822 00515 5031 UNIVckSITv of CALiPORtJiA SAN CiE3C e:j [Jf^iVFRSllY OF CALIFORrJiA, SAN DiEGO DATE LOANED illN 7 i^«n JUN1 fi REC'O 1 GAYLORD 3563 PRINTED IN U.S A. VV I llIll'lllimiMl'„^!;,J^f)trORNIA, SAN DIEGO 3 1822 00515 5031 v./ ^ THE NEW SYDENHAM SOCIETY. INSTITUTED MDCCCLVIII. VOLUME XXVIII. CLINICAL MEMOIRS ON THE DISEASES OF WOMEN. HY M. GhUSTAVE BERNUTZ, Physician to la Pitie, AND M. ERNEST G^OTDRIL, Late Physician to the Bureau Central. (Ars tota in observationibus, sed perpendendse sunt observationes.) IN TWO VOLUMES. VOL. I. TRANSLATED AND EDITED BY ALFRED MEADOWS, M.D., Lond., PHYSICIAN TO THE HOSPITAL FOR WOMEN, SOHO SQUARE, AND TO THE GENERAI, LTING-IN HOSPITAL, HONORART SECEETART TO THE OBSTETRICAL SOCIETY OF LONDON. THE A^EW SYDENHAM SOCIETY, LONDON. MDCCCLXVI. LONDOrJ: Printed bj J. W. IIoche, 68, Paradise Street, Kotherhithe. AUTHOR'S PREFACE. The title of this work clearly indicates that I have no intention of writing a dogmatic treatise on the diseases of women. Indeed I do not think it is possible in the present state of knowledge to write such a work. In saying this, however, I do not wish to pass any criticism upon the treatises which have appeared in Germany and Trance; my only object is to justify the publication of this work in the particular form which I have adopted. Some, I know, have thought it possible to produce a work, which, in my opinion, ought not to be attempted until a variety of disputed questions of great importance in any dogmatic treatise on gynaecology are satisfactorily settled. Tor this reason I shall abstain from the discussion of several affections of the generative organs which are at present sur- rounded by doubt, either because their existence has not been proved by clear evidence ; as, for instance, the disease called acute paren- chymatous metritis ; or because they are met with only in connexion with other diseases, so that the symptoms of each cannot be sepa- rated. It is my intentio-n only to treat of such aflfections as are undoubted, and whose symptomatology is attested by a goodly number of cases. I take care at once to point out the real scope of this work, in order to avoid any misconception on the part of those who might expect to find in these pages an anatomical classification of diseases. As I have said, I believe this to be impossible of accomplishment in the present state of our knowledge of these subjects. 'V\'hen I began the work I determined that I would be guided simply and entirely by the teachings of experience ; I still think that the best course to pursue, though I did not consider how long a time it would take. I have thought it necessary to study clinically each functional disorder of the genital organs, so as to recognise their various causes, and from observation alone to deduce the sym- ptoms of these several affections. In adopting this course I did not VI AUTHOR S PREFACE. at first consider the endless dif&culties which would arise to hinder me at every step, and after years of labour I have only learned how impossible it is for anyone to describe all the diseases to which women are hable. As far as possible, I have avoided everything that could hinder the accomplishment of my task. I have passed many hours at the bedside in studying my patients, and nights in reading and arranging the materials I had collected. Notwithstanding all this continuous labour, and the valuable assistance of my pupils and friends — especially of him whose name is associated with mine on the titlepage of this work, who, having been my assistant, lived with me at the Hopital Lourcine, and undertook the study of some of the questions which I had not time to accomplish — notwithstanding all this, I say it with regret, that what I have learnt is but a very small part in comparison with what I have yet to learn, or what I know only too superficially to attempt to describe. At the risk of being considered unmethodical, I have in these pages treated the subjects in pretty much the same order which I followed in my investigations. It seemed to me necessary, in a work of this kind, to treat first of those simpler questions, a knowledge of which will facilitate the study of the more complex. The course pursued in my inquiry was first to study the simpler forms of functional disturb- ance, for instance, the difficulties of menstrual excretion ; these form, as it were, a starting-point of a series of morbid phenomena which are generally understood by pathologists. In the case of congenital im- perforation, the symptoms arising from menstrual retention gradually increase in intensity, and they form fit subjects for comparison with analogous cases in which the obstruction is due either to existing or to antecedent disease. By this study and comparison I have been able to trace out the history of the various affections which arise in consequence of this difficulty. The residt of my investigations, which I published first in 1848, will form the Eirst Part of the present work. It contains also some account of the two varieties of pelvi- peritonitis, an affection which presents itself at almost every step in gynaecology, and the knowledge of which precedes that of all other diseases of the genital organs; just as the knowledge of pleurisy in the beginning of this century preceded that of pulmonary affections. Following the subject of dysmeuorrhoea, and before entering upon the consideration of the difficulties of secretion which will be found in the second volume, is the general history of pelvi -peritonitis, com- prising two perfectly distinct orders of facts. In the one, the infiam- author's preface. vii mation of the pelvic serous membrane is the consequence of effusion of blood into the pelvis from the generative organs ; it is indeed subordinate to that effusion, and forms one element only of that complex affection to which I have given the name of hsematocele. In the other, the inflammation results from a kind of reaction upon the peritoneum from some coexisting disease of the genital organs, probably of an inflammatory character, the latter being overlooked very frequently in the severity of the peritonitis. In the female, this form of peritonitis resembles very much that which, in the male, is described under the term orchitis. It is necessary, therefore, that the history of pelvi-peritonitis proper, and hEematocele, should be considered separately, and I shall com- mence with the study of the latter, as it is more closely connected with the subject of menstrual retention than is the former; this we shall see when discussing the question of intra-pelvic haemorrhage. The subject of haematocele is, however, so complex, that I have thought it best to subdivide it into two parts. The one comprising only those haemorrhages which occur in the course of the non- pregnant condition ; the other, those which take place during the puerperal state, more particularly in the course of extra-uterine gestation. The former of these, forming Part II., is, together with Part I., entirely the product of my own pen ; while the latter, which constitutes the Third Part of this volume, has been written solely by my colleague, M. Goupil, my own share in it being quite insigni- ficant. Thus arranged, the present volume is complete in itself. The second volume will contain the history of all the varieties of pelvi-peritonitis (spurious peri-uterine phlegmon), together with that of uterine devia- tions, the latter in the great majority of cases being directly con- nected with ijiflammation of the pelvic serous membrane. I need not stay to point out the importance of this latter affection, for it is associated with so large a proportion of the diseases of the female genital organs, that it is impossible fairly to study the history of any one of them without an intimate acquaintance with it. M. Goupil and I have grouped together all the cases on which this memoir is based ; we have carefully dissected all the preparatio]is described therein, and have discussed together the different points in the history of this affection. But as I alone have Avritten that Part, I only am responsible ; not merely for its form, but for its substance also, and especially for the views put forth regarding the puerperal VIU AUTHOR S PREFACE. state {puerperaliU). It is right I should mention this last point in order .to save my colleague from any criticisms which my opinions may provoke. On the other hand, the Part on uterine deviations belongs exclusively to M. Goupil. I have no share in that, beyond merely seeing the patients. From all this it will be understood, that though we have bestowed great care upon this work, we do not pretend to regard it as free from omissions or other imperfections. We think it likely that it may have but a transitory existence, or be merely the starting-point for other works. We can certainly claim to have accumulated cases, and made many bibliographical references, so that those who come after us may be spared considerable trouble, while at the same time they will be in possession of our opinions. The correctness of the references I can guarantee, for I have referred to the original works wherever that was necessary; and when not, I have noted that the reference was drawn from another anthor : if in any of these latter instances the quotations are incorrect, authors must not blame me for the fault. I will only add that' throughout I have endeavoured to act im- partially both to others and to myself, and to lay aside every other feeling except the desire of being useful to the sick. This, I may say, has been the sole motive of my labour. Amico lectori sahitem. G. BERNUTZ. EDITOR'S PREFACE. The original of the present work occupies two volumes of very closely printed matter, together extending to more than 1300 pages, A large part of it consists of the narrative, at considerable length, of cases, some of them original, others quoted from previous authors. The Council of the Ivew Sydenham Society decided that the work was too large to be translated in full, and Dr. Bernutz, tlie only remaining author, with great courtesy gave his consent to the publi- cation of an abbreviated translation. Of this the present volume is The first and smaller half. Just before the translation was commenced, the profession had to deplore the death of M. Goupil, one of the authors ; a loss to medi- cal science, which those who study the chapters written by him in this work will deeply appreciate. It shoidd be understood then in reference to my capacity as Editor, as well as Translator of the work of MM. Bernutz and Goupil, that my object has been simply to produce an abridged translation. In accordance with the author's wishes and my own judgment, the process of condensation has been principally restricted to the Cases and notes; the text being given as fully as the space at my disposal would admit of. I have not introduced any new matter, either as notes or otherwise. The general arrangement as to Chapters, Sections, etc., I have somewhat altered, with the object of giving it more of an English character, and the weights and measurements I have reduced to our English standards. I may perhaps be allowed to explain the meaning which the authors attach to the terms ' secretion ' and ' excretion,' as they are frequently used in these pages, and scarcely in the way we are accus- tomed to in this country. With us they are sometimes used synonymously ; the urine, for instance, is at one time a secretion, at editor's peeface. another an excretion. Generally we call that an excretion, the separation of Mliich from the blood is essential to the maintenance of life, while those products which are separated for some ulterior pur- pose, as milk, saliva, etc, are called secretions. — Not so, MM. Bernutz and Goupil : in reference to menstruation, the product itself, thej designate bj neither term, the act of separation from the uterine glands and vessels they call the menstrual secretion, and its further escape from the uterine and vaginal canals, they term the menstrual excretion. So that iu both cases it is not the product, but the escape of that product that is called after those terms. I venture to hope that the publication of this work will direct the attention of English Physicians more pointedly to the diagnosis of the affections herein discussed. From my own observation I am satisfied that ha^matocele though not common is certainly by no means so rare an affection or symptom as is generally supposed, nor, in many cases, is the diagnosis a matter of much difficulty. The careful study of the history of those affections which eventuate in hsematocele, as w^ell as of the coincident symptoms, is of more value I believe in diagnosis than even vaginal examination. I am conscious of many defects in the way I have performed my task, for which I must crave the indulgence of my readers. On sub- jects so important as those treated of in these pages, condensation is not always an easy matter. ALFEED MEADOWS. George Street, Hanover Square. €ONTENTS. PAET I. MENSTRUAL RETENTION. CHAPTER I. General Observations Physiology of menstruation , Accidents resulting from menstrual retention Mechanism of hasmorrhagic peritonitis Varieties of menstrual retention . Page 1 1 3 10 11 CHAPTER ir. Causes and varieties of menstrual retention . . .12 Sect. I. — Menstrual retention from congenital or acquired imper- foration of the vulvo-uterine canal, before puberty . .12 a. defective separation of the external genitals . . 13 0. imperforate hymen . . . , .13 y. malformation of the vagina . . . .15 8. imperforate cervix . . . . .23 Sect. II. — Menstrual retention from cicatrices occurring after pu- berty . . . . , .25 Sect. III. — Menstrual retention from congenital contractions or cicatrices of the vagina or cervix . . .34 Sect. IV. — Menstrual retention from enlargement of the uterus . 38 Sect. V. — Menstrual retention from adventitious deposits in the uterus . . . . .46 Xll CONTENTS. 1. Polypoid growths . . . . • 2. Dysmenorrhceal membrane . . • • Sect. VI.— Menstrual retention from deviations of the uterine canal Sect. VJI. — Menstrual retention from spasmodic contraction of the cervix ..•••• Sect. VIII. — Menstrual retention from abnormal conditions of the Fallopian tubes . . . . • Page 46 52 55 56 62 CHAPTER II., continued. Symptomatology . . . . • Symptoms of first stage of menstrual retention Ditto, second stage .... Formation of hsematocele and haemorrhagic peritonitis Characteristics of hsematocele Diagnosis of haematocele and pelvic abscess Successive changes of bloody tumours Dysenteric phenomena .... Prognosis of hsemorrhagic pelvi-peritonitis. Phlegmons of the broad ligament and iliac fossa Characters of. 74 74 75 77 81 84 86 90 96 98 99 CHAPTER III. Diagnosis ..... First stage of menstrual retention Menstrual retention and pregnancy Menstrual retention and tubo-ovarian disease Menstrual retention and abortion Menstrual retention and cancer uteri Menstrual retention and fibrous tumour Haematocele and ovai'ian drop.sy . Haematocele and hydatid cysts . 101 101 104 106 111 112 115 119 126 CHAPTER IV. Treatment ..... The primary object is to remove the obstruction Best time for operating Objections to puncturing ^er rec^MWj Debrou's operation Amussat's operation Mischievous effects of caustics to the cervix 130 131 131 133 133 134 140 CONTENTS. Xlll Utility of emmenagogues Incision of the cervix, versus dilatation Treatment of neuralgic dysmenorrhoea Utility of leeches Objections to depletion . And to expectant treatment Puncture of the haematic cyst Page . 142 . 142 . 145 . 147 . 150 . 151 . 155 PART II. PERI-UTERINE HEMATOCELE. General Observations . . . , . 158 Definition of the term " haematocele" and " thrombosis" . 158 Not a disease, but a symptom .... 160 Analogy of male and female genital organs . . 161 Varieties of hsematocele .... 165 I. Haematocele symptomatic of rupture of utero-tubar varic3s . 166 Symptoms of utero-ovarian varix . . . 175 Treatment . . . . . .177 11. Haematocele symptomatic of bloody exhalation from the pelvic peritoneum. . . . . .178 III. Haematocele symptomatic of rupture of the ovary or Fallopian tube . . . . . .180 Diagnosis of ovarian lesion .... 188 Extra-uterine ovulation theory of Gallard . . . 191 Diagnosis of ovarian and tubar lesion . . . 195 Treatment ...... 201 I V. Haematocele symptomatic of difficult menstrual excretion . 203 Diagnosis ...... 206 V. Haematocele symptomatic of excessive secretion from the geni- tal organs ; metrorrhagic haematoc ele . . . 207 Varieties of . . . . . . 208 1. Pyrexial ..... 208 2. Puerperal ..... 215 3. Inflammatory ..... 216 4. Cachectic ..... 219 Symptoms of cachectic variety .... 228 Diagnosis ...... 2.30 Treatment ...... 232 XIV CONTENTS. PAliT III. INTRA-PELVIC HiEMORRHAGE OCCURRING IN EXTRA- UTERINE PREGNANCIES. CHAPTER I. Page General Observations. ..... 234 Causes and varieties ...... 235 I. Intra-pelvic haemorrhages from ruptured utero-ovarian veins. 236 II. Intra-pelvic haemorrhage from rupture of the ovary . . 237 III. Intra-pelvic haemorrhage from rupture of the Fallopian tube . 242 IV. Intra-pelvic haemorrhage from rupture of the foetal cyst . 246 V. Intra-pelvic haemorrhage into the interior of the cyst . 25.5 CHAPTER II. Diagnosis ....... 265 Signs of extra-uterine pregnancy. . . . 268 CHAPTER III. Prognosis . . . . . . .272 CHAPTER IV. Treatment . . ... , . . 274 PART I. MENSTEUAL EETENTION. CHAPTER I. GENERAL OBSEUVATIONS. The various anomalies of menstruation have reference either to the act of secretion or to its excretion, and these constitute two series of pathological facts which, notwithstanding the many symptoms they possess in common, should be carefully distinguished from one another, in order that the different affections to which women are subject in amenorrhoea, may be correctly appreciated. I propose, therefore, to consider, first, the various causes which may impede the menstrual flow ; and, secondly, the accidents resulting from this defective excretion. To understand the pathology of dysmenorrhoea, a few words are necessary on the physiology of menstruation. An active congestion of all the generative organs is the first phenomenon of menstruation ; then, the free extremity of the Fallopian tube embraces the ovary, and is sometimes even united to it by a thin transparent membrane, as is seen in the cases mentioned below.