r ■S j:-*: ■'•:,i ..''/;,::.u>':: r•;■',■'>>. '•'.•:: '.:.-' '/. : if.; \ ? • f i f t ; ■ i J o Surgeon General's Office N< vOGQ&QOQ(yQ)GQOQ6Q>QQ>6Q>®Q>0 Qn ^/j, DUE TWO WEEKS FROM LAST DATE t«ov »1 OPO 262008 CLINICAL LECTURES ON DISEASES OF WOMEN. BY .e* J. Y. SpiPSON, M.D., F.R.S.E., PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF EDINBURGH, ETC., ETC. ILLUSTRATED WITH ONE HUNDRED AND TWO ENGRAVINGS ON WOOD. PHILADELPHIA: BLANCHARD AND LEA 1863. "■»».r&#y I/. ■ ;■_ PHILADELPHIA : COLLINS, PRINTER, 705 JAYNE ST. AMERICAN PUBLISHERS' NOTICE. The following Lectures on Diseases of Women were delivered by Professor Simpson at the Royal Infirmary of Edinburgh, and were published in the " London Medical Times and Gazette" during the years 1859, 1860, and 1861. The distinguished reputation of the author, and the valu- able practical matter contained in the Lectures, entitle them to a more permanent form than the evanescent columns of a periodical. They have, therefore, been col- lected and reprinted in a shape for preservation and refer- ence. Philadelphia, December, 1862. / CONTENTS. Page LECTURE I. VESICO-VAGINAL FISTULA . . . .17 Its cause; situation and extent; diagnosis ; prognosis; treatment. LECTURE II. VESICO-VAGINAL FISTULA—continued . . .26 Paring the edges—Introduction of the stitches—Coaptation of the edges— Securing of the threads and the consolidation of the parts—After- treatment. LECTURE III. CANCER OF THE UTERUS . . . .42 Pathology and semeiology of the disease : Its anatomical seat and course— Pathological forms—Symptoms—Diagnosis—Ages of patients affected— Prognosis. LECTURE IY. cancer of the uterus—continued . . .54 Palliative treatment: Measures calculated to palliate the attendant pains ; to arrest the attendant hemorrhages ; to counteract the offensiveness, etc., of the attendant leucorrhceal discharges. / LECTURE Y. CANCER OF the uterus—continued ... 65 Surgical treatment: Extirpation of the entire uterus—Excision—Amputa- tion—Dangers attendant upon amputation—Advantages or results to be attained. LECTURE YI. CARCINOMA OF THE UTERUS AND MAMMA . . 78 Treatment by caustics : Should cancers of the mamma be removed by the knife?—Results of excisions—Is removal by caustics preferable?—Is m extirpation by caustics more complete or lasting than by the knife ?— In what cancers are caustics applicable?—Principle upon which used- Varieties of caustics—Applications of caustics to the cancerous cervix uteri. VI CONTENTS. i Page LECTURE VII. DYSMENORRHEA .... 93 Seat of the pain—Ovarian dysmenorrhea—Uterine dysmenorrhoea—Diag- nosis—Prognosis—Treatment. LECTURE VIII. TREATMENT OF DYSMENORRHEA . . .105 Palliative treatment—Preventive treatment. LECTURE IX. closure and contractions of the vagina, etc. . 119 Causes of occlusion and stricture—Symptoms and diagnosis—Treatment, when producing obstructive amenorrhoea—Treatment of morbid con- tractions of the vagina from cicatrices—Treatment of congenital con- tractions of the os vaginae. Fissure of the orifices, of the vagina— Symptoms and diagnosis—Causes—Treatment. LECTURE X. CARUNCLES of the urethr^—neuromata of the vulva—hyper- esthesia and neubalgia of the vulva.....134 Urethral caruncles : Semeiology—Pathological anatomy—Diagnosis—Treat- ment—Methods to be followed for the removal of urethral caruncles— Palliative treatment. Neuromata of the vulva. Hypersesthesia and neuralgia of the vulva. LECTURE XI. abscess of the labia pudendi, and the various forms of vul- vitis .._..:......144 * Abscess of the labia pudendi—Treatment of fistula in vulva—Papillary vulvitis—Purulent vulvitis, or leucorrhoea in infants—Gangrenous vul- vitis, or noma—Pruriginous vulvitis. LECTURE XII. SURGICAL FEVER . . . .153 Causes of death after surgical operations and injuries—What is the nature of the malady which accompanies or gives rise to these secondary lesions ? LECTURE XIII. SURGICAL FEVER—ITS ETIOLOGY AND SEMEIOLOGY . 162 ^Etiology : Causes of the secondary deposits and abscesses. Semeiology : Signs of the secondary lesions.. CONTENTS. vii Page LECTURE XIV. SURGICAL FEVER—ITS TREATMENT . . .172 Preventive or prophylactic treatment. Curative treatment—Local curative measures—Constitutional curative measures. LECTURE XV. • PHLEGMASIA DOLENS . . . .189 Symptoms and diagnosis—Pathological anatomy and pathology—Origin,in blood disease. LECTURE XVI. PHLEGMASIA DOLENS—continued . . .200 Pathological nature continued — Treatment—General indications — Local indications. LECTURE XVII. COCCYODYNIA, AND THE DISEASES AND DEFORMITIES OF THE COCCYX . 209 Symptoms—Nomenclature—Pathological nature—Treatment — Injuries of the coccyx in connection with parturition—Surgical injuries—Malforma- tions—Deficient development—Tumours—Treatment of these tumours. LECTURE XVIII. PELVIC CELLULITIS . . . .229 Nomenclature—Pathological anatomy—Symptoms and diagnosis ; before suppuration has begun; after it has been established—Prognosis. LECTURE XIX. TREATMENT OF PELVIC CELLULITIS . . .246 Before suppuration has begun; after suppuration is established—Abscess of the uterus. LECTURE XX. PERI-UTERINE OR PELVIC HEMATOMA, AND VARIX OF THE PUDENDAL VEINS............259 History of hematoma of the pelvis—Nomenclature—Pathological anatomy and Pathology — Symptoms—Prognosis — Treatment — Haematoma or thrombus of the vulva—Varix of the pudendal veins. LECTURE XXI. SPURIOUS PREGNANCY, OR PSEUDO-CYESIS . .276 Constitutional pseudo-cyesis—Frequency of the disease—Times of its oc- currence—May the disease occur in the unmarried?—Symptoms and diagnosis—Repetition of special idiosyncrasies—Physical diagnosis. Vlll CONTENTS. Page LECTURE XXII. SPURIOUS PREGNANCY—ITS PROGNOSIS, PATHOLOGY, AND TREATMENT 289 LECTURE XXIII. OVARIAN DROPSY . . . .301 Pathology—Nature of the fluid contained—History and Prognosis. LECTURE XXIV. OVARIAN DROPSY—ITS SYMPTOMS AND DIAGNOSIS . .314 iEtiology—Symptomatology—Physical diagnosis : when the tumour is still in the pelvis ; when it has entered the abdomen—Differential diagnosis. LECTURE XXV. OVARIAN DROPSY—DIFFERENTIAL DIAGNOSIS CONTINUED — MEDICAL TREATMENT..........330 LECTURE XXVI. OVARIAN DROPSY—ITS SURGICAL TREATMENT . .341 Application of pressure—Paracentesis ; is tapping a dangerous operation ? LECTURE XXVII. OVARIAN DROPSY—ITS SURGICAL TREATMENT CONTINUED . 348 Forming a communication between the interior of the cyst and the cavity of the peritoneum—Establishing a fistulous communication between the interior of the cyst and a mucous or cutaneous surface. LECTURE XXVIII. OVARIAN DROPSY—INJECTION OF IODINE . .359 Injection of iodine and other stimulating substances—Application of elec- tricity, or galvanism. LECTURE XXIX. OVARIOTOMY.....375 History of the operation—Objections to ovariotomy. LECTURE XXX. OVARIOTOMY—continued . . . .387 Cases requiring the operation-—Mode of performing it—Results. CONTENTS. IX Page LECTURE XXXI. CRANIOCLASM: MODES OF DELIVERY IN OBSTRUCTED LABOUR . 397 Conditions justifying the operative diminution of the foetal head—Cephalo- tripsy—Craniotomy—Cranioclasm—Mode of operating—Comparison of cranioclasm with cephalotripsy and craniotomy. LECTURE XXXII. DROPSY AND OTHER DISEASES OF THE FALLOPIAN TUBES . 423 Displacements of the Fallopian tubes—Hypertrophy—Fibroid tumours— Carcinoma—Tuberculosis—Inflammation—Hemorrhagic effusions into —Dropsy: ^Etiology ; Pathological anatomy ; Semeiology ; Diagnosis ; Prognosis; Treatment. LECTURE XXXIII. PUERPERAL MANIA . . . .437 ^Etiology and pathology—Its connection with albuminuria, etc.—Semeiology of the disease. LECTURE XXXIY. puerperal MANIA—continued . . .449 Prognosis—Treatment: at the onset of the disease ; after the disease has become established—Puerperal hypochondriasis. LECTURE XXXV. SUB-INVOLUTION OF THE UTERUS AFTER DELIVERY . 462 Pathological nature of the disease—^Etiology—Semeiology—Physical diag- nosis—Duration and degree—Treatment. LECTURE XXXYI. SUPER-INVOLUTION OF THE UTERUS AND AMENORRHCEA . 472 ( Symptoms and diagnosis of super-involution of the uterus—Physical diag- nosis—Amenorrhoea. LECTURE XXXVII. AMENORRHEA—continued . . . .484 Semeiology—Symptomatology: Symptoms dependent on condition of ute- rine system; Constitutional symptoms. LECTURE XXXVIII. AMENORRHEA—continued. . . .491 Symptomatic treatment—Systematic or constitutional treatment—Specific treatment—Local treatment—Amenorrhoea connected with undersized uterus. LIST OF ILLUSTRATIONS. FIG. PAGE 1. Speculum used in operating on vesico-vaginal fistulse, with blades at either end of different sizes (quarter size) . . . . . 27 2. Tenaculum, or sharp hook used for catching up the edge of the mucous membrane of the vagina around the fistula (half size) . . 28 3. Straight knife used for paring the edges of fistulse (half size) . . 28 4. Bent knife used for paring the edges of fistulse (half size) . . 28 5. Lateral view of the same (bent) knife . . . . .28 6. Tubular needle for passing wire threads in vesico-vaginal fistulse . 30 7. Fork or pulley used in drawing through the wires to prevent them from cutting the vaginal mucous membrane above the wound (half size) 30 8. Blunt hook for directing the point of the needle (half size) . . 30 9. View of the anterior wall of the vagina, showing a fistula with the edges pared, and the stitches passed. (Modified from a figure by Sims) . ' 31 10. Bozeman's suture-adjuster (half size) . . . . .32 11. The manner in which Sims adjusts and fixes the sutures. (After Sims) 33 12. Bozeman's "button" passed along the threads. (Bozeman) . . 34 13. Bozeman's " button-suture" applied with perforated shot. (Bozeman) 34 14. The iron-wire splint passed along the threads to the pared' wound . 36 15. Instrument for adjusting and twisting the ends of the wires after the splint has been applied (half size) . . . 3(5 16. End of the same instrument in the act of twisting the wire . . 36 17. The iron-wire splint finally adjusted and the ends of the stitches twisted and secured across the lower bar of the splint . . .37 18. The manner in which Sims removes his silver sutures. (After Sims) 38 19. Carcinoma beginning in the cervix uteri, and ending in the production of recti-vesico-vaginal fistula. (Farre) . . . .45 20. Section of uterus filled up by a polypoid or sessile mass of carcinoma . 47 21. Perpendicular section of a commencing cauliflower excrescence of the collum uteri (cancroid). (Virchow) . . . .48 22. Development of cells in carcinoma mammae. (From Virchow) . 49 23. Arrangement for applying carbonic acid to the uterus . r ~? 1A. Section of the perforated cork used in the local application of carbonic acid gas to the uterus ..... -o 25. Arrangement for injecting the vapour of chloroform . . eg 26. Amputation of neck of uterus by the straight ecraseur. (Chassaignac) 68 27. Section showing how amputation of the cervix uteri may be performed without dragging down the uterus. (Altered from Chassaignac) . 69 LIST OF ILLUSTRATIONS. XI FIG. 28. Cervix uteri excised for cancroid disease .... 29. Same cervix uteri, viewed from surface of amputation . 30. Cervix uteri amputated for cauliflower excrescence of the posterior lip 31. Appearance presented by a section of the tumour 32. A single, very wide, and thin-walled bloodvessel, from a cauliflower excrescence on which the cells are lying. (Virchow) 33. Diagram illustrative of the introduction of conical arrows into the base of a tumour for its cauterization or destruction. (Maisonneuve) 34. The mode in which flat arrows are introduced for parallel or fascicular cauterization or destruction of cancerous tumours. (Maisonneuve) 35. A fusiform arrow, such as is used for the central cauterization or de- struction of cancerous tumours. (Maisonneuve) 36. Sketch of a dysmenorrhceal membrane, as seen under water 37. A dysmenorrhceal membrane laid open. (Coste) 38. Inner surface of a uterine cast, viewed with a low magnifying power 39. The openings of the uterine follicles more distinctly seen 40. ) Intra-uterine stem pessaries used for dilatation of the os and cervix 41 ) uteri ....... 42. Point of the staff used in the introduction of intra-uterine pessaries 43. Sketch of the virgin os uteri ..... 44. Sketch of the os uteri of a woman who has borne children 45. Section of the uterus . . . . 4iJ. The hysterotome or metrotome ..... 47. Urethral caruncle. (Boivin) ..... 48. Arrangement of the vessels in a urethral caruncle. (Wedl) . 49. A caruncle at the urethral orifice, and a number of red painful spots in the surrounding mucous membrane .... 50. Thrombi arising in one vein, and passing continuously into another (Virchow) ....... 51. Embolism of the pulmonary artery. (Virchow) 52. Puriform debris of softened thrombi. (Virchow) 53. Obstruction and inflammation of the lower part of the aorta, and of the iliac and femoral arteries ..... 54. Sketch of the anatomical relations of the coccyx 55. Sketch of a coccygeal tumour attached to the child 56. Sketch of the coccygeal tumour dissected 57. Sketch of a coccygeal tumour which presented at birth 58. Coccygeal tumour in a child born eighteen years ago and still living 59. Sketch of a case similar in nature to the preceding 60. Diagram showing the situation of a purulent collection behind the uterus 61. Situation of the hsematoma between the uterus and the rectum 62. Sketch of varicose veins of the nyniphae. (Brasse) 63. Section of a multilocular ovarian cyst, with secondary cysts in the largest primary cysts, and broken-down dissepiments between others 64. Section of a colloid tumour of the ovary .... 65. Lateral position of ovarian tumours in their earlier stages, as contrasted with the central position subsequently assumed 66. Relation of an ovarian tumour to the descending colon 67. Large ovarian tumour, showing the position of such tumours behind the abdominal wall, and in contact with the omentum. (Bright) . 73 74 75 76 77 89 89 90 98 99 100 100 115 116 116 117 117 118 135 137 140 167 167 168 201 214 223 224 225 226 227 254 263 274 304 305 319 327 331 Xli LIST OF ILLUSTRATIONS. FIG. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. S3. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. Compression and displacement of the abdominal and thoracic viscera produced by the tumour. (Bright) . [ Canulse with trocar attached. ..... Trocar with quadrangular point for large openings into ovarian cysts Corresponding canula ....••■ Scanzoni's trocar and canula for tapping ovarian cysts through the roof of the vagina . . • • • The canula or tube which is left in the wound Bistoury for dilating the opening made by the trocar . Apparatus for injecting fluids into evacuated ovarian cysts Patches of lymphy exudation in the interior of an inflamed ovarian cyst Mr. Wells's clamp, for securing the pedicle of the tumour, in cases of ovariotomy Mr. Wells's operating table ..... Manner in which a bloodvessel may be secured by means of an acupres sure-needle, and the pedicle of the excised ovary may be fixed against the abdominal wall ..... Manner in which the pedicle is secured with the clamp, and position of the clamp and pedicle when the operation is completed. (Wells) Acupressure-needle of small size .... Impossible view of the inner surface of the anterior abdominal wall with the stem of an acupressure needle crossing a wounded artery, &c Kilian's cephalotribe, applied in a pelvis contracted at the brim Base of a foetal skull reduced in the operation of craniotomy Perforator ....... Cranioclast . . . . . Cranioclast ....... Bones of the skull of an infant delivered by means of cranioclasm Base of a foetal skull reduced in the operation of craniotomy . Cast of the crushed head of an infant delivered by means of cranioclasm and of the same head in a redistended state Head of a child delivered by means of cranioclasm Fibroid tumour growing from the Fallopian tube Front view of the arteries of a patient in whom the uterine appendages were much diseased from repeated attacks of inflammation Uterus, Fallopian tubes, ovaries, &c. .... Dilatation of the Fallopian tubes from obliteration of their orifices Muscular fibre-cells of the uterus three weeks after delivery . Outline of the uterus in its normal and in its hypertrophied conditions Internal organs of generation from the patient whose history is given Porte-caustique for the interior of the uterus .... Instrument for dry-cupping the interior of the uterus Galvanic intra-uterine pessary, and staff used for introducing it PAGE 331 351 355 355 360 360 360 371 373 390 391 393 394 395 395 409 410 411 411 413 414 415 416 418 424 429 431 434 464 469 481 503 503 505 CLINICAL LECTURES ON THE DISEASES OF WOMEN. BY J. Y. SIMPSON, M.D., PROFESSOR OF MEDICINE AND MIDWIFERY IN THE UNIVERSITY OF EDINBURGH. LECTURE I. ON VESICO-VAGINAL FISTULA. Gentlemen: The ward in the Royal Infirmary set aside for the treatment of the Diseases of Women, is intrusted, by the Managers of the Hospital, to my care, under the condition that I endeavour to give that part of my course of lectures which refers to female maladies clinically, and by reference to the cases admitted into this special ward. Last year I attempted to do this, by devoting, dur- ing the academic course, one lecture a week to the discussion of some subject or subjects connected with female diseases, which hap- pened at the time to be illustrated by a case or cases under treat- ment in the hospital. This year I intend to follow the same plan. In pursuing it I shall be obliged, as in all similar clinical lectures, to go through the consideration of Ovarian, Uterine, and other female diseases irregularly, and in no systematic order; but, pro- bably, during the session we will find cases enough to enable me to make the course in the long run one which will embrace most of the maladies, surgical and medical, that are peculiar to the female economy. I purpose to devote the first of this series of lectures to the treatment of perhaps the most distressing and deplorable of all the infirmities to which woman is liable, viz., chronic perforation of the septum between the bladder and the uterine passages, permitting the escape of urine, and designated, according to its seat, urethro- vaginal, vesico-vaginal, or vesico-uterine fistula. This is certainly one of the most afflicting accidents that can befall the parturient female; for, though it is not immediately fatal, it renders life misera- ble, seeing that the acrid urine is constantly escaping and excoriat- ing and irritating the pudenda and thighs ; and too often its continual decomposition makes the unhappy patient not only loathsome to herself, but an object of disgust to all around her. 2 18 VESICO-VAGINAL FISTULA. I speak of the treatment of this disease more willingly because it was long looked upon as incurable, and reckoned among the oppro- bria of surgery. With others I used to regard a patient afflicted with it as a case generally beyond all relief and all hope. But within the last few months I have come totally to change my opinion ; and I want now to tell you by what means we can cure—I had almost said, certainly and easily cure—most cases of vesico-vaginal fistula. Yesterday some of you had an opportunity of seeing me operate for this disease on a woman who has laboured under it for eight years, and whose history is the following:— Mrs. McK., aged 40, a native of Ireland, has been married twenty years, and given birth to ten children. The last two labours were attended with difficulty, from the fact of the presentations being irregular. She is not sure whether instruments were used to effect delivery or not, but she kept her bed for more than a year after her last confinement, and it was about a fortnight after it that she first found the urine dribbling away, which it has continued to do ever since, producing constant soreness and great annoyance and dis- comfort. She first came under my care about two months ago, and at that time she was placed on the table with a view of being operated on; but the great extent of the fistula and the complete extroversion of the bladder through it deterred me; and those of you who were present at the operation yesterday can best judge how formidable a case it was. The opening was large enough to admit easily three fingers; the anterior wall of the vagina was so far destroyed that one of the middle stitches used to close the gap touched at one ex- tremity the cervix uteri and reached at the other to within an eighth of an inch of the orifice of the urethra; and its form was very irre- gular, varying with the movements produced by the muscular con- tractions of the part. Then the constant protrusion of the red and vascular anterior wall of the bladder, projecting like a hernial tumour through the wound, complicated the first stage of the operation, and rendered the paring of the edges very difficult from the risk of wounding the bladder. This difficulty I attempted to get over by introducing a heavy bullet of lead attached to a wire, expecting, as the patient was placed on her hands and knees, that the weight of the lead would keep the anterior wall of the bladder down in the ab- dominal cavity ; and it did so, so long as the patient kept quiet; but the moment she coughed, or gave utterance to a cry of pain, the bullet was shot out and the bladder was protruded as before. Yesterday I tried to keep it down by means of a sound passed through the urethra, but the bladder continued to press out on each side of it; and I only succeeded in getting the edges at last partially pared by having the bladder kept back by means of a whalebone probang, tipped with a piece of sponge, and pushed through the fistula. Having pared the upper and lower margins of the fistula, I passed a wire ligature through them, and had the ends of it drawn VESICO-VAGINAL FISTULA. 19 tight and fixed. In this way the hernia of the bladder was prevented from recurring, and I was enabled to make raw the remaining parts of the fistulous border with more ease and safety. The edges were then brought into apposition by means of eight iron wire stitches, and kept in apposition by means of an iron wire splint, such as I now show you, and of which I shall have something more to say pre- sently. The patient is quite well this morning, and no. urine escapes per vaginam. I can hardly bring myself to believe, however, that the operation will be at once completely successful, when I think of the great extent of the fistula; and then the catheter which had been provided proved to be too short (for the patient is even stouter than the generality of such patients are liable to become from their inactive life); and the urine for some time was not allowed to drain away so freely as it ought. Here I show you a wire splint with stitches, which I this morning removed from a patient on whom I operated nine days ago. The woman is now in her 66th year, and has suffered during nearly the half of her lifetime from a vesico-vaginal fistula resulting from a tedious labour. The opening was situated high up, close to the portio vaginalis uteri, and of small size, requiring only three stitches to hold the pared edges in apposition. For thirty-two years she has not been able to retain a drop of water, except once or twice when the temporary swelling of the edges of the fistula produced by cauter- ization with the galvano-cauter of Marshall and Middeldorpf, pre- vented for a few hours its escape per vaginam. Since yesterday week every drop has come through the catheter. Passing from these special cases, allow me to make some general remarks upon this deplorable disease ; and, 1. As to its cause.—It is most commonly found as a consequence of difficult and prolonged labour, more especially the latter; and this result has been attributed, 1st, to the long-continued pressure of the fcetal head on the maternal passages, producing mortification and sloughing of the vagina, and part of the wall of the bladder; and, 2dly, to direct injury from the use of instruments. That in such cases the fistula is not usually caused by the forceps or other instruments employed is proved by the fact that the urine does not flow per vaginam immediately, but only begins to trickle away some days afterwards, when the slough commences to separate, and leaves a communication between the bladder and vagina. It is far more frequently caused, I believe, by the mere morbid prolongation of the labour giving rise to inflammation, and sloughing of the compressed soft tissues, than it is caused by obstetric instruments employed to shorten the duration of parturition. It may in some cases, however, be caused by the direct use of instruments. A patient, the subject of fistula, lately told me that she met with her misfortune many long years ago, at the hands of a medical student, who attended her as his first midwifery case, and who, in using a lancet to evacuate the liquor amnii, by perforating the membranes, wounded instead the 20 VESICO-VAGINAL FISTULA. urinary bladder. Vesical fistula has sometimes been produced by the incautious use of the perforator. It has been known to arise also from long retention of a pessary in the vagina. _ Stones and foreign bodies in the bladder are said to have occasioned vesico- vaginal fistulse, by the ulceration which they set up; in some instances it has more certainly been left as a result of removing calculi from the female bladder, by incising the vesico-vaginal septum. _ 1 have often seen it in cases of cancer of these parts, complicating and aggravating a malady already sufficiently distressing, and then, of course, irremediable. I had in the hospital here under my charge some years ago, a very rare case where a vesico-uterine fistula en- sued from an abscess forming between the bladder and uterus, and opening into both organs. After some weeks the inflammatory deposit became absorbed, and simultaneously the fistula contracted, gradually healed up, and at last completely closed. 2. In regard to their situation, urinary fistulse in the female usually implicate the base of the bladder where it rests on the vagina, sometimes high up, sometimes lower down, but commonly at some point in the bas-fond. Occasionally the perforation is into the urethra. In very unusual cases only is the communication between the bladder and the neck of the uterus. 3. Their extent is very various. Sometimes they are so small as only to permit the escape of the urine by drops, and hardly to admit of the entrance of the finest probe. At other times they are of vast extent, as in our case of yesterday, where the whole base of the blad- der, and the corresponding part of the vagina, had sloughed away. The opening may be, and usually is, single; but occasionally there are two or even three of them. As regards the extent of the wound, I would only make this further remark, that the size seems to make little difference as to the power of the patient to retain her urine, for almost the smallest opening is sufficient to let out the water, accumulation of which in the bladder depends more on the situation of the opening very high up in the vagina, than on its diminutive size in any case. Yrou will find that some patients with vesico-vaginal fistula acquire a power of collecting a considerable quantity of urine in the vagina and bladder as long as they maintain the recumbent posture. 4. The shape of the opening may be round or oval, or very irre- gular. In the patient operated on yesterday it looked of irregular T shape, or more circular, according to the degree of contraction going on in the septum and the degree of protrusion of the bladder. 5. The diagnosis is usually so easy that I need not dwell unon it. The loss of power of emptying the bladder, and the constant escape of water by the vagina or vulva, taken in connection with the antecedent circumstances, excite your suspicion, and all doubt may be at once cleared up by introducing a catheter into the blad der, and passing your finger along the anterior wall of the vagina" when you may touch the catheter through the opening. Any fur' VESICO-VAGINAL FISTULA. 21 ther uncertainty, in regard to its size and relations, may be removed by introducing a duckbill speculum into the vagina, when the open- ing will be exposed, and a probe or larger instrument may be intro- duced through it into the bladder. Occasionally the diagnosis is not quite so simple. In a patient whom I have seen with Dr. Thomson, the fistula is so minute that at first it was with difficulty detected. On watching carefully the vesico-vaginal wall after the single-bladed speculum was introduced, a very small quantity of clear urine was at last seen issuing from one point, and through this point or fistula only a very slender wire could be passed. In vesico-uterine fistulse in order to discover the perforation, you will generally require to plug the os uteri with a sponge tent. The use of the tent aids the diagnosis in two ways. First, by its presence it prevents the escape of urine per vaginam, thus proving the communication with the bladder to be placed higher than the os uteri. And secondly, the due expansion of the os and cervix uteri with tents, will enable you to reach the fistula with your finger, or a sound, so as to empower you to trace the intercommunication between the urinary and uterine cavities. In instances in which the diagnosis proved obscure, either from the smallness of the opening in the vesico-vaginal septum, or from its being of the vesico-uterine variety, the obscurity of the diagnosis might perhaps be cleared up by water, and more particularly by coloured water being injected by the urethra into the bladder, while the vagina, os uteri, and anterior wall were exposed to sight by the use of the single-bladed speculum, for the point of issue of the coloured fluid would immediately guide us to the site of the fistulous communication. 6. Prognosis.—Till lately, most obstetricians and surgeons des- paired of being able to do anything in the way of a radical cure of vesical fistula. My predecessor, Dr. Hamilton, used to speak of such cases as utterly incurable; and Dr. Davis averred that all reported cases of cure were misrepresentations. Vidal, whose book is probably more extensively read on the Continent than any other systematic work on surgery, says: "I do not believe that there exists in the science of surgery a well-authenticated complete cure of vesico-vaginal fistula, a fistula due to a loss of substance from the bas-fond of the bladder." I have often seen cases operated on, and in many different ways, and have sometimes tried to operate myself; but till lately I never saw a cure. I have often before seen a large opening reduced to a small size, but the smallest opening left is enough to keep up all the patient's misery. Matters are now, however, entirely and happily changed, and this leads me to speak of, 7. The treatment of vesico-vaginal fistula.—One former mode of treatment consisted in introducing a catheter into the bladder as soon as possible after the fistula had formed, and leaving it there to prevent accumulation of the urine, in the hope that in the con- traction which ensued after the sloughing the fistula might close 22 VESICO-VAGINAL FISTULA. up. Cases of success from this treatment have been reported from the time of Desault downwards. But it can scarcely be expected to succeed in puerperal vesico-vaginal fistulse except either when they are very small, or the result of cutting instruments. This simple means has apparently also succeeded in some cases in which an opening in the vesico-vaginal septum was intentionally made for the purpose of removing calculi from the urinary bladder. Caustics and the actual cautery have long and frequently been employed, but with a success which at the best is usually only tem- porary. So long as the swelling of the margins produced by the application of the irritant continues, the escape of the urine may be restrained; but when this has subsided the case soon becomes as bad as ever. I have seen this treatment applied by Dr. Liston and others, and have often adopted it myself; but I never once saw it succeed in effecting a complete cure. It has been also proposed to close vesico-vaginal fistulse by ob- structing them, for a time, with a removable plug of caoutchouc or gutta percha, applied on the principle of the ball-valve, to their vesical opening; and again by filling them, when small, with hemp or worsted threads, and withdrawing a thread from time to time as the perforation contracted. I have perseveringly tried both of these plans in very favourable cases, but altogether without any beneficial result. Nearly two centuries ago, in 1663, Hendrick van Roonhuyse, a practitioner of Amsterdam, whose name is connected with the his- tory of other suggestions in operative midwifery, first proposed to cure vesico-vaginal fistulse on the same surgical principles as hare- lip—namely, by paring or vivifying the lips of the fistula, and then bringing and keeping their raw edges together with stitches of silk. But there is no evidence that Roonhuyse ever put his own proposi- tion into practice. In the course of the last century, Voelter, of Wurtemberg, and Fatio, of Basle, were the first apparently to try this operation; but both of them failed to cure their patients by it. Even the very remembrance of this method of treating vesico-vaginal fistulse seems to have afterwards fallen into oblivion, till, in 1812, the late Professor Naegele, of Heidelberg, recalled the attention of the profession to it. I am not certain who had the good fortune first to cure a case by this means. But during the last half century many modes of vivifying the edges of the fistula by differently shaped knives, scissors, and caustics, have been suggested and practised ; many varieties of stitches employed—as the "interrupted," the "continuous," the "quilled,'' the "twisted" suture, etc., and many means and modes of passing these stitches or sutures have been proposed. It has been attempted even to introduce the stitches from the cavity of the bladder, as well as from the vagina. And other means than stitches have been employed to hold together the raw lips of the fistula, such as the bladed compresses or leaf-like in- struments suggested by Naegele, Laugier, and Lallemand. Serres VESICO-VAGINAL FISTULA. 23 fines, also, have been used in this way. But sutures of hemp and silk have been most commonly made use of, and some cases have been published where they were reported as successful. Jobert, of Paris, and Wutzer, of Bonn, who have operated in this way by paring the edges and bringing the raw surfaces into apposition with them, more frequently and with better success, perhaps, than any other surgeons, have effected cures only as exceptional instances ; and when in Bonn, I saw Wurtzer operate for the fourth time on the same patient. In Paris they still operate in this way, as I learn from a letter I had a day or two ago from Dr. Bozeman, who saw Robert lately close up the wound with tape. Lately, Simon, of Darmstadt, has reported some cases of success by using a kind of double silk suture. The grand revolution, however, that has of late been accomplished in the success of the operation for the cure of fistula, is owing to a change in the mere material of the suture, or, in other words, owing to the introduction of metallic sutures instead of the sutures of hemp and silk, or other organic materials which were formerly employed to bring and keep the edges of the wound in apposition; and the success which attends their use is to be explained by the important general law that living tissues bear the contact of non- oxidizable metallic bodies for any length of time without being ex- cited to take on an inflammatory action, or if such action be excited, it does not usually go beyond the stage of adhesive inflammation. We see this law in surgical pathology exemplified in those cases where bullets, small shot, needles, &c, get lodged, and remain imbedded in the tissues for many years without causing any high grade of inflammation. There was here, a few weeks ago, a noble Duke who carries in his shoulder a bullet which got lodged in his body in the time of the Peninsular war, now more than forty years ago. Silk and other organic sutures, on the contrary, produce an inflammation which soon passes on to suppuration and ulceration, or the higher grades of the inflammatory process. We see a striking proof of the different effects of the two kinds of suture in this, that formerly, when silk or hempen threads were used in the operation for vesico-vaginal fistula, cures were so rare and exceptional that a suc- cessful case was boasted of as a triumph ; whereas, during the last two months, I have operated in four cases, using metallic sutures, and all but the first of them have been successful; and three cases of vesico-vaginal fistula cured in succession, each by one operation, was a success which we formerly never dreamt of. Dr. Marion Sims, of New York, who has in a great measure led the way in this modern revolution regarding the treatment of vesico-vaginal fistulse, tells us that he operated twenty-nine different times on one unfor- tunate patient, using always threads of hemp or silk, and always without success; but that on using metallic sutures in the thirtieth operation a cure was at once effected. Last summer I took occasion to make an extensive series of ex- 24 VESICO-VAGINAL FISTULA. periments upon the relative merits of metallic inorganic sutures and ligatures, and upon the relative surgical qualities of different metallic threads. These experiments were for the most part kindly per- formed for me by my friends Mr. Edwards, Mr. Jardine Murray, and Dr. Coghill, and the subjects of the experiments were a number of unfortunate pigs, which were always, of course, first indulged with a good dose of chloroform. We made corresponding wounds of various kinds, usually on directly opposite sides of the body, and sewed some with threads of silk, hemp, cotton, &c, and others with threads of silver, gold, platinum, lead, iron, &c. As a general result the contrast between wounds sewed with organic threads, and wounds of corresponding size and situation upon the same animal sewed with metallic threads, was most striking and remarkable. For while the silk and other organic sutures almost invariably began to inflame and suppurate along their tract a few days after their introduction, the metallic sutures remained, as it were, quite passive in the lips of the wounds, and without exciting any appreciable inflammatory disturbance. I have seen enough of cases in the human subject to convince me that the same comparative results as a general law follow the uses of these two forms of suture in the surgery of the human body. In fact, the surgeon is almost invariably obliged to cut out a silk or other organic thread a few days after its introduc- tion, in consequence of the suppuration and ulceration which its detention excites. You may leave, on the other hand, a metallic suture without any such consequences for weeks or months instead of days. Why do metallic threads not lead on to the higher degrees of inflammation, such as suppuration and ulceration, along their tracts and in their neighbourhood as organic threads do? I believe this question is to be solved by the mere fact of metallic bodies or threads lying unchanged and inert in and among the tissues with which they are in contact. If we introduce a metallic wire into a part, it has no power of absorbing the fluids there, and lies in apposition to the tissues without irritating them. A thread of silk absorbs the fluids thrown out—lymph, or pus,'or whatever else it might be—and these dead fluids remaining in the thread, and becoming decomposed, ren- der it a small tract or nidus of putrefaction and infection. In the experiments already alluded to, I repeatedly took silk threads which had been a few days in the lips of wounds in the pig, and had there produced suppuration in their tracts, and placed small portions of them in the bottom of new wounds in the same animal. Within a day or two severe inflammation, sometimes of a carbuncular form appeared in the lips and sides of these new wounds, showing the acrid and morbific nature of the dead and decomposing materials absorbed by and retained within these organic threads. What metal is best ? This question has been often asked and variously answered. Sims uses always silver wire in preference to any other. Mettauer, like Dieffenbach, operated with leaden wires. VESICO-VAGINAL FISTULA. 25 I have always used the ordinary simple and cheap blue iron wire of the shops ; and believe it is the best. What is required is a mate- rial not readily oxidizable, and possessed of a certain degree of strength and tenacity. Now, it has been found that a certain thick- ness of wire, if made of lead, will sustain a weight of 1 lb., silver, 9 lbs., platinum, 13 lbs., iron, 26lbs., from which it will be seen that iron wire will not so readily give way as some of the others. But is it from any particular reason more irritating than these, or more likely to produce a high, and dangerous, or destructive degree of inflammation ? The liability of iron to rust, or become oxidized, at once occurs to most minds as likely to impair its usefulness, and render it irritating to the tissues with which it is brought into contact. But we know that iron in some forms does not become oxidized in the body, and causes no disturbance whatever in the tissue. Needles, for instance, usually excite little or no inflammation; and I show you here a portion of a needle removed by Dr. Murray, from a child's foot, in which it had lain three years and four months without becoming in any degree roughened on the surface by rust or oxida- tion. And Schonbein has shown that by being submitted to certain processes, iron maybe rendered what he calls "passive;" and in this passive state it is not at all liable to become changed and oxi- dated. For while iron in the ordinary condition gives rise to a sort of effervescence on being introduced into strong nitric acid, of specific gravity 1.3, this phenomenon is not seen when the iron is in the "passive" state. This condition may be induced in various ways—by passing a piece of wire through the flame of a spirit lamp, by introducing the wire into nitric acid at the same moment, and in contact with a piece which is already passive, or, as in the wire which I commonly use, by annealing, which is done, I am told, by putting the hot wire into an oil bath. The wire, then, which I always use, and which I believe to be the best, as it certainly is the cheapest, is the ordinary annealed iron wire of the shops, and of the size known as No. 32. I have by me here some specimens of iron wire coated with tin, silver, &c, as well as wires of platinum and other metals; but not one of them fulfils any indication better than the simple annealed blue iron wire, which may be bought at any wire- workers for a shilling a pound. Through the kindness of my es- teemed friend, Dr. Aveling, of Sheffield, the firm of Cockers, Brothers, of that town, have lately manufactured an iron wire for surgical purposes, drawn out of the finest procurable material, and in this respect superior to the common iron thread I have always used. At our next meeting, I will explain to you minutely the mode of performing this operation, step by step. 26 VESICO-VAGINAL FISTULA. LECTURE II. ON VESICO-VAOINAL FISTULA. Gentlemen : Before explaining to you the details of the opera- tion for the cure of vesico-vaginal fistula, allow me to observe that you must choose a bright clear day for it, and have the patient placed well exposed to the light. It is an operation for a sunny summer, rather than for a bleak November day, as you must have abundance of light sent along the speculum to enable you to guide your knife and needles correctly and safely. When operating on a patient some days ago, the light was sometimes so obscured by heavy passing clouds, that I was obliged at times to desist; and particularly if one of these clouds came athwart the sky after the needle had been passed, I found it quite impossible to introduce the wire into the eye until the cloud had cleared away. Then you will require three or four assistants. One is always necessary to hold the speculum in situ, to keep aside one of the labia pudendi, when required, with the finger or with a bent copper spatula, and be ready to -hold aside some of the ends of the wires. Another will, if requisite, keep aside the other labium, and catch the ends of wires on his side ; a third takes charge of instruments and sponges ; and the fourth attends to the exhibition of chloroform, provided the patient is placed under its influence. The mere amount of pain endured by the patient is perhaps less than in most surgical operations, as the walls of the vesico-vaginal septum are far less sensitive than you would d prion imagine. In what position will you place your patient ? Formerly we were generally advised to have her placed on her back, as in the position for lithotomy. Wutzer turned his patients upon the belly. Dr. Sims has effected an important improvement in teaching us to place the patient either on her elbows and knees, or simply on her left side, and to introduce a duckbill speculum, resembling the one I now show you, with which the rectum is pulled upwards, and a flood of light thrown on the exposed fistula. The instrument I hold in my hand is one slightly modified by Dr. Bozeman, from the original pattern of Dr. Sims ; and a very good and serviceable speculum it is for this operation. But it always seems to me that it might be improved by being made self-adjusting and self-supporting, by means of a spring or screw, as we might then dispense with the services of an assistant, for whom it is a very irksome task to hold this heavy implement so long and so steadily in the required position. Having thus arranged for the position of the patient, and the exposure of the fistula, you have now to consider what instruments VESICO-VAGINAL FISTULA. 27 you are likely to require. Taking the after-treatment into considera- tion as part of the operation (as, indeed, it is essential to its success- Fig. 1. The speculum used in operating on vesico-vaginal fistulse, with blades at either end of different sizes (quarter size). ful issue), you will find the proceedings divisible into five stages, in each of which a particular instrument or set of instruments comes into requisition. 1. The edges have to be pared. 2. Stitches have to be introduced. 3. The raw surfaces have to be brought into apposition. 4. The threads have to be fixed or tied, and the lips of the wound kept firmly together. 5. A proper catheter must be chosen and adjusted, and an appro- priate and careful after-treatment has to be pursued. 1. Paring the Edge of the Fistula. For denuding the margins of the fistula, you require to catch up the middle point of the edge of the lower lip of the fistula, with a long-shafted tenaculum (Fig. 2), or with artery forceps, or with a small volsellum, and then the cutting is effected either with knives or scissors, or both. Sims and Bozeman use both—the scissors being employed by the latter to pare the upper border of the fistula, or to remove any small portions of mucous membrane that may chance to have been left. I find that I can succeed best with knives alone for this and for all the other purposes in which cutting is required in the operation. You may either employ the two knives of Mr. Baker Brown, the blades of which are set at an angle to the shaft, with the cutting edge of the one turned to the right, and the other to the left side (Figs. 4 and 5), or you may use a straight spear- shaped knife (Fig. 3), which will serve alone all your objects. In per- forming this part of the operation, you must be careful to have the ed^es bevelled off to a considerable distance from the vesical margin 28 VESICO-VAGINAL fistula. so as to leave as large a surface for adhesion as possible; and to effect this with greater certainty, you will do well to enter the point of your knife into the vaginal mucous membrane at some distance from the fistula; then transfix with your knife the edge of the fistula Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 2. The tenaculum, or sharp hook used for catching up the edge of the mucous membrane of the vagina around the fistula (half size). Fig. 3. Straight knife used for paring the edges of fistulse (half size). Fig. 4. Bent knife used for paring the edges of fistulas (half size). Fig. 5. Lateral view of the same (bent) knife to show the angle at which it, the blade, is bent (half size). to the extent you intend to remove it, and, bringing it out at the vesical border, carry it right and left fairly round the opening, so as, if possible, to bring out a complete circle of tissue. Do this part of the operation cautiously and carefully, and I would beg to add slowly, in order that you may do it thoroughly and well. In this way you can make sure of leaving a raw surface all around the vesico-vaginal fistula. 29 opening, and this is absolutely essential to the success of the whole operation, seeing that the least bit of mucous membrane left would prevent the much desired union by the first intention. I have here a very ingenious knife invented by Dr. Heywood Thompson, of Aigburth, furnished with a blunt protecting blade in^the manner of the razors used by insane persons, and intended to prevent the knife from cutting too deeply. Naegele seems to have thought of a simi- lar knife for the same purpose. In certain cases Jobert, after paring the edges, dissects the cer- vix uteri from the bladder, close up to the peritoneum, with the object of allowing the edges of the fistula afterwards to keep better in apposition ; but this proceeding seems both very unnecessary and very dangerous, and serves, perhaps, in some degree to account for the mortality of the operation which has happened from his mode of operating. You will require a pair of long artery-forceps to seize and twist any small vessel that may bleed very profusely ; or you may have ice provided to stop any hemorrhage that occurs; but usually time and exposure to the air, or the temporary introduction and pressure of a sponge in the vagina suffices. And now you may allow your patient to rest for a little to see that all the necessary apparatus is prepared for. 2. The Introduction of the Stitches. Till lately this has been found to be the most difficult part of the operation, and that which demanded the greatest expenditure of time, when metallic sutures were used. For the fact is, that metallic threads cannot be inserted easily into the lips of any wounds with common surgical needles. If the angle of the metallic thread passing through the eye of the needle become bent or twisted, or even dis- placed, the thread will not readily follow the needle. To overcome this difficulty, Drs. Sims and Bozeman have been in the habit of first passing needles armed with silk threads, to the ends of which the metallic threads were subsequently attached and so pulled through. In this way they passed always a double set of threads, first a set of silk threads, and then a sort of metal threads. For passing the needle, Dr. Bozeman, like Wutzer, Jobert, and others, has invented an ingenious porte-aiguille, while Sims uses a simple notched pair of forceps, which answers the purpose admirably well. In my first cases I followed out the same plan for introducing the stitches, viz., silk first, and afterwards iron threads; but having found it exceedingly cumbersome and tedious, I had recourse to a long needle in a fixed handle bent towards the point at an angle and distance corresponding to the bend and length of the blade of the knives I have shown you. This I first passed through the two edges of the opening; and then having introduced the end of an iron thread into the eye, I withdrew the needle, and in this way brought 30 vesico-vaginal fistula. Fig. 6. i\ Fig. 7. V Fig. 8 the thread backwards through the fistulous margins. The introduc- tion of the stitches was thus so far simplified, and the time spent in the previous passing of silk threads was saved ; but still there remained the difficulty of passing the iron thread into the eye of a needle situated in a deep and rather dark cavity. This final difficulty was got over in the yesterday's operation by the use of the hol- low needle, which I here show you (Fig. 6). The immediate idea for the construction of this instrument was derived from the description which my friend, Mr. Startin, of London, wrote me a few days ago of a curved needle which he is get- ting made. The needle which I have had made for vesico-vaginal fistula, is formed of a simple tube fitted into a metallic groove, to which the handle is fixed; one orifice is close to the point, the other is near the handle. The wire is pushed a little way into the latter of these orifices, and after- wards, when the needle has been passed through the margins of the wounds, it is pushed right through, and seized with a long pair of dress- ing forceps. The needle being then withdrawn, the iron thread is left in its place, and may be pulled through as far as is required. In pulling it through you may make use of a fork or director (Fig. 7), invented by Dr. Bozeman, to pre- vent the wire from cutting the mucous membrane. The only other instrument required in this stage of the operation is a blunt Fig. 6. Tubular needle for passing wire threads through the lips of vesico-vaginal fistulse. A wire is represented as passing through the tube. The figure is of full size—the extremity of the needle, looking thicker and larger than it really is. Only the commencement of the handle is represented in the woodcut. Fig. 7. Fork or puUey used in drawing through the wires to prevent them from cutting the vaginal mucous membrane above the wound (half-size). Fig. 8. Blunt hook for directing the point of the needle (half-size). VESICO-VAGINAL fistula. 31 hook (Fig. 8), which is used to fix and support the parts through which the eye of the needle is to pass; or rather the points from which it has to emerge. In this respect you will find it of great use; and the hooked extremity holds forward, and steadies the end of the needle after it has protruded, until you have secured and pulled forward the wire. If the thread is thus drawn through sufficiently before the needle is retracted, you have no need of Dr. Bozeman's "fork." Let me make one observation more, and that a most im- portant observation, regarding the breadth and depth of the stitches which you introduce. I have advised you to pare the edges of the fistula fully and freely; I now beg to advise you further to bring together its pared edges with stitches that will hold strongly and Fig. 9. View of the anterior wall of the vagina, with the os uteri above and the orificium urethrse below ; and showing a fistula with the edges pared, and the stitches passed. (Modified from a figure by Sims.) steadily. Enter your needle below, and make it emerge above, nearly half an inch on either side of the fistulous opening (see Fig. 9), where the distance of the entrance and exit of the threads from the edges of the fistula is represented perhaps as too narrow. When the iron threads are at last pulled together, this distance will appear 32 vesico-vaginal fistula. greatly diminished. And pass your needle down near to the mucous membrane of the bladder, or down near to the vesical side of the wound, without, however, allowing it to perforate through the vesical mucous membrane itself. If it does happen to pass either thus too deep, or not deep enough, withdraw it and reintroduce it properly. It is a thousand times better to do this and other steps of the opera- tion well, than to do them quickly. 3. Coaptation of the Edges of the Fistula or Wound. Dr. Bozeman recommends the edges of the wound to be brought closely together by passing the ends of each pair of threads through the perforation of this, his "suture-adjuster" (Fig. 10), and sliding the adjuster along them down to the wound, when by pulling tightly on the extremities of the sutures the raw surfaces may be brought into apposition. The stiffness of the wire suture pre- Fig. 10. vents the re-opening which would ensue on the re- moval of the adjuster from the elasticity of the tissues, if sutures of silk or hemp were employed. But per- haps the best form of "adjuster" consists of your own fingers, applied to the wires passed through the lower lip of the wound. For if you merely pull tight each separate pair of threads, and then the whole together, and press up below the lower layer of them] the in- ferior lip of the fistula so as to press it against the upper, you will usually get the lips into more perfect apposition than by other means. In this and the next part of the operation, as the ends of the different wires are liable to become entangled with each other, you will require to be provided with a sort of rake or small steel rod, bent near the point at a right angle, with which you will be enabled to separate the extremities of the several stitches. To facilitate the apposition and adaptation of the lips of the wound, Dieffenbach proposed to make incisions through the mucous mem- brane at short distances on either side; but these, I believe, will rarely, if ever, be found necessary. 4. The Securing of the Threads and the Consolidation of the Parts. After the margins of the fistula have been pared, the stitches properly introduced, and the raw surfaces brought fairly into apposition, the next point is to tie and fix the threads in such a manner as to favour a speedy union, and provide against the reformation of Bozeman's suture-adjuster. The long figure gives a face view of the instrument, the short figure gives a lateral view of its extremity (half-size). VESICO-VAGINAL fistula. 33 the fistula. It is in the manner in which this object is sought to be attained that we find at present the chief differences in the modes of operating pursued by the various surgeons and accoucheurs who Fig. n. Figure 11 shows the manner in which Sims adjusts and fixes the silver sutures. (After Sims.) have lately been giving their attention to this subject. Dr. Sims now contents himself with introducing a series of simple silver sutures, inserted closely together, and fixed by being twisted at the extremity. He adjusts the edges by pulling the ends of the wires with a pair of forceps, steadily through a sort of adjuster held in his left hand, and afterwards used as a fulcrum of support, whilst the wire is twisted by making a rotary motion with the forceps, as shown in Fig. 11. But it is a grave objection to this plan of procedure, 3 34 vesico-vaginal fistula. especially in large fistulae, that it makes no provision against the movements which are produced in the surrounding parts and lips of the fistula, by the spasmodic workings of the muscular wall of ^ the bladder, and of which we have an evidence in the frequent^ twistings and occasional expulsion of the catheter. The simple twisted wire stitches offer no check to this muscular action, and afford little or no support to the yielding margins of the wound either transversely or longitudinally; and the consequence is that the urine is liable to be allowed to pass into the wound at some temporarily gaping point, and thus prevents adhesion. As it is essential to the success of the operation that this spas- modic action of the bladder be restrained, or its effect at the seat of the wound counteracted, one or two important additions have been made to the simple suture. Dr. Sims used at one time what he called a " clamp-suture," the essential part of which consisted of two longitudinal metallic bars to be placed on each side of the wound, and with perforations in each corresponding to the number of stitches introduced. Through these the ends of the threads were fixed by means of split shot, compressed tightly upon them. The ulceration produced by the pressure of the clamps has induced him, however, to lay them aside, and to use solely, as I have said, the simple metallic sutures, as was done several years before, by his country- man, Dr. Mettauer. An important improvement was effected by Dr. Bozeman, in the introduction of what he has called the "button suture." The " but- ton" or shield consists of an oval piece of flexible lead, rendered concave on the surface which is to lie next the wound, and perforated along the ridge with a row of holes corresponding to the number of stitches used. The ends of threads having been brought through these holes, the button is pushed down along them and adapted to Fig. 12. Fig. 13. Fig. 12. Bozeman's "button" as it is being passed along the threads down to the wound. (From Bozeman.) Fig. 13. Bozeman's "button-suture" finally applied and fixed with perforated shot. (From Boze- man.) the part by means of a special instrument—the "button-adjuster." A small perforated "crotchet" or pellet of lead is then passed over the ends of each suture, and afterwards pushed down close to the button, and tightly compressed by means of a pair of strong forceps —the so-called " crotchet-adjuster." By this excellent and original vesico-vaginal fistula. 35 contrivance the parts are settled and consolidated in one direction, at least; for all motion is prevented longitudinally, or lengthways in the direction of the wound; but it may still be produced cross- wise, or transversely to the course of the wound, as you may satisfy yourselves by handling this piece of soft leather on which Bozeman's suture-apparatus has been fixed. I operated on one patient accord- ing to this plan, but the operation did not succeed, and I should not be inclined to repeat it. I used five stitches in this case, and the failure was due, I believe, to the circumstance that in attempting to adjust and compress the third or middle " crotchet," I accident- ally crushed it obliquely, so that it was not accurately fitted to the corresponding perforation in the "button." I observed this at the time; but as I could not remedy it without removing three of the stitches and introducing others in their place, I thought it better to finish the operation and trust to the other four sutures keeping the edges sufficiently in apposition. On the second day, however, urine began to escape through the wound, and when the appa- ratus was removed on the tenth day, a small opening was left at the site of the central thread. This unfortunate result was, perhaps, owing to my own awkwardness; but where the consequences of a slight mistake are so important, it would be well to simplify as much as possible the plan of the operation, and so obviate more effectually all risk of failure. On the next occasion where I had an oppor- tunity of operating for vesico-vaginal fistula, I was under rather unfavourable circumstances—in the country, and with imperfect instruments—so that I had not the means of applying the button according to Bozeman's method. I therefore made two parallel rows of holes along the leaden plate, and bringing the respective ends of each suture through opposite perforations, I simply tied them across the intervening ridge or bar. No doubt tying or twisting the threads in this way is simpler and easier, and less complex, than fixing them with a leaden shot. In this case the patient had had the fistula for twenty-nine years; but now she can retain and make her water as comfortably and freely as she ever did in her younger days. In removing the button on the tenth day after the operation, however, it struck me that it had very nearly proved unsuccessful from the amount of transverse motion that had been going on, and that had prevented the edges of the button from constantly resting on the surface of the vagina. To consolidate the lips of the fistula and surrounding parts, there- fore, still more, and to keep them perfectly at rest in all directions, I have used an iron-wire splint (such as the one already shown you) in the last three cases in which I have operated for vesico-vaginal fistula. It is made by twisting with the fingers 10 to 15 strands of the iron thread into a cord, the ends of which are then doubled over each other and plaited round into the form of a circle. This is very light and flexible, and may be compressed into an ovoid or other shape, according to the necessities of the case. A sharp- 36 vesico-vaginal fistula. pointed instrument or borer is used for passing among the ami es to make a corresponding number of openings along each side to admit the ends of the several sutures. Those coming from the lower margin of the wound may be first passed, in their order through the perforations on one side of the splint, and then those from the upper margin through the respective opposing holes on the other side. With the fingers or a pair of dressing-forceps the splint may now be passed down to the wound and there carefully and accurately adjusted, and adapted. An instrument, of which the original idea was derived from my late assistant, Dr. Coghill (see Figs. 15 and 16), and which consists essentially of two extremely short and very Fig. 14. Fig. 15. Fig. 16. Figure 14 shows the iron-wire splint as it is being passed along the threads down to the pared wound. A fistula of this size would require more stitches than are represented in the wood- cut. Fig. 15. The instrument for adjusting and twisting the ends of the wires after the splint has been applied (half-size). Fig. 16. The end of the same instrument represented of full size, and as in the act of twisting the wire passed through its two terminal eyes. W fine tubes fixed on the end of a steel rod, is then used for finally tightening and fixing the sutures. One end of a wire having been brought through one of the small tubes of this twister, and the other end through the other, the instrument is pushed down close to the lower bar of the splint; and then both ends of the suture having been drawn quite tight, so as to make the splint compress and con- solidate the parts, a turn of the twister suffices to fix them there. To make sure you may give a turn or two more, and then clip vesico-vaginal fistula. 37 through the threads close to the point of the twister, with a pair of stout sharp scissors. If the fistula is low down, you may, as I have once or twice done, tie the threads with the fingers, by a common double surgical knot. The open wire splint allows you to see all that is going on while adjusting the wires and fixing them, and after- wards it keeps the parts around the wound firm and motionless in every direction. In fact, when this splint is used, and properly fixed, all the lips of the fistula or wound included within the circle of the splint are held, as it were, in a consolidated state, and the included portion of vesico-vaginal septum can neither be moved longitudinally nor transversely. It solidifies, if I may so speak, for the time being, that portion of the mobile vesico-vaginal septum, and thus promotes greatly the chances of union. A portion of fine wire- cloth or gauze, of the same shape, and strengthened by having its margin turned in and doubled, will fulfil the same important indica- tion, and can be made also readily into a splint of Dr. Bozeman's button form, but much lighter than lead. Fig. 17. Fig. 17 shows the iron-wire splint finally adjusted and the ends of the stitches twisted and secured across the lower bar of the splint. 5. The After-Treatment. When the operation has been thus far completed, the case still demands an amount of careful attention and treatment which is as important as the performance of the operation itself. Immediately after the operation, and before the patient has been removed from the table, the water which may have been accumulat- ing in the bladder is to be drawn off, and means must be taken to prevent its re-accumulation in any degree during the whole period that the apparatus is allowed to remain. The collection of the smallest quantity of water would have a distending action on the bladder, and would tend to separate the lips of the wound, between and into which the urine would immediately pass, and lead to disas- trous consequences. To avert these, the short sigmoid catheter- made of some flexible metal, with a quadruple row of holes at the 38 vesico-vaginal fistula. inner, and a runlet or gutter at the outer extremity, of a thickness suited to the peculiar case, and of just sufficient length to allow the gutter to project beyond the labia—is to be at once introduced into the bladder, and left there to drain away the constantly secreted urine. It must, particularly at first, be looked at every ten or fifteen minutes in order to see that the water is dropping freely from it; and whenever the flow is seen to be checked, and is not restored by passing a probe along the tube, it must be taken out and cleaned. Fig. 18. Fig. 18 shows the manner in which Sims removes his single silver sutures. (After Sims ) It ought, moreover, to be taken out and cleaned thoroughly twice a day. The vagina has to be very gently washed out with some tepid water two or three times daily. VESICO-VAGINAL FISTULA. 39 On the eighth, ninth, or tenth day, the splint may be removed. This is easily effected by clipping through with a pair of sharp- pointed scissors, the stitches just below the twist and close upon the lower side of the splint, which is thus loosened, and may be now removed by being cautiously lifted upwards, taking great care in doing so not to stretch and tear open again the lips of the closed fistula. When simple stitches are used without any button or splint, in the manner now recommended by Dr. Sims, great care is needed to cut through the wire in the loop, as represented in Fig. 18, for each suture is usually sunk deep into the tissues, and if the pro- jecting twisted portion be removed, the part that remains will get more imbedded, and its removal will be rendered more difficult. The patient must still wear the catheter for a day or two, and afterwards be habituated gradually to retain the water first for an hour, then for two hours, and then for any longer period ; and you will be astonished to find how soon the bladder seems to regain its normal size and capacity. A most important feature in the after-treatment is the constant administration of such doses of opium or morphia, as shall suffice to keep the patient fully under the influence of the drug. It fulfils the three imperative indications of subduing the movements of the bladder, of locking up the bowels, and of enabling the patient to maintain for a long period the supine position which would other- wise soon become intolerable. From two to eight grains or more of opium may be given in the course of the twenty-four hours; and the success which attends the use of the agent in this case leads one to wonder that it is not adopted by surgeons in the after-treat- ment of all capital operations. It does not interfere in any degree with the healing process, but dispels the ennui which the sufferer, deprived of all power of action and all source of enjoyment, must always feel; and would make him forget to brood over his aches and miseries ; and fill his mind instead with cheerful thoughts and bright anticipations. There are, I believe, almost no cases of vesico-vaginal fistula which you will not succeed in curing in one, two, or more opera- tions, by adopting such a procedure as that which I have just ex- plained to you, and that procedure will, no doubt, betimes come to be simplified and improved. This is truly an astonishing degree of success to have attained in the treatment of an ailment, which till lately was looked upon so hopelessly; and if you inquire into the cause of the advance so rapidly made, I believe you will find it, as I have already said, to be owing mainly to the use of the metallic sutures. Dr. Sims, indeed, to whom, as you know, is due the merit of resus- citating this improvement at the present time, has declared the application of silver sutures to the cure of vesico-vaginal fistulae and other wounds, to be the greatest triumph of surgery in the present century, and has pronounced all such discoveries as the use of anaesthetics to be but frivolous in comparison! Dr. Sims further 40 VESICO-VAGINAL FISTULA. modified and improved the operation as far as regards the position of the patient, and the use of the catheter afterwards ; and he and others have claimed for America and American obstetricians and surgeons, nearly all the honour of the success which attends the performance of the operation. But in the Lancet of November 29, 1834, you will find an account of an operation performed and re- corded by Mr. Gossett, formerly surgeon to Newgate, London, and who, I believe, is now dead, resembling in almost every detail the operation as now carried out by Dr. Sims. The fistula resulted from an operation undertaken for the removal of a vesical calculus; and the case has been always overlooked, probably from the circumstance that it is entered in the index as a case of "calculus in the bladder." I take the liberty of reading to you from page 346 of vol. i. of the Lancet for 1834-35, Mr. Gossett's description of the proceeding which he adopted to cure his patient of vesico-vaginal fistula by the " gilt wire suture." " Having placed her on a firm table of conve- nient height, covered with a folded blanket, and resting on her elbows and knees, the external parts being separated as much as possible by a couple of assistants, so as to bring the fistula, which was immedi- ately above the neck of the bladder, into view, I seized the upper part of the thickened edge of the bladder, which surrounded the open- ing, with a hook, and proceeded with a spear-shaped knife to remove an elliptical portion, which included the whole of the callous lip sur- rounding the fistula, the long axis of the ellipsis being transverse. This was readily effected; but, in consequence of the very contracted state of the parts, the next steps of the operation were with difficulty executed; and I should not have succeeded in passing the sutures, had I not used needles very much curved, and a needle-holder which I could disengage at pleasure, the needles being withdrawn with a pair of dissecting forceps after the holder was removed. In this way three sutures were passed; and afterwards, by twisting the wire, the incised edges were brought into contact, and retained in com- plete apposition until they had firmly united. One of the sutures was removed at the end of nine days, the second at the end of twelve days, and the third was allowed to remain until three weeks had elapsed, before it was withdrawn. After the operation she was put to bed, and desired to lie on her face, an elastic gum catheter, having a bladder secured to its extremity for the reception of the urine, being introduced and retained by means of tapes. She had not the slightest discharge of urine through the vagina after the operation, which has completely succeeded in restoring the healthy function of the parts." Here you have the position, the wire sutures the mode of introducing the sutures, the mode of fixing them and the after-treatment—in short, the whole operation in all its details successfully carried out in England more than twenty years ago in the very same way in which it has lately been proposed to carry it out in America. And it is quite clear, from what follows that Gossett was perfectly well aware of the advantages which sutures VESICO-VAGINAL FISTULA. 41 of wire possessed over those of thread. " The advantages of the gilt-wire suture," says he, "are these: It excites but little irrita- tion, and does not appear to induce ulceration with the same rapidity as silk, or any other material with which I am acquainted; indeed, it has scarcely any effect of the kind, except when the parts brought together are put much upon the stretch; you can, therefore, keep the edges of a wound in close contact for an indefinite length of time, by which the chance of union is greatly increased. I have used it now in very many operations, as after extirpation of the breast, tumours of various kinds, and for bringing the lips together after the removal of a cancerous growth, in all of which cases it answered extremely well. In the larger operations above mentioned, I do not, however, particularly recommend it, as there is more difficulty in applying it than the common suture. It is in minute and delicate operations, such as hare-lip, staphylorraphy, and for the closure of fistulous openings, where success mainly depends upon a speedy union of the parts, that the advantages of the gilt-wire suture are most manifest." This is certainly a most extraordinary forestalling of all that is now being done and said in the matter of metallic suture. To give you an idea of the pride, the just pride, with which our American brethren talk of their achievements in this department of Obstetric Surgery, let me read to you, in conclusion, what Dr. Francis, the learned and respected father of medicine in New York, has publicly said with regard to vesico-vaginal fistula, and the appli- cation of silver sutures for its cure by Dr. Sims. " Prior to the discovery, surgery could do nothing for this formidable class of affec- tions. In Germany, Dieffenbach, Jaeger, Wutzer, and others, had exhausted all their resources in vain. Prolific Germany seems, in this instance, to have been barren. In France, Desault, Dupuytren, Lallemand; and more recently, Jobert, Vidal, and their contem- poraries, had been equally unsuccessful, although Jobert claims a success that has never been demonstrated; and I fear that this eminent man, like the late Lisfranc, had scarcely that devotion to practical results which the written annals of medical science demand from all who give publicity to their cogitations and the issues of their practice. In England, their greatest men, their Coopers, their Abernethys, their Lawrences, their Guthries, could do nothing. Nor have I learned that there has emanated from that practical school of medical and surgical learning, which sheds so much glory over Ireland, a single practical idea that can be truly said to have favoured this improvement;" and then he goes on to speak of the shortcomings of Scotland, and in terms too flattering for me to read here, he speaks of myself, as if in this matter I represented Scotland ; averring that here, too, nothing had been done to promote the cure of vesico-vaginal fistula. But, perhaps, Dr. Francis may be induced to recall this observation when he comes to know the advantages which the iron thread sutures, the hollow needle, and the splint of wire present in facilitating the performance of the operation, and in insuring for it a successful result. 42 CANCER OF THE UTERUS. LECTURE III. OX CANCER OF THE UTERUS. —PATH 0 L 0 GY AND SEMEIOLOGY OF THE DISEASE. Gentlemen : Cancer, in its various forms, affects and destroys the members of the female sex to a far greater extent than it affects and destroys the members of the male sex. In support of this ob- servation, let me merely point out to you the proportion of fatal cases of cancer in the two sexes, which occurred in England, exclud- ing the Metropolis, during the first five years in which the Registra- tion Act was in operation, as shown in this table of the Mortality from Cancer in England, as regulated by Sex. Year of Eeport. Total Fatal Cases of Cancer. In the Female Sex. In the Male Sex. 1838 . . . . . 2304 1717 587 1839 . . . . . 2549 1924 628 1840 . . . . . 2238 1656 582 1841 . . , . . 2215 1692 523 1842 . . . . . 2356 1757 8746 599 Total 11,662 2916 Cancer is, therefore, nearly three times more fatal among women than among men ; and this difference is principally due to the cir- cumstance that this fatal disease is extremely apt to become localized and take origin in two organs peculiar to the female—viz., in the uterus, and in the mamma. Of these two organs the uterus is most frequently attacked; and, perhaps, of these 8700 deaths from can- cer in women, about 3000 were cases of cancer of the uterus—more than one-third of all cases of cancer in the females being instances of cancer of the uterus. We have at present in the hospital two instances of the occur- rence of the disease in the uterus, and I shall now first of all read to you the history of these cases, as they have been drawn up by the clinical clerk, Mr. Cayzer, and then take occasion to speak of some points in connection with the symptoms, diagnosis, and treat- ment of carcinoma uteri. I.—" M. R., aged 42, native of Dunfermline; married. Has had nine children: the youngest is now nineteen months old. Has re- covered well after her confinements, and always enjoyed good health until ten months ago, when she first noticed a discharge from the uterus. She describes this as resembling ' thick white cream ' in color and consistence. This discharge continued during two months and this was gradually displaced by fluid blood and clots of variable size. CANCER OF THE UTERUS. 43 During the flow of this discharge, which sometimes ceased for a week or more, the pain which she felt at other times was relieved. The smell has continued to be very offensive. Her rest has been much disturbed by the constant burning pain. Bowels generally costive. Appetite pretty good, but not so keen as formerly. None of her family have suffered from uterine disease, so far as she can remember. " Admitted into No. XII. Ward on October 29, complaining of a constant burning pain referable to the uterus, and stating that for the past three weeks she has had but little uterine discharge, and that what does appear is thin and watery, slightly tinged with blood, and of a very offensive odor. She has a frequent desire to pass water, but the act of micturition is not attended by pain or scalding. Ordered nourishing diet and rest, and at night suppositories with \ grain of morphia in each. " November 16.-—To use every night and morning a pessary con- taining three grains of McDougall's disinfecting powder. " 23d—Since using the pessaries the pain is much relieved, and she has in consequence enjoyed better rest. Still complains of pain in the loins. There is very little blood now in the uterine discharge. " An examination per vaginam reveals the whole of the lower segment of the uterus enlarged, with an irregular, hard, and nodulated outline, and but little sensitive. The os and the whole of the cervix uteri appear to be implicated in the disease; but the finger can be passed quite round in the cul-de-sac of the upper extremity of the vagina. The parts have a red, congested appearance, and bleed readily about the margins of the os under slight pressure." II.—" A. S., aged 34, a native of Banff. Married eleven years. Has had three children, all healthy, as are the other members of her family. " Up to this present year she has enjoyed very good health, and has been in the habit of working very hard at washing and cleaning. In April last (after a week of unusually hard work, in the course of which she was often lifting heavy weights), while she was menstru- ating, menorrhagia supervened, and continued in various amount for five months. During this time she became very weak, and rapidly lost flesh and colour. She was under treatment at the Dis- pensary during September and October last, and in the latter month became so enfeebled that she could not continue, her regular attend- ance then, and was visited at her own house. The treatment at the Dispensary consisted of the use of astringent injections, and the internal administration of some preparation of iron. " She was admitted into No. XII. Ward on November 10, and on admission was thin, weak, and sallow. She states that she was robust before her illness commenced. She complains of great pain in the cavity of the pelvis, and at the lower part of the back, occasionally lancinating, but always present, though varying in intensity. The pain was at its first appearance attended by an 44 CANCER OF THE UTERUS. extremely offensive discharge, much resembling dirty water streaked with blood, and more or less discoloured. The persistence of the pain interferes much with her sleep. The appetite is now a little improving, but has been very bad. Bowels rather costive. Pain in passing water, and a frequent desire to empty the bladder. " A vaginal examination shows extensive disease of the os and cervix uteri, with considerable loss of substance. _ The diseased mass hard and nodulated, and the irregular edges give a sensation to the finger resembling that produced by cartilage. There is an extremely fetid discharge, of a dirty brown colour, and tinged with blood. The edges of the scirrhous mass are sensitive, and consider- able pain is caused by pressure. " Ordered nourishing diet, and tincture of the muriate of iron. To use pessaries with ten grains of McDougall's disinfecting powder. " November 20.—To have three ounces of port wine daily. " 2Qth.—Remains much the same. Complains of pain caused by introducing the pessaries, which is avoided by a little care, intro- ducing them so as not to press unduly on the edges of the scirrhus." These two patients afford you examples of carcinomatous disease of the uterus, such as it will often present itself to you in practice. They will not be kept long under observation in the hospital. They will remain for a week or two, to give them time to recover their strength a little, and an opportunity of learning how to treat them- selves. The rest, freedom of care, and good diet of the hospital will restore them, you will find in some degree to better health. I am not going to enter into the details of these cases, and enlarge upon their peculiar features; for in fact they present nothing pecu- liar. They are good common examples of a common disease, viz., cancer of the uterus, and afford me thus an opportunity of making some general observation on the nature, the symptoms, the diagnosis, the progress, and the treatment of that malady. And first let me direct your attention to 1. Its Anatomical Seat and Course. Cancer in the Cervix Uteri.—When cancer attacks the uterus it usually does so in its lower segment, or in the region of the os and cervix, as has happened in these two cases in the hospital. But can- cer does not attack in the first instance the cervix uteri invariably or exclusively, as some have averred; for it sometimes originates in the body, or even in the fundus. Its course, however, is commonly such, that we find first of all an enlargement of the cervix which is not to be readily distinguished from other swellings occurring in the part, and which is produced by the deposit of cancerous matter in its substance. This deposit spreads rapidly and early into the surrounding cellular tissue, which becomes hard and indurated. So far it is still in the condition of scirrhus; but betimes it begins to soften and ulcerate, and as the ulcer forms and deepens, hemorrhage CANCER OF THE UTERUS. 45 is produced. The early and extensive infiltration which takes place into the tissue surrounding the cervix renders it firm and immobile, and this is one of the distinguishing characteristics of the affection. For while you may often see chronic inflammatory affections of the cervix producing enlargement and induration, you will still find it loose and movable, because there is none of this inflammatory deposit in the cellular tissue around. In cancer uteri, as the neigh- boring textures get infiltrated and indurated, and ulceration takes place in the seat of the original deposit, the os becomes hollowed out, irregular, and rough, and the resulting excavation has its walls sometimes of a soft and friable character, especially at particular points; while in other parts and cases the walls are hard and carti- laginous, and, as the second case in the hospital, impart to the finger pretty much the same sensation as the interior of a leather dice-box. Sometimes, instead of ulceration and excavation you will find fun- gous masses growing at one or more points from the excoriated sur- face. Ere long the disease spreads to the neighbouring organs— backwards to the rectum, more frequently forwards to the bladder, and downwards along the vagina and urethra. It keeps always extending itself along the walls of these viscera, and when ulcera- tion goes on after the bladder has become implicated, vesical fistulas are sometimes produced; or the rectum may be opened into and a hopeless recto-vaginal fistula ensue. In some few cases all the Fig. 19. Carcinoma beginning in the cervix uteri, and ending in the production of recti-vesico-vag'mal fistula. (Farre.) three canals come to communicate, and the urine and fecal matters mingling with the discharges from the diseased mass, and all escaping per vaginam, render the condition of the unfortunate sufferer one of the most hopeless misery. Some of the drawings, which I show 46 CANCER OF THE UTERUS. you, are illustrative of these various points. The lymphatic glands of the groins, pelvis, and abdomen, sometimes become swelled from cancerous deposit in them; but secondary carcinomatous infiltrations into distant organs, as the liver, spleen, lungs, etc., are rarer in ute- rine than in most other fatal forms of cancer. After death, besides the cancerous deposits and infiltrations alluded to, morbid inflamma- tory adhesions and limited effusions of pus are frequently found among the contiguous surfaces and folds of the peritoneum in the neigh- borhood of the uterus, and in a considerable proportion of instances you will find mechanical distension of one or both ureters, and cor- responding degeneration of one or both kidneys—the lower end of the ureters having become compressed and partially obstructed by the cancerous affection of the uterine and vesical walls. Occasion- ally in the same way the rectum is obstructed, and the bowel above dilated. Cancer in the Body and Fundus of the Uterus.—I have said that the body or fundus of the uterus may become the primary seat of the disease, and here it may assume different types which are not always very easily recognized. And if the cervix be at the same time healthy, the case becomes extremely deceitful, and the true disease may be readily overlooked. The principal forms under which carcinoma appears, when it begins in the body or fundus of the uterus, are, as far as I have myself had occasion to observe them, the following: 1. The cancerous deposit may become located in the outer layer of the middle coat of the uterus, or in the sub-peritoneal or peritoneal coat. Here is a drawing of a case which I attended some years ago, and in which you will perceive the os and cervix uteri, the cavity of the uterus, and its lining membrane, sound and entire. But cancerous deposit has taken place to a great extent in the thickened walls of the fundus and body of the uterus, forming a large irregular shaped tumour which became adherent to the bladder, and, at last, fungated into the vesical cavity, leading on to severe hematuria before death. 2. Carcinoma occasionally attacks the whole thickness of the uterine walls, without producing any local protrusion or prominence upon them, either exteriorly or interiorly. 3. The most common form of the disease, however, is that in which it has its primary seat—like cancerous disease of the stomach, in the mucous or submucous coat of the body or fundus—producing, as in the case of which I show you this drawing, general cancerous ulcera- tion of the interior of the uterus, ending in fatal ruptures of the fundus; or assuming, as I have much more frequently seen, the form of a sessile irregular excrescence or fungoid mass projecting into, and distending, the uterine cavity, or even dilating and partially press- ing through the healthy, but distended, os uteri. The first time I ever saw and fairly made out the case of this last and most common form was in a patient who had long suffered from an abundant serous and sometimes offensive discharge. She was here from England CANCER OF THE UTERUS. 47 under the care of an old master of mine by the application of caustics to the vag of arresting the copious and constant in regard to her case, I suggested the introduction of a sponge tent into the os uteri, that we might then have an opportunity of making out more clearly the source of the discharge, or, at least, of making sure whether it might not be proceeding from the uterine cavity, instead of the vaginal walls. After the sponge had been introduced, the discharge was found to be checked for the first time for many months, and on its withdrawal a fungating mass was discovered by the finger in the interior of the uterus. You must not hold, therefore, that a patient has not got a cancer of the womb, because the cervix is healthy; for the cervix may remain quite sound when the body of the organ has be- come extensively diseased. In a very large proportion of cases—in 28, per- haps, out of 30, the cervix is the pri- mary seat of the disease ; but in the other two, it remains healthy after the rest of the organ has degenerated. and had been often treated ina and cervix with the hope discharge. When consulted Fig. 20. Section of uterus showing its cavity filled up by a polypoid or sessile mass ot carcinoma which sprung from the pos- terior wall of the body of the organ. The cervix uteri healthy and still shut (one- third of full size). 2. Pathological Forms of Uterine Cancer. In regard to the pathology of carcinoma uteri, it has been much discussed what type of the disease is most frequently met with in the neck and body of the uterus. Almost every one now recognizes it as a peculiarity of the disease, that, 1st, as it occurs in the cervix, it is here almost always primary; and 2d, when it extends, it does not often lead to secondary deposits in distant parts of the body by contamination of the system through the blood or otherwise, but spreads mostly by involving the neighbouring and contiguous tissues and organs. Then Virchow, the greatest living authority in patho- logy, holds that the type of malignant disease usually found here is the epithelial or cancroid. We find some growths retaining this character longer than others, and the malignant formations in the uterus remain cancroid longer, perhaps, than tumours in any part of the body. By epithelial cancer I mean, of course, that we have a deposit of cells, having more or less the form and appearance of epithelial cells among the tissues of the part, without the develop- ment of any additional stroma. 