having tubal and ovarian disease. Two years ago, Martin, of Berlin, reported that he found one in fifteen with diseased tubes. So other uterine clinics may show as many or more of these dis- eases if the diagnosis is as accurately made. Martin says, “The diagnosis receives too little attention prob- ably not all are diagnosed. Hut, whether recognized or not, there are still many 29 cases of ovaritis, acute and chronic, from whatever cause they may be produced. If by septic poison, this septic poison may originate from other conditions of the system than the puerperium or from peritoneal inflammation. In a large majority of instances I believe the ovary is in- fected by the unhealthy secretions from the uterine cavity, which find their way through the Fallopian tubes to the ovary.1 The ovary is more liable to, or in more danger of, this septic poison from the circumstance that, when an ovule escapes, there is left behind a funnel-shaped cavity, as if to invite or drink in the poison. The only wonder is that the ovary is not more frequently infected and diseased. The infection of the ovary from this cause is rendered yet more easy by any fusion or flexion of the uterus. In cases of flexion, especially, the uterine secre- tions to some extent almost necessarily find exit through the tubes, so infecting both tubes and ovaries. The normal position of the uterus and its appendages is the most favorable for avoiding these possible dangers, which is also helped by the anatomical structure of the tubes, the longitudinal and circular fibres producing the peristaltic action which tends to force the secretions back into the uterus. Also the ciliated epithelii of the tubes aid in preventing fluids from passing into the peritoneal cavity ; these millions of cilia may blow along the micro- scopical egg to its possible resting-place, also “ hinder the contact of the spermatozoa with the ovum until the latter has reached the cavity suited for its maturation.” Yet another important function of these ciliated epithelii is to prevent fluids a?id noxious secretions from reaching the pelvic viscera,a just as the cilia of the breathing or- gans hinder dust and dirt and other contaminations from reaching the lungs. 1 have watched the cilia in the liv- 1 The uterine discharges are sometimes exceedingly noxious. “ In a woman who died of pneumonia, the whole internal surface of the uterus was covered with puriform pus, which was continued along the whole tract of the Fallopian tubes.” '2 It has lately been demonstrated that the epithelii in the uterus are ciliated, which further helps in this wonderful work. 30 ing oyster, like millions of Hashing diamonds, producing such currents in the water as bring necessary food to the inert mollusk. In the Fallopian tubes the cilia are no less effective, nor is their function less important. But young women, by a universal custom, push down, bind, or displace the uterus and its appendages, the cilia can no longer do their duty, the contagion finds an easy entrance, then commences a course of disease continuing and lin- gering for years. I have a patient—a magnificently developed young woman—eighteen years of age. She should be the very picture of health, but her blanched lips, pale and ago- nized face, tell a different story. She says for years she has had such an aching, from which she is never free. When a little girl of fourteen she often leaned her head upon the desk and said, “ What is it ? ” On examina- tion I found the uterus completely retroverted, the fun- dus reached the lowest point in the pelvis, and was bound down by inflammatory adhesions ; left broad ligament shortened and thickened; organs enlarged, extremely tender, and dislocated low down into the retro-uterine cul de-sac. Her vital organs were compressed and pushed out of position, and this displacement allowed the noxious secretions of the uterus to pass readily out through the tubes, and so infect the ovary, causing dis- ease and enlargement, which last favored the dislocation. Another young lady called to see me, same age, and equally well developed—a pupil in one of our fashion- able schools. She had a small, anteflexed uterus, and back of it the ovaries and tubes bound up in one mass of peritoneal inflammation, which inflammation was doubt- less caused by the unhealthful and catarrhal secretions passing from the uterus through the tubes. A young lady, twenty years of age, called at my office. She had been treated for anteflexion. So extreme was her suf- fering during menstruation she had to keep her bed. But her trouble was beyond the flexion—probably caused by it. 31 There are many such cases, young women suffering from more or less disease of the appendages. They may put on their bright attire, their cheeks are flushed, they look well,1 yet the cause of suffering is there. We see proofs of the frequency of these conditions in the number of married women who are incapable of bearing children. Marion Sims says, “ Every eighth marriage is sterile.” One woman whom I was called to see had been married ten years ; no children. She had been much treated for dyspepsia, but for years had suffered pain and distress in the pelvis ; a mass of disease was in the region of the appendages, and there was the trouble and there was the cause of her sterility, all resulting from