^ Soon the cavity of the tubes is dilated by a bloody mucus which mixes in the uterus with the blood exhaled from its cavity, now hned by an imperfect decidua, and then escapes by the open cervix. * J. E. Panck. Eiitdcchunfi (lev orpntiischen Vcnlihinifi zxu'.scJirn Tnha und Eirslock heim mciischlkheii Wv'ihvhalch nach der Conception. Dorpat, Leipzig, 1843. {Extrait des Archives generules de medecine, 4° serie, t. iv. p. 81.):- J. K., aged 2.3, died from the inhalation of carbonic acid gas. On opening the a})domcn, tlie genital organs were seen to be much congested. The right Fallopian tube was thrust forward and attached to the ovary, not merely by mechanical union, but hy an organic connection in the shape of h 2 MENSTRUAL RETENTION. The object of these occurrences is, on the one hand, to secure the independence of the abdominal cavity from the generative tract during menstruation ; and, on the other, to estabhsh a freer communication along that tract than exists at other times. They prevent the flow of the menstrual fluid into the peritoneal cavity, and facilitate the passage of the ovule with the fluid, which serves as a vehicle for it. It is evident then that menstruation requires for its normal per- formance the concurrence of several phenomena, and should any fail, more or less severe accidents result, the true cause of which must be known in order to arrive at a correct hue of treatmeiit. Practition-' ers in the i)resent day direct their attention exclusively to the congested state of the organs. They recognise in this, if not the first step of inflammation, at least, a condition so allied to it that, in their opinion, a very slight cause develops it. I by no means dispute the frequency of inflammation of the uterus or its appendages, and the reaction of these affections on the pelvic peritoneum when the con- gestion deviates from its normal type. Nor do I deny the occurrence of phlegmons of the broad ligament ; ^ but I believe that in many cases morbid congestion or inflammation is secondary to defective excretion, and ought to be attributed to the action of the retained fluid, and the reaction of the organs which expel it. It appears to me that in these cases the earliest indications of mischief are caused by the retention of the fluid, which, though imperfectly secreted and not outwardly visible, is nevertheless there. The symptoms ought there- fore, in my opinion, to be referred to menstrual retention, and not to any defect in the secretion. The proof of this is seen if we compare the symptoms which a thin transparent membrane ; the left tube was not in contact with the ovary at all. Case of M. A. Puech. De l' hematocele per i-iiterine et de ses sources. Obs. 18., p. 71. iMontpellier, 1858. S. P., aged .38, died suddenly of meningeal hajmorrhage. The right Fallopian tube was found adherent to the corresponding ovary. The left was also adherent to the left ovary, by a tubular membranous union five lines long. This tubular canal served as a conduit from the one to the other, and was filled with blood. The space on the surface of the ovary, which it enclosed, presented no rupture, either of long standing or otherwise, but two Graafian vesicles, one of which was on the point of rupturing. Both ovaries, but especially the right, presented abundant evidence of past ovulation. The uterus presented the characters of a multipara. * Gendriu, These inauffurale de Satis. Paris, 1847. GENEKAL OBSERVATIONS. 3 actually occur with those which theoretically should result from an obstruction of the cervix uteri. If the discharge does not appear while the act of secretion continues, even imperfectly, it soon occasions more or less repletion of the secreting cavities, characterised by a sense of fulness, of weight and distension, and some phenomena of uterine reaction. These dysmenorrhoeic phenomena are analogous to the symptoms of congestion, generally supposed to be the cause of these accidents ; but in the case of retention all these symptoms disappear as soon as the flow is re-established. But if, on the contrary, the flow is not established, the secretion increases, and with it the distension of the uterus and Fallopian tubes. The uterus, however, by the thickness and contractility of its Avails, offers some resistance, and forces the incompressible liquid into the unresisting tubes. This gives rise to symptoms resembling very closely those resulting from phlegmons of the broad ligament, with which it has often been confounded.^ This mistake is the more likely to occur, because the mere fact of distension sometimes gives rise to inflammation, and the attention is concentrated upon this secondary atfection. Other changes not infrequently result from the inflammation, which require a longer time for their disappearance; and, meanwhile, the continuance of the flow relieves the symptoms caused by the distension. If, however, the affection is carried a stage farthei-, or if the union between the tube and the ovary is feeble, we can understand how the catamenial fluid is extravasated into the abdominal cavity, and sets up inflammation of the peritoneum, which may remain partial, as most frequently happens, or it may invade the entire serous mem- brane. Under these circumstances, there is superadded to the menstrual retention an element, the severity of whose symptoms so mask the original disease, that the case is either regarded as one of simple peritonitis when general,t or, if partial, as a circumscribed effusion of blood, which, since the publication of my memoir in 1848, has received the name of hamiatocele.X We can understand that so long as this new element remains in the acute stage it will prevent the excretion of the menstrual • Gendrin, Thi-se de M. Verjus. Paris, 1844. t Chomel, Dictionnaire de medecine, en 30 vol., t. xxiii. ]). 578. \ N6laton, 1851. Lccotis oralrs sitr Vln'matocelc, faites a Vhupitul des Cliniques et recueillies par 3IM. Buiiclitt ct (lailht. [Gazittc iles ItdpHitiix, 11, 13, et 16 decembre, 1851 ; 20 Janvier et 10 fcvrier, 1852.) h 2 4 MENSTKUAL RETENTION. fluid, which can only talce place after the subsidence of the peritonitis; when menstruation occurs it exercises a heneficial in- fluence on the peritoneal lesions by relieving the distension of the generative organs. But the return of the excretion cannot always disperse the last traces of peritonitis, which will sometimes remain and expose the patient to a repetition of dysmenorrhoeic accidents similar to those \\h\d\ occasioned the peritonitis. Cases of this kind, then, present three characteristic degrees ; first, repletion of the secreting cavities ; second, distension and reaction of the uterus and tubes ; and third, rupture of the union between the tube and the ovary, and the passage into the abdomen of a part of the blood which distended the generative organs. But should rupture not take place, or if it occasions only a partial peritonitis, the orgasm will in a short time diminish, and a new series of phenomena result, consequent upon the changes occurring in the fluids and their containing cavities, natural or arti- ficial. Hence, concretions of blood,"^ dropsies of the uterus and tubes, or tubo-ovarian cysts f may be the direct results of retention ; while metritis, phlegmons of the broad ligaments and iliac fossse, may occur indirectly. Perhaps I have already dwelt at too great length upon the reasons which seem to establish a pathological relationship between narrowing of the uterus and those accidents which have hitherto been thought to arise from congenital or acquired occlusion of the uterus or vagina. But I have thought it right to do so because the symptoms resulting from occlusion are so very similar to those of dysmcnorrhoca, that it is surprising that observers have sought rather to dissociate these two affections than otherwise. J My discovery of the etiology of this affbction was quite accidental. I chanced to see stretching across the floor of the pelvis a clot of blood, and this led me to the opinion that there were other forms of amenorrhoea from retention than those previously recognised. The following case was, as it were, the point-de-depart of this work : — Case I. — First symptoms with the non-appearance of menstruation ; increased in severity in the absence of any discharge during the * Boivin et Duges, Maladies de Vutenis, t. ii. p. 409. \ Idem, ibid., t. i. p. 260. I Desormeaux et P. Dubois, '' Amenorrhee." Diet, de med., 2nd edit. t. viii. p. ofil. GENERAL OBSERVATIONS. 5 four folloioing montlis ; fatal 2>eritoniiis. — Recent and old-standing alterations of the peritoneum ; tumour formed by hypertrophy of the uterus, by dilatation of the tubes and their adhesion to the ovaries, by the intestine and sigmoid flexure all united together. — Liquid blood in the uterus and right Fallopian tube; large dot in the jjelvic cavity. r. B., aged 40, was admitted into the Hospital S. Antoine, August 13thj 1844. She began to menstruate at 18, and had cou- tinued regular every three weeks for about three days each time. Had beeu pregnant seven times, but aborted five times at about the sixth month. The two last were born at full term ; and since then she had had goad health. Her present illness she attributes to carrying heavy weights in the spring. IMenstruation did not appear in June, and she suffered much in consequence in the lumbar and pelvic regions. Early in July expulsive pains were felt across the lower part of the abdo- men accompanied by nausea, with vomiting and fever ; leeches were ap- plied to the anus and blisters to the iliac foissaj ; this gave some relief, but the expulsive pains remaining, baths were used up to the 20th of July. While in a bath that day, after some severe pain, she expelled a membranous clot, which was followed by smart hseuiorrhage ; ever since then a sanguineous discharge with expulsive pains had existed. There had been more or Iqss fever, and in the last few days the pains which had diminished have increased. On admission she was pale, anxious, and emaciated ; no sickness ; urine normal. Abdomen distended towards the lower part, especially in the iliac fossae ; very tender on pressure. Uterine and lumbar pains intermitting. Occupying the whole of the lower part of the belly was a trilobular non-fluctuating tumour, extremely tender to the touch. Pressure upon it caused a renewal and increase of the pain, starting from the lumbar region and extendhig into the uterus ; it resembled both in severity and intermittence the pains of the first stage of labour. The left portion of the tumour extended about two inches aljove the Fallopian ligament, the right one inch above the corre- sponding ligament. Uterus large and heavy, situate low down and near the pubis ; could be lifted slightly upwards but not from side to side ; the cervix was the size and form of a hen's-egg ; the os swollen and patuhms; the discharge constant. Vaginal examinations very painful; pidse72; skin natural; ordered vegetable diet, potdticcs to the abdomen, aiid baths. 21*/. — Discharge increased. Tlie pains are still very severe; the 6 MENSTRUAL RETENTION. tumour was thought to have diminished somewhat, and to be indis- tinctly fluctuating on the left side only. The cervix was lower in the vagina, closer to the pubis, and slightly arching with the con- cavity upwards. Three liquid evacuations. Micturition frequent, but not painful. 2Qf/i. — The uterine pains have been relieved by the discharge of yesterday. Tumour diminished in size and less tender; fluctuation distinct at the sides, not in the middle ; cervix uteri sufficiently open to admit the flnger, marked anteflexion ; slight diarrhoea. Treatment continued as before, pulse 72, no fever. 27^5/^-. — Pain greatly increased after the examination yesterday ; con- dition otherwise the same. After the visit she was seized while in the bath with violent pains ; no rigors. In the evening the paius increased and her general condition was much worse ; forty leeches were applied to the abdomen followed by fomentations : this gave slight relief, but in the morning she was much worse ; face pinched and anxious, eyes sunk, great thirst, tongue red, vomiting incessant, abdomen considerably distended ; pain slightly diminished, but increased with the least pressure, defsecation painless ; tumours much the same; pulse small, jerking 110; skin hot and dry; ordered, castor oil, lemon drink, fifty leeches and poultices to the abdomen. 2dt/i. — Much worse, pain and tenderness increased ; abdomen more distended, pulse imperceptibly quick ; ordered a large blister to the abdomen. The vomiting is almost constant, nothing can be retained on the stomach. No diarrhoea. SOt/i. — Expression cadaveric, abdomen extremely tympanitic; vomiting ; blister re-applied. She died at mid-day. Posi-mortem examiyiation, forty-six hours after death. — General peritonitis of recent origin; slight serous effusion. On examining the pelvis two tumours wdiich seemed to be ovarian were seen; the uterus was partially twisted round with its left border at the symphysis pubis, its right corresponding to the right sacro-iliac joint ; the posterior surface of the uterus was close to the left ovarian tumour; the uterine walls were thickened to three times their original size. The tumours, to which we had improperly given the name of ovarian, were of different size — the right was the size yn a hen's-egg, reddish-brown in colour, and irregularly villous. On o[)ening this cyst, its cavity was found to communicate with that of the uterus through the Fallopian tube, the orifice of which in the uterine wall only admitted a small stilette, but immediately GENERAL OBSERVATIONS. 7 enlarged into a pouch, part of which was formed by tlie anterior sui'face of the ovary, to the circumference of which the iindoriated extremity, slightly folded on itself, adhered ; the union was so firm that traction caused a laceration of the cyst. It contained a liquid resembling a mixture of blood, pus, and brown clots of a jelly-like consistence, while the intra-uterine portion of the tube contained blood. The other tumour was the size of a turkey's-egg, the surface covered with false membrane ; the cavity contained clots, some recent, others firm and fibrinous lloating in a brown liquid A fine stilette, introduced through the uterine orifice of the left Eallopian tube, entered the cavity of the cyst. 'J'he calibre of the tube presented a considerable dilatation at its outer part, where it formed a portion of the cyst ; tlie latter was formed by a part of the broad ligament, the ovary, the false membranes which united them together, and by the parietal peritoneum ; 'the inner wall of tlie cyst presented a fungous appearance. Careful examination failed to dis- cover any communication between the pouch and the abdominal cavity ; deeper in the pelvis on the left side was a conical clot of blood, three inches long, one inch wide, firm, especially at its lowest part, where it presented a pale-rose colour : this clot almost entirely filled the left side of the pelvis ; a little fiuid surrounded it ; the right side of the pelvis contained fluid only. The walls of the cavity presented villous excrescences, soft and friable, growing from a substance, wliicli by its colour, consistence, and texture, resembled cartilage, and in which it was impossible to discover any peritoneum. In no part of the pouch could any open vessel be discovered, still less could any vessel be detected in the cartilaginous structure. All the thoracic oi'gans were quite healthy. The urinary organs were also quite healthy. Ill order correctly to appreciate the importance of this case, which I have detailed at some length, we must compare the anatomical changes found after death with the symptoms observed during life, and classify them under their several heads. Eirst, as regards the anatomical changes in the peritoneum ; these were both recent and of old standi ing; the former occurred probably on the 27th of August when the severer peritoneal symptoms set in; tlic latter most likely related to symptoms which occurred two months before death. As regards their cause, nve may I think attribute the two attacks of peritonitis to the very complex nature of the disease, in which not only was the uterus considerably enlarged, but two encysted tiunours existed, one 8 MENSTRUAL RETENTION. on each side, that on the right being caused by adhesion of the ovary to the dilated tube; that on the left to the interposition of false membranes between the borders of the enlarged fimbriated extremity of the tube and the neighbouring parts; the general character of the changes in the generative organs prove that they were not of very recent date. The hypogastric tumour, the fixity of the uterus, its increased size and weight, and the prolapsed cervix; the functional disturbance, the sense of weight in the pelvis, the uterine spasms, the stoppage of the menstrual excretion followed by the expulsion of a clot, and subsequent sanguineous discharge ; all these sufficiently demonstrate the seat of the affection, though they leave its nature still a matter of uncertainty. The real character of the disease is, however, rendered more apparent by the nature of the post-mortem appearances, for the indu- ration of the hypertrophied uterus, the false membranes which formed the ovarian tumours, the villous condition of the inner surface of those tumours, and the puro-sanguineous serum which they contained could only be regarded as evidence of acute inflammatory action of long standing. It did not, however, appear to be of primary origin ; on thecontrary, itwouldseemto haveresultedfromthepresenceof a foreign body against which the uterus exhausted itself by fruitless efforts at expulsion. The sense of weight in the pelvis, the intermitting pains resembling those of labour, which came on three years after an arti- ficial delivery, without any assignable cause, in the place of ordinary menstruation, have nothing which incontestably connects them with uterine inflammation. The earlier symptoms are, on the contrary, satisfactorily explained by the menstrual retention, produced in the same way as retention of urine from enlargement of the prostate. The increased volume and weight of the organ was due to the reten- tion of blood in the uterine cavity, consequent on the swollen con- dition of the cervix, and the expulsive efforts were attempts to ter- minate this state of things. But these symptoms also bear another and more evident interpretation. Tor instance, they maintained the same character to the end of the month, when the second period should have occurred; then they assumed greater intensity and the first attack of peritonitis, accompanied by swelling of the iliac fossae, supervened. As soon as this subsided, the hypogastric weight, and the uterine pains, which had ceased for a time, reappeared" during the second month, more marked even than in the preceding, and lasted till July 20th. Then she experienced a great accession of pain, which GENEKAL OBSERVATIONS. 9 ended in the expnlsiou of a clot of blood, and was followed by some sliglit improvement. StiU the pelvic weight and the uterine colic remained, while the hfemorrhage gave place to a slight dis- charge of blood which continued till the fourth menstrual period. At that time the patiejit became worse, but not till seven or eight days after did the more severe symptoms set in_, which ended in fatal peritonitis. Thus the symptoms wliich might lead us to suspect metritis, though they may equally occur in cases of uterine enlargement, here assume a very decided character, increasing at each catamenial period by the non-excretion of the menstrual fluid. Nor did they show any abatement till some discharge had taken place. This improve- ment, however, was but slight and transient; for after the fourth period the mischief showed itself in a more aggravated form. Concurrently with these symptoms due to periodical enlargement of the uterus, there are others which suggest an abortion rather than metritis: for instance, violent and intermittent uterine action, toijeiher with sanguineous discharge. In short, it seemed like an abortion with this peculiarity, that it persisted for three months, the body to be expelled increasing in size each month. Moreover, the expulsive effort was fruitless so long as the cervix refused the passage of the fibrinous clot, and it cannot be doubted that the induration of the hypertrophied cervix offered too great an obstacle to the expul- sive power of the uterus. The idea of a miscamage is, however, negatived not only by the lengtli of time and irregularity of the return of the expulsive effort, but by the fact that no product of conception was discoverable after death. The only foreign element found either in the uterus, the tubes, or the peritoneum, was blood. In the right ovarian tumour there wereabouttwo spoonfuls of blood, with some recent clots ; in the left, which was formed chiefly of false mem- branes, there was three times the quantity of blood, with some almost colourless clots. In the uterus the quantity was very small and red. It is important to note these diflPerences in the character of the blood, as they indicate corresponding dilferences in the age of the several deposits, according to the menstrual periods the excretion of which was prevented. But had the blood which was formed in the abdominal cavity the same origin ? The difl'erent characters which this presented warrant a similar explanation to that given above. Thus the fluid blood and puridcnl serum contained in the abdominal and pelvic cavities with 10 MENSTRUAL RETENTION. the upper layer of the pelvic clot, would appear to be the result of a receut htemorrhagej while the lower and almost dry portion of the same clot would be the result of a previous loss. These characters correspond very closely, the one with the product found in the right ovarian tumour, the other with that of the left, and thus a con- nection is estabhshed between these intra-genital and intra-abdominal blood-clots on the one hand, and between these and the two peri- toneal attacks on the other. In short, the coincidence of the peri- tonitis with the menstrual epochs and the effusions of blood, justify the belief that the latter were in reality the cause of the former. At any rate there was no hsemorrhagic diathesis, nor any rupture of blood-vessel to explain it. Nor could it have resulted from any menstrual metastasis, for the existence of collections of blood in the generative organs negative such an idea. The situation of the effusion and the disposition of the tumour on which it was, so to say, implanted, show whence it came. In all probability, at the time when the inflammation was de- veloped, the left tube and ovary had ceased to be united, and this disunion afterwards repaired, by the organization of false membranes, allowed the passage into tlie abdomen of a part of the menstrual secretion. This formed the first pelvic effusion, and thus occasioned the first attack of peritonitis. In like manner, I believe that the later haemorrhage was due to a laceration of the left ovarian cyst, not only because of the diminution in size which the tumour underwent some hours before the development of the last peritonitis, but also on account of the situation of the pelvic clot. Prom a review of all these phenomena, I think we are entitled to conclude, that in this patient the cervix, though not obliterated, was enormously increased in volume, either by chronic inflammation, or by simple hypertrophy, the result of an artificial delivery ; that this increased volume presented an obstacle to the escape of the menstrual secretion similar to that which occurs in prostatic enlargement. The retention of four successive menstrual products brought about the following results : — At the first period, repletion of the genital organs which reacted upon the foreign body. At the second, distension of the cavities, the formation of hypo- gastric tumours, and, at last, the passage of blood into the abdomen, which occasioned the first attack of peritonitis. GENERAL OBSERVATIONS. 