43 CANCER OF THE UTERUS. As to the cells themselves, we now know that there is no one form peculiar to cancer, and the presence of cells such as I have indicated " Perpendicular section of a commencing cauliflower excrescence of the collum uteri (cancroid). The papillas of the os uteri, of a tolerable size, are seen on the yet intact surface, surrounded by some regular layers of epithelial cells. The disease begins at first beyond the mucous membrane in the proper parenchyma of the cervix, where the tissue is traversed by cell-deposils (alveoli) of a rounded or irregular form. Magnified 150." (Virchow.) in the stroma of the cervix uteri, are only indicative of malignancy in so far as they are altogether heterologous to the part. But in addition to the infiltration of heterologous cells in the tissues of the cervix, and probably from some irritation resulting from it, a change is produced in the papillae, on its surface, so that these become greatly hypertrophied. They not only enlarge, but split up into a number of branches or villi, and as each villus contains a fine walled capillary loop, they come to present an appearance under the microscope very much resembling that of a placental tuft; and to this excessive papillary development is due, according to Virchow, the fungous character of the cauliflower excrescence. In other cases, however, the morbid structure in uterine cancer is of the truly car- cinomatous type; that is, a development occurs of a tissue consisting of an areolar stroma, from which a more or less abundant fluid con- taining many nucleated cells can be expressed when a section of the mass is made. Both the cells and the stroma in which they are imbedded may resemble in every histologic character the cells and the stroma of tumours which we are wont to regard as non-malignant CANCER OF THE UTERUS. 49 in character, or they may even not differ widely in appearance from some of the normal tissues of the body ; but we set them down as malignant or carcinomatous when occurring here, inasmuch as they are of a nature altogether different from those of the organ in which they have their seat, even, although they may have originated from some of the cells of that organ which have taken on a perverted type of development. And then the clinical history of the patients in whom such growths occur is just that of other patients in whom malignant disease in other organs is found—varied only by the nature of the local symptoms; for here, as else- where, they show that rapidity of growth—that tendency to fun- gate, to ulcerate, and to bleed ; and that almost absolute cer- tainty of a fatal issue which have made them to be desig- nated malignant. In short, the disease is still cancer, though it may present itself here under a variety of forms which have received sep- arate nosological names. The so-called " cauliflower excres- cence" of the cervix uteri is cancer in its epithelial or can- croid form. The so-called "cor- roding ulcer" of the cervix uteri is a variety of the same, and having some analogy with the "rodent ulcers" of other parts. And the cancer in the cervix, body, or fundus, is, in some cases and stages, scirrhous in its type, in other cases is ulcerated cancer, and in others, again, it comes to assume a medullary or fungoid character. We have next to inquire, What are the phenomena of the disease? or, in other words, to investigate— 3. The Symptoms of Carcinoma Uteri. You find all the ordinary symptoms in the two cases in the hospi- tal. The chief local symptoms are three, viz : 1, pain; 2, monor- rhagia ; and 3, leucorrhoea in the form of a variously colored, and usually offensive discharge. Local Symptoms of Carcinoma Uteri. 1. Pain.—Both of our patients have suffered from pain, in one of them of an intermitting character; in the other more constant. 4 Fig. 22. Development of cells from the connective tissue in carcinoma mammae.—a. Cells of the connective tissue, b. Division of the nuclei, c. Division of the cells, d. Aggregation of the cells in rows. e. En- largement of the young cells and formation of the cancer-masses (alveoli). /. Further enlargement of the cells and cancer-masses, g. The same process of development in a transverse section. Magnified 300. (From Virchow.) 50 cancer of the uterus. The intermitting pains which sometimes accompany cancer of the womb are sometimes very changeful and evanescent, and have been compared by a Scandinavian writer to the coruscations of the aurora borealis. The other more constant pain is greatest when the patient assumes the erect posture, or when she takes exercise, or does anything, in short, which will tend to produce congestion of the parts. I have under my care just now a patient from the West Indies who will not take opiates, in whom the pain, nevertheless, sometimes disappears entirely, and then after a time ^ returns and causes her the greatest suffering. You must not go into practice with the idea that where there is no pain there can be no carcinoma- tous affection of the womb, or that any particular sort of pain is distinctive of the disease. You will meet with many cases where at first there is no pain at all. When the cells are first being deposited in the walls of the cervix the tissues are pushed aside gradually but not painfully. Again, there are other cases where pain is present, but only slight in degree, and occasionally disappearing for a time. Or you may find cases where the disease runs its whole course with- out producing any painful sensation. In a patient who was brought to me from the country by her medical attendant not very long ago, I found a large carcinomatous growth involving all the anterior lip of the womb, and causing obstruction of urine, from the pressure it exerted on the bladder, but exciting no other form of suffering; and when we told her that she was the subject of cancer in an advanced stage, she laughed in our face, and told us that it could not be so, for she had never felt any pain whatever. The case was all the more deceptive that she had still a healthy appearance, and showed no sign of the cachexy which is usually so marked in such severe cases as hers. In carcinoma uteri, not only may pain be absent, or, when present, slight and intermitting—it may sometimes also be sympathetic and located elsewhere than in the uterus, as in the mamma, in the sides down the thighs, or elsewhere; in which case the attention of the practitioner may be quite drawn away from the real seat of the disease. Many years ago I saw with the late Dr. Johnston, of Berwick, a lady who had been treated in London for the disease of the mamma, in consequence of a pain which she constantly felt there but no kind of treatment ever seemed to relieve her. When she came under Dr. Johnston's care, he had occasion to examine her, and suspected that there was some disease of the uterus ; and sub- sequently, when I saw her, she had extensive carcinomatous degene- ration of that organ, and yet she had never had any pain that seemed to point to disease there at all. Her pain was in the mamma, where no hardness or organic disease existed. 2. Menorrhagia.—As to menorrhagia as a symptom of cancer of the uterus, let me observe, that an unusual discharge of blood is often the very first symptom that excites your patient's alarm. She cancer of the uterus. 51 loses blood once or twice during an intermenstrual period; or the blood, at the menstrual period, passes away clotted, and in quanti- ties such as never used to come. On examining such a patient you will often find that ulceration has already set in. The first stage of the disease, in fact, has been, as it very often is, altogether latent and unsuspected. I have been seeing, just now, a patient with Dr. Newbigging, who said she was at the turn of life, and was frequently losing blood. She is the wife of a hotel-keeper, and goes through a great deal of work. Yet this active woman, with no complaint but menorrhagia, has almost all the cervix uteri destroyed by cancer. So then this blood discharge is as frequent a sign of carcinoma as pain is. In some cases you will have none; but it is as early and constant an indication of the disease as any other, and when occur- ring in a woman at the climacteric period, or beyond that period, bhould always be looked upon with much suspicion. But the disease may sometimes be recognized before either pain or menorrhagia has been complained of. Just as carcinoma of the mamma is often discovered quite accidentally by the patient, from her hand coming in contact with a hard knot there ; so the same disease may some- times be detected in the uterus when the practitioner is making an examination with any other expectation than that of finding a cancer of the womb. 3. Serous or Sanious Leucorrhoea.—As to the serous discharge which continues pretty constant during the intermenstrual periods, I would only observe that it has often a very offensive odour, which is so peculiar that I have heard some practitioners aver they could diagnose cancer by means of it. It varies in character and consist- ence; being sometimes watery and pale; more frequently it is of a yellowish or greenish colour, and of creamy consistence; and, at times, it may be tinged with blood. It very often contains flocculi, from the separation of small portions of the friable growth; and is usually of such an acrid character as to produce excoriation of the external parts. Constitutional Symptoms and Effects. Whilst these changes are going on locally, the constitution of the patient may long remain sound and strong, and only break down under the long-continued discharge. In proportion usually as the disease extends, the patient becomes worn out with the pain and the discharge; and gradually acquires the sallow hue and peculiar expres- sion which indicate the general cancerous cachexy. The digestive and assimilative functions become weakened, and you have maras- mus added to the symptoms of anaemia. In other cases you find the patient's system breaking down before the disease becomes localized. She suffers from occasional uncertain pains in different parts of the body, becomes low-spirited and weak, and acquires a dingy or chloro- 52 cancer of the uterus. tic-looking tint of skin; and after this has been some time established, localization of the disease is indicated by the occurrence of hemor- rhage from the uterus. Finally, after the disease has been fairly established in the part, and the cachexy has become developed, the functions of other and distant organs begin to be impaired, the digestive organs become weak, and the circulation irregular; in some a sort of cancerous fever sets in, not so intermitting in its character as the hectic fever of phthisis, nor quite so well marked, but point- ing as surely to a fatal issue. 4. Diagnosis of Carcinoma Uteri. As to the differential diagnosis of carcinoma uteri, I have little to say regarding it at present; for you have not yet had an opportunity of being made acquainted with the other diseases with which it is liable to be confounded. But there is one observation which I should wish to urge upon this point; it is this—that you are not entitled to diagnose the existence of cancer in the womb from any degree or kind of pain, bleeding, and offensive discharge, from which the patient may be suffering, not even when these are combined with the pale cachectic look which is usually pathognomonic of the dis- ease. All these local and constitutional symptoms may be present in other uterine diseases besides cancer; and, in some latent cases of cancer, they may be found absent. You can detect it with per- fect certainty only by physical diagnosis. You must make a vaginal examination with the finger—for the speculum is here of little ser- vice—and only when the sense of touch has assured you of the condition of the cervix uteri, and not till then, can you honestly and conscientiously pronounce upon the nature of the case. One morbid condition of the cervix uteri with which cancer'of the organ may be, and often is confounded, is that which results from chronic inflammation in it. This causes enlargement of the cervix and expansion of the os, attended with great induration, and when ulceration sets in, and pain and menorrhagia are developed, the case may very readily be mistaken for a case of cancer in its first stage. But here you have always the distinguishing characteristic, to which I have already alluded, that in chronic inflammatory induration of the cervix the deposit is confined to the organ itself, which remains loose and mobile; whereas in the case of cancer the surrounding tissues usually become early involved in the disease, and, being infiltrated with the morbid deposit, make the ceivix uteri feel firm and fixed. And when ulceration has set in, you will find that the ulcer which results from inflammatory change—though it may look very irregular, rough and ugly—is always on a level with the un- broken surface, or even projects above it, whereas the cancerous ulcer is always depressed, excavating, as it were, and eating out the part in which it has its seat. One often sees mistakes made with regard to the diagnosis of cancer of the uterus, which are almost cancer of the uterus. 53 inconceivable, and which you may in almost every case avoid if you will just keep your wits about you when making an examination, and use a little common sense—a most invaluable and indispensable aid in all kinds of diagnosis. When you feel a rough, irregular, excavated or anfractuous ulcer seated on a hardened base, and sur- rounded by hardened tissue in any other part of the body, as the exterior of the chest, face, or extremities, you set it down at once as cancer; and when the finger applied to the os uteri recognizes the same condition, you need not doubt that here, too, you have to deal with the same disease. Cancer of the uterus used often for- merly to be confounded with simple polypus uteri; and Dupuytren and other Parisian surgeons have recorded instances of patients being sent to them from the country, who had been told by their own doctors that they must inevitably die of their complaint, and who were completely cured by the simple operation of the removal of the polypus, and were thus recovered, as it were, from the very brink of the grave. I have seen the same mistake frequently com- mitted in our own times, and yet it is a mistake which care will always enable you to avoid. Cancer of the uterus may further, as I have hinted, be confounded with some other diseases, such as elongation of the cervix, but the differential diagnosis will be more properly considered when we come to speak of these diseases. 5. Ages of Patients affected with Carcinoma Uteri. Cancer of the uterus attacks usually the adult, or those advanced in years, the period of its most frequent occurrence being between the ages of 40 or 50. Out of 409 cases tabulated by Madame Boivin, she has noted twelve as occurring in individuals under 20 years of age, but these were most probably cases of chronic inflam- mation, or of some other simple affection of the uterus. Rejecting, therefore, these doubtful cases, and adding to Madame Boivin's table the report of the ages of 122 patients with carcinoma uteri, fur- nished by the late Professor Kiwisch, of Wiirzburg, we obtain the following Percentage of Cases of Carcinoma Uteri, occurring at different Ages. From 20 to 30 years of age, 88 cases, or 17 per cent. " 30 " 40 " " 121 " 23 " 40 " 50 " " 249 " 4S " « 50 " 60 " " 40 " 8 " " 60 " 70 " " 20 " 4 " Above 70 " " 1 " 0.1 " 519 Cancer of the uterus, contrary to a common opinion, doubtlessly is found far oftener in the married than in the unmarried, and the subjects of it have very often borne large families. 54 CANCER OF THE UTERUS. 6. Prognosis in Cases of Carcinoma Uteri. In the uterus, as elsewhere, cancer is a disease oyer which medi- cine has little or no control. As to its course, it isjery various, sometimes carrying off the patient very rapidly, sometimes going on more slowly. Patients usually die in from two to two and a half years after the detection of the disease ; but if the system be deeply affected we have no power to check its ravages, and the patient may be in the grave within a few months. In other patients—chiefly aged ones, in whom the cancer has taken on the slow and senile character of all the functions and processes of the body—the course of the disease is sometimes very protracted. Thus I attended a patient with cancer of the uterus seven years after the death of Dr. Hamilton, who had recognized the disease as present during his lifetime. In my next lecture I shall refer to the Treatment of this disease. LECTURE IV. OX CAXCER OF THE UTERUS. —PALLIATIVE TREATMENT OF THE DISEASE. Gentlemen : There is one point in reference to the diagnosis of cancer of the uterus, which I forgot to allude to in my last lecture, and of which I was reminded by seeing a patient in Westmoreland yesterday; and that is, the difficulty of sometimes determining the true nature of the case when the disease has assumed the soft or encephaloid form. In the case which I saw yesterday, there was a tumour on the exterior of the right side of the pelvis, firmly attached to the bone, and another similar but smaller mass inside the ileum. The medical attendants were at variance as to the nature of the disease, some holding it to be an abscess, and some regarding it as an aneurism. Without letting me know, Mr. Page had come to the same conclusion as that which I arrived at, viz., that it was a case of encephaloid cancer. At some points the mass was very soft, and had a very deceptive feeling of fluctuation ; but a decisive proof of its nature was obtained by introducing an exploring-needle into its softest point, and bringing away no pus. A few weeks ago, I saw along with Dr. Walker at Glasgow, a patient with a soft tumour extending from the left side of the uterus. It felt extremely like a purulent collection in the cellular tissue of the left broad ligament • but dissection afterwards showed that it was in reality a soft cancer connected with the body of the womb. CANCER OF THE UTERUS. 55 But it is time that we should pass on to the study of the 7. Treatment of Carcinoma Uteri. In the way of constitutional treatment of uterine as of other forms of cancer, we then do nothing or almost nothing, except, perhaps, retard and alleviate the course and the effects of the malady. Nearly every form of mineral and nearly every form of vegetable remedy has been exhibited and tried which seemed at all likely to stay the progress of the malady, but as yet with little, or indeed with absolutely no success whatever. All that we can do constitu- tionally is to keep the patient as near the standard of health as possible by generous diet, by invigorating regimen, and by tonic medicines, and thus enable her to bear up against the debilitating and destructive march of the disease. But we can employ various measures which are of more or less avail to stay and stem, at least, the local symptoms and sufferings, and smooth the patient's progress to the grave. With this view, we have three leading indications to attend to, viz., 1. To use means to alleviate the pain and sufferings attendant upon the disease; 2. To use means to prevent and arrest the attend- ant menorrhagia; and 3. To use means to counteract the offensive- ness and acridity of the attendant discharges. Let us first consider the 1. Measures calculated to palliate the attendant pains. To relieve the pain you must learn to administer opium by the stomach or rectum, or to apply it locally to the uterus, according as you find the patient can best bear it. Begin it always in small doses. Most women suffering from this or from other painful forms of malignant disease, become, as it were, opium-eaters ; and I think it is our duty to teach them how to keep themselves as easy and com- fortable as possible, whether the object be best attained by the use of opium or in any other way. It is certainly our duty to alleviate, when it is beyond our power to cure. Where opium disagrees with a patient, you must have recourse to some other anodyne drug. You will find that conium has been much employed and recommended by some authorities, who have supposed it not only to be of use in relieving the pain, but to have some specific power of checking the progress of cancer. I have never been able to satisfy myself of the existence of this power; but I believe it to be a very good sedative. So also are belladonna, lupuline, stramonium, and Indian hemp, in some exceptional instances. Besides being used by the mouth, most of these anodynes may, if it be deemed better, be administered by the rectum in the form of a suppository, or applied to the cervix uteri in the form of a medicated pessary. By this term of " medi- cated pessary," I mean, as most of you know, small balls of a round 56 CANCER of the uterus. or ovoid form, and of the size of a walnut, made of some medicinal substance mixed up with ointment, and brought to a proper degree of consistence by the addition of yellow wax. Our Edinburgh drug- gists keep medicated pessaries of various kinds, containing morphia, belladonna, tannin, etc. The patient can usually introduce them herself, and they have the advantage over injections and lotions of applying the medicinal agent in a more continuous form. They are made of such a consistence as to dissolve gradually in the vagina at the temperature of the body. Generally they are coated with a layer of ointment made firmer from containing a larger proportion of wax, with a view of facilitating their introduction. We have other local sedatives in the vapour of chloroform, and in carbonic acid gas, which may be used to supplement the action of these anodyne remedies, or to supplant them entirely where some idiosyncrasy prevents their use. The carbonic acid has been chiefly employed here within the last few years, and I imagined for a time that this application of it was something new and modern. But I may as well warn you,, that should any one of you imagine that he has made a discovery of something practical in medicine, if he will take the trouble carefully to look over the works of Hippocrates, or Galen, or Paul of iEgina, or of some other ancient medical writer, he will very probably get all the glory taken out of him. When the ancient Greek and Roman physicians burnt various herbs, the fumes from which they were conducted by a tube to the os uteri in cases of uterine pains, ulcers, etc., they in reality applied carbonic acid gas. In Germany the waters of some of the baths, such as those of Marienbad and Nauheim, have long been used as local sedatives to the uterus, and these waters contain always a proportion of free carbonic acid. Dr. Dewees, a distinguished American author, also speaks of having used the pure gas in this way as a sedative for the pains of carcinoma uteri. My attention was first called to the sub- ject by a paragraph in one edition of Dr. Pereira's Materia Medica ; but Dr. Pereira himself considered this paragraph of so little import- ance that he expunged it from the last edition of his work. The paragraph was to the effect that his friend, Dr. Clutterbuck, had been requested by a lady suffering from uterine pain and irritation, to be supplied with some means of applying carbonic acid gas to the womb, as she had formerly experienced great benefit from such an application at the hands of an Italian physician. Latterly, I have used it extensively in many cases of uterine pain, and in some with excellent effect; for it is, in fact, a good and powerful local anges- thetic. The application is very easily accomplished. A table- spoonful of crystallized tartaric acid is mixed with a tablespoonful of crystallized bicarbonate of soda in an ordinary wine-bottle three or four wineglassfuls of water are added, and the gas which is evolved is carried off through a caoutchouc tube, and applied to the womb by means of a gum-elastic nozzle attached to the extremity of the tube. (Fig. 23.) Our chemists have got into the way of supplying cancer of the uterus. 57 patients with boxes such as that I have beside me, containing twelve powders or packets, with six drachms of tartaric acid in each, and Fig. 23. Arrangement for applying carbonic acid to the uterus—viz., a long caoutchouc tube of three or four feet in length, with a nozzle at its free extremity, and fixed at its other extremity into a com- mon wine-bottle, with a tubular or perforated cork. In the specimen here drawn there is a metallic box affixed to the top of the cork, which, when filled with sponge, may contain a teaspoonful of chloroform, so that, when desired, the two local anaesthetics, carbonic acid and chloroform, may be used together. other twelve with an ounce of bicarbonate of soda. They furnish them also with the appropriate tubes, which, let me add, are some- times provided with a sort of brass box (see Fig. 23) immediately above the cork or stopper to hold pieces of sponge, and by pouring on these sponges some chloroform, you may have the combined seda- tive action of the two anaesthetics. Usually, however, the hollow cork and tube used are simple, like this (Fig. 24), and without any box; and if you wish to apply chloroform vapour along with car- bonic acid, you require, when employing the simple tube, to add merely a teaspoonful of chloroform to the contents of the bottle before introducing the cork. When the tube is introduced into the vagina, after the evolution of carbonic acid gas has commenced, there is perceived first of all a rush, and a slight feeling of heat; by and by a soothing effect is produced. Besides its anaesthetic properties, carbonic acid is one of the best of local curative applica- tions that can be made to an ulcer. In the last century, Dr. Ewart, 58 CANCER OF THE UTERUS. of Bath, made cancers of the with this good Fig. 24. Section of the perforated cork used in the local application of carbonic acid gas to the uterus, a a. Metallic tube passing through the centre of the cork, and receiving the gas at its wide extremity d. b b. Metallic ring, in which the metallic tube is fixed, c c. The perforated cork sheathed by a layer of caoutchouc, d. e. A coil of wire in the com- mencement of the India-rubber tub- ing, to prevent it from collapsing at the point of flexion: the metallic tube may be prolonged and bent, and in this case the coil of wire can be dispensed with. the experiment of applying this gas to two open breast constantly and for a considerable time, and result, that one healed up completely, though of course only temporarily; and in the other the pain was relieved and the ulcer par- tially healed. When carbonic acid fails to relieve the pain, the vapour of chloroform may be superadded to it in the manner I have indicated: or chloroform vapour by itself may be applied by means of an ordi- nary Higginson's (barrel) syringe, which, let me add, is the cheapest, best, and most convenient of all syringes for all purposes. The long or free extremity of the syringe is introduced into the vagina, and the other end of the instrument is inserted into the mouth of a four or six-ounce bottle, about one-third or one-half filled with chloroform, and then the application of the fingers to the middle part or barrel being in the way of alternate compression and relaxation of the barrel, sends speedily a current through the apparatus. If the bottle were full, or nearly so, there would be a risk of the liquid chloroform getting into the instru- ment, and being pumped into the vagina, which it would blister and scald, and thus produce an effect quite the opposite of that which is desired. After the tube has been introduced into the vagina, by working the barrel in the ordinary manner, the Xf vapour of the chloroform rises into the in- _^ strument, and may be projected for any length of time against the uterus: for you can send through the instrument a current of air or vapour as easily as a current of liquid. Applied in this manner to mucous surfaces generally chloroform vapour has a very soothing and sedative effect. Ten minutes usually suffice for the application at one time, either of carbonic acid gas, or the vapour of chloroform; but patients sometimes desire it to be continued longer. Either of them, or both, may be repeated, if necessary, many times a day. I would just add one other remark in a supplement to my observations on the of the regard to chloroform, as constitutional, as contrasted with the local sedative treatment CANCER OF THE UTERUS. 59 pain which attends a cancer of the womb, and it is this, that where opium disagrees with the patient, or where she requires such large doses that she is deterred from using it, you may relieve the pain by bringing her occasionally under the general anaesthetic influence of chloroform, by inhaling small quantities from time to time, and thus you may occasionally procure for her a rest and a respite from her suffering, more easily and completely than by any of the usual forms of ano- dynes. I have seen chloroform, when swallowed, also answer well for a time as a general sedative in cases of cancer. One of the best modes of exhibiting it, is by making a mixture of chloroform with com- pound tincture of cardamons, in the proportion of five or ten drops of chloroform to each drachm of the tincture. A teaspoonful of the solution or mixture may be given in a wineglassful of water several times a day, or whenever the pain becomes severe. Laudanum or solu- tion of morphia may be added to this mixture in appropriate doses, if you wish to combine it with an opiate. Remember to order the dose of the solution of chloroform in the tincture of cardamons to be added to and stirred up with the wineglassful of water; for, if you reverse this, and add the water to the mixture, part of the chloroform is generally sepa- rated and precipitated. There is another means by which you may sometimes succeed in alle- viating the pain of cancer. I allude to the application to the part of some freezing mixture. Dr. J. Arnott, who has directed particular atten- tion to the anaesthetic effects of a low temperature to various parts of the body, has suggested that the freezing of a cancerous part may be of use not only for soothing pain, but also as a means of curing Arrangement for injecting the vapour of chloroform—viz., a common barrel syringe inserted by one extremity into a four-ounce phial containing only a small quantity of chloroform. The free or upper extremity is introduced into the vagina. For this pur- pose it is well sometimes to have attached to it a longer portion of terminal tube than is here represented. 60 CANCER OF THE UTERUS. the disease. And when first experiments began to be made with it, some cases of temporary cure were reported, just as in the last cen- tury, Ewart and others met with partial and temporary healing of open cancer of the mamma from the continued application of car- bonic acid gas. We had a patient with ulcerated carcinoma of the cervix uteri in the hospital a few years ago, whom we treated by the occasional application of freezing mixtures to the os. These gene- rally relieved her pain, and seemed to check the discharge, and make the ulcer partially contract and heal up for a time. But ulcer- ation soon set in again and the condition of the patient speedily got as bad as before. Yet possibly the application of a refrigerating mixture might prove a useful adjunct to our means of treatment, and might be much more frequently and regularly employed if we could get over the one great objection to its use which lies in the difficulty of its application. At present the method employed is to introduce a speculum into the vagina, and through this to apply to the os uteri, in a muslin bag, a freezing mixture. The mixture most commonly employed consists of two parts of ice to one of common salt. The ice must be pounded or bruised, and when thoroughly mixed up with salt in the proportion I have just stated, and applied in a muslin bag to a part for a certain length of time, the circula- tion there is stopped, and the part becomes cold, pale, and insensible. This condition remains for a short while after the removal of the bag, and then the parts gradually return to their previous condi- tion. Perhaps some simpler and more manageable method of apply- ing great cold may yet be devised, and if this do happen, it may prove a valuable boon. For we know that the application of ice, or, to speak more correctly, of a temperature at or below the freezing point, to other parts of the body, has the effect of temporarily alle- viating pain, or temporarily inducing an insensibility during which some of the slighter surgical operations can be performed without causing any pain to the patient. Thus I have lately seen two gen- tlemen have each several teeth extracted without pain, from having their gums previously frozen. One of these gentlemen, my friend Dr. Small, from whom seven teeth were extracted after a stream of water of a temperature of from 10° to 20° Fahrenheit had been for some time allowed to pass through a thin metallic box accurately fitted to his gums, certainly made very wry faces during the opera- tion ; but he explained afterwards, that the contortions of his coun- tenance were not excited by pain, but by the mortal terror he was in at every application of the forceps, lest the " grunch" which he distinctly felt would be accompanied by pain. If, I repeat, we had some simpler means of freezing the os uteri and other parts affected with cancer more easily, we should more frequently perhaps have re- course to this expedient. As yet our only means are only a source of irksomeness to the patient and of difficulty to the practitioner. It has always seemed to me that solid carbonic acid applied in a caoutchouc bag, or otherwise, and mixed perhaps with ether, ought to be the CANCER OF THE UTERUS. 61 most convenient and best freezing agent for producing local anses- thesia in the practice alike of the dentist, the surgeon, and the accoucheurs, and that we may find some easy means of applying this to the os uteri; but I have not yet been able to obtain the acid in the solid state, so as to have an opportunity of reducing the theory to practice. Patients with cancer of the uterus will often require your medical care for other forms of distress and suffering than the mere local uterine pain connected with the disease. They have sometimes their sufferings aggravated by a tendency to constipation, particularly when they first begin to use opium, which is kept up in the latter stages by mechanical obstruction of the bowel from the spread of the carcinomatous deposit. Gentle aperients, or what often serves better still, mild enemata, are required under these circumstances. In the same way the bladder is apt to be irritated during the progress of the deposit, and you will find it occasionally necessary to relieve the symptoms of dysuria with infusions of uva ursi, buchu, etc., and with the addition of alkalies or acids, as indi- cated by the condition of the urine. Besides, the secondary or sympathetic pains which may spring up in different parts, and of which I have already told you, occasionally demand for their allevia- tion local anodyne liniments or plasters, or even the injection of a few drops of the watery solution of morphia into the subcutaneous cellular tissue of the affected part. Occasionally you will find that they will disappear after the application to the ulcerated surface of the cancerous uterus of slight caustics or sedatives, such as a solution of nitrate of silver, acid nitrate of mercury, and the like. 2. Measures calculated to arrest the attendant hemorrhages. But there are other indications which require to be fulfilled besides that of the alleviation of pain. Thus you will sometimes be called upon to check and counteract the hemorrhage which occasionally occurs to an excessive and exhausting extent in the cauliflower ex- crescences, and other malignant diseases of the cervix uteri. In these cases you have large, tortuous, thin-walled vessels coming up in loops towards the surface of the papillae, and merely surrounded by radiating layers of epithelial-looking cells, as shown in Virchow's memoir on Cancroids of the Os Uteri. From these vessels, which are very liable to injury, profuse 'floodings readily occur, debilitating and destroying the patient, who would not be so rapidly worn out by the disease if we could always manage to arrest them. Such a flooding, let me again repeat, is often the first symptom that attracts the patient's notice. It is apt frequently to recur in some cases, rapidly ruining and running down the patient's health and strength, and not infrequently proving the more immediate cause of her death. This bleeding, therefore, you will often be called upon professionally and practically to abate and arrest; and as one means of attaining your object you may occasionally require to have recourse to plug- 62 CANCER OF THE UTERUS. ging of the vagina. But a mere plug of lint or sponge will not always suffice ; you will sometimes have to medicate them with some agent which has the property of coagulating the blood. Some have recommended the use of a concentrated tincture of iodine as pos- sessed of this property in a high degree. Others have spoken in favour of a strong solution of nitrate of silver. In either case it has usually been proposed to apply the medicaments through a speculum introduced into the vagina, and pushed up to the cervix. But when I stated to you in reference to the diagnosis of uterine cancer, that the speculum was a useless instrument, I should have added also that it was a dangerous one, for coming in contact with the vascular mass it almost necessarily excites more or less hemor- rhage, or aggravates it when it has already been established; and we gain a very important point, if, in the application of our styptics, we can dispense with its employment. We have two remedies, the application of which is easy, and in almost every case is perfectly sufficient. One of these is tannin, which, when applied in the form of a fine powder through a small tube, or mixed up in the form of a medicated pessary, serves as a valuable means of coagulating the effused blood, and thus preventing the further flow. Matico and other vegetable astringent washes are useful merely in proportion to the quantity of tannin which they contain. But we possess a still simpler and surer styptic in the perchloride of iron, which I generally use as made at my suggestion by Messrs. Duncan and Flockhart, druggists, dissolved in glycerine. A saturated solution of it in glycerine is more adhesive to the surfaces with which it is placed in contact, than the solution of it in water. Perchloride of iron was proposed, as you know, by some physicians and surgeons on the continent not very long ago, as a preparation which—when injected into the sac of an aneurism, or the cavity of a varicose vein —would produce coagulation of the blood in them, and so lead to the permanent cure of these morbid states. For stopping the hemor- rhage from leech-bites, it is the best and readiest agent we possess; and for arresting the bleeding from small orifices over an extended surface, such as exist in piles, I know no better remedy. A gentle- man in our profession, for whom I have a very high regard, told me, lately, of the great success which had attended its use in his own wife, who had long suffered from internal haemorrhoids, which fre- quently came down and bled to a'great degree. Six months ago, she had a very bad attack, at a time when her husband happened to be from home. There had been much hemorrhage, and she was reduced to great weakness and faintness. Though the wife of a doctor, she was one of those ladies who have a great and salutary aversion to seeing doctors professionally; and so when she sent one of the members of her family to ask me for something to relieve her I sent simply some perchloride of iron in glycerine, with instructions to apply it on a piece of lint. The bleeding was checked by this means at once, and her symptoms relieved; and, what is better CANCER OF THE UTERUS. 63 still, the hemorrhage has never since returned. In connection, I say, with hemorrhages from the uterus, it is likewise a most valu- able agent, and may be applied in various ways. It deliquesces very readily, so that it cannot be kept and applied in the form of powder; but it may be made up for use into a medicated pessary. I apply it most frequently, however, on some lint or on a piece of sponge, to which a string is attached for its easy removal afterwards. Introduce a piece of sponge or lint partially dipped, or rather wetted in its centre, in glycerine, saturated with perchloride of iron, into the vagina; push it up to the os uteri, and leave it there for twenty- four hours; and usually you will find this result, that the bleeding is completely arrested, and there is no recurrence of it for a time. I sometimes see a patient at present in whom the hemorrhage from an ulcerating cancroid of the cervix had been allowed to go on for three months, under the idea that it was only an ordinary menstrual discharge of unusually long duration. Early in my attendance upon her there occurred a sudden and profuse drain, which rendered her almost pulseless. A sponge was applied, steeped in the solution in the manner I have told you, which at once put an end to the bleed- ing. There has been no recurrence of hemorrhage from that time to the present—a period of three months; but the disease is progress- ing in its fatal course, and lately has perforated the bladder, so as to allow all the urine to escape per vaginam. 3. Measures calculated to counteract the offensiveness, etc., of the attendant leucorrhoeal discharges. Another symptom which you will sometimes find it necessary to do something to relieve, is the fetid and acrimonious discharge. The odor it exhales is occasionally sickening to the last degree; the very breathing of it fevers the patient; and therefore, the discharge must be checked or its effects counteracted as far as possible. This may be effected in some instances by the frequent injection of a weak solution of the chloride of zinc, in the proportion of a grain to the ounce of water; or one or two grains may be applied occasion- ally in the form of a medicated pessary. Or you may endeavour to fulfil the indication, as we have attempted it in the two cases in the hospital, by using pessaries containing from three to ten grains of M'Dougall's disinfecting powder. This deodorizing powder was discovered, not by Mr. M'Dougall, but by Dr. Andrew Smith, the late director of the Army Medical Department. It contains, I believe, as its active ingredients, carbolic sulphite of magnesia and lime, with the addition of five per cent, of carbolite of lime, and has the property of precipitating all fetid and decomposing animal matters in foul waters, etc. When applied here in the form of a pessary or lotion it is of great use in relieving the odour, and serves at the same time as a cleansing and non-acrid application to the ulcerating surface. 04 CANCER OF THE UTERUS. Sometimes the vaginal discharge in cases of carcinoma uteri is, for along period, watery and serous, without offensiveness or acridity, but weakening and detrimental from its great abundance and_ copi- ousness. This occurs particularly in instances in which the disease has a warty or cauliflower character. Such patients occasionally require to use many napkins each day in order to absorb this ex- cessive serous discharge as it escapes from the vagina. In these cases the abatement and arrest of this profuse and debilitating drain becomes occasionally an important indication of treatment; but it is an indication which it is by no means easy to fulfil. Sometimes the assiduous and repeated use of astringent vegetable or mineral injec- tions has the desired effect. More frequently their effect is only either very partial or very temporary. In order that they may be successful you generally require to change every few days from one astringent to another—as from a solution of tannin, or from a strong infusion of oak bark or green tea, to a solution of sulphate of zinc or sulphate of alum, one of the least irritating and astringent of all —being a solution of the so-called aluminated iron, or sulphate of alum and iron in the proportion of three or four grains of the salt to the ounce of water. Sometimes these astringents answer more effectually if the patient apply them in the form of a small plug of sponge dipped in the fluids or solutions. In all cases of carcinoma uteri, accompanied with discharge, due cleanliness and frequent ablution of the external parts and lower portion at least of the vagina, is a matter of moment, with the view of obviating the disagreeable and irritating effects of the acrid fluid which is passing over them, and adds greatly to the comfort of the patients. Sometimes the mucous membrane of these parts and the surrounding skin can be protected much from the irritation of pro- fuse and irritating discharges, by the free application of liniments or ointments after each use of the bidet, or after each washing. Equal parts of glycerine and simple ointment, or of glycerine and olive oil, or of lime-water and olive oil, often answer this purpose well. Before I conclude these observations on the palliative treatment of carcinoma uteri, I must add one observation, lest my remarks may have misled you, so as to make you too officious in your man- agement of your cases. Do not unnecessarily oppress your patients with the nimia cura medicinx. In instances where the pain of the disease is not very great, nor the bleeding or discharges at all great, you will perhaps only aggravate the one and the other by unneces- sary and meddlesome local treatment. You will frequently find cases of uterine cancer, particularly those of a slow type, go on better with- out any local treatment at all than with it. Such patients are often happier and more comfortable when cleanliness merely is duly at- tended to, and nothing special in the way of treatment is attempted or done. Reserve the palliative local measures I have spoken of for those CANCER OF THE UTERUS. 65 cases—and they form a large class—where such measures are really called for by the severity of the attendant symptoms. But has nothing been done, and can nothing ever be done in this terrible disease in the way of surgical or radical treatment ? I shall try to answer that question in my next lecture. LECTURE V. ON CANCER OF THE UTERUS.—ITS SURGICAL TREATMENT. Gentlemen: Two surgical operations have been proposed and practised in some cases of cancerous or cancroid diseases of the uterus, viz. first, extirpation of the whole organ; and secondly, extirpation of the diseased cervix only. The first of these opera- tions need not detain us long, for I have very little to say regarding the Extirpation of the Entire Uterus. Some twenty or more cases have been placed upon record where this operation was performed, but with such disastrous results as to hold out no encouragement whatever to its repetition, but rather to serve as a loud warning against it. Judging of it a priori, we should regard the operation as unjustifiable, and experience serves only to confirm the judgment: for where patients have not died of the operation itself, the disease has soon recurred and proved rapidly fatal. Most of the patients on whom the experiment has been tried, have died immediately of the operation or its consequences; and of the only three or four who did not, all, excepting one who lived a year and a few days, have died within two or three months of its performance, from the disease returning, or rather from its continu- ing to spread from a spot from which it was found impossible to eradicate it. The operation has been performed by cutting through the abdominal parietes, and extirpating the uterus from above ; and also by dragging it down through the vulva, and excising it from below. The unfortunate patients have died in some cases of shock; in others of hemorrhage, primary or secondary; in others of in- flammation and surgical fever. I have always said that the opera- tion could only possibly be ever dreamt of in those cases where the body or fundus of the organ is alone affected; for when cancer is seated in the cervix it has usually spread to the neighbouring parts before it is recognized ; and once it has extended beyond the bounds of the organ in which it began, there can be no hope of a complete 5 66 CANCER OF THE UTERUS. eradication. But even when the cancer is confined to the body or fundus, extirpation of the uterus is such a hazardous operation, that I have no hesitation in saying that it should even then be rejected, as an utterly unjustifiable operation in surgery. Excision of the Cancerous Cervix Uteri. But another operation has been proposed for the radical cure of cancer, which is not by any means so fatal, and which has occa- sionally been performed with most satisfactory results. It is appli- cable, however, only to those very rare cases where you find the disease seated in the lips of the cervix and fairly limited to the va- ginal portion. In these cases it is usually confined almost entirely to one lip, most frequently the posterior, leaving the other almost free; just as when epithelial cancer attacks the mouth, it usually begins in the lower lip, and if it spreads to the upper, does so only to a very inconsiderable degree. You will sometimes see cases of cancroid disease of the cervix where the growth is of a size as large as the fist; where it is seated entirely in one of the lips; and, which is of still greater moment, where it has not extended upwards be- yond the line of reflection of the vaginal mucous membrane upon the cervix uteri. It is in such limited and defined cases only that you can hope to produce a radical cure of the disease by amputating the cervix above the part where it has been infiltrated; or, let me rather say, may hope to stay the progress of the disease, and pre- vent its recurrence for a time. And when it does return afterwards, it does not always make its appearance again in the same part at all, but attacks some different and distant organ. The operation only came into vogue in the beginning of this century; was first per- formed by Osiander, and afterwards by Dupuytren and others. It was speedily carried to an extravagant excess by Lisfranc; and we find Dr. Nott, the celebrated American surgeon, recording this against him, that on his visits to Paris he found Lisfranc latterly curing by the application of nitrate of silver, the kind of cases of diseased cervix uteri in which he had formerly employed amputation of that part. In other words, Lisfranc had used this operation in instances of chronic inflammatory disease of the cervix—an affection in which assuredly no such heroic and dangerous treatment is necessary. The operation, let me distinctly tell you, is one which can be employed only in very few cases of cancroid disease of the cervix,* seeing that it is only when you can catch the disease, so to speak, before it has reached the line of reflexion between the cervix and vagina, that you can amputate with any hope or prospect of success. When the disease has begun to creep along the wall of the vagina, or has passed high up into the cervix, the operation is of no avail to check it. CANCER OF THE UTERUS. 67 Mode of performing Amputation of the Cervix Uteri. 1. By means of Cutting Instruments.—As regards the operation itself, it used to be formerly performed in a much more clumsy manner than it is necessary to pursue now. I show you here some casts and wet preparations of the diseased cervix uteri, which I have amputated at various times according to the old method or by means of cutting instruments. The amputation was effected by in- serting a strong volsellum or two into the cervix uteri, carefully and distinctly above the line of the diseased part; dragging down the end of the uterus to the vulva ; and then clipping it across above the volsella with a pair of strong scissors. The great secret of suc- cess in the performance of the operation seemed to be to seize hold of the cervix beyond the line which marked the extent of the dis- ease, so that by cutting out above the volsella you might make sure of having no portion of it left. I used to have the patient placed on her face, and cut across the cervix uteri from behind forwards, in order to avoid wounding the posterior cul-de-sac of the peri- toneum which reaches lower down behind the uterus than it does in front between the uterus and bladder. The uterus had to be dragged right down, not on the hollow of the sacrum, but straight down towards the vulva; and this forcible and long-continued dislocation of the uterus formed often one of the great difficulties in the per- formance of the operation ; and doubtless, also, was one of the chief sources of danger in connection with it. For cutting across the cervix, Lisfranc and others preferred the knife; but the constant drag upwards of the uterus renders the division of the cervix with the knife irregular and oblique. I have found a pair of strong curved scissors the most convenient instrument, one or two rapid clips with them being sufficient for the detachment of the diseased and a small margin of the healthy cervix. By this means the am- putation can be much more rapidly performed before there can occur any effusion of blood to obscure the track of the wound. But in any case you are likely to have some bleeding afterwards, which at times becomes excessive, rendering it necessary for you to plug the vagina firmly, or to apply some styptic. 2. By means of the Ecraseur.—But all these difficulties in con- nection with amputation of the cervix uteri have now passed away ; for latterly we have become possessed of a much simpler means, by Avhich we can effect our object without submitting the patient to the dangers resulting from the dragging down of the uterus, or subject- ing her to the risk of hemorrhage. The instrument by which this is effected has been lately discovered in France, and it performs its work by an action which its inventor has described as linear crush- ing. If you will look around you, and mark the improvements that take place from time to time in Surgery, and in Medicine as well, you will find that they consist often, as here, of the application to 68 CANCER OF THE UTERUS. actual practice of well-known facts, and of observations which had been made long previously, but which have been allowed to lie hitherto sterile and dormant. Thus it has been regarded as a well- established fact, at least from the time of Cheselden, that when an arm or other limb was torn roughly off, or avulsed by machinery, there generally occurred no bleeding from the lacerated surface and vessels. But no actual use was made of the observation, till M. Chassaignac, one of the most talented of living French surgeons, took up the idea of making a practical application of it. The dis- tinguished discoverer of this new mode of operation, and some of our English Surgeons, make use of the instrument called ecraseur (for we have as yet no English name for it), which I here show you, for the purpose of removing some vascular tumours, portions of Fig. 26. Amputation of the neck of the uterus by means of the straight ecraseur. A. Miows the cervix uteri dragged down to the vulva by means of Museux's forceps. C, D. The chain of the instrument passed round the cervix uteri to its base. (Chassaignac.) tongue, &c. In using it the chief thing to be attended to is to work it very slowly—moving it only at the rate of a notch everv fifteen or twenty seconds, so as not to cut through the tissue too CANCER OF THE UTERUS. 69 rapidly. I have seen it employed several times for the removal of morbid growths, and never saw any marked bleeding occur from the wounded surface. M. Chassaignac himself proposed the application of it to the removal of the cervix uteri, and pointed out the neces- sity of having the instrument made with a curve near the point, to permit of its adaptation to the part; or else of dragging down the uterus through the vulva in order to admit of the application of the ordinary straight instrument. But I believe Mr. Spencer Wells was the first actually to perform the operation. He used Charriere's chain and screw. You will find an account of his case, with draw- ings of the tumour, in the last volume of the Pathological Trans- actions, and he has informed me that the woman has since remained quite well. In one case in which I operated last summer with the straight instrument, I avoided the necessity, and obviated the dan- gers of dragging down the uterus, by supplanting the inflexible chain by a piece of twisted wire, which could be bent at right angles, or in any degree necessary for its proper adaptation to the cervix, and which is of sufficient power to crush through the soft tissues in its embrace. I have here an instrument which I have recently got made to effect the same object as the dcraseur of M. Chassaignac, but of a different and more simple construction, the efficient power here being a screw, and the crushing part consisting of a strong coil formed of twenty or thirty strands of fine iron wire, such as we use here for stitches and ligatures, twisted together. It has, in other words, a flexible wire rope, instead of an inflexible jointed Fig. 27. Section intended to show how amputation of the cervix uteri may be performed without pre- viously dragging down the uterus. A. Body of the uterus. B. Keck of the uterus, surrounded by a loop'of twisted wire, C E. The rectum. F. The bladder. (Altered from Chassaignac.) chain, as its (see Fig. 27) dividing agent. There is still another bloodless mode of amputating the cervix uteri, which has been had 70 CANCER OF THE UTERUS. recourse to in modern times, for this part has now been once or twice excised, viz:— 3. By means of the Galvano-caustic Wire.— Several years ago Mr. Marshall, of University College, London, first ingeniously sug- gested the use of platinum Avire heated by a strong current of galvanism as a new caustic and cutting instrument in surgery. It has been employed on the Continent, particularly by the Professor of Clinical Surgery at Breslau, for the excision of tumours, broad based polypi, &c. He has removed the diseased cervix uteri by surrounding it above with a loop of platinum wire, then heating the wire by sending a poAverful current of galvanism along it, and im- mediately dragging it gradually through the tissue by means of an appropriate handle or instrument. It has been argued, and perhaps not without justice, that this mode of amputating the cervix uteri has the double advantage of being rapidly performed, and of being free from all risk of hemorrhage. But it has the disadvantage of requiring a battery of enormous power to heat a wire sufficiently long and strong to make its way through so much living tissue, and although the apparatus has been pretty extensively employed of late in Vienna, Munich, Wurzburg, and other continental hospitals, it has not yet been introduced, so far as I am aware, into any of the hospitals in Britain. There are various Dangers attendant upon Amputation of the Cervix Uteri. Before stating to you some facts by which you may judge of the propriety of ever amputating the cervix uteri in cases of limited cancerous, or cancroid disease of this part, I Avould beg you to re- member, first of all, that the operation is one Avhich is by no means free from immediate dangers. 1. Hemorrhage.—In the first place, there is the risk, particularly when cutting instruments are employed, of excessive and fatal he- morrhage. I never saw a case which proved fatal by bleeding, or even one where hemorrhage occurred to any alarming degree ; but such cases have occurred, and it is well that you should be on your guard against this accident. With proper and methodic plugging of the vagina, assisted particularly by such a powerful styptic as perchloride of iron, I believe you will in every case be able to pre- vent it from proceeding to a fatal extent. But, secondly, another alarming complication may occur and prove fatal in spite of all your endeavours to counteract it, viz :— 2. Collapse.—Lisfranc has recorded two or three instances where his patients died soon after the operation of a kind of faint or col- lapse, setting in suddenly without any premonitory symptoms, and sometimes rapidly carrying off the patient. I once saw this fearful symptom occur after amputation of the cervix uteri, in the case of a lady on whom I had performed the operation, along Avith Drs. Wat- son and Wilson, of Glasgow, whose patient she Avas. The tumour CANCER OF THE UTERUS. 71 removed was a cauliflower excrescence or epithelial cancer, of the size of a lemon, growing in the anterior lip of the uterus, a por- tion of the higher and healthy tissue of which was, of course, ex- cised along with the cancroid mass. The loss of blood Avas not great, and no bad symptoms occurred till two hours after the opera- tion, when the patient began to feel rather faint and became very restless. By the end of another hour the collapse Avas so great that the pulse could not be felt; the first sound of the heart was inaudible; the extremities were cold; there was intense thirst, and occasional violent vomiting. This state of collapse lasted, despite of all the means employed, for many hours, and for fifteen or six- teen hours the pulse could not be felt at the wrist. After the symp- toms of collapse passed away the patient made a good recovery, and her general and uterine health soon became re-established. I have seen the state of collapse after excision of the cervix prove fatal by itself, and independently of any other complication. A few years ago I operated on a patient in the hospital for the removal of a limited cancroid disease of the cervix uteri, and where at time of the operation everything promised fair to yield a good result. The disease was distinctly limited to the lips of the womb: amputation was effected above the line which seemed to mark its extent without more than ordinary difficulty, and was followed by almost no bleed- ing whatever. The patient was well and in good spirits when I left her half an hour after the operation was completed; but when Dr. William Zeigler, who was then clinical clerk, went to visit her some four or five hours afterwards, he found her pulseless, cold, and col- lapsed. He came at once to fetch me to see her; but when we got to the hospital she was already dead. On making a post-mortem examination, we could only find the smooth bloodless surface of the fresh-made wound; but no hemorrhage, no injury, and no morbid change which could at all account for the sudden death. The patient died, in fact, of collapse; and this is an accident which you some- time's see occurring after other operations. I met with it once, for example, in the case of a distinguished friend of mine, on whom Mr. Syme had performed his operation of perineal section. On the second night after the operation, he was seized with alarming symp- toms of depression of the circulation, coldness and clamminess of the surface, weakness, or rather absence of the radial pulse, &c. In about twenty-four hours these symptoms disappeared as a pro- fuse eruption of herpes about the mouth broke out. I have seen the same collapsed condition occur two or three times after the emptying of ovarian cysts; and I have met with it once or twice in women soon after the termination of a natural labour, lhe first time that I saw it after parturition, was in a patient who had quite a natural and easy delivery, and had suffered from no unusual amount of hemorrhage. When I saw her in this collapsed condition, an hour or two subsequently, I could not be certain whether she was merely in a state of chronic faint, or pulseless collapse, or whether CANCER OF THE UTERUS. there might not be some bleeding going on into the cavity of the peritoneum. I had made sure there was no collection of blood in the uterus or vagina. It is an accident Avhich seems peculiarly liable to occur after operations or injuries about the pelvic organs; and no sufficient explanation of it has yet been offered—nor does it even appear that sufficient attention has yet been given to it. _ I am not sure but that in amputating the cervix uteri, by obviating the necessity of forcibly dragging down the uterusfrom its position in the pelvis, Ave do something towards the prevention of this alarm- ing and dangerous complication. 3. Wounding of Peritoneum.—A third danger which patients subjected to amputation of the cervix uteri have to encounter is that resulting from the injury sometimes occasioned to the perito- neum during the performance of the operation. I have never seen any misfortune arising from this cause, for in the only instance in which I met with such an accident inflammatory changes of long standing had led to adhesions of the uterus to the rectum, and to a multitude of puckerings and foldings at the thin posterior part of the roof of the vagina, so that when a small oval portion from the surface of one of the folds or projections was accidentally cut off, no spread of any inflammatory action that may have been set up could take place along the adherent peritoneal surface, and accord- ingly no bad effects ensued. When the amputation is affected by means of the ecraseur, however, danger from this source becomes more imminent, from the difficulty which even the most skilful opera- tors experience in preventing the loose tissues above the cervix from being dragged within the embrace of the crushing chain or rope, and from being mangled and torn there. This accident occurred and proved fatal in the hands of perhaps the most dexterous sur- geon in Germany now living; and I can hardly see how you can make sure of avoiding it in those cases where you are to employ the ecraseur of Chassaignac, unless by putting some pins through the cervix uteri below the point at which you mean to apply the loop of the chain. By transfixing the cervix in this way you could, per- haps, regulate the exact height at which it was removed by the ecraseur in the same way in which you can regulate the height at Avhich it is to be removed by the knife by the use of the volsella. In order, hoAvever, to fix such pins, the operation would require to be complicated by first dragging down the cervix uteri, and then introduction would not be so easy as the application of the volsella. 4. Surgical Fever and Inflammation.—In relation to the dangers attendant upon amputation of the cervix uteri, let me, lastly, observe, that "some" patients, but not very many, have died of peritonitis or that form of surgical fever which is liable to occur and prove fatal after every form of operation Avhere a cutting instrument is employed. CANCER OF THE UTERUS. 73 Advantages or Results to be attained by Amputation of the Cervix Uteri. Such being the drawbacks and dangers attendant on this opera- tion, is it, you may ask, useful and advisable in any case to have recourse to it? To this question I unhesitatingly answer, that there are cases in which amputation of the cervix uteri is both a useful and a commendable procedure; for by means of it you can some- times eradicate the disease; and oftener you can stay its progress for a time. As in other operations for the excision of local cancers, here also the results will occasionally disappoint your hopes. The operation, I should have already told you, is not always a very painful one for the patient, and does not always even require chloro- form, as was proved by a case in which I operated last summer with the e'craseur, along with Dr. Zeigler. The patient was scarcely aware of any painful sensation which could lead her to suppose that a severe operation was being performed. You will prolong the life of your patient by this operation in some instances for several months, while in others the prolongation of her life is to be counted rather by years. In either case you rid your patient for a time of a pain- ful and distressing disease, with the temporary restoration of the patient's general health, and in some rare instances you may hope to work for her a more perfect and permanent cure. The patient Fig. 28. a—- a-" Cervix uteri excised for cancroid disease, a a. Piece of whalebone passed through the os and along the canal of the cervix. 6 6. Cancroid tumour growing from the posterior lip. c. Anterior lip. d. Line showing the extent to which the disease has extended. of Dr. Watson, to whom I have referred, lived for three or four years after the operation, and had no recurrence of the disease in 74 CANCER OF THE UTERUS. the original seat of it, but died in consequence of its appearance in the mesenteric and other abdominal glands. The patient from whom the cancerous cervix uteri was removed, of Avhich I show you these draAvings, lived for four years after the operation in perfect health, and died of acute diarrhoea or dysentery. Fig. 29. Same cervix uteri as in preceding figure viewed from surface of amputation, c c c. a a. Whalebone probe through os and cervix. 6. Cancroid mass on posterior lip. At the time I operated upon her, the patient had already suffered, for a considerable period, from all the usual symptoms of the dis- ease in a very aggravated degree. She had experienced much pain ; the discharge had been very profuse, acrid, and for some days be- fore I first saw her, at Kincardine, with Dr. Wilson, most profuse menorrhagia had been going on, which no amount of plugging, and no kind of astringent or cold application seemed to be sufficient to arrest. Though naturally a strong and robust woman, she was, in consequence, soon reduced to such an extreme state of weakness and exhaustion, that she required to be lifted with sheets when they ventured from time to time to get her bed made dry, and she became sick and faint whenever her head was attempted to be raised. In this case the posterior lip of the os uteri was enlarged, indurated, and roughened, and the surface of it, and of the anterior lip was the seat of irregular ulceration. The base of the cervix, hoAvever, appeared to be sound, and I therefore excised it; making the line of incision above the seat of the disease, and so removing all the morbidly affected part. When the cervix had been removed, the posterior lip was found to be enlarged, in the form of a tumour, to the size of a pigeon's egg; roughish and tuberculated upon the sur- CANCER OF THE UTERUS. 75 face. The base of the tumour upon the posterior lip and some part of the unenlarged anterior lip were the seat of ulceration, marked by an acute sharp edge. The diseased structure of the posterior lip slightly passed the angle or commissure of the left side, and partially invaded the anterior lip. Dr. Anderson, Professor of Medi- cine in the Andersonian University of Glasgow, who was at that time devoting his attention to the histological study of these groAvths, detected in the diseased structure all the usual microscopic and ana- tomical characters of carcinoma fasciculatum, as described by Miil- ler. The patient rallied rapidly after the operation, and lived, as I have already told you, for four years afterwards, in the enjoyment of the most perfect good health. If it be true, which has been stated, that cancer is more constantly primary in the cervix uteri than it is in any other organ or part of the body, then, Avhen we catch it in a stage still admitting of removal, we may hope for a better result after the operation here than after excision of a cancerous growth from almost any other part. The great drawback is, that here the disease is hidden from vieAv, and generally does not attract attention till it has attained such a degree of development as to excite grave symptoms, and such a spread as to render its extirpation an operation of danger and uncertainty. Fig. 30. Appearance presented by a cervix uteri amputated for cauliflower-excrescence of the posterior lip. i. Healthy anterior lip. c c. Base of anterior lip. d d d. Portion of healthy vaginal mucous membrane removed along with the cervix. But the best case of all was that in which I first performed the operation, now eighteen years ago. The patient had been under 76 CANCER OF THE UTERUS. the care of Dr. Lewins, at Leith, and Avhen I first saAv her, in 1840, she seemed to be at death's door, so reduced was she by the hemor- rhage and excessive serous discharge constantly going on from a cauliflower excrescence of the posterior lip of the uterus. I ampu- tated the cervix at that time, removing a caulifloAver excrescence of the size and form here faithfully represented (Fig. 30). The patient rapidly recovered, and has remained Avell and free from all cancer- ous disease up to this time. She has borne five children since the date of the operation, and when I saw her a few days ago she was in the enjoyment of the most perfect good health. As this case of amputation of the cervix uteri for cauliflower ex- crescence is one of great interest, from its results, the patient having, as I have stated, borne five children since the operation, and being still perfectly well, eighteen years after its performance, per- haps you will pardon me for adding that the microscopic structure of the excrescence was carefully examined at the time by Professor Reid and Goodsir. We could find in it none of the caudate or spindle-shaped bodies which were then supposed by Miiller and others to be distinctive of cancer but which we now know not to be necessary histological elements of cancerous tissue. On the con- trary, Ave found it composed of groups of cells, each of them en- closing nuclei and nucleoli. Those cells Avere, to use the modern Fig. 31. a. Appearance presented by a section of the tumour. 6. Microscopic appearance of the cells which constituted the chief mass of the tumour. nomenclature, epithelial cells; and, consequently, the excrescence was an example of epithelial cancer. To prove this, compare the drawing of the histological appearances from this excrescence (see Fig. 31), Avhich I published in 1841, with the drawing of the histo- logical appearance which Virchow published lately in his collected Memoirs (see Fig. 32) of epithelial cancer of the cervix uteri and you will find the two perfectly identical. In originally publishing an account of the case in the Edinburgh Medical and Surgical CANCER OF THE UTERUS. 77 Journal, five or six months after the performance of the operation, I stated that "I undertook the amputation of the diseased part with strong doubts as to its ultimate success. The patient's peace of mind was broken and her constitution so rapidly breaking down under the constant, profuse, and weakening discharges which afflicted her, that she would, in all probability, have soon sunk under them. Immediately after the opera- tion was performed, these discharges com- pletely ceased, and have never since return- ed. Her health and strength have, in the meantime, been restored to her, and she is at the present moment advanced beyond the mid- dle period of her pregnancy. The morbid characters of the diseased structure that I re- moved are such, certainly, as to render its future regeneration not at all improbable; but as yet there are no local appearances of its return; and taking the very worst vieAV of the case, there seems to be no reasonable doubt but that the operation has restored the bodily comfort and prolonged the life of the patient, if it has not entirely freed her from the risk of a future return of the disease." When I penned these remarks, some few months after the operation was done, I had no very great hopes that eighteen years aftenvards I should be able to state, as I have stated to you already to-day, that the patient continues per- fectly well and has borne several children in the interval. You must not suppose, however, that those cases where the disease has spread its roots so widely as to have become inaccessible to the knife or e'craseur, are altogether beyond the reach of art; for even then we have at our command a means of which we can, in some cases, check the progress of the disease for a time, and in rare cases destroy it altogether. By the same means we can occasionally remove the disease more easily and more safely, perhaps, than by any surgical operation, even so as often to supplant the use here of either the scalpel or ecraseur. I refer, of course, to the employment of caustics, the consideration of which must, hoAvever, be reserved for another lecture. " A single, very wide, and thin-walled bloodvessel, from a cauliflower excres- cence on which the cells are lying." (Virchow.) 78 CARCINOMA OF THE UTERUS AND MAMMA. LECTURE VI. ON CARCINOMA OF THE UTERUS AND MAMMA.- TREATMENT BY CAUSTICS. Gentlemen : In the course of last Aveek I one day took occasion to show you a poor woman, Avho Avas about to return to her home in the Highlands, and in whom you saw on the site of the right breast a simple granulating, healing ulcer. As I then stated to you, she came to me a month or six Aveeks before with a large elevated carcinomatous growth in the same situation, ulcerated on the surface, fungating at some parts, and bleeding freely when roughly handled. This was treated by the introduction first of a piece of caustic potass, which caused a portion of the tumour to slough away, and then by the application of a mixture of sulphate of zinc and sulphuric acid, in the manner of Avhich I shall have something more to say anon. Large masses of the tumour, some of which I showed you, were by this means made to slough and come away, till all the infiltrated tissues were removed, and a simple cica- trizing sore Avas left. Only at one corner there was a hard knot; and with respect to it, I gave the patient a note to her own doctor, calling his attention to it, and desiring him to have it removed by the same agent as had been used for the eradication of the rest of the mass. Taking, then, this case into consideration, I propose to speak to- day of cancer as it occurs in the two organs conjunctly, in the uterus, to wit, and in the mamma, in relation to the question of the propriety of removing the disease by the knife or by caustics. I am not going to speak just noAV about the nature, the symptoms, or the diagnosis of cancer as it occurs in the mamma, but only of the treatment of the disease; for here observation and experiment are both more easy, and their results have been more abundantly recorded than is the case with regard to cancer of the uterus; and the experience obtained from the treatment of the disease in the one organ may serve equally Avell to guide us in our treatment of it as it occurs in the other. The first question that meets us in our proposed path of inquiry is this— Should Cancers of the Mamma be removed by the Knife ? The propriety, let me then remark to you first of all, of having recourse in any case to the surgical removal of a cancerous tumour has been long a subject of great discussion, and very conflicting and contradictory are many of the statements that have been ad- CARCINOMA OF THE UTERUS AND MAMMA. 79 vanced in support of the different views that have been entertained. Those who object to all interference with cancerous growths, do so on the ground of the great liability of the disease to return and prove fatal; and very startling bodies of facts have been adduced to show, with almost absolute certainty, that such a relapse should be counted upon. Thus Dr. Macfarlane, Professor of the Practice of Physic in the University of Glasgow, one of the most unprejudiced and trustworthy observers alive, tells us that he1 "has never seen a case, even of the most favourable description, in which the disease did not return, although every precaution was adopted to render the operation successful." And the experience on which this statement rests is far from being very limited. Dr. Macfarlane refers to a hundred and eighteen cases (thirty-two operated upon by himself, eighty-six by friends) and though in the majority the " parts were freely and extensively removed . . at an early period, and under the most favourable circumstances ... in many instances no distinct indication of constitutional deterioration being present, yet in all the disease returned both externally and internally, and proved fatal." Many minds can hardly conceive that not one out of such a number of patients operated on for cancer should have been fairly freed from the disease : but the word of Dr. Macfarlane is entirely to be relied upon. Mr. Mayo, Surgeon to the Middlesex Hospital, declared as the result of his experience with regard to the removal of scirrhous breasts, that there was a return of the disease in ninety-nine cases out of a hundred, and that, too, where the amputation had been performed under the most favourable circumstances! The great French Surgeon Boyer maintained that a permanent cure was effected only in four out of a hundred cases. We are already getting a more favourable view of the results of the operation than Dr. Macfarlane's gloomy statistics would have led us to anticipate; and in the last and best work we have received from France on the diseases of the female breast—that of M. Velpeau —we find that illustrious surgeon stating that he has "more than twenty perfectly reliable examples of radical cure " out of a thousand, in whom carcinomatous mamras had been extirpated. Even that, as you will perceive, gives after all a favourable result in only two cases out of a hundred; but it is enough to afford encouragement, and you and your patient may both entertain the hope that she will be one of the fortunate few. Those fearful figures of Dr. Mac- farlane, I confess always haunt my mind, viz., 118 cases of cancer- ous mammae; all the 118 operated upon, and yet m all the 118 the disease recurring and proving fatal. But I feel convinced that this very gloomy and indeed desperate view of the subject is not entirely justifiable; for I find from my own observation, and from inquiries made in different directions, that Dr. Macfarlane's startling state- ment is not borne out by the experience of others. There certainly ' Walshe on Nature and Treatment of Cancer, p. 220. 80 CARCINOMA OF THE UTERUS AND MAMMA. are cases of undoubted cancer in which a permanent cure has been effected by ablation with the knife, even if these fortunate cases do not stand in a higher ratio to the unsuccessful ones than from one to four in a hundred. I have myself seen a patient under the care of Dr. Girdwood, of Falkirk, who had been cured of cancer of the mamma by the double extirpation by the knife, first by Mr. Liston, and secondly by Dr. Girdwood. There could have been no doubt in that case as to the nature of the disease, for the tumour was fully developed in its characters—large and fungating; at the second operation a number of diseased glands were removed from the axilla. When I saAv her dying of acute accidental peritonitis eight or ten years after the date of the operation, the scar of the wound Avas firm and healthy—there was no sign or symptom of cancerous disease in any other organ—excision of the diseased part had effected for the patient a permanent and perfect cure. Dr. Malcolm and I were attending together lately for epithelial carcinoma of the cervix uteri, a lady whose mother is still alive and well, and who had a cancer of the mamma removed successfully eight or nine years ago. That the affection of the mamma in this case was true cancer was ascertained by every applicable test. I have been told of various other similar cases in like manner by my professional brethren. And then in regard to the uterus, there is the Leith case of epithe- lial cancer, or cauliflower excrescence, of which I have already told you in my last lecture, where a patient has remained free from cancer for eighteen years after the removal of a groAvth was pro- nounced by all who saw it to be malignant, and which was proved microscopically to be an epithelial cancer. Results of Excisions by the Knife. We haATe patients, then, in other words, sometimes escaping and obtaining a radical cure of carcinoma of the uterus and mamma, when the disease has been removed by the knife. The proportion is, no doubt, small, very small, not more than one, two, three, or four out of a hundred obtaining exemption, and the disease returning, sooner or later, in all the remaining ninety-six or eight. But, then, there is one other fact which I must here give along with this ap- palling result; it is this: that you can never predicate Avhich one, or two, or three, out of one hundred given cases will prove success- ful ; for the happy result has sometimes been attained in cases that looked the most unpromising, where the disease was of the ence- phaloid variety, open, bleeding, and apparently of the very worst character, and in some instances referred to by Velpeau, where Lebert and Robin, after microscopic examination, had declared the tumour to be of a most distinctly malignant nature. We have seen that the final history of the patients in whom ex- cision of carcinomatous mammae has been practised is far from bein^ a bright one, and affords us little, very little, encouragement to a CARCINOMA OF THE UTERUS AND MAMMA. 81 repetition of the operation; but you must not suppose that in stating the frequency with which malignant disease is likely to recur after extirpation of the affected part by the scalpel, I stated the only drawback attendant upon such a procedure. For you will find some eminent surgeons maintaining—and I believe Mr. Paget is of their number—that unless you can operate early, ere the morbid mass has attained any high degree of development, surgical interference becomes not only useless, it becomes positively hurtful, inasmuch as it Aveakens the patient, and by exciting new action in the seat of the disease hastens the progress of the malady and shortens the life of the patient. And then you must remember, besides, that the operation i'tself of extirpation of a cancerous mamma, is not without its direct dan- gers. Velpeau tells us that of a hundred and seventy-six patients on whom excision of the mamma was performed by him, thirty-two died of the operation or its immediate consequences, or nearly one in every five. Now this is a very high mortality, nearly equal to what has sometimes been stated as the amount of mortality resulting from the severe operation of lithotomy. I am not much acquainted with the statistics of the operation, and the only other figures of any extent which I can at this moment recall are those given in Dr. Cormack's Journal for 1843, where it is stated that, in the hospital practice of the late Professor Roux, of Paris, out of ninety- five cases of excision of the mamma, twenty died, or rather more than one in every five. So far as I know, no very extended or reliable statistics have been published Jon this matter in England; but I think the operation is far less fatal with us than in Paris. The only return I could lay my hands on this morning is that of Dr. Reid in the report of our Infirmary here, where we find it stated that out of twenty-five patients operated on, two died from the effects of the operation, or about one in twelve. But even such a favour- able return as this shows that the patient incurs no small amount of danger in connection with the operation itself. Is the Removal of Cancers by Caustics preferable ? We have thus seen that there are two very serious objections to the removal of carcinomatous mammae by means of excision, viz., the great probability of a relapse, and the degree of danger attend- ant on the operation; and to these there still remains to be added a third, and that is, the natural fear and horror of the knife so universal among womankind, ay, and perhaps still more so among mankind also. Nor can the cheering prospect of a painless opera- tion, which the use of anaesthetics enables us to hold out to our patient, suffice entirely to remove this feeling; for there are still many people who would rather bear anything than subject them- selves under any circumstances to the edge of the surgeon's knife. In consequence of the dangers of the operation, and the repugnance 6 82 carcinoma of the uterus and mamma. of patients to submit to it; and in consequence, moreover, of the good results that have sometimes appeared to attend the empiric use of caustics in the treatment of carcinoma of the mamma, caus- tics have begun to attract no small degree of notice, and to receive a more systematic and extended application. Various reasons have been advanced for employing caustics in preference to the knife in the removal of cancerous growths. 1. Some surgical pathologists have been inclined to argue that extirpation of malignant growths by means of caustics is not so liable to be followed by relapse as is the case after removal by ex- cision. The man who has made the strongest asseverations, and who has had also probably the greatest amount of experience in this matter, is Landolphi, of Naples, who has destroyed, it is alleged, several thousand cancerous productions by means of caustics. Lan- dolphi is said to aver that his cures to his relapses are in the pro- portion of three to one ; or that 75 out of every 100 patients treated by him permanently recover, and in the remaining 25 the disease relapses. I only wish that I could believe in these alleged results; but be assured there is some tremendous mistake about them. I, for one, would feel quite content if we could cure by caustics not the 75 per cent, but even 25 per cent, of our cases of cancerous mamma. When proper statistics are attained—for as yet they do not exist—the cases of permanent cure by caustics will not be found, I fear, to amount nearly to 25 per cent.; but probably they will be larger than the proportion of permanent cures by the use of the knife. 2. Patients who are imbued with the utmost dread of the knife, will sometimes be found willing and ready to submit quietly to the application of caustics for the removal of scirrhous mammae. 3. The employment of caustics does not necessitate confinement to bed and the loss of time entailed by excision of the gland. The patient is, of course, not equal to any heavy work during the period when the caustics are in action ; but still she is not unfitted for every occupation, nor condemned to the unmitigated ennui of her bed for a length of time. 4. There is no such fear of a fatal issue from ablation of a tumour with caustics as there is from excision of it with the knife; for in the former method neither ligatures nor sutures are required for arresting hemorrhage from pouting arteries, nor to effect coaptation of the edges of a gaping wound. So that all the principal dangers attending the use of the knife are kept in abeyance by the use of caustics; or if they cannot in every case be prevented, the chances of their occurrence are at least greatly diminished. When you avoid the use of ligatures and sutures, you do away with those chief centres of suppuration and decomposition in a wound, which give rise to fatal surgical fevers and pyaemia; and around the mortifying part you are not so liable to have that erysipelas which, as you know, frequently supervenes on incised wounds, and not infrequently carries off the patient. Some have even averred that erysipelas carcinoma of the uterus and mamma. 