THE ADDRESS IN OBSTETRICS. Hysteria and its Relation to Diseases of the Uterine Appendages. Delivered at the Thirty-Seventh Annual Meeting of the American Medical Association on Tuesday, May y, 1886, BY S. C. GORDON, M.D., OF PORTLAND, ME. CHAIRMAN OF SECTION OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN/ Reprinted from the Journal of the American Medical Association, May 22, 1886. CHICAGO: Printed at the Office of the Association. 1886. THE ADDRESS IN OBSTETRICS. Hysteria and its Relation to Diseases of the Uterine Appendages. Delivered at the Thirty-Seventh Annual Meeting of the American Medical Association on Tuesday, May y, 1886, by S. C. GORDON, M.D., OF PORTLAND, ME. CHAIRMAN OF SECTION OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. Reprinted from the Journal of the American Medical Association, May 22, 1886. CHICAGO: Printed at the Office of the Association. 1886. HYSTERIA AND ITS RELATION TO DISEASES OF THE UTERINE APPENDAGES. Mr. President and Fellows of the American Medical Association :-The year that has just passed has given no remarkable discoveries either in obstetrics or gynecology, and therefore in attempting to comply with the rule requiring the chairman of each Section to present a resume of new things in his department, I can only emphasize some of the matters that have been alluded to, perhaps in some former addresses, and weigh the experiences of indi- vidual members of the profession on some of the topics that have been more or less discussed. Time, which alone can give experience, makes sad havoc with many of our pet theories, however plausible they may seem when first advanced. We are con- stantly exploding some of the well accepted doctrines of the old teachers in every department of medicine, and in none more than in these two branches of the science. A familiar example of this occurred at the last meeting of this Association. I think no one theory held stronger place among us than that an accoucheur, after exposure to septic influences, should for a long time refrain from attendance upon new cases. A neglect of this rule was generally deemed criminal, and the penalty was visited upon the victim in the most severe and summary manner. The carefully prepared and exhaustive paper of Dr. George F. French, who collected opinions from the ablest men in the profession, from this country and Europe, together with his own critical experi- ments, shows us that by proper measures and strict, absolute cleanliness, we can safely continue the daily routine of obstetrical work, with no months of delay, or anxiety as to the results of such continuance. The criminality now lies in the neglect of the proper pre- 4 cautions within the reach of every practitioner. Time alone may not be sufficient-in fact, may be no ele- ment of safety, if all the other elements are omitted. If the seed sown by that one paper has been prop- erly cultivated and has borne the same kind of fruit, the harvest within the year just past must be abundant. I will not attempt to review the literature of ob- stetrics for the past year, so far as relates to new discoveries, or new methods of treatment of the parturient woman, but simply allude to some of the practical points which have been more or less sub judice for many years. Among the many of these questions, the early signs of pregnancy may be mentioned. I have several times within the past year applied the test recommended by Hegar and alluded to in several journals, viz.: the increase in the ante- rior curvature of the uterus, with increased elasticity of the walls. I think it a valuable sign and one that is apparent early. For obstinate vomiting of preg- nancy, I believe no one measure has been found of such value as forcible dilatation of the cervical canal below the internal os, and lifting the uterus out of the pelvis and supporting by cotton packs or some form of pessary. The cases requiring the induction of abortion for this very distressing symptom will, I think, be very few if these measures are faithfully and carefully carried out. The induction of premature labor for deformity of pelvis or disproportionate head, as found by former pregnancies, is, I believe, fast finding favor with accoucheurs. From my own ex- perience (very limited) I prefer the employment of the bougie, retained until labor begins, although some practitioners whose opinion I value, prefer the rapid manual dilatation. Where we fear a disproportion- ate head, I think the eighth month the best time for it, when a tolerable degree of certainty exists as to the period of conception. The post-parturient management of the woman I 5 think deserves much more consideration than it has formerly received. I am sure that until within a comparatively short period authorities have been dis- posed to teach a much more rigid system of dietetics for the woman who has just passed through her labor than the absolute necessities of the case require. . I believe the "poor sloppy diet" of the lying-in room has been a fruitful source' of the "lingering delay" and complications of childbed. Many a woman whose period of gestation has compelled her to forego all the pleasures of the table finds the demands of nature such that the most nutritious food is desired. In my opinion we will find much benefit from a lib- eral construction of the rule that nature does not make mistakes often. A word or two in regard