11 At the third, a futile attempt of the generative organs, Avhich showed itself by a long-continued discharge of blood. At the fourth, fresli distension of the cavities leading to re- gurgitation of blood into the abdomen, and consequent peritonitis, ending rapidly in death. Lastly, this retention gave rise to the formation of three blood- cysts, the contents of which varied according to the duration of the deposit : but they all resembled very much, both in structure and situation, those cysts which have been arbitrarily called encysted dropsy of the ovaries, though, in reality, the ovary has very little to do with it. Having given some little consideration to the several elements in, this case, I am satisfied that the diseases under which this patient suf- fered were all attributable to the retention in the generative organs of the menstrual products which they were unable to expel. I have also been led to group together the several affections w^hich heretofore have been regarded as idiopathic, and have been ranged under distinct classes, without regard to the circumstances under which they occur, such as uterine congestions ; ^ metritis ; t phlegmons of the broad ligaments; J ovaritis ;§ peritonitis ; 1| fleshy moles ; ^ and dropsies ^"^■^ whether of the uterus, the tubes, or the ovary. I have endeavoured to establish that all these are but different phases of one pathological order, all resulting from disturbance in the ordinary process of menstrual excretion. Reflecting upon this case and the mode of production of the more prominent symptoms, I have been led to a classification of the different varieties of this affection from a study of its natural history. The excretion may, for instance, be prevented by the impermeability of the vulvar or vaginal orifice, by abnormal conditions of the cervix or body of the uterus, or of the tubes ; and thus, as Galen pointed out, an analogy is apparent between menstrual and urinary retention. * Duparcqiio, Traite des mahtdies de Pidenis, t. 1, p. 6. t V'crjus, Tlti'.^e iiiuur/arale. Paris, 1814, p. 37. X Satia, These inawjurale. Paris, 1846; p. 83-89. § Chereau, Memoirc 2*otir scrvir a Vltistoire des maladies des ovaires, passim. II Chomcl, Diet, de med., 2* edit. Peritonite, t. x\iii. p. 500. H Boivin et Dug^s, Maladies de Puterxs, t. ii. p. 409, •• Ibid, t. i. p. 2G0. 12 CHAPTER II. THE CAUSES AND VARIETIES OV MENSTIIUAL RETENTION. In consideration of the various conditions which prevent the free escape of the menstrual fluids we may divide these cases into eight different classes. In the^r*^, the excretion is prevented by a congenital or acquired imjjerforatiou of the vulvo-uterine canal before the age of puberty. In the second, by cicatrices rendering the passage impermeable after the age of puberty. In the t/iirdj by congenital contractions or cicatrices of the vagina or cervix. In theyo? of the most important part of it, that is to say, the cervix. Lastly, in the eighth, which is less known than any of the other varieties, the disturbance is due to an abnormal condition, congenital or acquired, of the Fallopian tubes. Section I. — menstrual retention from congenital or acquired IMPERFORATION OF THE VULVO-UTERINE CANAL, BEFORE PUBERTY. This variety, M'hich was investigated some time since,^ presents several modifications as regards situation and extent. Instead of * Benevoli, observations, notamment la deuxienie : Delpech, 31emorial des hojntatcx dn Midi, t. ii., annee 1830, p. 479; colouue I"'. CAUSES AND VARIETIES. 13 describing minutely eacli of these, I shall select those only which possess the greatest interest for our subject, referring by notes to those of less moment. There are four modifications of this first variety having reference to the seat of obliteration. Thus : — a In the first, it is due to a defect of the separation of the exlej-nal genitals. )3 In the second, to an imperforate hymen. 7 In the third, to absence or obliteration of the vagina. ^ Lastly, to imperforate cervix uteri. a The first and the simplest, of these obliterations which may be found described by Ruysch and Delpech,"^ is caused by congenital defect in the separation, or subsequent agglutination before puberty, of the external genitals. /3 The second and most frequent of all is caused by imperforate hymen. There are so many cases of this kind that I shall not even give references to them, but content myself merely with mention- ing three ; one of which I must refer to in a note,t notwith- standing the interest which attached to it from the peculiar position of the obstructing hymen, in order to direct more particular attention to the two others, which present a very close analogy wath the case first described, page 4- * Ruysch (1691). Ohservationmn Anatomico-chirurgicarum centuria, Ohs. 32e, p. 42. Obs. de Delpccb, ^lemorial des hopitaux du Midi, 1S30, p. 479: — J., after having absconded from home at the age of 14, was found in a liouse of ill-fame, and on examination some ulcerative excre.«cences were seen round the margin of the anus and vulva. Further examination, how- ever, showed that the vagina was occluded by a thick membrane. The abdomen was swollen and tender, and there was some slight fluctuation to be felt behind the vaginal membrane. This, coupled with her previous history, led to the diagnosis of menstrual retention. Accordingly my friend Dr. Morrel agreeing with me, I made an incision perpendicularly for about an inch and a-half, from the meatus urinarius to the perineum. On passing the finger up the vagina, the uterus was found a good deal .idarged, and the os closed by a second membrane. This was divided, and a quantity of brown sero-sanguinolent fluid escaped, it was inodorous and measured about six or eight ounces. Warm water injections were used, and tents to the vulvar incisions. Hip-baths, and lead lotions were afterwards employed, and a mercurial course of treatment adopted for a time, till chalybeates could be given to facilitate normal menstruation. The patient ultimately made a good recovery. t Obs. de de Ilaen. Jia/io rnedcndi, p. vi., t. iii. p. .38. Didot, 1704. 14 MENSTRUAL RETENTION. Case TI."^ — Complete congenital imperforaiion of the hjmen; menstmal retention from the thirteenth to the twenty-second year ; dilatation of the vagina, uterus and Fallojrian tubes ; iticision of the hymen ; peritonitis on the fifth day ; death on the ninth day. — Intra- peritoneal effusion of blood from the dilated Fallopian tubes. A young lady, aged 22, had never menstruated, but had suffered since she was 13 years old from symptoms of menstrual retention, which were aggravated every month. The abdomen was distended and tender. On examination, the hymen was found to be imperforate, and fluctuation was detected behind it. The membrane was crucially incised, and a black fluid escaped. For three days all went on well ; but on the fifth day peritonitis came on, and she died on the ninth day. On making a j^ost-mortem examination, there was found general peritonitis ; great distension of the uterus and vagina ; the Fallopian tubes were tortuous at the uterine end and distended with black blood, and at the ovarian end shght pressure forced it out of the tube. Some of this fluid was seen in the pelvic cavity, and in that situation the peritonitis was most evident. Case Ill.t — Congenital imperf oration of the hymen ; menstrual reten- tion from the thirteenth to the seventeenth year ; dilatation of the vagina, uterus and Fallopian tubes ; incision of the hymen ; fatal peritonitis on the fifth day. — Intra-peritoneal effusion of blood from a tubo-ovarian cyst. M. W., aged 18, had never menstruated ; had sufifered from symptoms of retention for more than a year. The abdomen was large, tender, and fluctuating ; the vagina was occluded by a mem- brane; fluctuation was felt behind it. On October 14th, 1852, the membrane was punctured, and three or four pints of thick black fluid escaped; peritonitis supervened on the 17th, and she died in four hours. On making a post-mortem examination, there was found to be general peritonitis ; a pint and a-half of black fluid was discovered in the pelvis, of the same kind as was evacuated during life per vaginam. The uterus was enlarged to three times its natural size, as were also the * Marcband et Masse, Journal de medecine de la Loire- Infcrieure, t. xxvi., 131*^ et 132'' livraison. Extrait Archiv, 4*^ serie, t. xxvi. p. 353. t Th. Paget, Leicester. Brit. Med. Jour., July 23, 1859. Case L CAUSES AND VARIETIES. 15 Fallopian tubes aud ovaries ; the latter had formed tumours, each of which had rujitured and the fluid escaped. I need not analyze these two cases to show the complete analogy which exists between them and Case I. It is sufficient to compare them all to be convinced of the great similarity which will be found in a large number of cases of menstrual retention resulting from congenital or acquired imperforation, and especially among those of )ny third variety of this class. ' y The vaginal malformations which constitute this third variety offer sufficiently marked differences to be divided into three sub- divisionSj comprising — 1, cases of absence of the vagina ; 2, con- genital obliterations of this canal ; and o, cases of double vagina, one side of which is imperforate. The first of these varieties is by far the least frequeiit. It comprises cases in which there is such a complete absence of the vagina that the bladder and rectum form one pouch. One such I saw in 1856, and in that I followed the practice recommended by Amussat in the case recorded below.'^ * Obs. d' Amussat, Seance de I'lnstitut, 2 Dec. 1835 (Gaz. med., 1835, p. 785 et 817).— A young girf, aged 15, came under notice in February, 1832, suffering from menstrual retention. At 13, she first experienced some colicky pains, whicb were thought at first to be due to intestinal obstruction ; but as they recurred in a month and the abdomen began to swell. Dr. Langenbeck was consulted, when he discovered that there was imperforation of the vulva and absence of the vagina. The symptoms recurring every month, she came to Paris. It was then found that the abdomen was distended to the extent of a six months' gestation by a tumour, hard, tender, and situate in the mesial line. The external genitalia were well formed, but there was no vaginal orifice ; the position of the vagina being covered with mucous membrane, in the centre of which was the meatus urinarius. Examining ^;e?- rectum, a tumour could be felt filling up the pelvis, it was tender and fluctuating. It was clear, therefore, that there was a menstrual accumulation in the uterus which had been collecting about two and a-half years behind a congenitally deficient vagina. The bladder and rectum were quite healthy. In a consultation that was held, I proposed to attempt to reach tlie uterus by separating the bladder from the rectum with the finger, and not to use the knife. M. Magcndie recommended puncturing the uterus per rectum, to which also M. Marjolin agreed. M. Boyer advised that nothing should bo done, as such operations always ended fatally. On rebruary 29th, I commenced the operation by forcibly separating the bladder from the rectum as proposed. Having partly succeeded, I introduced a sponge tent. Three days after I repeated the process, push- ing the finger firmly onwards in the cul-de-sac, while the bladder and rectum 16 MENSTRUAL RETENTION. In the following case of de Haen, instead of attempting to sepa- were drawn apart by an assistant. This proceeding, thoug"h very painful^ •was also very efficacious. On the 4th March the operation was repeated, the sponge tent in the intervals being kept in the opening. On the follow- ing day I reached the timiour, it was bulky, fluctuating, and filled up the cavity of the pelvis. The artificial canal now measured two and a-half inches. Two days afterwards it only measured two inches, but I could not tell whether or no this was owing to enlargement and depression of the tumour, or to contraction of the artificial vagina. On the 8th, the patient was restless, and in pain. On the 9th, the operation was com- pleted, the tumour was then pressing down to within two inches of the vulva. A trocar was introduced, and a few di-ops of black blood escaped. I then used a bistouri ; the tissues were extremely hard ; some thick, black, gluey sort of fluid flowed out. I endeavoured to introduce the finger, but failed, and again had to resort to the knife to enlarge the opening. Now I could introduce the finger into the cavity, which seemed like that of a uterus at full term ; the pain xvas extreme. About ten or twelve ounces of fluid came away. Into the opening a large gum elastic canula was introduced and there fixed. On the 10th she had passed a good night, had voided urine several times, was not in much pain, no fever, and the dis- charge continued. Next day there was a good deal of irritative fever, but she was otherwise fairly well ; the tumour was well washed out with tepid water. On the 12th she was very weak and feverish, and complained of much pain in the left iliac fossa, for which ten leeches were ordered and some mercurial inunction, which greatly relieved her. On the 13th, the leeches, fifteen, were repeated over a hard swelling which could be felt in the left iliac fossa. She was better next day, but the uterus felt hard per rectum. On the 16th, salivation being accomplished, the mercurial inunction was stopped. On the 18th, while the bowels were acting, a large quantity of bloody fluid, exactly like that which came from the uterus after the tapping, passed, and this discharge continued for several days. After this she gradually improved, and she left Paris on April 23rd. On the 25th she menstruated for a few hours only. Two days afterwards she was seized with severe pain, and then menstruation came on vigorously, she passed a large quantity of thick blood and clots like liver. All went on well till September, when she again had an attack of pain like that experienced before the operation, and after it a glairy sanguineous dis- charge took place. In November the pain came' on again, and leeches were applied. After this, menstruation came on regularly, and she re- gained her health. She was examined two years after the operation ; the artificial vagina was very small, and though a hard body, supposed to be the uterus, could be felt, no orifice could be discovered. By an unfortunate misunderstand- ing, the sponge tents which had been ordered for the artificial vagina, were introduced into the meatus urinarius with very great pain to the patient, and with the result of dilating that part considerably. Ultimately, how- ever, she got quite well, and menstruated regularly. CAUSES AND VAEIETIES. 17 rate the bladder and rectum witli the finger, the knife was employed, and the bladder opened. The case is, therefore, interesting on this account, and also for anatoQiical connections, in which respect it very closely resembled the first of these cases. Case IV. — Absence of the vagina ; sijmptoms of retention beginning at \Q and increasing gradually ; ojieration at 24 ; the bladder laid open; death on the third day afterwards ; autopsy. — Rupture of the Fallopian tubes; effusion of blood into the abdominal cavity from the distended uterus and Fallopian tubes. Case IV. of de Haen, loc. cit., part VI,, vol. iii., p. 32. A young girl, age 24, had suffered from symptoms of retention of the menses since she first began to menstruate at 16 years of age. On examination there was found to be complete absence of the vagina, and as the symptoms of retention became more and more urgent, it was decided that an operation should be performed, which was accordingly done on the 25th January, 1761, the patient then being in her 24th year. The knife was used for the purpose of cutting a way into the uterus, but the operation was unfortunately unsuccessful, and in the attempt to reach the uterus the bladder was laid open. Death took place three days after. On making a post-mortem examination, the Fallopian tubes were found to be both ruptured, both they and the uterus having undergone extreme dis- tension. A considerable quantity of bloody fluid was found effused into the peritoneal cavity. I will only make one remark in reference to this case, and that is by way of warning against the employment of the knife in these cases, instead of using the finger, as in the case recorded by Amussat; The difference in the relative mortality of these two proceedings has induced me to separate cases of congenital absence of the vagina, requiring the j)rocess of separating the parts by means of the finger, from other cases of fibrous obliteration, congenital or acquired, in early life, for which the knife alone must be resorted to, although it is always under circumstances of extreme danger. These fibrous obliterations sometimes occupy the whole vagina, as in the case of M. Debiou;^ sometimes, on the contrary, they • Obs. dc M. Debrou, Out., jner/., 1851, p. 32. L., aged H), bP2;an to have symptoms of menstruation, but without any discharge, at 17. These C 18 MENSTRUAL RETENTION. only occupy a limited portion of that canal, and more frequently it is the middle than any other part, as was pointed out by M. Debrou in the remarks appended to his case, to which I would refer those who wish particularly to study obliterations of the vagina, not only on account of the interest of his remarks, but also for the bibliographical notices there given. The three following cases, with theiv post-mortem examinations, aW. exhibit the same deformity ; viz., dilatation of the tubes, and the escape through them into the peritoneal cavity of the blood contained in the genital organs. symptoms contiuiiecl for two years, and her general health began to suffer. On examination, a tumour was felt in the right side the size of an egg, and in the centre of the pelvis a larger one, both were tender to the touch. The external genitalia were intact. By the rectum a tumour was felt filling up the pelvis, hard, elastic, and fluctuating. In the place of the vagina was a firm, tense, fibrous structure three or four lines thick. Accordingly, on the 22nd February, 1847, an operation was performed. With one finger in the rectum, a bistouri was passed up along the fibrous septum, which was found to be very liard and dense. At the distance of two inches from the vulva a solid round body was felt, but into it no orifice could anywhere be found. It was accordingly punctured, and a large quantity of semi-coagulated blood came away. The wall of the uterus was very thin, quite unlike that development which takes place during gestation. She suffered a good deal that night, and was worse next day, with sym- ptoms of inflammation and fever; for this she was bled from the arm, which greatly relieved her. She continiied to improve iip to the 20th March, when symptoms of menstruation came on ; they passed off, how- ever, without any appearance. On the 26th April, a band was found stretching across the os uteri, which was accordingly divided; next day a considerable quantity of blood escaped. This proved to be ordinary men- struation. After this, for several months, no menstruation occurred, and in March, 1848, I was again consulted, when I found the uterus much distended, and a tumovir in the right iliac fossa. No opening into the uterus could be felt. On the 29th the uterus was again punctured, and a quantity of fluid blood evacuated. Menstruation came on again in May, and continued every two months. I saw her again in February, 1849, she was then in good health, and had a well-formed vagina; the os was small and circular. A few days after that she married, and im- mediately became pregnant. She was delivered on the 2nd November. After having been in active labour for six hours, the orifice scarcely dila- ting at all, she was seized with violent convulsions ; for this she was bled, and afterwards delivered of a dead child by means of the forceps. For a i'ew days all went on well, but on the Gth metro-peritonitis came on, and .she sank on the lOth. No 2)ost-tn()rtom examination was allowed. CAUSES AND VARIETIES. 