83 never occurs in a part where caustics have been employed; but I have sometimes, though certainly very rarely, known it to occur in such circumstances. It has been stated, moreover, that patients in whom caustics had been employed for the removal of cancerous mammae, would not die of the disease known as surgical pleurisy. But I know of, at least, one instance where this complication proved fatal. This was in the case of a Scotch lady, who had one of her breasts amputated here because of a carcinomatous growth in it some years ago. The wound healed for a time, but scirrhous no- dules returned in the cicatrix, and for this she went to London, and there for some time caustics were used for their removal, but with- out much effect. Then she followed a fashion at present very com- mon among English ladies in like circumstances, and went to Paris, there to submit to a more effectual application of caustics. Her husband, when on a short visit to Scotland, told me that the diseased mass had been all removed, and that she was now, it was declared, in a fair way of recovery, and suffered only from constant nausea and vomiting, and from pain in the side. I told him that in all probability the disease had become localized in some internal organ, and that its progress was likely to be rapid. Soon thereafter she died, ere yet the wound left on the separation of the slough was by any means cicatrized; and it was found, on dissection, that the cancer had developed itself in the stomach and other of the abdo- minal organs, but that a subacute pleurisy had proved the imme- diate cause of the fatal issue. Then comes the question, which is the more painful—caustics or the knife? As the patient is in an anaesthetic condition during the operation, the only pain she can experience in the case of excision, is that which she suffers from the subsequent dressings of the wound, and the removal of the ligatures and stitches ; so that on the whole, one would expect this to be the less painful procedure. And yet you Avill have patients making some most curious statements in reference to this matter. I had lately under my care a lady with carcinoma near the site of the mammae, which was excised by my excellent friend, Dr. Petrie, of Liverpool, some time ago. Two new scirrhous masses sprung up in the same spot, both of which I enucleated and destroyed by caustics, and requiring first to remove the skin over them by the same means. Yet this patient has frequently assured me that, though chloroform was used for the operation of excision, the pain which was entailed in the dressing of the wound was far more acute and intolerable than the whole pain produced by the caustics. Again, in reference to the time required for the healing of the part, it has been very often averred that the sore left after the separation of the slough produced by a caustic takes much longer to heal than the simple incised wound left after excision of a tumour with the knife. This allegation I do not pretend to answer on my own authority, for I have not had sufficient experience to entitle me to give a decision on the subject; but you must allow me to read 84 carcinoma of the uterus and mamma. to you what has been said in reference to this matter by the greatest of living surgeons, Sir Benjamin Brodie. In his Lectures on Pathology and Surgery (p. 334), he has these sentences: ler- haps it will be asked, Is there not this objection to the use of caustic, namely, that some time is necessary for the slough to come away; then a further time for the healing of the wound ? and does not all this make the process more tedious than it would be if the knife were used instead ? The fact is, that a wound always heals much more readily after the application of caustics, than after the use of the knife. Take two cases: if you destroy one tumour of a given size with the knife, and the other supposed to be of the same size, by caustics, in spite of the time occupied by the separation of the slough, the sore in the latter case will be healed sooner than that in the former." Is the Extirpation by Caustics more Complete or Lasting than by the Knife ? I have already adverted to the question, as to whether extirpation by means of caustics is more complete and less likely to be followed by a relapse than is excision with the knife, and I have told you what Landolphi has stated in reference to this point. His state- ments, as I told you, are to be received only cum grano ; but there are two reasons for believing that the use of caustics will be more effectual and the resulting cure more permanent than we gene- rally find to be the case after simple excision. The first is, that the cicatrix left by caustics is much firmer than the cicatrix left by an incision ; and the observations of Dr. Young and Dr. Arnott have shown us how beneficial the effect of pressure is in restraining and preventing the development of all tumours, whether simple or ma- lignant. The second is, that the action of caustics is not of neces- sity confined to the part which mortifies and sloughs away: but there is good reason to believe that their mortifying influence pro- bably sometimes extends also to cells and structures which may be wholly or only in part affected and morbidly altered, and which lie beyond the line of immediate extirpation. Suppose that in any case you wish to extirpate a scirrhous growth, if you use the knife you only can remove so much of the morbid mass as is included within the line of your incisions. If you use a caustic, you can remove as much of the mass as can be done with the knife ; but you have in addition the probability of the substance becoming absorbed and infiltrated into the tissues around, and poisoning or modifying the character of any cells there which may have a tendency to take on the cancerous type of development. That such absorption does occur is proved by the fatal result ensuing in some of the cases where arsenic has been employed as an ingredient in the escharotic and in the distressingly painful effects of some less fatal agents. Such being the case, if we could only discover some agent which would first destroy the great mass of the diseases, and then becoming carcinoma of the uterus and mamma. 85 absorbed into the surrounding textures would there destroy altogether those cells which have taken on a perverted type of development, or modify, in some degree, their vitality—then we might hope, by the use of such a caustic, not only to remove the disease more effect- ually at the time, but to afford more security against the chances of its return. In what Cancers are Caustics applicable? Caustics were at one time used by surgeons as applicable only to some special forms of cancer, such as: a. Secondary cancer, where it occurred in the form of returning nodules after removal of the original growth, b. Cancers occurring in organs deeply seated and beyond the reach of the knife, as in the cervix uteri, &c. c. Can- cerous growths attached to the surface of bones. Then (d) flat superficial cancers specially belong to the category of those to which caustics were thought to be peculiarly applicable. But it was not till very lately that surgeons began to think of employing them in all cases of cancer, even in those where the tumour, say, in the mamma, is still small and quite movable, for it was formerly deemed an indispensable indication for the employment of caustics of all sorts that the skin should first be broken, and the condition of open cancer be established. The Principle upon which they are used. What principle do we follow, or what natural process do we at- tempt to imitate in the employment of caustics for curing scirrhus ? The principle is not always very correctly stated or distinctly enun- ciated ; and I should, therefore, like to make a few remarks regard- ing it. I hold in my hand the best monograph which we possess in English on the nature and treatment of cancer, that of Professor Walshe, of London, who points out in one of his chapters different ways in which cancers may possibly terminate in cure when left to themselves. It is only to one of these modes of termination in cure to which I wish at present to direct your attention particularly—to that cure, namely, which is effected in the way of mortification. Under this head we find Dr. Walshe saying: " In some rare cases a spontaneous sphacelus of the morbid substance and of the surround- ing parts has led to the total separation of cancerous growths, and been followed by the recovery of the patient. Garneri, Cruveilhier, Everard Home, Cline, Steideley, Dupuytren, Richerand^C. T. Jack- son, and others, have observed this fortunate accident." Then he goes on to say, what is no doubt true, that "the separation of can- cer in the manner now described is not, however, as a necessary sequence, followed by recovery. Cruveilhier alludes to a case in which healthy cicatrization set in after the fall of the groAyth, yet indurated masses soon made their appearance in the cicatrix, and, though these were destroyed with the chloride of zinc, the disease 86 CARCINOMA OF THE UTERUS AND MAMMA. spread to the axilla." I have seen it in like manner recur in the mamma after it had been removed and enucleated by spontaneous sphacelus. But the opposite and happier result has apparently been more frequently observed. Now, it always appears to me that the question we have to solve is, can we not in all cases produce this rare and fortunate accident, as Dr. Walshe terms it, by artificial means, turn an accident of nature into a certainty of science, and by inducing mortification of the morbid mass, lead to its enucleation and separation ? Dr. Walshe does not refer to this view of the matter further than to notice two cases in which an attempt had been made to imitate the natural process, and these cases he holds up rather as warnings than as examples to be followed. One of these cases is altogether so peculiar, and the procedure is one so unlikely to be repeated that I shall take the liberty of reading it to you as given by Dr. Walshe in another part of this work. "The occasional fortunate issue of cases in which mortification had destroyed the morbid growth, led to the bold and hazardous proceeding of inducing artificial destruction of the kind by the inoculation of the matter of common or hospital-gangrene. M. Rigal, Surgeon to the Hotel Dieu at Gaillac, appears to have had recourse to this experiment, in one instance, at least, with success of a very remarkable stamp. He made a small incision in the centre of a mamma (so much enlarged by an irregular, uneven, fixed varicose tumour, that it measured thirty-one inches in circumference) and covered the place with lint soaked in gangrenous sanies. On the third day the wound inflamed, and exhaled a putrid odour. Gangrene made such rapid progress, that in eighteen days the entire of the enormous mass had separated; four months and a half after, the wound had completely closed; eighteen years later the lady was still living, and had never had a relapse." The experiment with hospital-gangrene is certainly one which neither you nor I would like to see repeated. But then comes the question, may we not hope to attain the same object with as much certainty, but with less risk, by means of caustics introduced into the centre or below the base of the tumour ? Formerly, as I have told you, caustics and escharotics were applied only to cancers with open surfaces, and then in such a manner as only to remove the mass layer by layer until the base was arrived at. But matters are now changed; and since attention has begun to be more especially directed to this department of Surgery, various methods have been devised—and these may yet be greatly improved upon—of destroy- ing the tumour from the centre, or of blowing it up at once (if I may so speak) from the base. Varieties of Caustics. As regards the substances employed, you will ever and anon find the allegation is being made that some new vegetable has been dis- covered possessed of escharotic properties, in a degree sufficiently CARCINOMA OF THE UTERUS AND MAMMA. 87 high to enable it to be used for the destruction of cancerous growths. Such vegetable plants or preparations have never yet in reality been discovered, nor are they ever likely to be. But there are a number of powerful enough mineral caustics, which admit of division into three groups. First of all, we have the concentrated alkalies, as potassa, lime, and soda, which may be used either singly or combined. These form admirable applications to chronic inflammatory indurations and enlargements, as of the cervix uteri; but they do not answer so well in the case of cancers, for here their use is apt to be attended with bleeding, which quenches the caustic. Secondly, we have the group of the concentrated acids, such as the nitric, hydrochloric, and even the fluoric acid, which I have found to act in some cases as a good escharotic. Sulphuric acid made up into a pasty mass with saffron and other substances, has been much used by Rust and Velpeau, and with good effect. But in all instances these substances have only been applied superficially, in the hope that they would sink downwards and exert a deep escharotic effect, without being introduced and imbedded in the substance of the tumour. Thirdly, metallic preparations have yielded the best results that have as yet been attained. Of these, arsenic in its various forms has always been much in vogue, and it matters little in which of its forms it be used. You will always be hearing from time to time of cures of cancer effected by non-professional people up and down the country by means of particular preparations; and on inquiry you will almost invariably find the active ingredient to be some form of arsenic. It certainly has a wonderful effect in searching and sink- ing into and destroying the carcinomatous mass; but there are two very serious objections to its universal application. There are, first, the intense pain which it excites, and which lasts for two or three days after its application; and, secondly, the danger to life which attends its use, for its destructive effect is not always confined to the morbid part, but it sometimes becomes absorbed into the system and causes death with vomiting, and all the other symptoms of arsenical poisoning. The paste or preparation into which it enters as the main ingredient, does not usually contain more than from two to ten per cent, of the arsenic; but even where it is present in a propor- tion no higher than four per cent, it may become absorbed through the open surface and produce its fatal effects. Landolphi made ex- tensive use of chloride of bromine, which has the disadvantage of being extremely suffocating. Canquoin, of Paris, acquired a for- tune and a reputation by his success in the cure of cancers by means of caustics, and the preparation which he chiefly used was chloride of zinc. This is a very deliquescent salt, and does not keep, except when made up into the form of a paste with starch or flour; it is, moreover, very apt to cause hemorrhage, at least when used pure. But on the whole it is an excellent escharotic. The pernitrate of 88 CARCINOMA OF THE UTERUS AND MAMMA. mercury has been much used by some practitioners, chiefly as an application to lupus and corroding ulcers. Two years ago I showed that in a very simple salt—the sulphate of zinc—we have a very powerful caustic, when it has been dried and reduced to a powder. I applied it at first to superficial cancers, and in several cases with complete success. Last year I had an opportunity of showing to the class a poor woman who for ten or twelve years had a large can- cerous ulcer on the cheek involving the facial nerve, and who had been quite cured by several applications of the dried powder. I saw quite lately a lady who at one time suffered from a superficial creeping cancer, which began on the neck and spread in two years upwards to the cheek and temples. In that case, too, the dry sul- phate of zinc was applied, and she is noAV quite well. To apply it to the base of a tumour or into its interior, it may be mixed with sulphuric acid, as first suggested by Dr. Thomson. The greatest advance, hoAvever, which of late years has been made in the caustic treatment of carcinomatous growths does not consist in the discovery of any new caustics, so much as it consists of more clear and practical views as to the mode or modes of employing them, and especially in the introduction of the destroying agent into the centre, or beneath the base of the tumour, so as to produce at once, or as speedily as possible, mortification of the entire mass. Various methods have been tried for effecting this object. Two years ago a great deal of attention was attracted to the sub- ject in consequence of the alleged success which attended the treat- ment of cancer by means of caustics in the practice of an American, Dr. Fell, who was allowed in London to try his plan of treatment on the cancer patients in the Middlesex Hospital. What he did was first to remove the skin over the tumour by means of nitric acid applied in lines to the surface, and afterwards to insert some paste compounded with chloride of zinc into the fissures. This was allowed to remain and exert its escharotic action for one, two, or three days; and then, after removing the slough with a knife, he introduced some more of the paste into the deepening and enlarg- ing grooves. ^ By repeating this process several times he deepened the fissures, till they reached to the base of the tumour, when the whole mass sloughed and separated. Chloride of zinc, however, is, as I have told you, apt to cause bleeding, and the procedure is'at- tended with this further drawback, that it involves the use of a knife and that, as we have seen, is always a source of dread to patients _ You will find an ordinary quill pen to be an instrument as effica- cious and, to the patient at least, much less formidable than the knife If you make use of the caustic made by saturating strong sulphuric acid with a quantity of sulphate of zinc, dried and powdered you can manage, by dipping the pen in this mixture as if you were goine to write with it, to lay it in a number of lines across the tumour the number of lines corresponding to the size of the growth which'you wish to destroy. Very speedily the super-sulphate of zinc kills the CARCINOMA OF THE UTERUS AND MAMMA. 89 skin in the course of the lines which you have drawn ; and if you will now scratch assiduously with the filled pen along these lines, you will cut through the skin in a few seconds. Leave for a day the fissures filled with the caustic paste, and then every day or two by renewing the application of the scratching and caustic you can cut down to a greater depth. In making the first application I usually make a fissure of about a fourth or three-eighths of an inch in depth, and then destroy the tumour more deeply by successive applications. In this way five or six days may suffice for the removal of a good-sized tumour. Let me add, that in thus destroying and digging out, as it Avere, from its very base, a cancerous tumour of the mamma, or other external part—neither of the two caustics applied by the quill would suffice singly and individually. If you used the sulphuric acid alone you will find that the acid so chars and hardens the spot to which it is applied that you cannot, next day, cut or scratch deeper through it with the pen; while the super-sulphate of zinc paste keeps the parts soft and pliable. Again, if you used sulphate of zinc alone you could not cut through the skin or penetrate deeply with it. For that purpose the aid of the sulphuric acid is required, and the relatively slighter pain attendant upon this than upon most other caustics is perhaps explicable by the fact that sulphuric acid acts almost instan- taneously in producing its destructive effects upon living tissues. Usually the healthy skin at the edge of the sloughing-out mass is granulating, contracting, and partially cicatrizing before the dead tumour itself separates. Dress the exposed tissues or ulcer before and after the tumour is enucleated with black wash, chloride of zinc, sulphate of zinc, nitrate of silver, or any other appropriate surgical lotion. M. Maisonneuve, of Paris, has of late recommended the employ- ment of what he calls caustic "arrows;" a practice, however, not entirely neAY either in French or English Surgery. These are little Fig. 33. Fig. 34. Fig. 33.—Diagram illustrative of the introduction of conical arrows into the base of a tumour for its circular or radiated cauterization or destruction. (Maisonneuve.) Fisr. 34 shows the mode in which flat arrows are introduced for parallel or fascicular cauterization or destruction of cancerous tumors. (Maisonneuve.) 90 CARCINOMA OF THE UTERUS AND MAMMA. pieces of paste containing chloride of zinc made into the form of small cones, sharp at the point to facilitate their entrance into the substance of the tumour. In applying them he sometimes makes punctured wounds into the tumour all around its baseband into each wound introduces an "arrow," in the manner shown in Fig. 33. Again, instead of conical arrows introduced into the base of a tumour in a circular direction, he sometimes makes use of small flattened pieces of caustic paste introduced in great numbers from the surface of the tumour, and all parallel to each other. (Fig. 34.) In other cases he has the caustic introduced in the form of a larger ovoid mass right into the centre of the tumour at once. (Fig. 35.) Some of these arrows, which I here show you, were made according to his description, but I find them too soft to be easily introduced, and if a wound be previously made, they do not suffice to check the bleeding. I have caused some others to be made up with sulphate of zinc, which are harder ; but hemorrhage is apt to accompany both kinds, which they are both utterly unable to ar- rest. I made the attempt in the end of last week to produce sloughing in a cancerous mamma by the insertion of chloride of zinc arrows into the centre of the tumour; but such a severe hemor- rhage occurred that I was obliged to desist and to apply perchloride of iron to check the flow. Might not arrows made of chloride of zinc and per- chloride of iron answer better ? We may yet find a means of applying caustics to the interior or to the base of cancerous masses which shall be more effectual than any of those to which I have referred. I attempted in some cases to inject a saturated solution of sulphate of zinc into the heart of a scirrhous mamma by means of a small syringe. such as I hold in my hand. It is that contrived by Dr. Alexander Wood, for the subcutaneous injection of narcotic fluids, and consists simply of a small graduated glass syringe capable of containing thirty or forty minims of any liquid, with a very fine silver tube screwed on to the nozzle. This tube is tipped with steel, and sharpened in such a Avay that the canal opens at the side close to the point. By means of this instrument, various substances might be injected into the tissues; but its use, as I found in the cases in which I employed it, is attended with this drawback, that the fluid will not enter into the hard scirrhous texture so readily as it will pass around it, destroying and decomposing the softer and healthier tissues. Perhaps this objection could be got over by using a somewhat similar instrument, provided with a wider and stronger tube like that of a paracentesis trocar, which could be made itself to penetrate into the centre of any scirrhous or cancerous mass ; and the escha- rotic with which it is filled should be left in the track of the trocar as Fig. 35 shows a fusi- form arrow such as is used for the central cau- terization or destruction of cancerous tumours. (Maisonneuve.) CARCINOMA OF THE UTERUS AND MAMMA. 91 it is withdrawn, instead of being injected through it. If necessary, it could be passed in many directions through the centre and sub- stance of a tumour, without requiring to be passed more than once through the skin. Perhaps you will excuse me adding that I have now several times seen small fatty tumours of the body, talpae or wens of the scalp, &c, die in the centre, and • their contents become eliminated after they were injected, in small quantity, with saturated solutions of sulphate of zinc, perchloride of iron, &c. Applications of Caustics to the Cancerous Cervix Uteri. I have, in the preceding observations, dwelt at such unexpected length upon the application of caustics to the cancerous mamma, as to have forgotten to speak of their application to the cancerous cer- vix uteri. The principles of their utility and application are indeed the same in both organs ; but at the same time there are one or two important points of difference. First, the epithelial form of cancer is infinitely more common in the cervix uteri than in the mamma, and all pathologists know that the excision by the knife, or the de- struction by caustics of epithelial cancer, is more likely to be suc- cessful than the excision or destruction of common cancer. But while we are thus entitled to hope for better success in the surgical treatment of a tractable case of uterine than of mammary cancer, the application of caustics to the cervix uteri is attended with more danger than to the mamma, as the peritoneum is in such close pro- pinquity as to be readily reached and fatally injured. I have seen potassa fusa frequently applied to cases of cancer uteri which appeared limited, but still beyond the reach of excision. In most cases it failed to do any good; perhaps, indeed, in most it did harm, as it is almost impossible to apply it in cancerous disease so as to produce any great slough; for bleeding _ almost invariably supervenes and arrests its action. In one case which I saw with Dr. Moir, it was often applied by him with the result at last of bringing out a large and apparently complete slough; and the patient has since that period—now ten or twelve years ago—remained quite well. The most manageable of all strong caustics, as applied to this part of the body, is dried sulphate of zinc. You may apply it either through the speculum in the form of the simple powder, laid on in thick quantity upon the part which you wish to destroy; or, you may apply it, without the speculum at all, in the form of two or more medicated pessaries, made with as much of the sulphate as the oint- ment can be made to take up. In this latter case, you apply the medicated pessary with the fingers to the cavity of the existing ulcer, and fill the cavity carefully with two or more pessaries. It is always further well to introduce into the vagina below two or three pessaries, made with carbonate of soda, to neutralize the zinc if it happen to 92 CARCINOMA OF THE UTERUS AND MAMMA. run down. I have been much pleased with the results of this treat- ment in a few cases ; but the practice is too recent to be able to ob- tain sufficiently accurate results. One of the first cases in Avhich it was used was in a case—the notes of which were draAvn up carefully by my assistant, Dr. Skinner, who took a deep interest in its manage- ment. The patient, a woman of 38 years of age, came from the Highlands to consult me in the beginning of September, 1856, in regard to a constant and sometimes profuse menorrhagia which had set in three months before, and had been going on almost uninter- ruptedly until the time when I saw her. She had been married for five years, and had given birth to three children, the youngest of whom was then about twelve months old. On making a vaginal examination, I found the cervix uteri enlarged and indurated, and though still somewhat mobile, it was the seat of an extensive ulcer, with ragged, indurated, irregular margins, soft and boggy in the centre, secreting a quantity of sanious fetid fluid, and bleeding freely when touched. Her general health had begun to give way, and her face was already marked by the cadaverous look and the sallow hue, which are supposed to be peculiar to those who are the subjects of the cancerous cachexia. Dried sulphate of zinc, in the form of a fine powder, was freely applied to the ulcerated surface ; and as one application did not seem to be sufficient for the removal of the mor- bid mass, it was repeated on the third day by my assistant. When I examined the patient a few days after the first application of the escharotic I could hardly believe at first that it was the same case— so great was the change that had taken place. The induration was all gone, the bleeding and offensive discharge were stopped, and a puckered defined slough, which presented an exact model of the ulcer, was beginning to separate. On the ninth day the slough was completely detached, and a simple cicatrizing sore was left. As for further treatment, she was ordered to take fifteen drops of the tinc- ture of the muriate of iron three times a day, and occasionally al- terative and aperient powders of rhubarb and soda. The healing surface was touched occasionally with some tincture of the muriate of iron, and the patient was ordered to use injections containing aluminated iron to remove a flabby patulous condition of the os uteri. The patient was only five weeks under treatment altogether, and at the end of that time she returned home, with the local disease completely destroyed, and her general health in a great degree re- stored. Ten weeks afterwards I heard that she had remained per- fectly well; and only yesterday morning I had a letter from Dr. Irvine, of Pitlochrie, telling me that she had lately been confined of a healthy mature child, after a labour which was somewhat tedious in the first stage, from the undilatability of the os, but otherwise quite normal and natural. She is now, he further states, " in per- fect health. The os uteri is somewhat uneven, but there is neither hardness, ulceration, nor discharge. Indeed, the woman has never experienced any discomfort since she passed from under your charge." ON DYSMENORRHEA. 93 In reference to the use of caustics for cancerous diseases of the cervix uteri, I have only this further remark to make, namely, that we have at least one very interesting case recorded to show that the simple muriate of iron may prove to be a most useful agent in the destruction of carcinomatous growths. I allude to a case occurring in the practice of my friend, Dr. Boulton, of Horncastle, who had a patient with epithelial cancer of the cervix uteri, which had at- tained a considerable size, which frequently was the source of pro- fuse hemorrhage, and which was quite friable, and broke down under examination with the finger. He applied some tincture of the mu- riate of iron to the broken-down tissues, and this seemed to act by coagulating the blood in the small bloodvessels of the part, and so destroying its nutrition that it mortified and sloughed away. Per- haps a saturated solution of the perchloride would act still more effectually. The disease returned, and was again treated in the same way, and with the same result; and after it had in this way several times recurred and been destroyed, it was finally cured, and the patient has now remained well for several years. The observa- tion is an extremely interesting one, for it may be that while arsenic would destroy the cancerous parts, and then pass deeper and exert its poisonous action on the whole body, iron or some other metal may have merely the more local effect of poisoning the morbidly disposed cells, in and near the diseased part. And in reference to this mat- ter you must remember that iron, in its various forms, is also one of the best of all tonics that you can prescribe for a cancer-affected patient. There is evidently in such cases a diminution of the quan- tity of iron in the blood, as is shown also by chemical analysis ; they are usually chlorotic; and so convinced was Mr. Carmichael, of Dublin, of the beneficial effects of iron in the treatment of cancer that he proposed to keep patients saturated with it as the best means of checking the progress of the disease. It certainly is one of the best tonics we possess for such cases; and a few instances like that narrated by Dr. Boulton would show it also to be a very admirable escharotic, and might lead to its more general application for the local destruction of the carcinomatous groAvth. LECTUKE VII. ON DYSMENORRHEA. Gentlemen : Yesterday, as some of you had an opportunity of seeing, I dilated the os and cervix uteri by dividing the portio vagi- nalis on each side in the case of a young unmarried female, Avho suffers great pain at each menstrual period; and as this affection, 94 ON DYSMENORRHCEA. though rarely enough met with in hospital patients, is one of those which you will most frequently be called upon to treat when you come to practise, I think it will not be out of place for me, at the present time, to direct your attention to some_ of the varieties of dysmenorrhcea, or painful menstruation; to point out their nature and symptoms, and to explain to you how they may be most success- fully treated. Let me first of all observe, that there are many women who have no suffering during the menstrual period at all. Menstruation sets in without producing any unusual symptoms, and without exciting any notice till the blood is discovered escaping from the passages ; and almost no amount of pain is experienced during the continuance of the flow. A very considerable number, however, do suffer pain at that period ; in some the painful sensations being felt before the discharge sets in, whilst in others they are first experienced after the catamenial flow has become established. The pain in such cases may last for a longer or shorter period; usually it is not of long continuance, and as it is not very severe in character it is not much complained of by the patient. But there is a third class of females who ever and anon demand our aid, because of the high degree of suffering and agony they endure at the menstrual period, either before the blood begins to appear, or whilst the discharge is going on. Patients of this class—those labouring under dysmenorrhcea, as it is called, or painful menstruation, sometimes suffer to a degree which renders life a burden to them ; for though in some instances the pain occurs only during two or three periods, and then gets cured and passes away, yet in most it continues long—it may be for many years, or until some curative treatment has been instituted. Many patients thus suffer the greatest agony from month to month, and no sooner has the pain of one period passed away than they begin to look forward with horror to the next, and the prospect renders their life miserable. You will find, further, that where this type of disordered menstruation occurs in married women, these seldom or never become capable of bearing children until the dysmenorrhcea has been cured. The disease seldom interferes with the life of the patient; but it does interfere in a very great degree with her health, and strength, and happiness. It is a disease, I repeat, which you will very frequently meet with in practice, and one by which you will bring much discredit on yourself if you do not know how to de- tect and cure it. Under what circumstances, let us first inquire, does menstruation become painful ? Here I would, in the first place, remark, that the degree of pain experienced during menstruation, is not in any way regulated or modified by the amount of fluid which is discharged during the period of its flow. And the proof of this observation is to be found in the fact that some patients suffer much pain where there is little or almost no discharge of blood at all; while others with a very profuse discharge, may be quite free from pain during ON DYSMENORRHEA. 95 the whole period. You will meet with it, indeed, under the most opposite circumstances. In some it begins when the menses first appear, and lasts till some remedial measures be adopted. In others it only supervenes upon exposure to cold at a catamenial period, or upon some other cause producing chronic metritis or other affection of the womb. You will have it in other patients beginning after marriage, although it occurs much more frequently among unmarried females. You will meet Avith it occasionally among married women —usually associated with sterility; but its occurrence in one who has been pregnant is altogether an exceptional case. Seat of the Pain. I am not going to dwell much on the subject of the seat and ori- gin of the pain, for it is one of those points on which our knowledge is particularly defective. So much, however, seems certain, viz., that the pain may be seated in one or other of two organs; and dysmenorrhcea may therefore be divided into two classes, according as it originates, 1, in the ovary, or, 2, in the uterus. I. Ovarian Dysmenorrhea. At each menstrual period one or other of the ovaries undergoes, as you are well aware, a variety of changes, which are all essential to the fulfilment of its physiological function, but which, at the same time, bring it into a condition that may be regarded as almost patho- logical. When at such times an ovum enlarges, comes to the surface of the ovary, and there escapes from its follicle; when such a de- gree of congestion is required as shall lead to an effusion of blood into the follicle to favour the expulsion of the ovum, and to fill up the cavity which is left; and when the organ is in a state of such high nervous excitability—then it is easy to conceive how a slight aggravation of any of these phenomena may lead to the occurrence of dysmenorrhcea. It needs but a sl'ght exaggeration of the con- gestion to produce inflammation ; and no great exaltations of the nervous phenomena will be required for the full development of a distressing neuralgia. And besides, from clinical observation we know for certain that the ovary is an organ possessed of a certain degree of sensitiveness, and liable at times to be the seat of pain; for there are some women with perfectly developed ovaries and rudi- mentary uteri, in whom all the secondary phenomena of menstrua- tion may occur, with the exception of .the discharge from the imper- fect or atrophic uterus. These women suffer from pain in the back and inguinal regions, and from the other uneasy sensations peculiar to women at the menstrual period; and though the symptoms are not so well marked as in females with all the organs fully developed, yet their occurrence in any degree is sufficient to warrant us in be- lieving that in ordinary cases of dysmenorrhcea, the ovaries may 96 ON DYSMENORRHEA. occasionally be the peculiar seat of the pain. I have lately seen two patients, who had both suffered for months continuously from pain, and all the other symptoms of dysmenorrhcea, but in Avhom any other form of dysmenorrhcea than this ovarian form could not properly occur, seeing that the uterus was in both cases altogether absent. You may meet with other instances of this malformation, however, where no pain is present. I have seen such a case along with Dr. Arthur Mitchell, where there was no uterus at all, and the vagina ended in a cul-de-sac. We could easily satisfy ourselves that there was no uterus by passing a sound into the bladder, and then introducing a finger high up into the rectum, Avhen the sound could be readily felt above the apex of the vaginal sac without any intervening body or substance whatsoever. The ovaries seemed to be present, for the sexual appetite was fully developed, and all those feminine characteristics whose presence is supposed to depend on a healthy condition of the ovaries; but in this instance there was no dorsal pain, nor any other symptom of dysmenorrhcea. There are, again, some curious cases of malformation occasionally met with, where the ovary is found to have descended into a hernial sac, and as has been related by Oldham, in reference to such a case, the ovary has sometimes become swollen and tender at the menstrual period, and given rise in this way, apparently, to the dorsal and other sympathetic pains. Finally, let me observe, there are other cases where the ovary becomes displaced downwards, and is found lying in the recto-vaginal cul-de-sac of the peritoneum ; and in such instances it may at times be felt to be enlarged, and tender to the touch, and clearly in a state of acute inflammation. II. Uterine Dysmenorrhea. You might suppose, then, since such changes are known to occur in the ovary, and give rise to painful sensations, that this organ should be regarded as the seat of the pain in all cases of dysmenor- rhcea. But, on the other hand, pain is usually not the only symp- tom present, for it is commonly accompanied with sickness, nausea, and vomiting—such as you often see in the commencement of labour, where the pains and concomitant symptoms are only referable to the uterus itself; and, therefore, I think we must come to the conclusion, that while there are some cases of dysmenorrhcea where the neuralgia is localized in the ovaries, yet that in the greater number of cases it is developed, and has its peculiar seat in the uterus itself. Now, as the disease may depend on different morbid conditions of the womb, you will find that it presents itself in several varie- ties, to which you must allow me to direct your attention somewhat more in detail. 1. Neuralgic Dysmenorrhcea.—All pathologists admit a neuralgic division. That is, all admit that dysmenorrhcea may occur in pa- tients who are subject to neuralgic affections, and in whom pains ON DYSMENORRHEA. 97 disappear from the other organs and parts of the body at the time of menstruation, only to become concentrated, as it were, in the re- gion of the womb. Such patients complain habitually of aches and pains in the face, the head, the mammae, the intercostal spaces, or elsewhere, and these pains all become aggravated for a day or two before the appearance of the catamenia. Then acute and constant pain begins to be developed in the uterus, and as the menstrual flow sets in, the pains in other parts of the body become quite relieved. In such cases, the uterine neuralgia persists during the whole men- strual period—remitting, perhaps, for a time, but never altogether intermitting. 2. Congestive Dysmenorrhcea.—Another class which most authors acknowledge as pretty frequent, is that of the congestive cases of dysmenorrhcea, where there is usually nothing to be found further than an exaggeration of the ordinary phenomena of menstruation. At every menstrual period there occurs a certain amount of conges- tion in the womb from the determination of blood to it, which is eventually relieved by an escape of the blood from the mucous lining of the organ. This congestion—which goes on not only in the uterus, but in the ovaries as well—may, and sometimes does, rise beyond the normal standard, and then uneasy sensations may be produced, and all the symptoms of perfect dysmenorrhcea. 3. Inflammatory Dysmenorrhcea.—Inflammatory forms of dys- menorrhcea are usually due to the occurrence of inflammation in the cervix, which is the portion of the uterus most frequently affected with that disease. Ulcers may be present around the os and be irritated by the fluid; or they may have existed at some former period, and in cicatrizing they may haA'e led to contractions of the orifice ; or the organ may be indurated and thickened, and its lumen narrowed in consequence of chronic inflammation; or it may be at the time in a state of acute inflammation. In any case, the passage of the menstrual discharge through the morbidly affected part, will be a source of actual and acute suffering. 4. Gouty or Rheumatic Dysmenorrhcea.—There is a fourth class, which we can only talk of as gouty or rheumatic, and that^ for two reasons, viz: 1st. Because it is a class where the patient has suffered before, or, it may be, at the time of the attack from various other gouty or rheumatic diseases, or has shown symptoms such as are caused by excess of uric acids or urates in the blood. In the rheumatic cases, the patient has been subject to pains and swelling in the knee, the shoulder, and other large joints, perhaps has got some cardiac bruit; in the gouty cases, the smaller joints have been previously affected, and the patient suffers from excessive windy se- cretions in the bowel, and all the other symptoms usually met with in gouty individuals: it is in such cases that Avind is sometimes apt to be developed, and to accumulate in the cavity of the uterus, as described by Dr. Rigby. The second reason for our classifying such cases as gouty or rheumatic is that they yield, as has been shown by 7 98 ON DYSMENORRHEA. Dewees, Gooch, Hamilton, and others, to colchicum, guaiacum, and the other remedies Avhich are ordinarily more especially efficacious in the treatment of gouty and rheumatic diseases generally. 5. Dysmenorrhcea may be accompanied by organic diseases, or by displacements of the uterus ; or, rather, it may occur as a compli- cation of such diseases or dislocations. In cases of polypus of the uterus, for instance, or of fibroid tumours of its walls, or of any other organic lesion, menstruation is often attended with great pain and discomfort in every form and degree of retroversion or antever- sion, or other displacement of the womb, dysmenorrhcea is one of the most distressing and constant complications. 6. Membranous Dysmenorrhcea.—There is a membranous form of dysmenorrhcea, which, as was long ago noticed by Morgagni, a pe- culiar membrane is shed from the uterus, and discharged at every menstrual period. Fig. 36. Sketch of a dysmenorrhceal membrane, as seen under water. I show you here two such pieces of membrane which were brought to me by two of my patients some time ago, and are now pretty much broken down. But from the drawings which I noAv point out, you will obtain a clearer view of the form and appearances of the bodies in question. Dr. Granville, in his work on abortion and the diseases of menstruation, has figured the membranes from a long series of cases occurring in his own practice. In this form of dys- menorrhcea the pain is present from the commencement and lasts for two or three days, or till such time as the obstructing membrane ON DYSMENORRHEA. 99 gets discharged ; and then the patient is relieved till the next period, or in some cases till the second following menstruation. For it is to be observed, that though this membranous discharge may occur at every catamenial period in some cases, yet in others it takes place only every second, third, or fourth month. This was formerly re- garded as an inflammatory form of the affection; and the explana- tion usually had recourse to was that an exudative type of inflammation occurred here such as that occasionally seen in the intestinal canal, and more frequently in the respiratory tubes in cases of croup; and that a fibrinous or plastic effusion was poured out on the surface of the mucous membrane, which, in becoming organized, assumed the shape and size of the cavity in which it was formed. Rigby, Dewees, and Fig. 37. A dysmenorrhceal membrane laid open. (Coste.) others, supposed that such membranes were peculiarly liable to be produced in cases of gouty or rheumatic dysmenorrhcea, and they accordingly included the membranous in that other class of dis- ordered menstruation. For some years past we have had our no- tions in regard to this matter entirely changed. Ever since I began to lecture on this subject, and to make some special observations regarding it, I came to the conclusion, and have always taught, that we had here to do, not with an inflammatory exudation, but with a desquamation or exfoliation of the mucous membrane of the uterus; and the proof that such is the case is irresistible. For if you exa- mine it, particularly when it is placed in water and unfolded, you will find it to resemble, in every respect, the early decidua. Like the decidua, it is a shut sac, triangular in form, rough and irregular on the outer surface, and on the interior smooth and of a cribriform 100 ON DYSMENORRHEA. appearance. It possesses the complex structure of the mucous membrane of the uterus, containing crypts or follicles with nucleated cells and vessels intervening ; and in all respects corresponds to the mucous membrane, as it presents itself to us more especially in that hypertro- phied condition which is seen in the earlier periods of preg- nancy. If the decidua be simply the altered mucous membrane of the uterus, as it is now believed by most ana- tomists and physiologists to be, then there can be no doubt that the shreds cast off in this form of dysmenorrhcea are also portions of the altered mucous membrane, seeing that they present all the same ana- tomical characters as the de- cidual membrane does; for when working at the subject some fifteen or sixteen years ago, I gave some preparations to Mr. Goodsir to examine microscopically, Fig. 39. Appearance presented by the inner surface of a uterine cast, when viewed with a low magnifying power. Fig. 39 shows the openings of the uterine follicles more distinctly than the preceding. and he declared, and enabled me to declare, that the two kinds of membrane were identical in structures, and were both merely due to changes in the mucous membrane of the uterus. The dysmenorrhceal membrane is in some cases very thin, consisting merely of a layer of ON DYSMENORRHEA. 101 the epithelial covering of the mucous membrane of the uterus ; but more frequently it is, as I have told you, of greater thickness, and represents the whole of the swollen and hypertrophied membranes. Some authors have doubted the possibility of this monthly exfo- liation from the interior of the uterus, and have questioned as to how it could occur. You will find some admitting a desquamation of the epithelial covering, but scouting the idea of the whole or the greater portion of the mucous membrane becoming detached and discharged by the contractile efforts of the uterus. When I first published a memoir about it, Dr. Ashwell wrote to say that it was a very curious sort of observation to make, and one which he would defy me to prove, because it was utterly impossible to dissect off the mucous membrane of the uterus in the dead body. True, you cannot with the scalpel detach the mucous membrane from the interior of the uterus with perfect precision, but nevertheless you have proof suffi- cient in the identity of structure between the expelled membranes and the uterine mucosa to convince you that an exfoliation of the latter does occur in cases of membranous dysmenorrhcea, whether from fatty degeneration occurring in its deeper layers, or in conse- quence of some other change with which we are as yet unacquainted. The manner in which the separation of dysmenorrhceal membranes is effected is a subject that requires still to be investigated, as does also one other point in connection with this as well as some of the other varieties of uterine dysmenorrhcea, namely, the changes that occur in the walls of the uterus, particularly as regards their en- largement, or the increased development of muscular fibres in them at these periods. Let me merely add in regard to this form of dysmenorrhcea that more lately Handfield Jones has come to the same conclusion regard- ing the uterine casts, as that which I have explained to you, and that Lebert, Raciborski, and last of all, Virchow, have furnished additional proof of the correctness of our explanation. Virchow, indeed, has gone a step further than any of the others, for he tells us that in opening the bodies of women who have died while suffer- ing from dysmenorrhcea, he has found the mucous membrane of the uterus in a state of partial separation; and has thus supplied a dis- tinct anatomical proof that up till that time was wanting. 7. Obstructive Dysmenorrhcea.— And lastly, there is an obstruc- tive form of dysmenorrhcea connected with a state of stricture, or contraction of the calibre of the cervix uteri. The seat of it may be at the os tincoe, along the whole cervical canal, or at the os in- ternum, but usually it is at the external orifice. This form of dys- menorrhcea was long ago pointed out in this School of Medicine, and much insisted on by a man of much renown as a teacher of the Practice of Physic, Dr. Macintosh, who proposed a plan of treat- ment for the disease, of which I shall have more to say anon. Then comes the question as to how pain arises in the uterus in cases of dysmenorrhcea. The pains of labour, as I have endeavoured 102 ON DYSMENORRHEA. to proATe to you in the course of my obstetric lectures, are only ex- plicable by the fact that the uterus is thrown at the time into a state of very active contraction. At the period of parturition it is a highly developed muscular organ, and in expelling the foetus it con- tracts with preternatural force, and to a degree corresponding _ to spasmodic contractions in other muscles; and as in them excessive action is attended with cramps or pains, so the strong action of the muscular Avails of the uterus required in the parturient process is at- tended with a correspondingly severe degree of pain. We have an action in the uterus, though less in degree, yet of the same kind, and attended with the same symptoms in all cases where any obstruction is offered to the escape of fluids which have become accumulated in its cavity. In such cases you have occurring what has been called uterine tenesmus, or painful muscular contraction of the womb, of the same nature as those occurring in the bladder when urine accu- mulates to too great an extent, or in the intestinal tube under various circumstances. In relation to the simple form of dysmenorrhcea to which I first referred, I would remark, that the uterine pain in such cases seems only to be explicable by the occurrence of irritation in that organ in a neuralgic subject: and as regards the rheumatic and gouty forms of the disease, there is probably at the time of men- struation a determination to the uterus of the morbid material which excites the specific symptoms in other parts of the body; just as a determination of it might occur to any other part or organ which happened to be in a state of exalted action. But I must again re- peat what I have already told you, that we have as yet no accurate and distinct idea of the cause and source of the pain so bitterly complained of by patients suffering from the various forms of dys- menorrhcea. Diagnosis of the Disease. With respect to the diagnosis of dysmenorrhcea, there is not much that I have to tell you. You will generally be right in setting down a case as one of dysmenorrhcea where you have pain in the lumbar and uterine regions occurring at monthly intervals, accompanied with a bloody discharge from the womb, and relieved when this ceases to flow. But there is one mistake Avhich you would possibly be in danger of making, and against which it is right that I should warn you—the mistake, namely, of supposing that you have to do with a simple case of dysmenorrhcea when a patient is suffering from the pains of an abortion^ You will generally guard against such a mis- take by making full inquiries into the history of the case, and by examining the womb so as to discover whether it be in any degree enlarged. Or the converse mistake in diagnosis may be made. It has twice happened in the history of the old Lying-in Hospital in Park-place here, that maid-servants have been sent in to the Insti- tution by Edinburgh practitioners who imagined that the patients ON DYSMENORRHEA. 103 were in labour, while they were only suffering from the severe pains of an aggravated form of dysmenorrhcea. And it so happened that in both of these instances, actions for damages were raised against the medical men (though they were ultimately suppressed) by pa- tients who believed their moral character to be damaged by the erroneous diagnosis of their medical attendants. I need only al- lude to this subject, to prevent the possibility of your falling into such a grievous error. The Prognosis is usually perfectly favourable, but it necessarily varies according to the form of the disease. Treatment of the Disease. This we may consider under two divisions, according as it is in- tended to be palliative or preventive. 1. Treatment of the Paroxysm.—The first, or palliative treatment, is that which is required at the time of the attack, and you will find that in the severer cases you are driven to the administration of various stimulants, sedatives, and sudorifics, and to the application of sedatives locally. It is a common idea among dysmenorrhoeic pa- tients themselves that they can relieve the pain by drinking large quantities of infusions of sage, pennyroyal, and other vegetables with stimulating principles, and the belief is in a great degree con- firmed by experience. It is only too common a custom with such patients to have recourse to stronger and less innocent stimulants; for many women, when suffering from dysmenorrhcea, make free use of various forms of alcoholic liquor, and usually with decided relief to their sufferings. But you are not called upon to prescribe such remedies in every case, and, except in extreme cases, you will be able to dispense with them altogether. The agent which you will find the most serviceable for relieving the^pain of dysmenorrhcea, and that on which I chiefly rely, is morphia in one or other of its forms. You may begin by administering a strong opiate—for in these cases there seems to be a tolerance of the drug, and the pa- tients bear large doses with impunity. You may give as much as forty drops of laudanum, or a corresponding dose of any other opiate, at first, and repeat the dose, or, perhaps a smaller one, every hour or two hours afterwards till the pain begins to abate. You will do well in many cases to combine the morphia with some strong diffusi- ble stimulant. Thus the addition of a drachm of chloric ether is often an admirable adjuvant to the action of opium; and I might add that you will find a teaspoonful of chloric ether in a wineglass- ful of Avater to be one of the readiest and most efficacious remedies of that class that you can employ. Many use camphor in this way ; and sometimes camphor may be administered alone in large doses 104 ON DYSMENORRHEA. instead of opium in those cases where all forms of the latter disagree with the patient. Stramonium, belladonna, conium, Indian hemp, and many other narcotics have all been used, and have all been found to be more or less efficacious for relieving the pain of dysmen- orrhcea. But in most cases you will find opium the most serviceable remedy. You can often aid its action by exciting the skin, and in this way warm baths, vapour baths, hot drinks, and such like mea- sures come to be of service. Sometimes all these means fail, and you are called upon to administer some anaesthetic by the stomach or the lungs. Chloroform may be given internally in combination with cardamoms—ten or twenty drops of chloroform to the ounce of the compound tincture of cardamoms is a very common and a very useful prescription—but its use is more apt to be attended with headache than when it is inhaled in the form of a vapour. One of the first uses to which chloroform was put after the discovery of its anaesthetic properties, was to relieve the pain in a case of dysmen- orrhcea. The patient was an unmarried lady, and one of those Avho lived in perpetual dread of the recurrence of the catamenia. She lived with her sister in a house in the New Town, and when I first went to administer the chloroform to her, I could hear her groans and cries as I entered the door, although she was lying in a room three stories up. She suffered in fact quite as much pain at those periods as most women do when in labour, and it was no wonder that she looked forward to the monthly return of her agony with horror. I kept her asleep, at that time, for about half an hour with the chlo- roform, and she had no return of the pain during the continuance of that catamenial period. This was owing to my having adminis- tered the chloroform just at the commencement of the period; for, mark you, if you can bring the patient into the anaesthetic condition for only a short time at the very onset of the attack, you may hope to find her remaining free from pain while the discharge continues; whereas, if you delay it till many hours have elapsed, the drug must be used for a longer time, and the relief experienced is never so per- manent. As local sedatives, opium and belladonna have been often used, but with little benefit. Lately it has been proposed to use veratrine applied to the loins to relieve the dorsal pain, and its advantages have been much pressed upon the Profession ; but it possesses little or no claim to confidence. There are only two local anodynes from which I have obtained much good results, and these are carbonic-acid gas and the vapour of chloroform. Dysmenorrhcea was one of the diseases which carbonic-acid gas was first used to relieve. Mojon, of Geneva, wrote a paper some thirteen years ago, in which he showed the efficacy of the gas in relieving the pain of disordered menstruation; and I have often seen it afford instantaneous relief: or the vapour of chloroform may be employed locally, applied in the manner I described to you when speaking of its use in relievincr the pains attendant on carcinoma uteri. It may, as I then told you be TREATMENT OF DYSMENORRHEA. 105 applied alone or in combination with carbonic-acid gas. When the local application of the vapour is sufficient to relieve the pain, it is always the most satisfactory mode of applying it, for then it does not have the sickening effect that sometimes attends its internal administration. Let me only add, in regard to the internal use of opium, that there is one great drawback attendant on it, and that is the horrible sickness which it causes in many patients; and if one of you could only devise some preparation of the drug which would develop its sedative action without producing any nausea, he would confer a mighty boon upon us all—patients and practitioners as well. I have hitherto been speaking merely of palliative measures, such as are to be adopted during the time of the attack ; but when you have used them successfully, you have not yet done all that is ne- cessary for your patient. You must also treat the disease in the intervals between each menstrual period, with a view to prevent its recurrence. Now there are various preventive measures with which you must become acquainted, and which you must learn to apply to each appropriate case ; and these measures must be adopted and carried out perseveringly and from month to month until a cure is effected; for you will find that when you are not making progress you are losing ground, and your unfortunate patient may relapse into a condition as bad or worse than that in which you found her. But I shall reserve the consideration of those measures for our next lecture. LECTURE VIII. TREATMENT OF DYSMENORRHEA. Gentlemen: Towards the close of my last lecture I was speaking to you about the treatment of dysmenorrhcea. The treatment of this disease, I then told you, might be considered under the two heads of the Palliative and Preventive; or, in other words, 1, the treat- ment necessary to palliate and subdue one of the monthly paroxysms of the malady ; and 2, the treatment necessary to cure the disease, and so prevent in future the recurrence of these paroxysms. I. Palliative Treatment. In carrying out the palliative treatment we found that four lead- ing classes of remedies might be used for the alleviation of the suf- ferings attendant upon a dysmenorrhceal paroxysm, viz :— 1. General diffusible stimulants—as chloric ether, spirit of nitrous ether, compound tincture of valerian, camphor, spirits of wine in warm water, &c. 106 treatment of dysmenorrhea. 2. General anodynes or anaesthetics; and particularly opium or morphia in their innumerable forms ; and in exceptional cases, hen- bane, Indian hemp, stramonium, sumbul, chloroform by swallowing or inhalation, &c. 3. General diaphoretics, as antimony and ipecacuanha; when com- bined with these anodynes, the small doses often seem to increase their good effects ; and a general warm bath is occasionally of great use, probably upon the same principle. Let me here add that this auxiliary action of diaphoretics is specially of use when the dysmen- orrhceal paroxysm has produced, or is attended by, heat of skin, rapidity of pulse, or, in short, by indications of febrile reaction. 4. Local anodynes and anaesthetics, as the injection of carbonic acid gas and vapour of chloroform ; the application of belladonna and morphia ointment; warm hip-baths. Before I quit the subject of palliative remedies, permit me to add, that at the close of the last lecture, my friend Dr. Little, who has long practised at Singapore, came and told me that in severe cases of dysmenorrhcea he had frequently succeeded in relieving the pa- tient, by applying chloroform as an anaesthetic vesicant, if I may so term it, in a manner which he had used first of all with success in curing some neuralgic symptoms from which he himself had at one time suffered. His plan is this : a small circular piece of lint, just of sufficient dimensions to be easily contained within a watch-glass, being steeped in chloroform, is placed on either groin, and covered at once with the watch-glass. This had the effect in a feAV minutes of producing a blister, and is usually successful in relieving the pa- tient's sufferings. So much for the measures to be employed for the immediate re- lief of the more urgent symptoms of dysmenorrhcea—an indication of more importance, and one which all of you will very frequently be called upon to fulfil to the utmost of your ability. But however important it may be to be able to combat with success the distress- ing symptoms of dysmenorrhcea, this is after all the least part of your duty to your patient; for however suitably and skilfully you may apply your remedies, and however successfully you may meet the several symptoms, you will never by such means be able to se- cure your patient against the recurrence of her monthly misery ; and you Avill be urgently called upon to adopt some measures for procuring her a more perfect and permanent relief. This leads me, therefore, to speak now of II. Preventive Treatment. The preventive treatment of dysmenorrhcea includes all the reme- dial measures which may be had recourse to during the intervals be- tween the menstrual periods, with a view to the radical cure of the diseased condition which gives rise to the menstrual paroxysms, and as these measures vary with the pathological cause of the disease, treatment of dysmenorrhea. 107 we shall have to consider the treatment appropriate to each variety of it. Let me, however, premise that the same line of treatment will often succeed in curing two quite different forms of dysmenor- rhcea, and, on the other hand, the same form of dysmenorrhcea may sometimes be cured in one patient by some means which will prove ineffectual in another case. Moreover, unless you can succeed in effecting a radical cure for your patient, you will find that you are generally losing ground every month, and that she is getting worse at every succeeding period; and therefore you must be prepared to employ a variety of measures, if need be, in each particular case. 1. Treatment of Ovarian Dysmenorrhoea.—No special organic or structural disease of the ovary has ever, as far as I am aware, been found to be a pathological cause of ovarian dysmenorrhcea. The morbid conditions of the ovary that have been hitherto observed to be connected with the production and persistence of dysmenorrhcea are neuralgia, congestion, and inflammation in their chronic forms. The preventive treatment of dysmenorrhcea when dependent upon ovarian neuralgia, is the same in its principles and details as the preventive treatment of dysmenorrhcea when dependent upon uterine neuralgia: and that I will describe to you immediately. When dysmenorrhcea is kept up by a state of ovarian congestion or inflammation, we must try to reduce these morbid states during the catamenial intervals, by repeated leechings, applied to the cervix uteri, or hemorrhoidal vessels, by assiduous counter-irritation to the groins or sacrum, and by all the usual internal remedies and means employed against local inflammations and congestions of other iso- lated organs of the body. 2. Treatment of Neuralgic Dysmenorrhcea.—Where the disease as- sumes the neuralgic form, put the patient through a course or courses of the alteratives and tonics, particularly the mineral tonics, which are specially serviceable in all other neuralgic diseases. By this means, and by the enforcement of a good diet and regimen, try to raise the standard of her health up to the normal type, or indeed, if possible, above it. By following out such a line of treatment after a painful menstruation, you will sometimes be able to protect your patient from the same degree of suffering at the succeeding term. Set every organ to rights whose function seems in the least degree languid or impaired, whether it be the skin, stomach, bowels, kidney, &c. In this neuralgic form of dysmenorrhcea, regulated muscular exercise, riding on horseback, and analogous hygienic means, in the intervals, are sometimes of the highest moment as curative measures. Rouse and stimulate the mind as well as the body, by new studies and new scenes. In these cases a visit to some alterative or saline mineral waters is, in this double way, sometimes of wonderful use. Afterwards, a course of chalybeate waters or chalybeate pharmaceu- tical preparations, will sometimes establish the cure. Have no fear, for I believe it is a groundless fear, that the use of iron will congest and irritate the uterus. Ferruginous remedies are often our best re- 108 TREATMENT OF DYSMENORRHEA. medies in the latter stages even of distinct uterine congestions. Let me make one remark more before leaving the subject of neuralgic dysmenorrhcea. All forms of dysmenorrhcea, when long continued, are apt to become more or less neuralgic in their^ type^ and some- times remain and persist as such Avhen their more immediate patho- logical states have been removed and cured. Hence it happens that many cases of dysmenorrhcea require to be treated as neuralgic at last which are not neuralgic at first. 3. Treatment of Congestive and Inflammatory Dysmenorrhcea.— When the morbid irritability of the uterus producing recurrent and successive paroxysms of dysmenorrhcea, is the result of chronic con- gestion of the organ, or of chronic inflammation in its cervix or walls, you can only hope for a permanent cure by permanently removing, in the first instance, the congestive or inflammatory morbid states that may be present. What antiphlogistic and other means we pos- sess for fulfilling these indications, I shall have occasion to state to you at full length, when subsequently discussing these special morbid conditions themselves. 4. Treatment of Grouty and Rheumatic Dysmenorrhea.—For the gouty and rheumatic forms of the disease, you will find useful results from the administration of colchicum and guaiacum, either alone, or in combination with alkalies. According to my experience the best prescription you can order in such a case would contain six to ten grains of powder of guaiacum, and six or eight grains of bromide of potassium, with the addition of an equal quantity of magnesia where this seems to be required, to act on the bowels. The use of the bro- mide of potassium, as Trousseau first tried to show, and Sir Charles Locock afterwards found to be confirmed in practice, is that it exerts a sedative action on the sexual organs possessed by no other drug in the Pharmacopoeia; and such a powder as that I have indicated, taken three times a day during the interval between two menstrual periods, will in many cases succeed in warding off any further at- tack of dysmenorrhcea. 5. Treatment of Organic Dysmenorrhcea.—Where the dysmenor- rhcea is dependent on some organic disease of the uterus, the latter will require to be treated without any special regard to the neural- gia which occurs at the time of menstruation. You will only relieve the dysmenorrhcea by removing, when possible, the organic morbid state, as polypus, retroversion, &c. 6. Treatment of Membranous Dysmenorrhcea.—Before I speak of the radical treatment of the membranous form of the disease I have to make one remark in reference to it, supplementary to what I was saying to you yesterday about the pathology of membranous dysmen- orrhcea, and it is this, that investigations are still wanting as to the influence Avhich is exerted by the ovaries in exciting the formation of the membranes discharged in such cases. We do not know whether there exists any special kind of disease or diseased action in the ovaries, or whether on these occasions they become the seat TREATMENT OF DYSMENORRHEA. 109 of any unusual degree of excitement, such as might be indicated by a degree of change in the burst Graafian follicle, so great as to cause it to assume more nearly the character of the corpus luteum occurring on impregnation. As regards the treatment of membran- ous dysmenorrhcea, you will find that various plans of treatment have been recommended according to the view entertained as to the nature of the disease. Thus, by some authors, the remedies appro- priate for the cure .of the rheumatic dysmenorrhcea have been much bepraised, and held to be of special advantage in this form of the affection ; while others, who regarded it as inflammatory, and looked upon the membrane as a fibrinous exudation, held that a cure was only to be sought for by means of antiphlogistics. We have here, in fact, a most notable example of how a change in our ideas as to the pathology of a disease will lead to a corresponding change in our therapeutic procedures. For we now know that the disease is not peculiar to rheumatic subjects, nor produced by any peculiar rheu- matic poison; and further, that it is not of a purely inflammatory character, but that it is due merely to an exaggeration of a normal condition, or to an exalted degree of a physiological action ; and the consequent change brought about in our treatment consists in this, that while we administer bromides and iodides, and other internal remedies which are likely to exert an alterative action on the uterus, we at the same time apply local remedies with a Adew of changing the condition of the organ and modifying its action, so as to lead it to perform its functions in a healthier and more natural manner. I think I have sometimes seen good results in this way from the local application of mercurial preparations—putting the uterus, as it were, through a sort of independent mercurial course. It may very easily be applied by the patient herself, in the form of a medi- cated pessary, introduced twice a day into the vagina and pushed up to the womb. Used in this way, mercury does produce not only a local effect, but also, in some exceptional cases, I have seen it produce its constitutional effects, and lead to salivation. That drugs applied in this form may be absorbed into the system, is evinced also by the narcotic effect sometimes produced by morphia given in the form of pessaries. The constitutional action of the drug is not by any means so marked as when an equal quantity is administered per anum ; but in some very susceptible patients I have seen pessaries containing half a grain of morphia cause contrac- tion of the pupils, and all the effects of a full dose of the drug when taken into the stomach. But whether the mercury produce a gen- eral action or not, I am certain that you will often find much good resulting from its local application, all the more, if at the same time some alterative and tonic constitutional treatment be employed. On this treatment you will find some valuable practical remarks in the excellent work which Dr. Rigby has lately published on the Diseases of Females. In more obstinate cases I have sometimes used with advantage 110 TREATMENT OF DYSMENORRHEA. remedies of an alterative type, applied directly to the lining mem- brane of the uterus. This kind of treatment seems to be more par- ticularly indicated where, after each expulsion of a dysmenorrhceal membrane a sort of leucorrhceal discharge from the interior of the uterus sets in, and continues for a longer or shorter period. It may be likened, on a small scale, to the lochia! discharge occurring after parturition, or after an abortion. In such cases some caustic or al- terative stimulant, such as nitrate of silver, may be applied to the interior of the uterus by means of this instrument resembling the porte-caustique of Lallemand for applying caustics to the orifices of the spermatic ducts in males—only with this difference, that it is curved towards the point in the manner of the uterine sound in or- der to suit the axes of the pelvis, and is furnished at two inches from the end with a small knob to mark the normal length of the uterine cavity. The instrument consists of a long tube curved near the ex- tremity, and provided with a stilette, which is capable of being pushed through the tube to about the extent of an inch—the length to which the tube is retracted being regulated by means of a ring which may be fixed at any point near the handle. In one side of the stilette, in the part Avhich may be protruded, is a groove into which the finely-powdered nitrate of silver is placed. The instru- ment is introduced into the womb with the end of the stilette pro- tected by the tube, and then the tube having been withdrawn to the required extent, the powder is scattered over all the interior of the uterus by turning round the handle of the stilette. By this means you may sometimes produce a salutary effect on the mucous mem- brane ; and other substances, such as pounded iodine, &c, may be used in the same manner. Even perchloride of iron may be em- ployed, but as it is too deliquescent to be kept applied in the form of powder, you will require to apply it in solution, by means of an in- strument essentially of the same construction as that which I have described, only differing from it in having a narrow piece of sponge, about an inch in length, fixed to the end of the stilette for the ab- sorption and application of the liquid. But, mark you, never think or dream of throwing liquids into the interior of the uterus by means of any injecting apparatus, for severe and fatal inflammations are very likely to ensue. Such a result may, perhaps, be caused by the fluid running along one or other patent Fallopian tube and es- caping into the peritoneum ; more probably it may be due to lacera- tion of the mucous membrane and entrance of the fluid into one of the uterine veins; but, however it may be produced, the consequences of injecting fluids into the cavity of the womb are so often danger- ous and deadly that the practice has now been given up, I believe, by all accoucheurs. We can still, however, apply solids with safety in the manner I have told you; and by doing so once, or twice, or thrice, in the intervals between the menstrual periods, you will often succeed in changing the action of the uterus, and in wearing out the TREATMENT OF DYSMENORRHEA. Ill tendency of its mucous membrane to become exfoliated at every menstruation. 7. Treatment of Obstructive Dysmenorrhcea.—Lastly, it remains for me to speak of the radical treatment of the mechanical form of dysmenorrhcea where there exists some obstruction to the escape of the menstrual secretion, or of those cases where the os or cervix uteri are too narrow and contracted to allow of the free discharge of the secreted menstrual fluid. It is a pathological principle in the case of all other hollow organs with orifices or canals of outlet, that when their canals or orifices become strictured or obstructed, accumu- lation of the appropriate fluid takes place within their cavities, that muscular contractions are then excited in their walls for the expul- sion of the accumulated contents, and if these accumulations become common or chronic, the muscular coats of the distended organ are apt to become thickened and hypertrophied. This principle, for ex- ample, we see illustrated in the case of the bladder, when, from stric- ture of the urethra, an obstruction is presented to the free flow of the urine, and the manifest indication for treatment in such a case is the removal of the obstruction. The same pathological principle ap- plies to the uterus in the case of contractions of the os and cervix, and the same principle should guide us in the treatment of it. Dr. Macintosh, a medical teacher of great reputation in this school some twenty-five years ago, thought he was the first to call attention to this particular form of dysmenorrhcea, and proposed to treat it in the same manner as surgeons do strictures of the urethra. But, in passing, allow me to say that the idea that stricture of the os uteri may cause dysmenorrhcea, is far from being so novel as Dr. Macin- tosh believed, for it was known long before that it could not merely give rise to dysmenorrhcea, but that it could also be in some cases a source of sterility. Not only so, but the plan of treatment then re- commended by Dr. Macintosh was forestalled ages before. For, in the works included among the Hippocratic writings, the disease is most distinctly spoken of, and the appropriate treatment described. In the thirteenth section of the Twaixtiuv n^wtov, the treatment of those cases is given where sterility is due to some unusual conditions of the os uteri; and among other things, the writer tells us that where the orifice is very much contracted, it must be opened up with bougies and leaden instruments. So that this plan of treat- ment is at least 2500 years old. Some others among the older Greek and Roman writers on female diseases have also alluded to this form of dysmenorrhea or sterility, and to its treatment by dila- tation of the os uteri, though none so distinctly as the Father of Medicine himself. But there are various surgical works of later date in which mention is made of this matter in the most explicit terms. Thus in the " Marrow of Chirurgery," published in the lat- ter part of the seventeenth century by Mr. Cook, of Warwick, a work containing various curious notices and cases in obstetric, medi- cal, and surgical practice, this author treats in one of his chapters 112 TREATMENT OF DYSMENORRHEA. of closure of the '• inner orifice" of the womb, or os uteri, and re- commends it to be enlarged when necessary by gentian root or pre- pared sponge, and afterwards by the introduction of hollow instru- ments of silver, ivory or horn, and these means, he adds, are better than incision. When I first read these observations by Mr. Cook five or six years ago, it appeared to me that this English provincial practitioner had quite anticipated every modern principle in the treat- ment of these cases. Mr. Cook published another work several years before the "Marrow of Chirurgery" appeared. This second book was published in 1627, and entitled " Select Observations on English Bodies; or Cases both Empiricall and Historical performed on many eminent persons in desperate diseases; first written in Latin by Mr. John Hall, a physician residing at Stratford-on-Avon." This work (and the original Latin manuscript of Mr. Hall, is in the possession of my friend Dr. Jackson, of Edinburgh) does not con- tain among its two hundred cases any notice of any instances of dysmenorrhcea, and is more interesting in other respects than its medical relations. For Dr. John Hall—whose cases Cook trans- lated from Latin into English—was the son-in-law of the immortal Shakspeare, having married Shakspeare's favorite daughter, Susan- nah ; and he inhabited and practised in Shakspeare's " great house" at Stratford after the poet's death. He died several years before his wife ; and Susannah Shakspeare sold her husband's manuscript vol- umes to Mr. Cook. In his preface Cook tells us how cunningly Susannah drove the bargain with him for her husband's manuscript work, all the time denying it was her husband's. But I have no doubt that, though a puritan surgeon, the buyer was as sharp as the saleswoman. At least I am inclined to judge so from the fact that the remarkable passage which exists in his " Marrow of Chirurgery," regarding the treatment of obstructive dysmenorrhcea, is taken by Cook deliberately almost verbatim, without his having tried the practice, and without one hint or word of honest acknowledgment, from a work published some years previously at Amsterdam, by one of the inventors of the obstetric lever. In the Medico-Chirurgical Observations of Henry van Roon- huyse, which were " Englished out of Dutch by a careful hand," in the year 1676, you will find a chapter devoted to the consideration of " The Clausura Uteri'' (p. 107), from which I take the liberty of citing the following paragraph: " Proceeding to the third part of our division of the womb, which is that they call the neck of it— beginning from the inner end of the vagina, and being that space which is from that end of the vagina to the fundus uteri itself—we are to know that this neck is very narrow, and comes to be shut very close, and even so close that a thin stilette will not pass into the bottom of the womb, by which infirmity the womb remains shut, and it is caused by some cold humours, stale seed, or stale menstrua, whereby this neck comes to be swelled together when they are com- pacted upon it. . . . In some women this neck is so hardened, TREATMENT OF DYSMENORRHEA. 113 tapering out, and sunk down, that sometimes I can do them but lit- tle good by emollient and discutient fomentations, nor by anointing remedies; but am forced in that case to enlarge it by means of the radix gentiana, medulla sambuci, or even by a prepared and dried sponge, having been first moistened in melted white wax, and squeezed in a press, to make of it convenient pessaries, according to the exi- gency of the case, by which means the neck of the womb can be disclosed and widened, and made to have its due purgations. Now, being thus widened, there may easily be inserted in the opening an instrument turned of silver, ivory, or horn, in the screw fashion, but having one end somewhat thicker than the other, and the upper end being like a great Clyster-pipe, within turned hollow and pervious, of which I have caused to be made many, and of different fashions, some bigger and thicker than others, so I have them in readiness upon occasion. . . . The patient may, without any inconve- nience, when the said instrument is inserted in the part, carry the same and go about with it, for a constant discharge of the womb. So that it is much better to make use, in this case, of this prepared instrument, whereby it may be constantly entertained, than to hasten the cure by the violence of a knife." Dr. Macintosh was led, by considering that cases of stricture of the urethra are cured by means of dilating instruments, to apply the same treatment for the cure of strictures or contractions of the os uteri; and for this purpose he made use of straight metallic sounds or bougies of different degrees of thickness, such as those I now show you. He began the treatment by introducing very small probe-like rods or sounds into the os, and then gradually always larger and larger ones in succession, till the os was dilated to such an extent as easily to admit a staff of the size of a No. 13 urethra bougie, or even sometimes larger; and in his Practice of Physic he states the results of his treatment in such cases in the following words :— "I have treated twenty cases of dysmenorrhcea by dilating the os uteri, and have permanently cured eighteen of the patients. Of the eighteen successful cases, eight were either young unmarried women, or living in a state of widowhood; ten were married, and living with their husbands. Of these ten, seven subsequently fell with child. This is the statement made in 1832. Since that period I have tried the practice, after every other means had failed, in seven cases ; in one of the seven only has it failed, the others have been completely and permanently cured. Of the six successful cases, four have since had a child each. Thus, in twenty-seven women, twenty-four cures have taken place, and of these eleven have since had children. This plain statement of facts, and a visit to my mu- seum, should stop the sneers of an illiberal brotherhood." It has been argued in relation to this kind of practice, that if the os uteri is open enough to admit of the entrance of a probe, it should admit of the escape of the menstrual fluid as well. But it always seems to me that the degree of dysmenorrhcea, and the amount of 8 114 TREATMENT OF DYSMENORRHEA. suffering depend not so much on the actual degree of contraction in any case, as on the amount of the fluid, or rather on the rapidity with which it is secreted. If the secretion be very rapid from the commencement, or contains solid coagula or lymph, the os, though pervious to a probe, may be too small to allow all the eliminated fluid to escape from the uterine cavity. Consequently the retained secretion will accumulate within the uterine cavity, and the disten- sion produced by this accumulation will lead on to the establishment of expulsive or dysmenorrhceal pains. For where the os is relatively small, Avithout being greatly and morbidly strictured, the pain is not perceived until after the discharge has set in, and even then it is not steady and continuous, but more paroxysmal in character. It may not altogether intermit, but it remits. When, I beg to repeat, the amount of fluid secreted is too great to allow of its easy escape, it becomes accumulated in the cavity, and causes pain by distending and exciting the uterus, till it begins to contract with such force as to expel a quantity of the fluid, and then a temporary relief is ob- tained, Avhich lasts until a reaccumulation of the secretion produces afresh the painful sensations. In this way retention and obstruc- tion may even occur with a comparatively wide os, provided the menstrual fluid be very rapidly secreted, and especially if it be mixed up with solid masses of coagula or fibrin; and, on the other hand, in cases where the uterus gives out only and always a very small and scanty, or rather a very slow secretion, no pain may be experienced, although the os may be of the smallest calibre. Me- chanical dysmenorrhcea may occur, in short, in some cases where the os is nearly of the normal size, and does not of necessity occur where the os is contracted and strictured to the greatest possible degree ; and it very generally happens that when irritation has once been applied to the womb, and the muscular fibres have once been called into action, the contractions go on for hours afterwards, and give rise to painful sensations. I have repeatedly followed out Dr. Macintosh's plan of treatment by means of bougies of daily increasing size, and sometimes with perfect success. But you will find, if you come to try it, that it is an irksome and tedious process, taking up a great deal of your time, and often causing very great pain to the patient. So much suffer- ing do some patients experience from this daily distension and dila- tation of the os and cervix, that they are content to bear their monthly pain rather than submit to the ordeal of such a frequent torture, and therefore I have been led at various times to try dif- ferent methods of attaining the object in view, viz., dilatation of the contracted orifice. I made use for a time, after the first stages of dilatation were effected by bougies, of a fine, hollow, two-bladed instrument, which could readily be passed into the canal of the cer- vix, and could then be dilated by having a bougie of larger size pushed in along its cavity or between its blades. Others have used instruments with two blades, which could be separated by means of TREATMENT OF DYSMENORRHEA. 115 a screw, somewhat resembling the instrument contrived by Mr. Weiss for dilatation of the female urethra for the removal of urinary calculi. Again, as you are aware, some French surgeons have found good results in cases of stricture of the urethra from leaving bougies in the passage for a lengthened period, and this plan of treatment for that disease would, doubtless, have come more into vogue, and have been much more extensively employed, had it not been attended with this one drawback, viz., that the urine required to pass along the sides of the instrument, and was a source of constant annoyance and discomfort to the patient. In the case of stricture of the os and cervix uteri, however, no such drawback could possibly occur, as in the intervals between the catamenial periods nothing but a slight mucous secretion escapes along the cervical canal, and to save my own time, and that of the patient, I had recourse to the use of per- manent bougies or small sounds, which are introduced into the inte- rior of the uterus and left there; and this treatment has been attended, in many cases, with the happiest results, for there is this peculiarity connected with the use of bougies for dilating the cervix uteri, that while the introduction of the instrument sometimes causes pain for a short period at first, and possibly excites some spasmodic action in the muscular fibres, this very soon subsides when the in- strument is left in the canal, and there it may remain days and weeks without causing any further disturbance. For a long time I employed these intra-uterine bougies as the chief or only agents for Fig. 40. Fig. 41. Intra-uterine stem pessaries used for dilatation of the os and cervix uteri. the cure of mechanical dysmenorrhcea, passing in one of a larger size every th ee or four days. The principal disadvantage attend- ant on their use was the length of time required for obtaining a cure 116 TREATMENT OF DYSMENORRHEA. by means of them. That disadvantage may be, however, oA'ercome by effecting the dilatation by sponge-tents, which will expand the The point of the staff used in the introduction of intra-uterine pessaries. os and cervical canal in twenty or thirty hours. But I very fre- quently found that when the dilatation was effected mechanically, and whether slowly by sounds, or rapidly by sponge-tents, relapse of the stricture or contraction was very apt to occur after a time; just as so often happens after the treatment of bad stricture of the male urethra by merely dilating instruments. For some years past I have thought that the best and speediest mode of cure is to have recourse at once to dilatation of the os by incising it at both sides. In order to understand the mechanism of this operation, just consider for a moment what is the object which you wish to attain by your treatment. A married patient applies to you for the cure of ob- structiAre dysmenorrhcea and its usual accompaniment, sterility. Now, knowing that the one condition as well as the other is com- paratively rare in the case of women who have once borne children, what you want to effect is to bring a uterus that has never contained an impregnated ovum as nearly as possible into the condition of one that has. The occurrence of pregnancy once seems to bring the uterus into a condition favourable for its recurrence, although this may not be evident in ordinary cases where pregnancy goes on to the full term, and ends in the parturition of a living child, for then lactation comes in with its counteracting tendencies. But you can satisfy yourselves of the truth of the remark as a general principle, to which there are doubtless many exceptions, by making the neces- sary observation in the case of mothers Avho do not nurse, and some of whom in consequence bear a child almost annually; and also in the case of women who are frequently aborting, for in them you will find that so soon as the immediate local and general effects of the abortion have passed away, impregnation very often occurs again immediately; whereas in the first instance it may not have supervened for some months or more after marriage. And the only appreciable difference in the state of the uterus in such a patient at the time of marriage and after parturition, or after a miscarriage, is, that at the latter period the os and cervix uteri sketch of the virgin os uteri. are less contracted. A patulous condition TREATMENT OF DYSMENORRHEA. 