infectious discharges. A young married woman called to see me; no children. Tubes swollen and adherent, derived from unhealthful uterine discharges. But in this case the discharges were gonorrhoeal; more serious, more quickly infecting, and most disastrous of all! So young, so lovely, and her life so blighted! Sad that mothers, daughters, reared so tenderly, should be exposed to such a vile danger. About the same time I was sent to see another patient. Found the appendages wrapped in a mass of inflammation, from septic poison from the puerperal state. Laying both hands upon the pelvis, she said, “ Such a misery ! ” She had been suffering from it since the birth of her last child, eight years ago. Now she is confined to her bed most of the time, yet during these years she has been treated by various reputable physicians and surgeons for “womb disease.” “When will we learn that all the ills of womanhood are not due to inflammation of the neck of the womb ? ” Many are treated for “ womb disease,” when the trouble is with the ovaries and tubes ; probably the appendages are more frequently diseased than is the uterus. Meigs said, more than forty years ago, “ Disease 1 September 20, 1884, Lawson Tail operated on a patient in Bellevue Hospital, “ of very healthy appearance, yet for years her life has been one of prolonged misery. She had a malady that is often fatal” (New York Medical Journal). 32 of the Fallopian tubes is many limes unsuspected, when it is the cause of disease treated under another name.” But there are many other causes or conditions that are constantly operating to produce disease of the ovaries or of the uterine appendages; cold feet and extremities and im- perfectly clad limbs tend to, and must necessarily produce, some form of congestion. Some of the most serious forms of pelvic congestion, or inflammation, result from a dis- turbance of the peripheral circulation. It should not be supposed that women are able to stand more exposure than the opposite sex, yet many of them go out with one thickness of muslin around their lower limbs, when the opposite sex will be found to have double and treble thicknesses of woollen goods. As one writer says, “Only fools and beggars take cold.” No doubt this one cause, unbalancing the circulation, has produced many instances of disease of these important structures. There is a chill, symptoms of fever, and the trouble has commenced, more serious if during the period of menstruating. Scan- zoni says, “ We must seek the causes of ovaritis in some disorder of menstruation but ovaritis 7vi/l cause these “ disorders.” Another cause of frequent disease of these organs is nervous excitement during the developing period of life, exhausting the vitality when nature needs all the vital re- sources for maturing and growth. One of the saddest instances of this was a woman, twenty-five years of age, broken down with tubal and ovarian disease ; her strength was used up—she had lived in a whirl of dissipation and mental excitement. In the daily habits of young women there are many cases of ill health, all having the tendency to react upon the condition of these vital organs. And when we think of the fine organization and exquisite structure of the ovaries, their important and complex functions, that they are performing the highest physical function 1—perpetuating 1 “ All the facts of comparative anatomy indicate that the female organism is in advance of the male” “Within the ovary there is ceaseless activity, changes as subtle and eluding as the vital principle itself” (Coe). 33 the race, elaborating that growth that by differentiation will develop into the most complex animal organization —and that while performing these important functions there is a certain amount of physiological hyperaemia, is it any wonder, especially when we consider thet hou- sand untoward circumstances of woman’s daily life, that these exquisitely delicate organs, while performing these complicated functions, repeated every month, should take on morbid conditions—that this physiological hyperaemia should be changed into unphysiological hyperaemia, con- gestion and inflammation ? As they have a fine organi- zation, they are apt to suffer more seriously. During the function of ovulation young women should as much as possible rest in bed, just as for every one rest after a meal is promotive of good digestion, and the digestive process will go on more healthfully. And as there is no physiological function higher or more impor- tant than ovulation, so the more reason women should rest, especially when we consider the miserably inherited bodies which many of our American women possess, bodies that are poorly cared for, and have very little vitality. When we consider this, more especially is there need for rest during this period. But, let it be understood, there are many magnificently constituted women who can go forty or fifty years, severely taxed all the time, never resting during menstruation, yet never experiencing the least trouble, distress, or sensation in the performance of the ovarian function ; just as there are a countless num- ber of men, for as many years, amid their business activi- ties, who never think of their stomachs or have any trouble therewith, while there are millions of others who have as many diseased peptic glands as there