19 Case Y."^ — Congenital oUitcrallon of the vagina; ^yundure ; fatal peritonitis ; escape of menstrual jluiil into the peritoneal cavity from the uterus, through the Falloptian tubes. Cases of congenital obliteration of the vagina, says Sir B. Brodic, are more common than is supposed ; I have seen four cases of occlusion of the vagina, which are commonly described as imperforate hymen. Once a patient consulted me at St. George^s Hospital, she was operated upon, but would not remain in the Hospital, and she died of peritonitis at her own house. In another case, treated in the Hospital, a short time after puncture of the vagina, symptoms of acute peritonitis came on and she died. At the post-mortem examination we found in the abdomen a great quantity of menstrual fluid ; it was impossible to explain the presence of the liquid blood in the abdomen, other than by supposing that it had passed from the uterus through the tubes into the peritoneal cavity. The following case, recorded by M. Locatelli,t is more complete and conclusive, and more interesting too, by reason of the similarity of the anatomical changes described in this case with those which existed in Case I. Case YI. — Congenital impeif oration of the vagina ; at 20, symptoms recurring each month ; abdominal enlargement ; hysteria ; at 26, incision of the membrane obstructing the vagina ; evacuation of from six to eight ounces of blach coagulated blood and mucus ; peri- tonitis a few hours after the operation ; death on the second day, — Jjilatation of the uterus and ttibes, especially the left, which was ruptured, and from which putrid blood escaped, similar to that tohich was found in the corresponding iliac fossa. A girl, aged 26, began, when 20, to suffer symptoms of retained menstruation, which have recurred every month since for four or five days. On examination there was found to be com})lete occlusion of the vagina at about its middle. An abdominal tumour the size of a foetal head was felt over the uterus, it was tender on pressure ; fluctuation was felt at the vaginal ol)struction; the membrane was incised and about eight ounces of black coagulated blood mixed • Sir B. Brotlie, T.otul. Meil. Gar,., v. xxvii. ]>. 810. t Locatclli, septcmbre, 1818, ClazzelUi mcdira dl Milnuo, cite dans r Encydonrajthie belye, 9"= scric, t. i. p. 2G8. (IJruxclles, 1848.) c2 20 MENSTRUAL RETENTION. with mucus was evacuated; pressure on the tumour favoured this evacuation. Peritonitis set in and death on the second day. On making -a jMst-mortem examination there was found peritonitis with sero-puru]ent effusion mixed with a little putrid blood in the left iliac fossa ; the uterus was about the size of a fist; the Fallopian tubes were adherent by membrane to the posterior part of the ovaries and were distended with black blood. The left tube was the size of a turkey 's-egg, and had ruptured ; the right about the size of a iiut^ the ovaries showed several cicatrices, and ovules in various stages ; several ovules the size of a millet-seed were found in the left Pallopian tube. In the following case by Mtinck we find the same anatomical lesions occurring in the course of the disease, without any operation having been performed. Case VIL* — Obliteration of the vagina from a cartilaginous cicatrix ; symptoms commencing at Yl ; hypogastric tumour formed 07ie tnonth before death ; ruptiire of the tumour and fatal peritonitis on the fourth day ; uterus enlarged and filled with blood; Fallopian tubes enormously distended ; rnpture of the fimbriated extremity of the right tvhe j ejfusion of menstrual finid into the peritoneum ; cartilaginous obliteration of the vagina. R. S., aged 18, was in articido mortis when seen first by Dr. Munck, February 24th, 1847. For eighteen months she had suffered symptoms indicating the accession of menstruation, but without any results : these symptoms recurred periodically with increasing severity. After nine months a tumour appeared in the abdomen, it was very tender on pressure. On February 20th, she felt something give way, and the abdominal tumour disappeared. Severe pain followed, attended by a good deal of febrile disturbance ; a blister was applied and a saline aperient administered ; but she died in three days. Post-mortem examination. — On opening the abdomen, twelve or fourteen ounces of thick redflish fluid was seen ; the peritoneum was highly congested, and traces of lymph were evident. The uterus was large but soft, and contained four or five ounces of fluid like that in the abdomen. The Fallopian tubes were enormously distended, the Munck. London Medical Gazette, vol. xxvii. p. 867. CAUSES AND VARIETIES. 21 free extremity of the right being closed, and a rupture of about three lines in extent was seen, forming a free communication between th& uterus and the cavity of the peritoneum through which the fluid had escaped. The vagina was closed by a firm cartilaginous membrane. The following case of double uterus and vagina, published by M. Deces,"'^ illustrates a very rare example of imperforation of the left half of the uterus and of the corresponding vaginal pouch, which gave rise to all the accidents of menstrual retention; \ki^ post-mortem examination showing these lesions on one side only. Case VIII. — Symptoms beginning at 15, when menstruation began with great difficulty ; lumbar and hypogastric pains each succeeding month ; tumour in the left iliac fossa, which increased steadily for eight months prior to admission; retro-lateral uterine tumour; exploratory puncture ; fatal peritonitis. — Effusion of altered blood into the abdomen, from the rupture of a multilocular cyst, formed by the enormously dilated left fimbria ; altered blood in this tube, in the left uterus and corresponding vaginal infundihulum, which wan separatedfrom the right vagina by a membrane which showed the puncture made during life ; right uterus and tube healthy, both ovaries healthy. X. aged 16, was admitted into the Hospital la Riboisiere, May 16th, 1854. She had been regular for a year, but had always suffered great pain in the lumbar and hypogastric regions. Menstruation was scanty, lasting oidy for about two days. Eight months ago a tumour formed in the left iliac region which continued slowly to increase, especially during the periods. When admitted, she looked in perfect health. A triangular tumour, the size of the fist, was discovered near the left iliac fossa, hard and nodulated, and slightly tender ; tluctuation in it could be felt ^\a\x\^ per rectum.. On the 14th, three leeches were applied to each thigh, and on the 21st menstruation came on for two days. On the 26th, the tumour was punctured /?2 ; discharge of altered blood for ten or twelve days ; sudden stoppage of the same, followed by symptoms of inflammation ; death four days after. Fost-mortem examination. — Dilatation of the uterus and Fallopian tubes ; perforation and communication between the tubes and that joart of the vagina situate behind the fibrous constriction, in front of which a kind of cloaca existed containing the urethra. A girl, aged 22, was admitted into la Charite in June, 1814; she had never menstruated, but had suffered great abdominal pain with enlargement. On examination, there was found to be complete absence of the vagina. Abdominal pains began at 13; tumefaction at 17, which was most marked on the left side. On November 29th a quantity of thick, reddish-brown, inodorous fluid escaped through the meatus ; examination failed to discover whence it came; the abdomen diminished in size. On December 7th inllanimatory symptoms set in followed by diarrhoea; she continued Boyer. 'I'raite dcs maladies chirurgicalcs, 4*^ edit., t. x. p. 44. CAUSES AND VARIETIES. 35 to get worse up to January 18th, when she died, forty days after the first examination. Post-mortem e.xamhiation. — The only vulvar orifice which was dis- coverable led to a canal an inch and a-half long. In its interior were two others, placed one above the other ; the upper was the naeatus urinarius, the lower represented the vagina and abutted on the cervix uteri. The cavity of this organ was lai'ger than usual ; at its sides and upper part were two tumours, the right, a little smaller than the fist, contained a fluid like that which escaped from the vagina during life ; joined to this was another, which reached up to the stomach and contained a number of cavities filled with blood, with cysts of an hyda- tiform character. The tumour on the left side contained from eight to ten ounces of thick blood ; the ovaries were absent, or, at least, not distinguishable, and we thought that these tumours were developed in their substance. The cavity of the tumours did not communicate with that of the uterus ; but there sprang from each of them a canal, which extended as far as the small cavity placed near the vulva, without actually communicating with it. I ought, perhaps, to have placed this case among the congenital obliterations, and to have insisted on the remarkable character of the first part of the vulvo-uterine canal, which resembled, in some degree, the cloaca of certain animals ; a condition which I once saw during my residence at the Ilopital Beaiijon in a still-born infant. In that case, the rectum, uterus, and bladder all ended in the cloaca. But I place this case in the position to which it belongs anatoniically, and, though there may be some doubt as to the origin of the menstrual fluid, which, instead of coming from the uterus, seemed rather the result of perforation into the vagina of the blood-tumours of the tubes ; it is a sort of transitional case between the preceding and the following. I must here make one remark in reference to the existence of the san- guineous tumours which were attached to the uterus, and the difference of the fluids contained in the cavities of one of them, because in this we see the successive changes which may occur in the effused blood of an hsematocele. I am surprised that the pupils of M. Nelaton, who wished to credit Ilijjpocrates with a knowledge of this affection, have not referred to this vciiy interesting case of Boycr. This strange forgetfulness compels iric to refer to a case, which I shall only mention in order to show that examples of hsematocele exist in all varieties of cervical obliterations. Moreover, it proves this fact, ,12 36 MENSTRUAL RETENTION. viz. :— that the reflux of menstrual blood from the uterus, through the tubes, into the peritoneal cavity, rests now upon evidence so strong that there is no longer any need of further illustration. Case XVI. — Painful menstruation; sterility; death by a gun-shot. Post-mortem examination. — Incomplete obliteration of the cervix by vaginal mucoiis membrane. A woman, aged 50, who during nineteen years of married life had never been pregnant, was killed by a gun-shot. Menstruation had always been scanty with her, and attended by a good deal of pain and distension about the lower part of the body. On examining the body after death, the cause of the sterility was soon apparent. The internal os uteri was firmly closed by a mem- brane which lined the vagina, and the external os was also very small. The cervix was twice as long as usual, apparently because of the long-continued expulsive efforts, of the body of the uterus to get rid of the menstrual product. The cavities of the Pallopian tubes, especially near the uterine orifice, were much larger than usual. Case XYII.* — Painful and scanty menstruation ; sterility ; division of the cervix ; cure ; pregnancy. J. G., aged 30, had been married two years, but had not been pregnant. She consulted me 26th October, 1845, for dysmenorrhcea and sterility. Menstruation had always been regular, but scanty and painful, and had been worse since her marriage. Sexual intercourse was always painful before the period. The discharge relieved the pain. The uterus was found to be normally placed and moveable ; the os exceedingly small. I determined on incising it after the manner of Simpson, with the metrotome cachee. Next day a sound could easily be passed into the uterus, and it measured just two and a-half inches. On the 10th November, 1845, she menstruated in a way she had never done before, viz., for five days, and without any pain. On the 2nd I'ebruary, 1806, she complained of a feeling of discomfort, and by the end of April menstruation temporarily ceased. She was then some months advanced in pregnancy. * Oldham, loc. cit., Case I. p. 920. CAUSES AND VARIETIES. 37 Case XVIII."^ — Scanty menstruation ; extreme dysmenorrlma ; divi- sion of the cervix ; partial relief. M. R,, aged 31, single, consulted me for difficult and scanty men- struation ; it was quite regular in time, but only lasted one day, and sometimes the pain was so severe that she was obliged to go to bed. In vain I tried, by attention to the general liealth during the intervals, and by the application of local anodynes, to cure this defect. I found the vagina smooth and relaxed ; the uterus low down in the pelvis, quite moveable ; the cervix small, and the os remarkably contracted. I divided the cervix, and passed metallic bougies afterwards, when I discovered that the uterus only measured one-and-three-quarter inches. The result was, that the pain was greatly relieved, but the discharge only lasted one day. Two months afterwards I divided it again, and the result was no better. It is to be regretted that Dr. Oldham contented himself in this case with the remark, that the uterine orifice was remarkably con- tracted, without showing, at least by comparison, what was the amount of contraction ; and it is still more to be regretted that he did not note, in either of his cases, M'hat was the condition of the cavity of tlie cervix, and especially that of the cervico- uterine orifice, a matter which appears to me to be of the utmost importance in this question. I make this remark because, in order to determine the smallest diameter of the cervico-vaginal orifice through which the free excre- tion of menstrual fluid is possible, I have measured that orifice a great many times, but the result hitherto has not been very definite or satisfactory. In the beginning of 1855, a woman was admitted into Lonrclne, who had suffered a good deal from dysmenorrhoia after an instru- mental labour, for which she was nine mouths in the Hotel Dieu ; where she had the actual cautery applied. The cervico-vaginal orifice was so contracted that it would not admit the smallest sound, and when a stilet was passed, the oridce appeared lo he iuextensible. Menstruation came on while she was under my care — painful, it is true, for it brought on a recurrence of the peri- uterine pseudo phlegmon, which dated from the miscarriage. The excretion itself was easy. The same year two patients, both of them mothers, came under <" Oldbain, loc. cit., Case II. 38 MENSTRUAL RETENTION. my care. According to the statement of one of them, menstruation was perfectly rcguhir ; with the other, it was painful, the blood being ex- pelled in clots after some pain ; in both, the cervico-vaginal orifice was circular, soft, and of such small dimensions that a silver stilet entered with difficulty. Daring the time they were under my care, menstruation came on normally in both. In another case, which came under my notice in la Piile in 1856, the particulars of which are given in the diagnosis of pelvi-peritonitis, the cervico-vaginal orifice scarcely admitted a No. 2 urethral sound ; yet in this woman, who had once miscarried, menstruation was quite normal before she had the affection which brought her under my notice, and continued so after « her cure, without any incision of the cervix. Prom a consideration of all these cases I have come to the conclu- sion that, so long as this narrowness of the cervico-vaginal orifice is not carried to an extreme point, such as I have never met with, it does not of itself interfere with menstrual excretion. To disturb this function, it is necessary that some morbid phenomenon should be added to the atresia. I have insisted on these circumstances, because they account for the extreme reserve with which we have accepted in Prance the theory of mechanical dysmenorrhoea, described in England ; and the still greater reserve exercised in regard to the operation recommended for its cure. The success of these operations certainly does not imply that they have not been done for spasmodic or congestive dysmenorrhoea, which would equally be improved by these proceedings. Section IV. — menstrual retention from enlargement of the UTERUS, I pass on now to the consideration of my fourth class, because the condition which we have been discussing is pretty certain even- tually to lead to hypertrophy in the length of the cervix, as in Case XV., and thus cases of the third kind are very apt to be mistaken for those belonging to this class. But though the cases we have now to consider resemble one another as regards their symptoms and the mechanism of their pro- duction, yet they differ materially as to their one essential feature, viz., the nature and cause of the enlargement of the uterus. It may be due cither to simple hypertrophy, inflammatory or organic, using those words in their most generic sense. I need not insist on CAUSES AXD VAEIETIES. 