to ameliorating the suffer- ings and shortening the process of labor. It seems that an unnecessary amount of suffering, both in de- gree and duration, attends the " normal labor " (so called) among the large majority of American women -that they do not, as a rule, bear children so easily as the women of the British Isles. I am very well con- vinced of this-not only from statistics, but from the general sentiment so prevalent among British practi- tioners, that a forceps delivery is rarely required. While it is not pertinent on this occasion to elaborate this very much-statistics being accessible and more or less familiar to all of you-I cannot but believe that the use of anaesthetics and the forceps, in labor, has done much to relieve the suffering and prevent many of the injuries formerly incident to the partu- rient process. I believe that vesico-vaginal fistulas are becoming less frequent under the more careful and judicious use of the obstetric forceps, by means of which a long and tedious labor has been shortened, and the pressure has been removed from portions of the vagina that would otherwise have lost vitality and sloughed. The treatment of the placenta, both at normal labor 6 and at abortion, has been the cause of much discus- sion for the past few years. The views of Pajot, re- cently published, are so nearly in accord with my own experience and practice, that I cannot forbear alluding to them. He believes that, as a rule, the full- term placenta is best delivered by prompt and gentle traction upon the cord, with the left hand, while the right index finger passed up along the cord intelligently regulates the amount of force necessary to be used. The earlier after the delivery of the child this is done, the more easily is it completed and less evil results follow. I believe also, with him, that the forcible removal of the secundines in abortions, at almost any cost (now so prevalent), is by no means the safer practice. Remove them if it can be done without much trouble, or instrumental interference, but otherwise a careful tamponing and close watching will do less harm, save more lives and prevent a vast amount of future suffering. In passing to the subject of gynecology I propose to occupy your time principally with one theme, that has engaged the attention of the profession and pro- moted much discussion during the past year, viz.: the removal of the uterine appendages-familiarly and variously characterized as Battey's, Tait's and Hegar's operation. I am sure any practical work done in this direction will be regarded as testimony before a jury of the profession, and a basis for making a proper decision upon the merits or demerits of the operation. The mere dictum of any one man or set of men amounts to but little in our profession. Nothing is conclusive or convincing short of absolute experiment. When a man, however distinguished he may be, says that he has never seen any case where, in his opinion, the operation wa$ required, such opinion amounts to but little in comparison with that of another who has believed it was required, and demonstrated by the 7 operation a well-marked pathological condition, and cured his patient, who has suffered for years. The profession has differed very widely as regards the indications for this surgical interference, some claiming that only by a "demonstration by touch" which shall determine absolute organic changes in the ovaries and tubes, should a diagnosis of disease be made. On the other hand, others become satis- fied of the existence of structural changes by certain manifestations, which we term functional disturb- ances, and are commonly called by the terms reflex and hysterical. That a large class of cases exist in every community, that have been invalids for years, and have defied all methods of treatment, is a well known fact. It is largely to this class that I call your attention, and shall therefore devote the remaining portion of the time allotted to me to the discussion of HYSTERIA AND ITS RELATION TO DISEASES OF THE UTERINE APPENDAGES. I suppose it is equally true of medicine as every- thing else, that there is really ''nothing new under the sun " -therefore we may as well select, as one of the topics for consideration, a well-worn subject for an essay on any medical occasion. Certainly nothing has been talked about or written upon more than hysteria. Even the laity are as familiar with the symptoms, pathology and treatment, as the (I might almost say) majority of the profession. No litera- ture of the profession in any age is complete, that does not embrace more or less learned discussions upon this ever fruitful subject. No one man from his own experience is able to fully represent in language the various and ever changing symptoms of this bane of the profession. I am well aware that in presenting this subject before you a smile of derision may almost unconsciously come, and a degree of surprise be manifest at the presumption of one who would attempt to evolve 8 anything that might be new or interesting out of such a threadbare theme. And yet, when we find one of the modern writers on nervous diseases making the confession that " hysteria contributes absolutely noth- ing to the science of morbid anatomy," we are fully justified in advancing any theory that has a semblance of reason, especially if we can present any evidence that in the remotest degee will