117 Sketch of the os uteri of a woman who has home children. of these parts seems to admit of the more ready entrance of the spermatic fluid, and so to favour impregnation. Now, then, how can we best bring the uterus of a female who has never borne children into a condition resembling the uterus of one who has aborted or borne living children ? If you look at the os tincae of a once gravid uterus, such as I now shoAV you, you will perceive it to be of an elongated oval form, the long axis of the opening being directed Flg' 44, from side to side, while the ori- fice of a virgin uterus, such as this, is much smaller and more nearly circular. The os of the former kind of uterus is not only wider than that of the latter, but its form is different; and while by means of bougies or sponge- tents you may render the open- ing of the virgin uterus for a time sufficiently patent, you cannot by such means impart to it that lon- gitudinal form which seems to counteract its tendency again to contract on removal of the di- lating force. But all this you can effect at once, rapidly and cer- tainly, by making incisions of sufficient depth into both sides of the cervix uteri. To make such incisions, you require to introduce this instrument or metrotome as far as the os in- ternum, where the incision begins—at first quite shallow, and then make it deeper as the instrument is withdrawn, till at the os externum the cervix is cut across in all its thickness. An incision of this nature into both sides of the cervix makes its canal Avide and pyramidal in form, so as easily to admit the finger; and in healing leaves the orifice more like that of a uterus from which an im- pregnated ovum has been expelled. The first patient on whom I performed this operation, in 1843, was a lady of high rank, who had been married for several years, without hav- ing had a family, and who used to suffer at each menstrual period from most excruci- ating pains. She had heard about the dila- tation, and had got up the whole subject—> anatomy and all—and came to Edinburgh with the view of obtaining relief by that means. I explained to her that the process would occupy a considerable period—two Fig. 45. Section of the uterus. The dark triangular portion on either side between A and B is intended to show the extent to which the in" cision should he made for the relief of obstructive dysmenor- rhea. It ought, however, to have been carried more closely to the reflection of the roof of the vagina on both sides. 118 TREATMENT OF DYSMENORRHEA. Fig. 46. I months or more, when she at once said that the time was too long, and that unless she could be cured by some speedier method she would not submit to be treated at all. I then told her that I had often thought of dividing the cervix in such cases, and that though I had never yet put it in practice, I believed it would be both a speedy and a most effectual means of procuring relief. She readily comprehended what was meant, and seeing the feasibility of the proposal, at once said that I must perform the operation on her as the first patient. I made the incisions as I have told you, but with a very imperfect instrument, and the patient soon was perfectly well, and about four months afterwards I heard that she had become pregnant. I was afraid that the cicatrix might present some ob- struction to parturition, and so was Sir Charles Locock, who was to attend her in her confinement in London. I was waiting very anx- iously to know what effect the operation might have had on the labour, when a letter from Sir Charles relieved me from my anxie- ties, for he told me that the labour had not only gone on quite favourably, but had even been re- markably easy for a first confinement. Since that period I have performed the operation in a very great number of cases. Last week, for ex- ample, I had recourse to it in not fewer than five cases. In fact it has come with me to be the usual mode of treatment for all cases of dysme- norrhcea depending on contraction of the os or cervix uteri. How are the incisions to be made ? The in- strument which I use for the purpose is a sort of concealed bistoury, such as I now show you. The patient being placed on her left side, the point of the instrument is passed up to the os internum, and when there is a stricture at that point— which, however, is rarely the case—a slight notch is to be made there on either side. This, I say, you will rarely find it necessary to do; what you most commonly require, is to incise and open up the canal of the cervix and the external orifice. To do this you must introduce the in- strument nearly to the internal os, and then, as you withdraw the instrument, press out the blade and cut through the cervix on one side in such a way that at first only the internal fibres are di- vided, and the incision, as it becomes lower, be- comes also always deeper till the point emerges somewhat below, where the mucous membrane of the vagina becomes reflected on the cervix, and below this point the portio vaginalis uteri is di- vided in all its thickness. You then turn round The hysterotome or metrotome. To allow of the protrusion of the blade a to the desired ex- tent, the rod 6 in the han- dle must be screwed out to the proper distance. CLOSURES AND CONTRACTIONS OF THE VAGINA. 119 the instrument, and make a similar incision on the other side. When you have thus divided either side you will feel that a conical open- ing has been left, the base of which includes all the thickness of the portio vaginalis uteri. The canal may contract to some degree afterwards when the wounds heal, and to prevent this I have some- times made use of sponge-tents or intra-uterine bougies. But the introduction of these instruments in such cases causes pain and irri- tation of the raw lips of the wound; and you will find that by open- ing up the wound every two or three days for a time with the finger, you can effectually prevent all union by the first intention, and in this way provide against the chances of a recurrence of the stric- ture ; or you may touch the corners of the wound with a piece of nitrate of silver with a like good result. Hemorrhage may some- times follow division of the cervix, more particularly if you cut too deeply in the upper portion of it, where you run the risk by so doing of wounding some of the veins of the plexus uterinus, and it ought always to be guarded against by plugging the vagina immediately after the operation with some pieces of sponge. In some few in- stances the hemorrhage is pretty smart, but I have never seen it occur to any very alarming extent. Inflammation may sometimes be set up and spread to the surrounding loose cellular tissue; and though this rarely goes on to any dangerous extent, yet you may expect sometimes to meet it, and you must always be prepared to treat it, and treat it according to the principles which I shall have to explain hereafter when I come to speak of pelvic cellulitis in gene- ral. Attended with such rare and slight risks, the operation is a very safe one, and there is only this further to be observed in con- nection with it, that unless all the fibres are fully divided, there is sometimes a chance of the wound healing too rapidly, and the stric- ture being reproduced. But altogether, I believe I am entitled to say that there are few operations in surgery so perfectly simple in their performance, and so entirely satisfactory in their results, as division of the cervix uteri in cases of obstructive dysmenorrhcea and sterility. LECTURE IX. ON CLOSURES AND CONTRACTIONS OF THE VAGINA, ETC. Gentlemen : In the last of my Clinical Lectures I was speaking to you of dysmenorrhcea and the treatment of it, and more particu- larly of that form of the disease which is produced by a contraction or stricture of the canal of the cervix, or of the os uteri, offering a partial obstruction to the free escape of the secreted catamenial fluid. It sometimes happens that the catamenial discharge is im- 120 CLOSURES AND CONTRACTIONS OF THE VAGINA. peded, or, indeed, arrested by such a contracted state of the os uteri, or more frequently of the vagina, as amounts not to mere stricture, but to actual obliteration or closure of the maternal canals. In cases of this kind, there is not merely dysmenorrhcea—you have amenorrhoea in addition. I allude to this subject on account of the circumstance that we have at present in the hospital a case of this kind, where retention of the menses has occurred in consequence of morbid con- traction and closure of the vagina, and probably of the os uteri also. The account of the case, as it stands in the hospital records, is as follows:— " I. A., aged 21; admitted January 3d. Usually very healthy, until her confinement with her first child, eighteen months since. She then gave birth to a male child after a protracted labour, attended with great suffering, and lasting for two nights and one day. Living at the time in the country, she was attended during the labour by some female friends only, the medical practitioner of the district being from home at the time, and not able to see her until five hours after the birth of the child, Avhen he removed the placenta, which had been retained in utero until his arrival. The removal of the placenta was attended with much pain. She states that she suffered from ' inflammation' for some time after delivery, but does not re- member having had any purulent discharge from the vagina. It was six weeks before she left her bed, and four months before she was quite convalescent. " Previously to her pregnancy and delivery, she had menstruated at somewhat irregular periods, the catamenia being occasionally absent for two months together, but never exceeding that interval. Since her confinement she has never once menstruated, but at first suffered considerable pain at the usual monthly periods, although the catamenia did not appear externally. This pain she describes as of a lancinating character, accompanied by ' bearing-down feel- ings,' and the presence of a defined tumour in the loAver part of the abdomen. This tumour disappeared partially after a variable time, being tender on pressure, especially on the left side. She has been under medical treatment at different times, blisters and counter-irri- tation to the surface of the abdomen having been tried, but without success. No local remedial measures have hitherto been adopted. " On examination, a roundish tumour can be felt in the supra- pubic region, extending as high up as three inches above the pubes; somewhat tender on pressure, and with its fundus leaning to the left side. "About an inch above the orifice of the vagina, that canal is felt suddenly contracting. The contraction is so great as only to leave an orifice large enough to admit the tip of the little finger. Above this orifice a canal runs upward for an inch or more, as ascertained by the passage of a probe or sound. On January 4th, this contracted orifice was begun to be dilated by the introduction of a sponge-tent. A tent of a larger size was introduced on the 5th. CLOSURES AND CONTRACTIONS OF THE VAGINA. 121 " On the 6th, the first contraction was found completely dilated by the tent, and the finger could now be readily passed into the upper portion of the vagina, to the extent of two inches, when a second and closer constriction was discovered. " On January 7th, the patient was put under the influence of chloroform, and Professor Simpson, upon examination, found that the narrowing was not so much of the nature of a stricture as an adhesion of the walls of the remaining upper part of the vagina. This adhesion was easily broken down by the finger; but the os and cervix could not be completely exposed, owing apparently to the presence of a septum still intervening. The os and cervix appear to be much inclined to the left side. There was slight hemorrhage after this breaking down of the adhesions between the vaginal walls." I would only add further, in regard to this case, that the patient looks healthy and strong, and that the difficulty in making out the state of matters in the generative organs was increased by the cir- cumstance that the uterus is partially displaced, the os being bent down to the left side and fixed there. A slight degree of febrile action supervened on separation with the finger of the vaginal ad- hesions. This irritation we must allow fairly to subside before we take any further steps for our patient's relief. When she is quite recovered, we shall proceed -to divide the intervening septum of which you have heard, and try to afford an exit to the accumulated catamenial fluid. I. Causes of Occlusion and Stricture of the Vagina. 1. Contraction and Closure of the Vagina as a Result of Difficult Parturition.—In relation to occlusion of the uterine or vaginal pas- sages causing retention of the menstrual fluid, let me state that, when this occurs as a consequence of parturition, it is usually due to inflammation excited during the process by the long-continued pressure of the child's head on the maternal soft parts, and which ends in sloughing and adhesion of opposing raw surfaces. Such destructive gangrenous inflammation in the maternal passages is more frequently owing to the want of operative interference than to the improper use of instruments; for, in most of the cases where this accident has happened, it might have been avoided by applying instruments to hasten the labour, and by relieving the parts more early from the fatal continued pressure to which they are subjected. Pressure, hoAvever slight in degree, when applied continuously for a lengthened period to any part, has a much more prejudicial effect upon the life of the structures, than a degree of pressure, however strong, which is only applied during a short space of time. In treat- ing of this point in connection with parturition, my friend, Dr. Beatty, refers to a fact which is very impressive and instructive, viz., that when a malingerer in the army wishes to produce on his leg, or on some part of his body, a sore which shall cause him to be invalided, 122 closures and contractions of the vagina. he knows that it is not necessary to inflict on himself any great and severe blow to produce the ulcer, but he simply straps down a coin on the chosen spot with a slight degree of pressure, and lets it there remain till such time as the vitality of the tissues pressed upon has been destroyed and the part is ready to slough away, the pathological fact being, I repeat, that slight pressure long continued is more apt to produce gangrene and mortification of a part than an infinitely higher degree of pressure applied for a shorter period. Moreover, when inflammation and sloughing are produced in the vagina, there is, in the process of healing, thrown out at the seat of these changes a new sort of so-called " cicatricial'' tissue, which in- duces in the part a very strong disposition to contract in healing. It is the same sort of change which you see occurring in cases of burns on the neck, for example, and the consequences are of the same nature; for, as in the neck, obstinate contractions and almost irremediable deformities occur, so here you have contractions occur- ring, and deformities and displacements produced by the gradual contractions of the new cicatricial tissue, which it is a matter of the greatest difficulty to reform and remedy. In our case in the hospital contraction to a great degree has occurred at the lower site of the vaginal stricture, and there Avas adhesion between opposed surfaces at some points situated higher up in the canal. Allow me here merely to add, in passing, that the vaginal contrac- tions which follow difficult labour are not, by any means, always of course so great as to produce, as in our present patient, entire closure of the canal, and consequent amenorrhoea and dysmenorrhcea. Much more frequently they are less in degree, and cause, in the vagina, only partial contractions and strictures of very various and irregular forms. 2. Closure and Contraction of the Vagina as a Result of Inflamma- tion, and independently of Pregnancy.—But you may meet with cases of closure of the genital passages of the female which have come on as a result of inflammation, occurring quite independently of labour. Thus you may see inflammation of the vagina, and then usually in its lowest point, in young children, ending in contraction or closure of the canal; and when the patient arrives at puberty, menstruation is interfered with, and there may even be complete obstruction to the catamenial flow. That such cases should ever and anon occur need not be to any of you a matter of surprise, for you have here the constant irritation of urine, which is frequently acrid in its nature, tending to excite and inflame the parts; and, in very young children, a leucorrhoeal discharge and a degree of chronic inflammation in the lower end of the vagina are phenomena of very frequent observa- tion. But it is not in such cases as these, where want of cleanliness is the chief cause of the morbid condition, that the inflammatory contractions which we are considering are very apt to occur. They take place, I believe, more frequently under quite different circum- stances, viz., where, under a specific type of inflammation, there closures and contractions of the vagina. 123 seems to be a special tendency in the part to the development of some uniting material, and an almost insuperable tendency to adhe- sion between opposing excoriated surfaces. This tendency to the union or adhesion is not unfrequently seen in young children at the very orifice of the vagina, and is limited to that point and to the portion of mucous membrane more immediately external to it, Avith- out its stretching upwards along the canal of the vagina. I saw two instances of this kind of closure of the vulva, last year, in the cases of children who were well nursed and attended to, and where there was no want of cleanliness whatever; yet in both this tendency to adhesion of the sides of the vulvar orifice of the vagina was very marked; and when the adhesions were broken down, and the lips of the orifice separated, they always speedily showed an inclination to reunite. There was here in fact a type of inflammation of the vagina of which no description has yet been attempted to be given, attended with no formation of pus, and tending merely but inveterately to the formation of adhesions. In such cases separation of the opposing surfaces is not enough to effect a permanent cure of the morbid con- dition. You may tear up the adhesions with a probe, or Avith the head of a pin, or by stretching the lips with the fingers; but the sides of the canal will again cohere, unless the nurse be taught care- fully to introduce some lint steeped in oil or glycerine every day, to prevent the separated surfaces from coming into constant contact. In such cases the adhesion comes on usually without any very marked symptoms. Perhaps in consequence of pain in micturition or other reasons the nurse examines the parts, and is alarmed by noticing the obliteration of the vaginal orifice. On a proper inspection you will find the os vaginae (as in some cases of congenital closure of the same orifice) closed up by a thin grayish membrane, which is non- vascular ; and when this is torn across no hemorrhage ensues. You may meet likewise among adults with cases of a kind of adhesive or obliterative vaginitis of an analogous type. But the disease in adults differs from the disease in infants in one or two important respects. In infants this inflammatory closure is usually limited to the very orifice of the vagina, and produces complete occlusion of the canal. In adults it generally commences at the upper part of the vagina, and spreads gradually downward, and seldom causes complete closure. In infants there is commonly cohesion merely of the opposed sides of the orifice of the vagina, without any tendency to circular contraction in the calibre or cir- cumference of the orifice. In adults, on the contrary, the state of inflammatory cohesion and obliteration is almost always attended with a simultaneous tendency to circumferential contraction of the canal at the site of the disease, so that when it is limited, as it often is, to the top of the vagina, the os uteri is felt drawn up, as it were, to the apex of a narrow conical or funnel-shaped cavity. I have met, hoAvever, Avith obliterative or adhesive vaginitis without the coexistence of this circular contraction. For example, I saw some 121 closures and contractions of the vagina. years ago a remarkable instance of this form of malady along with Dr. Dickson, in the person of an adult unmarried lady, who was suffering from retention of the menses, and in whom I found the vagina completely occluded. The occlusion here was due to cohesion of the opposite walls of the canal, Avhich had become glued together in consequence, apparently, of chronic inflammation—not very firmly, but just so that they could be easily separated by the finger, and very much resembling to the touch that degree of adhesion Avhich you often find between the contiguous serous surfaces when making a post-mortem examination of patients who have died of subacute peritonitis or pleuritis. Then there is this peculiarity sometimes noticeable in such cases as these, that the adhesion does not appa- rently become in any marked degree strengthened by being left undisturbed during a lengthened period; for even Avhere it has existed, or appears to have existed for months at least, and perhaps years, pressure with the finger still suffices to overcome it. Nor does frequency of separation seem to affect much the degree of firmness of these adhesions. You may separate adhesions such as I haAre been speaking of, several times at intervals of months, and the adhesions which are reproduced after rupture of the pre-existing ones never seem to be in any degree firmer than those which were originally present. I can only compare the obstinate tendency to recur manifested by these adhesions and contractions in the vagina, to the obstinacy of recurrence seen in cases of flexion of the fingers, produced by morbid contraction of the palmar fascia, after the em- ployment of operative measures for its relief; and it may be that the cause of both forms of affection is the same in kind. There is evidently a tendency in some rare cases to the occurrence of oblite- rative inflammation of the uterine canal itself; for in the instances I refer to you may open up the canal repeatedly with the uterine sound, and yet they will occasionally come back to you with perfect amenorrhoea, and when you pass again the sound along the canal you will have the sensation imparted to you of the instrument sepa- rating the adherent surfaces, just as you can feel the adhesions of the vagina separating under the pressure of the finger. In such cases the inflammatory process seems to have the result of causing the epithelial lining to scale off, and thus permitting the sub-epithe- lial tissues of opposing surfaces to come into contact and to cohere. In the feAv cases in which I have noticed this morbid state, the patients were all, or almost all, the subjects of amenorrhoea from an unde- veloped or undersized uterus—a complication to which I will direct your attention on a subsequent occasion. 3. Closures and Contractions of the Vagina from Congenital Mal- formation.—We have thus seen that occlusion of the vagina may result, first, from inflammation supervening on parturition, and, secondly, from inflammation, or, at least, from morbid cohesions, occurring independently of that process. But there is a third class of cases rarer, certainly, in their occurrence, than the two I have closures and contractions of the vagina. 125 been telling you of, but of which instances will occasionally present themselves to you in practice, where the obliteration of this canal is not inflammatory in its origin, but is due to some congenital mal- formation. Sometimes the orifice of the vagina is completely occluded, or nearly so, in consequence of the hymen being developed to an un- usual degree and of unusual thickness, so as to render the vagina imperforate, or to leave an orifice too small to admit of the fulfilment of its functions. If you study the homologies between the male and female organs of generation, you will find, I think, that the hymen is in the female a representatiA'e or analogue of the fully closed perineum of the male; and its excessive development in the class of cases I allude to, leading to occlusion of the vaginal canal, and, when complete, to retention of the menstrual secretion, only indicates a tendency in the female to that more complete closure of the peri- neum which occurs as the normal type of development in the male. Congenital occlusion may occur not only at the introitus vaginoe, but may be seated higher up, just as Ave find in the case of congenital obliteration of the bowel, where the seat of closure is usually at the lower end, but is sometimes found in different points of its course. When situated high up in the vaginal canal, congenital closures of it are not generally local and limited to one point. Generally, the occlusion is complete from the point you touch with your finger in examination up to the os uteri. Often, indeed, in these cases Avhere the vagina ends an inch or two above its os, in a cul-de-sac, the uterus itself is imperfectly developed and rudimentary, or, it may be, altogether absent; so that if you could with the scalpel restore the higher part of the vagina, it would be attended with no practical benefit. Usually, however, when the vagina is completely occluded and closed for any considerable length of its course by congenital malformation, the walls of the rectum behind and of the urethra or bladder in front are so intimately blended and united, and the amount of tissue existing between them is so slight, as to render any operative attempts at restoring or extending the vaginal canal both futile and dangerous. I have seen this kind of operation re- peatedly and cautiously tried, but never with complete and perma- nent success. What are the phenomena resulting from this state of affairs ? What forms of distress and suffering do these contractions and occlusions of the genital canals entail on the patient, so as to render their investigation a matter of practical moment to us ? What, in short, are II. The Symptoms and Diagnosis? You will have often patients of eighteen or twenty, or older, con- sulting you, who suppose themselves to be the subject of obstructive amenorrhoea, complaining that the catamenial discharge has never appeared. In these cases, the patient herself is not unfrequently 126 closures and contractions of the vagina. conscious of peculiar sensations and uneasiness in the loins or pelvis, and sometimes of a state of general malaise, at particular and irre- gular monthly periods, which seem referable only to a menstrual molimen. In forty-nine out of fifty cases, it will turn out to be only an instance of retarded menstruation, but in the fiftieth there is present some mechanical cause. There may be obliteration at the vulva, or os vaginse, either congenital or acquired, or it may be higher up in the vaginal canal, or the uterus may be imperfectly developed and small, though open ; or, far more rarely, the os may be closed, and the organ rudimentary or absent. Again, it may be that after a parturition the patient does not again begin to menstruate as before, not even when the period of lactation has been brought to a close; but a tumour begins to be perceptible above the pubis, gradually en- larging month by month, and leading the patient, perhaps, to imagine that she has again become pregnant. In one patient which I saw along with Dr. Keiller, the patient had come to delude herself with this idea. She had had a long and tedious confinement, which led to inflammation and sloughing in the vagina, where contraction and adhesion between the opposite surfaces, and, finally, complete occlu- sion of the canal ensued. Every month she had a feeling as if she should be unwell, but no bloody discharge appeared externally. It was, nevertheless, secreted on these occasions; but, instead of being allowed to escape, it became pent up and accumulated within the cavity of the uterus, which gradually filled and got distended and dilated to such a degree as to form in the end a hypogastric tumour, smooth on the surface and of considerable size. On examination, per vaginam, all that could be felt by the finger was the upper end of the canal, perfectly obliterated, and preventing all possibility of feeling the os uteri. How can you make sure, in such a case as that of which I have been speaking, that the enlargement of the uterus is due to an accumulation of the retained menstrual fluid? You can only argue it out rationally in some such way as this: The patient has had no catamenial discharge appearing externally for some months, although formerly she menstruated quite regularly. Then there is, perhaps, the further history of a tedious labour, producing symptoms of inflammation and sloughing in the vagina, or of inflam- mation having occurred there from other causes. The patient, more- over, has a feeling of distension referred to the womb; and a tumour slowly and gradually enlarging is felt rising above the pubes, and imparts, it may be, a very indistinct feeling of fluctuation. The fluctuation may be more distinctly felt by the finger introduced into the vagina, or more distinctly still on passing it along the rectum past the point where the vagina is occluded. In most cases Avhere you have to do with fluid fluctuating collections in the pelvis, the diagnosis can be facilitated, and the nature of the case clearly made out, by introducing an exploring needle into the part, and drawing off some of the fluid. But in such cases as we are now considering, this instrument affords us no assistance, for the fluid is then too thick closures and contractions of the vagina. 127 and glutinous to allow of its flowing through such a slender tube. In the case of Dr. Keiller's patient, of whom I have told you, I introduced a common-sized trocar and canula, such as are used for tapping hydroceles, with the view of emptying the uterine sac, but no fluid would come. The fluid is very viscid and glutinous, dark and tarry, and does not flow out except through an opening of con- siderable size. By due physical examination with the finger and sound in the vagina and rectum, you can make out much, or, it may be, everything, with regard to the anatomical site, extent, and cha- racter of the contractions and closures that exist, the condition of the uterus, etc. In reference to the effect of complete closure of the vagina or os uteri upon the phenomena of menstruation, let me make in conclu- sion these remarks : 1. Usually under this condition of matters, and when at the same time the uterus and ovaries are fully developed, there is a gradual accumulation of menstrual fluid above the site of occlusion, which increases with recurring dysmenorrhceal pains from month to month. But there are exceptions to this general law; for, 2. It happens sometimes, as in our patient in the hospital, that the accompanying dysmenorrhceal pains and symptoms disappear for a time, although the accumulation goes on increasing, as shown by the increasing size of the distended uterus. And again, 3. Occasion- ally there is no increasing accumulation of menstrual fluid in the uterus after many months, although the closure remains complete: or, indeed, there may be no accumulation at all. I have seen in practice tAvo or three well-marked instances of this last exceptional form of case. The first instance in which my attention was specially called to it occurred many years ago now, in a patient Avho had been the subject of extensive sloughing of the upper part of the vagina after delivery. A vesico-vaginal fistula had followed. A surgeon had applied the actual cautery repeatedly to the edges of the fistula: and, in consequence, the os uteri became closed and menstruation ceased. During the last years of her life, this patient repeatedly applied to me to reopen the os uteri with a small steel sound, when menstruation ceased for some consecutive months. This treatment regularly relieved her, and menstruation always regularly recurred for some time after it; but on no occasion did I find an accumulation of menstrual fluid in the uterus when I reopened the occluded os. III. Treatment of Closure of Vagina, etc., when producing Obstructive Amenorrhea. If you meet with a case of amenorrhoea combined with dysmen- orrhcea in a patient who has got a tumour in the region of the ute- rus, which increases in size every month, and is evidently due to an accumulation of fluid in the uterine cavity, and if in this patient an occlusion of the vagina prevents you from reaching the cervix uteri, it will be your duty in such a case to give a vent to the pent-up fluid. 128 closures and contractions of the vagina. An incision or perforation of some sort must be made through the intervening septum, so as to open up the closed canal and allow of the escape of the accumulated secretion. As to the propriety of such a procedure, nay—even as to the urgency of it—there cannot be a doubt. But there is one thing I have to warn you against in connection with it, viz., that the operation is by no means free from danger. When a young female is brought to you with the Avomb or vagina distended by long-retained menstrual secretion, and even only a thin septum intervenes between your exploring finger and the retained fluid, beware of making light of such a case to the friends, and beware, above all, of telling them that the operation you are about to undertake is either harmless or trivial. For when the case has seemed of the simplest kind, and has appeared as if it would easily be remedied by a slight incision, it has often happened that the patient has been thrown into great danger from the operation; and in not a few instances the result has proved fatal. The risk becomes very much greater when the seat of closure or obstruction is high up in the vagina, for there the mere division of these organic contractions is sometimes in itself dangerous, even without the addi- tional peril derived from the chance of inflammation in the cavity and walls of the distended uterus. Dr. Ramsbotham has collated several cases where this very simple operation terminated fatally; and numerous similar cases are on record. We had a lamentable instance of this in the Hospital three or four years ago, in the case of an interesting patient of 22 or 23 years of age, who had always suffered from amenorrhoea and dysmenorrhcea, which we found to be due to occlusion of the vagina from adhesion, producing a septum of no great thickness. Accumulation was still going on, and the divi- sion of the thin septum was clearly indicated. This was effected by making a small incision, and the patient remained well for two days; great quantities of the usual dark grumous fluid constantly escaping by the vagina. But on the third day surgical fever set in, and in a few days death supervened. The autopsy showed that the interior of the distended uterus had become the seat of a very intense in- flammation, which had spread thence and led to a severe and fatal peritonitis. The important lesson which is very impressively taught us by this case, is that we should be extremely cautious in giving our prognosis as to the result of similar operations. In making the division of the obstructing membrane or tissue in these cases of obstructive amenorrhoea, you may employ either the trocar or knife. The trocar does not always make an opening large enough to allow the retained thick and glutinous fluid to escape by it, and never one of such dimensions as is permanently requisite if the closure is high up in the vagina. You will perform the operation more easily and completely by employing a small tenotomy knife. The patient may be placed either upon her back or side; and if the closure is above the orifice of the vagina, you must guide the knife entirely by touch, and not by sight. Feel, carefully, with the fore-finger of the right closures and contractions of the vagina. 129 hand for the point where, from any sensation of fluctuation or other causes you judge it best to make the centre of the proposed opening, and hold the finger there; then slip the tenotomy knife, held in the left hand, up along the fore-finger of the right hand, used as a guide; bring its tip in contact with the point you wish to perforate ; and, after pushing it through the intervening septum, move it slightly first to one side and then the other, so as to make an opening through which you can force the finger. Increase subsequently the size of the opening to the dimensions which you wish, by stretching it with the finger or fingers, rather than by any further use of a cutting in- strument. After the incision has been made, two or three courses may be followed with reference to the evacuation of the accumulated fluid. You may press slightly upon the uterus so as to hasten the expul- sion of the contents; or you may leave it to the uterus to expel the matter by its own elasticity or by its own more gradual contractile efforts ; and perhaps this is the safest and wisest course that in most cases you can follow. Others again try to evacuate and clean out the interior of the womb as rapidly as possible by throwing up in- jections of tepid water, with the very commendable object of getting. rid at once of a fluid prone to decomposition, and liable to become a source of putrid infection to the tissues with which it lies in contact;. but in practice you will really find profuse injections of very little use in displacing and washing out the tar-like fluid forming catame- nial accumulations. If the opening which you have made is at the orifice of the vagina, and the obstruction has been produced by imperforation of the hymen, or closure of the os vaginas, you will have little or no subse- quent difficulty in preventing the reclosure of the perforation. The introduction of the finger, once a day; or, at most, the maintenance of an oiled plug of lint or sponge in the opening, will suffice for the purpose. But if the closure of the vagina has been the result of deposits and contractions following inflammation and sloughing, you will find it, on the contrary, one of the most difficult indications in obstetric surgery to prevent the re-contraction of the canal; though, by the occasional use of bougies, and tents, if necessary, you will generally succeed in preventing its total and complete reclosure, and the consequent repetition of a state of retention and accumulation of the menstrual fluid. In these cases the measures which we may employ to prevent the recontraction of the canal may be stated. under the head of Treatment of Morbid Contractions of the Vagina from Cicatrices. Where the contraction is partial, and consequently does not give rise to amenorrhoea from catamenial retention, you will only require to interfere under the following circumstances—namely, 1. When 9 130 CLOSURES AND CONTRACTIONS OF THE VAGINA. the stricture is so great, and situated so low down as to interfere with and prevent marital intercourse; and, 2. When, by its pre- sence, at the time of parturition, the progress of the labour is inter- fered with. In the latter case, if the contractions are such as ^ to prevent the descent of the child's head, you will require to divide the cicatricial tissues, in order to gain adequate space for the passage of the infant. If ever you are compelled to do so, remember the two or three following simple rules. 1. Apply your knife or bistoury to the contractions or cicatrices during a parturient pain, for then the morbid parts are placed fully upon their stretch. 2. Make rather two, three, or more small incisions than one large cut; for the single subsequent tearing and extension of the latter is more dangerous than the multiple tearing and extension of the former. 3. Make your incisions in the sides of the vagina if possible, and not on its anterior or posterior walls, lest they extend into the rec- tum or urinary passages. 4. Allow always the full extension and enlargement of the contractions to be made in the way of pressure by the child's head, and not by your knife ; these tissues, in fact, being far more safely torn than cut. Lastly, let me add, that in most such cases, however extreme, it is possible by due preparatory incisions and tearings to deliver the child by the long forceps, or by turning, and consequently alive ; and that such vaginal contractions form no justifiable excuse for the dreadful alternative of destroying the child, and delivering it by craniotomy. In cases of severe cicatrices and contractions situated in the course of the vaginal canal, and rendering connubial intercourse painful or impossible, you may try to overcome the difficulty either by the knife or by distension of the contracted part with sponge tents and bougies, or by both means combined ; and indeed both will often enough fail. In the slighter forms, trust for a time to the employment of tents in the first instance, and subsequently to the persevering use of bougies of increasing size made of caoutchouc, gutta-percha, wood, etc., introduced for a short time every day or every few days; or each worn, when properly fitted, for several days successively, on the principle of solid pessaries. You will ren- der the use of these bougies and pessaries both more easy and more effectual by always introducing into the vagina before them, or along with them, abundance of olive oil, and simple or medicated oint- ments. If the contractions are greater, or Avill not thus yield, first divide them sufficiently, and immediately dilate freely the part by stretching with the fingers. Then try to keep up an adequate de- gree of dilatation by bougies or pessaries worn continuously for a time, or very perseveringly used at short and frequent intervals. The tendency, however, to the recurrence of the contraction is sometimes so great as to defy both of these measures, even when the dilatation following the division of the stricture has been most thorough and complete. There Avas a patient in the Hospital, some years ago, in whom pregnancy occurred although a contraction of CLOSURES AND CONTRACTIONS OF THE VAGINA. 131 the vagina existed; and when labour came on, and drew on to a dangerously protracted length, I had at last to make incisions into the constricted part in order to allow of the introduction of the long forceps for the extraction of the child. The stricture was, of course, enormously distended during the process of parturition ; yet it after- wards was reproduced, and became again as bad as it was before. You all know that it is one of the most difficult problems in surgery to solve as to the straightening of parts of the skin which have be- come contracted in consequence of burns ; and in obstetric surgery there is no problem more difficult of solution than the mode of over- coming these contractions of the vagina. Last summer there was a patient in the Hospital, from Shetland, with a very dense cicatricial band greatly contracting the vagina. Mere division of it did not prevent the recurrence of the contraction. In consequence, I cut completely out a portion of the cicatricial tis- sue, hoping that this proceeding might lead to a better result. But, I am sorry to add, that this modification of operating proved also quite futile, and the patient went home little or not at all improved. There is a form of contraction of the vagina much more amenable . to treatment than the above, and which you will sometimes be con- sulted about, in consequence of the patient suffering unusually from marital intercourse, or from the completion of that act being impos- sible. I allude to cases in which there is a mere congenital narrow- ness or contraction of the circle of the os vaginae, not from the pre- sence of the hymen, but simply from congenital smallness of the vaginal orifice. Such cases often give rise to extreme unhappiness and distress. How may we remedy them ? or what is the proper Treatment of Congenital Contractions of the Os Vagina? There are two plans of procedure—either of which you may follow out. First, you may introduce sponge-tents or bougies of some sort, to be left in the canal, and so to dilate it gradually and persever- ingly. If you use large sponge-tents for the purpose you will some- times find that they will retain their place better during their expan- sion, by introducing them with the broad end first. Or, secondly, you may have recourse to an operation, and divide the strictured orifice by making incisions into some part of the circle. I believe the best and easiest operation that you can in such cases adopt is to follow the example set by nature, and make your incision into a part which you sometimes see divided in the process of parturition—to wit, the posterior commissure and the perineum, the parts which first give way when the outlet of the vagina is too narrow to allow of the ready exit of the foetal head, in common first labours. If you begin to make one or more incisions laterally you run great risk of Avounding the veins, which are so numerous on both sides of the vulva, and so producing an excessive amount of hemorrhage, or, it may be, as I have seen, a fatal phlebitis. But something must be 132 fissures of the orifice of the vagina. done to relieve the patient from what is to her a state of the great- est misery; and, I repeat, an incision of sufficient depth may easily, safely, and successfully be made backwards into the perineum. Having dilated the orifice in this way, and having sufficiently stretched it afterwards, if necessary, with the fingers, you must next be careful to take some steps to provide against the immediate closure of the wound, and the recurrence of the contraction. In carrying out this indication you will find that different cases present very different degrees of difficulty. But here a steady and perse- vering use of tents and bougies is usually followed by complete suc- cess. In obstinate cases the patient may require to have introduced into the vagina daily for a considerable time a well-oiled bougie of gutta-percha or caoutchouc. A large wax taper is used by some practitioners for this purpose. I have known this kind of mechanical dilatation of the vagina folloAved by a complication, which is also the occasional result of other causes, but is not, as far as I know, described in any of our Avorks on female diseases, viz:— FISSURES OF THE ORIFICE OF THE VAGINA. This complication consists of a linear, irritable ulcer, fissure, or cleft in the mucous membrane of the os vaginas. You will find its seat to be generally, if not indeed always, the posterior commissure of the vaginal orifice. You all know of the pain which sometimes accompanies fissures in the anus or orifice of the rectum, and hoAV they have attracted the attention of practised surgeons in conse- quence of the agony to which they so constantly give rise. When occurring at the root of the nipples, too, these cracks or fissures, as you are well aware, become there also a source of the greatest suf- fering to mothers, whenever they have to suckle their children. Symptoms and Diagnosis. Fissures of the vagina become a source of pain when the patient is walking or taking any exercise which causes motion of the part. In some cases pain is only felt during defecation or micturition ; or when the urine gets into the crack, and irritates the excoriated part. Marital intercourse sometimes becomes very painful, and may even be rendered altogether impossible from the great suffering arising from a source apparently so simple. Examination with the finger in such a case detects the existence of a painful point behind and on the posterior aspect of the vaginal orifice; and on looking at the part the eye discovers in the posterior angle a small red linear ulcer, usually, especially when chronic, with rough, slightly elevated and everted edges. If you will only bear in mind the possibility of such a condition occurring, you will hardly fail, when you do meet with such a case, to make out the existence of the fissure. FISSURES OF THE ORIFICE OF THE VAGINA. 133 Causes. Fissure of the vaginal orifice may result, as I have already said, from the mechanical dilatation of this orifice when it has been pre- ternaturally contracted. A chronic ulcer or fissure may persist in such a case in the site of the cut or tear that has been made as a means of cure. But this result is very rare. A far more common cause of this affection is that tearing of the perineum which occurs so frequently to a greater or less extent in first labours. If this tear heals slowly and imperfectly, it is liable to leave the linear form of irritable ulcer which constitutes fissure. I have known of one case of it, which caused great pain and suffering, till it was at last detected and cured, in an unmarried lady; but almost all the patients in whom I have met with the disease were married females: although some of them had never borne any children. The worst instance of the disease I have ever met with was in the case of a lady who came here from England, unable to walk or take any exercise from the pain which all motion caused her. The passing of the urine over the raw surface caused her acute suffering, and her health was giv- ing way under the distress occasioned by a small vaginal fissure, which had endured for a long time, and yet immediately yielded to the simple treatment that was indicated. For The Treatment of Fissure of the Vagina is very simple. Either you must introduce two or three fingers to dilate the orifice, and tear open the edges of the fissure, so as to convert it into a larger ulcer, which may be healed by the use of cold water or simple lotions, or you must deepen the fissure by di- viding the mucous membrane to the depth of an eighth or a fourth of an inch, with a knife, in the s'ame manner as most surgeons are in the habit of treating fissures occurring in the anus. It is, perhaps, as a general principle in surgery, desirable to avoid the use of the knife, whenever its use is avoidable. And no doubt fissures of the anus are at least as successfully treated by stretching the orifice of the rectum so as to increase and tear open to some extent the fissure, as by dividing the base of the fissure with a knife. Indeed, I have seen more than one case of anal fissure at once re- lieved and cured by stretching the anal orifice with a couple of fin- gers, which had not yielded previously to division by the knife, though practised by some of our ablest surgeons. The object is the same whether we use the knife or fingers—viz., the conversion of the chronic ulcer constituting the fissure into a new and simple wound, capable of being cured and closed by the usual treatment of recent wounds. Let me only make one remark more. If you pre- fer the knife in the treatment of a vaginal fissure, you need not make the required incision of any great depth. The great French 134 CARUNCLES OF THE URETHRA. surgeon, M. Boyer, supposed that for the cure of a fissure of the anus, it was necessary to make the curative incision pass through the sphincter of the bowel. Many years ago, Mr. Oopeland, of London, made that important modification in the operation which is now generally followed by surgeons; namely, he showed that a simple, shallow incision through the base of the ulcer, and to the depth of the mucous and submucous tissues only, was really all that was in general sufficient to secure success. LECTURE X. ON CARUNCLES OF THE URETHRA—NEUROMATA OF THE VUL- VA— HYPERESTHESIA AND NEURALGIA OF THE VULVA. Gentlemen : At the close of my yesterday's lecture, I showed you a small fleshy excrescence or caruncle which I had removed on the previous day from the urethral orifice of a patient, and I then intimated to you my intention of devoting a portion of this lecture to the consideration of these URETHRAL CARUNCLES. Florid red caruncles not infrequently make their appearance at the external orifice of the female urethra, proving a source of very severe suffering and distress to the patient, and bringing the doctor who procures her relief by detecting their presence and effecting their removal no small degree of credit—credit, unfortunately, which is oftentimes not very enduring, seeing that these morbid growths are extremely liable to become reproduced, and with them all the painful symptoms and sensations of the disappointed sufferer. I show you here some representations of the disease, published by Madame Boivin, which will give you a sufficiently vivid idea of the general appearance presented in such cases. In these plates, how- ever, the caruncles are represented as being of a far larger size than they are in most of the cases that will come under your observation, for though they may vary in size from a millet-seed to a cherry, those of small size are of most frequent occurrence. They vary also in form, and are sometimes seen to be quite round and smooth, at other times they are more irregular and nodose, and sometimes they are flat and spread out like a newt's foot all around the mar- gins of the orifice, where they usually grow from the inner edge. In some cases they are sessile, in others pediculated. Sometimes they are situated more deeply within the canal of the urethra, where they lie concealed from view, and undiscoverable, unless the orifice CARUNCLES OF THE URETHRA. 135 be by some means dilated. More frequently they protrude, and are at once visible on separation of the labia pudendi. They seem in Fig. 47. Urethral Caruncle. (Boivin.) some cases to be not merely connected with the orifice of the urethra, but to extend to some distance along the canal, a fact which must not be lost sight of when you come to attempt their removal. Such an excrescence, so small in size, may appear to you to be a very in- significant piece of pathology; but in a practical point of view, it comes to be of very considerable importance, for you will often meet with patients whose lives are embittered by it, and who will urgently demand of you to exert your professional skill to effect for them a cure of this very distressing disease. Semeiology. What, then, are the symptoms produced by the bodies in ques- tion ? and how do they come to attract the attention of patients, and become a subject of interest for practitioners ? First of all, they sometimes become a source of intense suffering and pain, and this class includes the majority of cases where your aid will be demanded. In other patients the occurrence of hemorrhage from the part, or the occasional admixture of a little blood with the urine, serves to direct attention to their existence. But in a third class of cases they are discovered quite accidentally, producing no special symptom and no 136 CARUNCLES OF THE URETHRA. degree of suffering, and only attracting your notice by their peculiar appearance when you chance to be making some examination of the vaginal canal. We have at present in the Hospital a patient from Banff, who has been cured of a vesico-vaginal fistula of fourteen years' standing, in whom, as some of you have at different times had an opportunity of observing, there is one of these caruncles, of con- siderable size, at the orifice of the urethra, which seemed to become enlarged during the period when she had to wear the catheter—pro- bably from the contact and irritation of the instrument—but since she has begun to move about, it is again diminishing in size. In this case the urethral caruncle causes no pain or inconvenience to the patient, who is probably not aware even of its existence. In another patient, on whom I operated successfully for vesico-vaginal fistula about two months ago, there were two such excrescences at the urethral orifice, which were slightly sensitive, and proved a source of pain to the patient when the catheter was used. We tried to make this patient wear the instrument for a day or two before the operation was performed, to accustom her to the use of it; but it caused her too much pain at that time, although after the operation she bore it perfectly well—a result which was no doubt due to the anodyne effect of the large doses of morphia which were constantly administered to her. So, then, there are some of these growths which cause no particular discomfort at all to the patient, while in others they are as painful to the touch as the most sensitive neu- roma. Pathological Anatomy. It would be a matter of much interest to determine whether there are differences in their anatomical structure corresponding to these differences of their clinical phenomena; but so far as I know they have not yet been very carefully examined. Mr. Quekett found one, which he examined microscopically, to be composed of epithelial cells, and a number of capillaries coming up close to the surface; and this observation explains the occasional tendency to bleeding witnessed in these bodies. We have also a description of the disease, and a figure of the appearances presented by the vessels in a ure- thral caruncle in the Pathological Histology of Wedl, who regards these bodies as " dendritic, papillary, new-formations of connective tissue." The one that he examined " was of a somewhat elongated figure, above 0.5"' in length, and 3.1—3.5" ' in diameter, of a bluish-red colour, and spongy texture, and exhibited, when cut into, cavities containing colloid matter. . . The most interesting point was the distribution of the bloodvessels, which could be very dis- tinctly traced in transverse sections, moistened with a solution of sugar or of common salt. The ramification of the vessels precisely resembled that witnessed in the vasa vorticosa. Several considera- ble sized vessels entering one of the lobules, divided into a multitude of smaller ones, which, though not of capillary dimensions, made CARUNCLES OF THE URETHRA. 137 Arrangement of the vessels in a ure- thral caruncle as seen under the micro- scope. (Wedl.) numerous undulating curves, extending up to the periphery of the lobule where they terminated in mostly short and abrupt loops." (See Fig. 48, a a.) He goes on to ob- serve that the walls of these vessels FiS- 48- were everywhere simple like those of capillaries, and that the red blood-cor- puscles were of unusually small size. He found, further, extravasations of blood at several points, both of old and of more recent occurrence. But these observations as to the distribution and character of the bloodvessels, while they afford a very satisfactory explanation of the liability to hemorrhage which the caruncles present, do not in any mea- sure account for the peculiarity of the nervous phenomena. The late Dr. John Reid once examined for me most care- fully with the microscope a very sensi- tive and painful caruncle which I had removed from a patient, and he came to the conclusion that there was a very rich distribution of nervous filaments in it. It is, I believe, a matter of great difficulty to make a satisfac- tory observation as to the terminal filaments of nerves, but Dr. Reid was a true and faithful observer, and his opinion on a histologic point such as this is of the highest value. And we may yet find that the observation will hold good in all those cases Avhere these bodies are so exquisitely sensitive that they are very richly supplied with nervous filaments. It is, at all events, what we should, a priori, expect. If you inquire further into the history of any of these cases, and question the patient as to the particular form of distress from which she suffers, you will sometimes have curious, statements made to you. Thus you will often find—though this is not so frequently the case now as it formerly was, when the disease had been but seldom noticed, and but few practitioners were prepared to recognize it, you will often still find, I say, that the patient has been consulting a great many different medical men, with the view of obtaining relief from her suf- ferings, but that no one has been able to discover their source. In some cases the patient suffers pain chiefly at the times when she is micturating, and it may then be most excruciating. I was told by a shepherd's wife, who had one of these sensitive caruncles at the orifice of the urethra, that whenever she was obliged to pass water, she was in the habit of going some distance away from her cottage, in order that she might moan and scream unheard, and not distress her family with the sound of her cries, so intense and intolerable was the suffering which at such times she experienced. About three 138 CARUNCLES OF THE URETHRA. years ago we had in the Hospital a little girl about the age of puberty, in whom one of the largest caruncles I ever saw was grow- ing from the urethral orifice; it was of the size of a cherry, and seemed to extend along the canal for some distance, and in her case the pain she felt on passing water was so severe, that she used to retain it in the bladder for twelve hours at a time; and she looked forward to the period when the bladder must be emptied with the utmost horror. But the pain is not necessarily felt during micturi- tion, or then only. It is sometimes occasioned at other times. In married women, attention is often first directed to the disease by the pain experienced during marital intercourse. Some patients only suffer when in walking or taking exercise of any sort, friction of the parts is produced. Occasionally there is reflex or sympathetic pain in some different and distant part. Thus, in one of the first cases I ever saw, the patient not only suffered from pain in the A'ulva dur- ing micturition, but also, then, and at other times, from acute pain in the lower extremities, stretching down even to the heels and soles of the feet. Dr. Whytt speaks of such sympathetic pains in the extremities;" connection with calculus of the bladder, and irri- tation of the urinary organs, and I have traced them, I repeat, several times in connection with these urethral caruncles. Diagnosis. To discover the presence of these urethral caruncles it is not enough that you make a digital examination. By the touch of the finger you can elicit an expression of pain, and so determine the ex- istence of a painful point. You may sometimes feel a small projec- tion there, but the sensation is very deceptive. You can come to no certain conclusion in such a case until you separate the labia pu- dendi, and examine with the eye, when you will see the bright red caruncle of variable size lying at or in the orifice of the urethra. Sometimes as I have already observed, it will be sessile, and attach- ed by a broad base; in other cases you will find it attached by an elongated neck or stalk, and resembling a polypus. There may be only one; sometimes there are two or three; occasionally even more, in which case they are mostly small. You will find the orifice of the urethra in different states of dilatation in this affection. Some- times it is open and dilated, and occasionally the lining membrane of the urethral canal is partially prolapsed through it. More fre- quently the orifice is short and natural in appearance; and in a few cases it seems small, contracted, and, as it were, in a state of spasm. It always appears to me that urethral caruncles resemble internal hemorrhoids more than any other pathological structure, and that they look, so to speak, like urethral hemorrhoids. They have the same florid red colour, often the same rounded lobular form, and the same tendency to bleeding. They differ from rectal hemorrhoids in being in some cases painful at all times, and not merely, as is the CARUNCLES OF THE URETHRA. 139 case with the latter, when they are in a state of congestion and in- flammation; and in this other feature, that when they are removed with a ligature, with the knife, or with caustics, they show a far greater tendency to return, than is seen in the case of piles. They sometimes give rise to a sort of leucorrhoeal discharge, and you will sometimes find a slight degree of suppuration going on around them. I think I have in one or two instances found the sufferings of the patient considerably aggravated by the existence of a slight fissure at their base resembling those you sometimes meet with at the root of an external pile. Treatment. Having detected in any particular case the presence of such growths as I have been describing to you, the question arises, what are you to do with them ? If the caruncles cause no pain nor in- convenience, and are not particularly sensitive, I should advise you by all means to leave them alone. In those cases, on the other hand, where they are sensitive, and a source of much and frequent suffering to the patient, you should by all means attempt to palliate at least that suffering by the application of local anodynes; and generally you will find it necessary to have recourse to the surgical removal of the painful growths—a proceeding which will in almost all cases afford a temporary relief, and in some affect a permanent cure. This operation, let me warn you, however simple as it may appear, is not always so easy and successful as the descriptions of it, which you will find in books, might lead you to suppose. You will read, that if you apply a ligature to the polypoid forms of ure- thral caruncle, cut off the sessile ones, and apply in some cases alum, nitrate of silver, or some astringent or caustic to the parts, you will be able in most cases to cure your patient. But those who speak thus cannot have had many patients for a lengthened period under their observation; otherwise they would have found the disease re- curring far more frequently after such operations than their publish- ed accounts indicate. For after simple removal with a ligature or scissors, they almost invariably grow again; and there is one fur- ther point about their pathology to which I have forgotten to refer, but which renders it a matter of the greatest difficulty to effect a perfect and permanent cure by removal of the urethral caruncles. There is often in such cases not merely a prominent red caruncle, or a number of them, lying at the orifice of the urethra; but there are in addition to these, a number of small very red specks scattered all about the mucous membrane, around the orifice, and upon the neighbouring mucous surfaces, which red specks and patches are not very striking in appearance and may very easily be overlooked, but which are found to be as exquisitely tender as the urethral caruncles themselves when touched with the point of a probe. These insigni- ficant looking flat red spots are all so many seats and centres of the 140 CARUNCLES of the urethra. painful sensation; and if in removing the larger bodies you leave them unheeded, you will never succeed in curing your patient or in affording her permanent relief. From the study of the homological anatomy of the organs of generation in the two sexes, physiologists Fig. 49. A caruncle at the urethral orifice (a), and a number of red painful spots in the surrounding mucous membrane. have come to recognize in the female organs, parts or members cor- responding to each of the different constituents of the generative organs of the male with only one very marked exception. Thus we know that the large and well-developed uterus of the female is only the representative or analogue of the small pouch or sinus pocularis in front of the crista galli of the male urethra into which the semi- nal ducts themselves—the analogues of the Fallopian tubes—enter. So that when in passing a bougie into the male bladder your instru- ment becomes arrested at this point, as is very frequently the case, you have in reality got entangled in the male os uteri. But there is one member of the generative apparatus of the male for which anatomists have not yet been able to determine the existence of a certain analogue in the female; I mean the prostate gland. All anatomy, both human and comparative, leads us, however, to suppose that the female urethra corresponds to that portion of the male which CARUNCLES OF THE URETHRA. 141 lies in or behind the prostate at the neck of the bladder, and that the prostate gland belongs rather to the urinary than to the genera- tive organs. In this case analogue in the female of the prostate in the male should be sought for in connection with the urethra or urinary canal, and not in connection with the uterus, as has most commonly been attempted to be done. Now it may be that in the numerous glandular structures which are scattered about so pro- fusely in the neighbourhood of the orifice of the urethra in the fe- male, we have the representatives of the mass of acini which com- bine to form the conglomerate prostatic gland of the male; and, if so, it would be a curious subject to determine how far the disease which we are now considering depends upon an enlargement and change in these small scattered follicles, and how far it bears a re- semblance to some of the diseases occurring in the prostate.^ But whatever may be said as to the pathological anatomy of the disease, one thing is certain in regard to it, and that is, that, as a very gene- ral rule, no hope of a permanent cure can be entertained except by the radical removal of all the small red spots, as well as of the more prominent and projecting tumours. Different authors have recom- mended different Methods to be followed for the Removal of Urethra Caruncles. 1. Application of a Ligature.—As in the case of so many other morbid growths, and encouraged, more especially, by the success which attends the use of the ligature in the removal of internal hemorrhoids, some have proposed to get rid of these urethral carun- cles by tying a ligature tightly round their base, and so strangulat- ing and causing them to slough off. But here it could only be ap- plicable to those cases where the growth was stalked or polypoid; and even then it would be a much more tedious and painful process to tie a thread round the neck of the tumour and leave it there to die and separate, than to have recourse at once to the simpler 2. Excision with a Knife or Scissors.—If the ligature may seem to possess some advantage theoretically over cutting instruments in such cases—inasmuch as there can be no fear in using the former of the hemorrhage which you might suppose likely to attend the latter when applied to such vascular growths—yet in practice you will imd that while the ligature is in most cases very difficult, or indeed im- possible of application, the excision of the diseased structures is not attended with any formidable degree of hemorrhage. I never saw a case where it was not very easily controlled. You may use either a knife or a pair of scissors for the excision. It is usually advan- tageous to draw out first the caruncles with a hook or small vulsel- lum, in order to make their removal complete. In operating, you must be careful to remove not only the projecting tumours, but also the piece of mucous membrane on Avhich they are seated, as well as 142 CARUNCLES OF THE URETHRA. any pieces of membrane that may be studded with the red spots of which I have spoken to you. Removal of urethral caruncles in this way, I must again warn you, however, though it does sometimes effect a permanent cure, usually affords only a temporary relief. For a month or two, or even longer, the patient may remain free from pain ; but, unless some further more potent remedial means be had recourse to, her sufferings are almost certain to return. Along with Dr. Fowler, I saw a few days ago a patient with a painful tu- mour at the orifice of the urethra, Avhich I removed along with a portion of sound mucous membrane; and this has had the good effect of releasing her in the meantime from the local pain and irritation which would have heen distressing to her. But I greatly fear that you will find, as a general rule, that the reproduction of the caruncle and of all its painful symptoms will take place, unless you make use of some powerful means for destroying the morbific tendency of the part; and I believe that the most hopeful and the most effectual means that you can in such a case employ is the 3. Application of the Actual Cautery.—I have tried caustics of many different kinds, for the cure of this intractable disease. But seldom have I found permanent success from the employment of any of them. I had a patient under my care several years ago, with a very painful growth at the orifice of the urethra, which I had fre- quently attempted to burn down with different kinds of caustics, but it was always reproduced; and when excision was had recourse to the result was no better. I was beginning to despair of ever being able to effect a cure, when at the suggestion of my friend Professor Retzius, of Stockholm, who saw the case with me, I destroyed it with the actual cautery; and ever since the patient has remained perfectly well. Since that time I have used it frequently, and, in many cases, with the happiest result. Yet I must confess to you, that this means, too, has in some instances failed to effect a perma- nent cure. In order to apply the actual cautery to destroy a carun- cle or caruncles of the urethra, 1, you may use either an iron of proper size and shape adequately heated; or, 2, you may apply the requisite degree of heat through the galvano-caustic wire. The latter method is specially useful when the caruncles extend up the urethra higher than the orifice—because you can introduce and ap- ply the wire before heating it up by the transmission of the galvanic current. Apply immediately afterwards cold water and cloths soaked in it; and subsequently treat the ulcerated surface, after the slough separates, with very frequent applications of black wash, zinc lotion, or other surgical applications. The position, therefore, in which we at present stand with regard to the treatment of these urethral carun- cles is such, that their excision with the knife or scissors, and their removal by means of caustics, are to be looked upon and employed as measures for affording usually a temporary relief only; while their destruction by means of the red-hot iron, or the galvano-caus- tic wire, affords a reasonable prospect of a permanent cure, although HYPERJESTHESIA AND NEURALGIA OF THE VULVA. 143 even by this more heroic treatment we cannot be absolutely certain in every case that we free the patient from her disease forever. Palliative Treatment. I have one word more to add with respect to the treatment of this painful affection before I have done with it, and it is this. In those cases where all radical measures have proved ineffectual for relieving your patient, or where the caruncles are in such a situation as not to admit of their removal, you will require to administer sedatives of various kinds internally, or, what is better still, to apply some local anodyne. The best local remedy that I know of for this purpose is prussic acid applied in the form of an ointment made up of two drachms of the dilute hydrocyanic acid of the Pharmacopoeia to the ounce of lard. A bit of this ointment about the size of a pea ap- plied to the part three or four times a day, often relieves the pain more effectually than any quantity of opium administered internally, or than any other form of local anodyne which I have used. Aco- nite and chloroform ointments sometimes also form good palliatives. So does tepid water. You will add, sometimes very greatly, to the comfort of your patient, by advising her to sit in a warm hip-bath during micturition. NEUROMATA OF THE VULVA. I have alluded to the existence of sensitive points and structures external to the orifice of the urethra, and have spoken of them as closely allied to, or identical with the caruncles at the opening of the urethra. There is a diversity of opinion in regard to them, some regarding them as partaking of the nature of true neuromata. It may be that there are two different kinds of them—one more vas- cular and glandular, the other more nervous and papillary. How- ever this may be, I have found true small nodular neuromata occur- ring under and beneath the mucous membrane here, such as are found subcutaneously in other parts of the body ; and as in the case of the urethral caruncles, our only hope of curing them is by the most complete and radical removal that we can by any means effect. HYPERESTHESIA AND NEURALGIA OF THE VULVA. There is one other morbid condition of the female genital organs, regarding which you must allow me to say a word or two during the few minutes we have still at our disposal. It is observed chiefly in married women who come to you complaining that contact with a certain point in the sides of the vaginal orifice, or vulva, causes them such acute suffering that they are totally unable to endure any attempt at marital intercourse. This pain seems to be due to a state of hyperesthesia of the pudic nerve, and was first described by Dr. 144 ABSCESS OF THE LABIA PUDENDI. Burns, of Glasgow, who, in his Principles of Midwifery, after de- scribing the anatomical distribution and relations of the nerve, goes on to say that it " is often preternaturally sensible, so as to cause great pain in coitu, as well as at other times. Itmay be exposed, by cutting through the skin and fascia, at the side of the labium and perineum; beginning on a line with the front of the vaginal orifice, and carrying the incision back for two inches. The nerve being blended with cellular substance is not easily seen in such an operation ; but it may be divided by turning the blade of the knife, and cutting through the vagina to its inner coat, but not injuring that. It may be more easily diA'ided by cutting from the vagina. Slitting, merely, the orifice of the vagina will not do; we must carry the incision fully half an inch up from the orifice, and also divide the mucous membrane freely in a lateral direction" (p. 45). I for- merly knew one or two patients who had consulted Dr. Burns in re- gard to this affection, and in whom the pudic nerve had been divided in the manner he describes, either by himself or by his son ; yet in these patients the painful sensation returned, though sometimes not in the same place, but in the track of some other nerve. I believe, with Dr. Burns, that the best palliative treatment for such cases is division of the affected nerve; but, instead of laying it bare, I have usually cut it through subcutaneously, by means of an ordinary tenotomy knife. It is a surgical measure far more simple in its character. Occasionally there is greater supersensitiveness and neuralgia of the vulva and vaginal orifice, without there existing any local lesion whatever capable of accounting for it. The pain is not then usually limited to any one single point. Such cases require the usual constitutional treatment of neuralgia, as iron, manganese, arsenic, etc., sometimes in long continued courses. You have to use general anti-neuralgic tonic medicines and measures; and locally all forms of sedatives and anodyne applications. LECTURE XI. ON ABSCESS OF THE LABIA PUDENDI, AND THE VARIOUS FORMS OF VULVITIS. Gentlemen : Here is a small quantity of purulent fluid measuring in all about one ounce, which I removed the other day from the left labium of a poor patient who was sent from Fife. She laboured under the impression that she had got an inguinal hernia, but on examining the part I found the swelling of the labium to be due to a collection of fluid underneath the skin. As the patient seemed never to have experienced any particular degree of pain in the part, ABSCESS OF THE LABIA PUDENDI. 145 and as on cross-examining the woman there was nothing to lead one to suppose that it had ever been the seat of any acute inflammatory process, I concluded that it was a collection of serous fluid in a cys- tic cavity. Let me observe, as I pass, that we may have two forms of serous collections in the labium, viz., 1, a collection in the process of Nuck, a disease exactly corresponding to hydrocele in the male ; or 2, a collection of it in a simple serous cyst; such cysts being sometimes found in the submucous tissue of both the vulva and vagina. Supposing the swelling to be of the latter kind in the patient I speak of, I proceeded to cure her of the deformity, and relieve her from the inconvenience produced by the presence of the fluid by letting it out with a tenotomy knife, when there escaped not the usual clear fluid of a cystic growth, but the grayish-yellow purulent fluid which you see in this bottle. It was thus shown to be an instance not of cystic development in the part, but of a disease not at all uncommon here, I mean, Abscess of the Labia Pudendi. 1. Pathological Anatomy .—There is, as you are aware^a conglo- merate gland seated in the submucous tissue, on either side of the entrance to the vagina, opening on the inner surface by a small straight duct, and resembling in structure and situation the Cowper's glands of the male. They were first particularly described and demonstrated by Bartholini, whose name they bear ; but perhaps the best account we yet possess, both of their normal and pathologi- cal anatomy, is that given by Huguier in the Memoirs of the French Academy. These Bartholinian glands are liable to take on from time to time an inflammatory action, which may pass on to^ the higher stages, and end in the formation of an abscess in the labium. But phlegmonous inflammations and abscesses of the labium are not necessarily limited to the substance of the gland, and the abscesses which form here do not always arise in the gland itself; but the in- flammation may begin in the proper cellular tissue of the labium, which may be the seat of the suppurative process. Usually, such an abscess is limited to one labium only, but often enough it occurs simultaneously in both. You will in most cases be able to detect a depression on the surface of the abscess, corresponding to the orifice of the small excretory duct. You can sometimes see the orince ot the gland blocked up, with a drop of pus shutting it up. 2 Aetiology.—Yon will in most cases find considerable difficulty in discovering any special cause to which these inflammatory and suppurative changes can be distinctly assigned. But I have met with several instances where patients were subject to inflammatory attacks in these glands, coming on like the sore-throats to which many are liable, with the various changes of the weather. As in the instance of the chronically inflamed tonsils, these glands may m some cases become merely enlarged and painful, or in others they 10 146 ABSCESS OF THE LABIA PUDENDI. may at such times become the seat of a more or less copious puriforra discharge. Not infreqently phlegmonous abscesses in the labia are the results of direct injury. 3. Symptoms and Diagnosis—It the patient apply to you early, while the inflammation is still recent, and the changes not very advanced, you will find the inflamed gland hard and enlarged—often to the size of a hazel-nut. But usually the primary stages have been passed ere your aid is sought for, and in most cases you will find the tumour already soft and fluctuating from the formation of pus. In the case from Fife, of Avhich I have told you, the abscess had existed for many months, and all trace of inflammatory action had so com- pletely disappeared, that I imagined it to be, as I have said, a simple cyst. Sometimes the labium in which the pus has thus been col- lected becomes distended and deformed, forming a large protuberance towards the perineum, and overlapping to a considerable extent the labium of the opposite side. If in any case you should be in doubt as to the nature of the collection, you may soon come to a decision by introducing an exploring needle into it, and bringing away some of the fluid. The swelling may give to the labium an appearance as if it contained a hernial loop of intestine ; but the freedom from swelling of the inguinal canal and upper part of the labium, the absence from the tumour of all impulse on coughing, etc. will enable you to decide as to the nature of the case. 4. Treatment.—If you meet with a case early, while the changes are not far advanced, you may be able, by the ordinary antiphlo- gistic and discutient remedies, to arrest the inflammation and coun- teract its effects. But when it has already advanced to a certain stage this is beyond your power; and it then becomes your duty to hasten the formation of the pus, and to effect a speedy cure by punc- turing the abscess. There are two different methods which you may follow in evacuating the fluid. You may open up the duct with a fine probe, and suffer the fluid to escape along it. But this canal is usually so small that the dilatation of it is a matter of the greatest difficulty. Besides, when the pus is found around the gland, dilata- tion of the excretory duct will not be sufficient to evacuate it; and even when the fluid does escape from it at first, it has a tendency again to close up and lead to a re-accumulation. I should advise you rather to open the abscess with a bistoury, and to open it very freely on the vulvar or mucous, not the cutaneous surface. After apparently the freest opening, there is, in fact, only a very small wound left when the parts collapse. Besides, if you take care to make the opening large enough to let out all the pus, you will, in all likelihood, have no further trouble with the case. If you make the opening too small, or if you allow nature to evacuate it by a small spontaneous opening, you run the risk of finding a fistula forming in vulva, just as you may have fistula in ano produced in a similar manner. This fistula in vulva may have its internal opening pretty high up, and if not detected and cared for in time, it may come to burrow in ABSCESS OF THE LABIA PUDENDI. 147 the cellular tissue of the labium and lead to the formation there of sinuses Avhich it becomes very difficult for you finally to heal up. Such a condition having by some chance been established, it becomes a matter of much importance for you to determine Avhat is the best method you can adopt for the Treatment of Fistula in Vulva. There is one very simple means which is usually very effectual in curing fistula here as well as fistulse and sinuses in other parts, and that is, the injection of strong tincture of iodine. Tincture of iodine injected into the canal of an anal fistula will sometimes cause con- traction and consolidation in its track and effect a perfect cure. I have seen some severe cases of fistula in ano cured by this simple means. One case in particular occurs to my mind at this moment, Avhere the effect of the injection was most striking. The patient came to me some three years ago or more from Ireland, with a fistula in ano of very long standing. Before setting out for Edinburgh this patient had been foolishly told, that an operation would be under- taken which was almost certain to prove fatal, so that I Avas at once and most earnestly asked if there was no other way of cur- ing this fistula but by cutting it. I directed Dr. Skinner, who was my assistant at the time, to inject some tincture of iodine into it; but the injection Avas not attended on that occasion with any very marked result, because in all probability the fluid had not passed along the Avhole fistulous track. The next time, the injection was performed more effectually, as was proved by the escape of some of the fluid from the internal or rectal orifice of the fistula; and this injection was speedily followed by a most complete and perfect cure. If in any case you cannot succeed in making a fistula in the vulva close up by sending a stream of tincture of iodine through it, you may try to effect a cure, as I have once or twice succeeded in doing, by leav- ing a wire for a time in its track, until such a degree of adhesive inflammation is set up as shall lead to its complete obliteration. Should this means also unhappily fail, then it only remains for you to cut through with a knife all the tissues between the two extremi- ties of the fistula, and induce the wound thus made to heal up from the bottom by granulation. But, remember, there is always much danger of profuse venous hemorrhage in this operation, and you must be duly prepared for it. As I am speaking of inflammatory diseases of the external parts and their results, let me add, that these parts are liable to various other types of inflammation besides the simple inflammatory or phleg- monous, of which we have been speaking, and also quite independ- ently of any syphilitic origin. Various forms of eruptive inflamma- tion are liable to appear in this part of the body, and particularly in some females at the menstrual period, and in others in consequence of the acridity of the discharges which may pass from the vagina at 148 PAPILLARY VULVITIS. other times, and under states of internal disease. Thus, these parts are the occasional seat of attacks of erythema, eczema, etc. Herpes occasionally appears, generally after some constitutional disorder, on the external labia or vulva, of the same form and running the same course as herpes labialis, or rather, as herpes preputials in the male. I have seen also very distinct herpes upon the cervix uteri. Various other forms of acute and chronic inflammatory eruption may appear in these parts, but they require no special notice, as they require no treatment specially different from the same diseases when situated elsewhere. One of the most common varieties of eruption on the vulva consists of an affection like acne, i. e. it consists of scat- tered tubercles sometimes of considerable size, formed by inflamma- tion of the follicles of the vulva and nymphae. But there are some forms of specific inflammation, if we may so call them, of the vulva, some varieties of vulvitis, if we may so speak, which call more particularly for our notice, such as papillary vulvitis, purulent vulvitis (which is liable to occur in infants), gangrenous vulvitis, or noma, etc. PAPILLARY VULVITIS. This is a form of chronic inflammatory disease of the vulva which is fortunately not very frequently met with in practice, but when it does occur, it is usually accompanied with much distress, and is often very obstinate in the way of cure. By this term, papillary vulvitis, I mean a chronic inflammatory affection of the mucous membrane of the vulva, and sometimes of the vagina, in which that membrane pre- sents an intensely red colour, either in raised red patches on the edges of the lower vagina folds, on the tips of the carunculse myrtiformes, or the nymphse, or on the sides of the vulva, or more generally dif- fused over a large portion of the surface of the vulva. On these red patches or surfaces you find, on examination, the enlarged mu- cous papillse standing out like the swollen villi of a raw and irritable tongue. Often some of the most elongated papillae bleed at their tip when touched. Any rough pressure of the vulva gives pain to the patient. The disease may be found in the unmarried, but not frequently; it comes on after marriage, and produces such tender- ness of the parts that sexual connection is attended with much suf- fering, or becomes impossible. Usually indeed, there is a sort of spasmodic contraction of the orifice of the vagina aggravating the evil. Along with the red and enlarged papillse you will sometimes, but not always, find interspersed the small follicular glands of the Arulva, swollen and inflamed, and sometimes ulcerated. Treatment.—Patients affected with this disease anxiously demand professional relief, as their happiness as well as their health is some- times destroyed by it, and the treatment, as I have already hinted, is sometimes by no means easy. I haAre known the diseased surface treated heroically and perseveringly with a repetition of strong caus- PAPILLARY VULVITIS. 149 tics; but the simplest and surest mode of cure, according to my experience, consists in the continued use of local astringent measures, combined when necessary with sedatives, such as a strong solution or liniment of tannin frequently applied during the day, and Avith morphia or other sedatives added to it. Or you may dissolve your astringent in glycerine, and in this form it will remain more perma- nently in contact with the diseased surface. Latterly, I have trusted principally to the daily free application of a saturated solution of perchloride of iron in glycerine—an application producing little or indeed no pain—and I think with the happiest effects. General tonics, warm bathing, etc., must not at the same time be forgotten. Purulent Vulvitis, or Leucorrhea in Infants. This is a form of inflammation of the vulva which is by no means infrequent in female infants and children. It is, perhaps, however, more interesting and important in its medical jurisprudence relations than in its purely practical aspect; for very often, especially when it occurs in patients of the lower orders, the disease is improperly imagined, by the relatives and friends of those attacked, to be the result of venereal infection. The child is brought to the medical practitioner, under the idea that he will confirm this unhappy and dangerous notion. An excitable mother will, by threats and by sug- gestive and leading questions, get the frightened child to own to some absurd and groundless tale, in confirmation of her maternal theory of the origin of the malady; and no doubt men have been repeatedly tried, and convicted too, of imparting this disease to young children, by forced sexdal connection, when they were totally innocent of such a crime, and when the affection had a totally differ- ent origin; for the purulent vulvitis, or leucorrhoea, seen in young female children has, as a general rule, no more an impure sexual origin than has inflammation of the eyes, throat, or lungs. Like most other local inflammations, it usually arises first from some de- gree of deranged or impaired general health in the patient, and secondly from the patient, when in this, it may be quite temporarily, depressed condition, being exposed to cold and wet, or the_ other exciting causes of inflammation. Want of cleanliness, the irritation of acrid urine, etc., sometimes act as local exciting causes. Like angina, diphtherite, and some forms of catarrh and dysentery, this inflammation of the mucous membrance of the vulva, like those in- flammations which I have named of the mucous, pulmonary, and intestinal membrane, attacks more than one child in the same family, and may even prove partially endemic or epidemic in a district. Symptoms and Course.