39 these differences, a correct appreciation of which is Very important in reference to treatment. The remark which I made at the beginning of this work, and whicli is indeed the ground- work of the vohune, though, with regret be it said, it has been forgotten in many of the cases of iuiperforation I have detailed, is especially applicable here, namely, that dysmen- orrhroa may, in the same way as amenorrhoea from obliteration, be followed by effusion of the menstrual secretion into the peritoneal cavity. Happily, such serious consequences as are exemjjlified in the case now to be detailed very rarely happen ; but it is nevertheless true, that hsematoceles are much more common as a result of defective menstruation than from any other cause. I insist upon this point, because the knowledge of the extreme dangers which may arise from errors in this secretion has a practical im])ortance beyond those vain speculations which do not benefit the ])atient. It is, in fact, the fear of these dangers which has led me to study at great length the different varieties of dysmenorrhcEa ; especially that form of the disease which we are now considering. Case XIX. — Bysmenorrhcea ; t /tree abortions ; menstrual suppression at 34, with symptoms of peritomtis at the second period ; at the fourth period, expxdsion of old clots and hcemorrhage, followed by relief ; at the fifth, Increase of the discharge ; at the sixth, more hemorrhage and more relief ; at the seventh , painful m.enstniation ; at the eighth, improvement in every way ; hypertrophy of the cervix. U., aged 34, was admitted into la Pitie, on Tebruary 5th, 1847. Though short of stature, there was no evidence that she had had either rachitis or scrofida in early life. She began to menstruate at 13, and was always regular, though menstruation was extremely painful. At 24 she married. She had three miscarriages, the last six years ago. On October 20th, having been unwell for 24 hours, menstruation suddenly stopped without any ajjparent cause, and was followed by extreme pain in the abdomen, which in a few days subsided. On the 20th November, menstruation did not come on, but the pain was more severe than at any previous period, resembling, she said, that of labour : in two days it extended over the whok^ abdomen. Vomiting, constipation, and smart fever snccecded, for which ninety-five leeches were ap[)lie(l in three applications. 'I'his gave only partial relief: she was still quite unable to sit up lor the severity of the intermitting pains. Seven weeks after this she passed 40 MENSTRUAL RETENTION. some clots from the uterus after severe expulsive pain; this was followed by sharp haemorrhage, which continued, though to a less extent, up to the time of admission. When first seen the face was anxious, and painful, pains very severe, intermittent, and cramp-hke, extending from the loins to the pelvis. The abdomen in the middle line was swollen, firm, and hard, but this did not extend to the iliac fossae. The sound proved that the bladder was small. The cervix was depressed, and the labiae hypertrophied. The fundus was felt in the anterior vaginal cul-de- sac. The uterus seemed quite double its normal weight and size. It was moveable. Micturition was frequent and painful ; defsecation also painful ; pulse small and frequent ; no rigors. Ordered rest in bed, baths and poultices to the abdomen. In a few days she greatly improved in nearly every respect. The uterus diminished in size, but the anteflexion remained, and the dis- charge continued. On February the 18th she was not so well, the hsemorrhage re- turned, the sense of weight in the pelvis increased, and the uterine con- tractions returned more severely. After the bleeding the swelling disappeared, the uterus could be felt in the right ihac fossa, it was more moveable than before ; the cervix was much lower and more to the left. The broad ligament on the left side could be felt obscurely enlarged. The same treatment was continued. On the 16tli March, pains came on again severely. Hsemorrhage followed, for five days, and was succeeded by a slightly sanguineous discharge. On the 30th, much improved. Intermittent uterine pains less severe. All discharge has ceased. The uterus is felt behind the pubis, the cervix in the hollow of the sacrum. It is smaller, the anteflexion has disappeared and anteversion only exists. By the 9th of April, she had so far recovered as to wish to leave the Hospital ; but she took too long a walk, and indulged in sexual intercourse which was very painful. Two days after there was in- creased sense of pelvic weight, more painful uterine action, and some bloody discharge. April Wth. — So great was the pain that she could hardly stand up- right. Her face was pale and anxious, no vomiting, no colic, defsecation and micturition extremely painful. Pressure in both iliac fossse caused great pain ; there was no anteflexion, but some anteversion ; uterus almost fixed ; cervix very low, large, hot, slight sanguineous discharge, examination extremely painful ; pulse small, feeble, and frequent. CAUSES AND VARIETIES. 41 On the 17th she was inuch worse; the discharge was more abundant ; uterine action energetic. This lasted for five days. May 2nd. — She was seized with severe uterine coHc, followed by syncope and some loss, which lasted nine days. After this the severity of the symptoms gradually passed off, and for the next few months she continued pretty well. The following year she had a slight retui'n, which ultimately passed off. Case XX. — Profuse leucorrhcea j absence of menstruation from fatigue, followed by violent dysmenorrhoea, and escape of altered blood; enlargement of uterus and broad ligament, especially the right ; hypertrophy and indxiration of the cervix ; menstruation regular i cure three months after the commencement of the attack. E. C, aged 38, was admitted into la Pitie, November 24th, 1848; she had been ill for three weeks ; her iUuess began by cessation of menstruation after some fatigue. She began to menstruate at 16, and continued regular up to 18, when she married. Menstruation was always scanty. At 19 she was confined, after a painful labour; from which she suffered through laceration of the perineum. Menstruation came on six weeks afterwards, notwithstanding lactation, and con- tinued regular for fifteen months, when she again became pregnant, and was delivered at full term. She continued to suckle the child for three years. Menstruation being at times very profuse, and accompanied by excessive leucorrhcea. Early in November she was seized with pains resembling those of abortion, but she had no reason to expect pregnancy. On the 10th some pale decomposed blood passed, the pains continued increasingly till the 29th; ceased on the 21st, reappeared on the 23rd, accom- panied by discharge of blood; stopped again on the 24th, and returned more severely than before on the 26th. The loss increased up to the 29th, when both it and the pains diminished, and were felt mostly in the iliac fossa. On the 30th the following was noted, uterine pain diminished, size and tension of the abdomen less, just above the pelvis a tri-lobular tumour is felt, the larger })ortion of which is situate on the right Fallopian ligament, very firm a)ul painful to the toucii, movement of the uterus is communicated to the swelling on the right ; the cervix is elongated, increased in size and indurated. Tenesmus after micturition, nausea, but not vomiting, constipation, tenesmus, ordered to be bled to sixteen ounces. December 5th. — lias been improving since the 2nd, when after the application of ten leeches to the right iliac fossa, a good many clots 42 MENSTRUAL RETENTION. passed, but no evidence of pregnancy, there is now less pain, the abdomen is softer, except in the right iHac region ; the vaginal cul- de-sac on that side is less deep than the other, but the tumour on that side cannot be reached ; the uterus more moveable, the cervix softer and smaller ; formication, whicli has existed in the thighs in front since her illness began, has ceased. December 1th. — Improvement continues, no expulsive pain, but a sense bf weight in the pelvis. The right iliac swelling much dimin- ished under the influence of a sanguineous discharge which has been going on for some days. Micturition and defsecation without pain. jSTo tenesmus. Wth. — Since the 9th, when the discharge ceased, she has been much worse, has had more colicky pain, tenesmus, and formication in the thighs, lancinating pains in the right iliac fossa, where the tumour lias also increased ; no fluctuation is felt externally, but in- distinctly it is per vaginam, where it is also extremely tender. The uterus is pushed to the left side. There was a rigor last night. Ordered a mixture of rhatany, and opium. 16^!/;. — The last two days she has been improving; the expulsive pains and sense of weight have ceased. The only pain is felt in the right iliac region, where there is some induration and fulness, which cannot however be felt per vaghiam. Uterus much the same; ordered iodine inunction. 'i.^tk. — Is still improving ; all discharge ceased; no pain; slight tenderness, only on pressure ; uterus somewhat enlarged, and slightly to the left of pelvis. Micturition and defaecation painless. On the 30th she left the Hospital. Towards the end of January menstruation came on with but slight pain. Swelling in right iliac fossa disappeared. In 1855 I saw her again, she was in good health. Menstruation regular, painless. She had grown stout, but had not had any children since her attack of menstrual retention. Case XXI. — Difficult menstniation ; suppression from cold; sym- pto7ns of retention occurring four times, and followed hy improve- ment ; enlargement (f the cervix ; dilatation of the uterus ; swell- ing of the right hroad ligament; menatruation regular at next period ; cured. H. L., aged 27, admitted 1st August, 1851, said she had been ill only a few days, began to menstruate at 18, with very severe CAUSES AND VARIETIES. 43 pain and little or no discharge. From 18 to 20 menstruation was regular, but always accom2)anied by severe pain which for a period of fortj-eight hours was excessive^ the discharge being very slight. At 20, during menstruation she washed some linen in cold water, this at once stopped the discharge and aggra- vated the pain, which became so severe that she was admitted into the Hospital ; leeches were applied, and repeated ; at the end of three weeks she was relieved by the loss of a large quantity of red watery fluid, after which she left the Hospital. For three months menstruation did not appear, though there was much pain. At the fourth month a discharge came on, and the pain was relieved. For eighteen months her periods were regular but painful, and of the character before described. At that time she had a second suppression without apparent cause ; the pain was extreme, but was again relieved by free discharge. In the spring of 1851 the discharge again ceased, when she sufl'ered so acutely that she was admitted into la Pitie ; leeches were applied to the upper and inner part of the thighs. At the end of fifteen days, after extreme suffering, an abundant discharge came on with relief to the pain ; ever since then menstruation has been irregular, both in time and quantity, and in the amount of pain. This irregularity has increased of late. In April there was no dis- charge, but great pain and enlargement of the abdomen, which led her to suspect pregnancy. In May the discharge appeared for one day ; in July it was abundant, all pain disappeared, together with the abdominal enlargement, and she seemed quite well. On the 24th July, menstruation began as usual with pain, but no discharge appeared ; the pain increased each day, the abdomen was extremely tender to the touch; she had no sleep, no appetite, and vomited everything ; poultices were applied to the abdomen, which gave some relief. The abdomen was tense over its lower part, especially in the iliac fossae, where was some fulness which was dis- tinguishable externally, but still more, per vaginam. The cervix was depressed, conical, increased in length and thickness, and pushed to the left side ; the whole uterus was enlarged and very tender ; the right cuUde-mc felt full. Fifteen leeches were applied to the right ibac fossa and some relief followed, which was increased by continued apphcation of pouhices and warm baths. She left the Hospital on the 11th, but returned on the 1.3th with a repetition of th(! symptoms; these again yielded to the application of leeches, poultices, ami baths. On th(; 20tli she had an attack of erysi[)elas of the face. On the 44 MENSTRUAL RETENTION. 22nd the uterine pain returned with extreme severity. The patient writhing in bed ; in the evening a discharge came on, and on the following day a clot was expelled, after which the pains gradually ceased, and by the 27th she was tolerably well; the swelling in the iliac fossfe had entirely disappeared ; the uterus alone remained enlarged, and to it the sense of weight in the pelvis was attributable. A fortnight after even this had disappeared ; the uterus had decreased in size, though the cervix remained very large. I saw her again after the next menstruation, she was still very well, but the period presented the same phenomena as had characterised it previously. Case XXII. — Cancer of the cervix; retention of blood ; enlargement of the uterus ; violent expulsive pains for five days,folloioed by the extrusion of a clot and hemorrhage ; cessation of pain ; repetition of the symptoms the following month. M. B. aged 38, admitted into la Pitie, the 12th December, 1847. She began to menstruate at 13, and was always regular, without pain, and with moderate discharge. She married at 18, and has been pregnant five times, her pregnancies and labours being natural. Three years ago she was in great grief at the time of menstrnation, and ever since then instead of its lasting three days, it has been seven or eight. She has also suffered from pain hi the back, and occasional uterine cohc. In July last menstruation was extremely painful, and a week or so after it she had an attack of bleeding which lasted thirty days. Since then it has recurred every fifteen days, and has gradually undermined her health. On the evening of her admission, bleeding came on, which lasted a fortnight. The lower part of the abdomen was very tender, and tense, but no tumour could be discovered. The uterus was placed somewhat to the right, the anterior hp was enlarged, indurated, and irregular, upon it was a growth, hard, and of a yel- lowish-white colour. In the left cul-de-sac some induration could be felt. The uterus was moveable ; there was no discharge. Consti- pation : no tenesmus, no formication of the thighs. January Ind. — She was in extreme pain, and there was difficult mic- turition, A tumour could be felt over the lower central part of the body. The cervix was enlarged ; the uterus dilated, and its tissue in- durated. There was slight discharge, and the parts were very tender. Ordered poultices, and rest. 12^/^.— On the 4th, 5th, and 6th, expulsive pains continued, and were accompanied by the extrusion of coagula; these have now CAUSES AND VARIETIES. 45 ceased. Abdomen somewhat enlarged. Uterus sliglitly enlarged, hard, fibrous, and nodular. The left vaginal cul-de-sac is fuller than normal ; there is no discharge. Felruary 2nd. — For some days all seemed going on well, but the pains returned with severity, and the uterus increased in size. On the 4th the pain ceased, and the discharge which had stopped, returned. During the next few days it increased, but again stopped on the 10th, and, a few days after, the patient left the Hospital. On the 23rd the discharge became excessive, and she was re- admitted; the pains were not severe, and in a few days she so far recovered as to be able to leave the Hospital. I never saw this patient again. I will not recapitulate the peculiarities which this case presents, because every practitioner must have met with cases of cancer uteri, occurring before the cessation of menstruation, in which symptoms resembling those I have described have occurred, though they may not have been interpreted in the same way. It clearly establishes, I think, this fact, that dysmenorrhceic accidents, the result of narrowing of the OS, may occur wherever there is increased volume of the cervix, •whether that be caused by simple engorgement and hypertrophy, or by the existence of any organic deposit, such as cancer. The obstruc- tion is the prime factor, and, in the cases now under consideration, the mechanism of the retention is precisely the same as in retention of urine from enlargement of the prostate. I am anxious that this should be generally accepted, viz., that dysmenorrhcEa which results from enlargement of the cervix uteri deserves the name mechanical, quite as much as that which results from atresia of the cervix, that it may give rise to the whole series of phenomena which occur in imper- foration, and may lead to effusion of the menstrual secretion into the peritoneal cavity. I should not so often reiterate this opinion were it not for the fact, that the conclusions laid down by me in 1848 have been disputed. Moreover, the idea that an obstruction may give rise to lucinatocele, and all its sad consequences, is of far greater practical importance than any of the theories which, since the ap- pearance of my first work, have been put forth to explain the develop- ment of this affection. I need not here enter upon the consideration of those theories which up to the present time have remained barren of any therapeutical apj)lication, because I shall have to allude to them in discussing the question of hsematocele being not a disease itself, 46 MENSTRUAL RETENTION. but a symptomatic affection. I will only state, that I have never held the opinion, that all intra-pelvic effusions of blood depend upon any one cause, and notably that of menstrual obstruction ; on the contrary, as I shall show in the following pages, these hsematoceles result from a variety of morbid conditions, not the least important of which, however, is menstrual retention. Section V. — menstrual retention from adventitious deposits IN THE uterus. In the fifth class w'hich we have now to consider, the men- strual excretion is, as I have already shown, temporarily dis- turbed by the interposition of an organic product, developed either in the cervix itself or in some part of the body of the uterus. This class includes a large number of cases, for the deposit itself varies much in different cases. I think, however, to avoid complication, it is possible to arrange them in two divisions. In one, the obstacle is due to the presence of a polypus, using that word in its generic sense ; m the other, to a sort of membranous deposit, a kind of deciduous structure produced by a process of moulting in the uterus, which in these cases occurs at each menstrual act, and deserves the name given to it by English authors, viz., pseudo-membranous dysmenorrhoea.^ I shall only now consider the former of these two, because it is generally understood that poljpi, whatever their nature, may occa- sion a mechanical difficulty to the uterine excretion; indeed, this has been regarded as one indication of their presence. The following is a fair example of this kind : — Case XXIII. — Chronicleucorrhcea ; dysmenorrlKBic pains increasing each month for a year ; admission into the Hospital; extrusion of a fibrous polypus from the uterus after a most severe attack of pain; extirpation; three days after, pelvic peritonitis, followed by thicken- ing of the posterior vaginal cul-de-sac, resembling a chronic retro- uterine phlegmon. R. P., aged 35, admitted into Lourcine 23rd May, 1854, com- plaining of a long-continued white vaginal discharge ; is of a scrofulous habit. She had no symptoms of menstruation till about 19, when she was seized with severe colicky pains which returned the following * Oldham. London Medical Gazette, 1846, vol. ii. p. 970. Simpson. Edin. Monthly J our7ial of Medical Science, September 1846, p. 161. CAUSES AND VARIETIES. 