appear to sustain that theory. The absolute in our profession may be very limited, but the probable is almost indefinite. The sum total of medical science and knowledge rests upon the basis of this limited absolute and indefinite probable, the former having for its foundation princi- pally anatomy and physiology, while the latter has the accumulated experiences, and observations, and experiments of thousands of educated students, through thousands of years. To the mass of the practical minds of these students the latter is as valu- able as the former. When we find, after a series of experiments, that a constant result is reached by a continued course, we must finally admit that there is a relation of cause and effect. By countless multi- tudes of practitioners it has been found that opium is the antidote to pain, that quinia is antipyretic and that chloroform is anaesthetic. These and many other now well accepted facts in the profession came to us, not by any inductive reasoning, but by the more common mode of experiment and close obser- vation. Applying the latter method, together with what has come to us through the well known princi- ples of physiology, to the disease known as hysteria, I believe we can at least make some little progress towards " contributing something to the science of morbid anatomy." At the risk of being prosaic I must briefly allude to some of the more prominent symptoms of this classified disease. I am quite sure I shall not chal- lenge very much discussion on this- point, even if I incorporate into my description nearly every symp- 9 tom of human suffering known to medical science. Their name is legion; I will use those necessary for the several illustrations. Sydenham thus describes the multiform manifestations of hysteria: "A day would scarcely suffice to reckon up all the symptoms of hysterical diseases; so various are they and so contrary to one another, that Proteus had no more shapes, nor the chameleon so great a variety of col- ors, and I think Democritus was pretty right (though he mistook the cause of the disease) when he wrote in an epistle to Hippocrates, that the womb was the cause of six hundred miseries, and of innumerable calamities. Nor are they only very various, but also irregular, that they cannot be contained under any uniform type, which is usual in other diseases, for they are, as it were, a disorderly heap of phenomena, so that it is very hard to write the history of the dis- ease" His only explanation of the fact that women have the disease so much more frequently than men, is that " kindly nature has bestowed on the former a more delicate and fine habit of body, having designed them for an easy life, and to perform the tender offices of love." His "confusion of spirits," too many of them "collected in a crowd," and that the "ataxy of the spirits has vitiated the humors," seem hardly a sufficiently lucid explanation of the etiology of the disease, in these modern days of exacting pathology, and yet it was nearly if not quite as satisfactory as any of the many theories of our later pathologists: " It is nothing but an attack of hysterics; " "she is only nervous;" let her alone and she will come out of it all right; " "i sn't this hysterical largely?" " surely there cannot be any organic lesion," etc. Perhaps no better modern history of hysteria has been written than that of Hammond in his " Diseases of the Nervous System." In the first paragraph under the head of symptoms he says: "The phe- nomena of hysteria may be manifested as regards the mind, sensibility, motility and visceral action, 10 separately or in any possible combination. Thus it is not uncommon to meet with cases in which the only evidence of the disease is seen in abnormal mental action; others are characterized solely by de- rangements of sensibility, such as hyperaesthesia or anaesthesia; others by aberrations of the faculty of motion, such as paralysis, spasms and contractions. Again, all these categories may be witnessed in the same person, giving rise, among other phenomena, to coma and convulsions; and again, some one or more of the viscera may be deranged in their functions, and thus the appearance of organic disease be simulated." These mental symptoms are so very various that any attempt to recite them would be a history of the whole class of mental diseases, from the slightest emotional disturbances to the most violent exhibi- tions of joy or grief, entirely disproportionate to the cause, to be followed, perhaps, by the utmost indiffer- ence to all surrounding influences. That the will to a great extent loses its power, at times, no one familiar with these cases can for a moment doubt, although under the influence of some strong exciting cause, the patient suddenly acquires the lost volitional power. Illusions and hallucinations of all kinds and degree occur in many of these cases, and we find most strik- ing illustrations of the most complete aberrations of the special senses. " Images are seen where there is nothing, voices are heard where there is absolute silence, odors are smelt where there is nothing to smell, and strange tastes are perceived where the mouth is empty." The vagaries of the intellect are not less strange than of the special senses. The perceptive faculties are often most wonderfully sharp- ened, while the reasoning powers and volubility are remarkably increased. As often