are diseased folli- cles in as many ovaries. I have spoken of the causes of these diseases, and inci- dentally of their prevention ; now a word as to their cure. How can these diseased conditions be relieved? Our standard English gynecological author, speaking of the pain in the region of the ovaries, says : “ It is very hard 34 to cure ; leeches do not relieve, blisters sometimes afford ease, chloroform applied to the site generally gives tem- porary relief, so may camphor liniment, extract of bella- donna,” etc.; then adds: “I have never been able to trace the permanent cessation of suffering to the unaided use of any local means.” For the second patient mentioned, with anteflexion of the uterus and inflammatory masses on each side, prob- ably much may be done : the adhesions may be softened, the peritoneal inflammation reduced, acute salpingitis re- lieved. But after all this is done there yet may be found an ovary that is more than “ scorched in the general con- flagration.” The patient who has enlarged and adherent tubes— shall we aspirate, run the risk of wounding vital struct- ures and poisoning them with septic material, or shall we first open the abdomen to be sure it is hydro-salpinx, and if it is, then aspirate ? The enlarged tubes of the patient with gonorrhoeal in- fection are without doubt filled with pus, even the fim- briated extremities are possibly distended into -pus-sacs and closely agglutinated to a diseased ovary, the cilia desquamated, and the lining membrane changed. Can such organs be restored to health, or to their normal function ? How shall we help the last-named case with enlarged tubes and ovaries diseased from septic material of the puerperal state ? She has grown gradually worse under the varied treatment of many physicians. In the young woman with dislocated ovaries, the first patient mentioned, treatment has removed lymph-like adhesions which bound down the uterus ; but how are the ovaries to be held in position ? By broad-brimmed pes- saries ? Who has succeeded ? Where are the pessaries that will hold them in position ? The patient is on the eve of a brilliant marriage. Shall we leave the ovaries to “give her the chance of some future baby” 1—leave the 1 Routh : British Gynecological Journal. 35 woman with the certainty of future trouble, the possibility of being permanently invalided ? Even if the ovaries are healthy, the tubes may be so changed in structure, or so misplaced by adhesions or some shortening, that they “ cannot acquire their periodic relations to the ovary,” any one of which conditions will be a cause of sterility. Shall we resort to Imlach’s suspensory operation, oophor- raphy,1 by which the ovary is stitched up to the infundi- bulo-pelvic ligament ? An ovary so displaced and so sensitive is doubtless very much diseased, and from the history of the case we would judge the ovaries had been long and profoundly diseased, and consequently must have undergone certain organic changes, and where would be the good of stitching them up ? Lawson Tait, who is the best authority on this subject said : “ When there is really chronic inflammatory disease of the ovary, no such operation can be expected to be successful.” Soon after the report of Imlach’s operation appeared in the British Gynecological Journal, Dr. Paul Munde, of New York, sent me the following note in reply to a letter of inquiry I had sent him : “ I should feel doubtful whether in real- ity such an accurate anatomical adaptation could be secured as to facilitate or permit conception as Inilach intends. It seems a considerable danger to incur, merely to retain in approximately normal position a prolapsed and perhaps an already diseased ovary.” If we leave the ovaries as they are, it is leaving the patient with a source of misery and suffering, probably in time may compromise her life ; or, if she marries, she will not only be sterile, but unable to submit to the marital relations. Were she a dispensary patient, a young girl who by labor had to earn her own bread, and for whom it did not count much whether she had children or no, to save all future trquble and suffering, to enable her to be a useful 1 The stitching up of the ovary was suggested to my mind when, three years ago, I read Tail’s method of stitching up the uterus, and doubtless his mind traversed the whole field. 36 member of society, to enable her to do her daily work, and to prolong her life I would at once advise the re- moval of the uterine appendages. And, after all, what better can be done for this patient ? Bantock said (November n, 1885) “he knew of no remedies which had the slightest effect upon a diseased ovary.” Lawson Tait said, the same date, “his own experience was that an ovary once inflamed and adherent, the disease was practically incurable save by removal (British Gyneco- logical Journal, p. 383). But lately there is a great hue and cry about the pos- sible future baby. They do not stop to think of the count- less number of women who are barren and childless for years from various forms of uterine disease—“ a drop may stop a dynasty.” When women are suffering from hope- lessly diseased tubes and ovaries they must not be “ un- sexed,” they must continue years in torment and misery and inability for any kind of employment or avocation, because perhaps in the diseased