47 month, and still more severely at the third month. For this she was admitted into Hotel Dieii, M'here she remained a month, and was dis- chai'ged relieved, but not cured, A few days after some dark clots passed, and this was repeated every week for five months. Then all discharge ceased for tive months, but she was free from pain. At the end of that period she had slight haemoptysis which she ascribed to the ameuorrhoea. Menstruation came on the following month, and continued regular afterwards, moderate in quantity and without pain, until the last few weeks. Two years after she began to menstruate, that is, in her 23rd year, she became pregnant, and was delivered at full term of a still-born child. Menstruation returned two months after, and continued regularly afterwards, but she did not become pregnant again. During her pregnancy she was subject to a rather profuse leucorrhceal discharge with some pains in the back, and this reappeared after the cessation of the lochia. It was on this account that she applied for and received admission hito Lourchie Hospital in 1850. It could not then be determined what was the cause of the discharge, nor whether or not it was contagious. The affection was then de- scribed as uterine catarrh ; the discharge was pale ; the menses were regular, painless, scanty, and almost colourless. While in the Hos- pital she took ferruginous preparations, and was cauterized every week. She left it relieved, but not cured. Menstruation still con- tinued regular and without pain till last year, when it began to be painful. On admission into the Hospital in May, 1854, she was again suffering fi'om increased vaginal discharge, and, in addition, from severe dysmenorrhoea. The following note was made the day after : — May Zi'i//. — Menstruation is now at its height ; all pain has ceased. Micturition is frequent and abuiidant_, and followed by tenesmus. She has a healthy appearance, and the other functions are normally performed ; there is no abdominal tenderness, nor enlargement, but some tenderness exists in the anterior lip of the cervix uteri, the direction of the cervix being towards the sacrum. The body of the uterus is also retroilexed upon the cervix, and the latter is somewhat enlarged and indurated, but not generally tender to the touch, it is pretty freely moveable in all directions. There was no syphilitic history. Ordered rest in bed, and poultices to the abdomen. June Isi. — Menstruation lasted four days; after which rather severe pain came on in the lower part of the abdomen, accompanied 48 MENSTRUAL RETENTION. by frequent micturition and tenesmus vesicae. No formication of the thighs ; vaginal discharge free and of greenish colour ; os slightly open ; passage of the uterine sound obstructed at the cervico-uterine orifice^ after overcoming which it entered freely the uterine cavity. Ordered, intra-vaginal sponge; alum injections morning and night; Yichy water to drink. J^hne Sth. — Sense of pelvic weight diminished ; the cervix uteri has become twisted half round, so that the retroflexed fundus uteri occupies the left side of the pelvis ; ordered to continue the vaginal sponge, smeared with belladonna. \Qth. — Yesterday the patient experienced a good deal of pain through the pelvis, and this morning it has taken an expulsive character. The cervix is very low, tender, and open ; menstrua- tion has not come on to its time. The abdomen is painful, especially over the lower part; the retroflexion has disappeared, and the posterior wall of the uterus is now tui'ned to the right ; the entire organ is enlarged. Ordered four leeches to the cervix, and a hot bath afterwards, rest in bed and poultices to the abdomen. 'i^th. — Menstruation came on after the leeching, and was abundant for three days ; the expulsive pains have ceased, but the abdominal and lumbar pains have increased. The vaginal examination revealed the same state of things, except that the cervix is remarkably thinned, and the os dilated so as to admit the finger when a large round body could be felt, but no pedicle. By the speculum a tumour could be seen coming through the os, and the sound passed freely round it. Jtdy 3rd. — There is a constant muco-sanguineous discharge. Micturition is frequent, tenesmus vesicae painful, vaginal examination the same ; the attachment of the tumour cannot be made out. From the 7th to the 10th ergot was administered internally, and belladonna to the cervix in order to secure dilatation, it having been determined by M. Gosselin to remove the polypus. Por this purpose the uterus was drawn down, the cervix was divided on both sides, and the polypus (fibrous) speedily detached ; there was no haemor- rhage of importance. On the 11th she was very comfortable, but less so next day, having had some abdominal pain ; the os was very patulous ; a sanguineous discharge continued. On the 13th the pain increased, skin became hot and dry; pulse 110 ; rigors in the evening, followed by restless- ness, thirst, and great abdominal tenderness ; the discharge ceased ; the cervix was found to be closed ; the posterior vaginal cul-de-sac CAUSES AND VARIETIES, 49 liot^ painful on pressure, resisting; pulse 120, peritoneal. Ordered twenty leeches to the iliac fossae, and mercurial and belladonna ointment. 1-i//. — The leeches gave some relief; she passed a tolerable night, and is better ; abdomen slightly distended and tender. Discharge shght; cervix hard; pulse 110; ordered eight leeches to the right ihac fossa. From this date she improved steadily, and left the Hospital on August the 14th. There is no doubt that the inflammation of the serous membrane in this case was the result of the operation, and not of the menstrual disturbance; though the latter may give rise to such inflammation, as we shall see hereafter, and as Dr. Oldham has pointed out in liis memoir on pseudo-membranous dysmenorrhoea. These cases are, however, very rare, though of their existence there can, I think, be little doubt. The first published cases of the kind were recorded by Madame Boivin, and it may be well to compare those two with one lately presented to the Anatomical Society. In all these the false membranes were expelled entire, and, when filled with blood, they presented exactly the appearance of polypi, and would, no doubt, occasion retention of the menses in precisely the same manner. Case XXIV.* — KolMo polypoid tumour, due apparently to dijsmen- orrhcea. — Extirpation hy the ligature. Madame V., aged 44, began to menstruate at 17, married at 23, and had her first child at 24. At 26, she aborted at the third month. At 36, she suffered very acutely from the loss of her child, and from that time she has been subject to menorrhagia ; for the last three months it has been excessive, and no treatment has been of any avail. On November the 15 th, 1819, she had a fall, which was followed by great pain in the hypogastric region. Then defseca- tion became difficult, and a few days after, while straining at stool, a tumour appeared externally. This she returned into the vagina, but the prolapsus remained and the hsemorrhage continued, though less than before. On January the 8th, a tumour, the size of a foetal head at term, was felt, and on the 12th Dubois encircled it with a liga- ture. On the 15th it separated, and the patient made a good recovery. • Boivin et Dug6s, he. cit., t. ii. p. 119. 50 MENSTRUAL RETENTION. Case XXV. "^ — Venereal excess ; menstrual suppression ; dysmenor- rJioeic phenomena at the third month ; easy extraction of a sanguin- eous tumour covered with a sort of decidua ; cure. A 3^oung- woman of an ardent temperament after some erotic abuse tlioaght herself pregnant, because menstruation bad stopped for two months; but at the third month symptoms came on which made her think menstruation was returning. Such, how- ever, was not the case ; for though the pain was severe, there was no discharge. On examination, the uterus was found depressed, the OS patulous, and within was a soft shining tumour, the shape of a green fig, attached by a pedicle to the cervix ; by slight traction it came away, and then it was found to be merely a cyst filled with brownish semi-fluid blood. It was pear-shaped ; there was no ap- pearance of fibrous areolar tissue, no trace of blood-vessels, and it entirely dissolved in an alkaline liquid. " It appears to me/'' writes Chaussier (p. 376), "that this concretion modelled in the uterine cavity had gradually become detached : (1.) by the exhalation which forms continually on the internal surface of the uterus ; (2.) by the impul- sion and successive accumulation of blood which flows at each men- strual epoch ; and as at our visit the tumour occupied only the cervix and OS uteri, the slight traction which we made in the examination eff'ected the separation, a proceeding which nature would probably have accomplished ere long.-''' All pain and spasm soon ceased, and she made a good recovery. Case XXVI. t — Menstrual retention of fifteen days, followed by violent uterine colic, and the expulsion of some clots and decidual membrane. A woman, aged 33, had for some months been irregular ; the last period was fifteen or sixteen days late, and then violent uterine colic came on, followed by the expulsion of clots on August 1st. On examination, a soft membrane was felt, protruding from the cervix, which M. Dufour withdrew with the forefinger, and which proved to be an exact cast of the uterus, having its three openings * Chaussier, lettre, traduction de Rigby et Duncan, par Madame Boiviu, p. 374. t Dufour. liuUetm de la SocieU anatoynique de Paris, 1856, xxxi** annee, p. 321. CAUSES AND VARIETIES. 51 corresponding to the JPallopian tubes and os uteri ; it was evidently the mucous hning of the uterus ; there was no trace of conception within it. I have brought together these three somewhat similar cases, because thev present us with all the morbid phenomena of pseudo-membranous dysmeuorrhoca ; a disease which, as may be seen by comparing the dates of Madame Boivin^s case (1815) with the observations of Dr. Oldham (IS^G), had been clearly recognised in France long before it was observed in England. The result of the examination to which Dr. Oldham and others have submitted the dysmenorrhoeal membrane, establish very positively that this organic product is com- posed entirely of the histological elements of the uterine mucous membrane, and ought, consequently, to be attributed to a dis- turbance of the ordinary physiological moulting, if I may so term it, of which the generative organs become the seat at each cataiiienial period. Unfortunately, this discovery, which was a great advance in the history of a disease that, up to this time, had been very obscure, has, owing to that unfortunate tendency to multiply diseases, of which the doctrines of M. Piorry may be regarded as a salutary exaggeration, led many English authors to regard pseudo-membranous dysraenorrhoea as a distinct morbid entity, deserving of a separate place in our nosological table. Such a conclusion is, however, in direct opposition to the case recorded in Dr. Oldham's pajjer, which I subjoin. Case XXVII.* — History of numerous ahortlons ; uterine catarrh ; enlargement and retroversion of the uterus ; pairfiil and profuse menstruation, followed hy the expulsion of fragments of dysmen- orrhoeal membrane. — Treatment hy leeches and mercury. — Cure. Mrs. G., aged 31, became pregnant soon after a miscarriage. Since then she has had several premature labours at the sixth and seventh months. In December, 18i'4, she comjjlained of a variety of symptoms, all referable, in one way or other, to the uterus : she had a constant leucorrhoeal discharge ; painful sexual intercourse ; and thougli menstruation was regular, it was attended with violent suf- fering, and an abundant clotty discharge, accompanied by membranous shreds ; the uterus was large and retroflexed, with granular ulcera- tions. The treatment consisted of leeching, scarifying, rest, and • Oldham. London Medical Gazette, 1846, v. ii. p. 970. 52 MENSTRUAL RETENTION. sedative injections. She got well under this treatment, and subse- quently brought to Dr. Oldham a portion of membrane which, on examination, he found to be the mucous lining of the uterus. The patient stated her belief that some of her abortions had been nothing else than this. In February 1846, the above symptoms recurred with increased severity; she was then treated by mercury, leeches, and rest ; this again cured her for two months. In May it returned, and a similar plan of treatment was adopted, a cure resulting. In this case, which Dr. Oldham gives as typical of pseudo-mem- branous dysmenorrhoea, we find united two groups of symptoms. In the first group are those which may be attributed with more or less reason to the exudative affection, and are of an irregularly intermittent character. In the second group are those continuous symptoms which may be regarded as the expression of a permanent morbid condition of the generative organs, which existed concurrently in this patient. It is not necessary for me to enumerate these several symptoms, or to point out their importance. The character of the leucorrhoeal dis- charge, which had existed for many years, is evidence of a chronic aff'ection of the uterine mucous membrane, which Dr. Oldham himself admitted. Whatever then may be the relation between these two affec- tions — the hypertrophy of the uterine mucous membrane, and its separation and expulsion, with more or less of pain and difficulty — it is quite clear that they are in some way dependent upon one another. The question is, whether the uterine affection is the consequence of the functional disturbance or, whether, on the contrary, the latter is symptomatic of the former, as at first sight appears more probable. Tliis opinion, differing entirely from that of Dr. Oldham, which is, I may add for the information of those who have not read his paper, based on the microscopical characters of the dysmenorrhceal mem- brane, has very much in its favour. For instance, it is difficult to believe that a non-hereditary functional malady should be reproduced duri)ig a series of years, as in the preceding case, and ultimately give rise to a disease of the uterine mucous membrane, without being itself connected with some antecedent disease. I cannot regard the ovarian hiflicence, to which Dr. Oldham attributes this afi'ection, as constituting a disease. Its existence should at least be proved, and its nature defined, otherwise it can only be regarded as a mere speculative of opinion, resting upon no positive evidence. It seems to me, on the contrary, that the affection may be legitimately CAUSES AND VARIETIES. 53 attributed to those lesions of the uterine mucous membrane, which have been found in all the post-mortem examinations of dysmenor- rhceal females made in England. The constancy of these lesions is clearly established by the following observation which I extract from an interesting paper read by Dr. Tilt to the Medical Society of London.''^ " The pathology of these cases of dysmenorrhcea (pseudo-mem- branous), is indeed very obscure; because the opportunities of making a post-mortem examination are extremely rare. But if, in the few examples to be met with in our hospital museums, you compare the uterus of females who were affected with this form of dysmenorrhcea, with those who died during menstruation, you will find that when the mucous membrane of the uterus habitually exfoliates its superficial layer, that mucous membrane was thicker and more injected than ordi- nary.'" I may add, that the existence of the lesions pointed out by Dr. Tilt, especially the Avell-marked evidence of inflammation in the case which was the subject of his communication, completely annihilates the argument of Dr. Oldham. Relying entirely on the microsco- pical examination of the dysmenorrhoeal membrane. Dr. Oldham be- lieved himself justified by that examination in denying the existence of all inflammatory action, and he therefore regarded it as a specific affection. To show the shallowness of this argument, I might add that the microscopic examination of those uterine fungoid growths, for which Recamier unfortunately recommended the employment of the curette, demonstrates that these exuberances of uterine mucous membrane, which are undoubtedly due to chronic inflammatory action, contain precisely the same histological elements as the dysmenorrhoeal membranes. The fact, therefore, is established, that the microscopical characters of the dysmenorrhoeal mucous membrane do not exclude the possibility of inflammatory action ; indeed it is unnecessary to insist on this point since Dr. Oldham^s examination of his own case proves, contrary to his expressed opinion, that the uterine affection, instead of being a consequence of any functional disturbance, was in fact the cause. I insist the more upon this point, because the solution of this doctrinal question regulates the history of pseudo-membranous dysmenorrhea : that, whatever it be, which gives rise to this affection, occasions also, I believe, the peritonitis, and the various • Tilt. Lancet, 1853. 54 MENSTRUAL RETENTION. uterine deviations resulting therefrom. In the same way menor- rhagia which often accompanies the dysmenorrhcea^ and the extreme pain which seems to be due to the difficulty experienced in the dila- tation of the cervix ; all these arise not from any mere functional disturbance, but from the lesion of the genital organs : an inflamed cervix preventing the menstrual excretion in the same way as inflam- mation of the neck of the bladder, occasions retention of urine. But I must dwell a httle longer on this very important branch of the subject, for up to the present I have implied that the menstrual retention was due in these cases to the obstacle presented by the dysmenorrhoeal membrane. Such, however, is not my opinion, on the contrary I believe that the difficulty arises from the morbid condition of the attached uterine mucous membrane, especially the cervico- uterine portion of it. Nor can I accept the view propounded by Madame Boivin ; because, though it seemed to tally with the two cases she recorded, it was opposed by those I placed beside hers, though they closely resembled each other in some respects. I willingly allow that the dysmenorrhoeal membrane floating about the cavity of the uterus may occasion temporary difficulty to the exit of the menstrual fluid, just as a clot might do so, but I do not believe it could give rise to so serious an obstruction as occurred in the preceding cases, unless there coexisted defective dilatation of the cervix uteri. These remarks, made in reference to the case of M. Dufour, are especially applicable to that of Dr. Oldham. Here, the shreds of membrane which at different times were expelled with the blood, instead of representing the lining of the entire cavity of the body of the uterus constituted but a small portion of it, and could not therefore occasion any very serious difficulty. The real obstruction was to be found in the morbid condition of the uterus itself. To this, which was indicated by many symptoms in each of the four cases I related, may be attributed the defect in the regular dilatation of the cervix uteri. Under these circumstances the products of the uterine exfoliation which ordinarily pass unperceived are here expelled only with extreme difficulty. The post-morte?)i appearances fully warrant the comparison between this affection and that of retention of urine from inflammation of the neck of the bladder, I need make no further remark on this point : what has been said seems to me to establish the doctrine that pseudo-membranous dys- menorrhoea, occurring as it does both in internal metritis and in uterine catarrh, cannot be regarded as a specific affection, and that CAUSES AND VARIETIES. 