—The disease usually begins with local heat and itching; some degree of redness and swelling; pain and scalding in passing water, and sometimes uneasiness in walking; but for the first twelve or twenty-four hours, there is no discharge from the inflamed mucous membrane. But you will seldom see the disease 150 PAPILLARY VULVITIS. in this early stage. Almost always you are called upon to see or prescribe for the patient, because the affection has so far run on in its course, that there is already more or less discharge from the vulva. The discharge is at first of a thin mucous character, but rapidly becomes purulent and yellow, or yellowish-green in its tint. Occasionally the discharge becomes extremely profuse. It is apt to become thick and hardened along the outer edges of the external labia, binding these opposed edges slightly together by a kind of imperfect crescentic crust; but when the labise are drawn asunder, the whole surface of the vulva is found to be covered over by a layer of the liquid puriform secretion. The disease very rarely extends upwards into either the vaginal or urethral canals. Occasionally there is, at points, an appearance of vesicular or pustular eruption ; and, indeed, some type of mucous eruption in the part would probably be dis- cerned as a common, if not constant, phenomenon, if we had an oppor- tunity of searching for it early in the course of the disease. Some- times, but by no means frequently, there supervene one or two spots of ulceration, especially towards the orifice of the vagina. Treatment.—Acute infantile leucorrhcea shows, like many other analogous ailments, a natural tendency to run through a definite, and, often not a very long course, and has a natural tendency to end in a spontaneous cure. But, if not arrested, it sometimes ends in a chronic, protracted form of discharge; and our medical interference is required not only to prevent this termination, but also to relieve the patient from the immediate distress and annoyance which the disease produces. In the first stage of the affection you will often find your patient requiring some little constitutional treatment. A dose of calomel, or gray powder, with a few grains of some aperient alkali, as mag- nesia, is sometimes all that is necessary; but it may require to be repeated. If the discharge become protracted, chalybeates, or other tonics may become necessary. Use, in short, your constitutional remedies here as elsewhere, to bring the constitution and its princi- pal functions as far as possible to the normal standard of health, and cure the local disease by appropriate local applications. In the earlier and more inflammatory periods of the disease, use locally to the vulva sedative applications ; in the latter periods, and for the purpose of reducing and arresting the attendant discharge, use astringent applications. And you may employ these local appli- cations in the form of lotions, or liniments, or ointments. Frequent ablution with warm Avater, or warm milk and water, is one of the best and most soothing local applications; and sitting in a warm hip-bath during micturition is one of the surest means of relieving the pain and scalding attendant on the passage of the urine. A solution of acetate of lead, or two grains of acetate of lead and one grain of acetate of morphia to the ounce of water, makes a good sed- ative lotion when there is much local smarting and pain : or you may use a weak solution of borax, or of nitrate of silver. When seda- PRURIGINOUS VULVITIS. 151 tive lotions are preferred, it is generally necessary to leave a slip of charpie, or lint, wetted with them between the labia. But I think you will find the local affection more manageable under sedative liniments; as by applying several times a day with a brush or feather, cold cream, with, if you think fit. a little morphia added to it; or a liniment made of equal parts of olive oil and lime- water. Liniments are more lasting as local applications than lotions; and not so liable as ointments to fret or irritate. But the time soon arrives when you must add local astringent remedies to the sedative; or substitute the former entirely for the latter. With this view, use tannin, or sulphate, of zinc, or aluminated iron, or any analogous astringent, in the form of a lotion or liniment; but take care not to use them of such strength that they prove irri- tant in their action, so as to force you back again, for a day or two, to the sedative treatment. Gangrenous Vulvitis or Noma. A variety of vulvitis is seen sometimes, but fortunately very rarely, in practice, which generally begins with erythematous inflammation of the vulva, and the formation of one or two blisters or bullae, and rapidly runs on into gangrene and phagedaena. This gangrenous vulvitis has been seen in adults as a complication in particular epi- demics of puerperal fever ; and in infants it has been observed either under an epidemic form, like epidemic gangrenous or malignant sore- throat ; or in isolated cases—most frequently as a sequela of scarla- tina, measles, and other debilitating forms of febrile disease—or as a result of some constitutional cachexia. The disease not infre- quently runs on to a fatal termination. Treatment.—You will generally find your patient requiring early, or even from the first, stimulants and quinine. If these are not yet called for, trust to considerable doses of chlorate of potass; or of this and muriate of iron every two or three hours. Apply poultices and sedatives locally in the early stages of the disease at least. The progress of the gangrene has, it is said, been sometimes arrested, or appeared to be arrested by the application of nitric acid, etc. Pruriginous Vulvitis. Not infrequently a pruriginous eruption appears on the mucous membrane of the vulva, and extends up along the vagina as far as the cervix uteri. It extends also often, and is sometimes, indeed, originally situated on the cutaneous border of the vulva, and appears on the outer cutaneous surface of the labium, spreading backwards along the perineum to the circle of the anus. Occasionally, it is a flitting and transient affection, recurring with menstruation, preg- nancy, or delivery. But patients will apply to you from time to time, in whom the disease has become more chronic and fixed, having 152 PRURIGINOUS VULVITIS. lasted for weeks, or months, or even years; producing almost con- stant irritation and distress; frequently interfering with rest and sleep, and rendering the victims of it miserable and almost deranged. When the disease has become somewhat chronic and necessitates the patient to attempt to alleviate it by constant and sometimes rough friction, you will find the mucous and even the cutaneous surface at the most irritated parts white and thickened with red fissures, and scratches appearing on the affected part. I have spoken of the disease as fundamentally pruriginous ; and we can often see on the affected surface a small papular, and sometimes a vesicular, or even aphthous eruption ; but cases ever and anon occur, of severe pruritus in these parts, without your being able to trace in them any distinct eruptive appearance. Treatment.—Pruriginous disease of the vulva or neighbourhood can be relieved, and generally cured, by the assiduous and persever- ing application of a solution of biborate of soda (five or ten grains to the ounce of water), infusion of tobacco, either alone or containing a similar quantity of borax dissolved in it, or an ointment of iodide of lead (one drachm to the ounce), or an ointment of bismuth and morphia. Chloroform also applied locally, in the form of vapour, liniment or ointment, forms one of the most certain means which you can use. The simplest way of employing it is by adding a drachm of chloroform to an ounce of any common or sedative ointment or liniment. You will find great advantage in the management of the disease in alternating some of these local applications with each other, for most of them begin to lose their good effects when persevered in above a few days consecutively. In the more obstinate and severe cases, strong astringents are sometimes of the greatest use, employed either alone or along with sedatives, as a very strong solution or ointment of alum or aluminated iron or tannin; or the powder of these substances mixed up with some powdered morphia, and applied continuously, for a few days, to the irritated part. Several times, in very obstinate cases, and where the disease was limited to a por- tion or circle of the cutaneous tissue, I have temporarily separated the affected portion of skin by a free subcutaneous incision with a tenotomy knife. Of course it leaves no wound except the small wound left by the entrance of the knife itself. I have found this little operation perfectly and entirely successful in some cases, an$ only of temporary benefit in others. Perhaps it is unnecessary to add that the general health of the patient must be fully attended to, and that sometimes arsenic, aqua potassae, and other alterative medicines of that description are required. ON SURGICAL FEVER. 153 LECTURE XII. ON SURGICAL FEVER. Gentlemen : Two weeks ago I directed your attention to the sub- ject of complete contraction of the vagina as a cause of retention of the menstrual secretion, and of its accumulation in the cavity of the uterus. I did so in relation to a case of that kind at the time in the Hospital; and I revert to the subject to-day for the purpose of acquainting you with the further hapless history of the patient, and with the view of calling your attention to some of the other lessons taught us by her melancholy fate. From the account of the case which I formerly gave you, you are already aware that Ave had opened up the adhesions in the vaginal canal to some extent with the finger, and that this apparently sim- ple procedure had been followed by some slight but distinct febrile symptoms. These symptoms, however, subsided after a day or two, and Avhen they had finally and fully disappeared, we proceeded to relieve the uterus of its long-accumulating contents, by making a small opening into the dilated uterus at its most yielding point with a tenotomy knife. I told you that puncturing of the uterus through the vagina, in such cases, was an operation by no means free from danger, but by having recourse to it in this instance, we gave to a young and interesting female her only chance of relief from a diseased condition, which was surely, though slowly, tending to her destruc- tion. I punctured the uterus through the roof of the vagina, and there escaped about twehre ounces of the dark tarry viscid fluid, of which I showed you a specimen two days subsequently. The patient remained Avell for thirty-six or forty hours afterwards, but then a rigor occurred, and fever set in with all its fatal consequences. The pulse rose and became very rapid, the abdomen became tym- panitic and very tender to the touch, an anxious expression over- spread the patient's countenance, an icteric tint became developed over all the body, and, in spite of our utmost care, she sank, and died on the fifth day from the time of the operation. On making a post-mortem examination, the uterus, which I here show you, was found to be enlarged and about the size of a uterus in the third or fourth week after parturition; its internal surface dark and sloughy, and its walls thickened and in a state of fatty degen- eration. There was a great collection of pus and inflammatory exu- dations all around it, and in the cavity of the abdomen as well, gluing too-ether the different viscera, and covering the surface of the liver, 154 ON SURGICAL FEVER. more especially, with a regular layer of coagulable lymph. The left Fallopian tube was curiously tAvisted back upon itself, and its fim- briated extremity was folded inwards, and glued like a cap on the fundus of the uterus in the remarkable manner Avhich you can still see in the preparation. On being cut into, this Fallopian tube was found to be filled and distended with a quantity of dark tarry-looking fluid, precisely resembling that which had been found in the uterus. The artificial opening into the uterus was found to have been made in the cervix, immediately in front of the os uteri, which Avas quite occluded; and the canal of the cervix Avas also obliterated to some extent. No secondary or metastatic changes were found in any dis- tant organs or viscera. Another fatal case has occurred in our ward during the last Aveek. The patient was an elderly woman A\hom some of you had an oppor- tunity of seeing me tap for dropsy of the ovary two weeks ago. According to all appearance the patient ought to have got on quite well, for there was only this one bad feature about the operation, that we could not get the cyst completely emptied in consequence of the canula getting always obstructed towards the end by means of flakes of a substance Avhich looked like decolorized coagula of old blood, but which were in reality, for the most part, composed of the debris of the septa between the different cysts; and which cysts had amalgamated to form the one large cavity into which the trocar and canula were thrust. The fluid that escaped was dark in colour and very viscid, and contained a considerable admixture of blood corpus- cles. The patient did Avell for two or three days, but then she began to have shiverings and vomiting, with quickened pulse and tender- ness of the abdomen. These febrile phenomena lasted for a fe\v days, and then began gradually to subside. A day or two later, however, the abdomen began to swell, and become tympanitic, evi- dently from the development of gas Avithin the cavity of the cyst; and then the fatal fever and inflammation returned, marked princi- pally by vomiting and acceleration of the pulse, and attended appa- rently by no degree of pain or local tenderness whatever. Finally, she died, as most patients carried off by severe peritonitis and ova- ritis do die, of a form of slow fainting or sinking, Avhich no kind and no quantity of tonics and stimulants served in any marked degree to restrain or arrest. At the autopsy, we found the ovarian tumour to be adherent to the walls of the abdomen in all its extent; so that Dr. Haldane, in cutting through the abdominal parietes, opened into the sac at once. Yet it was not so firmly adherent but that it could readily be sepa- rated with the fingers, and might probably have been removed had the operation of ovariotomy been here attempted during life, without encountering any risk of hemorrhage. Only at one point the sac was joined to the mesentery by an old adhesion, which contained one or two bloodvessels; but even from these no formidable bleeding could have occurred. I do not myself venture to touch this prepa- ON SURGICAL FEVER. 155 ration, in demonstrating it to you now, because I firmly believe that if I did so, my fingers might become impregnated with a poison which, Avhen applied by chance to some puerperal patient, would almost certainly have the effect of inducing in that patient an attack of puerperal fever. For, as I shall endeavour to prove to you, when in another department of our course I come to treat of that disease, surgical and puerperal fever are identical in nature and intercom- municable. On the interior of this large cyst you see a number of smaller cysts projecting into the cavity, and towards the base of the tumour there is likeAvise an agglomeration of cysts of every possible size, from this secondary one of the bigness of a child's head, down- wards. Altogether it gives you a very good idea of the appearance usually seen in such tumours, and you can see from this how one large cyst is sometimes formed from the dissolution and fusion of a vast number of smaller ones. There was a large quantity of purulent fluid inside the cyst, as Avell as some noxious gas; and you can still see on the interior large flakes of lymphy deposit. There was no remarkable degree of peritonitis, and no morbid change of recent date in any of the abdominal or thoracic viscera. Most of the lym- phatic glands in the abdomen had been destroyed by some morbid and probably tubercular change of ancient date, and were represented in most cases by cysts containing only a cheesy or putty-like mass. These two cases present you with very striking examples of opera- tions, apparently of the most safe and simple nature, failing and ending fatally ; and I need, therefore, to make no apology for occu- pying your time to-day with the discussion of the question, What do patients die of after undergoing surgical operations, either in the course of general or obstetric Surgery? Causes of Death after Surgical Operations and Injuries. In entering upon this discussion I would take leave, first of all, to observe, that the inquiry as to what patients die of after surgical operations, is a question which has not hitherto attracted thatdegree of attention from surgeons themselves Avhich its paramount import- ance imperatively demands. In vindication of the members of my own department of the Profession, I would remind you that there is not a text-book on Midwifery in which there is not one lengthy chap- ter devoted to the consideration of puerperal fever, the common cause of death in obstetrical patients; and there are besides many monographs and bulky treatises in which it is discussed fully and in all its bearings. On the other hand, there is hardly a large work on Surgery in Avhich you will find a word stated as to the cause of the mortality of patients who have been subjected to surgical opera- tions. We have one large standard German work on Surgery trans- lated into English, which is very complete and exhaustive on most surgical topics; but on looking at it this morning to see what the author or translator had to say about the causes of death after 156 ON SURGICAL FEVER. operations, I found not a word on the subject; and in one of the most recent and perhaps the best English work on Surgery—a bulky tome of some thousand or more pages in length—this all-important question is dismissed in the short space of one half page. In other text-books and systems of Surgery we have not even so much as this half-page. Faithful to their designation and original vocation, Chi- rurgeons have, with some great and brilliant exceptions, gone on trying to improve the merely manual part of their profession—what some have spoken of as the cutlery and carpentry of Surgery only, without attending sufficiently to some of its most important patholo- gical relations; and especially without showing any anxiety to in- quire as to the pathological effects of their operative procedures upon the bodies of their patients. Indeed, some Surgeons seem to lose all interest in their patients from the time that they are carried off the operating-table, and eschew rather than otherwise their treat- ment, if they are attacked with surgical fever. Our books and man- uals devoted to Operative Surgery elaborately describe various and sometimes many modes and methods, by which almost every indi- vidual operation may be performed, and they learnedly discuss the site, length, depth, shape, form, &c. of the incisions required, Avhile they seem all agreed to leave unheeded and uninvestigated the fact that patients die in startling numbers after every operation, and each and every form and variety of incision, of whatever length and depth, and hoAvever and wherever made. This notorious neglect on the part of our surgical brethren is all the more provoking, because they are, forsooth, continually boasting that Surgery is that depart- ment of the Profession Avhich has attained the highest state of ad- vancement and perfection, forgetting, all the while, that it is only the mere handicraft part of it that has been brought to this boasted degree of development. Irritated by this arrogant assumption, Dr. James Gregory, formerly professor of the Practice of Physic in this University, and a man who spared neither friend nor foe in the caus- tic utterance of his satirical sentences, once wrote as follows. To understand, however, Dr. Gregory's observations, let me premise, that in his time, two eminent surgical writers practised in Edinburgh, each of them the author of large treatises on Surgery, viz. Mr. Ben- jamin Bell and Mr. John Bell; and between them there existed the rivalry of opinion and doctrine so common among cotemporaneous surgeons. " Within my memory," writes Dr. Gregory, " a new mode of cutting off legs was introduced (or an old one revived, I am uncertain which), and strongly recommended by an eminent surgeon, Mr. Alanson. It was called the flap operation, or cutting with flaps. I remember to have heard some disputes about it; for as there were flappers, of course there must have been anti-flappers; and as the dispute began little more than twenty years ago, far from being ended as yet, it can scarce be arrived at full maturity and violence. Mr. Benjamin Bell must be either a flapper or an anti-flapper; and I humbly conjecture (for I do not know the fact) that if he is a flapper, ON SURGICAL FEVER. 157 Mr. John Bell will be a determined anti-flapper; but that if Benja- min is an anti-flapper, John will be a most strenuous flapper. But flap or no flap, he certainly may take his choice of several ways of cutting off a leg." Nearly thirty years have come and gone since these Avords were penned, and still surgeons continue, I believe, to wrangle as idly and bitterly as before, about how a limb may be best lopped off, and still very strangely forget to ask themselves why it is that so many of their patients die after every possible form and fashion of dismemberment, and how this mortality may possibly be met and diminished. That surgical operations taken as a whole, and particularly, the more severe forms of these operations, are frequently followed by the death of patients, who are subjected to them, is easily proved by the statistical tables published by some of our large hospitals. I have brought with me two of these sets of tables, the only two on which I could lay my hands this morning. In the official " Report of Guy's Hospital," for the year 1856, there is a table of the con- sequences of 329 operations of all kinds, from which we find that of these 329 patients, 43 died, or one in every seven and a half. In the " Report" of our own Infirmary, for the year 1842-43, drawn up by Dr. Peacock, the results of 150 operations of every kind are tabulated, and this table shows a mortality of one in every five. In the "Report" for 1849-50, drawn up by Mr. McDougal, the propor- tion of deaths is greatly less, amounting only to one in every ten and a half. This is to be explained partly by the circumstance that there is included in this table the results of a large proportion of slight and comparatively safe operations, such as that for fistula in but the lessened amount of mortality in the later period, is, ano doubtless, also in part due to the circumstance that during that time all the patients, almost without exception, were first brought into a state of anaesthesia by means of chloroform. If now you look to the result of some of the larger operations, you will find the amount of mortality to be much greater. This is shown, for example, in the following table, the materials for which I collected and published some ten years ago:— Table of the Mortality of Amputation of the T/iigh. Name of hospital and reporter. Parisian Hospitals—Malgaigne Edinburgh Hospital—Peacock General Collection—Phillips Glasgow Hospital—Lawrie . British Hospitals—Simpson . Number of cases. 201 43 987 127 284 Number of deaths. 126 21 435 46 107 Percentage of deaths. 62 in 100 49 in 100 44 in 100 36 in 100 38 in 100 Thus you see that in Paris, where amputation of the thigh was performed, no doubt, in the most approved and artistic manner, and with all the aids of the most perfect handicraftism, more than one- 158 ON SURGICAL FEVER. half of the patients subjected to that operation died; while in other hospitals patients died after the same operation in a less, but still a very high proportion, the general result being, that nearly 1 in every 2 patients operated on died. And from other operations you have a corresponding high degree of mortality, as shown by this Table of the Mortality of Ligature of Arteries and Herniotomy. Operation. Reporter. Number of Number of Percentage cases. deaths. of deaths. Ligature of arteries . Phillips 171 57 33 in 100 Ligature of arteries . Inman 199 66 34 in 100 Ligature of subclavian artery Inman 40 18 45 in 100 Herniotomy . Inman 545 260 47 in 100 Herniotomy .... Cooper t1 36 45 in 100 These tables will suffice to show you that the mortality after the severer kinds of surgical operations is something frightful and enor- mous. At the same time, confessedly, the chances of a fatal issue after even the slightest operations are by no means few. And the question comes to be, what do these patients die of? First of all, let us inquire, do they die of purely surgical compli- cations ? In a few cases they do, but not in many. In Guy's Hospital "Reports" for 1843 Dr. Chevers has published an "Inquiry into the Causes of Death after Injuries and Surgical Operations," which is one of the best memoirs on the subject we yet possess, and written by a physician, not a surgeon. In this memoir Dr. Chevers gives an account of the post-mortem appearances found in the bodies of one hundred and fifty-three patients, many of whom " had undergone severe operations or suffered from extensive accidental injuries," while "others had been the subjects of wounds or contusions of an apparently very trivial kind." Of these 153 patients only 19, or one in every eight, died of tetanus, sloughing, hemorrhage, suppura- tion, and other immediate and purely surgical complications. Secondly, if thus only so very small a proportion, therefore, of surgical patients die of fatal surgical complications, Avhat do the great mass of them die of? They perish showing symptoms of acute fever during life, and showing on examination after death, in various internal organs, the products of acute and recent inflammation. They die of surgical fever, a disease consisting of a combination of coexisting acute fever, and acute internal inflammations, just as puerperal patients die of puerperal fever, a similar compound disease, consisting exactly like surgical fever of coexisting acute fever, and acute internal inflammations. Of Dr. Chevers' 153 surgical patients, 134 died of surgical fever, and presented after death recent acute inflammatory effusions and lesions in various internal organs. The relative frequency Avith which different internal organs and parts of the body were found attacked with acute inflammation in these 134 cases, is shown in a condensed form in the following table:— ON SURGICAL FEVER. 159 Inflammatory Lesions in 134 Cases of Surgical Fever. Peritonitis was observed in Enteritis (excluding cases of hernia) Pneumonia and its results Pleuritis . Bronchitis, laryngitis, and diphthe- ritis ...••• Pericarditis 52 9 47 35 4 14 Arteritis and aortitis Phlebitis Meningitis j Cerebritis Cystitis . Pus in muscles or joints | Inflammation of tunica vaginalis {From Chevers.} Cases. 4 3 27 9 When in Vienna last summer, my nephew, Dr. Alexander Simpson, obtained access to the pathological records of the large General Hospital there, where the autopsies are made under the supervision of Professor Rokitansky, and drew up for me from these records some statistical tables to show the relative frequency with which the various organs and parts of the body become the seat of secondary inflammatory changes in the cases of patients dying of surgical and of puerperal fever respectively. Allow me to call your attention now to this Table showing the relative frequency with which different Organs and Parts of the Body were found to have undergone recent Inflammatory Changes in 100 Cases of Surgical Fever. Cases. The lungs and pleura in Veins Seat of the operation or injury Cellular tissue and muscles Peritoneum Brain and its membranes Bones and joints Spleen . Kidneys Stomach and bowels 69 53 40 28 16 16 15 10 9 7 Bladder . Liver Pericardium Lymphatics Arteries . Vagina Interior of uterus Heart substance Parotid gland . Ear. The patients in whom inflammatory lesions of these various inter- nal organs and parts were discovered after death, had been subjected to operations and injuries of all parts of the body, and of all degrees of severity, from amputation of the thigh, down to the operation for phymosis, and the simplest, most superficial wounds. Consider now that table of the organs and tissues most commonly affected by inflammation in cases of surgical fever, with this Table showing the relative frequency with which different Organs and Parts of the Body were found to have undergone recent Inflammatory Changes in 500 Cases of Puerperal Fever. Seat of the inflammatory lesion Kidneys . Stomach and bowels Pericardium . Seat of the inflammatory lesion Interior of uterus Veins of uterus Peritoneum Lungs and pleura Lymphatics Ovaries . Cellular tissue and muscles Veins other than uterine Brain and its membranes Spleen . Vagina aud pudenda Bones and joints No. of Per cent. cases. of cases. 372 349 321 202 129 98 46 40 23 21 19 18 74.4 69.8 64.2 40.4 25.8 15.6 9.2 8.0 4.6 4.2 3.8 3.6 Mamma . Fallopian tubes Bladder . Parotid gland . Heart substance I Endocardium . I Iris | Tonsil . | Larynx and trachea No. of cases. 17 13 12 7 5 4 o 3 2 1 1 1 Per cent. of cases. 3.4 2.6 2.4 1.4 1. 0.8 0.6 0.6 0.4 0.2 0.2 0.2 160 ON SURGICAL FEVER. A comparison of these two tables will serve to show you how far we are justified in speaking of surgical and puerperal fever as anal- ogous in their nature; and the difference in the frequency with which different internal organs and parts are apt to become the seat of the acute inflammatory effusions and changes in the two sets of cases, is owing mainly, if not, indeed, altogether, to the difference in the seat of the primary lesion; for the identity between the two diseases becomes more striking, if we compare the latter of these two tables with such a one as this : — Table showing the relative frequency with which different Organs were found to have undergone recent Inflammatory Changes in 19 Cases of Surgical Fever, resulting from operations and injuries of the Pelvic Organs (including three cases of Herniotomy). Seat of the No. of Per cent. Seat of the No. of Per cent, inflammatory lesion. cases. of cases. inflammatory lesion. cases. of cases. Peritoneum 12 63.1 Liver . 3 15.8 Lungs and pleura 12 63.1 Veins . 2 10.5 Seat of wound . 5 26.3 Spleen . 2 10.5 Cellular tissue around kid Vagina . 1 5.3 neys 5 26.3 Uterus . 1 5.3 Cellular tissue elsewhere 4 21. Bronchi . . 1 5.3 Intestinal canal 3 15.8 Parotid gland . . 1 5.3 Bladder . 3 15.8 The proportion in which different internal organs are the seats of acute inflammatory action and deposits, is very much the same in this table as in patients dying of puerperal fever, apparently, because, I beg to repeat, the primary lesion or wound in the surgical cases included in this table was, as in the puerperal patient, in the pelvic \Tiscera or neighbouring parts. But we must hasten on to discuss another question, viz :— ^ "What is the Nature of the Malady which accompanies or gives rise to these secondary lesions ? We have seen that every patient who is placed upon an operating table runs no small risk of death, and that, when the operation is severe, the patient is in as great, or indeed greater danger than a soldier entering one of the bloodiest and most fatal battle-fields. We have seen also that while a few of these patients die of the im- mediate surgical consequences and complications of the operation itself, the vast majority of them are carried off by a febro-inflamma- tory malady resulting, indeed, from the operation, but proving fatal from the morbid changes which it produces in different and some- times distant parts of the body. In this surgical fever, as in puer- peral fever, you have a constitutional fever accompanied by the de- velopment of local acute inflammatory disease, confined often to organs and parts lying in the vicinity of the site of the primary injury, but in many cases diffused over other more remote organs and ON SURGICAL FEVER. 161 textures. This fever may be of three kinds, or rather, it manifests itself in three different kinds of cases. 1. Fever from Local Inflammation.—Fever may be a symptomatic result, first of all, of a very intense degree of inflammation set up in the seat of the operation or injury ; but in such cases it rarely leads to a fatal issue. For unless the patient be very much reduced in strength, or altogether in a very bad habit of body, the inflammation excited in any injured part can but seldom be of such a high degree of intensity as to prove fatal of itself. This may also occur in such exceptional cases as you have an instance of in the second of the patients whose history I have given you, and Avho died in conse- quence of the inflammation set up in an evacuated ovarian cyst. There the inflammation was spread over all the interior of an enor- mous cavity, and proved fatal, just as inflammations of such an ex- tensive surface as that of the peritoneum do, viz., by gradual depres- sion of the action of the heart. 2. Fever with Inflammation extending to neighbouring parts.— Fever in surgical patients is much more frequently found to arise from, or, at least, to be associated with inflammation not confined merely to the seat of the injury, but spreading thence to other parts and organs, either from continuity of texture or contiguity of posi- tion. In almost every instance of this kind, the nearest lymphatic glands are more or less hypersemic and hypertrophied, for the mor- bific agent seems in them to have a tendency to spread along the lymphatic system of vessels, and to excite in them a high degree of inflammation. 3, Fever with Disseminated Centres of Inflammation.—In a third and by far the most extensive class of cases of surgical fever, the inflammatory lesions and manifestations are not confined to the seat of the injury, or to the textures in its vicinity, but are found situated in different and distant organs and parts of the body. Of all inter- nal organs the lungs are those which are the most liable to become the seat of those secondary or metastatic inflammations; and when a careful examination of such cases is made, there is almost always to be detected some morbid condition of the veins in the neighbour- hood of the original wound. Now in the case of patients dying of fever consequent on surgical operations or injuries, you will find, as I have already stated, that very few indeed die of the fever attendant on inflammation confined to the wounded part; and that in the vast majority of cases, the fever is found to have been complicated by the occurrence of inflam- matory changes in other parts—sometimes^ near the seat of the injury, but sometimes more remote; and it is of this latter class of cases that I wish at present more particularly to speak under the designation of Surgical Fever. How is it, then, that surgical patients are so apt to die of this form of fever? In olden times, surgeons would have^been content to believe that the fever resulted from in- flammation set up in the site of the wound, or from sympathetic 11 162 ON SURGICAL FEVER. inflammations, as they Avere called, in other parts. But this idea has been given up since it was found that there was no proportionate degree of intensity between the amount of fever and the amount of inflammation at the site of the surgical wound. A very high degree of inflammation may arise, for instance, in the stump of an ampu- tated limb, and pass on to suppuration and ulceration, while the patient presents but few or no symptoms of surgical fever: and on the other hand, fever may set in and prove fatal in cases where the wound appears to be the seat of no higher degree of inflammation than is necessary to produce adhesion of the opposed raw surfaces. There is not of necessity, either in surgical or in puerperal fever, any relation of intensity between the local lesion and the constitutional malady, and there is no surgeon or pathologist, so far as I know, who now seeks to find in the former the only cause of the latter; for all are rather inclined to the belief that they are both effects of of one common cause, that cause being some toxic or diseased con- dition of the circulating fluids. In smallpox, measles, dothinenter- itis, and some other natural fevers, if I may be allowed to call them so, where likewise a constitutional fever and local inflammations are found associated together, we no longer believe that these, viz., the general fever and the local inflammations, stand to each other simply in the relation of cause and effect. Doubtless the fever may be aggravated by the severity of the local lesions, but they are both in the first instance excited and engendered by some morbid material circulating in the blood; they are both due in each particular case to some peculiar form of toxaemia. They do not stand to each other in the relation of cause and effect, but are both the effects of one common cause—the special toxaemic state of the blood. And in sur- gical patients, too, the blood may become poisoned and perverted in its nature: and it now remains for us to inquire by what means the blood becomes altered, or what are the changes which it under- goes, and which excite in the patient such a fatal fever and so many local lesions. But I must postpone the consideration of this part of the subject until we meet here again. LECTURE XIII. ON SUEGIOAL FEVER—ITS iETTOLOGY AND SEMEIOLOGY. The 2Etiology of the Disease. Gentlemen : As in other febrile diseases, so in the case of Sur- gical Fever, we classify the causes which produce it according as they are, 1. Predisposing, or, 2. Exciting. ITS AETIOLOGY. 163 I. Predisposing Causes.—When I speak of the predisposing causes of the disease, the vitiated atmosphere of hospitals, the bad habits and unhealthy occupation of patients, their impaired nutrition, their debility from long previous disease, or depression from sudden injury, the nervous shock of a severe operation, and other kindred evils, will all occur to your minds as so many predisposing agencies, which may each and all prove sources of danger for any particular individ- ual. And keeping that in view, you will readily understand how it is that this disease is relatively so frequent and fatal among hospital patients, and why it should be more common in large toAvns than it is in country districts. But along Avith and in addition to these pre- disposing causes perhaps there is another source of danger, not so self-evident as these, yet present to a greater or less degree after operations and injuries, and dependent on the altered condition of the blood. When patients have been subjected to surgical opera- tions and injuries, a disturbance seems generally to take place to a greater or less extent in the interchanges Avhich should go on between the constituents of the blood and the injured textures, and in the case of amputations, more particularly, various substances come to be retained in the circulating fluid, which ought to have been appro- priated to the nutriment of the limb that has been lost: the chemis- try of the blood becomes, for the time, disordered and deranged, by this and by the agency of the preceding predisposing causes, which I have named ; and further, it appears to be disordered and deranged principally perhaps by the morbid retention and accumulation of secretory and excretory matters within it. The testimony of Dr. Chevers is strikingly corroborative of this vieAv ; for he has pointed out in the paper to which I have already referred, that the liver, the spleen, and above all, the kidneys (those organs which are chiefly concerned in the formation and purification of the blood), showed evidence of previous chronic disease in three-fourths of all the cases of surgical fever, where the results of the post-mortem examination in Guy's Hospital had been kept. You will be better able to appre- ciate the importance of this source of predisposition, when you know something about the II. Exciting Causes.—-We have just seen how it is that the blood of surgical patients may come to be loaded with matters which readily decompose and give rise to febrile phenomena; and our next inquiry must have reference to those materials which get into the blood, and act as ferments in throwing these retained excretory and probably highly azotized matters into a state of decomposition, and so act as the immediate or exciting causes of surgical fevers. Now, here you will find that there are two morbid materials which have been re- garded as pre-eminently capable of producing that sort of fermenta- tion ; if in accordance with the views of some high modern—as well as ancient—authorities, we may so term that change, which consti- tutes the toxaemic cause and essence of surgical and other fevers. And these are, 161 ON SURGICAL FEVER. 1st. Septic Matters absorbed from the Wound.—Some pathologists have been content with the idea that when the wound becomes inflamed, and the inflammatory action passes beyond the purely adhesive stag", a depraved or decomposing fluid is liable to be pro- duced, which may become absorbed, and exert a zymotic influence on the fermentable matters already present in the blood. In some instances the rigor and commencement of the fever follow almost too rapidly after the operation to have allowed of any true inflammatory products to haA'e been generated in the Avound; certainly too soon for pus to form. But, perhaps, the Avhole pathological mechanism of the disease in relation to its origin in the absorption of septic or other matters, and otherwise, will be better understood by you by contrasting it with some toxemic malady, the nature and course of which is better known. Let us take, for example, an illustration I have already named, viz., smallpox. Smallpox (like surgical fever) is generally, if not universally, acknoAvledged to depend upon a spe- cial toxasmic or diseased state of the blood, as its pathological cause or essence. 2. As a result of this morbid or toxsemic state of the blood there occur, in both diseases, two sets of symptoms or conse- quences, the one constitutional, the other local. 3. The constitu- tional symptoms or consequences in both affections are a special form of fever. 4. The local symptoms or consequences in both affections consist of acute disseminated inflammations ; in smallpox on the skin and mucous surfaces, in surgical fever in various and different internal organs. Inoculated smallpox is further, I believe, analo- gous to surgical fever in this respect: that in both maladies the diseased action takes its origin from a Avounded surface, and by the absorption of a septic poison from that surface. Both require ma- terials to exist in the blood or body for their respective poisons to act upon ; and in the case of smallpox, if these materials have been already exhausted by a previous attack of the malady, no consequences follow the admission of the septic poison into the blood. We do not in the least degree yet know upon what the septic or poisonous pro- perty of inoculated smallpox matter depends; nor are we at all acquainted with what forms the peculiarity of the septic matter in surgical fever. 2d. Pus absorbed into the Bloodvessels.—Some pathologists have held that pure pus is absorbed as pus from the wound, and gives rise to the febrile symptoms either by its own decomposition or by the decomposition Avhich it produces in some of the matters circulating there. No point in connection Avith the pathology of surgical fever has been more disputed than the question as to whether pus, as such, ever becomes absorbed from a wound and mingles with the circulating fluid. As obstetricians, Ave know that the passage of pus into the blood is not at all a necessary condition for the develop- ment of fevers attended with local purulent inflammations. For Ave occasionally meet Avith cases where the foetus in uteri is attacked by a morbific agent which leads to the development of a multitude of ITS ETIOLOGY. 165 disseminated abscesses over all parts of its body. We know, in other words, that the foetus, Avhile still in the mother's womb, may be at- tacked Avith smallpox; and yet there is no direct vascular communica- tion between the mother and the foetus—there is no interchange of blood-corpuscles between them—and there can occur no transition of pus-corpuscles from the maternal to the fcetal bloodvessels. But some finer form of morbific agency than pus must pass from the maternal into the fcetal system; and arguing from such facts as these, those sur- geons and pathologists are justified in their opinion, who hold that the absorption of pus from a wounded surface is not necessary for the pro- duction of a general fever, like surgical fever, accompanied with se- condary local inflammatory lesions. Those who hold an opposite view tell us that in such cases pus-corpuscles are found in the blood, and they ask how it comes that these get there, if they have not been ab- sorbed from the suppurating wound. Here, however, I must remind you that the cells in question are not of necessity to be regarded as pus-corpuscles. For, as you know, the pus-corpuscle differs so little in microscopic appearance and chemical reaction from the white or colourless blood-corpuscle, that the only ground of distinction which the best histologists can discover between the two, lies in the situa- tion in Avhich the body is found. You know further that there are a variety of cases in which the number of colourless corpuscles in the blood comes to be greatly increased, and that there is one con- dition common to all those cases, whether they be morbid or more normal, viz., a temporary or more permanent enlargement of the spleen or lymphatic glands, or of other glands or textures in Avhich the corpuscles are constantly being developed. In the much-debated leucocythsemia, you have an instance of this condition becoming per- manent and usually fatal, and depending in one set of cases on en- largement of the spleen, in another on enlargement of the lymphatic glands, while in a third set of patients both kinds of glands are found to be simultaneously affected. A temporary increase of the number of Avhite blood-corpuscles, or leucocythosis, as Virchow has designated this condition, is seen in females during pregnancy, and soon after delivery, and in them there are important changes in the uterine organs, and enlargement of the pelvic glands. In all individuals, indeed, according to some of our latest physiological observers, this condition is established after every meal, and may be traced to the enlargement that then takes place in the mesenteric glands. It need not, therefore, surprise us to find in patients affected with surgical fever that the number of the colourless corpuscles in the blood is greatly multiplied, seeing that in such cases there is almost ahvays more or less inflammatory excitement and enlargement of the cellular tissue at the seat of the injury, and of the lympha- tic glands in the vicinity, and very frequently some acute morbid change in the liver, kidneys, or spleen, as Avell; and we need not have recourse to the hypothesis of an absorption of pus-corpuscles from the wounded surface, to explain the phenomenon of the large 166 ON SURGICAL FEVER. number of pale granular cells, with one, two, three, or more nuclei found circulating in the patient's blood. It may be that some por- tion of element of the liquor of pus, or some material resulting from its disintegration, comes to be absorbed from the wounded surface, and acts the part of a ferment in the blood ; but whatever it may be, in can certainly not be the pus-corpuscles. Now are we to regard them as the Cause of the Secondary Deposits and Abscesses, or collections of purulent matter that we occasionally see in cases of surgical or puerperal fever in the lungs, spleen, liver, &c. ? For, independently of the two facts, 1, that pus-corpuscles are not, as a general rule, taken up at all by the bloodvessels, and only are found there in those exceptional cases where a vessel is directly broken into by a purulent collection originally formed outside of its walls; and 2, that the lining membrane of veins is apparently, from all late evidence, incapable of secreting pus, we find that there is no pus at all in those secondary abscesses in their first stage. In truth, those disseminated centres of disease which we meet with frequently in the lungs, spleen, kidneys, and other organs of patients dying of sur- gical and puerperal fever, are not to be regarded as genuine abscesses resulting from a simple inflammation in the parts; but the opinion is gaining ground that we have here to do Avith two forms of the multiplication of disease. Either, firstly, they are due to a vital alteration or destruction of the part, resulting from the impaction of some material in the afferent bloodvessel, which has been brought from the veins at the seat of the injury, and been here arrested or filtered out; or, secondly, they may be produced by the mis-secre- tion of some finer material Avhich Ave have no physical means of re- cognizing, and which, in its effects and irritant mode of action, has more affinity with chemical substances. There is, if I may so express it, a mechanical or physical, and a chemical or secretory metastasis. 1. Mechanical Metastasis. Embolism.—In very many instances the blood in the veins at the seat of a wound in the case of surgical fever, like the blood in the veins of the uterus in the case of puer- peral fever, becomes, as Dr. Wise has expressed it, '.'consolidated." This "consolidation" or coagulation of blood, which has been care- fully investigated by Virchow, and described by him as thrombosis, is not confined to that contained in the smaller veins, but is con- tinued on to that in the vessels of largest size, and according to the further changes that occur it may lead to the production of metas- tatic inflammatory centres of disease in one or other of two different ways. First, the " consolidation" of the blood may go on in a vein up to the point Avhere it opens into one of larger calibre without pro- ducing any further injury. But should the process still go on, as is so frequently the case, then from the superposition of fresh fibrinous layers, the clot or "thrombus" comes to project into the cavity of ITS .ETIOLOGY. 167 the larger vessel in the manner shown in the annexed woodcut from Virchow's late very masterly work on cellular pathology (see Fig. 50); Fig. 50. "Thrombi arising in one vein, and passing continuously into another, c c'. Smaller, varicose, lat- eral twigs (vense circumflex^ femoris) filled with autochthonous thrombi, which stretch beyond the ostia into the trunk of the femoral vein. t. Continued thrombus produced by concentric apposition from the blood. V. Appearance of a continued thrombus after separation of some pieces (emboli) has been effected." (Virchow.) and then you can readily understand how in some movement of the body, or from some other accident, this projecting cap may become detached and be carried along in the circulating stream, only to be arrested at the bifurcation of some subdivision of one or other pulmonary artery. (See Fig. 51.) This transport of bodies in the blood and their final arrest in the smaller vessels, are phenomena not confined, by any means, however, to the venous system, for they are met with also in the arterial sys- tem, and sometimes of a large size, in cases of vegetations on the aortic valves, of atheroma in the larger arteries, and such like. These travelling bodies have been, as you know, termed "emboli," and their impaction with its results have been summed up in the designation of " embolism." When such an embolus gets arrested, as they most commonly do, at the bifurcation of an arterial trunk, neither of the branches of Avhich are large enough to allow them to pass, the immediate result is that the sup- ply of blood to the part beyond the obtu- rated vessel is greatly diminished or alto- gether cut off; and this is speedily followed by an infiltration of blood into all its tis- sues. The way in which this infiltration of blood into the tissues of a part, whose vascular supply has been suddenly diminished or cut off, takes place " Embolism of the pulmonary ar- tery. P. A medium-sized branch of the pulmonary artery. E, the em- bolus, riding on the fork of the di- viding artery. 11'. The enveloping (secondary) thrombus, t. The por- tion in front of the embolus reaching as far as the next collateral vessel (c) above it. V. The portion behind the embolus, nearly filling up the branches r r', into which the artery divides, and at last ending conical- ly." (ATirchow.) 168 ON SURGICAL FEVER. Fig. 5S A. has not been satisfactorily explained; but the result is that either the part becomes gangrenescent, and is separated by a demarcating inflammatory process, as gangrenescent parts usually are, or it be- comes the seat of an induration and degeneration which effectually, destroy its functional activity. The great majority of the so-called secondary or metastatic "abscesses" seen in the lungs of patients dying of surgical and puerperal fever, are simply instances of gan- grene with its results as produced by embolism of the pulmonary arteries. But, secondly, where the emboli are of smaller dimensions, the impaction takes place in vessels of a smaller calibre, or what has been designated "capillary embolism," becomes established. In this case also the thrombosis gives rise to the foreign body, but in a different man- ner. The thrombus, instead of groAving onwards towards the centre of the circu- lation, undergoes a variety of changes. In the first place, the red corpuscles lose their vitality and part Avith their hgematin, which escapes and becomes diffused all around, and in this way the clot becomes decolorized. Then these same corpuscles break down, and the fibrin becomes dis- integrated and dissolved, Avhile the colour- less corpuscles remain still unchanged, so that the softened mass presents a decep- tively puriform appearance. Now, if some portions of such softened thrombi get by some chance into the circulating fluid, they will be carried first of all to the lungs, Avhere the grosser particles will be filtered out, and lead to the changes already ad- A-erted to ; while the finer particles may pass through both sides of the heart, and lead to the production of capillary embolism, so minute as to be readily overlooked, in various other organs of the body. With reference to this point, Professor Beckman, of Gottingen, has made some interesting observations on the kidneys of persons dying of surgical and puerperal fever ; and has almost invariably detected the existence of great numbers of minute emboli in kidneys which presented to the naked eye only the appearance of small ecchymosed or purpurous spots; and it still remains for further investigation to show how far those inflammations of the liver, spleen, and kidney, which are found in such cases, may be due to this capillary embolism, or to some more subtle and refined morbific agency. " Puriform debris of softened thrombi. A. The various large pale granules of the disintegrating fib- rin. B. The colourless blood-cor- puscles set free by the softening, and in part degenerated, a. With several nuclei, b. With single, an- gular nuclei and several fatty gran- ules, c. Without nuclei (pyoid) and in a state of fatty metamorphosis. C. Blood-corpuscles becoming de- colorized and disintegrated." (A'ir- chow.) ITS iETIOLOGY. 169 2. Secretory Metastasis.—There is another common mode by which inflammatory action seems liable to be set up in various parts of the body, namely, in surgical fevers and other toxsemic diseases, and particularly on serous and synovial surfaces, in consequence of the local deposition and irritant effect of some morbid material or mate- rials circulating in the blood. The effects produced by such a materies morbi and its mode of action become intelligible, as it seems to me, by studying the manner in which acute secondary inflammations are produced, as so very frequently happens, in the case of patients affected with Bright's disease of the kidneys. I think we can see our road to the explanation in this Avay. When a patient with albu- minuria takes diarrhoea, we find that the dejections are loaded with urea; and seemingly for this reason—viz., that the urea, accumulated in some conditions of this affection in morbid excess in the blood, does not escape through its ordinary channel, the kidneys, which are in a state of disease, but becomes mis-secreted or mis-excreted by the mucous membrane of the intestinal canal, upon Avhich mem- brane urea acts the part of an irritant, and excites there an inflam- matory serous or Avatery effusion. Urea is not an irritant to its natural emunctory, the kidney, but it is a strong irritant to some mucous membranes, and to serous surfaces and other tissues. Pleu- ritic and pericardiac effusions are very frequent in cases of Bright's disease; and when such effusions have been examined chemically and early, they have been found to contain a large amount of urea. There is a quantity of effete matter in the blood, of which nature has to get rid; and the ordinary channel of relief being shut up, this matter is throAvn out upon the pleura, &c, where it acts like blisters applied to the skin, and produces a more or less intense degree of inflammation. In rheumatic fever, pericarditis, &c, is probably lighted up by a similar mis-secretion into the pericardium of the accumulated lactic acid, a poison of rheumatic fever, whatever it maybe. Studying the secondary lesions of surgical and puerperal fever with this key, we may yet perhaps find the explanation of some of the common and acute forms of secondary inflammatory lesions and effusions observed in these diseases—as those inflammations of the pleura, joints, &c. which end so rapidly in sero-purulent effu- sions—to be produced and set up in the first instance by the mis- secretion 6r elimination upon the inflamed surfaces or at the inflamed spots of morbid materials existing in the blood, and capable, when thus localized, of lighting up acute inflammatory action by their presence as local irritants. There is another question on which I would beg to make one or two observations—viz., in addition to the conditions already stated, are there any other appreciable circumstances determining the seats of the inflammatory changes and effusions in Surgical fever ? Now there are many facts in pathology Avhich seem to prove that in cases of febrile and other forms of toxaemia, the resulting inflammatory action is specially liable to become localized and lighted up in any 170 ON SURGICAL FEVER. parts or organs that are temporarily weakened and depressed in their vital force and powers. Thus boils, erysipelas, &c, are apt first to break out upon, or in the immediate neighbourhood of parts recently hurt and injured. I have known a patient attacked with smallpox Avho shortly before had required to get the knee blistered. The eruption was very thin and sparse everywhere, except upon this knee; but its still damaged and debilitated cutaneous tissues Avere covered with concrete pustules. In a similar case Dr. Budd saAv the smallpox eruption covering in an almost confluent form the nates, which shortly before had been contused by a fall; and everyAvhere else on the surface of the body they Avere discrete and very few. In puerperal fever, probably on the same principle, the inflammatory changes and effusions are usually greatest in the uterine organs and peritoneum, which have been temporarily depressed and damaged by the process of delivery. And in cases of surgical fever, one marked seat of the attendant inflammations is in the wound, and in its neighbouring parts, particularly if these parts happen to be one of the great serous cavities of the body. SEMEIOLOGY. Such being the different modes in which the secondary lesions are produced, the question next occurs—How are we to recognize the onset of an attack of surgical fever ? And to enable you to ansAver this question for yourselves, I must point out to you, shortly, the most common and constant symptoms of the disease. 1. Rigors.—The patient whose history I first read to you had, as you must have observed, a rigor about thirty or forty hours after the time of the operation. Now, whatever may be the physiological explanation of this phenomenon—and many explanations have been given, which it were more curious than practically interesting to dwell upon—a shivering fit of greater or less intensity, and of longer or shorter duration, is common to all the various forms of surgical fever, and is the first and one of the most common symptoms of the occurrence of the disease. You must not expect, however, to find every attack of surgical fever ushered in by rigors ; for in some cases it would appear as if they neArer occurred at all, and in others they are so slight as to be readily overlooked. But still the occurrence of a rigor in a patient who has been subjected to any operation, should at all times make you alive to the probability of an attack of fever, and then the next point to be attended to is, 2. Acceleration of the Pulse. Respiration.—For next to the ri^or the rapid rise of the pulse is the most common indication of the onset of the disease ; and is its most constant and most pathognomonic phenomenon throughout its course. Every medical man who is told that a surgical patient has had a shivering fit, at once puts his finger on the patient's pulse to ascertain whether it be in any degree ac- celerated. If he find that it is up, and beating from 100 to 120 SEMEIOLOGY. 171 strokes in the minute or oftener, he knows at once that some mis- chief is going on ; and generally speaking, the case is dangerous according to the degree of exaltation of the pulse. In some cases it runs up early to even 130,140, or more. It is generally more weak as well as more rapid than usual. The occurrence of a rigor, and sudden and marked acceleration of the pulse are, then, the two most constant indications of the occurrence of surgical fever. Dyspnoea and accelerated laborious respiration often come on in the course of the disease, and are always most unfavourable phenomena. The other symptoms are all subject to much variation, and depend on the, . . mi t i 3. State of the Tongue, Skin, ^c—Most practitioners will look at the tongue to see in what state it is; but it varies so much m different patients affected with this disease, and is so liable to be affected according to the predominance of some of the minor lesions or morbid conditions, that we cannot regard any particular condition of the organ as characteristic of surgical fever. When glazed and dry, it presents itself to us in its worst aspect, and continued moist- ure'and softness of the tongue in any case make us always more hopeful of our patient's recovery. The colour and condition of the skin are likewise variable. In some cases it becomes moist, and is covered with a perspiration which you might suppose to be critical and beneficial, but which in reality is not so. When suffused with such perspiration the surface is usually cold; in other cases it is some- times cold to the touch, sometimes burningly hot. Not unfrequently the skin takes on an unusual dingy yellowish tint, or becomes leaden- coloured or icteric. As regards the nervous symptoms, you will find that there is usually great depression from the first; and in some cases low muttering delirium sets in early, and is always to be looked on as a very unfavourable symptom. Sickness and vomiting are very common occurrences; especially where the primary lesion is in any of the abdominal organs, and was seen in both of the cases in our Avard. Diarrhoea is a frequent complication. These symp- toms of surgical fever, I repeat, are all subject to the greatest varia- tions, but in no case will you find a slow and steady pulse. Signs of the Secondary Lesions. The secondary or metastatic inflammations are not usually so in- tense in character as to lead to the development of any very marked symptoms. They are often masked and merged in the general phe- nomena, and may be altogether overlooked. Nor is their detection Z every case a matter of vital importance The supervention of inflammation in any organ will usually be indicated by some derange- ment in its functional activity. Thus, if the lungs have become affected the patient will most likely have slight cough and expecto- ration and will complain of stitches in the side. But this is no necessarily the case; and great effusions may occur into the pleural 172 ON SURGICAL FEVER. cavity, for instance, Avithout the production of any marked symp- toms. Auscultation and percussion would, of course, serve to detect such a condition; but the patient is often too weak to allow of our subjecting him to the ordeal. LECTURE XIV. SURGICAL FEVER —ITS TREATMENT. Gentlemen : On the treatment of surgical fever I do Avish that it were in my power to state something more precise and certain than it is possible for me to offer you; but the whole subject forms a topic regarding which few or no definite and determinate principles have yet been established. We may divide the treatment, however, into two great departments, namely, first, the prophylactic or preventive treatment of the disease; and, secondly, the curative treatment of the malady after it has once commenced. In this, as in other cases, the prophylactic will ultimately, in all probability, come to be of more moment and of more practical import than the curative treat- ment. But as yet, I repeat, Ave know too little of either. I. The Preventive or Prophylactic Treatment. A variety of propositions have been suggested by surgeons at dif- ferent times with the view of preparing patients against the contin- gencies and dangers of surgical operations, or rather against the chance and danger of surgical fever supervening after these opera- tions. 1. Date of Operating.—The question, for example, has been agi- tated as to whether it was right and advisable to proceed to amputa- tion immediately in cases of traumatic or gunshot injury requiring that operation, or Avhether it Avas safer to postpone the operation for thirty, sixty, or more hours subsequently. This constitutes, as you are aware, the essence of the discussion that was carried on among military surgeons for many years as to the eligibility of primary or of secondary amputations among soldiers wounded in battle. It seems now generally decided that the chances of the recovery of the wounded patient are greatly increased, and consequently the chances of sur- gical fever greatly diminished, by the damaged limb being amputated at once ; instead of that operation being postponed and delayed for two, three, or more days. This principle probably applies to cases of traumatic injury in civil as well as in military practice. But, again, many of our best hospital surgeons have thought in re- gard to chronic cases requiring surgical operation, that it was better ITS TREATMENT. 173 and safer not to operate till the patient Avas acclimated to the hos- pital by a residence in it of a few days' duration. Others, however, act upon the opposite rule, and operate as soon as the patient enters the hospital, believing that a state of anxiety kept up for some days is liable to damage the patient's constitution and likely to decrease his chances of recovery. I am not aAvare that any extensive obser- vations have yet been made tending to settle either on one side or the other the question of the advantage or disadvantage of a short preparatory residence in hospital as a protective against the chances of surgical fever. This question of predisposition to surgical fever may perhaps be stated in other words, thus: Is not the patient more predisposed to surgical fever Avhen his blood has become dete- riorated and charged with effete organic matters, from being allowed to remain unoperated upon for some days after a severe traumatic injury; or in chronic surgical cases, from being allowed to live for a time in the vitiated air of an hospital before being subjected to the surgeon's knife ? 2. Preparation by Previous Restraint.—Patients previously in a state of comparative health are sometimes apt to have more or less constitutional disturbance if they are suddenly and inevitably con- fined to bed; and particularly if they are restrained in one fixed and unchangeable position. They pass through, in other words, what some old surgeons have called "bed-fever." Now there are some operations in surgery, and those of a kind which*, though slight in themselves, are apparently specially liable to be followed by danger- ous consequences, Avhere the patient, from the hour of the operation, is of necessity fixed and restrained in one position. Such an opera- tion is that otherAvise seemingly simple one of removing loose car- tilages from the cavity of the knee-joint. Listen to the sagacious prophylactic treatment which a London surgeon, Mr. Young, used formerly to apply to such patients as he operated on for this affec- tion. I quote the account from Mr. Twer's work on Constitutional Irritation. "A healthy carman," Writes Mr. Young, "came under my care with a loose cartilage in the right knee-joint. It had seve- ral times occasioned him to fall suddenly, and he was very anxious to submit to an operation to get rid of it. It appeared to me desir- able to accustom him, before the operation, to the reduced diet, rest, and restraint which would be necessary after it. He accordingly kept the house. On the second or third day of his confinement I put on the roller and bound on the back splint exactly as I intended to do after the operation, to keep the limb perfectly steady. This confinement of the limb occasioned a restless night, some fever, a Avhitish tongue, a quickened pulse, a little headache, spare and high- coloured urine. He was very unwilling to continue the bandage and splint, to which he ascribed (and justly) all his constitutional dis- turbance ; and the utility of which, prior to the operation, he could not at all comprehend. This circumstance, however, forcibly sug- gested to me the importance of accustoming him to restraint; it was, 174 ON SURGICAL FEVER. therefore, continued; the excitement which it had produced grad- ually subsided, and when I found that the bandage no longer occa- sioned any irritation, I performed the operation. Not one untoward symptom arose, the constitution was not in the least ruffled, and the wound healed by the first intention." 3. Antecedent Dieting.—-It has been proposed to attempt to guard surgical patients against the danger of surgical fever by the antece- dent use of particular kinds of diet, and still more of particular kinds of medicine. Of course, this indication can only be carried out where the surgical operation is for some chronic form of disease or injury, and where this kind of preparatory treatment can be carried on for a week or two, or longer, before the date of the intended ope- ration. Some men, fed in a particular Avay, are specially liable to fatal attacks of surgical fever after even the slightest operations. Their blood is probably permanently supercharged with such excess of fermentable organic materials as readily to undergo those zymotic changes which, as we have seen, apparently constitute the founda- tion and essence of surgical fever. Thus, many London surgeons tell us that the draymen and other servants connected Avith the large breweries in the metropolis, and Avho, as a general laAV, are perhaps in the habit of drinking too much of their OAvn ale, almost all go Avrong Avhen admitted into hospital with surgical wounds or injuries. Is the Irish peasant, fed almost solely on potatoes, or the Scottish peasant fed almost solely upon oatmeal, as liable to fatal surgical fever after surgical injuries? I can adduce no statistical proof in answer; but the general impression seems to be that they stand sur- gical knocks, and injuries, and operations with a Avonderful impunity. We knoAv statistically that the rice-eating Hindoo usually recovers Avith unusual speed and certainty after severe surgical mutilations. There was some time ago published a series of a hundred operations for elephantiasis of the scrotum, an operation which is often most formidable from the great size of the tumour Avhich is removed. In the list I allude to only six or seven, as far as I remember, died. But here, perhaps, the wonderful success that was attained was de- pendent upon the race on whom the operation was performed. For, as a general law, the black races seem to bear injuries and opera- tions with far more impunity than the white races of mankind; that is, they do not apparently fever after them with the same facility or the same intensity. But it is at the same time to be remembered that when epidemic diseases and fevers, such as cholera, yellow fever, &c, once do in reality attack members of the black race, they usually sink more speedily under them than members of the white race living in the same locality. We as yet know too little of the effects of rapid changesin food to be able to say whether any great alteration in the diet of a pa- tient for two or three days before the performance of a surgical ope- ration, is likely or not to have much influence on the result, though the subject is one certainly worthy of a more elaborate considera- ITS TREATMENT. 175 tion than has hitherto been allotted to it. You will find in practice that some surgeons are in the habit of placing their patients on a loAvish table of diet for a day or tAvo before operating. But most of them follow an opposite rule, believing that patients have the best chances of recovery Avhen operated on Avith their constitutions, their blood, secretions, and excretions, unaltered by any previous notable and extreme changes in their food. Perhaps the indication ought to be to attempt to bring the patient as near the normal or natural standard of health as possible, by an improved diet if they are Aveak and asthenic; by a reduced diet if they are plethoric and inflamma- tory. 4. Prophylactic Medications.—Therapeutic prophylactic measures have also, as I have already hinted, been tried with the view of pre- paring surgical patients to encounter the danger of the surgical knife with increased chances of escape and safety. With this view, various tonics and alteratives have sometimes been given to surgical patients before operations to avert the chances of surgical fever aftenvards. No very great or marked results have hitherto attended this form of surgical prophylaxis; and, indeed, we need the less wonder at this, seeing that these experiments haA'e never yet been conducted on any very extensiA'e scale. But I confess that it has always appeared to me that this line of inquiry Avas—in relation to surgical operations—one of the most important to which the "young surgery" of these times could turn its attention. Look at these two patients lying next bed in the same ward ; they are nearly of the same age, and were a few days ago operated on by the same surgeon. One of them has had his leg amputated, and though thus the sur- geon's knife has produced upon his body a great mutilation, and left upon it a great surgical wound, yet his pulse is quiet, his skin is cool, and, in short, constitutionally he seems perfectly well. The other patient, lying within a few feet of him, has merely had a small and simple subcutaneous tumour removed from the surface_ of his thigh—an operation requiring infinitely less cutting, and leaving an infinitely smaller surgical wound. But his pulse is ranging up to 130 or 140, his skin is alternately burning and perspiring, and alto- gether he is suffering under a dangerous, and, probably, a fatal attack of surgical fever. Now, there must have been something different in the two constitutions of these two men before operation ;^ the ex- isting state of constitution in the first patient not rendering him liable to surgical fever, even after one of the severest operations in surgery; the existing state of constitution of the second patient ren- dering him, on the contrary, liable to be attacked after a very small wound, and a slight application of the surgical^ knife. The great question for solution is, could we by any artificial means, adopted beforehand, produce in all our surgical patients that defiant or re- sistant state of the constitution which enabled that first patient with the amputated limb to bear with impunity, and without danger from surgical fever, the severe surgical operation to which he has been 176 ON SURGICAL FEVER. subjected? Or, in other Avords, could we by any antecedent means so change, improve, and fortify the existing state of constitution of the second patient, as to make him bear Avith impunity the applica- tion and effects of the surgeon's knife? The problem is a practical problem, not so impossible in its nature and principles as to prevent us making earnest and anxious attempts at its solution ; and, avIio- CArer could successfully solve it for the prevention of surgical fever in surgical patients, or, let me add, for the prevention of puerperal fever in puerperal patients, Avould, in my opinion, make one of the greatest advances that could possibly be effected at the present hour in the onward march of medical science; because it is one that would probably save more human lives in surgical and obstetric practice than any other one single discovery. Various alteratives and tonics, as I have stated to you, have been tried, with this prophylactic intention, but none of them on any great scale, or with any great degree of perseverance. With this view, patients have, preparatory to operations, been placed upon doses of disulphate of quinine, of chlorate of potass, &c. You all know that Mr. Hamilton Bell, and other practitioners in this city, have of late years been led to place great reliance upon the curative powers of tincture of the muriate of iron in cases of erysipelas. In many points, there is a strong analogy, though by no means an identity, between the compound febrile and inflammatory character of surgical fever and of erysipelas. Arguing thus, I long thought that muriate of iron if given as a prophylactic against surgical or puerperal fever, might probably contribute to prevent the constitu- tion being attacked Avith these diseases; seeing that it Avas one of the simplest means of getting rid of the analogous erysipelatous af- fection after it had once begun. For about eighteen months before he retired from the position of operating surgeon to the Royal Infir- mary, my friend Dr. Dunsmure Avas so good as to place, at my sug- gestion, all the patients whom he operated upon, and in Avhom there Avas time to use such prophylactic measures, upon doses of muriate of iron given two or three times a day. Dr. Dunsmure has repeat- edly assured me, that after adopting this prophylactic measure, his surgical patients seemed to him to- recover better and with fewer threatenings of surgical fever than at any previous time during his connection Avith the hospital. All this might be a coincidence, but Dr. Dunsmure's own impression was that this favourable result was a consequence of the therapeutic measure Avhich he thus employed. Of course a far more extensive experience is required to establish this as a fact, and far more certain and successful prophylactics may be found than the tincture of the muriate of iron. Allow me only further to observe that if the views which I have attempted to give you of surgical fever be in any degree correct, these prophylactics Avill probably consist of therapeutic means capable of sustaining in their fullest activity the secretory and excretory functions of the system, and thus of keeping the blood itself as free as possible ITS TREATMENT. 177 from any over-accumulation within it of unnecessary and effete or- ganic materials. And no doubt the greater accumulation there is of effete matters in the blood at the time Avhen fever happens to be set up in the system by the imbibition of any septic poison, the greater is the peril attending the febrile action. This is true even when the existing effete matter is not the organic material upon which the imbibed zymotic poison specifically acts. Smallpox, for example, scarlatina, and measles, have specific predisposing mate- rials upon which these different poisons severally act, these specific predisposing materials being, as a general law, exhausted in the economy by one attack of these special fevers. But when the poi- son of any of the diseases which I have just named enters the body of ,a woman in the puerperal condition, and consequently at a time when her blood is temporarily overcharged with an unusual excess of organic materials in a state of retrograde metamorphosis, in con- sequence of the rapid absorption of the involving uterus, &c.; then the febrile action which supervenes is usually so extreme in its degree as almost always to prove speedily fatal. Hence, smallpox, scarlatina, and measles, are ten or twenty times more disastrous and dangerous in the puerperal state, than in the common normal state of the system. 5. Purer air of country, of home, $c.—Among the prophylactic measures against surgical fever, there is a series which from their great importance I ought to have mentioned earlier, I mean all those which are calculated to enable the patient to breathe the purest pos- sible air, and to burn off in the way of respiration any excess of effete organic material which is removable by that channel, and that might otherwise accumulate within the circulating system. Surgical patients no doubt recover in greater numbers when breathing the pure air of the country, than the more vitiated air of the city, and when operated on at home, rather than in the close and crowded wards of a hospital. I have often taken occasion to ask of country surgeons the results of their greater operations, such as amputations, and been astonished at the small proportion of losses which they met with in comparison with the mortality accompanying the same operations in our larger hospitals. Many years ago, Mr. Wardrop, of London, published some observations, in which he suggested that the great success attendant upon surgical operations, in country practice, was explicable by the circumstance, that owing to less assistance being at hand in country than in town operations, exces- sive bleeding more frequently happened in the former at the time of operating. This unintentional bloodletting was, according to Mr. Wardrop, the cause of the greater success of country than of town operations. In these anti-venesection days, I doubt if such an ex- planation could be at all admitted, and besides, I doubt, on the whole, whether in these more educated days most surgical operations are not as well and adroitly performed by those country practitioners who undertake them, as they could possibly be elsewhere. We know 12 178 ON SURGICAL FEVER. that when all precautions as to placing surgical patients in abund- ance of free and fresh air are set at naught, and when many are crowded together into a small Avard, the worst forms of surgical fever, with hospital gangrene, spread rapidly among the unhappy inmates. You can thus create and manufacture the disease almost at will, by directly disregarding and neglecting all cleanliness and purity of air; and it may yet come to be a question whether Ave should not give, on the contrary, our surgical patients a greater chance of escape by changing our large hospitals into villages, and the palaces of which they consist into cottages, than by adhering to the present system of erecting for their reception houses built Avith wards above wards. Perhaps, even, hospital wards get deteriorated by long use, and the emptying, cleansing, and whitewashing of them from time to time is, no doubt, a prophylactic measure of paramount importance. Old surgical hospitals, and old surgical wards seldom offer such good returns from practice as newer hospitals and newer surgical wards. 6. Particular seasons, §c. preferable.—Under the sway of old- world wisdom and experience, many ancient surgical authors recom- mend all operations admitting of delay to be postponed till the return of the more healthy seasons of the year, believing, as they did, that the convalescence of surgical patients was more favourable in summer and autumn than in winter and spring. Some modern continental surgical writers still repeat the same prophylactic advice. British surgeons, perhaps, look upon all such advice Avith too much carelessness and contempt. But do not despise a single atom of human knowledge that gives you any chance of saving a human life. Most medical diseases are somewhat more severe, and the convales- cence from them somewhat more slow and unfavourable in this coun- try during the prevalence of the east wind. Why, when it is avoid- able, should we unnecessarily submit surgical patients to the increased dangers of surgical fever at such times. In some localities, on the contrary, during particular winds, the community becomes greatly healthier than at other times and seasons. Thus Dr. Winterbottom long ago stated, that in Sierra Leone and its neighbourhood, during the blowing of the Harmattan wind, intermittent and remittent fevers straightway cease, and it is impossible to spread smallpox even by direct and repeated inoculation. Mr. Horton has confirmed to us the truth of these observations. The Harmattan wind blows usually for five or six weeks. Its great characteristic is its great dryness, for it has passed over the arid and rainless desert before it reaches Sierra Leone, and other parts of the west coast of Africa. I am not aware whether surgical operations prove specially success- ful during its prevalence; but probably it is so, as ulcers are averred to heal rapidly during its continuance. 7. Communication by contagious inoculation.—Surgeons have hitherto scarcely, or indeed not at all attended to a kind of prophy- lactic which ought to be to them of great importance, provided sur- ITS TREATMENT. 179 gical fever is so analogous as I believe it to be to puerperal fever, as to be capable of being propagated by similar means. Almost -all English accoucheurs believe that occasionally puerperal fever is lia- ble to be communicated by the medium of the medical practitioner from a patient already attacked to a person in labour, being spread from the diseased to the healthy by the accidental inoculation into the latter of morbid inflammatory secretions thrown out in the course of the disease in the body of the former. The evidence of the truth of this fact, as far as regards the communicability of puerperal fever, is, I think, quite overwhelming to any unprejudiced mind; and the neglect and defiance of it are constantly leading to unnecessary because avoidable mortality, particularly in the practice of conti- nental obstetric hospitals. Do the surgeon or his attendants after handling the wounds of patients labouring under surgical fever, or coming in contact with their discharges and any zymotic poison or poisons contained in them, and immediately afterwards touching recent surgical wounds in new patients, ever inoculate into these recent wounds a zymotic poison capable of stirring up surgical fever in the new surgical patient, supposing he is otherwise predisposed to an attack of the disease ? I believe that surgical fever is often enough propagated in this way, just as puerperal fever is. Surgeons will tell you that they have occasional runs of bad luck among those # on whom they operate. In other words, they have surgical fever occasionally in their practice, and are spreading it from patient to patient; and ought, under these circumstances, to do what I once heard of a distinguished English surgeon doing, viz. locking up his knives for some weeks. They should, like the accoucheur, under similar circumstances, suspend their practice for a time. Perhaps surgical fever is spread in this way in hospitals by surgeons them- selves, by dressers and nurses, to a degree that at present is not yet dreamt of. But prophylactic measures against surgical fever may be employed not merely before and during operations, but after them. In all cases there is an interval between the date of the operation and the date of the attack of the disease. This interval may be an interval of hours, or an interval of days. During it various of the prophy- lactic measures of which I have already spoken in the way of ven- tilation, regimen, &c, require, of course, to be enforced. Above all the patient, as an important prophylactic measure, must be kept perfectly quiet, and as free as possible from all excitements and causes that could irritate either the vascular or the nervous system. It is with this view that some surgeons, particularly after great ope- rations, are in the habit of giving their patients a full dose of opium. They usually content themselves with the exhibition of a single dose. But if it is thus of use why not keep the patient under the influence of the drug, not for twelve or twenty-four hours only but for some days? In the treatment of patients after the operation for vesico- vaginal fistula, I have already spoken of the safety and success 180 ON SURGICAL FEVER. which attends the practice of keeping the patient on small and often- repeated doses of opium or morphia for a week or ten days from the time of operating. In some operations as the operation for stran- gulated hernia, this practice would surely be attended with happy results; and indeed after all operations, of any greater severity it would have this beneficial result at least, that when the drug agreed it would keep the patient quiet and comparatively comfortable dur- ing the tedium and ennui of the first week or so of the inevitable condemnation of the surgical patient to his bed. But we must hasten on to say a few words regarding the curative Treatment of Surgical Fever. SURGICAL FEVER—ITS CURATIVE TREATMENT. This curative treatment of surgical fever may be divided into local and constitutional measures. A. Local Curative Measures. These are all so far antiphlogistic in their object, but include again two varieties, viz : 1. Measures directed to the primary wound or lesion ; and 2. Measures applied to any part or organ which may chance to become the seat of any of the secondary inflammations. 1. Local measures at the seat of the primary wound.—I have already taken occasion to state to you that in instances of surgical fever, the primary wound does not necessarily show any special or exaggerated amount of inflammatory action in it. In other instances there are appearances of the wound becoming over-excited and in- flamed, if not before the surgical fever, at all events shortly after the first rigor, and after the first symptoms of rise in the pulse and of heat in the skin. Surgical fever, as I have already tried to ex- plain to you, consists essentially of a morbid or toxsemic condition of the blood, which produces as its double and contemporaneous effects, first, constitutional fever; and secondly, acute local inflam- matory changes in various internal organs. Again, we found that this morbid or toxsemic condition of the blood was itself the result of the conjoint action of two morbific causes, viz : first, the absorp- tion or entrance into the blood of some septic or zymotic material from the site of the primary wound; and secondly, the presence in the circulating mass of some effete or other organic matters accumu- lated in the blood, and ready to be thrown by the absorbed septic material into that state of organic decomposition, or, at least, of organic alteration, which chemical pathologists tell us resembles fer- mentation, and which many of them believe to take place in all other specific febrile diseases. This septic poison of surgical fever we saAv good reason to believe, was certainly not simple pure pus, as many pathologists had imagined; for, 1. It was sometimes formed before ITS CURATIVE TREATMENT. 181 suppuration had time to come on. 2. Pus was not secreted, as was at one time supposed, by the lining membrane of veins opening upon Avounds, or attacked with phlebitis, and was not from thence passed into the circulation. 3. The white globules seen in the blood of surgical patients were not pus globules, but the common colourless corpuscles of the blood. 