we find the most brilliant intellects dulled and the conversational pow- ers almost entirely wanting. The principal points of difference between this and insanity seem to be the 11 less duration of the phenomena and less power to influence the patient's actions. In the deranged sensibility we find all degrees of hypermsthesia and anaesthesia, the most common seat being the skin, in the region of the mammary glands, face, throat, extremities, and especially about the head in the form of headache. Hammond quotes Briquet as saying that "out of 356 hysterical patients 300 were constantly subject to headache." Neuralgia in all its manifestations, in all parts of the body, may thus exist, without our being able to give it a defi- nite origin. Anaesthesia, with a corresponding loss of feeling in all these parts of the body, may exist, and even the special senses be affected to the point of producing blindness, deafness, loss of taste and smell. I have seen some very remarkable cases of blindness due to reflex disturbances of the genital organs, which were at once relieved by appropriate treatment of these lesions. Hysterical paralysis, as manifested in hemiplegia, paraplegia, or, much more limited than either, aphonia- spasms, tonic and clonic, may affect almost every muscle in the body, continuing a long time, and sim- ulating organic lesions in muscles, joints and mucous membranes. The functional actions of the viscera are by far the most surprising manifestations of hysteria, and frequently the most persistent and distressing. Of all these perhaps there is no one more commonly affected than the stomach. Hammond says this seems to be the "favorite organ," and this is in ac- cord with my own experience. The most obstinate vomiting, persistent flatulency and all the various distressing symptoms of indigestion, characterize a majority of the cases under my own observation. The disturbances of function of other organs, like the heart, lungs, intestines, kidneys (with their inor- dinate secretion of limpid urine), the bladder with retention and incontinence of urine, the obstinate 12 constipation of the bowels, are all familiar to every practitioner. The various forms of, convulsions, at- tended with more or less loss of consciousness, bear- ing oftentimes a strong resemblance to epilepsy or tetanus, chorea or catalepsy, but distinguished from them by lack of consistency and constitutional dis- turbance, become the most distressing to witness and the most exhausting in their effects upon the nervous system. The functions of the uterus suffer in every con- ceivable manner, from complete cessation of the menstrual flow for months at a time, alternating with the most frequent haemorrhages, either very scanty (lasting but a few hours), or the most alarming in quantity. The pain and general nervous symptoms, as a rule, are most marked previous to the flow, oftentimes for many days, and these are so severe as to indicate with certainty the approach of the period even if the patient had no other definite means of knowing it. I think this an important diagnostic element. More rarely we find the exhaustion conse- quent upon the excessive haemorrhages produces the well known hysterical convulsions, so familiar to every practitioner. The week preceding and follow- ing the flow (including it) is the time during which we may expect, and in fact find the most of these nervous phenomena. In many cases the remainder of the month may be comparatively free from any suffering whatever, especially in early life. As age advances, however, the periodical suffering leaves its impress upon the entire system. Not infrequently we find, as a result of the long continued nervous symp- toms, marked changes in the facial expression, and a dull, listless melancholy rests upon a countenance once bright, animated and cheerful. The skin suffers especially, in many instances. Eruptions of various kinds, especially acne, appear, often to a degree that is disfiguring and loathsome to the patient. Alterna- tions of color occur, so that in a few hours we find 13 the'most ghastly pallor, followed by a deep mahog- any color, which may and in many instances does continue for several hours. In several cases under my own observation this latter symptom has been very marked, so that I now look upon it as a promi- nent diagnostic feature. But enough has been said on the symptoms, and we pass to the etiology. Having already given you Sydenham's views on this point, I will add that of a more modern author and then give you some cases from my own experience, and there leave the subject. All authorities agree upon one predisposing cause, as by far the most important-so important and pre- dominating that, in my opinion, it becomes very highly significant, viz. : sex. Until within a comparatively short time hysteria in the male was not even talked or written about, and even accepting all that we know of the reported cases, they are trivial in character by comparison. Men have a nervous system, and it would be wonderfully strange if we did not some- times find manifestations of disease that would very closely correspond with one or more of the multiform phases of what we have just described. Hammond says that in "332 cases observed by him in six years, 329 were females." Now it is not the object of this paper to attempt to enter into all the causes that have produced and may continue to produce hysteria in the female. The causes may be as various as the symptoms or the cases-I do not deny any cause that may seem to be well established by any mode of reasoning, whether derived from theory or prac- tice. I simply propose to give you some instances derived from my own experience, selecting such cases, from quite a large number treated, as will illus- trate a variety of symptoms, and results obtained by the methods employed. Case 1.