55 the temporary menstrual retention which constitutes one of the elements of tliis disease ought especially to be recognised as the exaggeration of menstrual hypertrophy ^vith a morbid condition of the uterine mucous membrane. The dysmenorrhcea which exists under these circumstances exemplifies one of the general laws of pathology, viz., that inflammation of an excretory canal more or less completely disturbs its normal functions. These remarks apply equally to all forms of dysmenorrhcea when they are connected with a morbid condition of the uterine mucous membrane, and I believe that in nil of them the pain is due entn-ely to some irregularity in the dilatation of the cervix uteri, caused by the existence of disease in that part. It is even probable that this also is the cause of the menstrual retention which occurs in some forms of uterine deviation, such as those which we have now to consider : — Section VI. — menstrual retention from deviations of the UTERINE CANAL. In some of the preceding cases* we have seen that under the in- fluence of menstrual retention and the difficulties which that gives rise to, more or less marked deviations of the uterus, sometimes even flexions of the body and cervix one upon the other, are produced, and this may materially increase the difficulty of the menstrual emission. The deviations in these cases are the result of the func- tional disturbance, not the cause. But in others the deviation is produced before the occurrence of retention, and thus may be, perhaps, or, at least, may seem to be, tlie cause of that defective ex- cretion which comes on after the uterine displacement. This re- striction shows that since my former memoirf appeared, my opinion as to the influence of deviations has undergone a change, owing, tt must be confessed, to the fact that my friend and co-worker, M. Goupil, lias pointed out my mistake. What principally changed my opinion was the observation that dysmcnorrhojic phenomena are so very uncertain in cases of deviation. The same kind and amount of displacement being followed and accompanied by very vari- ous phenomena. Notwithstanding the doubt as to the real influence of uterine deviations in the production of these affeetions, 1 have re- • Vide Cases XIX. and XXIII. t G. Bcrnutz, Arch., t. xix. y). 197. 56 MENSTRUAL RETENTION. served for these cases a distinct place, in order to prove that the deviation under these circumstances plays only an accessory part ; it will be considered by M. Goupil in the section on uterine displace- mentSj which will form the Pourth Part of this work. Section YII. — menstrual retention from spasmodic contrac- tion OF THE cervix UTERI. In this the most frequent variety, where the symptoms are usually so slight that the advice of the physician is seldom required, the excretion is temporarily prevented by the spasmodic contraction of the excretory canal. This ephemeral spasm, like all contractions of the kind, would never give much trouble were it not that either another morbid condition arises in consequence, or else the spasm itself is associated either with an hypertrophy of the uterus or with an antecedent catarrhal affection of that organ. The following cases, are very interesting from this point of view, especially the first. Case XXVIII. — Menstrual suppression on four occasionsfrom anger; the last time accompanied hy sudden and severe symptoms; relieved by opiate injections; violent uterine spasms from a dose of ergot; expulsion of putrid blood. Recovery. J. D.^ aged 37, was admitted into la Pitie, October 13th, 1847. She began menstruation at 14, and the discharge had since been very free and clotty. She married at 20, but had never been pregnant. Nine years ago she had sudden suppression of menstruation, followed by severe pain in the back and abdomen — for this she was treated, and in twelve days the period came on. Two years after she had an attack of menorrhagia, but this stopped suddenly, and after a few days a swelHng was felt in the right iliac fossa. This disappeared by the rupture of an abscess into the bowel, and the discharge of some pus per anum. Menstruation came on again in fourteen days and was accompanied by severe colicky pain ; the latter and the discharge alternating. She, however, soon recovered, and menstruation was after- wards regular, abundant, and painless. Tour years ago, and fifteen days after menstruation, while in a fit of anger hsemorrhage came on, and when it ceased, as it did suddenly, severe abdominal and lumbar pains succeeded. On October the 7th, 1847, during menstruation, she again had a violent fit of anger, which caused the flow immediately to cease, this was followed by shivering, headache, and fever, pain in the belly and CAUSES AND VARIETIES. 51 legs, and cramps in the uterus^ with tenesmus vesicee, constipation^ &c. On the 14th there was no pain or pressure above the umbihcus but great tenderness and pain below, and especially in the right iliac fossa. A round, hard, immoveable swelling was felt immediately above the pubis, and here sharp intermitting pains were experienced, which were increased by j^ressure from within or without. The cervix was situate far back, small, short, hard, and conical : the os closed, the uterus fixed and heavy, the fundus forwards. Eight leeches were applied to the groins, and an opiate injection was admiuistered. Tliis gave some relief, but on the 13th she suffered severe pain through the night, which was again relieved by injection. There was tenderness in the iliac fossse, and the swelling remained about the same. Pulse 104. Ordered fifteen grains of ergot, baths, injections, and emollients. On the 16th, shortly after a bath, a discharge of black foetid blood took place. She was much relieved by copious action of the bowels. Abdomen less tender, except over the tumour, where pressure caused great pain. Micturition still difficult, with some tenesmus vesicae. She was ordered absinth, five grains of ergot every half-hour, for three doses, night and morning ; bath, emollient injections, and simple electuary. On the 17th the bath again caused a coloured discharge, which was repeated after some ergot. Then followed severe uterine colic, and a sense of fulness in the left iliac fossa, this soon subsided; she slept well, and began gradually to improve. On the 18th the bath and ergot again caused some discharge and pain, the os was slightly open, the cervix being situate far back, and the fundus forward. The uterus gene- rally was more moveable, smaller, and less heavy; there was no tenderness. Pulse 80. Ordered, absinth, and five grains of ergot three times a day. After this she continued to improve ; there was less and less pain, and the tumour gradually diminished. By the 22nd the discharge and pain had stopped, but the uterine colic returned while in the bath, accompanied by some discharge. The uterus remained anteverted, the os open and soft, but there was no tenesmus. It is unnecessary for me to make any remark on this case, or to show that the menstrual retention, so sharply characterized as it was in this case, could not be caused by the slight old-standing antever- sion, since this deviation caused, no doubt, by the former pelvic ali'ec- tion, which terminated in a purulent evacuation by the rectum, did not 58 MENSTRUAL RETENTION. occasion any difficulty in menstruation during the preceding seven years. Unfortunately we cannot say the same of the following case : — Case XXIX. — Sudden suppression of menses from waslimg in cold water; symptoms of peritonitis ; formation of hypogastric tumours; re-establishment of the flow; corresponding diminution in the tumours; rapid recovery ; induration of the left broad ligament. A womaU; aged 26, was admitted into the St. Antoine Hospital, 24th October, 1844, she began to menstruate at 15, and had con- tinued regular ever since. At 17 she married, but had never been pregnant. A fortnight previously she washed the vulva with cold water during menstruation, which was thereupon checked. After this she complained of some abdominal pain, especially in the right iliac fossa, which was not relieved by either baths or poultices. The last three or four days she had become w' orse, with a feeling of general malaise and tenesmus vesicae. Soon after her admission the pain be- came much worse, but intermitted with intervals of perfect ease; there was some tenderness all over the abdomen, which was worse on pressure, especially below and in the left iliac fossa. Behind the left Fallopian ligament a tumour was felt which by its position appeared to be independent of the abdominal walls. It adhered to the uterus which was somewhat drawn from the pubis, it was also higher than that organ. The cervix was enlarged, and only about half-an-inch from the vulva; the uterus was slightly moveable, but could not be inclined to one or other iliac fossa, it could be lifted a little. Movement of the cervix affected the iliac tumour ; pulse 80 ; skin cool ; she w^as ordered a purge and to be bled to sixteen ounces. On the 26th she had not slept the previous night, and was in such pain in the right iliac fossa that she could not move ; the abdomen was very tender on pressure. Thirty leeches were applied to tb.e upper part of the thighs, and poultices to the abdomen. On the following day she was not so well, and the leeches were repeated. After this she was much relieved by a discharge of blood from the vulva. She was ordered Seltzer water, lemonade, poultices to the abdomen, and an electuary. On the following day she began gradually to improve, the pain and tenderness diminished, as did the abdominal swelling. The cervix uteri was left depressed, and the entire organ enlarged. For a time she was obliged to lie on the right side. On the 1 4th November she was discharged cured. CAUSES AND VARIETIES. 59 I have allowed this case to occupy the place which I gave it in my first memoir,"^ in order to show that the explanation I then gave of it was not correct. I now recognise that it does not belong to the variety wherein I had ranged it. An analysis of the symptoms which this patient presented, and the order in which they occurred, shows that the dysmenorrhccic pains indicative of the functional disturbance, did not come on till the evening of the day of her admission. Before that, the symptoms were those only which resulted from the con- dition of the generative organs induced by the patient's M^ashing in cold water during menstruation. Thus the difficulty of the excretion, instead of being the cause of the inflammatory affection of the uterine mucous membrane was, on the contrary, the result, and, in this respect, resembled retention of urine occurring in cases of inflammation of the neck of the bladder. Regarded in this light, the menstrual retention was, as it were, secondary to the traumatic inflam- mation, which affected the generative organs at the end of the catamenial period. This became more marked on the return of the next menstrual period, and involved either the left tube or ovary. Then pelvi-peritonitis followed, not from the migration of blood into the abdominal cavity, but merely by contiguity of structure. It is unnecessary for me to dwell longer on this subject which I shall have again to discuss at length in a succeeding chapter.t I ought, however, to state, that we can never hope to produce a return of menstruation until the peritonitis has subsided. I have taken care to insist on the error committed in my former remarks on this case, and to make it understood that it arose from my not having sufficiently studied the order of the occurrence of the symptoms. In the investigation of the diseases of the female gene- rative organs, it is of the utmost importance to study the order in which successive symptoms arise, indeed this order often constitutes one of the principal elements of diagnosis. Case XXX. — Suddeii suppression of menses from fright and cold; accession of symptoms lohich increased daily in severity ; amenor- rhea for three months with aggravation of symptoms ; at the fourth * G. Bernutz, yircliires generales, Joe. cit., t. xxvii. p. 452. t Pelvi-pcritoiiitis. See also Q. Bernutz and E. Goupil, Rcchcrches cliniqucs sur lea phlegmons peri-uterine (Obs. II.), Arch, gener. de medec, 5= serie, t. ix. p. 209. 60 MENSTRUAL RETENTION. period expulsion of black li(piid blood with violent titerine tenesmus; cure. A. B., aged 18^ had her menstrual period suddenly stopped through frightj and was immediately seized with severe abdominal pains, which, with other inflammatory phenomena, increased in severity for several days though she did not lay up for it. During the three following menstrual periods she had to keep her bed owing to the severity of the pain, no discharge appeared. Antiphlog-istic treat- ment was resorted to at the fourth period, and this was followed by the expulsion of some dark blood after a violent attack of uterine tenesmus. At the succeeding epoch all passed ofP naturally. M. Duparque remarks upon this case, " When the skin is chilled in females, it excites by a sort of sympathetic influence a spasmodic contraction of the os uteri. The same thing takes place under the influence of mental impressions ; in the rigors of intermittent fever, &c. Wlien these causes are in operation at the beginning of men- struation, or at the approach of the menstrual molimen, they prevent the preliminary stage of congestion, and thus amenorrhoea occurs without there being any uterine affection. But when the menstrual molimen is in full activity, the suppression of the flow is followed by local phenomena which indicate a morbid condition of the uterus, as was met with in the preceding case. It is very desirable to recognise that in these cases, the amenorrhoea is not the disease, but an effect, a symptom or consequence of the uterine lesion. " That class of medicines called emmenagogues, which are mostly taken from the stimulant order, whose effect is to provoke or increase uterine congestion, cannot be otherwise than hurtful. Bleedings, emollients, and baths, are the best means of dissipating the conges- tion and of reducing the uterus to its natural condition, so as to fit it for the performance of its ordinary functions."' It is evident that as applied to the foregoing case, these remarks are entirely hypothetical. There is no proof that the fright which stopped the flow produced a congestion. The dull, heavy pain in the hypogastrium, the creepy chilliness and sense of suffocation which the patient experienced almost instantly, these are not indicative of uterine congestion. The more violent pains in the loins and hypogastrium, the increased volume and firmness of the breasts, and the loss of appetite, &c., these do not favour such a CAUSES AND VARIETIES. 61 diagnosis. They all, with the exception of the hypogastric and lumbar paius, occur in the case of uterine repletion, no matter what the cause ; M. Duparqne himself recognised their analogy to those which occur in pregnancy. Granting, however, that there was in this, as in preceding cases, repletion of the uterus, I wiUingly allow that this may have been produced through sympathy ; but then I hold that this would give rise to a spasmodic contraction, not of the exhalant orifices merely, if at all, but of the neck of the uterus, and especially of the cervico-uterine orifice. This supposition limits the spasmodic act to a purely muscular organ, and in all probability such a spasm occurs in a modified form during every menstrual act. It would appear in short, that menstru- ation, abortion, and labour, present the same physiological travail ; the difference between them is simply one of degree and as to the charac- ter of the ejected product. Modern investigations point to the con- clusion, that the expulsion of a non- fecundated ovule occurs at every menstruation, that abortion is the expulsion of an ovule arrested in its development ; and labour that of a viable product. When under these latter circumstances there exists contraction of the neck of the uterus, the uterine action is more energetic and pain is felt in the lower j)art of the back and stomach. If the expulsive elTort remains without effect, the repletion is increased at each succeeding menstruation, but whether in M. Duparque's case the obstacle was caused by simple contraction of the cervix cannot be determined as no note of its condition is made. The fact of engorgement is, however, admitted ; for M. Duparque remarks, " All causes which excite congestion in excess of the exhalant power of the uterus may occasion an acute or chronic engorgement of that organ.'" Such a condition occurs sometimes through the irritating influence of a foreign body when the uterus tries to exj)el it. It may also give rise to a state of retention, but I confess I do not under- stand how the causes acting in the case just cited could have instan- taneously produced such an engorgement as suddenly to arrest the flow. There is no doubt that congestion of the uterus can and does produce suppression and retention and occasions severe uterine action. In the case now quoted such was the condition, and only after the adoption of antiphlogistic treatment was the obstacle over- come so as to enable the escape of the menstrual fluid. Until this 62 MENSTRUAL RETENTION. took place the pain continued, but it ceased so soon as the uterus was relieved of its contents, and thereby enabled to resume its proper functions, which it did after a month's rest. The remarkable feature in all the cases recorded under the fourth head, is the sudden suppression of the flow during menstruation. In Cases XXVII. and XXIX., where the suppression occurred some few hours after the commencement of the discharge, the result- ing symptoms were very serious. As a rule it will be found that the severity of the symptoms is proportionate to the amount of dis- charge, the escape of which is prevented. In Case XXVIII. where the retention occurred only towards the end of the period the com- plications were comparatively slight. In cases of spasmodic contraction of th6 cervix uteri similar phenomena result. These are generally met with either in hysterical or chlorotic persons, or where there is some congenital defect which is common perhaps to all the female members of a family, being, in short, a kind of neurosis similar to that of asthma. This form of dysmenorrhoea usually terminates spontaneously after a few hours or days of suffering by the production of the catamenial flow, after which, and until the follo\\dng period, all appears to be quite well. Section YIII. — menstrual retention from abnormal conditions OF THE fallopian TUBES. Difficulties of a very different order are met with in the cases now under consideration, namely, those where the menstrual retention is caused by some defect, congenital or acquired, of the Fallopian tubes, especially at the ostium uterinum. Indeed in these cases uterine symptoms, properly so called, are completely wanting. The ex- pulsive effort which characterizes dysmenorrhcea instead of being situated in the womb, is here limited to the tubes. Hence the diffi- culty of diagnosis ; for hitherto this affection has not been studied ; and, moreover, the physical signs derived from a digital examination are very easily mistaken. The number of recorded exam})les of this kind is consequently very limited ; indeed I have only been able to collect the three following, which I may arrange in one group, though they present very important differences. The first is an example of congenital imperforation of the tubes ; the second, of inffammatory obliteration of those parts ; and the third, an instance of narrowing of the ostium uterinum by an organic growth. CAUSES AND VARIETIES. 63 Case XXXI."