4. The white matter found in the ob- structed veins at or near the seat of primary wounds was not puru- lent matter, but only decolorized, changed, and broken-down blood. And lastly, I might have added, that when pure and simple pus has been injected experimentally, and in large quantities too, into the blood of the lower animals, it has not been found to produce the phenomena and lesions of surgical fever. At the same time the sep- tic poison of surgical fever no doubt often coexists with, and is com- mingled with the purulent and inflammatory secretions of wounds; and possibly may sometimes arise from their decomposition, as when pus, etc., are long retained and confined between the lips or in the interior of a Avound; and in experiments on the lower animals the injection of septic and decomposing pus into the circulation has led to symptoms during life, and lesions after death, analogous to, if not identical with, those of surgical fever. Generally, indeed, the septic poison of surgical fever would appear to be in some way a product of inflammatory action or secretion, derived, either first, from the bo- dies of other affected patients, and inoculated into the recent wound, as in the case of the contagious communication of surgical fever ; or, secondly, and most commonly, formed in the site of the wound itself by some special septic change or decomposition in the inflammatory or organic products thrown out on the wounded surface. At all events, surgical practitioners have hitherto used no methods of pre- venting the inoculation and infection of the system from the Avound, except by keeping the wound and its site under the action of local antiphlogistic measures. Hence, it is generally held by British sur- geons that cases of surgical fever are more rare when wounds are treated simply with cold water dressings, than when they are in- volved in warm layers of lint, straps, and bandages, and with heal- ing ointments directly applied to them. Every means, perhaps, that we can use to produce union of the whole wound by the first intention, and prevent arising between its lips points of suppuration, ulceration, and gangrene (phenomena that actually occur at the site of every ligatured artery), are measures calculated to prevent the supervention of surgical fever. I am not aware that it ever does occur to any dangerous extent in any case of operation where the lips of a wound adhere entirely, and in every point by primary union. When a wound shows marks of inflammation, however in- tense, surgeons seem usually to content themselves with dressings of cold water, or hot poultices, changing from the one to the other, according to the feelings of the patient; or they medicate these applications with lead, opium, etc. ; but they seldom or never apply any more direct local antiphlogistic measures, such as leeching, etc.; 182 ON SURGICAL FEVER. though perhaps the adoption of such more active antiphlogistic mea- sures might sometimes be of benefit. Before leaving this subject of topical treatment, let me observe, that probably it may yet come to be a question whether local means, not exactly antiphlogistic, but consisting of specific prophylactic applications to the wounds themselves, may not, under some circum- stances, prevent the chances of septic absorption and surgical fever. In the case of venereal chancre, this principle is constantly acted upon to prevent the poison being absorbed, and the constitution be- coming affected; the free application of various substances to the primarily inflamed spot or chancre being generally acknowledged as sufficient to prevent the chances of constitutional absorption and ta'int, provided these ectrotic substances are used sufficiently early. Some continental pathological anatomists firmly believe that they can withstand in their own persons, and in those of their assistants, all chances of septic matters introduced by dissection-wounds of the hands, by washing these wounds with any acid, such as vinegar, etc. They hold that the poisonous matters in cases of these dissection- wounds is alkaline in its reaction, and is always sufficiently neutral- ized and destroyed by the free local application of acid washes. Would not applications on the same principle to surgical wounds be sometimes successful in preventing the accession of surgical fever ? Lotions could be easily acidulated; and I have elsewhere tried to show that carbonic acid gas would perhaps form one of the most sedative, and one of the most rapidly healing applications to &\\ kinds of wounds and sores. To wounds in their secondary putre- scent or gangrenous stage, carbonic acid used to be applied by the older surgeons in the form of the yeast poultice ; and to the same state of Avound, solutions of chloride of zinc or lime, aqua chlorinata, etc., are applied by surgeons in our own day. It is alleged also that these chlorine preparations have been employed successfully in neutralizing the septic poison of dissection-wounds. In relation to the prophylaxis of surgical fever, the question is, whether acid, chlorinated, or other antiseptic applications employed in the first days or hours of primary wounds, would not in some cases, and under some circumstances, neutralize or destroy any septic poisons in these wounds, and prevent the mischances of surgical fever aris- ing in patients who are the subjects of these wounds. 2. Local antiphlogistic measures at the seats of the secondary in- flammations.—When these secondary inflammations light up at some distance from the primary wound, as in the chest, in the synovial membrane of one of the large joints, etc., the patient is seldom in such a state of power and strength as to bear much antiphlogistic treatment in the way of leeching or cupping. If you then use local antiphlogistic measures at all, you will generally find more advan- tage, in the case of affected joints, by applying warm sedative lotions of lead and opium, and placing and fixing the affected part so that it should be maintained in a state of absolute rest; or by employing* ITS CURATIVE TREATMENT. 183 there, and over the large cavities when attacked, rapid and exten- sive counter-irritation with turpentine, iodine, solid nitrate of silver, or chloroform. In cases of toxsemic fever, complicated with dis- seminated inflammations—as smallpox—the topical inflammations are liable, as we have already seen, to localize themselves almost altogether upon any part debilitated by previous inflammation or in- jury. Does not this fact afford us the true rationale of the action of blisters in most acute inflammations, dependent, as most of these inflammations are, upon some state of toxsemia ? Would not early, free, and full cutaneous counter-irritation localize and determine to the external surface the inflammatory effusions in some cases of sur- gical fever ? There is one condition in which antiphlogistic mea- sures are sometimes pushed further in surgical fever, viz., where, as in our first patient, inflammatory action springs up on the general surface of the peritoneum after operations on the pelvic or abdominal organs. In this instance, there seems a general belief that we may sometimes safely and successfully push our local antiphlogistic mea- sures, as leeching, counter-irritation, etc., to an extent that would do harm rather than good to secondary surgical inflammations under other circumstances. In such a complication at the present day, gene- ral bleeding Avould scarcely be dreamt of. But yet, as I have shown you in another part of our course, in the analogous peritonitis of lying-in-women, Dr. Armstrong and Mr. Hey were so wonderfully fortunate as only to lose nine cases out of eighty-nine, or one patient in ten, in epidemic puerperal fever, by adopting this practice at the very first commencement of the malady. B. Constitutional Curative Measures. B. Constitutional Measures.—For only one type of fevers, viz., Intermittent fevers, have we aught to wield in the way of a specific ; for to their poisonous influence, as you know, quinine and arsenic are antidotes almost as certain as any that we have in toxi- cology. On the other hand, against surgical and other forms _ of fever medicine has, as yet at least, nothing whatever that is specific to offer. Most or all of these fevers have a tendency to run through a determinate and definite course, and if we can keep our patient alive, and without any mortal damage amidst the internal machinery of the body, till that course is terminated, his life is preserved. To attain this fortunate end, we have generally a number of secondary indications to follow. Let me attempt to point out to you briefly what these indications chiefly are in the special case of surgical fever. First Indication.—To obtund and reduce the irritability of the Nervous System.— Perhaps opium, in some form or another, is the drug that, on the whole, is most frequently used in the treatment of surgical—and its analogous disease—puerperal fever. It is espe- cially had recourse to whenever any of the concurrent secondary 184 ON SURGICAL FEVER. local inflammations are particularly severe, and give rise to much pain and distress. Under these circumstances, there is sometimes almost apparently a tolerance of this remedy ; and then it seems to act as a general supporter and stimulant, while by obtunding the nervous system it saves the patient from the depressing and danger- ous effects which mere local pain produces upon a febrile patient. Even when there are feAV marked symptoms of local inflammation in the disease, if the patient bears opium Avell, and Avithout sickness and vomiting, he may be kept under its influence for days in a pas- sive and vegetating state, if we may so express it, while the disease runs through its course and comes at last to a favourable end. When given in surgical or puerperal fever, opium should be exhibited, not in large doses every twelve or twenty-four hours only, but in repeti- tions of small doses every few hours, so as to maintain a steady narcotic action. In this way you are certainly not so liable to pro- duce that sickness and vomiting which unfortunately drive us too often from the continuance of this plan. Dr. Kelly, Dr. Clarke, and other American practitioners, have carried out the plan itself to an extent never, I believe, attempted by European practitioners; and it is averred in some bad and almost desperate cases of puerperal fever with the highest success. They give the opium in repeated, but at the same time in such large doses, as.to affect even the respi- ration of the patient, and to reduce, and keep reduced the respira- tory movements eight or ten below the natural standard. In some instances they have kept the patient in this state for days, and till the feverish action was worn out. Of course, such treatment ayouW require great care, and constant watching of the patient. Other narcotics besides opium, as belladonna, henbane, etc., have sometimes been tried, particularly where opium unfortunately disa- greed with the patient; but none of them have proved equally beneficial. Second Indication.—To subdue the excitement of the Heart and Vascular System.—This indication looks far too mechanical in its principles, though it is a well-known fact that great excess of rapidity in the movements of any machine is always dangerous, as being liable to damage and ultimately break down its mechanism. As, however, the over-excitement of the heart and vascular system in surgical fever principally results from the irritation of the morbid materials contained within the blood itself, the indication I allude to might be, perhaps, most correctly referred to our next head, viz., the artificial elimination of these morbid materials from the circulat- ing system. But I speak of it as a separate indication, because in reality various medicines have been proposed and used with the view of reducing the rapidity of the pulse, some of which are eliminatory in their action, others not. Colchicum and digitalis, for example, have been employed ; and both of them exert a depurating action through the kidneys, as well as a direct depressing action upon the heart. One medicine has of late been supposed to produce this ITS CURATIVE TREATMENT. 185 sedative effect on the heart, without exerting any other appreciable therapeutic action. I allude to aconite, a strong tincture of which has been employed by various European surgeons in surgical fever; but it is difficult to regulate it in its effects, and in many persons it produces an almost dangerous and depressing effect, even in very small doses. Some of our American brethren have latterly been using extensively, in febrile, inflammatory, and nervous diseases, a new and potent drug belonging to this class, viz., the veratrum viride. Its effects have been described by Dr. Osgood, Dr. Nor- wood, Dr. Barker, and other practitioners. They tell us that they find that by exhibiting in repeated doses a concentrated tincture of the veratrum viride, they can reduce the pulse and keep it reduced with a certainty and to a degree Avhich can be effected by no other drug. Dr. Barker and others have published cases Avhere they have thus brought down the febrile pulse in a few hours from 140 beats to 80, 60, or less in the minute, and kept it at will at this lower standard. It is a drug altogether which is certainly entitled to the strong attention of European practitioners. And it is not merely an arterial sedative. 'It is at the same time apparently a powerful depurant, stimulating the action of the skin, kidneys, and secretory functions generally. It has been successfully used as a depurant in acute gout and rheumatism, instead of colchicum. The veratrum viride is an American plant; but I think, from what I have seen, that we may fulfil the same therapeutic indications with the species which is in all our European pharmacopoeias—the veratrum album. As the different species of cinchonas depend for their therapeutical effects in ague, etc., upon their all containing one and the same principle, namely, quinine, so in all likelihood the different species of veratra depend for their therapeutical effects upon a principle common to all members of the genus, namely, veratrine. Many of the old Greek physicians trusted often in chronic diseases, as Are- taaus, Oribasius, and others tell us, to a course of hellebore after they had failed in curing their patients by other plans of treatment. The researches of Dr. Adams leave little or no doubt that the white hellebore preparations of the Greeks were derived from the veratrum album. It will be curious if, in the cyclical changes to Avhich Medi- cine is even subject, we now turn back after 2000 years to the ancient " helleborism," or hellebore cure of Hippocrates and his successors. Thev had recourse to it, however, principally in chronic affections, as insanity, epilepsy, neuralgias, dropsies, etc. American practitioners have, on the contrary, been using the veratrum viride, or American hellebore, as Dr. Wood terms it, principally in acute diseases, as in pneumonia and other forms of inflammation, in puer- peral and other forms of fever. Let me allude to one other drug before leaving the present indication. Chloroform when given in full doses, either by inhalation or by swallowing, depresses and brings down the rate of the pulse. In any surgical patient operated on under a complete dose of this drug, you will find the pulse sunk 186 ON SURGICAL FEVER. from 90 or 80 to 70, 60 or less. I have taken advantage of this action of chloroform in some instances of disease. The first case I used it in was the folloAving : A lady, Avhom I saAv with Dr. Scott, of Musselburgh, was attacked with peritonitis after abortion. The peritonitis was so very acute and severe, and all the accompanying symptoms so very formidable, with a weak and scarcely perceptible pulse racing above 150, that I had little or no hopes whatever of the patient surviving. At her own request, to relieve her from her great abdominal pain, she was placed under the influence of chloroform ; and when so, Dr. Scott and I found the pulse sank down to 100 or less, and became stronger and steadier. We found further, that as long as the action of the chloroform continued, the pulse continued thus greatly lowered in rate, and improved in power. Hence we agreed to keep, her for a time continuously under chloroform ; and in consequence of the evident good results, she was retained upwards of sixty consecutive hours under its influence. By the end of that time the great abdominal tenderness and tympanitis were almost entirely reduced, and the patient in an infinitely more satisfactory and hopeful state than Avhen she first breathed the chloroform. The pulse never rose again to any very high rate ; and all danger Avas over. But you cannot obtain the same beneficial and sedative influ- ence upon the excitement of the heart from chloroform in all patients; or, to state the fact more correctly, you will find it difficult in some, and impossible in others, to regulate its dose so as to keep up its continuous depressing action on the heart without sickness, vomiting, and other symptoms, coming on in such severity as to force you to leave off its use and have recourse to other means and other indica- tions of treatment. Third Indication.—To depurate the blood.—This, doubtlessly, would be by far the most important indication of all, if we had the means of fulfilling it with anything approaching to perfect certainty and accuracy. As it is, we constantly try to accomplish this indica- tion in practice in surgical and in other fevers, and by a variety of means and channels. There are various channels in the economy by which superfluous and deleterious matters are thrown off from the blood. Some may be thrown off by the skin by the use of diapho- retics, or excreted through the intestinal canal and chylopoietic viscera by purgatives and mercurials. Perhaps a combined antimo- nial and ipecacuanha emetic is one of the most powerful depurants, and most powerful alteratives too, which can be employed in the earliest stages of febrile action. Occasionally it will prevent or cut short an attack of continued fever, for instance; and in some varie- ties and types of puerperal fever it seems to act most beneficially. After a surgical operation leaving a large wound, many would fear giving an emetic lest the consequent retching and succussion of the body would too much disturb the wounded part; but the same objec- tion does not hold good in reference to rigor and other commencing ITS CURATIVE TREATMENT. 187 symptoms of surgical fever following any of the minor forms of surgical operation. Hitherto two emunctories—the skin and intestinal mucous surface —have been chiefly used as artificial eliminatories by medical prac- titioners in most forms of fever; and preparations of antimony, calomel, various aperient and diaphoretic salts, and various vegeta- ble purgatives have been long used, and still are used in endless combinations with this intention. But, perhaps, there are other channels of elimination of as great, if not still greater, practical value. Much of the effete carbonaceous matter of the body in a state of health is eliminated or burned off at the lungs ; and in some diseased conditions any excess of such matters might probably be got rid of in the same way, provided we were acquainted Avith some means of exciting this elimination artificially. But the subject has not yet, so far as I knoAv, excited in any sufficient degree the atten- tion of therapeutic inquirers ; though we have ample evidence to show that various medicinal and poisonous substances, when intro- duced into the body, are exhaled, in part at least, from the pulmo- nary mucous membrane. Most of the nitrogenous excreta from which the blood requires constantly to be cleared pass out of the system through the kidneys. This remark holds true of the body in health ; and, perhaps, it holds equally true of the body in disease. And when we remember that a large part of the morbid materials liable to be accumulated within the blood in febrile and other dis- eased conditions are highly azotized, the importance of the_ renal organs as a channel for the depuration of these morbid materials at once becomes evident. In fact, in the treatment of surgical and some other forms of fever, " renal purgatives," if we may use such a term, thus become in practice more important even than intestinal purgatives. We have various medicines that can with more or less certainty depurate the system by increasing the eliminative activity of the kidneys. In surgical, and still more in puerperal fever some eliminative diuretics have acquired great reputation in the hands of various practitioners from empiric observation only, and without their mode of action being considered. Let me merely enumerate, as a specimen, acetate and nitrate of potass and other diuretic alka- line salts, spirits of nitric ether, colchicum, oil of turpentine, and tincture of the muriate of iron ; which last drug has sometimes appeared to me under these circumstances to act both as an excel- lent renal purgative, and in part also to fulfil the next indication for treatment which I have to speak of, A'iz:— Fourth Indication.—To sustain the vital powers of the patient by stimulants, etc.—As surgical fever advances to its height this always becomes a most clamant and important indication. Sometimes un- der apparently the most desperate circumstances, the steady and methodic use of stimulants will enable you to pull your patient through. You are not utterly to lose hope of doing so in almost any case unless, what too often happens, the stomach becomes so irrita- 188 ON SURGICAL FEVER. ble as to reject all sustenance in this way. This irritability may be sometimes cured, and still more frequently prevented by the free and frequent swallowing of small pieces of ice, a drug not entered in the pages of the pharmacopoeia, but one more useful in reducing febrile action than the thousand medicines that are to be found in our apothecaries' shops. Be assured also that by far the best and most manageable form of stimulant is wine or brandy ; and do not run the risk of upsetting the patient's stomach and losing your last chances of saving him by having recourse to lengthy medicated mix- tures and prescriptions as stimulants. If you add any form of nutri- tive material to the stimulant, let it be of the simplest kind, as the whites or albumen of three or four eggs beat up in half a tumbler of cold water; which at once makes a nutritive and by no means disa- greeable drink. The time of commencing the stimulating treatment is to be regu- lated by two circumstances—by the patient's strength beginning to fail, and by the good effect or the reverse of the first dose or two upon the patient's pulse, and other symptoms. If an error is com- mitted in regard to the time of their exhibition, that error, I think, is oftener that they are begun too late than too soon. Some patients benefit by them from a comparatively early stage ; nor does their employment prevent or counteract the effect of almost any of the other sets of remedies which I have mentioned. They may be used, for instance, along with the opium or the various depurants, as alka- line salts or the muriate of iron; and sometimes those medicines that reduce the excitement and rapidity of the heart, do not appear to exert their specific influence till they are combined with some amount of stimulant. Thus my friend, Dr. Barker, in some of his interesting published observations on the veratrum viride, remarks, that while it will most surely reduce the quickened pulse of inflam- mation and irritation, "its use is not incompatible with that of stimulants. Experience has abundantly demonstrated the truth of this apparent paradox. One patient who recovered took, every hour for two days, one ounce of brandy, and three to ten drops of the tincture of veratrum viride, the quantity of the latter being deter- mined by the frequency of the pulse, which was never allowed to rise above 80 per minute, although it sometimes fell down to 40. In another case the veratrum viride did not seem to produce any effect on the pulse, which remained steadily above 130, until the condition of the patient was such that I decided to give brandy. After the first ounce was given, it fell to 108; after the second to 86. Continuing the brandy, the veratrum viride was suspended for a few hours, and the pulse again rose to 130. After this," adds Dr. Barker, " it was curious to note the fact that, if either agent was suspended, the pulse would rapidly increase in frequency, while under the combined influence of the two, it was kept below 80 per minute." ON PHLEGMASIA DOLENS. 189 LECTURE XV. ON PHLEGMASIA DOLENS. Gentlemen : I wish to speak to you to-day of a disease that is by no means infrequent among puerperal women, and which has been treated of under many different designations. It has been named Phlegmasia Alba, Phlegmasia Alba Dolens, (Edema Lacteum, White Leg, and, finally, Crural Phlebitis. I wish to direct your attention to this subject noAV, because some of you have had an opportunity of observing it in a case in our ward, where the disease presented itself in an unusual form, and with some peculiar modifications. Let me first of all read to you the history of the case, as it has been drawn up for me by my clinical clerk :— " E. A., aged 40 ; admitted February 7, 1859 ; married nineteen years. Has had five living children, and three miscarriages. The last miscarriage occurred nearly two years since. The last child (a girl stillborn) was born on January 3d of this year. Her labour was a tedious one, and was attended during its first stages by a consider- able amount of hemorrhage ; but she had no flooding afterwards, and states that the lochia have been very scanty, as also the mammary secretion. She remained comparatively well until the thirteenth day after delivery, when she first noticed a tenderness of the popli- teal space behind the left knee, which tenderness gradually increased in extent towards the ankle, but did not affect the thigh. The leg belsw the knee began to swell, and at last became tense and painful on all sides. A discoloration of the back of the leg now began ; and the veins over the calf and towards the ankle became hard, tender, and swollen. Fomentations were applied to the part, and bran poultices as soon as the swelling began to appear. " The first day on which the swelling and discoloration were noticed, she was affected with rigors two or three times^ a day, and these have continued ever since. She has had no pain in the right leg, back, or groin. She is unable to keep the left leg straight. The swelling and inflamed veins extend from the popliteal space to within two inches of the ankles ; very tender. The foot pits slightly on pressure ; bowels costive ; appetite bad ; pulse 120. Sleeps pretty well; has an anaemic appearance. No tenderness over the abdomen. To have hot fomentations constantly applied to the part, and tinct. ferri muriatis gutt. xx. thrice daily. Passes plenty of urine. " February 10.—Complaints of great pain in the calf of the leg, frequent rigors, and sleeplessness. Bowels very costive. To have 190 ON PHLEGMASIA DOLENS. a dose of aperient medicine occasionally. There is a feeling of fluctuation about the centre of the discoloration, and great tender- ness on pressure. To continue the fomentations. 13th.—An incision was made into the suppurative swelling, and more than sixteen ounces of pus escaped, mixed with a little blood. To continue the fomentations. " 15th.—The discharge of pus still continues ; the pain has dis- appeared, but there is still great tenderness on pressure, and ina- bility to extend the leg. Ordered ferri et quinse citratis gr. ij. ter die. Pulse 89. " 22c?.—The suppuration has ceased almost entirely, and but little tenderness remains, except at the upper part of the swelling, near the popliteal space. To have bandage and water dressing. " 3Iarch 8.—Patient continues to do well; the pain, swelling, and tenderness are rapidly disappearing. Has had no rigors for eight days, but complains of much weakness. To take, potassse chloratis 3ij, aquse bullientis 3ij, a tablespoonful three times a day; and, tinct. ferri muriatis, gutt. xx. " 15th.—The external wound completely healed." Symptoms and Diagnosis. The disease of which this is a modified instance has long been well known to the Profession, and has formed the subject of many valu- able essays. It consists of a general, tense, white, elastic, hot and painful enlargement or swelling occurring in one or other of the lower extremities, most frequently in the left. In three out of every five cases it is the left leg that is first or alone affected. This intu- mescence of the limbs is usually preceded by marked febrile symp- toms ; at least, in more than one half of the cases of phlegmasia alba dolens which come before you, you will find that your patient has had pain and a rapid pulse, and all the usual phenomena of fever before the swelling of the leg set in, and in many, the disease only comes on after a previous regular attack of puerperal fever. But, on the other hand, you will meet with a few cases where there will be no apparent premonitory febrile symptoms, and the affection of the leg will be the first condition to attract your notice, and to alarm your patient. In some cases this swelling that I speak of, begins high up in the extremity, at the upper part of the thigh, and then goes downwards; in others again, and more frequently, it appears first of all lower down, on the back of the foot or in the calf of the leg, and progresses upwards to the thigh. In one patient in the ward it was limited to the lower portion of the extremity, and in this respect was peculiar. Perhaps the symptom of the disease which is usually first complained of by the patient, is pain in the calf of the leg. There is in most cases no swelling at first until such pain has been felt; but after this has lasted for some time, the swelling begins, and goes on steadily increasing till the limb has ON PHLEGMASIA DOLENS. 191 become greatly enlarged, it may be, to double its normal size. The skin gets more and more distended, and becomes white and glisten- ing (and hence the designation, phlegmasia alba), and this distension generally goes on to such a degree that at last the skin will scarcely pit on pressure. Indeed, this elasticity of the skin is one of the marks of distinction between this affection of the leg and ordinary anasarca ; for in this last the skin readily receives and retains the impression of the finger. In nearly every case of phlegmasia dolens there is at first an increase in the temperature of the affected limb, sometimes to a very considerable degree. Then there is a loss of all muscular action in the limb, which lies stiff and motionless. While there is thus a decrease in the motory powers amounting to a kind of semi-paralysis, there is an increase in its sensory power leading to pain, occasionally limited in locality and not severe in degree ; but in other cases so great as to cause much suffering, and to render the disease in its truest sense a phlegmasia dolens. The affection is not always confined to the limits of a single limb, for not infrequently it attacks both legs simultaneously; or, after having shown itself for a time in the one, it may extend secondarily to the other also. Phenomena precisely resembling those that I have been attempting to describe are occasionally met with in other parts of the bodies of puerperal patients. I have seen the disease attack one of the upper extremities and prove fatal. Much attention has been bestowed upon the condition of the lochial discharge in the case of patients affected with phlegmasia dolens. In some instances the discharge has been found to be very fetid, and in many it ceases altogether when the disease sets in, or when it has become estab- lished ; but occasionally no noticeable variation can be detected. Then, as regards constitutional symptoms, you will find that the pulse is rapid and generally, at the same time, small and feeble ; commonly the tongue is white and moist; the face presents a pale, chlorotic appearance; the urine is muddy, with an abundant deposit of lithates; and perspirations are apt to be frequent and profuse. The disease is not confined to females in the puerperal state, but has been found to occur in connection Avith various diseased con- ditions, as cancer of the uterus and mamma. I have seen it pro- duced by the ligature of a uterine polypus, etc. In some rare in- stances it has been met with also in men, as after continued fever; after lithotomy ; in cases of phthisis. When occurring in connection with parturition, the period of its attacks may be very various, as shown by the tables of Dr. Lee, who found that out of twenty-two cases the disease began in eight of them between the fourth and fourteenth day after the termination of labour, while in fourteen it did not set in till after the second week. The symptoms usually begin to abate in about ten days from the commencement of the dis- ease ; but they rarely disappear until after a fortnight, and in some cases they remain even for a longer period. Even after the essen- tial phenomena of the disease have been dispelled, however, there 192 ON PHLEGMASIA DOLENS. may result various morbid conditions, such as tumefaction and de- bility of the limb, thickening or induration of the cellular tissue, and a varicose state of the superficial veins, which may retard the con- valesence of the patient for an indefinite period. In many the affected limb remains weaker, and occasionally someAvhat more swelled than the other limb for years, or eAren for life, the circu- lation through it never recovering its perfect freedom and force. In a case where both legs were affected, and probably the lower part of the vena cava obstructed, the patient told me that in bathing the lower half of her body always became so discoloured as to form a strong contrast with the upper half. In some rare cases gangrene of the limb has ensued ; and you have an instance of a more common, but still rather rare complication in the case of the patient in the Hospital, in whom an abscess formed in the leg, and gave rise to a long-continued purulent discharge. Pathological Anatomy and Pathology. Passing over many points which have given rise to much discus- sion, not always of a very high practical import, let me just state briefly with regard to the pathological anatomy of phlegmasia dolens, that obstructive inflammation of the veins of the affected limb is one of the phenomena most constantly observed on post-mortem exami- nation. In 1823, the late Dr. Davis, Professor of Midwifery in University College, London, published some cases in the Trans- actions of the Medico-Chirurgical Society, in which he had found the femoral and iliac veins impermeable and filled with firm coagula of blood. Shortly afterwards, Bouillaud published some similar cases ; and since then, Yelpeau and others have frequently observed and recorded the occurrence of obstructions of those particular vessels. In 1829, Dr. Lee pointed out. that the femoral and iliac veins were not the only vessels in which the obstruction and inflammation oc- curred, but that the venous inflammation commences in the uterine branches of the hypogastric veins, and subsequently spreads from them into the iliac and femoral trunks of the affected limb. Some cases have been observed, on the other hand, by Casper, Rigby, Fraser, Smeets, Jacquemier, and others, where in patients dying of phlegmasia dolens, no morbid change or obstruction could, it is averred, be detected in the femoral or other larger veins of the affected extremity. " Many authors of modern times," observes the late distinguished obstetrician, Professor Kiwisch, of Wurzburg, " have, as well as myself, found the veins perfectly healthy in cases of the most strongly-marked phlegmasia dolens." Hamilton and Ramsbotham have paid particular attention to the swelling and in- flammation of the lymphatic glands, Avhich is not infrequently to be found in such cases, and to which they attributed the swelling of the limb, and most of the other symptoms; while Bouillaud and others, have laid more special stress on an inflamed state of the on phlegmasia dolens. 193 lymphatic vessels as an essential anatomical condition of the disease. Duges again averred that he had discovered the nerves of the affected limb to be altered and inflamed ; Albers, Hankel, and Sie- bold maintained that it was primarily a disease of the nerves of the extremity; and Dr. Burns published some cases, as cases of puer- peral neuritis, but more, perhaps, from the intense pain which at- tends the disease in some instances, than from any particular patho- logical change in the nervous cords. In many cases, at all events, where very great pain has been experienced in the course of the disease, there has been no corresponding anatomical alteration of the nerves discovered after death. Various opinions have been entertained at different times as to the pathological nature of plegmasia dolens. It is unnecessary for me to do more than merely mention to you some of the principal hypotheses. 1. Retention of the Lochia.—Mauriceau believed that the disease depended on a suppression of the lochial discharge, and a subsequent determination of it to the affected limb. 2. Metastasis of Milk.—In his first Memoir on Lacteal Deposits, Puzos ascribes all the phenomena observed in cases of phlegmasia alba, to a deposit of milk in the part; and Levret, in referring to such cases, accepts and indorses the doctrine of Puzos, that the dis- ease is essentially due to a metastasis of milk. This opinion was more commonly receiA7ed than the former, and a supposed confirma- tion of it was derived from the fact, that when the limb Avas punc- tured a turbid serum was occasionally drawn off, which in some degree resembled milk; but on the other hand, the serous fluid which escapes is most frequently, perhaps, quite clear at first, and afterwards coagulates like the ordinary serum of the blood. 3. Rupture of Lymphatic Vessels.—In the beginning of this century Mr. Tyre, of Gloucester, wrote an essay on the subject, in which he attempted to prove that the phenomena of the disease were all to be traced to a rupture of the lymphatic vessels at the brim of the pelvis, allowing of the escape of lymph into the cellular tissue, and its gravitation downwards into the limb. 4. Obstruction of Lymphatic Vessels and Glands.—Dr. White, on the other hand, tried to show that the disease was due to an ob- struction in the lymphatic vessels and glands, leading to an accu- mulation of the fluids below the obstructed part. 5. Inflammation of Lymphatic Vessels and Glands.—According to a fifth theory, which numbered among its supporters such men as Ferrier, Gardien, Capuron, Hamilton, etc., phlegmasia dolens con- sists essentially of an inflammation of the lymphatic vessels and glands of the diseased limb. 6. Phlebitis.—I have already mentioned to you that "Dr. Davis had pointed out the frequent occurrence of crural phlebitis in con- nection with this disease. The conclusion to which his observations led him was, that the obstruction of the principal vein of the limb 13 194 ON phlegmasia dolens. Avas its essential phenomenon ; and many eminent authorities have held the same doctrine, differing only in this—that some have main- tained with Davis that the phlegmasia was due to inflammation of the femoral veins; while Lee and others have held that the disease originated in the uterine and hypogastric vessels. 7. Inflammation of all the Tissues.—Hull, Dewees, and others, finding it difficult to account for the phenomena of the disease by the affection of any particular texture, came to regard it as an in- flammation of all the textures of the limb. Lastly, seeing that no one of the local manifestations of the disease, nor all of them com- bined, sufficed to explain its nature and peculiarities, attempts have been made by some authors to trace the Origin of Phlegmasia Dolens in Blood Disease. In 1844, M. Bouchut first expressed the opinion that phlegmasia dolens was due not to a primary inflammation of the veins, but to a coagulation of blood in them resulting from some peculiar change in the quantity of the constituent elements of the blood, which ren- dered it specially liable to become coagulated. But it is to the observations and investigations of Dr. Mackenzie that we are in- debted for the first distinct enunciation of the doctrine, that primarily phlegmasia dolens is a blood affection, and the confirmation of it by careful experiment and research. Indeed, Dr. Mackenzie's admi- rable essay on "The Pathology of Obstructive Phlebitis, and the Nature and proximate Cause of Phlegmasia Dolens," is one of the best experimental monographs which we possess on any subject in obstetrics. In that essay he shows, first of all, from experiments on the lower -animals, that while simple obstruction of the crural veins Avill readily produce, as has been long shown, a certain degree of oedema in the limb below the obstructed point, yet that it is not in itself sufficient to give rise to all the phenomena essential to a case of phlegmasia dolens. For the phenomena of that disease are not confined to the mere effusion of a serous fluid into the cellular tissue of the limb, such as may recur in any case of anasarca ; but, as I have already told you, the oedema, which is much greater in degree than you ever find resulting from venous obstruction, is complicated Avith great tension and exalted temperature of the diseased member, usu- ally with increased sensibility and pain in it, and frequently also with more or less complete paralysis. Various experimenters have tied the femoral vein, and have succeeded in producing obliteration of it in many different ways, but without producing any of the pecu- liar phenomena of phlegmasia dolens. No increase in the heat of the limb has resulted, and no tension, tenderness, or impaired mo- bility ; nothing further than a slight degree of oedema, partial and passing. Then, after showing that obstruction of the femoral vein by means of a ligature is not sufficient to produce phlegmasia dolens, Dr. Mac- ON PHLEGMASIA DOLENS. 195 kenzie goes on to prove that the excitement of inflammation in that vessel, and the production of coagula in it of some extent, are like- wise incapable of producing the peculiar phenomena of that disease. In this set of experiments the veins were subjected to a considerable extent to the effects of a compressing agent, or had some hitherto unexplained changes set up in their walls by the introduction of pieces of bougie into their interior, or the application of a solution of nitrate of silver. Take the last of these morbific agencies as the means for making the experiment, and what results are obtained ? The femoral vein is ligatured at a certain point, and an .opening being made above it, a piece of lint steeped in a solution of nitrate of silver is applied to the whole interior of the veins to a certain distance. The blood is allowed to return immediately, and the open- ing in the vein closed up. The animal gets a little oedema of the limb—the usual result of venous obstruction, but it has none of the characteristic symptoms of phlegmasia dolens. After death, the vein is found to be filled throughout an extent corresponding exactly to the extent of surface to which the irritant had been applied, with a coagulum of blood, or rather with a mass of firm blood in the con- dition which in his late able treatise on the pathology of the blood and bloodvessels, my friend, Dr. Wise, has described as consolidated from the circumstance that no separation has occurred between the serum and fibrin of the blood during the progress of this " consoli- dation," but the whole commingled elements of the blood have con- tributed to the formation of this solid plug. This consolidated^blood is in such a state as to shoAV that the change had begun in it imme- diately after the application of the irritant; and yet that application was so rapid, and the blood was allowed to return so quickly that there was no time for the development of inflammation irf the walls of the vein, or, at all events, of such a degree of it as would account for this remarkable and sudden change in the blood. And, mark you, the experiments of Virchow, Meinel, and others, all go to prove that the lining coat of the vein is incapable of undergoing any of the higher grades of the inflammatory process, or of giving out on its . free surface any of the usual inflammatory products, such as coagu- lable lymph or pus, and that the only changes of this kind which it is capable of undergoing are such as tend to its mortification and destruction. In the description which some obstetricians have given of false membranes and pus in the interior of the femoral and other veins in phlegmasia dolens, they have mistaken for these products on the one hand, the sphacelated interior coat of the vessel, or the firmer layer of consolidated blood seen on the outer surface of the obstructing plug ; and on- the other hand the broken down, decolor- ized, and disintegrating blood seen in the interior of the plug, where the process of softening first commences, and which presents an appearance that might readily lead to its being mistaken for pus. When, then, in the lower animals obstruction is produced in the largest veins of a limb, either mechanically or chemically, and their 196 ON PHLEGMASIA DOLENS. cavity becomes filled up with clots of consolidated blood, a certain degree of oedema is produced in the limb below, but it never becomes the seat of over-distension, exalted temperature, or paralysis. In other words, obstructive phlebitis confined to the large vessels of a limb, does not suffice for the production of a phlegmasia alba dolens in that extremity. The conclusions derived from experimental investigations are only further confirmed by the clinical observation of those rather rare cases where the larger veins of a limb have become the seat of a distinct degree of inflammation during life, and have been found after death to be filled up and occluded by a mass of consolidated blood. I show you a preparation of obstructed aorta and iliac and femoral arteries which will give you some idea of the general ap- pearance of these obstructing plugs of consolidated blood, and which was taken from a lady who had suffered for some time from obstruct- ive disease at the orifice of the aorta, and in whom the aortic valves were found to have been covered with a mass of warty excrescences or vegetations. During the puerperal month, some of these excres- cences had got loosened and detached from their seat, and being carried along in the circulating fluid, they passed through the aorta and became arrested and impacted, some of them in the femoral arteries, and others higher up in the iliac arteries and at the bifur- cation of the aorta. In all of these vessels, but chiefly in the left femoral artery, they gave rise to the usual effects of such emboli, viz. first, to obstruction of the vessel and the formation of a coagulum to some distance, and secondly, to inflammatory changes in the arte- rial coats. But in this case the mischief went further, and the con- tiguous femoral vein became the seat of a secondary inflammation, in consequence of which its walls were thickened and its calibre came to be obstructed with consolidated blood to the extent of two inches just below Poupart's ligament. Was there any symptom of phlegmasia dolens developed here ? Not at all. There was nothing in the least degree approaching to phlegmasia dolens ; and the patient's symptoms were carefully watched throughout by Dr. Moir and my- self. Such a case proves distinctly that there may be a large coag- ulum in the principal vein of a limb obstructing its course effectually and extensively without giving rise to the phenomena of phlegmasia dolens, and that to produce this disease something more is necessary besides a simple crural phlebitis. But, on the other hand, when means were taken in the experi- ments made upon animals to produce coagulation or consolidation of blood not only in the largest veins of a limb, but also in a number of their branches of the third or fourth order of size as well, then something more than mere oedema resulted, for the heat, swelling, tension, and paralysis characteristic of phlegmasia dolens all became developed in a very marked degree. Consolidation of blood, then, in the whole plant of veins coalescing to form the tributaries of the femoral gives rise to the development of phlegmasia alba dolens to ON PHLEGMASIA DOLENS. 197 an extent corresponding to the number of vessels in which the con- solidation of blood has been effected. Observation of the effects of obliteration, of the veins in the human subject leads to the same conclusion. As in the experiments on the lower animals, so in man, obstruction of the femoral vein alone does not suffice for the pro- duction of phlegmasia dolens; while obstruction of a large number of its primary constituent branches is always attended by the de- velopment of phenomena precisely similar to, if not identical with, those which we regard as pathognomonic of phlegmasia dolens. Still the question remained as to what it was that could lead to the consolidation of blood in the veins to the extent usually observed in this disease. To solve this question, Dr. Mackenzie, after having first shown that the extensive obstruction of the veins necessary for the development of the characteristic phenomena of phlegmasia dolens was not producible by merely local causes, such as injury or inflammation of these vessels ; and that simple irritation of the lining membrane of the veins was alone sufficient for the production of such an amount of obstruction—after settling those two points, I say, Dr. Mackenzie proceeded to make another series of experiments in order to ascertain the effect of the direct introduction of various irritating matters into the circulating fluid. Lactic acid was the agent from the injection of which he obtained the most definite results; and by throwing some of this fluid in a dilute form into the femoral vein above a ligatured point, he found that coagulation of the blood was produced for a considerable distance towards the centre of the circulation, involving in some cases a considerable ex- tent of the vena cava inferior, and producing a corresponding degree of obstruction in these vessels. When the animals, on which such experiments had been made, were killed at a sufficiently early period, however, it was found that the process of consolidation had begun in the surface of the column of blood in contact with the venous wall, and that it had not taken place simultaneously in the entire column within the vessel; thus showing that the action of the irritant had been primarily upon the interior of the vessel, and through this, secondarily, upon the blood. But the effect of the lactic acid was not confined to its action on those vessels with which it first came into contact. Its action upon the interior of the veins immediately above the point of its introduction was, of course, strongest and most direct, because it was applied to them nearly pure, and but slightly diluted by admixture with the blood, on which it seems to have ex- erted no immediate influence ; and by the time that it arrived atthe upper portion of the inferior cava (in the case of its injection into the femoral vein), the poison had become so diluted and dispersed through the mass of the circulating fluid that its action on the vas- cular ^surfaces over which it passed was rendered impossible, from the rapidity with which it was hurried along through the heart and arteries in its now less concentrated condition. But the effects of the irritant reappeared so soon as it was carried to a point in the 198 ON PHLEGMASIA DOLENS. vascular system where the circulation was less rapid, and where it was thus allowed to remain for a longer period in contact with the interior of the vessels; and as the flow of the blood Avas necessarily retarded in the plant of veins contributing to the formation of those large vessels in Avhich the first action of the poison in its undiluted form had led to the primary obstruction, it was precisely in these tributary veins that it was detained for a length of time sufficient to enable it in its now diluted form, again to exert its irritating influ- ence upon their inner wall, and so to lead to a second consolidation of the blood and obstruction of the vessels containing it. These secondary obstructions were not entirely confined, hoAvever, to the vessels behind those primarily obstructed; they were repeated at all points where the circulation was weakened or retarded by other means, as, for example, by ligaturing of a vein. But in all cases" where lactic acid was injected, let us say into the right femoral vein, and obstruction of the veins above was produced, obstruction was also found to have resulted in the smaller veins of the same thigh and leg to such an extent as to lead to the development in it of all the usual symptoms of phlegmasia dolens. I would beg here again to remark, that it seems essential for the production of this diseaes that obstruction should have taken place in a large number or series of the veins of minor size, more than in the leading or principal veins of the limb; and we can account for the occurrence of such cases as have been recorded by Casper, Smeets, Rigby, etc., who found the femoral vein itself to be sometimes free, by supposing that the obstruction had in these instances been confined to the smaller vessels, where its presence, however, would be readily over- looked. From all Dr. Mackenzie's observations and experiments, therefore, it seems probable that phlegmasia alba dolens is essentially due to the presence of a morbid material circulating in the blood, and exerting such an influence on the internal surface of the veins as leads to consolidation or coagulation of the blood which they con- tain. Whether or not that morbid matter be lactic acid, which Dr. Mackenzie has shown to be capable of producing all the phenomena of the disease when introduced into the blood artificially, and which he seems inclined to regard, in some cases, at least, as the possible cause of the disease, is a matter that remains for future chemical investigation to determine. Probably various morbid matters may be capable of leading to this effect. But there is this one fact to be noted in regard to the disease, and perhaps I ought to have called your attention to it previously, namely, this, that the blood of the puerperal female is in a condition which peculiarly predisposes it to coagulation within the bloodvessels. There are two diseases in which this proneness of the blood to coagulation has been specially observed ; and it is in patients affected with them that we most fre- quently meet with cases of endocarditis and of fibrinous deposits on the cardiac valves. These are rheumatism, and Bright's disease of the kidneys ; and as in them so in the puerperal female, the blood is in the condition described as hyperinosis; that is, there is an in- ON PHLEGMASIA DOLENS. 199 crease in the quantity of fibrin in the blood, and a diminution in the number of red corpuscles. In the only instance which I know of on record, of the analysis of the blood in phlegmasia dolens, Becquerel and Rodier found the fibrin double its natural quantity, and the blood-corpuscles diminished. In the puerperal patient mat- ters are rendered still more complicated, and the proclivity to disease still further increased by the circumstance that in her constitution great and important changes are at the time taking place, such as the degeneration and the resorption of the hypertrophied uterine mass, and the establishment of the new mammary secretion, in con- sequence of which the blood becomes loaded and deteriorated by the introduction of a quantity of effete organic material. In short, the blood is so altered as to render the patient peculiarly liable to spon- taneous coagulation of blood in the bloodvessels, or as it has been called, thrombosis, and all its consequences. Among these conse- quences falls to be reckoned the disease which we have under dis- cussion, and of which the peculiar phenomena become developed when the thrombosis occurs in a sufficiently large number of the minor veins of any part. But modern pathology teaches us that in the first instance, at least, this venous coagulation, consolidation, or thrombosis may arise without any previous inflammation of the veins, which at first are simply obstructed and occluded by the plug of consolidated blood ; and if the external coats of the veins are found with evidences of inflammatory changes after death, these in- flammatory changes may in general be correctly regarded as second- ary phenomena, and the inflammation of the venous walls which led to them as a secondary result produced by the irritation and pressure of the contained thrombosis, and by the changes which take place in the obstructing mass. So that, if this doctrine be true, phleg- masia dolens does not arise from phlebitis properly so called, but is immediately due to obstruction of the veins by coagulated blood, and any resulting phlebitis is a secondary consequence only. This co- agulation of the blood and obstruction of the veins may, in their turn, depend on one or other of two causes, viz: either, first, on some morbid alteration in the blood itself, tending to its consolidation or coagulation ; or, second, on some morbid condition in the lining membrane of the veins, in virtue of which the relation between the bloodvessels and the blood becomes disturbed, and coagulation of the latter is induced. I believe that in some cases of phlegmasia dolens this required morbid condition in the lining membrane of the veins may be primarily due to phlebitis, as where the veins of the uterus have been inflamed, and the inflammation having extended by con- tinuity to the iliac vessels has led to coagulation of blood in the veins below. But in the great majority of cases it seems to me that we must look for the primary cause of the disease in some morbid condition of the circulating fluid, leading first of all, perhaps, to some peculiar change in the lining membrane of the veins, and through this, secondarily, to coagulation of the blood, occlusion of the vessels, and obstruction to the circulation in the limb. 200 ON PHLEGMASIA DOLENS. LECTURE XVI. PHLEGMASIA DOLENS.—ITS PATHOLOGICAL NATURE Continued. — ITS TREATMENT. Gentlemen : In the remarks which I have already made on the pathological nature of phlegmasia dolens I have endeavoured to show you that the disease could not be justly considered as merely and simply the result of the obstruction of the principal vein of the affected limb, by the occurrence of acute inflammatory exudations on the free surface of the lining membrane of that vein. I alluded to the experiments of Meinel and Virchow as proving that the sup- posed inflammatory exudations throwfi out in the interior of the crural vein in cases of phlegmasia dolens are not inflammatory exu- dations at all. I ought to have added, that their experiments were of the following kind. They isolated portions of the veins in the lower animals by two ligatures, emptied the vessels between these ligatures, applied various irritants to the free surface of the lining venous membrane, and failed entirely in exciting that surface to throw out either coagulable lymph or pus. The outer surface of the lining membrane of veins and its more external coats are liable, like other parenchymatous tissues, to exude coagulable lymph and pus, when excited to the necessary degree of inflammation ; but, appa- rently, the free surface of the lining membrane of the veins has no such power. We saw further, that the supposed inflammatory exudations found in the interior of the femoral vein in phlegmasia dolens, and usually described as layers of effused coagulable lymph and specimens of pus, were, so far, spurious inflammatory appear- ances resulting from the various changes which go on in the blood itself when it is spontaneously or accidentally arrested in venous tubes by coagulation or thrombosis. Further, that phlegmasia dolens is not merely crural phlebitis is evident from the two facts: 1. That, as we have already seen, no inflammatory obstructions whatever of the femoral vein itself have been observed by several high obstetric authorities in some important exceptional cases of fatal phlegmasia dolens, where they had an opportunity of making a due post-mortem examination; in these exceptional cases the thrombosis being, as I ventured to suggest to you, probably confined to the smaller plant of veins in the affected limbs; or possibly the disease being sometimes produced by obstruc- tion in the lymphatic system of the diseased extremity, though any adequate and decisive proof of this doctrine from either experimental ITS PATHOLOGICAL NATURE. 201 pathology or morbid anatomy is still wanting. But while thus, in some rare cases of phlegmasia dolens, the interior of the crural vein has been found healthy and unobstructed, proving that the supposed cause may be absent while the alleged effect is present; we know, on the contrary:—2. From experiments on the lower FlS- 53- animals and from observa- tions on the human subject, —that the supposed cause may be present and yet the alleged effect be not pro- duced. In other words, when the femoral vein is inflamed and obstructed, and crural phlebitis in- duced, phlegmasia dolens does not always follow. In the lower animals Avhen the femoral vein is tied, and thus inflamed and obstructed, oedema gene- rally comes on to some degree, but not a tense, general, painful, hot, semi- paralytic swelling of the limbs, such as is character- istic of phlegmasia dolens. I stated to you also that, in the human subject and in the puerperal state I had seen a case of inflam- matory obstruction of the femoral vein throughout an extent of two inches with- out any oedema or swelling whatever of the extremity. The femoral artery was, as I mentioned to you at the same time, obstructed by a travelled cardiac embo- lism. In this case my es- teemed friend and former assistant, Dr. Priestley, made a most careful ex- amination of the parts after death, and tried to trace any change, inflammatory or otherwise, in the nerves of the limbs, that could possibly account for the great pain which the patient suffered in the affected and unobstructed ex- Obstruction and inflammation of the lower part of the aorta, and of the iliac and femoral arteries, resulting from the impaction of emboli in their interior, with secondary inflammation and obstruction of the femoral vein. 202 ON PHLEGMASIA DOLENS. tremity for a considerable time before death. But no alteration whatever could be observed in the femoral nerve or its branches. I think the fact interesting as bearing on the origin of the pain so often present in phlegmasia dolens. That pain is sometimes so severe and extreme as to have led, as we have already seen, to the idea that the disease was possibly complicated occasionally with, if it did not originate in, neuritis. But the great local pain occasion- ally present in cases of puerperal embolism, or obstruction of the arterial tubes of a limb, and in cases of phlegmasia dolens or obstruction of the veins of a limb, is probably owing to a common cause of a different kind. For the proximate cause of the suffering in both diseased states seems to be the effect of obstruction and over- distension of the coats or tube of the implicated vessels, by the contained consolidated blood; and in the case of the artery, it has been in some instances produced instantaneously, and in an extreme and excessive degree by throwing perchloride of iron into the arterial tubes Avith the view of suddenly coagulating the blood in them for the cure of aneurisms in the course of the extremities. We have seen, further, that the pathological origin of phlegmasia dolens in a vitiated or toxsemic state of the blood, was so far experi- mentally proved in the lower animals by a diseased state very exactly resembling phlegmasia dolens, being induced when a solution of lactic acid Avas thrown into their blood. Clinical observation so far corroborates the same view. Phlegmasia dolens is an affection apparently always preceded by morbid states, more or less vitiating, and altering the constitution of the circulating fluid. In one re- markable case, in 1842, I saw a patient die of phlegmasia dolens of the left upper extremity, some Aveeks after delivery, and where the circumstances were as near as we ever can possibly find in practice, to the experiment on the lower animals of mixing the blood with some vitiating material. The patient to whom I allude had laboured, about a year before becoming pregnant, under a very severe attack of rheumatic endocarditis; and during the latter months of utero- gestation, she suffered greatly from attacks of difficult breathing, Avhich amounted sometimes to orthopnoea. After her delivery, which was effected with the aid of the long forceps, and was attended with severe and exhausting hemorrhage from partial presentation of the placenta, she seemed for a time to recover satisfactorily. But symp- toms of irritation afterwards supervened, and during the second week after her confinement embolism occurred in the right humeral artery, and no pulse could be felt in that arm below the elbow. In the course of a few days the pulsation gradually but feebly returned in the right radial artery, but the embolism recurred first in one and then in the other leg. Bye and bye, symptoms of phlebitis began to be developed in various parts of the body ; and finally, about five weeks after delivery, the patient sank under a fatal attack of phlegmasia dolens in the left arm and left side of the face. After death the emboli were found to have come from the valves of the left side of ITS PATHOLOGICAL NATURE. 203 the heart, which were profusely covered over with small Avart-like excrescences; and it Avould appear in this case as if the softening and disintegration of the plugs in the obstructed arteries had led to the introduction of a quantity of detritus into the circulating fluid, which acted as a toxsemic agent, and gave rise to all the subsequent phlebitic or thrombotic phenomena. The patient Avhose history I have just related affords you an instance of that unusual class of cases where phlegmasia dolens occurs in one of the upper extremities. To this fact I have before adverted, and I have told you also that the disease is more common in the left than in the right lower limb. But if the disease be essen- tially a general blood-disease, as we have seen reason to believe it to be, it forms a very legitimate subject of inquiry to determine why its local manifestations are confined in such a remarkable and strik- ing degree to one part of the vascular system, viz. to that of one of the lower extremities, and that extremity usually the left. Now I believe that the answer to this question will be mainly found in the fact that the coagulation of the blood, which is the immediate cause of all the other phenomena of the disease, is most likely to occur whenever the circulation is slowest; and if you examine the state of matters more narrowly, you will find that in the majority of cases those causes which lead to retardation of the flow of blood in the bloodvessels in a puerperal female must necessarily come to operate more on the veins of the lower than of the upper extremities, and most on the veins of the left lower extremity. There may, certainly, be other causes in operation as well which might suffice to account for the coagulation of blood in the veins rather than in the arteries, and in the veins of the left leg rather than in those of any other part of the body. Thus, if the veins left open on the inner surface of the uterus by the separation of the placenta, be capable of absorb- ing or admitting into them septic or poisonous materials from the interior of that organ ; and if these materials have, as such morbid materials generally have, the power of causing coagulation of blood in the bloodvessels, it is precisely in the veins of the left side of the pelvis, and in the veins of the corresponding extremity that we would expect to find the first and greatest effects of their morbific action, because the placenta is, as you are aware, most frequently attached to the left side of the uterus, and after its separation it is into the veins running into the left uterine and pampiniform plexus that tne morbid material would at first find access. Then, again, it is a matter of uncertainty how far phlegmasia dolens may notbe caused by a primary change of an inflammatory nature in the veins ; _ but it the disease depend in any case on a primary phlebitis occurring in the uterus, and extending backwards by continuity to the veins ot the pelvis and the thigh, we would naturally expect to find this also taking its origin among the veins in the left side of the uterus from which the placenta had been torn. All veins, like the torn uterine veins at the site of the placental attachment, which have been 204 ON PHLEGMASIA DOLENS. wounded, or injured, or otherwise morbidly weakened in any Avay, seem, as a general pathological law, to be far more liable than the other healthy veins in the economy, to be the seat of thrombosis or consolidation of the blood in their tubes, under any such constitu- tional toxsemia or diathesis as predisposes to this thrombosis or blood consolidation. But as I have said, it is to the delay offered in a great degree to the circulation of the blood in the veins of the left lower limb, that we must chiefly turn in endeavouring to account for the peculiar proneness which that member presents to be attacked with phlegmasia dolens. The causes which contribute to bring about this delay are, perhaps, mainly three. First of all, the great dilatation which occurs in the pelvic vessels during pregnancy, and which is not done away with instantaneously after delivery, tends to cause a retardation of the circulation in the veins of the lower extremities, and this, besides the general normal slowness of the venous circula- tion in the lower extremities, will suffice to explain why the disease in question should be more common in these than in the upper extremities, although it will not account for its greater frequency in the left than in the right leg. The explanation of this point, how- ever, will be seen if you compare the relation of the right and left iliac veins ; for you will find that, secondly, the left iliac vein is the longer, and is crossed, and more or less pressed upon by the termi- nation of the aorta, or by the right common iliac artery. Then, thirdly, the rectum lies in the left side of the pelvis, and by the pressure which it exerts more or less constantly on the veins of that side, the circulation of the blood below will be retarded, and its consolidation in the vessels greatly favoured. I believe that for these reasons you will find that phlegmasia dolens is relatively as frequent in the left limb, compared with the right, when the disease occurs in non-puerperal patients, as when it takes place after de- livery. But is now time that I should proceed to say something about THE TREATMENT OF PHLEGMASIA DOLEXS. As in the treatment of all other diseases in which we have to do with constitutional symptoms and local lesions, the indications for the treatment of phlegmasia dolens resolve themselves into the two categories of—1st, General; and 2dly, Local remedies ; and in following out both classes of indications you will find that there are three principal rules to be attended to. Among the A. General Indications, 1st. Depuration of the Blood holds the first rank. The import- ance of this indication must be at once admitted, if you have been convinced of the correctness of Dr. Mackenzie's observations and the truthfulness of his deductions. If there be abnormal and dele- ITS TREATMENT. 205 terious matters present in the blood, which have a peculiar action on the veins tending to the coagulation in them of the circulating fluid, then it is clearly a matter of prime importance to get rid of these morbid substances at once, so as to preArent the occurrence of coagu- lation altogether ; or, at least, to arrest and check the process when once it is begun. From this point of view this means of treatment must be.regarded as being almost as much prophylactic as curative in its nature. Trye tells us, in that paper to which I have already adverted, that he never lost a patient out of those whom he had seen with this disease; and this success he deemed to be due to the practice which he always adopted of administering an emetic as the first part of the treatment of every case. The shock produced by the emetic has a powerful effect in checking the progress of the malady; but probably the chief virtue of the remedy lies in its action as a most efficient depurant of the blood. At the outset I believe there is no better means of arresting the disease than by the administration of an efficient and gentle emetic of any kind, provided the state of the patient does not forbid its administration, and es- pecially in cases where exposure to cold has acted as the exciting cause. But if that fails, or is contraindicated by the debilitated condition of the patient, then we must try to purge and purify the blood by exciting the various organs of elimination to increased activity by means of their appropriate stimulants. Hence the value of the various diuretics, diaphoretics, and purgatives in the early stage of the disease. Many practitioners are in the habit of giving for the first day or two of the attack a mercurial purgative combined Avith ipecacuanha or antimony, using in this way both the intestinal and cutaneous surfaces as eliminatory excreting organs. But these, or any analogous therapeutic means, must not be pushed so far as to produce any very debilitating effects. Small and repeated doses of alkaline salts given in such quantities as to act upon the kidney, and, if necessary, also on the skin and boAvels, are perhaps, as the general rule, both more safe and more efficient—as bicarbonate, acetate, nitrate or tartrate of potass; conjoined, when required, with wine of ipecacuanha or antimony, or with some aperient tincture. ^ Besides these, salts of potass, the analogous diuretic and aperient salts of soda, are generally held to have the effect of impeding, prevent- ing, or arresting any morbid tendency in the blood to coagulate spontaneously, and of tending powerfully to the dissolution of these coagula when once they have taken place. In one patient chlorate of potass was used, and in addition tincture of the muriate of iron was employed, both as a renal depurant and as a tonic. 2d. The Use of Antiphlogistics and Febrifuges.—General anti- phlogistic measures are by many practitioners held to be indicated in the first stage of phlegmasia dolens when the pulse is high and strong, and the general symptoms of fever prevail. But if employed at all, they should, I believe, be rarely or never employed to any heroic degree. Formerly phlegmasia dolens was regarded as an 206 ON PHLEGMASIA DOLENS. affection which very seldom indeed proved fatal; and the strongest antiphlogistic measures employed by the authors who have reported it as such were little or nothing more than local blisters at the groin; or these preceded by moderate local leeching. Perhaps Avhen the history of phlegmasia dolens is fully Avritten, it will be found that the danger and mortality attendant upon the disease have been increased since venesection and other heroic antiphlogistic measures were resorted to in its management, under the idea that it was purely and radically an intense local inflammation of the lining membrane of the large veins of the affected limbs. In almost all cases of phlegmasia dolens, you will find the pulse much quicker, and more or less marked symptoms of fever present. But the best febrifuges which you can use are the depurants of which I have already spoken ; and usually the time soon comes when you must, in preference, have recourse to, 3d. The Administration of Tonics and Stimulants.—As the dis- ease frequently runs a tedious course, and is often asthenic in character from its first beginning, the use of this class of remedies is indicated in most cases from an early period, and their use gene- rally requires to be assiduously persevered in. It takes a long time to undo the effects of the changes in the nutrition of the limb con- sequent on the occlusion of so many of its bloodvessels, and while the process of absorption is going on and the tissues are gradually becoming restored to their normal condition, it is necessary to keep up the patient's strength by the judicious administration of tonics and stimulants, in addition to proper food. It matters little, in most cases, what special remedies of this class you employ; but Avine, and the preparations of iron and quinine are the constitutional remedies Avhich you will find to be most frequently had recourse to in the second stage of phlegmasia dolens. B. The Local Indications may likewise be classified under three divisions, viz:— 1st. The use of Local Antiphlogistics.—Means must be adopted to subdue the inflammation which is set up in the veins, whether this arise primarily from injury or disease of their walls, or secondarily from changes resulting from the primary distension and subsequent softening process that occurs in the occluding thrombus. The patient usually complains of much pain and tenderness on pressure along the course of the filled and cord-like iliac and femoral vein, and under the idea that the disease was fundamentally and primarily inflammation of the femoral veins, most practitioners have been in the habit of ordering one or two dozen leeches along the inside of the affected thigh; and after the bleeding consequent on the appli- cation of the leeches had ceased, the use of a series of blisters was strongly recommended by some of the older authors. What formerly I have usually done was to apply leeches at the outset, and after- its treatment. 207 wards to paint the tract of the femoral vessels all over with tincture of iodine. Latterly, I have seen several cases where little, or indeed no active local antiphlogistic measures of this kind Avere adopted; and I believe these cases have progressed as well, or indeed better, than where I followed the usual plan of local leeching and blistering. Perhaps these antiphlogistic measures ought to be reserved for cases where secondary inflammation comes on in the walls of the veins, as a result of the distension and irritation of these walls by the contained and disintegrating plugs or columns of con- solidated blood. Then to relieve the pain, you will require often in this disease to employ opiates internally and freely; and you must have recourse, further, to the use of fomentations. One of the best and most soothing measures that you can adopt for this purpose is to wrap the limb in a Avet toAvel or in a sheet of dry cotton-wadding, carefully and completely covered with oil-cloth to prevent the escape of the insensible perspiration. I believe you will find an applica- tion of this kind to be the best of all poultices : an ordinary poultice —say, of bread and milk—although at first several degrees warmer than the part to which it is applied, falls to the same temperature in a very short space of time, and then its continued soothing effect seems to depend entirely on its power of keeping in the insensible perspiration. But such also, as I have said, is precisely the modus operandi of the Avadding enveloped in oil-cloth ; and this application has one advantage over the poultice, that while the latter requires to be very frequently renewed, the former may be left unchanged for an almost unlimited period. I am seeing just now, with Dr. Moir, a lady suffering from a very smart attack of phlegmasia dolens, coming on after delivery, who has derived the greatest relief and comfort from the use of cotton wadding rolled all round the limb, and completely surrounded by a covering of oil-skin cloth. In this case the wadding has been taken off every twenty-four hours, and a fresh piece applied. If the pain of the limb is very severe, apply sedative liniments and applications, with or without the fomenta- tions, or in a permeable covering. As local sedative liniments, you may use equal parts of olive oil and laudanum ; or two parts of olive oil and chloroform; or the common opiate liniment of the pharma- copoeia. With all this the limb must be kept at perfect rest. The limb itself is usually very much paralyzed, and motion in it is almost impossible; but the patient must be enjoined to keep perfectly quiet, and to abstain, as much as possible, from moving any part ot the body. There is another local measure of the highest moment, and one you must not overlook, viz—position. The proper position is elevation of the limb, which frequently gives very great relief from pain, and always favours at the same time the process of resorption. In truth, position is one of the most powerful means in the treatment of many diseases. Attention to this point is fre- quently of more importance, and affords more satisfactory results, than the use of any kind or quantity of drugs. It is usually 208 ON PHLEGMASIA DOLENS. attempted to secure elevation of the limb by placing it upon a pil- low, but this means is not ahvays very satisfactory, as the limb readily rolls off whenever the bed comes by any chance to be moved or shaken. A better way is to raise all the lower half of the mattress, by placing something underneath, so as to make the limb lie on a sort of inclined plane, and in a position from which it cannot too readily be removed. Elevation of the limb in this manner not only tends to afford the patient the most effectual relief from her suffer- ing—it is also of most essential importance in aiding us to carry out another local indication for treatment, that, viz., according to which we endeavour 2d. To promote Absorption.—After the inflammatory stage has fairly passed over, it behooves us to try to bring about a reduction in the size of the limb by stimulating and promoting the process of resorption, so as to bring back the limb to its normal state. By careful and constant elevation of the limb, as we have just seen, much may be done to favour the absorption of the effused matters; but its effects may be greatly aided and increased by the firm sup- port afforded by a flannel bandage applied pretty tightly from the toes upwards. Frequent frictions, the use of stimulating liniments, and the occasional application of a small fly-blister to the groin, are also important adjuvants in the fulfilment of the indication. Dr. Dewees, Dr. Meigs, and other American practitioners, strongly recommend, indeed, the free and repeated use of friction of the limb, Avith sedative liniments even in the earlier and most acute stage of the malady, and totally envelop the extremity, in the inter- vals between the frictions, in flannels wrung out of a hot mixture of equal parts of vinegar and water. When the swelling has been reduced you require, 3d. To endeavour to restore the Power of the Limb.—The limb may remain weak and almost powerless for some months, or even for a year or two, or for life. To restore to it its proper power, you will be obliged to have recourse to such local tonics, if I may so call them, as frictions, bandages, and the use of warm douches, which must all be persevered with for a lengthened period. Sea-bathing, and all means calculated to restore and invigorate the general health, will also have a beneficial action on the weak extremity. Local stimulants, such as galvanism, may be applied to the limb itself; but its power will never be completely restored until the patient has begun to use it, and accustom it to frequent exercise. ON COCCYODYNIA. 209 LECTURE XVII. ON COCCYODYNIA, AND THE DISEASES AND DEFORMITIES OF THE COCCYX. Gentlemen : In the first bed at the right-hand corner as you enter the ward for female diseases, there lies a patient whose history is interesting and instructive in more than one respect. But I call your attention to her case now inasmuch as she presents you with a well-marked instance of a disease of Avhich you will find, I believe, no description in any book, and on account of which I have deemed it necessary to subject her to an operation, such as has not before, so far as I am aware, been performed, at least under sintilar circum- stances. I shall, first of all, briefly relate to you the history of this case; then take occasion from it to make some observations on the nature and symptoms of the disease from which the patient suffers ; and, lastly, try to point out to you hoAV it may be most successfully treated. E. F., a married female, of 40 years of age, has neArer had any children, but menstruated regularly and painlessly, and enjoyed good general health until about two years ago. At that time her menstrual discharges began to be more profuse and frequent than usual, and to be attended at times with pain. This she for a long time disregarded, believing the phenomena to be due to the "change of life;" but as she was becoming gradually weakened by the excessive losses of blood, she applied at my house for advice, about six or eight months ago, just after recovering from a severe attack of menorrhagia of three weeks' duration. In addition to the bloody discharges, and at the intervals between them, she suf- fered from a constant, fetid leucorrhoea; and she also complained of occasional shooting pains in the back and lower parts of the ab- domen. She was much emaciated, and had a very cachectic ap- pearance ; and my nephew, Dr. Alexander Simpson, who then saw her, found the cervix uteri to be very much enlarged, indurated, and ulcerated; and it felt rough and irregular, like a commencing cauliflower excrescence, and bled freely when rudely touched. The ulceration and induration were not distinctly limited^ the cervix, however, so that no hope could be entertained of curing the disease by amputation of the cervix uteri. But the dried sulphate of zinc was applied on several occasions, with the happy result of causing nearly the whole of the indurated and infiltrated mass to slough away and there is now left a firm and healthy cicatrix. The patient " 14 210 ON COCCYODYNIA. does not now suffer from any unusual loss of blood, although she menstruates freely and regularly; and, so far as regards the uterus, she may be considered perfectly well, if Ave except a small hard knot in the anterior lip of the cervix, which may still, perhaps, be regarded as suspicious. But as she recovered from her uterine dis- ease, and as the symptoms attendant on it began to disappear, she commenced to complain, after sitting on the damp grass in her avo- cation as a washerAvoman, of a dull, aching pain seated in the very loAver extremity of the spinal column, for which my nepheAV con- tented himself with prescribing in the first instance a belladonna plaster, and afterwards various local anodynes and general tonics for a space of two or three weeks. As this pain, however, instead of abating, seemed always to become more constant and harassing, and as the patient could not sit down except on one hip at a time, and even then Avith the greatest suffering, an examination Avas made of the painful part, when it was found that the cogcvx Avas unusually straight and long, so that it reached far backwards and downwards, while the very tip of it was felt through the rectum to be projected suddenly forwards. Pressure of the coccyx and movement of it in any direction caused pain. To subdue this sensibility thirty drops of a watery solution of the bimeconate of morphia were tAvice in- jected into the soft parts around the bone, on two different occasions, and with an interval of several days between each injection. This measure had the effect each time of deadening the pain, but it led to no permanent result. The next step employed for her relief Avas the separation of the coccyx from all the surrounding muscles, ten- dons, and ligaments, Avhich Avas done subcutaneously, with a teno- tomy knife. Three or four weeks afterwards the patient returned, saying that for a time she had felt better, but that during the last week she had suffered as much pain as ever, and was incapacitated for work from it. She Avas, in consequence, sent into the Hospital; and on Saturday, June 3, I removed the tAvo lower segments of the coccyx by cutting down upon them through the skin, and dividing the bone with a pair of bone pliers; and then the separated portion being pushed through the wound by the finger of an assistant passed into the rectum, it Avas easily detached from the soft parts, and so removed. The edges of the wound were brought together with two iron wire stitches, Avhich were removed some days aftenvards, and the wound is now almost closed up. Amputation of the coccygeal bones has been had recourse to in this patient, as it seemed to afford her the best chance of relief from a peculiar form of disease, which is anything but rare, although no written account of it has, as far as I know, as yet appeared. If you will take the trouble to make inquiry of observing men in ex- tensive practice, or if you have the opportunity of making the obser- vation for yourselves, you will find that cases are ever and anon occurring, where the patient complains of pain in the region of the coccyx, very constant, and aggravated by certain movements of the ON COCCYODYNIA. 211 trunk, and usually attributed by the patient to some kind of direct inJulT> or to exposure to cold. The most common cause of the dis- ease, so far as I have been able to discover it from inquiries addressed to the patients themselves, is injury of the coccyx, inflicted either by falling backwards upon it, or, more frequently still, brought on by sitting down suddenly and forcibly on the corner of a chair or other angled body. Often enough, however, it is impossible to trace it to any traumatic origin: and the patient can only tell you, as in the case of our patient in the Hospital, that she had been sitting on damp grass, or had been otherwise exposed to cold before she began to experience the pain; or she may be altogether unable to adduce any assignable cause. I say she, because all the patients whom I have yet seen affected with this disease have been of the female sex ; although I presume it is not entirely confined to them, and it is even not very clear why they should be more subject to it than the members of the other sex. I have said that when you have been made aAvare of the possibility of the occurrence of this complaint, and when you begin to look out for it, it is by no means very rare. Diseases, like other objects in nature, sometimes seem rare, not be- cause they are so in reality, but merely because our attention has not happened to be fully called to the recognition of them as they pass before our eyes. I think you will hold me justified in making this remark, when I tell you that within the last three weeks I can count up at least ten cases of this particular malady which I have seen in private or consultation practice. Of course, it is a very un- usual circumstance to meet with so many during such a short period ; but it is not more wonderful than what often enough occurs in the experience of all surgeons in extensive practice, who find that during a short space of time they may have a succession of cases all presenting the same form of injury, as an epidemic, as it were, of fractures or dislocations, and that a long period may elapse before they again meet with a similar case. Such a rapid succession of cases of the kind I allude to is, I repeat, of course an exceptional occurrence. But I know of old, and, on looking back upon many past years of practice, that I have seen and recognized a great many cases of this disease ; and I have probably seen many others also, the true nature of which I did not at the time understand. It is therefore, I believe, by no means an uncommon disease; and if you can discover and succeed in curing it, you will often get much credit to yourselves. That you may be enabled to do so, let me tell you how you are to detect it, or point out to you The Symptoms of the Disease. The leading symptom of the disease is pain in the region of the coccyx experienced by the patient whenever she sits down and rises, and sometimes while she remains in a sitting posture. Most of the patients affected with it are obliged to sit" on one hip, or with only • 212 ON COCCYODYNIA. one side resting on the edge of a chair, or with the weight partially supported by a hand on the chair; and they are rendered sometimes very awkward and miserable in consequence. Some of them ac- tually dread sitting down—so great is the pain then felt; and not only so, but, as I have hinted already, the pain is in many pases aggravated or reneAved whenever it becomes necessary again to resume the erect posture. There are other movements of the coccyx besides, Avhich are liable to be attended in such cases with pain. Thus, some patients have pain with every step they take in walking, Avhile in others the movements of progression excite no un- easiness whatever. Others, again, feel the pain most when the bowels are being evacuated, or under any circumstances in which the sphincter or levator ani, or the ischio-coccygeal muscles are called into action. The pain is not in every case very acute or in- tolerable ; and you will sometimes meet with patients who have borne with it for many years, sometimes Avithout having sought any relief at all, sometimes in despair from the inefficacy of the remedies that have been employed. I have under my care just now a patient suffering from menorrhagia, who tells me she has been annoyed more or less for about twenty years with a pain of this description in the coccyx, not very severe, but which she has never found any means of alleviating, though formerly she consulted various physi- cians and surgeons on the subject. Again, the pain is not at all times equally severe in the same patient. When in Cumberland lately I saAv a lady who had kept her bed the whole winter, because of the excruciating pain which she experienced in attempting to sit upright or walk about; but Avho, at the time when I saw her, had got so far relieved as to be able to move about a little. The distin- guishing feature of the disease in every case is that the pain is felt at the lowest part of the spine, or rather in the site of the coccyx, to which it is ahvays specially referred by the patient, and where pressure always aggravates it. Pressure and movement of the coccyx, too, with the finger in various directions, produce pain, and the kind of movement which is thus attended with suffering differs in different cases. Nomenclature of the Disease. If it be desirable, as I think it is, to give the disease which I have described a distinct designation, I think that by availing our- selves of the Greek (oSt^, pain), which enters into the composition of several names already sufficiently familiar to our ear, we can construct a name for this disease that will serve for its admission into a noso- logical list. We are constantly in the habit of speaking of pain in the side as pleurodynia, and the designations gastrodynia and masto- dynia are in common use for pains in the stomach and pains in the mammae; and following this analogy, it seems to me that we might very conveniently refer to this painful affection of the coccyx under • ON COCCYODYNIA. 