-Miss B., age 37, occupation a school teacher for many years. A woman of unusually fine culture and strong character in all respects. Had been 14 particular successful in her vocation. Possessing an indomitable will, she had continued in her work as long as possible, but for about five years previous to coming under my care, had been unable to do any labor, either in teaching or otherwise. Her illness dates from eleven years before. During the first few years she suffered from impairment of menstrual function, alternating amenorrhoea and menorrhagia, severe dysmenorrhoea, with marked premenstrual pain for many days. Gradually the nervous symptoms became more prominent, characterized by insomnia, headaches, neuralgia in spine and sides, flushing and pallor of face, the dark-red spot in the centre of each cheek becoming a prominent symptom in the later years. She had consulted physicians early in her trouble, but only at rare intervals, and for five years previous to my seeing her, had been constantly under the care of the best she could obtain. Notwith- standing she continued to grow worse until she be- came a helpless invalid, unable to work physically or mentally, or even to move about. The mind became disordered to the extent that her friends proposed removing her to an insane asylum. When I saw her she could get around her room and out of doors by holding on to the sides of the room and thus supporting herself, but her limbs seemed to have lost their use so far as supporting the body. She slept but little, and could not restrain herself from long attacks of crying. I think she had a strong suicidal tendency. As each menstrual period ap- proached the symptoms were all aggravated, and dur- ing the period she was apparently oblivious of much that occurred. Knowing that she had received as good care and treatment as the State afforded, with apparently no relief, I soon became convinced that nothing but a cessation of the menstrual function offered much hope. I found sharp retro-flexion of the uterus, to which pessaries gave no relief, on ac- count of the extreme sensitive condition of the vagina, 15 preventing her wearing one for any length of time. There was also prolapsus of the right ovary, so that it could be felt in the posterior cul-de-sac. It was not particularly tender, however, and was movable and easily pushed up, so I did not attach special im- portance to the fact of displacement alone. Where no pressure exists in these cases, I think we are not to regard it of so much consequence as it was formerly supposed to be. On June 20, 1883, I removed the uterine append- ages. I found very extensive cystic degeneration of each ovary, the right one being about twice the size. The tubes were partially closed, and had several small cysts adherent to them. There was a general passive congestion of all the parts removed. It was impossible to retain the uterus in place, so the retro- flexion continued, and I doubt not retarded the pro- gress of recovery, which from that time commenced, and slowly, but surely, continued, growing better each month. All the prominent hysterical symptoms had disappeared at the end of the first year, and she be- gan to enjoy the comforts of life. On the anniversary of the day of her operation, at the end of two years she writes as follows: " Please permit me once more an expression of gratitude for the gain of these last two years. I can see that I am stronger than a year ago, and much im- proved. from two years ago. I thank you very much and can always assure you of my best wishes." Within the past year she has grown still better. In many respects this was one of the very bad cases on ac- count of the severe and obstinate retro-flexion. Case 2.-Miss B., aged 24. From her first men- strual period until the day of operation, she suffered the most terrible agony sixteen days out of every twenty-eight. Twelve of these days of suffering were marked by epileptiform convulsions; pain of the most excruciating character in all parts of the body; the following four days had no less suffering, 16 but were attended with flowing. The remaining twelve days of the month were almost entirely free from suffering of any kind whatever, but always at the end began the same round of troubles. Her friends became very anxious in regard to her, as she frequently threatened to take her own life. In this case there was partial prolapse of one ovary. The operation for removal of tubes and ovaries was made, and the specimens showed a condition similar to the last, with the addition of a complete string of small cysts along the entire length of one of the fal- lopian tubes. They looked like a string of small beads. There was complete closure of both tubes. From that day until now, she has not had (to use her own language) "one minute of any kind of ache or painshe is perfectly well in all respects and the most grateful and happy person one would rarely meet, with no