ovary there may be a healthy follicle, which may contain a healthy ovum, which may find its way through a possibly diseased tube, and possibly find other favorable conditions—like Mrs. Toodles who purchased a door-plate on which was cut the name of Thompson, because she might have a daughter, she might grow up, and might marry a man by that name. Removing diseased uterine appendages is not unsexing a woman, it is restoring her from helpless invalidism to all the possibilities and opportunities of life and labor. It is not taking away the possibility of her having children— that has already been done by disease—it is only remov- ing a cause of suffering. In 1882 a young woman, twenty-seven years of age, was brought to me from Maine, married at fifteen, and again at twenty-two ; no children. Uterus retroverted, bound down by firm ad- hesions, and the appendages wrapped up in a hopeless mass of disease. Thus she had been suffering for years. Hystero-epilepsy and other grave nerve-symptoms were developed. To relieve the constant pelvic pain, and pos- 37 sibly also to relieve some of the nerve-symptoms, I ad- vised the removal of the uterine appendages, but was met by the objection, not only that a former medical at- tendant had advised a long course of treatment by bro- mides, etc., to cure her “ nervous diseases,” but mainly the objection to removing the uterine appendages was that she would be rendered sterile, that we would “ take away her capabilities of having children ! ” Fig. 7.—Ovary, posterior aspect; C, cyst ; FT, tube flattened out, closely ad- hering to cyst. Fimbriate extremity glued to ovary. A few months after, I removed the uterine appendages, and above we have a representation of them. We see how completely all functional action must have been de- stroyed. The right ovary is enlarged, containing a cyst. The fimbriae have disappeared from the adherent tube, and its extremity is closely glued to the ovary. Only small rem- nants of ovarian stroma left, and under the microscope the remnants are found to be in a thoroughly atrophic condition, cirrhotic atrophy, mainly consisting of dense 38 fibrous connective tissue, in which are many small amy- laceous corpuscles. The free arteries that were left were in a state of waxy degeneration. Thus all normal struct- ure was utterly destroyed, and any physiological func- tion would have been entirely impossible.1 Winckel is quoted in a late number of the Philadelphia Medical News as saying : “The time is not far distant when the extirpation of the healthy ovaries for the cure of dysmenorrhoea, ovaralgia, epilepsy, hysteria, etc., will stop.” But, Mr. Winckel and Mr. Rip Van Winkle, women with these conditions do not, as far as observation goes, have “ healthy ovaries.” I have never seen the ovaries removed in a single instance but they were more diseased than the symptoms had led me to suppose. Dysmenor- rhoea may come from other causes, but often it results from a hopelessly diseased condition of the appendages. Incurable epilepsy may and has been helped by these surgical procedures. Hysteria may demand it, and ova- ralgia is only an unmeaning word to sum up the suffering that may come from diseased ovaries and tubes : and these sufferings and this irritation may be so great as to render abnormal the mental conditions.a There is no advance made in modern surgery that will do more good, save more lives, or relieve more suffering, or add more to the sum of human life or human happi- ness than this one operation, known as Tait’s opera- tion.” It will save more lives than ovariotomy, because more need it. 1 This case was reported in the American Journal of Obstetrics in 1884 ; the microscopical examination was not given. In the report I drew the following con- clusions : “ 1. The operation should have been performed on the patient years before, a. There was no other way to relieve her than by the operation. Soon after the publication of the article I received a letter from Lawson Tait, Birming- ham, Eng., in which occurs the following sentence : “ l agree with your conclu- sions concerning the case absolutely. The whole gist of modern abdominal sur- gery lies in an earnest and continuous plea for early interference. There can l>e no doubt that the only fear about such cases is that they are allowed to go on so long without operation.” a Trenholm reported in 1884 “ a case of decided mania ; both ovaries were found to be diseased, and their removal was followed by complete recovery of the patient, both mental and physical” (Medical News, December *7, 1884). 39 In 1847 the eminent and distinguished Charles D. Meigs, Professor of Midwifery and Diseases of Women in the Jefferson Medical College at Philadelphia, reported a death from Fallopian pregnancy. Twenty hours after death, when inspecting the abdominal cavity, he said, “ What, alas, can we do in these cases ? We could make an incision and clean away the coagula and the serum. But who is he bold enough to do so ? Who is he astute enough to discriminate with so much clearness as to war- rant him in the performance of gastrotomy for Fallopian pregnancy ? There is no such wise and bold surgeon.” But there is, and this wise surgeon has led us out of this wilderness of doubt to the clear light of what is best to be done, and showed us how to do it successfully.