213 the analogous name of coccyodynia. Besides that it is sufficiently terse to be easy of use, the designation presents this great advantage, that it involves no pathological theory as to the nature of the affec- tion, but simply expresses its most striking symptom. But what theory can we form as to its proximate cause ? or what, in other words, is The Pathological Nature of the Disease ? I believe that the pain which is the characteristic of coccyodynia is excited during the action of particular muscles, or particular sets of muscles, and that Avhen the coccyx, or rather the coccygeal joints, have been in any way injured, or when it or its surrounding fibrous tissues have become the seat of inflammation, or other morbid change leading to super-sensitiveness of the part, any action of the muscles in connection with it Avhich causes motion of the coccygeal bones will, at the same time, give rise to a feeling of pain. Now, in order to understand aright the circumstances under which pain is likely to be produced by the action of muscles on an inflamed or otherwise diseased coccyx, I must beg of you to recall to mind your knowledge of its normal anatomy; and to revive your recollections on this subject, I show you here a sketch of the coccyx in its mus- cular and tendinous relations, which has been obligingly drawn for me by our able demonstrator, Dr. Cleland, from a dissection made for the purpose by my former class-assistant, Dr. Peter Young. (See Fig. 54.) This will serve to remind you that the coccyx gives attachment along either side to portions of the greater (a) and lesser {b) sacro-sciatic ligaments; and that as regards muscles it has in- serted into it, 1, the internal extremity of the fibres of the ischio- coccygei (/), which arise at their outer extremity from the inner surface of the tuberosities of the ischia, and pass directly imvardsto be attached to the outer border of the coccygeal bones along its anterior aspect; so that when both muscles are in action at the same time their tendency is to draw the coccyx somewhat forward, and when only one is in action the coccyx will be drawn to the cor- responding side. Then, 2, from the extremity of the bone spring the tendon of the sphincter ani (d), and some of the fibres of the levator ani (e) which have a powerful effect in pulling the end of the coccyx inwards whenever any straining action of the muscles that close in the pelvis becomes necessary, as in defecation, coughing, etc But, 3, the most powerful muscles connected with the coccyx are the large gluteal muscles {h) of either side, some of the ten- dinous and muscular fibres of which rise directly from the posterior surface of the bone (c), while others may come to act upon it indi- rectly by means of their origin from the great sacro-sciatic ligament. In sitting down and in rising up the glutei of both sides are simul- taneously in action, and during progression when the body is swayed from side to side they act in succession. Now I have already told 214 ON COCCYODYNIA. you that in some patients pain is experienced most severely during these movements, and I think that in them the pain is fairly referable Fig. 54. Sketch of the anatomical relations of the coccyx, a. Great sacro-sciatic ligament, b. Small sacro- sciatic ligament, c. Surface from which the gluteus maximus muscle (h) has been detached, d. Sphincter ani. e. Levator ani. /. Coccygeus muscle, g. Fascia in contact with the rectum, h. Gluteus maximus of the left side. to the traction upon the coccyx exercised by the great glutei muscles. Other patients, again, complain of pain chiefly when the bowels are being moved, and in them the sensation is probably due to the action on the coccyx of the sphincter and levator ani; while in a third class of cases pain may very possibly be excited, during the contraction of the coccygeal muscles, as in the act of sitting down. It is by no means very easy to understand why the action of par- ticular muscles should thus be attended with the production of pain in particular instances. It may be that the disease is confined to the tendons of the muscles or to the portion of the coccyx from which they spring: or, possibly, certain muscles during their action may bring the bone into contact with a super-sensitive nerve or in- flamed structure, and in this way give rise to the painful sensation. ON COCCYODYNIA. 215 Again, the fact of the disease being more common in women than in men, or being confined indeed almost exclusively to the former, may be due to the greater development of the gluteal muscles, which results from the larger size of the female pelvis. It is not necessa- rily due to lesions sustained during parturition, although sometimes so produced, for it occurs as frequently in the young and unmarried as in those who have passed through one or more confinements; and more probably it is dependent in some way on the peculiar form and large size of the female pelvis, and on the greater development of the gluteal and perineal muscles which result therefrom. But, how- ever that may be, Ave have most convincing proof that the pain is elicited by the action of the muscles in the fact that separation of the fibres of these muscles from the coccyx often affords the most effectual and instantaneous relief. And this leads me to speak next of The Treatment of the Disease. Formerly, before I knew much of the nature of the complaint, I used to have recourse to many different remedies, and many differ- ent modes of treatment, in order to procure for my patients relief from their pain. Opium, in its various forms, belladonna, hyoscya- mus, and a variety of other sedatives, were all administered inter- nally, or applied locally; but only in general with the most temporary benefit. Suspecting that the pains might have somewhat of a rheu- matic character, I in some instances caused the patient to make use for a length of time of the remedies which are usually most efficacious in the treatment of diseases dependent on the rheumatic diathesis; and in other cases I have administered the various preparations of iron, zinc, arsenic, and other anti-neuralgic tonics for a lengthened period; but generally none of these modes of treatment seemed to afford any real relief, and by none of them have I ever succeeded in effecting a permanent cure, except in a very limited class of cases. There are some cases where the pain seems to be due to acute in- flammation, probably of the sacro-coccygeal articulation, or of some of the joints between the several segments of the coccyx itself; and in such cases I have seen great benefit result from the application of leeches over the part, followed by counter-irritation, while the patient was kept at perfect rest, and subjected to other antiphlogistic treatment. I have sometimes tried the use of acupuncture needles; and not infrequently I have had recourse to the subcutaneous injec- tion of a solution of morphia into the tissues around the coccyx; and this plan of treatment, which is usually so successful in the treatment of local neuralgias, has comparatively seldom had the effect in this disease of relieving the pain, and never, so far as I can remember, of producing a perfect and permanent cure. All kinds of constitutional treatment, and most forms of topical applications, are often, however, almost or altogether of no avail for the cure of this disease; and the only means of obtaining radical relief—and 216 ON COCCYODYNIA. happily it is a means which proves successful in almost every case —is the complete separation from the coccyx of the muscular and tendinous fibres that are in connection with it. To effect this, you must introduce a tenotomy knife underneath the skin, at a short distance from the tip of the coccyx, pass it along the posterior as- pect of the bone, and then divide the muscular and tendinous attach- ments, first on one side and then on the other, and finally all round the tip of it. It is not in every case necessary to make such a free division as I have indicated. In some instances division of the fibres of the gluteus maximus of one or the other side will suffice, or detachment from the coccyx of the sphincter and levator ani may be all that is requisite for a cure. This simple operation is easy and rapid of performance, like other examples of subcutaneous surgery is not attended with bleeding, and is attended with no great degree of suffering; and the result is in almost every case instant relief of the pain, and in most cases a perfect and permanent cure of the disease. In illustration of these remarks, perhaps you will allow me to read you the history of a case of this disease which was cured in the manner I have described to you. The patient was a lady from India, who came under my care several years ago; and the history of her case, which I am now about to read to you, was drawn up for me by the lady herself. "On the 5th November, 1852, Avhile taking my usual morning ride on my favorite horse, about fifteen hands in height, he suddenly shied. I was thrown, and so severely shaken and injured that I fainted on the spot, and could not suffer to be touched or moved for a considerable time thereafter. On being taken home I fainted again, from the excessive pain in the lower extremity of my body, which baffled all and every remedy to alleviate or remove ; and for six weeks I could neither turn nor attempt to move from my couch. At length I began to get about again, suffering great in- convenience from my accident both in a sitting and reclining posture —the latter especially, which in travelling caused me intense and most excruciating torture. Indeed, after travelling some hours in a carriage, I quite dreaded getting up to step out of it, as I could not do so without severe spasms. I returned to England early in 1853, and hoped its bracing climate would speedily rectify all that was amiss with my back; but in this sanguine expectation I Avas disappointed, and still doomed to drag on a miserable and wretched existence up to the 4th March, 1855, when, as if by magic, I ob- tained immediate relief from a slight operation performed upon me by Dr. Simpson." The treatment in this case consisted, I say, of the isolation of the coccygeal bones from the surrounding tissue by means of a tenotomy knife ; and the results of this simple operation has proved as satisfactory and permanent as the relief obtained by it was in- stantaneous and complete. In the case of another lady, from India, who had long suffered from coccyodynia, while I was performing ON COCCYODYNIA. 217 the same simple operation to effect her relief, an accident occurred. I was dividing the last fibres of the coccygeal attachments, Avhen the slender knife gave way, and broke among the dense structures. I told the patient of it, and she at once raised herself up in alarm to hear of the calamity; but before I had done telling her of what had happened, she had had time in sitting up to discover that she had been cured of her disease, and rejoiced at the discovery. She quickly replied, " Oh ! never mind; my pain is gone—let the knife remain." And there, for aught I know, it remains to this day—an illustration of a pathological law to which I have already directed your attention in the course of these lectures—viz., that pieces of iron and other metals may remain in contact with the living tissues, and may lie imbedded in their midst for any length of time, without giving rise to any marked degree of inflammatory action. And the striking effects of this simple operation for the cure of coccyodynia are not confined to those cases where it is had recourse to at a com- paratively early period of the disease. I have under my care just now a patient who has been a martyr to it for twelve years past, and who night and day used to suffer great pain whenever she made any movement of the body. Yet in her case, isolation of the coccyx in the manner I have described to you, produced immediate relief, and ever since the operation Avas performed, a fortnight ago, she has been perfectly free from pain. I have met with one or two cases of coccyodynia, however, which I have failed to cure by means of this operation; and where divi- sion of the muscular and tendinous fibres—even the most complete— and thus setting the coccyx perfectly free and perfectly at rest for a time, has merely eased the pain temporarily without relieving the patient of it altogether. In our patient in the hospital the operation proved thus unsuccessful, and, therefore, I put in practice, Avhat 1 had often thought of having recourse to, the more radical measure of removing altogether the coccyx or a portion of the bone. Inis amputation°of some of the segments of the coccyx was resolved on the more readily in her case, because in her the several bones of it seemed firmly anchylosed, and it at the same time projected unusu- ally low down, and was turned suddenly inwards at the tip. Making an incision of about two inches in length through the skm stretched tightly over the end of the bone, I exposed the latter, and having separated it from its connection with the soft parts, and divided it between the second and third of its vertebra with a pair of bone nliers its two lower segments were easily removed. 1 have anotner mtient suffering from this disease, in whom I have repeatedly had Curse to thegisolation of the coccyx by means of the tenotomy knife but always with the effect of producing only a temporary relief" and in her case I have long proposed to perform an operation similar to that performed in the patient in the ward, if the results nrove as favourable as we desire, and as there seems at present every reasonable prospect of attaining. Removal of portions of the coccyx 218 ON COCCYODYNIA. is an operation that has been performed more than once before, in cases of necrosis in some of its segments ; but I believe its perform- ance under the circumstances I have been describing to you, is altogether novel. I have said, that as a general rule, the result of constitutional treatment of any kind affords us little hope of being able to cure this disease by its adoption. But, as I have already hinted, there is a class of cases, of Avhich I have seen a few rare instances, where the pain seems to partake someAvhat of a neuralgic character, and where I think I have seen the patient benefited by the use of the remedies which are usually employed for the cure of neuralgic af- fections. At all events, wherever you find a patient complaining of pain in the coccyx, who at the same time is affected with pains in the other parts of the body, and who has the unhealthy chlorotic aspect common to those subject to neuralgia, you would do well in such a case to put your patient through a course of iron, arsenic, zinc, manganese, or other nervine tonics, or to make her use some of them in combination for a time. By this means you may pos- sibly succeed in curing the coccyodynia and in dispelling her other symptoms; and should that plan of treatment fail in effecting a cure, it will still form a very good and safe measure preliminary to the adoption of the severer but more certain operative procedure. I Avould only add, in connection with this point, that there is a leash of nerves lying all round the coccyx; and I once imagined that the relief obtained by isolation of the bone was due to section of these nervous cords: but noAV the explanation of the phenomenon which I have already given you seems to me to be the more probable, and that when the coccyx is separated from the surrounding tissues, no more pain is experienced, because the bone is by this means freed from the action of the muscles formerly in connection with it, and is thus placed in a condition of absolute rest. As I am speaking of the coccyx, you will allow me to add that, if more attention were directed to the pathological and anatomical history of this organ than has hitherto been accorded to it, it would probably be found to be subject to diseases and disorders such as have hardly been even suspected. In the wide field of anatomical and pathological investigation, gentlemen, there is still much room for original observation and research ; and the corner of it, to which I am not trying to turn your attention, has hitherto remained en- tirely unexplored. We have no thesis or monograph of any kind on the subject of the coccyx in its pathological relations ; yet the organ is subject to various morbid conditions which are well worthy of care- ful examination. I have been telling you something about one of these morbid states, to which I have ventured to give a name and a place in pathology ; and now, to interest you still more in the matter, and to snoAV you in what direction inquiry might be most profitably directed, let me briefly indicate to you some of the other lesions to which the coccyx is liable. And, first, a word or two as to the ON COCCYODYNIA. 219 Injuries of the Coccyx in connection with Parturition. The coccyx is, as you know, articulated to the lower end of the sacrum by a joint resembling those which unite together the several vertebrae higher up in the spinal column ; and this sacro-coccygeal articulation is sometimes found to be inflamed, as a result of injury sustained during the parturient process. While labour is going on, as the head of the child descends along the floor of the pelvis, the coccyx can often be felt to be stretched very much backwards, and under the strain to which they are subjected some of the fibres of the anterior ligaments which bind this bone to the sacrum may be torn and give way, and in the joint thus exposed and injured inflam- mation is very apt to be set up. I have seen it swell up and become very painful from this cause after delivery; and in one case the in- flammation thus set up led to the formation of an abscess. Or without producing any such immediately bad effects, the inflammatory process may subside and end merely in the production of anchylosis of the sacrum and coccyx, and then the evil effects of it may pass unnoticed till the patient comes again to be in labour, when it will be found that the unyielding bone presents a great obstruction to the progress of the foetal head. A good many cases have been put on record where it was averred that fracture of the coccyx had occurred during labour, and where, probably, the accident was of this nature, that the sacrum and coccyx had become anchylosed together as a result of some foregoing inflammation in the joint; and under the pressure to which the coccyx was subjected during parturition the morbidly adherent bones became again disunited. If the coccyx be turned very much imvards towards the cavity of the pelvis at the time when it becomes united to the lower end of the sacrum, the obstruc- tion which it then offers to labor will be much greater than when it remains in its normal position after anchylosis had taken place, and it may then be found necessary to have recourse to seme operative measure to promote the progress, and to admit of the termination of the labour. What operation should be performed in such a case ? Some say that it then becomes necessary to destroy the child, and to effect delivery of the mother by means of craniotomy; but if you will observe the course pursued by nature when allowed to terminate such a case unaided, you will find that she has a much simpler plan, which you can easily imitate, and by following which you may suc- ceed in bringing the labour to a successful termination, without having recourse to the dreadful operation of craniotomy. What nature does in such cases I had once an opportunity of observing m a patient who was confined in the old Lying-in Hospital here. In a former labor this patient had suffered some injury of the coccyx, which ended in its becoming anchylosed to the sacrum at such an angle as to cause'it to project inwards towards the cavity of the pelvis, where it now formed a firm and unyielding obstacle to the progress of the 220 ON COCCYODYNIA. fcetal head. For when the head descended to the point in the floor of the pelvis, where the point of the coccyx was protruding, it was there arrested, and remained fixed and immovable for a length of time, Avhen at last, during a strong contraction of the uterus, the projecting bone gave way under the pressure of the child's head, the adherent bones were separated from each other, and the child was speedily expelled. And in every case of this kind, I think it would be better to break up artificially the morbid union that exists between the sacrum and the coccyx, than to have recourse to the deadly alternative of the destruction of the infant. Surgical Injuries of the Coccyx, by which I mean fractures and dislocations of the boiie occurring accidentally and independently of the parturient process, are not of very frequent occurrence in ordinary every-day practice, although a good many cases have been put on record. They Avere mostly produced by the patient having fallen backwards ; and the striking features peculiar to every case are—1. The intense pain suffered by the patient when the coccyx Avas moved, as in the act of defecation, coughing, or walking ; and 2. The instantaneous and complete relief afforded by the reduction of the displaced bone. I should like to cite to you two of the cases of this kind that have been published— one, because you have all the more common symptoms of the injury very concisely and touchingly recorded; the other because of the peculiar manner in which reduction of the dislocation was effected. Smetius, a Professor of Medicine in the University of Heidelberg in the end of the sixteenth and beginning of the seventeenth cen- tury, has left a kind of diary on record of some of the most inter- esting cases that fell under his observation during the space of forty-eight years, and among other entries there occurs the following delectable entry: " 1588, October 27th.—My wife has fallen back- wards, and so injured the coccygeal bone, that she cannot sit without great pain, nor can she empty the bowel or the bladder, or cough without much distress." In the "Ephemerides Medico-Physicae," one Gustavus Casimirus Gahrliep tells of an accident that befell his father-in-laAV, an old septuagenarian, who in descending the steps of a place when they were slippery with ice and snow, lost his footing, and fell with the loAver end of the trunk against the stone stairs. He sustained a fracture of the os coccygis in consequence, but said nothing about it to his daughter, a young girl, who was the only person living with him at the time. He could get no passage in his bowels; and his daughter, believing this to be the cause of the distress which she saw him labouring under, administered some aperients, but without affording any relief. He had become seriously ill on the fifth day, when he spoke of his accident to a sagacious friend, who told him that perhaps his spine was injured, and advised him to allow himself ON COCCYODYNIA. 221 to be rolled and tumbled and pushed about, as he lay on a wooden couch, by two robust women. He folloAved his friend's advice, and with the happiest result; for by the jostling the end of the os coc- cygis which was bent inwards was restored to its situation, and the obstruction being removed the bowels Avere moved cum impetu sumno. Allow me to quote a third case, Avhich will show you in what a simple manner this accident may sometimes be occasioned. Tobi a Meek'ren, an old surgeon of Amsterdam, gave to the Avorld in his Medico-Chirurgical Observations, among other cases, one in which this accident—dislocation of the caudal bones—took place. The patient, he tells us, was a female, addicted to the sect of the Ana- baptists, who went to the watercloset, and not knowing that the lid was down, suddenly injured her coccyx, so that she could neither sit nor stand, and was obliged to be carried to bed. On the second day the pain became greater, and she fevered and got convulsions; and then Meek'ren was called in in consultation with her ordinary attendant. They suspected the nature of the case, but the modest lady would not allow herself to be touched. But during the night her sufferings became so intolerable that her medical advisers had to be summoned again early in the morning; and this time they were allowed to reduce the dislocation which afforded her instanta- neous and complete relief. But besides being liable to be turned forwards, whether as a result of inflammation or injury during the process of parturition, or as the effect of direct violence from a fall or blow, the coccyx is found in some cases to project unusually far backwards. I do not refer now to those cases of which there are some few on record, and in which this dislocation of the coccyx backwards has been produced during labour, and has remained afterwards as a permanent but usually painless condition; the variety I allude to belongs rather to the class of Malformations of the Coccyx. In the woman in the hospital the coccyx was unusually straight, and the general inclination of the bone was somewhat backwards, although the last segment of it was turned rather abruptly forward and projected towards the rectum. In her case it is not easy to determine whether this condition of the bone was present from birth, or was the result of some injury in after life. But in a late number of the Dublin Medical Press, Dr. Wilson gives an account of a natient with a projection resembling a tail, attached to the lower end of the spinal column; and in the last number of the same journal there is a paper by Dr. Jacob, reprinted from the Dublin Hospital Reports, in which he describes a tumour of this kind that Lad been amputated by his father, and in which he speaks of a f.,milv several of whose members presented this remarkable variety of malformation. In the Chronicles of Lanercost it is related 222 ON COCCYODYNIA. that the Norman sailors used to believe the Englishmen to be fur- nished with tails, and when they had to execute them they hung them always with a dog alongside, thus anticipating the principle of similia similibus. Deficient Development of the Coccyx has sometimes been seen as a rare instance of deformity. The number of segments is liable to much deviation; but its total want, or its existence in merely rudimental condition, is rare. Perhaps the most frequent and striking instances of this kind of deformity occur in the domain of Comparative Anatomy. Thus in the Isle of Man there is a breed of cats, all the members of which are born without tails, the coccygeal bones being reduced in number to a very few, and these rudimentary in character. Absence of the caudal bones, I repeat, in man is a rare phenomenon, although their exist- ence at all is not often suspected by those who have no knowledge of anatomy, some of whom have entertained the most singular ideas on the subject. Perhaps no theory was more singular than that of Lord Monboddo, an old Scottish judge, who believed that the absence of the tail was a phenomenon peculiar to the modern human races, and that the modern curtailment of this appendage was a result of their higher degree of civilization. The worthy judge, at an early period of his investigations, believed that we must all Ire still born with tails, and that possibly the wise women and the doctors cut or twisted them off the moment the child was born. It used even to be told against his lordship, that on one occasion when an addition was about to be made to his own family, he was caught hiding in the bedroom, in some corner of which he had secreted himself with a view of watching all the proceedings, and witnessing for himself the removal of the new-born infant's tail. Tumours of the Coccyx—Double Monstrosity by inclusion. But leaving the mythical and mysterious part of the question, let me call your attention to the sketch (see Fig. 55) of the posterior aspect of an infant, whose entrance into the world created a great deal of noise some three years ago, and regarding whom a paragraph appeared in many neAvspapers, headed, " Curious Monstrosity—A Child born with a Tail." The case occurred in the practice of my friend, Dr. Bichardson, of Stockton-on-Tees, who relieved the child of its extraordinary appendix by amputation, and who had the kindness to send me the tumour for dissection along with this sketch of the child taken before the performance of the operation. The tumour, which is of an oval form, and about six inches in length by four in breadth, was attached to the skin of the back opposite the middle of the sacrum by a narrow rounded neck of about an inch in diameter, through which tAvo or three small vessels passed into ON COCCYODYNIA. 223 the tumour. At the loAver end, which projected slightly beyond the level of the folds of the nates, there was a slight depression, through Fig. 55. Sketch of the coccygeal tumour attached to the child. Dr. Richardson's case. which a'point of bone could be distinctly felt, while from the upper extremity, on the surface which was turned towards the back of the infant, there grew a projection about two inches in length, which bore a perfect resemblance to a finger or toe, containing, as it did, two bones like phalanges, and being furnished at the tip with a well- developed nail. The skin of the child's back immediately surround- ing the point to which this tumour was attached was altered in cha- racter, and resembled in appearance the mucous membrane of the lips, while the skin in contact with this peculiar structure was thickly covered with hair. The child was in perfectly good health; and, Dr. Richardson very wisely determined upon relieving it of its extraordinary encumbrance, which he succeeded in doing with per- fect safety by first tying a cord round the neck of the tumour, and then cutting it off beyond the ligature. There was no remarkable degree of hemorrhage, only one vessel requiring to be tied; and the infant showed no bad symptoms afterwards, while the wound soeedily closed. On dissection, the tumour was found to consist, as vou here see (see Fig. 56), of a mass of fat enveloped in skin, and containing in its midst a long bone, running nearly through the en- tire length of the growth, while a number of vessels and nerves 224 ON COCCYODYNIA. came through the neck and were distributed throughout the mass. The bone was well ossified and invested by periosteum; but it does Fig. 56. Sketch of the coccygeal tumour dissected. not present a sufficiently well-marked resemblance to any of the bones in the human skeleton to enable us to decide as to its real nature. It bears more resemblance to a tibia, however, than to any other bone. Towards the upper end of the one side it has at- tached to it a portion of tissue, redder in colour and denser in texture than the rest of the substance of the tumour, and almost resembling muscle in appearance. ^ Now, what is the nature of this curious caudal appendix? It is simply an instance of a kind of malformation which occurs when two ova have been impregnated, and when only one of the foetuses comes to maturity, while the other is blighted at an early sta^e, and arrested in its development, but becomes adherent to some part of the body of its co-twin, where it appears at birth in the form of a tumour. Tumours of this kind may be found adhering to different parts of the bodies of infants, and we occasionally meet with cases where they are attached to the very lower extremity of the trunk and in connection Avith the coccyx or region at least of the coccyx. ON COCCYODYNIA. 225 I show you here a drawing of a child (see Fig. 57) with a large sacculated tumour of this description groAving from between the Fig. 57. Sketch of a coccygeal tumour which presented at birth. nates. In this case the tumour presented at birth, and proved a source of great difficulty to the practitioner in attendance, who could not make out the nature of the case until the birth of the lower half of the body had been effected. In the practice of Dr. Paterson of Leith, a similar case occurred about eighteen years ago, when a boy was born with such a tumour growing from the lower part of the back of the pelvis. This tumour (see Fig. 58) was seen by a good many different medical men, and very different opinions were entertained as to its nature, but most were inclined to the belief that it was a case of spina bifida. I had just been reading Meckel s work on Double Monsters, in which he describes some cases of this kind and came then to the conclusion, which I still believe to be the correct one, that Dr. Paterson's patient was another instance J f tus born with an undeveloped one attached to it; but the bearer of that supernumerary foetus still lives, and as the tumour was 15 226 ON COCCYODYNIA. never removed there has been no means of verifying the diagnosis. Here is still another drawing (see Fig. 59) of a case of this nature, Fig. 58. Sketch'of a coccygeal tumour occurring in a child born eighteen years ago and still living. Dr. Paterson's case. occurring in the person of a girl, who came into the Hospital several years ago with a cystic mass attached to the back opposite the sa- crum and coccyx, which had been there at birth, and which still continued to grow. A portion of the growth was removed, and it was found to consist chiefly of a few large cysts, which gave out an intolerably offensive secretion. There are some preparations of this kind in the museum of St. BartholomeAv's Hospital in London, and among others a preparation of a supernumerary undeveloped foetus, which was removed from the lower part of the back of an adult female by Mr. Wormald. The tumour in this case, Mr. Wormald writes me,'seemed to come from the interior of the pelvis, and as it grew the sacrum and coccyx were turned upwards and backwards. It was of enormous size, requiring an incision on each side of twenty-five inches in length for its removal, and on examination afterwards it was found to be composed of a mass of cysts, some of them containing a watery fluid, others steatoraatous matter, hairs, fat, and osseous deposits. The patient gradually recovered from the operation; but the sacrum and coccyx never returned to their normal position. A gentleman died a few years ago, the heir to a Scottish earldom, avIio had a tumour growing from the lower and ON COCCYODYNIA. 227 back part of the trunk, regarding which endless consultations had been held during his lifetime. It Avas often discussed Avhether it Fie. 59. would be safe and proper to remove it; and when he died, at the age of forty, it Was found that this tumour, which had been a source of discomfort and uneasiness to him all his life, might very easily have been removed. If you inquire into the nature of these tumours you will find them to vary very much as regards their structure. Sometimes they ' consist of masses of fatty substance alone; sometimes they contain bones, rudimentary, or more or less developed ; or they may contain teeth. Some of them have been found having a jaw-bone with teeth in the sockets. Portions of intestine and portions of other organs and parts of the body have at times been found in them all tending to show that they are merely instances of secondary blighted foetuses attached to well developed ones, and obtaining nourishment from them Some of these secondary foetuses remain in the most rudimentary condition possible, presenting only a cellular mass. Others again contain tissues more highly organized; and some ot them present traces of parts approaching in development to the organs and parts of their more perfect mates. These additional foetuses attached to the sacrum and coccyx form a puzzle, however, to teratologists in this respect, that they cannot be found to be regu- lated in any way by a law which holds good in the case of double monsters of almost every other description. In all the common 228 ON COCCYODYNIA. types of double monsters it is a law that like is always attached to like in the two bodies. Thus the chest of one child is always at- tached to the chest of another, the back to the back, a sternum to a sternum, an occiput to an occiput, an artery to an artery, a nerve to a nerve, the corresponding bone, muscle, artery, nerve, etc., of one body, to exactly the same corresponding bone, muscle, artery, nerve, etc., of the. other body of the double monster. But to this law there are some few and rare exceptions. Thus I have in my hand the skeleton of a fully developed kitten which has the pelvis and posterior extremities of a secondary fcetal kitten attached to the lower end of the sternum. Such a union of unlike part's is very rare, and we may perhaps deduce a lesson from it in transcendental anatomy, as to the analogy between the pelvic and sternal bones. And the coccygeal tumours in question form also, I repeat, a very striking exception to a laAV which is so general; for in them you have parts and tissues of the secondary fcetus attached to parts and tissues of the developed child that are not at all similar. What are we to do in the way of Treatment of these Coccygeal Tumours ? When they can be removed with safety to the infant, it will, of course, always be advisable to do so; but it is not always very easy to decide upon the safety of the operation. In such a case as that of Dr. Richardson, where the tumour was pediculated and attached by a narrow neck, and where no tissue of. importance was present in the isthmus, the operation was safe, and the result satisfactory. The same may be said of Mr. Wormald's case, and of some others; but sometimes, as I have told you, portions of intestine pass out from the body of the child into the coccygeal tumour, and whenever there is any suspicion of the presence of such a communication the opera- tion had better be left undone. Where removal is to be effected at all, it is best to do it as Dr. Richardson did, as soon after birth as possible. In the case of the girl in the hospital, bad ulcers formed in the opened tumour, and exhaled such odors as to render her presence intolerable to all the other patients. In the case of Dr. Paterson's patient, nothing at all was dorte,.and the cystic mass has shrunk up and become reduced in size, instead of becoming devel- oped along with the rest of the body; and the young man, who is now a clerk in a public office, works all day at his desk sitting upon, and in one sense at least supported by, this undeveloped brother. ON PELVIC CELLULITIS. 229 LECTURE XVIII. ON PELVIC CELLULITIS. Gentlemen : I intend to direct your attention to-day to a malady which presents to us the following peculiarities in its history, viz: 1st. It is a disease of great importance, and as all now acknowledge, it is by no means unfrequent in practice; 2d. It is an affection which it is in general not at all difficult to detect; yet, 3d. It is not described, as far as I am aware, in any English systematic work on midwifery or the diseases of females, published earlier than twenty years ago ; and 4th. Though thus neglected and overlooked by our fathers and their predecessors, it is an affection a full and distinct account of which has been left us in the writings of various old Greek and Roman physicians. "Probably," observed Aristotle upwards of 2000 years ago, "probably all art and all Avisdom have often been already fully explored, and again quite forgotten." The remark at all events strongly applies to many facts in medicine, and among other things to the disease in question. One of the first modern accounts of the disease I refer to, Avas published in France by Marchal de Calvi, in 1844, under the title of an essay on "fntra- pelvic Phlegmonous Abscesses." This essay was reviewed at the time in the old Medico-Chirurgical Review. In the very number of the Medico-Chirurgical Review in which this essay of M. Marchal de Calvi is reviewed and most highly praised and recom- mended, the reviewer takes occasion, apropos of the publication by the Sydenham Society of Dr. Adams' admirable translation of Paulus JEgineta, to sneer at the medical knowledge of the ancient physicians, and to reprobate in no measured terms the study of the ancient authors. But in that translation of Paulus ^Egineta which the reviewer thus affects to despise, there is a very concise and lucid account of the disease, for a treatise on which M. Marchal de Calvi receives so much praise. Various diseases well known to the ancients, and fully described in their writings, have been lost from sight and observation for many ages ; so that when detected again in our day they appear in the light of entirely new discoveries. In the time of the Emperor Trajan, there was a physician in very extensive practice in Rome, of the name' of Archigenes, who equally with Acrathinus has been regarded as the head of the Eclectic School. Juvenal makes frequent reference to Archigenes, and describes him going about visiting his patients attended by fifty pupils, each feel- ing every patient's pulse by turns. This same Archigenes left a great many writings. Among the fragments of his writings that 230 ON PELVIC CELLULITIS. fiave been preserved, one relates to the disease I wish to speak of. If I can lay hold of the account of it which is quoted from him by iEtius, I may perhaps read it to you at my next lecture, in order to , shoAv you hoAV much he kne-w both of the course and treatment of the disease. Professor Doherty, of Galway, and Professor Churchill, of Dublin, were the first modern English authors who called the attention of the profession to the frequency and importance of the disease I allude to: the former describing it as "chronic inflammation of the appendages of the uterus after parturition;" and the latter, as "abscess of the uterine appendages." In some observations on uterine diseases published in 1843, after giving some details of two cases of the disease in the puerperal female, I added that " I had seen several cases in the female of chronic ' pelvic inflammatory tumours,' unconnected with the puerperal state ; and where the fixed condition of the body of the uterus, the surrounding tumefaction, and the apparent almost ebony induration produced in the roof of the vagina at one stage of the disease, by the tenseness and disten- sion of the pelvic fascia, gave rise to the idea that the affection was organic and carcinomatous, and not simply inflammatory.'' We all now know the disease to be far from rare, even in the non-puerperal female; and I have usually here lectured upon it under the name of Pelvic Cellulitis, a name which I ventured to suggest in consequence of its pathological seat and nature. We have had two instances of this disease in the wards during the session, and one of the patients is still under observation. Be- fore discussing the subject of Pelvic Cellulitis more at length, you will allow me to read to you the history of these tAvo cases from Mr. Sclander's report. Case 1.—"C. R., admitted Feb. 12,1859, aged 30, married twelve years. Was very healthy before her marriage ; menstruates regu- larly. Has given birth to six children, and had one miscarriage, which occurred between the fifth and sixth labours. She has had rapid recoveries from all her previous labours, and has been attended by accoucheurs. She had a midwife with her in her last confine- ment, which occurred two months ago. Had a very short labour, lasting only from 6 A.M. to 9.30 A.M., at which time the placenta was expelled naturally. She remained very Avell during the first Aveek, and was rapidly recovering; but at the end of the week she had rigors, which have continued at times up till noAV. She then noticed for the first time pain in the right iliac region and great tenderness on pressure, which was succeeded on the fifth week after delivery by a swelling in the part first affected by pain. This swell- ing was tense, hard, and circumscribed. Mustard poultices Avere first applied, and then leeches, and she experienced great relief although the abdominal swelling remained as painful as ever. The rigors were followed by profuse perspirations whenever they oc- curred. The pulse rose rapidly from the first symptoms; appetite ON PELVIC CELLULITIS. 231 was much impaired; great thirst, and feeling of weakness and de- pression. "On admission, there is a hard swelling in the left iliac region, extending to within a short distance of the mesial line. The space occupied by this hardness is dull on percussion and tender on pres- sure ; and when the finger is introduced into the vagina the internal surface of the swelling may be readily felt—it seems to be uneven and very sensitive. Much feebleness; tongue dry and coated with a whitish fur ; lips dry and fissured; expression anxious ; respiration natural; pulse 98 ; urine of natural colour and quantity; bowels regular. " R.—Hydrarg. bichloridi gr.j ; aquae 5*ij ; a teaspoonful to be taken three times a day. To have a blister produced by nitrate of silver. "Feb. 18th. The tenderness is much lessened; but the swelling remains of the same size and shape. " 19th. Complains of sickness and pain in the epigastrium. To have, R.—Bismuthi trisnitratis 3ss ; mucilaginis 3J ; aq. fontis 3v; a tablespoonful three times a day. " 23d. The sickness and pain have disappeared. The abdominal swelling is lessened, and the patient has not had any rigors since last report. To take Citratis ferri et quinse gr. iij per day. " March 2d. There is much hardness and tenderness in the region of Poupart's ligament on the right side. She cannot extend the right thigh in consequence of the excessive pain; the inguinal glands are enlarged and indurated. To have another vesication with nitrate of silver, arid to take Syr. ferri iodidi ttlxx ter in die. " 3d. There is a purulent discharge from the vagina, noticed principally when the patient empties the bladder. The pain over Poupart's ligament is much better. " 9th. The purulent discharge still continues, but in diminished quantity. To have unguent, bismuthi applied to the vesicated sur- face on the groin*." Case 2.—"S. N., aged 21, admitted March 24, 1859. States that she has always enjoyed good health up till the date of the present attack. Menstruates regularly ; occasionally observed her feet to swell towards night; but attributed it to her running up and down stairs so much. She attributes her present illness to having caught cold after menstruating, about three weeks ago, at which time also she suffered from diarrhoea. This diarrhoea continued for several days, after which she was seized with pain in the lower part of the stomach, back, and left iliac region. This pain, which has continued up till the time of her admission, is not constant, but more severe generally at night. She describes it as shooting round from the left to the right side and down the left thigh as far as the knee. Pain and tenderness over the lower part of the abdomen. On ex- amination per vaginam, a tumour is felt projecting from the left side in the situation of the broad ligament of that side of the size 232 ON PELVIC CELLULITIS. of an egg, hard and firm. Ordered two leeches to be applied round the anus, and Pil. mass, hydrarg. gr. iij; mitte tales xij. One every four hours, and a starch and opium injection. Fomentations to be applied to the lower part of the abdomen. "April 3d. Ordered: R.—Hydriod. potass. 5ss; syrupi simplicis oj; aquae fontis ad 3*viij. A tablespoonful thrice daily; diet to be light; chicken soup. " 12th. Patient complains of palpitation, with severe pain in back. Pulse 104. Ordered—Pulv. digitalis gr.vj ; potassae bitart. 3v; pulv. cinnamon comp. 9j ; fiant pulv. vj. '_'13th. Pain in the left side worse to-day. The tumour is felt to be increased in size. Ordered to use mercurial pessaries, and tinc- ture of iodine to be painted externally on the lower part of the abdomen. "17th. Ordered: R.—01. crotonis 3iss; ol. olivae 3j. Fiat lini- mentum. To be applied every night. " 18th. To-day she has been unAvell; very slight discharge. R.— Acidi hydrocyanici dil. 3ss; tine, hyoscyami 3ss; mist, camphorse liss ; tine, cardam. comp. sss.—M. Signa.—A tablespoonful thrice daily. " 20th. As the discharge still continues scanty, ordered leeches to be applied round the anus. " 23d. Catamenia ceased : to return to mixture prescribed April 3d, and continue the croton liniment. " 25th. Complains of great pain in the right side, much more than is usual; very restless, and does not sleep. "29th. Much better to-day—is going about the ward. " May 7th. Continues to improve. The tumour on examination is lessened considerably. Ordered emplast. lyttse 4 by 4, to1 be applied over the left side. " 15th. Complained of return of pains, very severe to-day. To have tincture of iodine painted externally. "25th. Ordered: R.—Quinse disulph. gr. xij; acid sulph. dil. n^xl; aquae ad 3*vnj. A tablespoonful thrice daily. "29th. Ordered: R.—Tine, hyoscy. eth. chlorici aa 3ss ; mist. camph. sss; aquae 3*j ; fiat haustus, as patient complains of great pain, and has not slept for two nights. _ "30th. Much better to-day. Ordered: R.—Hydrarg. iodidi gr.vj ; pil. galbani 9ij ; divide in pil. xii. Sig.—One twice a day." Nomenclature of the Disease. The disease of which you have had an opportunity of studying the phenomena in the patients whose history I have now read to you has been known under different names, which may be apt to cause you some perplexity in attempting to get at the literature of it. Some of these names I have already stated to you. It was generally described by the ancient writers as "abscess of the uterus-" it has ON PELVIC CELLULITIS. 233 very often been described by modern writers as "pelvic abscess;" but the designation is an incorrect one, for pelvic cellulitis is no more pelvic abscess, than pleuritis is empyema. In the one case as in the other, the inflammatory process, which is the primary and original disease, may pass on to its highest grades and lead to the development of pus. In pleurisy, if the inflammation be not checked in time and the membrane be not restored to its normal state, pus comes at length to be secreted into the pleural cavity, and the pleurisy merges into empyema. So in the case of inflammation of the different portions of cellular tissue contained within the pelvis, or, in other words, in Pelvic Cellulitis, you will find that usually it only merges into " pel- vic abscess" when no attempt has been made to subdue *the inflam- mation, or when even well-directed treatment has failed to prevent it from ending in suppuration. In the girl who is still in the Avard, there was at one period in the history of her disease a large inflam- matory swelling or effusion in the left broad ligament, which was dispersed and disappeared. Since then a similar swelling, or in- flammatory effusion, has, as you have been told, become developed between the rectum and the vagina, but instead of ending in resolu- tion as before, the inflammation now proves less amenable to treatment, and threatens to end in suppuration, and to lead to the development of a pelvic abscess. Again, descriptions o'f inflammation of the cellular tissue of the pelvis have been overlooked among the accounts of the other inflam- mations occurring simultaneously with it as the results of unfavour- able confinements, or they have been lost among the notices of other sequelae of unfortunate operations performed on the pelvic organs. You will find cases on record under the names of "psoas abscess" after delivery, "iliac abscess," &c. We meet the disease most frequently, perhaps, in the case of puerperal patients, who have been subject to injurious influences; but it occurs also frequently, as I have already mentioned to you, in non-puerperal patients as well, as we see in the case of the girl in the ward in whom the disease seems to have been caused by exposure to cold during a menstrual period. It may result from any operations in the pelvis, or injury of _ the pelvic organs. It may occur in patients of all ages and at all times of life. I have seen it in young female -children; and I have at- tended patients attacked with it when upwards of seventy. It is a disease not confined to women, although most frequently seen and recognized in them. Cases of pelvic cellulitis and abscess occur not unfrequently in the male sex from cold, after operations on the urethra, rectum, &c. Pathological Anatomy. The disease consists essentially and primarily of inflammation of the cellular tissue of the pelvis; arid to understand aright its nature 234 ON PELVIC CELLULITIS. and its course, and to be able to construct a proper plan of diagnosis and treatment, we must study, 1. The Seat of the Inflammation.—The pelvis, as you know, is lined and closed in inferiorly by means of a fascia, which gives off sheaths to the different pelvic muscles, and furnishes processes for the protection, support, and separation of the various pelvic organs. Wherever two layers of this fascia approach each other after cover- ing the opposite surfaces of any organ or muscle, and wherever two layers covering contiguous organs come to be in opposition, you will find that there is always a greater or less quantity of loose cellular tissue interposed between them. Thus, between the layers of the broad ligaments, between the vagina and the rectum, between the iliac muscle and the bone, and, in short, in almost every part of the pelvis, there is an abundance—a great abundance—of cellular tissue; and, I repeat, the disease of which 1 have now to speak consists of inflammation, acute or subacute, of this abounding cellular tissue. 2. The Products and Terminations of this Inflammation Arary according to the stage of the disease, and may be considered under the four folloAving divisions :— 1st. Serum; 2d. Pus; 3d. Coagulable Lymph ; 4th. Sloughing of the Cellular Tissue. * 1st. Effusion of Serum is the first phenomenon that occurs Avhen inflammation has become established in the cellular tissue of the pelvis. The necessary result of the effusion'of this fluid is a swell- ing in the part, Avhich may be felt on examination through the vagina or rectum, or even through the abdominal parietes, according to its special seat. This swelling is of greater or less extent according to the intensity of the inflammation, and according to the freedom with Avhich the fluid is allowed to escape along the cellular tissue, and to pass from one loculament or division of pelvic fascia to another. The swelling or tumour produced by the effused serum is from the first firm, dense, and resistant to the feel, and sometimes becomes very hard, particularly when the effusion takes place between two layers of the fascia which are not loose, and mobile, and yielding, but are bound at their margins to some osseous ridge or strong ligamentous band ; as when it occurs, for example, in the wall of the pelvis, externally to the margin of the broad ligament of the uterus. In such a situation the swelling comes sometimes to feel hard as a cricket-ball, or a "deal board," as Dr. Doherty has ex- pressed it, and has been, and might easily be, as far as mere hardness is concerned, mistaken for an exostosis of the ilium ; and when in the roof of the vagina it sometimes feels as firm to the touch as a scirrhous groAvth. -One other common and very characteristic feature of the tumour is this—it feels as if it were adfixed to and grew, as it were, from the side of the pelvic bones, whenever the effusion has extended to a sufficient extent laterally, so as to reach ON PELVIC CELLULITIS. 235 the walls of the pelvis. Fibroid tumours of the uterus, ovarian tumours, and others with which the "inflammatory tumour" of pelvic cellulitis are sometimes confounded do not present this symptom. After the effusion has invaded loculament after loculament of the pelvic fascia it soon loses its primary round or oblong form. In examining the swelling day after day you can sometimes find it daily altering its figure, and occasionally you can thus trace its gradual process, as it creeps from One side of the pelvis to the other, and passes before or behind the neck of the uterus, and at last involves and fixes the uterus in its mass. The inflammatory effusion is by no means always limited to the cellular tissue of the lower or true pelvis. Often from the first a large swelling or effusion can be felt in one or other iliac region; and I have seen one or two cases where the tumour was in a great degree central, and as large as the uterus at the fourth month. Occasionally the disease invades the cellular tissue of the upper or large pelvis, and especially the cellular tissue in the right iliac fossa, and around the head of the caecum, without even stretching downwards into the true pelvis. Again, we see occasionally in practice smaller inflammatory swellings and effusions limited to single loculaments of the pelvic cellular tissue situated in the anterior or on the posterior walls of the vagina, and not even passing upwards to the cellular tissue contained between the broad ligaments and lying around the neck of the uterus. I should wish particularly to have it impressed upon your minds in regard to this disease, that there is no pus in the effusion or tumour at first, and that it does not begin in any case by being an abscess, but that first of all an effusion of serum takes place into the inflamed cellular tissue, and no formation of pus generally occurs till about ten or fourteen days afterwards. In one of the first cases of the disease I ever saw, and when I was only beginning to learn something of its nature and course, I got a lesson in regard to this matter which is very strongly impressed upon my mind, Dr. Andrews, who was then a lecturer on midwifery in London, was on a visit to Edinburgh at the time, and I offered to show him a case of pelvic cellulitis as an object of interest; for the subject was then new and not many cases of the disease had been observed. The patient was a young girl, of twelve or thirteen years of age, in whom 1 had made sure that inflammation had been set up in the, broad ligament of the uterus, and caused great swelling and induration of it Ihis I supposed to be due to an effusion of pus, for we then spoke of and thought of the disease as always "pelvic abscess, and about the tenth day from the commencement of the disease, I introduced in presence of Dr. Andrews, an exploring needle with the view of briE away the pus and reducing the swelling. But to our as- S^nTthere flowed into the dish held to receive it, not yellow nustut6 ' trX«ent fluid so clear and limpid that Dr. Andrews at P ' l\Jivedto me, "Have you not punctured the bladder ?" I £ew frXSe direction of thl needle'backwards that it was not 236 ON PELVIC CELLULITIS. near the bladder, and after a considerable quantity of this clear fluid had escaped, we soon had evidence that it Avas not urine, by its rapid coagulation in the cup which contained it. It was serum, such as you see in the stages of many inflammations, and such as you may obtain from the skin after the application of a vesicant ; and in the earlier stages of pelvic cellulitis it is this inflammatory serum whose effusion gives rise to the swelling and hardness, and which is the only fluid you will then procure on using an exploring needle. If the inflammation be not now subdued, and the effused serum be not absorbed, it will betimes lead to, 2d. The Formation of Pus.—You may meet with a case of pelvic cellulitis where there is an effusion of serum attended with much pain and distress; yet if the disease proceed no further and resolu- tion of the process be effected, the disease might run its course, and its real nature might be altogether unsuspected, unless you had previously been made aware of the probability of its occurrence. But if the inflammatory process remains unchecked, and goes on to its higher stage of suppuration, the disease is not so likely to be overlooked; and hence most of the descriptions that we have of the disease refer to it only in this more advanced stage. The pus may become developed, in any part of the pelvis where inflammation has been set up, and in some cases it is confined to one fascial loculament, while in others it occurs in two or more simultaneously. It does not always remain in the part Avhere first it is formed, but forces its way from one loculament to another, until it reaches a cutaneous or mucous surface through which it may be evacuated. Its progress is often very difficult to trace, and to understand it aright requires an intimate knowledge of the course and connection of the fascial sheaths of the pelvic organs. Perhaps the most common seat for the development of an abscess is in the cellular tissue of one or other of the broad ligaments of the uterus, and when matter has been formed there it may make its way towards the roof of the vagina either by passing in front of the neck of the uteru3 between it and the bladder, or, as is far more frequently the case, by sinking backwards between the cervix uteri and the rectum. In such a case the abscess may open either into the rectum or into the vagina, which are the two most common canals for the evacuation of pelvic abscesses, and fortunately also the two most favourable. But there are two other cavities into which the matter sometimes, but less frequently, finds its way; and as they are not by any means so accessible, the treatment of the case becomes more complicated and difficult. These are the cavities of the bladder, and of the body or cervix of the uterus; and when one and the same abscess opens into both of these organs, as sometimes happens, a form of vesico-uterine fistula results which is not always very amenable to treatment. On the other hand, you will sometimes find the matter burrowing onwards, and finally making an opening for itself in some part of the cutaneous surface of the body. The pus may pass, for example, underneath ON PELVIC CELLULITIS. 237 the pelvic fascia, and escaping from the pelvis along Avith the femoral vessels, it may come to point someAvhere in the groin ; or it may pass backwards through the great sacro-sciatic notch along Avith the sciatic nerve, and lead to the formation of an abscess in the hip, as I lately saAv in a case which I visited along with Dr. Moir. Again, the matter in some cases sinks downwards, and escapes at some point in the pelvic outlet. One interesting point which it is of importance to observe and to remember in connection with the evacuation of pelvic abscesses is the extreme rarity with which they become discharged into the cavity of the peritoneum. When we knoAv that inflammation has been going on around some of the pelvic organs, and has led to the formation of pus beneath the peritoneum, Ave might be apt to form a very unfavourable prognosis, and to look upon a fatal peritonitis as almost certain to ensue. But experience of such cases assuredly does not warrant us in entertaining such a gloomy view, for this reason, that abscesses forming under the peritoneum very rarely perforate it, and open into its cavity. Why this is so, is not very easy of explanation. Cruveilhier avers that it is because the peri- toneum is lined, and protected by a layer of fascia, the existence of which is denied by others. In some cases adhesive peritonitis is set up, and the abscess is prevented from bursting into the peritoneal cavity by the resistance offered to it by the two adherent layers of the membrane. But whatever be the explanation of it, the fact is not the less true, and it is ahvays a hopeful one to be borne in mind —that the peritoneum has a very remarkable power of resistance to the passage of matter, and that, in consequence, pelvic abscesses very rarely terminate by evacuation into its cavity. I shall have to revert again to this point when I come to speak of the artificial evacuation of the pus; and I pass on now to notice another product of inflammation in the cellular tissue of the pelvis, viz., 3d. Coagulable Lymph.—When an effusion of firm, solid coagu- lable lymph or fibrin takes place into one or more of the fascial loculaments in the course of the disease, the swelling which results is extremely dense—really as hard as the "deal board" of Dr. Doherty—and many long months usually elapse before it softens, breaks down, and is discharged. I have a patient under my care just now in whom suppuration has set in after an attack of pelvic cellulitis, which came on when she was at the country, so that there is now formed an abscess in the right iliac fossa. But fourteen years ago she had an attack of the disease, which came on after a confinement, and took on the form I now refer to. On that occasion there was an effusion of coagulable lymph into the cellular tissue around the cervix uteri, forming an extremely dense solid tumour, like a hard cancerous growth or deposit in the roof of the vagina. Nearly two years elapsed before this effusion was fully absorbed. When pelvic cellulitis terminates in effusion of coagulable lymph, the swelling is always very long in disappearing. 238 ON PELVIC CELLULITIS. 4th. Sloughing of the Cellular Tissue of the pelvis sometimes occurs as a result of inflammation in it. It is produced by the compression of the vessels caused by the effusion of lymph or serum into the surrounding tissue. The parts, deprived of their usual supply of nutritive matter, die, and being separated by a suppura- tive process from the surrounding textures, they come to lie in the midst of a fetid abscess, and a cure in such a case cannot be accom- plished till a free opening is made, and these necrosed masses are evacuated, along with the pus in which they are imbedded. I have seen cases where very large sloughs thus escaped, or were removed rather by the finger passed through the artificial opening. These cases are ahvays most severe and exhausting in their character, and usually long also in their duration. Having thus given you a hurried sketch of the history of Felvic Cellulitis and of its pathology, I must now tell you something of the symptoms and diagnosis of the disease. THE SYMPTOMS AND DIAGNOSIS OF THE DISEASE. You will find that the symptoms of pelvic cellulitis differ accord- ing as you meet with the disease at a period before suppuration has begun, or after it has become established. They are, therefore, divisible into two groups, which must be considered separately. A. Before Suppuration has begun. 1. Inflammatory Fever.—In its earliest stages the disease is marked by fever of greater or less intensity, which is usually ushered in by rigors, more especially in puerperal females, in whom it some- times occurs as one of the forms or complications of puerperal fever. In non-puerperal patients the fever is usually of a highly inflam- matory type—the strong rapid pulse, the hot skin, the furred tongue, and all the ordinary constitutional phenomena of a well-marked synocha being present. Along with these general febrile symptoms you have various local symptoms, such as, 2. Pains in the Pelvis.—These pelvic pains are experienced more especially in those organs beside or around which the inflammation has been set up, and they are due to the pressure exerted on the particular organ by the matter effused in its vicinity. One of the most common symptoms of the occurrence of .pelvic cellulitis is dysuria, from the pressure of the inflammatory tumour on the bladder or on its neck; and whenever you find a patient labouring under a smart fever, and complaining of frequent desire for micturition, and pain in passing water, it will be your duty at once to ascertain if the symptoms be not due to a commencing attack of pelvic cellulitis. Or, again, the patient may suffer from pain in defecation, when the inflammation is set up in the cellular tissue around the rectum, and ON PELVIC CELLULITIS. 239 leads to the effusion of fluids there, as has happened in the case of one of our hospital patients. You have, then, symptoms of distress in the bladder and rectum when these organs are emptied, accom- panied generally by a constant throbbing pain in the pelvis ; and if these are attended with a marked degree of fever and constitutional cfisturbance, you may be pretty certain that pelvic cellulitis has set in. But you can only make yourself perfectly certain of the fact by instituting a physical examination, and ascertaining the existence of a, 3. Tumour in the Pelvis.—This is to be felt by examining with the forefinger of the right hand through the vagina or the rectum, palpation or pressure being exercised at the same time with the fingers of the left hand over the inlet of the pelvis. On making an exploration in this manner you can detect a swelling, usually at first more or less, oblong or rounded in form, but sometimes modified by the form and density of the fascial layers which invest and limit it. Commonly it is firm and hard, but exquisitely tender to the touch, and it rapidly increases in size and density. If the disease be checked at this stage, such a tumour may be.resolved, and all the attendant symptoms may graduallly subside and disappear ; and this is what actually occurs in perhaps about a half, or indeed more, of all the cases of pelvic cellulitis. But in the remainder the disease is of longer continuance, and leads to further changes, chiefly from the development of pus in the part; and as these are the cases which often come alone under our care, and which remain longest under treatment, it becomes a matter of importance to know hoAV to re- cognize the disease, B. After Suppuration has been established. When the disease has reached this stage you have still fever, pain, and intumescence, but all more or less altered in character. Pains that had for a time subsided may now return. Thus it not infre- quently happens that the dysuria which marked the onset of the disease disappears for a time when the bladder has become accustomed to the pressure of the inflammatory tumour, but recurs when suppura- tion is set up. Or the patient may begin to experience pain in other parts where formerly none was felt; and cases of pelvic cellulitis have sometimes come to be treated as cases of sciatica of an aggra- vated type from the pressure of the pus on the sciatic nerve, as it makes its way along it through the great sciatic notch, or from im- plication of the nerve in the inflammatory process. There is a state of the limbs on the side principally attacked which is not common, but still highly worthy of your remembrance. _ When the inflam- matory effusion is located principally or solely in the cellular tissue of one of the iliac fossae, and around the muscles there passing downwards to the thigh, the lower extremity on that side occasion- ally becomes drawn up, and cannot, without extreme suffering, or, 240 ON PELVIC CELLULITIS. indeed, cannot at all, be retracted and extended. I have seen this symptom principally in cases of puerperal pelvic cellulitis. The tumour, too, is changed, and instead of being hard and braAvny, it assumes betimes, and first in one or more central points, the fluc- tuating feeling of a fluid collection. In addition to the changes Avhich occur in the pre-existing symptoms, however, some entirely new symptoms develop themselves and demand our notice. Such is, 4. Hectic Fever.—Instead of the constantly high and bounding pulse and the equally elevated temperature of the skin characteristic ■of continued inflammatory fever, you will find the patient becoming subject to remissions and exacerbations of the fever. Hectic fever is established, and I have seen more than one case of the disease being actually mistaken for phthisis. The pulse becomes weaker and softer, though still very rapid; she has occasional slight rigors, and the fever becomes more intense in the evenings. The skin is still generally hot, but it becomes cold at times, and at other times it is covered with profuse perspiration, more particularly when the patient sleeps. She is gradually and occasionally rapidly reduced in strength, and comes to present an appearance Avhich it is not easy to describe, but which is almost pathognomonic of the establishment of suppuration. You will find Air. Travers telling of Sir Astley Cooper, that he Avas called on one occasion to see a patient in the country, and whenever he went into the room and looked at the patient he at once put the question to the medical attendants, " Where is the matter ?" It had not before been suspected that suppuration had occurred, but on more careful examination the facial diagnosis so promptly made was fully confirmed, for, under the pectoral muscle a large abscess Avas discovered, which Sir Astley at once evacuated, and so cured the patient. It is difficult, I say, to describe in so many words, the ex- pression of countenance assumed by patients who are suffering from collections of pus in any parts of the body; but you must go and observe it for yourselves in the Avards of the hospitals, and when once you have learned to recognize it, you will find it to be a sign of great value in enabling you to form a just conclusion as to the nature of many an otherwise obscure or doubtful case. Then, in endeavouring to make up your mind as to the presence of pus in a case of pelvic cellulitis, you will sometimes be enabled to come to a determination on this point, by taking into consideration the length of time during which the inflammation has existed. For, if inflam- mation have been going on in the cellular tissue of the pelvis for three or four weeks, and little, or indeed, no abatement has taken place in the severity of the symptoms, but only such changes as I have been attempting to point out, you may be almost certain that by that time the inflammatory process has reached such a stage as to have led to the development of pus. That such is in reality the case, however, you can become absolutely certain by noticing, 5. The Feeling of Fluctuation.—The spot at which you will most frequently be able to recognize the feeling of fluctuation for the first ON PELVIC CELLULITIS. 241 time in most cases of pelvic cellulitis, is in the roof of the vagina immediately behind the cervix uteri, or to one side, as if where the broad ligament would open and split below if its layers were sepa- rated by accumulated fluid. From some peculiar arrangement of the layers of the pelvic fascia, when pus is formed in the course of a pelvic cellulitis occurring in the upper half of the true cavity of the pelvis—and this, you must remember, is the most frequent seat of the disease—it has a tendency always to point in this direction and to find an exit for itself, either at the lower base of the broad ligaments, or in the posterior cul-de-sac of the vault of the vagina; and it is at these spots, where the fascial layer seems to be unusually thin and weak, that the feeling of fluctuation is ordinarily first to be detected. But in cases where the pus has been formed, but is too deeply seated to allow of your discovering its presence by the sense of touch, you must have recourse to some other means to assure yourself of its existence. The best means that you can employ with this view is, 6. The introduction of an exploring needle into the centre of the tumour. This instrument, which is of invaluable service in the ex- amination of diseases, is never used to more advantage than when employed for the exploration of pelvic abscesses, when they happen to be unusually difficult or doubtful in their diagnosis. For in the common run of cases you will usually be perfectly able to make out the diagnosis without this assistance. In any case, however, of pelvic cellulitis where you are in doubt as to the formation of pus, and have reasons for being certain of its presence, you may make sure of it at once by pushing an exploring needle into the centre of the tu- mour. The instrument has, perhaps, been neglected too much as a means of diagnosis in surgery, when we consider with what freedom from danger its employment is attended, and how frequently ab- scesses, aneurisms, and other tumours have been confounded together, when by its use such mistakes could easily have been avoided. I know of a case where a distinguished surgeon introduced an explor- ing needle into a tumour in the groin, under the belief that it was a bubo, and to prove to others present that it was so ; but, to his as- tonishment, no pus escaped, and instead a quantity of air. It was a crural hernia, the sac of which had become inflamed, and into it he thrust the exploring needle, and thus saved himself from com- mitting the fatal mistake of laying open a hernial tumour with a bistoury, when he intended only to open an inflamed and suppurating gland. The use of the exploring needle saves, I know, from many mistakes in obstetric surgery; and since the safety with which it may be introduced into the most important organs and the most malignant tumors has been abundantly demonstrated, I think its employment might be advantageously extended. The best explor- ing needle is a long, slender, thread-like trocar, with a wire stilet parsing through it. Of course there will be no escape of pus through it, Avhen it has been thrust into a solid tumour or into an 16 242 ON PELVIC CELLULITIS. inflammatory swelling before pus has been fully formed, and even when pus is there, it is usually only a drop or tAvo that escapes through the narrow tube. You will not find the pus in some cases traverse the trocar, particularly if the pus is thick, but on Avith draw- ing the trocar and blowing through it, a drop or two will escape from the end of the trocar. But when none flows out, the negative sign is itself of importance. While, on the contrary, if a drop escapes it may be a sufficient warrant for you to proceed to the more free evacuation of the purulent collection. A medical practitioner, of great ingenuity, who had been many years in India, when his health began to fail him, came home several years ago, and Avhile spending a short time in Edinburgh, I had an opportunity of shoAving him some cases of pelvic cellulitis, where I succeeded in demonstrating the presence of pus by the use of the exploring needle. Soon after going to London he met some medical men there in consultation upon an old Indian patient of his. The case, as he afterwards told me, seemed to him to present the chief characteristics of the examples of pelvic abscess which he had seen here. He expressed to the medical attendants of the lady his opinion of the case, and proposed as a means of settling the difficulty to introduce an exploring needle into the seat of the disease. The other doctors rather scoffed at the idea; but, as they were altogether at sea as to the nature of the disease, they agreed to allow him to introduce the exploring needle, which he accordingly did. To his great surprise and vexa- tion, hoAvever, no escape of pus followed the withdraAval of the stilet; but, being still unconvinced that his opinion was erroneous, as a last resource he applied his mouth to the end of the tube, and succeeded, by sucking it, in extracting a few drops of pus sufficient to convince his sceptical brethren of the true nature of the case, and of the value of the exploring needle as a means of diagnosis. He was then allowed to open the abscess, and the patient got speedily well. In consequence of his treatment of this case, my friend got rapidly into a large practice in London, but after a few years his disease unfor- tunately returned, and death struck him down. When, then, you have a patient attacked with rigors, followed by a high degree of fever, and attended with pain in the interior of the pelvis, and when, after a time, the fever changes in character, and instead of being inflammatory presents more of a hectic type, you may be pretty certain that she has been suffering from an attack of pelvic cellulitis which has passed on to suppuration. And in every case it will be possible for you to correct or confirm your diagnosis by means of a careful local examination. One or tAvo marked symptoms may enable you sometimes to make a good guess as to the existence of the disease. Several years ago, I was attending with my friend Dr. Andrew Wood, an anxious case of labour, where the lady had manifested symptoms of insanity in the last periods of pregnancy. While thus engaged, a gentleman came, bearing with him a note to me from the North of England. The note was written ON PELVIC CELLULITIS. 243 by the medical attendant upon the gentleman's wife, and anxiously desired me to visit the lady as soon as possible. In relation to her disease it stated only two bare facts, viz., that the lady, who had been confined six weeks before, was hectic, and was suffering from great pain in the pelvis and down one of the limbs. I read the note to Dr. Wood, saying it was, I believed, a case of pelvic abscess, against the accuracy of which diagnosis he was inclined to wager. On visit- ing the patient in England next day I found a large pelvic abscess, Avhich I freely opened, and the patient made an excellent recovery. Formerly, the changes produced by the disease caused it fre- quently to be confounded with cancerous, fibroid, or cystic tumours of the uterus and ovaries, or other organs of the pelvis; but now we may be almost always sure of the true nature of the case when we find the tumour associated with constitutional phenomena, run- ning a regular and rapid course, and adhering to the bone or perios- teum in the remarkable manner to which I have referred. For, let me repeat, inflammatory tumours feel fixed and immovable to a degree seen in the case of no other morbid growth, and more par- ticularly when occurring in the broad ligament—their most common seat—and lying close to the ilium, they feel so hard and adherent that they might almost be mistaken for an osseous tumour. The old stories of large ovarian and uterine tumours of a supposed nature yielding under mercury, &c, were in all probability merely tumours formed by inflammatory effusions of the kind I have been speaking of. Before leaving the subject of diagnosis, I wish to mention one point more, that perhaps I ought to have alluded to earlier. We have already found that abscesses, the result of pelvic cellulitis, may ulcerate and discharge the pus which they contain by various chan- nels. Internally, they may thus spontaneously open, 1, into the vagina ; 2, into the cavity of the uterus; 3, into the rectum; 4, into some higher portion of the intestinal canal; 5, into the urinary bladder ; and, 6, but happily very rarely, into the cavity of the peri- toneum. The same abscesses may open externally at the umbilical region, in the hypogastric or iliac region, or they may burrow down- wards and open at the top of the thigh, or pass through the posterior pelvic nitches and open on the ilium or sacral region behind. I have seen once or twice the thin plate of the ala of the ilium apparently perforated by them. Their spontaneous opening in any of the in- ternal mucous canals which I have named, is ascertained by watch- ing diligently for, and tracing the escape of pus from these several canals. But I am anxious to impress upon you an additional fact. When an abscess is formed in the cellular tissue of the pelvis, it may discharge itself through more than one opening and in more than one direction; I have known abscesses thus open in the same person simultaneously or consecutively both on the cutaneous surface of the abdomen and into the bowel; both into the bowel and bladder; both into the rectum and vagina, &c. I have seen cases where in this way fistulse have been established between the different points which 244 ON PELVIC CELLULITIS. I have named—and between other points Avhich did not seem at all likely to be in the course of them, as between the boAvel and bladder, the intermediate genital canal having escaped. But when in any case after the pus has been eA'acuated these various openings remain and continue to furnish a purulent discharge, it often becomes a mat- ter of importance to ascertain whether these fistulous orifices and canals communicate with each other, and whether the fluid that escapes from them be derived from one common source; and I have not yet told you how you are to settle this question for yourselves. Sometimes it is ascertained by observing the contents of one canal escaping through another, or escaping externally, as feces by a cuta- neous or vaginal fistulous orifice. In a case which I alluded to a minute ago, of inter-communication between the intestinal canal and bladder, this course of the fistula was first ascertained by small ap- pearances of feculent matter passing with the urine. But there are cases occasionally met Avith where you have not such peculiar dis- charges to guide you in your diagnosis—as where the inter-commu- nication is between a vagina and a cutaneous fistula, &c. How are you to ascertain the presence or absence of any inter-communication in such a complication ? The first time that I ever had an opportu- nity of making a diagnosis as to this point was in the case of a pa- tient Avho, after suffering for some years from the effects of pelvic cellulitis, was brought here from Holland to be under my care. She had three different openings—one in the vagina, a second in the thigh, and a third in the groin, all leading into the pelvis towards the side of the uterus, and all yielding a supply of pus. It became a question whether they all communicated with each other or not; and, although they seemed to converge, yet I could not succeed in passing a probe through one and bringing it out at the other, nor could I be sure that they met at any point until, on throwing a quantity of very much diluted tincture of iodine into the opening in the groin, I saw it come pouring out simultaneously into the va- gina and through the opening in the thigh. By injecting, then, milk, or any coloured fluid, as a little weak tincture of iodine in this way into one of the openings in any case where a pelvic abscess has made its way to the surface in more than one direction, you will be able to determine whether these openings are connected with a common sinus, without subjecting your patient to the unnecessary pain of probing her; and, in addition to its extreme simplicity and ease of application, this means of diagnosis has the further advantage, let me tell you, of sometimes being a most effectual means of cure. It may be employed in cases of complex fistula in ano or fistula in vulva as well. PROGNOSIS OF THE DISEASE. Pelvic cellulitis is by no means a very fatal disease, however for- midable it may be in appearance; and it proves, in the great ma- ON PELVIC CELLULITIS. 245 jority of cases, very amenable to treatment. In many instances it may lead to no further result than the effusion of serum for a week or two, which causes much pain and distress at the time, but soon becomes absorbed, and leaves no bad effects behind. If coagulable lymph have been effused, the case becomes more tedious, and the patient may be long an invalid, and unable to walk ; but ultimately you will succeed, or rather nature will succeed, in most cases, in effecting its complete resorption. When pus has been developed and an abscess formed, its evacuation, whether spontaneous or artificial, is usually succeeded by a cure of the disease; but it is from the de- velopment of pus that the chief dangers attendant on the progress of pelvic cellulitis arise, for when an abscess has formed it may prove fatal in one of three different ways. Either, first, it may burst into the peritoneum and lead to a fatal peritonitis—an accident which, as I have already had occasion to explain to you, is a very rare oc- currence indeed in connection with pelvic cellulitis. Or, secondly, the cavity in which the pus was formed may not close up after the fluid has been evacuated, but may continue to give out a purulent discharge, and if these sinuses be of considerable extent, and the purulent secretion copious, the patient may be gradually worn out by the long-continued drain. But, thirdly, I have seen one or two cases where the disease, after subsiding for a time, again returned, and gradually became established in a chronic form, and where the patients eventually died of tubercular disease of the peritoneum— almost all cases, as you are aware, of chronic peritonitis being truly cases of tubercular peritonitis. No doubt these patients were consti- tutionally predisposed to the occurrence of tubercular disease, but there can be as little doubt that the localization of it in the perito- neum was determined by the degree of irritation so long kept up in the peh'ic cavity. Pelvic cellulitis comparatively rarely destroys life; and if it does not go on to suppuration, it may not even afterwards affect the functions of the uterus. Menstruation is seldom much, or, at all events, permanently influenced by it; but what I mean is, that the function of reproduction is not necessarily destroyed, especially when the disease is cut short in its first stages, and before suppuration supervenes. Many years ago, I received an impressive lesson on this point. Along with Drs. Abercrombie and Begbie I visited a lady who was suffering under an acute attack of pelvic cellulitis. There Avas a large and hard inflammatory effusion, which felt so very dense and firm when examined through the rectum that Dr. Aber- crombie—and there never was a practitioner with a greater power and certainty of diagnosis—was inclined, after making a rectal ex- amination, to declare the case one of a malignant or carcinomatous tumour. I had seen a sufficient number of cases by that time to be assured of the true and simply inflammatory nature of the malady, and I ventured to prognosticate a perfect recovery of our patient; but I added that she would have no more children after such an ex- 24G TREATMENT OF PELVIC CELLULITIS. tensive pelvic effusion. She speedily recovered under the active antiphlogistic measures used by by Dr. Begbie; but she did more— she afterwards became pregnant, and was delivered of twins. In my next lecture I shall take occasion to point out how these dangers are to be avoided, and what should be the treatment gene- rally in cases of pelvic cellulitis. LECTURE XIX. ON THE TREATMENT OF PELVIC CELLULITIS. Gentlemen : The treatment of any case will vary, of course, with the stage at which the disease has arrived when it comes under your observation, and therefore it will be most convenient to consider it under two divisions, as we considered the symptoms of the disease, Adz., according as we have to treat it before or after the development of pus. Before speaking of the treatment of pelvic cellulitis A. Before Suppuration has Begun, Let me remind you of what I have already told you in regard to the period when this occurs, viz., that when the disease is discovered at the very commencement there is no pus present at all, and abscesses only begin to be formed in ordinary cases about the twelfth or four- teenth day, when the inflammation has attained a certain degree of severity. In puerperal females, indeed, in whom inflammatory pro- cesses seem often to run a more rapid course, you may find pus present at an earlier period after the apparent onset of the inflam- mation ; but in most cases you will not be able to detect its presence till the end of the second week. But having recognized a case of pelvic cellulitis early, soon after the patient has had the first shiver- ings, when she first begins to feel pain, and when the cellular tissue is just beginning to be congested, the first thing that you must do is to have recourse to 1st. The use of Antiphlogistics, or all those remedies which you would employ in any ordinary case of acute inflammation. Perhaps I could not state the matter better than by saying that you must treat a case of pelvic cellulitis precisely according to the same principles that you would treat a case of iritis, and from this point of view I believe that the first question you will be likely to ask yourselves on seeing a case of pelvic cellulitis would be, am I to bleed this patient or not ? Now I am not going to discuss at present the efficacy or inefficacy of general bleeding as a means of cutting short inflammations, nor to lay down the law as to whether it should treatment of pelvic cellulitis. 