hysteria or other abnormal nervous symptoms. Case. -Miss F., aged 17. Menstruation began at 15; from the first time to the last of a most violent character, both as to pain and quantity of flow-fre- quently flooding like a woman at childbirth-clots of immense size, and expelled with characteristic labor- pains. For several months prior to operation, she was not free from severe pain at all. Clonic spasms of a most frightful kind in lower extremities, necessi- tating the constant use of chloroform by inhalation for days together. The uterus normal in all respects -no fungus degeneration or evidence of unusual congestion-a curetting under ether revealed nothing abnormal-no enlargement of ovaries or tubes could be demonstrated. Everything in way of treatment was resorted to for a year without the slightest relief being obtained. The appendages of the uterus were removed, and each ovary was found so completely destroyed by inflammatory action and cystic degen- eration that, as my notes have it, " scarcely any nor- 17 mal tissue left in either,"-" tubes closed and cysts along the course of them." For four weeks she suffered no pain at all, scarcely requiring an opiate; at the end of that time she got out of bed herself, sat up nearly all day, got pelvic cellulitis, from which she suffered more or less for several months, which ended in abscess opening through the uterus into the vagina. From that time she began to recover, and is now as well apparently as any one. There was never any return of the spasms or general neuralgia, so constant before the operation. From a helpless, hopeless victim of ter- rible suffering, she is now a comfortable, useful young lady. In this case there was an entire absence of any of the usual developments at the period of puberty -no enlargements of the breasts-no hair at all on the mons veneris, or external genitals. I think the unsexing in this case could not have been very much. Cases 4 and 5-So closely resemble each other, and being of another type from those described, I give them together. Miss L. and Miss N., of about the same age, 24. Miss L., temperament, family and personal, nervous. Four sisters-all nervous--three have painful menstruation. Menstruated first at 13 -not regular first year-nausea, pain in back, head- ache and pain in the lower limbs; length of period five or six days. Had measles four and a half years before the operation, since which has been suffering much at periods-flow of but one day-within the past two and a half years the flow has been followed by nausea and vomiting nearly every morning for two weeks. Hysterical symptoms of a painful con- vulsive character at each period-screaming, crying, globus, etc. Never had hysteria before measles. Has been under the best medical care she could obtain, with all the opportunities of best hospital care-no relief whatever. I found a very sharp anti- flection at cervico-corporeal junction-made forcible 18 dilatation, followed by the usual local treatment of packs, douches, rest, etc. ; no relief. Operation showed extensive follicular cystic degeneration of both ovaries, with atheromatous closure of tubes. Miss N. so closely resembled the last, both in hav- ing measles as a cause of aggravation of symptoms and antiflexion, that a history of one is that of the other in many respects. The flow was preceded by many days of severe suffering, which became hyster- ical convulsions during the flow, which lasted two weeks. The character of pain and amount of flow, at each period, resembled a miscarriage of the sever- est kind; dilatation afforded no relief; no fungus growth that could account for flooding. After sev- eral years of treatment with no benefit, the operation of removal of uterine appendages was made with en- tire relief to all suffering. From being a chronic invalid she is now entirely well and able to perform any kind of labor. Miss L. was also completely re- lieved from suffering, but has not yet regained her strength so as to be able to be about, although she is improving rapidly, considering her very anaemic condition previous to operation. The pathological condition of the tubes and ova- ries were similar in Miss N.'s case, except that there were two or three cysts of the tubes as large as peas. Case 6.--Mrs. F., age 30, married seven years, had three children within four years; never pregnant after that, although no means were used to prevent it. Three years ago began to have nausea and vomiting, which in six months became a constant thing after taking food. She and her husband believe that for the two years previous to operation she did not re- tain a spoonful of any kind of food. She became almost entirely bloodless, and so weak that she would frequently fall to the floor, when about her work, in a hysterical convulsion, that would sometimes last for hours. Symptoms aggravated before and during menstrual period. 19 After two years of treatment under my care I be- came convinced that only a cessation pf menstrua- tion would give relief. For a few months she tried various modes of treatment, and finally consented to the operation. In three weeks she was able to re- turn to her home. From the day of the operation she did not vomit once, but was able to eat every- thing she desired. Previous to the operation her finger nails had become entirely dead, flattened, clubbed and turned up at the ends, so as to cause the ends of the fingers to bleed and be constantly painful. Since the operation everything has changed, she is a strong, florid, fine healthy woman as the city affords, taking entire charge of her family and riding on horseback and driving every day. The left ovary was twice the normal size and contained a cyst hold- ing half a drachm. A similar case to the last, so far as the constant vomiting is concerned, I operated upon two months since, and so far as we are able to judge at this time the result is equally good. Married sixteen years, a great sufferer from dysmenorrhoea fourteen years, during which time she has been under good treat- ment from various intelligent physicians. Never preg- nant. Alternations of amenorrhcea and severe flood- ing, with repeated attacks of pelvic peritonitis. Tubes and ovaries adherent throughout their entire length. I had great difficulty in detaching them, but finally succeeded. The ovarian tissue was entirely destroyed by inflammatory softening and exudate, tubes imper- vious and like whipcord, a chronic partial conges- tion in all the pelvic organs. Severe and obstinate vomiting followed operation for more than two weeks, accompanied and doubtless largely caused by peri- tonitis. Now she is taking a good quantity of nour- ing food with impunity, and is recovering very rapidly. I have selected these two together, as they illus- trate one phase of the reflex symptoms. 20 In another case Miss L., aged about 30, hysterical catalepsy had been a marked symptom for several years. She would lie for weeks at a time utterly ob- livious of everything and every one about her. At intervals rigidity of body would come on, lasting for hours. Neither drugs or other means of treatment gave any relief. She had all the benefit of hospital care and attention for months at a time. There was marked retroflexion with complete retroversion. Re- placement and support would relieve for a short time, but nothing permanent came until the operation of castration was made, since which she has never had the slightest return of any one of the symptoms. Extensive follicular degeneration of ovaries was found. Insomnia, vomiting and indigestion had been promi- nent in this case. She eats, sleeps and digests per- fectly, and is now a healthy, well nourished young lady. I have not time, even had I the courage, to tres- pass upon your patience to report any more cases- I have now made the operation twenty-five times, and each case has a certain amount of professional interest. Four or five have been made for uterine fibroids, mostly for excessive haemorrhage, with com- plete relief to the haemorrhage. One case the re- moval was made hoping it might stop the growth of a fibroid and relieve the suffering due to pressure. There has been no relief, however. I think cases like this should have hysterectomy. The cases re- ported were selected as types of the various phases of hysteria. Among the cases not reported are types of the same phases, and with as good results. In only one instance I was unable to remove the entire substance of the ovary and tube, and this is the only instance of continued menstruation. She suffers very much at these periods, and I think I shall make another trial to finish it. In no case have I failed to find well-marked disease of the append- 21 ages, either strong evidences of former attacks of oophoritis, as indicated by exudate and other organic changes in the substance of the ovary, or enlarge- ment and stenosis of the fallopian tube. In not more than four instances have I been able to make a diagnosis by the touch, but have in all the others operated entirely for the relief of the hysterical symp- toms. With the single exception named, in every case great relief has followed, and with two excep- tions, I have no reasonable doubt that a complete cure will result after a reasonable length of time. We cannot expect that a nervous system that has suffered for years will at once resume its normal functions. The wound is tender after the thorn has been removed. Effects do not immediately cease on removal of the cause; women suffer more or less from some disorders of the nervous system at the natural menopause; similar symptoms naturally fol- low an artificial one. I do not by any means claim that all hysterical symptoms are due to diseased uterine appendages; but I am sure, from this experience, that in these cases they stand in the relation of cause and effect. I know that in a very large majority of these cases these women have been suffering invalids for years, and that all modes of treatment have been of no avail. From being burdens to themselves, and dependent upon their friends for help, they are now comfortable and independent. Through long suffering and in many instances from lack of sympathy for their suf- fering, life has lost its charm and they would gladly have rid themselves of it, while now they are glad to take their places as useful members of society. I have never operated in any case where I have not been well satisfied, either from my own care of the case, or from that of intelligent physicians, that further treatment in any other manner would be of no avail. I have no regrets at the course pursued 22 up to the present time, and I know of no case where the patient regrets the step she took. In answer to the objection that it unsexes the wo- man, I have only to say that in all the