247 be resorted to or not in the treatment of pelvic cellulitis. I leave it to yourselves to decide as to its applicability to any special case that may come before you. But I must take leave to say—although you may perhaps regard me as heterodox for saying so—that I believe I have seen a free venesection made at the commencement of an attack of pelvic cellulitis cut short the disease, and lead to its speedy resolution. It is but rarely, however, that you will find yourselves called upon to have recourse to this measure. There are but few cases, however, of pelvic cellulitis seen in the earliest stage of the disease, in which the local abstraction of blood by means of leeches is not resorted to, and resorted to beneficially. The only question usually is, as to the point from which the blood should be taken ; for you have usually the choice of a variety of places to which the leeches may be applied. Some practitioners are in the habit of applying leeches to the groins in cases of inflammation in the interior of the pelvis; others prefer having them applied to the interior of the vagina, and the surface of the cervix uteri; while others again content themselves with their application to the anus and perineum. I believe you will in most cases find the last, viz., the application of the leeches around the loAver end of the bowel, to be the most simple plan, and the most effective. The hemorrhoidal vessels are freely connected with the vessels that ramify among the pelvic contents and viscera, and by abstracting blood from the former set of vessels you can act on the latter at least as directly as from any other point. And it is very easy to draw blood from this spot, for you have only to apply the requisite number of leeches in an inverted wineglass over the anus, and hold it there for about ten minutes, and at the end of that time you will find that most of them have fastened. When it is desired to bleed at the groin, the leeches are made to fix there just as on any other part of the surface of the body ; but Avhen leeches are to be applied to the cervix uteri, a special instrument is required. Before speaking of the manner in which they are to be introduced, however, let me remark that you will find some men talking of applying leeches to particular points on the surface of the cervix uteri, according to the special seat of the inflammation. Now, even supposing it Avere possible in every case to make such a minute and precise application, the process is too much refined, and savours too much of hair-splitting, to be attempted in practice. When we apply leeches to any part of the surface of the body we are not particular to an inch or two as to where they fasten, and we do not regard it always as a matter of very much moment if they fix on a point even someAvhat removed from the inflamed locality; and when Ave wish to apply them to the cervix uteri, all we have to do is to introduce them into the upper part of the vagina and allow them to fasten where they will. To do this, you may use a common uterine speculum'passed up to the os uteri, putting the leeches into it, and pushing them up Avith the staff. But the speculum stretches the parts, and causes unnecessary distress to the patient by its pressure 248 TREATMENT OF PELVIC CELLULITIS. on the inflamed and swollen tissues, so that its use is extremely apt to aggravate the disease. For this reason I usually prefer making use of a narrow bone or ivory tube, such as was first used in this country by Dr. Mackintosh, who was induced to make trial of it on the strong recommendation of a friend who had seen much benefit result from its employment in the hands of some Portuguese prac- titioners. It is simply a bone or ivory tube—or it may be made of wood or glass as well—of about three-fourths of an inch in diameter, and furnished with a loosely-fitting piston. The leeches having been put into the tube, and the tube passed up to the roof of the vagina, the piston is pushed forward, and the leeches are driven out into the upper part of the cavity. They fix very speedily upon the surface of the cervix uteri and roof of the vagina, and fill rapidly. By this means you can bleed very freely, for after the leeches have ceased to draw and have fallen out or been removed by the finger, the flow from their bites may be greatly favoured and may be kept up for a considerable time by making the patient sit over a vessel of hot water, for the bleeding usually continues as long as she can sit upright. The application of leeches to the cervix uteri is in this way a most effectual means for the local abstraction of blood in cases of pelvic cellulitis, as well as of inflammation of the uterus itself, for which, perhaps, it is more frequently employed; but it is not without its disadvantages. An eminent London physician declared to me that he would never again in any instance have recourse to the ap- plication of leeches to the cervix uteri, after witnessing the severe spasmodic pain which resulted from their application in a case where one of the leeches was retained for a time, apparently from its having travelled into the interior of the uterus. It is but rarely that such an accident happens, but it does happen occasionally, and is a strong drawback against this mode of leeching in acute uterine disease; but you can readily understand how, when it did occur, the leech as it fills will cause distension of the uterus, and give rise to great pain from the spasmodic contractions which are excited to effect its ex- pulsion, just as we see it in a case of abortion. The trouble attend- ant in the application of leeches to the cervix uteri is also greater than that attendant on their application to the anus; and hence, in most cases, you will prefer having recourse to the latter. But in any case, let me add, where it might seem to you particularly de- sirable to have the leeches applied to the cervix uteri, you could easily guard against the danger of any of the leeches finding their way into the cavity of the uterus by filling up the os with a plug of soap or sponge previous to their introduction into the vagina. As to the number of leeches that you are to employ, and the propriety of repeating them or not, these are circumstances which in every individual case must be determined and regulated by the severity and obstinacy of the attack. I need hardly add, under this head of antiphlogistics, that it will be most necessary in every case to enjoin TREATMENT OF PELVIC CELLULITIS. 249 on your patient the most perfect rest, and the use of a strict anti- phlogistic diet and regimen. Then, as regards, 2d. The Use of Mercury.—I must leave the question to yourselves to settle how far you will mercurialize your patients. It is ordinarily laid down, more particularly by English authorities, in regard to the treatment of iritis and of almost every form of acute inflammation, that the administration of mercury should be had recourse to as one of the most essential elements in it; and in the treatment of pelvic cellulitis I used formerly to have recourse to it in almost every case as a regular rule of practice ; and I often have recourse to it still in combination Avith opium, as in two grain doses every two hours of the calomel and opium pill of the Pharmacopoeia. But I begin more and more to lose faith in its efficacy, for the disease goes on sometimes unchecked even when the mouth is salivated ; and I really do not know that we have any certain proof of its power of produc- ing absorption of inflammatory effusions. Ophthalmologists tell us that they can see these effusions beginning to be absorbed in the eye just as the drug begins to exert its constitutional action; but it is assuredly doubtful whether these phenomena stand in the relation of effect and cause, or whether they are not merely coincidences. I have heard Professor John Thomson repeatedly and strongly state that he had occasion to treat forty cases of syphilitic iritis, and having no faith in the reputed power of mercury in the cure of that disease, he treated them without mercury, and succeeded in effecting a cure in all the cases, excepting twro, which occurred in the persons of two medical men who had had the misfortune, in the pursuit of their profession, to get their fingers inoculated with syphilitic poison, and who suffered from iritis along with other secondary affections. These two gentlemen had great faith in the power of mercury, and insisted on having it administered to themselves, and in them alone, out of all the forty cases of iritis, did the disease run an unfavour- able course and end in loss of vision. But though there is probably little benefit to be derived from the employment of mercury, there are other medicines which you can prescribe with advantage. Such are, 3d. Anodynes.—The patient, as I have told you, has usually considerable local pain, and complains frequently of severe dysuria, tenesmus, &c.; and to relieve these distressing symptoms you must alloAv her the free use of opium, in all cases, at least, where the stomach will bear it. I have a belief that the opium exerts some poAver as a direct antiphlogistic, and at least, when you give it com- bined with ipecacuanha or antimony, you use as good an antiphlo- gistic as almost any other you could employ. In addition, you may have recourse, further, to 4th. The Use of Alteratives and Depurants; by which I mean, that it will often be advisable for you to administer the alkaline carbonates and hydriodates, according to a practice much in vogue long continental physicians, and which I believe to be a successful 250 TREATMENT OF PELVIC CELLULITIS. practice in many cases of acute cellulitis. The French employ them frequently, and, as they aver, with the happiest results in cases of croup and other acute inflammations. They believe that these alkaline salts have the power of arresting inflammatory action and blotting out its effects. . 5th. External Fomentations, Counter-irritation, £c.—In addition to the use of these internal remedies, you will find warm fomentations and poultices externally, sometimes soothe greatly in the earlier stages of the disease, and when there is much local pain. I have seen also strong belladonna ointment laid on externally, or a liniment of equal parts of chloroform and olive-oil applied on the iliac or pelvic region, or any pained spot, relieve the patient of local suffering. Let me here add what I should perhaps have already mentioned, that medicated pessaries containing morphia, belladonna, &c., prove sometimes excellent anodynes when introduced twice or thrice a day into the vagina; and that medicated pessaries of mercurial and iodide of lead ointment form one of the best of local deobstruents, when it is your object to produce the absorption of the effused serum and coagulable lymph, either in acute or subacute forms of the dis- ease of which I am speaking. In the treatment of pelvic cellulitis, as of iritis and other forms of acute inflammation, a degree of counter-irritation is often of most essential service. The good effects of the application of counter-irritants in inflammations of internal organs are so well known to you, that it is altogether unnecessary for me to enter into any disquisition on that topic. The only ques- tion is, what is the best and most convenient form of counter-irritant that we can in such a case employ ? Now, here I must particularly warn you against the use of that most common and convenient of counter-irritants—the fly blister, because of the tendency which it has to excite dysuria or to aggravate it when it is already present. At all events, if you will use it, you must take the usual measures to prevent this unfortunate effect. But if you desire to produce a rapid and active counter-irritation, I believe that you cannot do so better than by applying solid nitrate of silver so as to produce vesication. Or you may use a strong tincture of iodine, painted twice a day over all the lower part of the abdomen. But, finally, with all your other treatment, you must not forget to attend to, 6th. The Regulation of the Bowels.—-With reference to this point you must remember not to allow the lower bowel to become filled and gorged with feculent matter, so as to be left to press upon the inflamed part, aggravating the pain and annoying the patient. Nor, on the other hand, must you be frequently administering strong medicines, which would purge and excite the action of the intestines and necessitate much motion on the part of the patient. Frequent and violent action of the bowel would act even more injuriously on the progress of the disease than the distension of it with feces, if this be accompanied by perfect rest; but the proper plan is to ad- minister from time to time, at intervals of three or four days, somf TREATMENT OF PELVIC CELLULITIS. 251 simple aperient by the mouth, and afterwards to aid its action by a mild enema. B. After Suppuration is Established. So much for the treatment of pelvic Cellulitis in its earlier stages. But sometimes the disease will go on in spite of the most skilfully- directed treatment, and end in suppuration ; and you will occasion- ally be called on to treat cases in which abscesses have been formed before they come under your care. If you see a patient, for instance, on the sixteenth day after the disease has begun, who presents all the symptoms of hectic fever, whose pulse beats with undiminished rapidity, and in whom the inflammatory swelling has.not lessened in size, but only become more soft and yielding, you may make sure that in that patient the disease has ended, or will ere long end, in the formation of pus. The question then arises, how is such a case to be treated? and we reply: You must have recourse to 7th. The Administration of Febrifuges and Refrigerants.—Your patient is thirsty, and you will require to give her ice or a few drops of nitric or phosphoric acid in water, for a drink. She is worn down and feverish, with fits of cold succeeded by burning heats ; and you will require to administer quinine to counteract the aguish tendency, and to keep up her failing strength. With this view, too, you may be obliged to have recourse to some gentle stimulant, or to the use of an alternation of tonics to support her until the abscess is ripe, and ready for evacuation. In some cases the use of wine, even in considerable quantities, becomes indicated. Again, perspi- rations sometimes occur, excessive and exhausting; and to moderate them you may have to administer some sulphuric acid along with the quinine, or to give her the phosphate of the alkaloid in dilute phosphoric acid. The next thing to be attended to is, 8th. The Evacuation of the Abscess.—But in regard to this point let us endeavour, as a preliminary step, to determine whether a pelvic abscess ought always to be opened or not. I have more than once already told you that when left to itself, the matter has a tendency to find its way to some point on a cutaneous or mucous surface, there to become evacuated. Such spontaneous evacuations take place most frequently into the vagina or the rectum, and these are precisely the places where we particularly desire to see the evacua- tion occur. But this, unfortunately, is not the invariable rule; and I feel perfectly sure that in any case it is better carefully to watch the progress of the suppuration, and to take it into your own hands to make a proper artificial opening for the discharge of the abscess in a safe and suitable situation, than to leave the guidance of it to nature, and to run the risk of seeing the purulent collection burst in some dangerous or disagreeable locality. By making a prompt and iudicious opening into a pelvic abscess, you may even in some cases 've your patients' lives. One of the earliest cases of pelvic cellulitis 252 TREATMENT OF PELVIC CELLULITIS. that I saw occurred in a patient Avhom I watched in the Lying-in Hospital, along with Dr. Ziegler. The inflammation had extended lower down than usual, to the cellular tissue lying between the rectum and the vagina, and had led to the formation of an abscess which had begun to point towards both of these canals. Such was the state of matters one day when we examined the patient; and we both decided that it was of no use to make an artificial opening, as it seemed certain that the matter must speedily find an exit for itself, either into the canal of the rectum or of the vagina. And, certainly, within four and twenty hours from the time when Ave made our examination the abscess did burst; t^ut Ave found, to our dismay, that instead of opening on one of these mucous surfaces, to which it pointed so distinctly, the abscess had burst into the peritoneal cavity, where the effused pus had given rise to intense irritation, and lighted up a peritonitis that proved rapidly fatal. But there is usually not by any means so much risk of the abscess opening into the perito- neum, as of its becoming evacuated in some unpropitious situation, such as the bladder, with which it may come to communicate directly; or high up in the rectum or intestinal canal; or the matter may find its Avay into both bowel and bladder at once; or by some other double opening; and this, as well as all the other unfavourable complications which I have pointed out to you as liable to result from the unguided process of suppuration in the pelvis, and from spontaneous rupture of the abscess, may almost always be easily avoided by early and well-directed artificial evacuation of the pus. I trust that from what I have said, the propriety of surgical inter- ference is sufficiently impressed upon your minds, and that you are now prepared to enter with me upon the consideration of three questions in regard to it, viz., When? where? and how? is the abscess to be opened ? a. The proper Time for Artificial Evacuation.—To the first of these three questions, that, namely, which asks when a pelvic abscess ought to be opened by the surgeon, it is impossible for me to furnish a reply that would hold good in every particular case. It is impos- sible for me to say that on any given day from the commencement of the inflammation, or the hectic fever, an abscess must be so far advanced as to be ready.for the knife; for in some patients and under certain conditions the processes of inflammation and suppura- tion go on more rapidly—in others, again, more sloAvly. But one piece of general advice I can give you, and that is to Avithhold your hand so long as there appears to you no risk of the abscess bursting into the peritoneum or opening into the bladder, or in some other situation less favourable than that in which you are prepared to puncture it. It is better not to open it too early, because there is usually more than one collection of pus, and if the case be left to itself for a sufficient length of time, these once separate collections will finally be found to communicate freely with each other, so that by making an opening into one you are able to empty them all, and TREATMENT OF PELVIC CELLULITIS. 253 thus obtain a prospect of a speedy cure. But if you make an open- ing at too early a period into one of the collections, you succeed in evacuating that loculament alone, and so give room for the enlarge- ment of the other abscesses, which, after a time, and each in succes- sion, may cause distress and call for a renewal of the operation. For this reason I would recommend you to defer the artificial evacuation of a pelvic abscess as long as it seems to you to be safe to allow it to go on unguided, and as long as the severity of the hectic symptoms, or the failing of the patient's strength do not appear to call for more immediate interference. But in any case where you have decided upon giving a vent to the pent-up matter, the next thing you have to do is to choose b. The proper Place for Artificial Evacuation.—If you find it possible in any case to open with sufficient freedom a pelvic abscess at some point on the cutaneous surface, by all means open it there. But it is only in cases where the cellular tissue of the brim or of an iliac fossa is implicated that it will be in your power to do so. Generally pelvic abscesses have a greater tendency to point inter- nally, and to open into some mucous cavity than to make their way toAvards a cutaneous surface. Internally I have seen pelvic abscesses open in almost every conceivable direction ; and, as the result of all my observations, I have no hesitation in saying that the proper place for their artificial evacuation is through the vagina. I have said that abscesses opening into the rectum usually heal very well also ; but there is this risk attendant on a communication between the cavity of an abscess and the cavity of the rectum, that fecal matters in some rare cases get into the abscess and either prevent and protract its healing, or light up a fresh inflammation ; and when a sinus becomes established high up in the pelvis it is very difficult of access through the rectum. On the other hand, pelvic abscesses discharging into the vagina usually heal very rapidly; and in those cases Avhere the healing process, from some constitutional peculiarity in the patient goes on more slowly, the opening is still very easily accessible, and in so far is more amenable to treatment. Again, in opening pelvic abscesses artificially, you may inadvertently wound a vessel of sufficient size to give rise to an alarming amount of hemorrhage; and if the incision has been effected through the rectum, you will find it very difficult indeed to arrest or restrain the bleeding there; whereas, in the case of the vagina, hemorrhage into it can always be restrained by plugging. It is not often that this accident happens, but we do meet with it sometimes. A year or two ago I attended, along with Doctor James Duncan, a patient with a pelvic abscess which Ave determined to evacuate through the vagina; and although I used every precaution in doing so, yet I wounded a vessel of considerable size, and we had to keep the vagina plugged for a couple of days to check the bleeding that ensued. You will usually find in selecting the part of the vagina through which to evacuate the abscess, that the best point for the purpose 254 TREATMENT OF PELVIC CELLULITIS. Fig. 60. is that spot in the roof of the canal immediately behind the cervix uteri, to which I called your special attention when treating of the pathology of the disease, and where, as I told you, the mucous membrane was supported and protected only by a very thin layer of the pelvic fascia. At this point, then, in the posterior cul-de-sac of the roof of the vagina, you will usually find the wall at one point soft and yielding, so that you can press the tip of the finger into it, and here it is that your opening is to be made. It is, I repeat, very easy of access; and as it is, in the great majority of cases, the most dependent point at which an open- ing could be made, you may hope to evacuate the abscess more effectually by puncturing it here, than by punc- turing it at any other point. Having decided, then, in any case that the abscess must be evacuated, and hav- ing determined at what point the opening is to be made, you have next to make up your minds as to c. The proper Means for Artificial Evacuation.—For opening pelvic abscesses some have recommended the use of a long curved trocar and canula, such as are used for puncturing the bladder through the rectum in cases of retention of urine, and if the pus be "well digested" and the abscess perfectly mature—to use the well-known and sufficiently expressive phrase- ology of the older Avriters—such an instrument will usually suffice for its complete evacuation. I saw a case some time ago, along with Dr. Young, where I passed a long trocar and canula of this descrip- tion along the inner edge of the iliac bone, and so gave vent to an abscess seated very deeply in the iliac fossa. This depth I could not well have reached with a knife ; yet in by far the greater num- ber of cases, the knife is by much the preferable instrument. It is not always that the matter is so fluid as to escape freely and full at first through the canula, and then the opening made by it is so small that it readily closes, and thus you are very apt to have a reaccumu- lation of the pus. Such a risk you do not encounter when you use a knife for opening the abscess, for with it you can make the opening as free as you will. You may use an ordinary bistoury, in which case you must wrap the whole of the blade round with lint or tape, except the tip of the instrument, so as to guard it and prevent it from wounding any part of the canal. But I believe that you will always succeed best, and operate most successfully with a tenotomy Diagram showing the situation of a puru- lent collection (d) behind the uterus (6), and the point at which it may be punctured through the vagina by means of an instru- ment (/). a. The bladder. ' c. The rectum. ee. The ends of the peritoneum. TREATMENT OF PELVIC CELLULITIS. 255 knife. Introduce the forefinger of one hand into the vagina, to guide and guard the point of the tenotomy knife up to the soft and yielding spot, and feel if there is any artery pulsating at the point you propose to puncture, and if so go to one side of this point, pushing in either case the tenotomy knife forward into the abscess with the other hand. On doing this you will usually feel the pus escaping through the opening, but the knife must not be at once withdrawn—not till you have made a slight incision with it to one or other side, wide enough to admit the tip of the forefinger to be pressed through. With the finger forced through enlarge the open- ing, avoiding the further use of the knife if possible. As you thus enlarge the opening with the finger still more, you will be able to feel with it whether there are further loculaments or dissepiments beyond. If all the different loculaments have already come to com- municate with each other, by enlarging the opening in the manner I have indicated, you insure a free outlet for all the matter. If you find the pus to be fetid when it escapes, as it sometimes is, then you must bear this further in mind, that that phenomenon is sometimes due to the presence of gangrenous masses in the abscess, and that a perfect cure can never be accomplished until these be completely removed. Break down the walls of these dissepiments or loculaments as much as you can before removing the finger. After a free and dependent opening has thus been made into the abscess, there is usually nothing further to be done. To exert pressure through the abdominal parietes, as has sometimes been recommended, is alto- gether unnecessary, for the abscess empties itself completely without any pressure whatever from above. All that you have to do now is to attend to the patient's general health, which requires to be sup- ported ; and to introduce the finger again into the vagina after a day or two, and open up the wound, to prevent its lips from ad- hering by the first intention, and so lead on again to closure and reproduction of the abscess. By following out these simple rules you will find that in most cases the purulent discharge begins to dry up after a few days, and in about a week the patient begins to re- cover from all her untoward symptoms, and becomes gradually restored to her former state of health. In most cases, I say, but unfortunately not in all; for in some instances where pelvic abscesses are evacuated either naturally or with the help of art, a sinus is left which keeps on discharging pus, and which renders it necessary for the practitioner to make one or more, 9th. Counter-openings.—After an abscess in the broad ligament of the uterus, for example, has been evacuated, suppuration may still go on and spread along towards its external border, and as the matter which is here formed might have difficulty in escaping through a wound in the roof of the vagina, the abscess may go on for years, alternately filling and being discharged, and never healing up at all until another opening has been made in the side of the pelvis. I once saw a very striking illustration of the necessity and value of 256 TREATMENT OF PELVIC CELLULITIS. making a counter-opening, in the case of a patient, the wife of a medical gentleman, Avhose history showed that several years before she had had an attack of pelvic cellulitis and abscess, which after spontaneously discharging and making a fistula had been allowed to go on for many years, until the hectic fever became so distinct, and the reduction of the patient's health became so great, that two emi- nent physicians, who had a consultation about her case, came to the conclusion that she was labouring under tubercular disease; and they sent her on a distant voyage in the hope that she might recover in a milder climate. After a year's absence she returned, improved in health, but still with two fistulous openings, one in the rectum, the other high up in the inguinal region, both of them ever and anon discharging quantities of pus. On introducing a long ball probe into the external orifice near the anterior spine of the ilium, and pushing it down along the fistulous track, I could feel it distinctly through the roof of the vagina. At this, the most dependent point in the whole course of the sinus, I made a counter-opening, through which I pushed the probe, and brought it out at the vagina. The late Dr. Bright was with me at the time, and he afterwards told me he never Avas in such terror in his life ; for, first, he saw the lady snoring under chloroform, the use of which he had never witnessed before ; and then, secondly, he saw that long metal rod sinking away down and down into the depths of the abdomen and pelvis until after my incision it emerged at the vaginal orifice. The result of that operation was most satisfactory, for the matter had now a free outlet for escape; the sinus speedily closed in its entire extent; and the patient recovered betimes her lost health and strength under the kind and able care of my friend Dr. Traill, of Arbroath. Such a case illustrates, in a very impressive manner, the value and import- ance of making a counter-opening, in the case of a sinus remaining after the evacuation of a pelvic abscess. But you may find cases of pelvic fistulae of this nature occurring in practice Avhere it may be impossible for you to adopt this plan of treatment. An abscess may have opened spontaneously on some surface, and through the opening from which the matter still escapes you may push a probe without arriving at any other point where a counter-opening Avould be likely to prove of any service; or in evacuating an abscess with the knife you may have found it impossible to make an opening sufficiently large to admit of the full and free escape of the pus, which continues sloAvly to be discharged during a lengthened period. When such a state of matters exists, there are two other different modes of treatment which you may adopt. You may have recourse first, for example, to, 10th. The Injection of Tincture of Iodine.—Of the value of this measure as a means of diagnosis I have already spoken. Let me now add only one word as to its value as a means of cure. Injection of tincture of iodine in a slightly diluted form into a fistula will almost never produce any bad effects; at least, I have never seen TREATMENT OF PELVIC CELLULITIS. 257 any untoAvard symptoms result from it, although I have had recourse to it in many cases and many kinds of fistula. Its use, I say, is always safe, and its action is often most satisfactory. The only drawback is, that the injection may require to be repeated again and again, if at first it does not prove successful; and when it be- comes necessary thus to have recourse to repeated injections, it is advisable to use a stronger and less diluted preparation. Should the injection of the strongest tincture of iodine fail in effecting a cure of a fistula, you may next have recourse to, 11th. The Introduction of a Piece of Wire.—In the beginning of the last winter session I saw a fistula resulting from pelvic cellu- litis in the case of a patient where an abscess had been evacuated 1 behind the cervix uteri. Having injected some tincture of iodine into it, and finding little benefit result from its use, I introduced some iron wire into it, and left it lying deep in the cavity of the abscess. In the course of a few days a sufficient degree of inflam- matory action was excited to lead to the formation of granulations, and the wire being then removed, the abscess quickly healed and closed up entirely. 12th. Use of Tonics and Deobstruents.— Finally, where,much effusion remains in the surrounding tissues, your treatment of the case does not end even when the abscess has been healed, and the fistula dried up. But the treatment is now easy and simple, for all you have to do is to endeavour to restore strength to your patient by the well regulated administration of cod-liver oil, quinine, iron, and other tonics ; and where some degree-of hardening and indura- tion remains, you must put her upon small doses of iodide of potas- sium, or, what I think you will find better still, give her five grains of the bromide of potassium three times a day dissolved in water, or in a vegetable tonic infusion. And, now, before I have done with this subject, let me fulfil a promise which I made to you when I began it, by reading to you the observations that Avere made regarding pelvic cellulitis by Archi- genes, and which have been preserved to us by iEtius. Remember that Archigenes practised at Rome at the termination of the first, and in the early part of the second century, and that the following account of pelvic cellulitis was written by him within a few years of that distant time when the Emperor Hadrian visited Britain, and commanded here the building of that enormous wall from the Tyne to the Solway, the gigantic remains of which, and of the dilapidated Roman cities raised along its course, form still in Northumberland such striking and startling objects even at the present day. " Of Abscess of the Uterus, from Archigenes. " Abscess in the uterus, as in other parts of the body, results from a previous attack of inflammation. In the first instance, therefore, the symptoms of inflammation will be manifested, and afterwards 17 258 TREATMENT OF PELVIC CELLULITIS. when the pus begins to be formed the pains are increased, and fever sets in with shiverings, mostly towards evening; a tumour is formed, and a pricking pain is felt; in some cases there is suppression of urine, and in others the evacuation of the feces is interfered with, or both may be simultaneously affected. But the local pain will indicate the seat of the disease. Then, if it cannot be discussed, the suppuration must be artificially promoted. For this purpose poultices of linseed, fennel, barley-meal, boiled figs, mallow root, or turpen- tine, are to be applied to the lower part of the abdomen and to the loins ; or we may even sometimes apply pigeon's dung with oil and honey. The pudenda are to be constantly fomented with a sponge, and vapours are to be introduced into the vagina by means of a reed inserted into the perforated lid of a dish. The patient must be made to sit frequently in baths containing decoctions of those herbs which have a draAving property, such as pennyroyal, horehound, laurel, sage, mugwort, dittany, centaury. But if the pain should set.in still more violently, poppy-heads boiled in Avater and bruised must be added to the poultices." Then he goes on to give prescriptions for various medicated pessaries, which may be useful under certain circumstances ; and afterwards he proceeds thus: " But when the abscess bursts, if the pus be carried into the bladder, and be excreted with the urine, the patient must drink milk and take cucumber seeds; and poultices such as we have described must be applied, and emol- lient and odoriferous ointments. But if it make its way into the intestinum rectum, and escape alone, or with the feces, Ave must ad- minister a decoction of lentils and pomegranate bark as a clyster. If, on the other hand, it should burst into the pudendal sinus, when the pus is pure, oil of roses, or tetrapharmacum with fresh butter, and the oil of roses is to be injected, and the parts are to be bathed with a decoction of roses or lentils, or with the juice of ptisan. When a thin and fetid sanies escapes instead, like that from a noma or a corroding ulcer, a less astringent injection must be used, as a decoction of myrtle berries, primroses, lentils, and pomegranate bark. Should the inflammation, however, still persist after the matter is excreted, the use of the poultices and hip-baths above referred to must be persevered with. If the discharges are unequal, the patient must use fomentations and hip-baths of water in which wormwood, horehound, vetches, centaury, or lentils have been boiled. The parts, moreover, must be washed out with juice of ptisan, to which honey and oil of roses have been added; but the os uteri and the anus ar,e to be anointed with a cerate of rose oil or butter, con- taining a small quantity of the dross of furnaces, antimony, plum- bago, or litharge of silver, with some milk from the human female. It may be done also with the juice of lead. But if the matter that escapes be extremely fetid, the pudendal sinus is to be washed out with mead, and the use of it is to be persevered in until the cure is completed." PERI-UTERINE OR PELVIC HEMATOMA. 259 LECTURE XX. PERI-UTERINE OR PELVIC HEMATOMA, AND VARIX OF THE PUDENDAL VEINS. Gentlemen : In my last two lectures I have been directing your attention to inflammation of, and inflammatory effusions into, the cellular tissue of the pelvis. To day it is my object to describe the HISTORY OF HEMATOMA OF THE PELVIS, another disease to which the cellular tissue of the pelvis is liable; and this affection, though still less known than pelvic cellulitis, be- cause less frequent, is well worthy of your most careful study, for this reason, if for no other, that it is relatively more fatal than pelvic cellular inflammation. In the' affection, too, which I am to speak of in the present lecture, there is an effusion into the tissue filling up the angles and spaces between the layers of the pelvic fascia; but here the effusion consists, not of serum or other inflammatory pro- ducts, but of blood from a ruptured bloodvessel. This pelvic hse- matoma or pelvic haematocele is, as I have observed, far from being as common as pelvic cellulitis; but it is not by any means such a rare disease as you might be led to suppose from finding that there is almost no notice taken of its occurrence in the whole wide range of modern English obstetric literature; and I feel assured that if any of you in after years have occasion to see much of female dis- eases, you will not have been very'long in practice ere you meet with one or more examples of this affection. The first case of pelvic hgematoma where I recognized the real nature of the disease, occurred, many years ago now, in the person of a patient whom I saAv in consultation with my friend, Dr. Baird, of Linlithgow. The lady was exposed to cold by sitting on the grass when she was menstruating ; she had a fit of shivering on going home which lasted some time, and was succeeded by sudden and severe pain in the region of the womb. Some days subsequently, on making a vaginal examination, a solid-like tumour was felt behind the uterus, stretching upwards towards the cavity of the abdomen. I thought it was a case of acute pelvic cellulitis, and it was treated as such for a time by means of antiphlogistics. Between two and three Aveeks having elapsed, and the tumour not having become dimi- nished in size, I believed that it was time to puncture it, imagining that suppuration must have taken place, though perhaps so deeply 260 PERI-UTERINE OR PELVIC HiEMATOMA. seated as not to give rise to a distinct feeling of fluctuation. I there- fore made an incision into the tumour through the roof of the vagina, but, instead of pus, there came out masses of old coagulated blood, partially broken doAvn and disintegrated. There was, indeed, a slight admixture of purulent fluid, for inflammation had occurred secondarily around the infiltrated part; but the great bulk of the evacuated matter consisted of the debris of blood-clots ; and after these had all been evacuated, the cavity speedily closed up, and the patient made a good recovery. I did not then properly understand all the phenomena of the case, and thought it to be simply an aberrant form of pelvic cellulitis; but since I saw that case I have met with a considerable number of others, and I have now no doubt that it is an altogether independent form of disease. We had a fatal case of it in the hospital five years ago; and as this case is a very instructive one, perhaps you Avill alloAv me to read you the history of it, Avhich has been preserved in the hospital records. I regret that this history is so imperfect, and especially in relation to the post-mortem appearances, as taken down by the clinical clerk. " A. W., aged 42, married. Admitted April 9th, 1854. Has generally menstruated two days every month since the first com- mencement of the catamenia in adolescence. The discharge was never in large quantity, and was generally unattended with pain. Gave birth to a child four and a half years ago, and for four years she has suffered from prolapsus uteri and profuse leucorrhoea. Dur- ing the first two years she used to keep the uterus reduced by wearing a globular wooden pessary, but during the last two years she has used nothing at all, the womb usually being prolapsed most of the day, and she reduces it herself on going to bed. She never had real pain during menstruation until the last period, which was protracted four or five days longer than usual. The pain then felt was deeply seated in the lower# part of the abdomen, and Avas so severe as to confine her almost constantly to bed. On the day after the menstrual discharge ceased she felt cold, and in the evening shivered a little; but no feverish symptoms followed, and it was only the continuance of the acute pelvic pain that caused her to seek admission. Since the commencement of the pain the uterus has not appeared in its usual prolapsed form externally. The patient is pale and spiritless, has a cool moist skin, a slightly furred tongue, no great appetite, and no thirst. Pulse 80, soft. Complains of pain deep in the pelvis, but states that it is not nearly so severe as it had been for three days before; no pain in thighs or back. " On vaginal examination, a globular swelling is met with in the posterior Avail of the vagina, not very tender, nor pitting upon pres- sure. The cervix uteri is very small, and lies immediately behind the symphysis pubis. The os is small, and the lips are very small and oedematous. The uterus feels fixed by this tumour, Avhich ex- tends from the posterior part of it down to within an inch and a PERI-UTERINE OR PELVIC HEMATOMA. 261 half of the vaginal orifice. The finger can be easily pushed upwards on each side of it in the direction of the broad ligaments, so that by this means it can be readily ascertained that this swelling has no lateral attachments to the sides of the pelvis, but is merely situated between the rectum and the vagina. This latter point is confirmed by recto-vaginal examination made by the fore and middle fingers of the right hand, for by this means the lower segment of the tumour is embraced between the two fingers. There is no fulness in either iliac region. Urine of sp. gr. 1012, alkaline; contains triple phos- phates, and much albumen. To have five-grain doses of bromide of potassium thrice a day. "April 12. To stop bromide. R.—Infus. gentianse Ivij; tinct. gentian. 3j ; corrosiv. sublim. gr. J. M. Sumat Ej, ter in dies. " 15th. Gums are red, tender, and a little spongy; breath fetid; slight salivation. Omit medicine. To have a gallic acid gargle. " 21st. The oedematous state of the vaginal tumour has now gone, but the tumour has not decreased in size. Dr. Simpson introduced an exploring needle into the tumour, and on withdrawing the canula found it filled with a bloody-looking matter with minute clots of blood. On microscopical examination this fluid was found to con- sist of a dark brown fluid containing a very few blood disks in various stages of disintegration, and also about an equal number of hyaline or pyoid bodies, but no pus-globules. To have five-grain doses of bromide of potassium. " 26th. Yesternight she had a slight attack of tympanitis without tenderness, and of vomiting. Hot turpentine fomentations, a tur- pentine enema, and an opiate by the mouth relieved these symptoms, and the patient slept well. To-day the sickness and vomiting have returned with great severity, so that the little fluid aliment Avhich the patient occasionally takes is almost immediately vomited. Tongue covered in the centre with a brown fur; margins clean and moderately moist. Skin warm and moist. There is no abdominal tenderness, and patient feels only a dull uneasiness in the region of the pelvis. Vagina is hot; no increase in size of tumour, but it is softer than before, and yields an indistinct feeling of fluctuation. Pulse 90. Twelve leeches to be applied over the abdomen, and a grain of opium to be taken every five hours. "27th. Vomiting almost incessantly. Had about three hours' sleep during the night. To have ice and brandy, with hydrocyanic acid mixture, and a blister to the abdomen. Vespere.—Unabated retching and vomiting; vomited matter contains a good deal of bile ; pulse 96. Vagina is tender, and so hot that it is painful to retain the finger a few seconds. Fluctuation much more distinct in tu- mour. Apply eight leeches round, the anus, and continue the treat- ment pursued in the morning. " 28th. Retching less, but still severe. Skin keeps cool and moist; pulse 90 ; tongue not much furred. There was drawn off from the vaginal tumour by means of a trocar and canula five and a 262 PERI-UTERINE OR PELVIC HEMATOMA. half ounces of a dark-brown fluid, containing a very few minute clots of blood, and patches of lymph or pus. Its odour was very fetid. On microscopical examination it is found to contain pus- globules in large quantity, puckered and irregular ^ blood-globules, granular matter, and small masses of aggregated particles, sometimes of a semi-crystalline form, and of a deep red colour (Hoematin ?). Stop all medicine, and use ice and brandy. " 29th. More fluid being still in the tumour, an incision about an inch in length was made into it at its lower part, on the right side of the vagina, and about two inches from its orifice. Four and a half ounces similar to that drawn off yesterday came away at the time, and about two ounces more escaped during the day mixed with a few clots. " 30th. Pulse 86. A good deal of fetid fluid comes away from the vagina. Still vomiting and retching every hour or so. Neither medicine nor food remain on the stomach above a few minutes. " May 1. Expression of face very much altered and pinched. Tongue dry and brown; vomited matters quite bilious; bowels opened to-day. To have injections of nutritive soups. Pulse 80. " 2d. Face more sunk and pinched than yesterday. Pulse 70. Vomiting and retching more urgent. Vaginal discharge diminished. Still using vaginal injections of tepid water, rectal injections of soups. Takes brandy by the mouth, but generally vomits it. " 3d. Pulse 40. Retching and vomiting still. Vaginal injections of tepid Avater came away almost colourless. "4th. Gradually sunk and died at 4 A. M. "Autopsy, made thirty hours after death.—Great rigor mortis. The thoracic organs quite natural. The inferior extremity of the great omentum was found to be adherent to the upper and back part of the uterus. On passing the hand doAvn into the pelvis, both the caecum and rectum were found adherent to the viscera. The whole of the pelvic contents were removed together, when it was found that there was a soft tumour just in front of the right broad liga- ment. On making an incision into this, some dirty purulent matter escaped; but the rest of the cavity was filled Avith large, unde- colourized, pretty firm clots of blood, and the opening at the bottom of the cavity, made during life, communicated with the upper part of the vagina. The liver was divided into a number of additional lobes by the presence of several deep fissures, and the kidneys were in a state of waxy degeneration." It so happened that during the same week in which the death of this hospital patient took place, I had a patient in private practice who died of the same disease. She was sent from a great distance to Edinburgh, in consequence of-a pelvic tumour having suddenly appeared. Fatal inflammation was set up by the journey. On dis- section, I found* the reflection of the peritoneum between the uterus and rectum raised up, as shown in this diagram (see Fig. 61), and a large mass of broken coagula of blood formed the tumour, having PERI-UTERINE OR PELVIC HEMATOMA. 263 been extravasated behind the peritoneum, forming the posterior covering of the broad ligament, and, as it accumulated, having sepa- Fig. 61. Shows the situation of the hematoma (d) between the uterus (6) and the rectum (c). (a) The bladder. rated and pushed before it that portion of peritoneum and the utero- rectal fold of this membrane. In the present state of uterine pa- thology, we can recognize the malady with tolerable certainty, and we all see cases of it ever and anon occurring. Nay more, now that we have a clear conception of the nature of the disease, when we begin to consult the older authors, we find that some of them had tolerably distinct ideas as to its nature, and a positive knowledge of its occurrence. Ruysch more particularly has described some cases of it; and in the obstetrical books that are usually classed with the Hippocratic writings, there are distinct indications that the author had some acquaintance with this affection even at that early period. Nomenclature of the Disease. The disease has received different names from the authors .who have written anything regarding it. There are many notices of it in French literature, and by French authors it is generally spoken of as Retro-uterine Hsematocele. Others call it Peri-metrine and Peri-uterine Hematocele, from the fact that it is not confined in po- sition to the cellular tissue lying behind the uterus, although that is 264 PERI-UTERINE OR PELVIC HEMATOMA. its chosen seat. It is spoken of, again, as Pelvic Thrombus by others, because the swelling is of the same nature as the surgical thrombus sometimes seen in the labia pudendi, as a result of injury to some of the vessels there. Here, we have been in the habit of speaking of it as Pelvic Hematoma, because that name expresses simply Avhat the disease in reality is, Adz., a blood-tumour or effusion in the cellular tissue of the pelvis; and that you may be able to un- derstand its nature, and to recognize the disease when it comes before you in practice, let me proceed to tell you something of the manner in which it seems to be produced, or to tell you, in other words, what is known regarding The Pathological Anatomy and Pathology of the Disease. It occurs, let me first of all remark, sometimes in puerperal wo- men, but more frequently we meet Avith it in non-puerperal females, and altogether unconnected with the parturient process. It is seen in patients of all ages; but is more frequent about the age of thirty, according to my experience, than at any other period of life. The disease seems to be usually produced by the rupture of one of the veins or arteries that supply the ovary, and pass to it between the layers of the broad ligament. The blood escaping from the ruptured and sometimes varicose vessel, infiltrates into the cellular tissue of the broad ligament, and those neighbouring parts of the pelvic cel- lular tissue which communicate freely with it, forming there a swelling or tumour composed of this effused and incarcerated blood, as in a thrombus or blood-swelling of the subcutaneous cellular tissue from injury, or as in the so-called sanguineous apoplexy of the brain, lungs, and other organs. As the blood extravasated from the broken utero-ovarian vessel accumulates in the surrounding cellular tissue, it separates the serous layers of the broad ligament from each other, or raises and pushes before it, more particularly, one of these layers, to form, as it Avere, a covering to the blood-tumour. More especially is the posterior peritoneal layer often apparently separated and dis- placed in this way, as well as the fold of peritoneum stretching be- tween the uterus and rectum. It is this affection which constitutes the true pelvic or retro-uterine hsematocele. But, occasionally, there is a form of pelvic hematoma of a different origin, and with the effused blood in a different site. For according to the evidence of various French pathologists, as Nelaton, Laugier, and others, a retro-uterine hematocele may be formed by blood accumulating within the pelvic portion of the peritoneum, the blood collected in this'locality having escaped from a ruptured ovarian vesicle during menstruation, from the fimbriated extremity or course of the Fallo- pian tube, or even from the cavity of the uterus—the blood regurgi- tating along the Fallopian tube into the peritoneal cavity. Certainly, sometimes, even when the site of the hemorrhage is a ruptured vessel of the ovarian or uterine plexus inclosed within the broad ligament peri-uterine or pelvic hematoma. 265 the effused blood has burst through the opposing layer of peritoneum, and escaped directly into one of the peritoneal pouches behind or in front of the uterus, where its presence has acted as an irritant to the peritoneum, and led to its being encysted and inclosed in a separate cyst or cavity, produced by the adhesion of opposed inflamed surfaces. These ruptures of the bloodvessels of the utero-ovarian plexus, and consequent extravasations of blood, most frequently occur during a menstrual period, when a certain degree of excite- ment and physiological congestion are set up in the ovary, for then the vessels being more distended with blood will be more likely to give way in their coats under the action of any unusual impetus. The blood which escapes from the injured vessel or vessels passes in between the layers of the broad ligament and separates them from each other, forming a tumour in many respects resembling the in- flammatory tumour produced by the effusion of serum into the same locality, but only forming more rapidly and suddenly, without any premonitory symptoms. Or, one of the terminal branches of these ovarian vessels may give way, and the blood be thrown into the substance of the ovary itself. This rarely happens in the healthy ovary, but it has now been not unfrequently seen in cases where the organ has been altered and rendered friable as a result of disease; and then the extravasated blood, after breaking up the softened structures of the ovary, may make its way eventually into the cavity of the peritoneum. It would seem, I have said, in some cases as if the rupture occurred in a superficial vessel, and the extravasation took pMce directly into the peritoneal cavity. A very melancholy and distressing instance of this kind of injury occurred, many years ago, in a patient of Dr. Malcolm, of Perth. This patient, when otherwise apparently in perfect health, was suddenly seized one fore- noon with pain in the abdomen, and faintness, which Avent on in- creasing during the day, in spite of the most skilful treatment. That same night the lady died, and at the post-mortem examination the abdominal cavity was found filled with coagulated blood which had escaped from a ruptured bloodvessel, lying in the broad ligament of the uterus. Most frequently, as I have stated, extravasations of blood into the cellular tissue of the pelvis result from rupture of one of the ovarian vessels as it courses along the broad ligament, and they usually occur in connection with menstruation. But it is proper to add that pelvic hematomas may have other sources and seats, for other vessels besides the ovarian vessels are liable to rupture. Thus I saw some time ago, along with Dr. Young, a patient in whom one of the upper hemorrhoidal vessels had given way, and led to the formation of a hematoma of large size in front of the rectum, where it could be distinctly felt between that canal and the cavity of the vagina. Tumours of this nature are not unfrequently met with also in "the walls or at the sides of the vagina, but rarely of any great size. Indeed, "there is almost no limit to the variety of situations in which a pelvic thrombus or hematoma may be found, for the veins 266 PERI-UTERINE OR PELVIC H.EMATOMA. may give way in any part of the pelvis, and the blood which escapes may fill sometimes one fascial loculament only of the pelvis, and at other times several at once. You will find that various accounts have been given as to the size of the swelling, and various statements made as to the extent to which hemorrhage may take place into the loculi of the pelvic fascia. Of course all this varies greatly in different cases and different pa- tients. I have seen two or three instances where a pelvic hematoma Avas as large in size as a gravid uterus in the fourth or fifth month of pregnancy. In practice you will usually find them much smaller, and in most cases you will ascertain their presence by a vaginal rather than an abdominal examination. The most frequent form is Avhere the extravasation occurs between the layers of the broad liga- ment, where it-is confined and limited in size, and rounded and elon- gated in form; or it may extend from this, separating the layers and passing doAvn among the cellular tissue behind the cervix uteri, or between the rectum and vagina. In this case the tumour, like that formed by the serous effusion of pelvic cellulitis, may be at first small in size and rounded in form, but rapidly, as the extrava- sation spreads, the tumour becomes enlarged in size, elongated or irregular in shape, and fitting itself to the contour of the cavities into which the blood is thrown. Symptoms of the Disease. Yrou will rarely be called to see a case of pelvic hematoma until the extravasation of blood has fairly taken place, and the cellular tissue in some of the loculaments of the pelvic fascia has become infiltrated and distended; and then on exarmining your patient you will find a tumour present, which in all its physical characteristics, and in all the functional disturbances that it produces, resembles very closely the swelling produced by the effusion of serum in the early stages of an attack of inflammation. But there are some marked points of difference. In a patient affected with pelvic cel- lulitis you would find a high degree of fever, with the pulse rapid and strong, and the skin alternately burning hot and suffused with perspiration. Where the pelvic tumour is formed by effused blood, on the other hand, none of these signs are to be seen, and the gene- ral absence of all constitutional irritation and excitement is one of the most striking phenomena of the disease. The patient, if show- ing any constitutional symptoms at all, is usually depressed instead, and in a state of weakness and prostration. Then if you examine the tumour itself a little more closely you will find there are some distinctive marks there also. An inflammatory tumour is tender to the touch, and pressure with the finger elicits signs of suffering. The first formation of a blood-tumour seems to be often attended with pain, sometimes with great pain, but once it is fully formed pressure on it with the exploring finger does not cause much uneasi- PERI-UTERINE OR PELVIC HEMATOMA. 267 ness to the patient. An inflammatory tumour in its earlier stages is very hard and unyielding, and in its later stages, after suppura- tion has taken place, it can be felt to be fluctuating. A blood tu- mour is comparatively soft and elastic, but the feeling of fluctuation is never very distinct in the mass of the swelling. There is usually, however, one spot where it is especially soft and yielding; and in the most common form of pelvic hematoma (that, namely, which depends on an effusion of blood into the broad ligament and behind the uterus), this point is always to be felt somewhat behind and beloAv the cervix uteri, where the finger sinks, as it were, into a kind of hollow. I suppose there is some natural opening or deficiency in the pelvic fascia at this point. In true pelvic hematoma, formed by an accumulation of coagulated blood between the layersof the broad ligament and in the neighbouring pelvic cellular tissue, the uterus itself is pushed strongly forward, and occasionally to one side ; and sometimes the os or cervix uteri is raised or elevated by the pressure of the blood-tumour. This displacement of the uterus is ascertained on your first examination, or, if the effusion at least is a day old, in cases of pelvic hematoma. It is often found also in pelvic cellulitis, but then much later in the disease; or, in other Avords, not until the inflammatory effusion is at its height; and then generally in pelvic cellulitis the pelvic swelling, as ascertained by repeated vaginal examination, varies in form from time to time, and is much more general around and on all sides of the cervix uteri than in pelvic hematoma. Besides, rarely if ever does the pelvic tumour feel fixed to, or springing from, the pelvic bones within, as is so frequently the case in pelvic cellulitis. Then, again, if you can trace back a case of hematoma to its commencement, you will find the patient gives you a different history from what she would have done had the tumour in the pelvis been of inflammatory origin. Pelvic cellulitis usually comes on with a high degree of fever, pre- ceded by rigors, and is *not necessarily associated with menstruation, while pelvic hematoma is almost invariably produced^ at a catame- nial period, often occurs in cases where the menstruation is in some way irregular, and although the patient has sometimes a sort of shivering fit at first, Avhile the effusion is taking place, she has no fever, but, on the other hand, rather a tendency to fainting. If we could by any chance watch the formation of the tumour, and find it forming rapidly in the space of half an hour or so, there would, of course, be then no doubt as to its nature, for its mere sudden formation would serve as a diagnostic mark ; but this is an observa- tion which it will hardly ever be in your power to make, although we may sometimes have occasion to know that the tumour has only had a comparatively short time to grow. There may be pain in both forms of tumour at their commencement; but in the case of hematoma though the pain may be at first even more intense than that usually seen at first in cases of pelvic cellulitis, yet, instead of becoming more and more severe, as is the case with the pain 268 PERI-UTERINE OR PELVIC HEMATOMA. attendant on a progressive inflammatory effusion, it usually becomes less and less acute, as the infiltrated parts become accustomed and accommodated to the morbid pressure of the extravasated blood, so that at last an almost painless SAvelling alone remains, which you must guard yourself against mistaking for some form of malignant tumour, or some kind of chronic disease. At the close of last autumn, a very delicate patient under my care was one day seized with a sudden faintness and a feeling of great oppression in the region of the heart, the action of which became irregular. She complained at the same time of unusual pain and distension in the uterine region. It was the first day of a catamenial period, and as I happened to know beforehand in what condition the Avomb was, I traced distinctly the first formation of a pelvic hematoma. For- tunately the extravasation did not go on to any great extent, and Avith perfect rest and the use of the remedies of which I am to speak anon, the effused blood gradually became absorbed, but not till after the lapse of many weeks. The case was interesting further in this respect, that the lady has a great dread of cancer of the womb, and is strongly apprehensive that she will be attacked with that dread- ful disease, and not Avithout reason—for her mother had been the subject of carcinoma. Now had I not known previously that the womb in that instance was perfectly healthy, or at least that there was no trace of any carcinomatous affection about it, and had I first made an examination after the extravasation of blood had taken place, and a firm, elastic tumour had been developed around, or rather behind, the n.eck of the uterus, I might very easily have been led to have adopted the patient's own gloomy apprehensions, and to have come to the conclusion that she was the subject of en- cephaloid disease. To sum up, then, I may say briefly, that the symptoms of pelvic hematoma are the same as those of pelvic cel- lulitis—with these two characteristic distinctions, that in the case of a patient affected with hematoma, 1st, there is an almost total absence of all constitutional fever ; and 2d, the local swelling is found large from the first, and not by any means so tender as in pelvic phlegmon. If, after making-a critical investigation into the patient's present symptoms and her past history, and if, after making a careful local examination of the tumour, you still remain in doubt as to the nature of the effusion, you must, if you deem it absolutely necessary, proceed to resolve that doubt by pushing an exploring needle into the mass, when the escape of the characteristic fluid of either form of tumour will at once reveal the real nature of the case. Always, however, bear in remembrance, further, that you may have both diseases present, and that large pelvic hematoceles often excite inflammation, and thus become combined with pelvic cellulitis and suppuration. Now that you have been made aware of the existence of this disease, and now that you know something of its pathology and symptomatology, I trust that when a case presents itself to you in practice, you will have no great difficulty about its PERI-UTERINE OR PELVIC HEMATOMA. 269 diagnosis. Before telling you hoAV it is to be treated, let me say a word or tAvo as to The Prognosis of the Disease. Many patients recover from this disease spontaneously. This fortunate result especially happens in those cases where the quan- tity of blood extravasated is small; for then it is capable of being absorbed, just as .we see blood absorbed after it has been effused under the skin as a result of injury. But where the amount of hemorrhage-has been greater, we cannot always be sure of such a fortunate issue. In such a case a variety of changes must first occur in the mass of blood before it can be absorbed, or be elimi- nated ; and frequently inflammation supervenes, and then you may have the size of the tumour increased from the presence of the effused serum. After a time suppuration sets in, and the fluid makes a way for itself to some mucous surface. It may open in this way into the rectum or vagina; but sometimes rupture has oc- curred into the peritoneum, and lighted up a fatal inflammation there. I have already told you that I saw two patients die in one week from this disease ; and there was this peculiarity observed in regard to one of these patients, that the pulse became, during the last tAvo days of life, lower and lower, as the patient sank and died. This peculiar change in the pulse is the very reverse of what we see in cases of death from pelvic cellulitis. Treatment of the Disease. The indications for the treatment of pelvic hematoma may be reduced to four. 1. The Employment of Hsemostatic Measures.—If you happened to be called to a case sufficiently early, Avhile the extravasation was still going on, and the tumour still in process of formation—a con- tingency not very likely to occur often—the indication should be to try, if there Avere any time for it, to check the effusion of blood by the prompt administration of some general hemostatic remedies, or of some of those medicines which, when taken internally, have the effect of moderating the flow of blood from injured bloodvessels. And at the same time you would do well to apply ice, or cold in some form, locally, with a vieAv of acting more directly on the vessels, and leading to their contraction and closure. But usually there is little time for the adoption of such treatment. In most instances, indeed, there is none; for in the vast majority of cases you are not called to see the patient until some time after the rupture has oc- curred, and until the blood-tumour has been fully formed, and the blood has ceased to flow. Some other indications, therefore, demand your attention, and you will accordingly be obliged usually to have recourse at once to 270 peri-uterine or pelvic hematoma. 2. The Use of Antiphlogistics.—-There is, perhaps, no point of more importance to be attended to in connection with the treatment of pelvic hematoma, than the necessity of putting the patient at once on antiphlogistic diet and regimen, in order to prevent, as tar as possible, all chance of inflammation being lighted up in the tissues Avhich are subjected to irritation by the presence of the effused blood. For the supervention of acute and suppurative inflammation in such a case is a most calamitous complication. I have already told you that hematoma is in itself sometimes dangerous—it is almost always tedious : and you may remember that in a former lecture I pointed out that cases of simple pelvic cellulitis were not always free from danger, and were often of long duration. But when the two diseases coexist in the same individual, you can per- ceive that the immediate risks and dangers of the patient are mul- tiplied, and as there has been a double effusion—a traumatic effusion of blood, and an inflammatory effusion of serum or pus—the time necessary for absorption becomes greatly prolonged, and the period of convalescence indefinitely postponed. Besides, inflammation set up around any large and decomposing mass of blood is ahvays dangerous and perilous, especially as here, in the vicinity of a large serous sac such as the peritoneum. Hence the paramount impor- tance of keeping the patient on a low and antiphlogistic diet, and of making her avoid every form of stimulant. Hence, too, the absolute necessity of keeping her at perfect rest. You may think this a simple matter, and easy to be attended to, but in practice you will find it extremely difficult to enforce complete quiet on your patient. She has often no pain, and no fever, and after the uneasi- ness and prostration immediately consequent on the extravasation of blood into the cellular tissues have passed off, it is sometimes very difficult to persuade her to keep her bed for ten or twelve days subsequently. One of the fatal cases to which I have already more than once referred, occurred in a patient who travelled from Rosshire to Edinburgh after she had recovered from the immediate effects of the extravasation. The excitement and irritation caused by the journey led to the occurrence of an inflammation around the seat of the effusion, which speedily proved-fatal. You must, therefore, try also to keep the bowels quiet for a time. Insist on the patient keep- ing free from all bodily and mental excitement, and maintaining the horizontal posture until the tumour begins to diminish. If it have been of such size as to project above the brim of the pelvis, you will be able to trace and mark out easily the daily diminution of it by external examination; if not, then by feeling it with the finger through the vagina, ^ou will succeed in making the observation. The first and most important indication, therefore, which you are called upon in most cases of pelvic hematoma to fulfil, is to avert, as far as possible, all chances of any attack of inflammation in the surrounding tissues, or to subdue any inflammation that may chance PERI-UTERINE OR PELVIC H2EMATOMA. 271 to have arisen, by the prompt employment of proper antiphlogistic measures. With these means you may perhaps conjoin, 3. The Administration of Discutient Remedies.—Most practi- tioners deem it necessary to prescribe some discutient medicines, which ought, at least in the opinion of the pharmacologists, to have the effect of promoting the dissolution and absorption of the extra- vasated mass of solidified blood; and if you really can prescribe remedies which are possessed of such an action, it would, of course, be advisable and right to administer them. But I know of no drugs that are very serviceable in this way, and it has yet to be shown that any one has the poAver of favouring the resorption of effused blood. All that you can usually do is to regulate the diet, by re- stricting the patient from the use of all stimulants and all indigesti- ble matters, and by curtailing her usual amount of fluids. You may even give some alkaline diuretics, Avith the vieAV at once of diminishing the quantity of the fluids already in the system, and of insuring the immediate secretion of the effete matters that are ab- sorbed from the seat of the disease. If you do, however, think it necessary to have recourse to the use of discutient or deobstruent remedies, let me advise you to have them applied locally through the vagina, in the form of medicated pessaries, in preference to administering them internally through the stomach. I have some- times used pessaries in this way, containing mercury, iodide of lead, etc., but not, so far as I could perceive, with any marked effect. All you have to do, usually, is to make a judicious use of antiphlo- gistic remedies, to enforce a strictly antiphlogistic regimen, with rest; and to take every precaution to prevent the patient from in- juring herself or aggravating the disease. Under this regiminal treatment, the blood, in most cases, will in time become absorbed, and the swelling will gradually disappear. Such, I say, is the most common course of the disease; but in some cases its course is changed, and a corresponding change of treatment is required at the hands of the practitioner. Sometimes inflammation sets in, in despite of your most skilful and careful treatment; or it may have begun before the case came into your hands ; or the patient may have an aggravation of all her sufferings from a renewed extrava- sation of blood. Now, where a pelvic hematoma begins to enlarge, and to become painful, I believe you give your patient the best chance of recovery by having recourse to, 4. The Opening of the Tumour.—When a hematoma is running its course gradually and quietly, causing no great amount of pain, and giving rise to no particular degree of distress, your patient's best chance of recovery lies in her keeping at perfect rest, and in your totally and resolutely withholding your hand from all kinds of surcn'cal interference. But if betimes the tumour begins to swell up and enlarge in consequence of inflammation being lighted up in the involved and surrounding tissues, you will find that the effused matters try to gain an exit for themselves through some mucous or 272 PERI-UTERINE OR PELVIC HEMATOMA. other surface, as the rectum, vagina, or into the peritoneum, and you must take the hint from nature and make an artificial opening into the fluid collection at the point most favourable for its free and full evacuation. As in the case of purulent collections commencing in the broad ligament, so in the case of hematoma when the hsema- toma becomes inflamed and softened, the most dependent point is usually to be found immediately behind the os uteri in the posterior cul-de-sac of the roof of the vagina; and a good, free incision made into the mass at this spot you will generally find to be folloAved by the best results. I have now repeatedly had recourse to that measure, and with the greatest benefit. In making the evacuation, do not try to draw off the fluid with a trocar and canula, as I im- properly did in the hospital case the account of which I read to you, because there are always masses of blood-clots mixed up with it Avhich are too large to escape through the canula, but which it is of the utmost importance to have removed. They act the part of a foreign body in the cavity, like the necrotic tissues to which I di- rected your attention when speaking of fetid abscesses ; and so long as they remain there you can entertain no reasonable hope of a cure. To open the hematoma effectually, you must make an incision into it with a tenotomy-knife, and then freely dilate the opening still further with the finger. By enlarging the orifice in this way, you run less risk of causing a dangerous degree of hemorrhage than when you at once make with the knife an incision of sufficient size to admit of the escape of the solid masses. For it is not enough in a case of this kind to make an opening into the cyst. You must introduce the finger through it and break down the septa and blood- coagula, so as to insure their complete removal; and it is only when all the contents of the cavity have been in this way well cleared out that you insure the best chance of its contraction and closure. This operation may even be performed with safety and success in cases that look most unpromising; in cases, for example, where the patient has become pale, and of an exsanguine appearance, in consequence of the effusion of a great quantity of blood into the cellular.tissue of the pelvis. Two or three years ago I saw a patient along with Dr. Cruikshank, when she was at the time the subject of an enormous pelvic hematoma. She was then extremely pallid and weak; and the hematoma had become tender and inflamed and was threatening to enlarge and burst. I made a free opening into it, and cleared out the contents of the cavity, which gradually con- tracted and healed up. She left Edinburgh before she had alto- gether regained her strength, and when she came to call on me lately, I did not at first recognize her, so very different did she look from the exhausted chlorotic-like patient whom I had previously seen. I repeat, then, What you have to do in most cases of hema- toma, is simply to watch carefully the progress of the case and protect the patient from every form of injury; to keep down as far as possible all chances and tendencies to inflammation in the part • PERI-UTERINE OR PELVIC HEMATOMA. 273 and if symptoms of inflammation and inflammatory effusion and swelling do come at last to manifest themselves, to make a free and early incision into the cavity, so as to evacuate the whole of its contents. The artificial evacuation of the collected blood may perhaps also be occasionally judged advisable in some cases, where no inflammation has supervened, but where the tumour continues large and presses injuriously and painfully upon the surrounding parts and organs. But such instances are rare. HEMATOMA OR THROMBUS OF THE VULVA. But hematoma are not confined to the portions of cellular tissue lying between the layers and prolongations of the upper division of the pelvic fascia. They sometimes occur lower down in some part of the wall of the vagina, most frequently towards the outlet of the canal. Here they may occur as a result of direct injury; oftener still they are produced during labour. The veins at this point are large and numerous, and during the course of pregnancy they become somewhat dilated from the pressure of the enlarging uterus on the veins above ; so that when labour supervenes, and they become themselves subjected to the direct pressure of the fetal head from above, one of them sometimes bursts, and gives rise to a SAvelling in the maternal passages, which may impede and seriously complicate the progress of the labour. Blood-tumours forming in this way in the labia pudendi, or in the walls at the lower end of the vagina during the parturient process, do not necessarily call for any immediate treatment. If of no great size they may be left to themselves, and after a time they usually become absorbed; but sometimes inflammation supervenes in them, and then you will re- quire to open them. Where, on the other hand, the size of the swelling is such as to interfere with labour by forming an obstacle to the passage of the fcetal head, the case becomes more critical, and the treatment, if the mechanical obstruction ever prevents the exit of the head, may require to be more heroic. In such a complication you may require to make an incision to allow the fluid to escape, and the swelling being thus reduced in size, the birth of the child is facilitated. But where it becomes necessary for you in this way to open the tumour, I would beg to impress upon your minds the pro- priety of postponing the operation if possible till such time as the effused blood has become coagulated, and till the blood has ceased to flow from the injured vessel. If you can't wait so long—if the extravasation is still taking place, but prolongation of the labour threatens to be injurious to the life of the mother or the child, what are you to do ? Then you must still evacuate the thrombus; but, in addition, you must be prepared to apply pressure to the bleeding surface, remembering that the blood is escaping from a ruptured vein, and that venous hemorrhage is always most effectually arrested by means of pressure. 18 274 PERI-UTERINE OR PELVIC HEMATOMA. VARIX OF THE PUDENDAL VEINS. As I am speaking of these veins of the pudenda and lower part of the vagina, let me make one or two further observations regard- ing another morbid condition to which they are sometimes liable. Like the veins of the inferior extremity, Avhen the flow of blood in them is impeded during a lengthened period they may become en- larged and varicose, and then they assume the prominent and tor- tuous appearance seen in this drawing. (See Fig. 62.) This state of Fig. 62. Sketch of varicose veins of the nymphse. (Brasse.) the veins is sometimes produced gradually during the course of pregnancy, so that during labour they become turgid and prominent leading to the idea that it will be necessary to have recourse to some extreme measure to obviate the chances of their being ruptured But in truth they rarely, if ever, require to be interfered with during labour. I have repeatedly seen and been consulted about pregnant and parturient women in whom this condition of the veins was present, but I never saw a case Avhere by their own bulk they PERI-UTERINE OR PELVIC HEMATOMA. 275 caused any such impediment or annoyance as required any special treatment during labour. But like varicose veins in other parts of the body, these varicose veins of the vulva are apt to become inflamed, and their walls may in consequence become indurated and inelastic, for then the diseased and stiffened vein bleeds as profusely as an artery. Should they, when in such a condition, be subjected to any kind of injury, a dangerous and even fatal hemorrhage may readily result. In the Scotch law-courts during the last five-and-twenty years a considera- ble number of trials have taken place in consequence of women bleeding to death after sustaining some injury of the pudenda. In most of these cases all that was alleged as to the cause of death was, that the woman had received a kick on the part at a time when she was pregnant, and that a slight laceration had been produced, from which the fatal hemorrhage took place. In such cases the veins are sometimes in the condition I speak of; and Ave have found experimentally that a blow on the part is sufficient to cut through these vessels by bringing them suddenly and forcibly in contact with the ramus of the ischium and pubis. In these cases death was so far accidental and unintentional. But in others a knife has been used, and an incision made into the veins, in order to mislead to the belief that the patient had died of puerperal hemorrhage. Some- times the injury has been purely accidental, from the patient falling and hurting herself, on some broken crockery for example. In other instances, again, the hemorrhage has occurred spontaneously. A case of this kind happened at Dundee some years ago, Avhere a patient died of hemorrhage occurring from a ruptured vein of the pudendi, and where she had been subjected to no kind of injury whatever. She was passing water when the blood began to flow, and she at once called the attention of those near her to the cir- cumstance. Medical aid was immediately sent for, but before the doctor arrived the patient had bled to death. When the late Dr. Martin Barry was acting as House-Surgeon in the Lying-in Hospi- tal here, a case occurred where rupture of the pudendal veins was produced during the act of coition, and nearly ended fatally; and m one of the English journals a few years ago there was an account of a trial at Bristol, where a butcher was accused of killing a mar- ried woman, who died from rupture of these veins, produced under similar circumstances. I have taken this opportunity of speaking to you of these cases, in order that you may be aware of the occa- sional fatality of lesions of the pudendal veins, and in order that you may be made alive to the importance of at once obeying the call should you ever happen to be summoned to aid a woman who had been subjected to such an injury. Here again, as in venesec- tion and other forms of venous hemorrhage, pressure is generally adequate to arrest the discharge, but it may require to be kept up both strongly and steadily. 276 SPURIOUS PREGNANCY. LECTURE XXI. ON SPURIOUS PREGNANCY, OR P S E U D 0-C YE S I S. Gentlemen: The author of the two remarkable dissertations on "Diseases of Women," usually published among the Hippocratic treatises, when at one place treating of displacement and stricture of the os uteri, takes occasion to remark that sometimes under such circumstances "the menstrual fluid is determined to the mamme, and produces their enlargement; the abdomen swells, and inexperienced patients believe themselves to be pregnant; in truth," he continues, "they present all the phenomena usually seen in women at the seventh or eighth month of utero-gestation ; the belly attains a pro- portional degree of enlargement; the breasts swell up, and milk seems to be secreted. But when this period has passed, and the full term of pregnancy should be complete, the mammae shrink up and diminish in size, the abdomen likewise collapses; all trace of the milk disappears, and the abdomen sinks in, and all tumefaction is dispelled." The diseased state described in the preceding quotation is that state usually spoken of as the state of "spurious pregnancy." In his "Nosology," Dr. Mason Good proposed to describe this peculiar affection under the corresponding Greek name of "Pseudo-cyesis," from ^s'dSoj, a lie, and xv^cuy, pregnancy. We have lately had two examples of this disease among patients visiting the female ward. One of the patients, who remained in the ward for a short time, suf- fered from suppression of the menses, continuing for a period of three or four months, and alternating Avith a state of menorrhagia ; she had occasional sickness; the mamme were slightly enlarged, and the abdomen somewhat protuberant. She suffered, in short— but not in a well-marked degree—from this morbid condition of spu- rious pregnancy. In the other patient, who was under the medical charge of one of the students of the class, not only were all the usual phenomena of pregnancy well-marked for the usual time ; but, Avhat is far less frequent, there latterly supervened all the common phe- nomena of labour; but of labour without any result, as the uterus was quite empty. There are tAvo varieties of pseudo-cyesis or spurious pregnancy, a local and a constitutional. The former I have already described to you as seen in those cases of dysmenorrhcea Avhere the patient has occasionally, or even at every monthly period, excessive development of the mucous membrane, which becomes vascular and SAvollen, and is in part shed off in the form of a separate membrane, resembling in SPURIOUS PREGNANCY. 277 every respect the decidual membrane Avhich is formed in the early weeks of every real pregnancy. In such cases the patients usually suffer a great deal of pain during the expulsion of these uterine casts, and they are sometimes affected with some of the ordinary constitu- tional and sympathetic phenomena of pregnancy. Thus they fre- quently are troubled with sickness and vomiting; the mamme some- times become enlarged, and the areole darkened for one or two Aveeks both before and after these dysmenorrheal membranes are thrown off. The most striking features of the disease in such cases, how- ever, and the most distressing symptoms depend upon the local changes in the uterus ; and as I have already discussed these, both as regards their pathology and treatment in my lecture on Mem- branous Dysmenorrhea, I need say no more about that subject now, but pass on at once to the consideration of that more frequent form or spurious pregnancy, of which the more striking phenomena are all of constitutional origin, and the disease true, or CONSTITUTIONAL PSEUDO-CYESIS. In this constitutional or sympathetic variety of spurious preg- nancy, then, there may be no appreciable local change whatever ; but the patient suffers from nausea and vomiting, and the other sympathetic phenomena common to pregnant females. The mamme become enlarged, the areole are darkened, and the gland gives forth its milky secretion. The abdomen enlarges gradually until it occa- sionally comes to assume the form, and size, too, of an abdomen which contains a gravid uterus, and the patient feels movements in its cavity, which she unhesitatingly pronounces to be movements of a fetus. Menstruation is usually pretty methodic, but you will occasionally find it altogether suppressed for a time, or only coming on very irregularly, and Avith a scanty flow. All these symptoms may arise and go on slowly and progressively for a period of nine months, or longer, and the patient may labour under the delusion that she is in the family-way, until, it may be, symptoms set in re- sembling the ordinary efforts of labour, and then, when a medical man is sent for to attend at the delivery, it may happen that she first discovers she has never been pregnant at all. Frequency of the Disease. Before I proceed to point out to you more particularly the nature of this disease, and to tell you how it is to be recognized and treated, let me first of all remark that it is a disease which, when you come to practise, you will find to be of far more frequent occurrence than the comparative silence of our obstetric text-books on this malady would lead you to infer. It is not by any means confined to the married, or to those Avho have borne children, but is seen among the unmarried and childless as Avell. Among the former, however, it is 278 SPURIOUS PREGNANCY. more frequent; and there are perhaps few women in married life who have not presented more or less marked symptoms of it once or oftener. The disease, as we have seen, was known of old, and is duly noticed in the Ilippocratic writings. But in modern times medical writers have passed it by in almost complete silence ; and the only notice of any importance in regard to it that I know of in the English language, is to be found in the admirable and classical work of my friend Dr. Montgomery on the " Signs and Symptoms of Pregnancy,"—a work which I beg strongly to recommend to your careful perusal, as a volume not less remarkable for its great accu- mulation of original and collated facts, than for its logical statements and reasoning, and its elegant and classic style. Yet, as I say, cases of spurious pregnancy are constantly occurring in practice, and patients often go about from one practitioner to another seeking relief, or desiring to obtain some certainty as to the nature of their affection, a point in regard to which they are often in the greatest doubt. They fancy themselves, for the most part, to be pregnant; but sometimes they suppose themselves to be subject to very different kinds of disease, as in the case of a patient from the West Indies, whom I have under my care just noAV, and Avho, it was there imagined, had some hydatids in the uterus. To shoAv you how difficult it is to distinguish cases of simple spu- rious pregnancy from other forms of disease, let me merely tell you one fact. Six different cases have been put upon record, where patients have been supposed to be labouring under ovarian disease ; and in these six cases, when the abdomen was laid open with the view of removing the ovarian tumour, there was found to be no tumour there—nothing unusual or abnormal except, perhaps, a slight degree of distension of the bowels. Such needless tampering with the lives of patients may suffice to impress upon you the dangers of making a false diagnosis, and teach you not to neglect any means by which you are likely to obtain a clearer insight into the nature of this often obscure and puzzling form of disease. Times of its Occurrence. As to the period of life when it is most likely to be met with, Dr. Montgomery thinks that it occurs most frequently at the climacteric period, when the catamenial discharges cease to appear, and when the female constitution seems to become more liable to be affected by morbific influences. But I feel pretty certain that the disease occurs at least as often during the first year after marriage as at any later period. At least, you will find, on making inquiries of patients, that they have very often been deceived into the belief that they have become pregnant at the time I refer to, from the tempo- rary suppression of the menses, attended with sickness, and some degree of swelling of the abdomen ; but probably from the circum- stance that the delusion is not usually kept up for such a length of SPURIOUS PREGNANCY. 279 time in these patients, they do not so often come under the observa- tion of the practitioner, and are thus very commonly altogether overlooked. Spurious pregnancy, however, may occur at any period during the catamenial life, and it is often enough developed during the intervals between two successive real pregnancies; and a suc- cession of attacks is sometimes seen in the same individual. May the Disease occur in the Unmarried ? Certainly, and then it constitutes a very delicate class of cases. When occurring in the unmarried, it is usually set down as hysteria ; but sometimes all the characteristic phenomena are most distinctly indicated, and it is then a very difficult and delicate matter to answer the patient's inquiries regarding her disease. No one would choose to speak to the patient or her friends of " spurious pregnancy " under such circumstances, as the mere name itself would be sufficiently offensive. Perhaps the descriptive designation proposed by Dr. Good of pseudo-cyesis would save sometimes the practitioner from difficulty—when hard pressed as we sometimes are—to give our patient's affection a proper name. That the affection may occur in the most moral persons, however, and in virgins, is certain ; and if any confirmation were needed, it would be found in the fact that it has sometimes been seen among a class of females as to whose mo- rality and state no question can be raised, namely, the females of our domestic animals. Harvey pointed out long ago in his cele- brated work on "Animal Generation," that "over-fed bitches which admit the dog without fecundation following, are nevertheless ob- served to be sluggish about the time they should have whelped, and to bark as they do when their time is at hand; also to filch away the whelps from another bitch, to tend and lick them, and also to fight fiercely for them. Others," he goes on to say, "have milk or colostrum, as it is called, in their teats, and are, moreover, subject to the diseases of those which have actually whelped ; the same thing is seen in hens which cluck at certain times, although they have no eggs on which to sit. Some birds also, as pigeons, if they have ad- mitted the male, although they lay no eggs at all, or only barren ones, are found equally sedulous in building their nests. 1 had a patient in the neighbourhood of Edinburgh, who used to keep a se- raglio of female dogs, and was interested in observing their habits and physical characteristics. This person was a careful observer, and told me that every year, and occasionally twice every year, some of these "over-fed bitches" had all the symptoms of pregnancy, although they had been kept secluded from all male society. And the phenomenon so often spoken of, of animals without any offspring of their own, adopting and nursing the young of other animals, be- longing sometimes to an entirely different class, is, doubtless, only one of the forms in which this peculiar affection may be manifested. 280 spurious pregnancy. Mistakes from it among the M