married wo- men, they either have never been pregnant or have not since the beginning of their most serious symp- toms, even though several years have elapsed since their last childbirth. Dr. W. Gill Wylie, professor of gynecology in the New York Polyclinic, in reporting thirty-seven oper- ations for removal of the uterine appendages, in the Medical News of March 27, 1886, says: "I have yet to see a well-marked case of hystero-epilepsy or decided hysteria operated upon, in which the ovaries were not found in a state of cystic degeneration or very much atrophied. And these are nearly always associated with an imperfectly developed or atro- phied uterus." And in the same paper he says, what I have found true in several cases, "that in those cases where the subjective symptoms were chiefly reflex and of a nervous order, the immediate results were by no means always satisfactory, although many recovered after being seemingly unimproved for sev- eral months." When we take into account how little has formerly been done in these long-standing reproaches to the profession, we can certainly get much comfort from the results in his cases. On this point he says: " It is yet too soon to speak positively about the results of the operation in all classes of cases, but I can say without hesitation that in those cases where the sub- jective symptoms were actual local pain and physical inability to go about without causing persistent pain -and almost all the cases of pyo-salpinx would come under this head-the results were good and satisfac- tory to the patient and physician. In many cases the relief from pain was gratefully acknowledged at once." This is so thoroughly in accord with my own ex- 23 perience that I need only to quote it as applicable in a majority of my own cases. The experience of Battey and Tait, who are deservedly the pioneers in this department of gynecology, is now so well known to the profession, that it would be supererogation at this time to allude to it in detail. It is no longer a question with them what shall be done with this large class of sufferers; by hundreds of cases they have demonstrated the utility of the procedure. The very extensive and valuable papers relating to to this and kindred subjects, by Mary Putnam Ja- coby, show that what at first glance may seem to be only slight changes in the ovary and tubes, are really severe structural organic changes, that without doubt have destroyed their function. If I were asked to formulate my views, derived from my own experience and that of the men who have done much more in this direction, I should sum up about as follows: 1. That these (so-called) hysterical symptoms oc- cur almost exclusively in women. That whenever any of them do occur in men they are much less in degree, even if they do not differ in kind. 2. That it is fair to presume from the first propo- sition that it is due to disease of some organ or or- gans peculiar to women. 3. That they are not due to disease of the uterus alone, for when all apparent abnormalities of the uterus are corrected, the symptoms, very often, are not in the least relieved. 4. That all modes of treatment, other than oper- ation, have failed to cure, and in most instances have not ameliorated, the symptoms, even where the dis- ease was believed to exist in the uterine appendages. 5. That the large majority of all cases operated upon have been entirely cured of the symptoms for which the operation was made, and the remnant have been relieved and are continuing to improve. 6. That it is impossible, in a majority of cases, to 24 determine by the touch, disease of these organs that will produce the symptoms alluded to. 7. That one can by these symptoms alone make a sufficiently satisfactory diagnosis to warrant the operation. 8. That if after correction of all well known and clearly diagnosticated uterine troubles, these symp- toms are not relieved, we are justified and required, for the cure of our patient, to recommend this remedy. 9. That the operation does not in any case destroy the sexual desire, or in any way unsex the woman, except so far as it may prevent further childbearing. 10. That in a majority of cases requiring the op- eration the woman is already sterile. 11. That in my own experience the specimens re- moved have been found so changed by inflammatory action as to be cirrhotic, or otherwise destroyed, either by softening or cystic degeneration of both ovaries and tubes, with very frequent stenosis of the latter. 12. That a fatal result from the operation is ex- tremely rare, if it is carefully performed and closely and intelligently managed as to the after treatment. In the twenty-five cases operated upon there has been but one death. It is certainly time that the profession were done with the old idea that a hysterical woman is only to be laughed at, and treated as one who deserves no consideration at our hands. Thousands of women, of the strongest character, have been cruelly and shamefully treated by their friends, even while they were suffering the most excruciating agony, and sim- ply because the profession has given countenance to the theory that "she could prevent it if she chose," that she was "only hysterical." We cannot expect more from the laity jhan we teach them. Instead, let us each strive to " contribute something to the science of pathological anatomy" out of this mass of distressing symptoms.