^ — Absence of menstruation till the twenty-fourth year ; accession of lumbar and abdominal pains ; dysmenorrhea ; forraa- tion of a tumour in the lower part of the abdomen simulating retro-uterine hematocele ; sanguineous discharge from the vagina, supposed to be menstrual ; puncture of the ttimour ; death. Post- mortem examination ; imperf oration and great distension of both Fallopian tubes ; phlebitis. A. W., aged 28, was admitted into the Hospital Beaujon, October 4th, 1817. She had never menstruated, and up to 24 years of age had had no symptoms referable to the generative organs ; she then had pains in the loins and hypogastrium, and these recurred every month for four years. During the last two years a swelling the size of an e^i' had come at certain times on the riu'ht side of the hypogastrium ; she did not know whether this was afl'ected by qjen- struation. She had pain in passing water^ but no constipation. There was duluess on percussion over the lower part of the body with some tenderness, and a swelling was felt in the situation mentioned above, which was absolutely dull. On examining, per vaginam, a tumour the size of a foetal head was felt occupying the entire brim of the pelvis; it was hard, tender, and painful ; no fluctuation. The cervix was to the left side ; the uterus retroflexed and only its left side coukl be felt, the right being lost in the tumour. The cervix was small, like that of a woman who had never borne children. For two months she remained much the same; had emollient and anodyne applications, and iodide of potassium rubbed in. On Novem- ber the 15th she had rigors, followed by fever; pulse 120. There was a slight discharge of blood from the vulva. By the 23rd the discharge had increased somewhat; the feverishness had subsided, but to-day it increased again with more pain; twenty leeches were applied to the abdomen. On the 24th the abdomen was tender on pressure externally, and also per vaginam. The tumour was hard and tender, the feverishness remained, and there was slight dis- cliarge. December Zrd. — M. Iluguier introduced a trocar into the tumour by the abdomen hoping to come upon adhesions ; a pint and a-half of chocolate-coloured fluid escaped. The tumour was found to be ; r-a rn ■- — ..— ^»^. • Besnier. Bulletins de la Societe unat, dc Paris, 2" seric, t. iii. juin, 1858, p. 286. 64 MENSTRUAL RETENTION. firmly adherent to both bladder and rectum. In the evening after the puncture a shivering fit came on, followed by great pain in the abdomen. Mercurial inunction was ordered ; twenty leeches ; and croton oil to the thighs. On the 7th she was much better. On the 8th Huguier introduced a trocar, per vaginam, and a pint of extremely foetid bloody fluid escaped, followed by a foetid gas. Iodine was then injected, and a bougie was kept in. In the evening shivering came on with vomiting ; pulse 130 ; extreme pain in the abdomen; twenty-five leeches were apphed. On the 9th she was better ; warm water was injected, which returned foetid and of a yellow colour. On the 10th she was much worse and appeared to be sinking ; counter-irritation was resorted to, with warm-water in- jections. On the 11th and 12th iodine was injected and a foetid discharge followed. Huguier thought that gangrene of the cyst had occurred. During the next week she improved; the tumour diminished in size, and the dulness on percussion over the abdomen was less in extent. From December the 24th to the 30th she gradually became worse and worse, and sank from exhaustion and diarrhoea on the 4th of January, 1858. Post-mortem examination. — On opening the abdomen diffuse peri- tonitis was seen, and some black, foetid pus was found in the pelvis. Adhesions abounded everywhere. The liver was enormously enlarged and friable ; the rectum, uterus, broad ligaments, and bladder were covered with false membrane. The left Fallopian tube was dilated in all its extent ; at its lower free portion corresponding to the ovary were two cysts, the size of a pea, containing a clear, transparent, colour- less liquid ; and at the free end was a tumour the size of a pigeon^'s egg containing some semi-fluid chocolate-coloured matter. There was no opening between the uterus and the tube. The left ovary was smaller than usual. On the right side of the pelvis was an irregularly-shaped pouch, which at its inferior part was in a state of gangrene, its walls being rugose and contracted. The size of the whole was that of an adult's fist. The uterus was healthy ; the right tube and ovary could nowhere be demonstrated. The super- ficial veins of the right arm, the axillary and subclavian, were all filled with coagula, which extended into the brachio-cephalic and superior vena cava, as also the right external jugular vein. Yery much the same condition existed on the left side. The internal jugulars were both healthy. CAUSES AND VARIETIES. 65 Case XXXTL* — Menorrliagia ; symptoms of internal effusion from mental emotion ; death. Post-mortem examination ; intra-abdomi- nal effusion of blood from rupture of a cyst formed by the right Fallopian tube, the uterine orifice of which was closed by a fibrous tumour. A lady, aged 28, had always enjoyed good health till some months before her death ; she then had menorrhagia which increased and continued so long that it was thought to have been a miscarriage. During a time of severe mental trial, she was suddenly seized with violent pains in the abdomen, fainting and vomiting. There was tlien no discharge. She sank soon after with symptoms of internal haemorrhage. Oxv post-mortem examination a good deal of blood was found in the abdomen and pelvis. All the organs were healthy except the left Fallopian tube, which presented a tumour the size of a pigeon's-egg ; this was ruptured, and, on its surface, was a small transparent cyst covered with filaments of the tube. At its junction with the uterus, this tube was rendered impervious by a small fibrous tumour. Case XXXIILf — Metro-pelvi-peritonitisfollowi'ng labour ; amenor- rhea ; death from pneumonia fourteen years afterwards. Post- mortem examination, tumour formed by retained menstrual fluid in, both Fallopian tubes ; obliteration of the tubes. A woman, aged 36, stated that she began to menstruate at 16, that she married at 21, and was delivered of her first child at 22. Three days after she had a severe inflammatory attack which appears to have been one of metro-peritonitis. She was bled freely and recovered, but since then has never menstruated, nor been preg- nant again. Every month she experienced symptoms of menstrua- tion, but none came. She died of pleuro-pnenmonia. On making an examination after death the tubes were both found to be dilated to the diameter of an inch, and contained a broAvn, viscid, inodorous fluid. Both ends of the tubes were perfectly closed. The parts are represented in CarswelPs Atlas, Plate XVII. • Fauvcl. Biilletinn dc la Socicte anat. dc Paris, xxx" annee, 1855, p. .'505. f HerqiKTel. TraitS clinique des maladies de FutSruJi et de ses annexes. Paris, 1859, t. ii. p. 278. / 66 • MENSTRUAL RETENTION. The priucipal feature in each of these cases was the distension of the tubes with blood : in the first case this was due to con- genital imperforation ; in the second to the existence of an organic constriction ; and in the third to cicatricial obliteration. The state of repletion common to them all, and its periodical increase at each nienstruation proves unmistakably that these organs play an im- portant part in this function, and that when the product of excretion is prevented from escaping, the tubes become transformed into blood- cysts. It is important to bear this in mind as it throws light upon the vexed question of the formation of tubo-ovarian cysts. When blood is thus effused into the Fallopian tubes it undergoes the same modifications as take place under similar circumstances in other ports of the body, consequently the blood is soon replaced by fluids which resemble those contained in certain cases of en- cysted dropsy of the ovary. These three cases justify our attributing the origin of a certain number of diseases arbitrarily comprised under the name of encysted dropsy of the ovary, to a defect in the menstrual excretion, as I pointed out in my memoir in 1848, and they specially point to this as the cause of a large number of tubo-ovarian cysts. Happily, in one of the cases above detailed^ the menstrual secre- tion ceased, and with it the further distension of the tubes ; the blood therefore remained encysted, and formed a tumour on each side of the uterus, but did not otherwise interfere with health. In the two other cases, on the contrary, the distension was carried to such a point that rupture took place, the blood extravasated into the abdo- minal cavity, and gave rise to a fatal hsematocele. These various terminations enable us to demonstrate anatomically the lesions which exist at different periods of the same morbid process, and they exactly illustrate what I have previously described as belonging to the last stage of menstrual retention — only in those which we are now considering the uterus remains meanwhile intact. The case published recently by M. Meniere illustrates what I have described as the second stage of menstrual retention, that which is characterised by distension and repletion of the uterus and tubes ; while the two other cases represent the third stage, namely, rupture between the tube and the ovary, and the consequent escape of the retained blood into the abdominal cavity. The remarks which I have previously made in reference to stricture of the cervico-uterine orifice apply CAUSES AND VARIETIES. 67 mutatis mutandis to the ostium uterinum of tlie tubes. All seems to establish the law that any obstacle to menstrual elimination in a part of the tubo-utero-vulvar canal^ leads first to dilatation^ then to distension of every part of the canal posterior to the seat of obstruction ; and, when the repletion is carried to an extreme point, to the effusion of the retained blood into the abdominal cavity. The principal difference refers to the cjuestion whether the uterus is or is not distended. In the former case the organ reacts upon the contained blood, and this contraction is the cause of dysmenorrhoea. In the latter the uterus is almost completely passive. Whether or no blood which is poured into the uterine cavity will regurgitate into the Fallopian tubes must depend upon the situation of the stricture in the tubes. No doubt the efficient cause of the escape of blood into the abdominal cavity is the distension of the Fallopian tubes, and this may arise either from a difficulty in the escape of their secre- tion into the uterus, Avhether this be due to a stricture of the ostium uterinum, or to an already distended condition of the uterus itself, in which latter case it resembles pulmonary congestion from aortic con- striction ; or, it may arise from a regurgitation of the uterine secre- tion into the Fallopian tubes by the contraction of the uterus upon its contents. Here the resemljlance is to pulmonary congestion from aortic constriction, coupled with insufficiency of the mitral valve. The reflux of blood from the uterus into the tubes is then one of the causes of the extreme distension which these organs undergo in cases of menstrual retention, and of the consequent passage of blood into the abdomen. But it is not indispensable that these two conditions should exist. They do not, indeed, occur in the eighth class : here the absence of uterine symptoms separates it from all other forms of this affection. In the two first varieties of menstrual retention, arising either from congenital imperforation of some part of the vulvo-uterine canal, or from an occlusion of the vagina or uterus occurring after puberty, the impediment cannot disappear spontaneously. The extreme gravity of the symptoms therefore invariably necessitates the having recourse to artificial measures for the establishment of the catamenial functions. The frequent occurrence of a fatal termination after the performance of these operations, though it inspired Boyer with an invincible repugnance to such interference, would seem to indicate the necessity for early operation. We ought, indeed, if possible, to operate before the genital organs have undergone any very marked distension : for, /2 68 MENSTRUAL RETENTION. under these circumstances, even the simple puncture of a distended hymeneal membrane may be followed by the passage of blood along the tubes into the abdominal cavity, aiul lead eventually to death. In the tliird variety, where menstrual retention is caused by con- genital or acquired atresia of the vulvo-uterine canal, surgical interference may be equally necessary. This, however, only occurs where the coarctation of the vacrina or cervix is carried to such a point that it is the efficient cause of the defective excretion. In other cases, nature alone, aided perhaps by medical treatment adapted to the circumstances, suffices for the re-establishment of the function. But, after any such improvement, attention slioukl be directed to tlie vulvo-uterine canal, to determine whether the constriction is really the cause of the inflammation of the cervico-uterine mucous mem- brane, or of the engorgement of the cervix upon which the retention depends. Because the indication then is to remove this constriction, and with it the difficulty in the excretion. In the fourth variety, those, namely, wliich are due to an enlarge- ment of the cervix, whatever may be its nature, there are several indications to be attended to. In all of them, the mechanical nature of the obstruction is the same, and they all indicate the necessity for dilatation. But the nature of the hypertrophy being so dissimilar, no one mode of treatment is applicable to all. Both the prognosis and treatment must necessarily vary according as the cervical enlargement is due to congestion, to acute or chronic inflammation, or to any organic deposit in the cervix, whether of a benign or malignant charactier. In the former, indeed, the treatment must recognise whether the deposit be limited to the cervix, or whether it invades the body of the uterus. The same indications hold good in one of the cases of the fifth variety, where, for instance, a polypus obstructs the cervix uteri. Here it is necessary, first, to dilate the os, and, then to remove the polypus. In other cases, those namely of pseudo-membranous dysmenorrhoea, the obstruction is, as it were, a secondary phenome- non, caused by the menstrual secretion itself being enveloped in an exfoliation of the uterine mucous membrane. Here, inflammation of the lining membrane of the uterus, which interferes with the proper dilatation of its cervico-uterine orifice, is the real cause of obstruc- tion. Nature will, in many such cases, remove the difficulty, but it surely reappears if the catarrhal affection of the uterus remains. The indication then is to reduce this inflammation, and as this is generally CAUSES AND VARIETIES. 69 a diathetic mauifestatioUj treatment ought especially to be directed to that object. The remarks now made on the fifth variety are almost equally appHcable to the sixth, that is to cases of menstrual retention depen- dent on some form of uterine flexion. The retentions composing the seventh variety, viz., cases of spas- modic contraction of the cervix, may be arranged in two classes, each diflering from the other both as to prognosis and treatment. In the one, indeed, the uterine spasm, due either to mental emotion (Case XXVIII.), or to some physical impression (Case XXIX.), or to the two combined (Case XXX.), may spontaneously disappear after a few hours^ or days' duration, and the re-establishment of the flow may take place before the functional disturbance has led to any organic change. This is so frequent a result that I have not thought it worth while to quote an example, for the physician is very rarely consulted in such cases. In purely nervous dysmenorrhea, due either to an hereditary pe- culiarity of the nervous system, or to some other affection ; the prin- cipal indeed, the first indication, is to combat that upon which the menstrual retention depends. Here the intervention of an acci- dental cause is unnecessary. The chief characteristic of these cases is, a monthly repetition of an extremely painful expulsive effort, coming on without any apparent cause, and lasting for a certain time before the actual appearance of the catamenial secretion : the latter usually leads to an abatement of the suffering. In spite of the intensity of these pains which are sometimes so acute that the patient will writhe in bed ; the prognosis is generally less grave than that of any other variety, at least, as regards the question of life. Usually at the end of a limited number of days or even hours, uterine contractions become regular and complete the expulsion of the menstrual product. It is very seldom in these cases that we meet with any disease, either of the cervico-uterine mucous membrane, or of the parenchyma of the cervix as a result of the dysmenorrhoea. Nevertheless, the prognosis is to some extent unfavourable, inasmuch as there is a great tendency to perpetuation, and they also share in the almost utter incurability of the allection from which they proceed. The hysterical dysmenorrhoea is not uncommon : indeed, dys- menorrhcjua is very often the first indication of that disease. Still this does not justify the opinion of Scanzoni '^ and others, that the • De Scanzoni, tradtict. fran^atse, pp. 106, 157, 163. 70 MENSTRUAL RETENTION. uterus is the seat of hysteria. It is impossible indeed to localize that affection, it is one totius suhstcmtia., an abnormal physiological con- dition which modifies all the organic actions, and reveals itself rather by dynamical disturbances of the several functions. It may, therefore, disturb the genitalia in common with the rest, though it need have no necessary or constant connection with them. I may content myself with this simple expression of my opinion, as it might other- wise, if I did not allude to it, be thought strange that I have omitted it from the consideration of nervous dysmenorrhoca. But to resume our subject : I have specified the leading characters of the eighth variety, which is distinguished especially from all others, by the fact that the obstacle is situated at a part of the vulvo-ovarian canal beyond the uterus, namely, in the Fallopian tubes, the uterus itself taking no, or but a small part, in the pathologal travail. The symptoms ought, no doubt, to vary according to the nature of the obstacle and the different conditions under which it occurs : as for instance, whether there be obliteration or merely constriction of the oviduct. It is, however, impossible to particularize and enumerate all these. The cases which I have recorded illustrate the differences between tubar menstrual retention arising from congenital imperfora- tion, and that due to obliteration occurring after puberty. The conditions which give rise to retention differ not only as re- gards their termination, but also as regards their commencement and progress : and these are important questions in reference to diagnosis. In congenital defects of the vulvo-uterine canal, the symptoms com- mence at the period when puberty is being established, and before any discharge has occurred; one is then disposed to attribute them merely to difficulties in the establishment of so important a function in the female economy. In such a case there has been little or no antecedent disturbance; there is an almost absolute calm between the several attacks of pain, the exacerbations are infrequent and irre- gular, and there is usually but little reaction on the constitution.. The genital organs then become enormously distended by menstrual secretion, and herein lies the great danger of operating. In all the other varieties the retention is preceded by a certain number of menstrual periods at more or less regular intervals; the mischief occurring at a variable time after puberty is established. In spite of this distinguishing feature of congenital imperf oration, the onset of the first and second varieties presents a close analogy CAUSES AND VARIETIES. 71 in those cases where the cicatrix completely closes the excretory canal. The analogy to which I refer is not met with in any of the next five varieties : there is not only absence of menstruation^ but even of all sign of menstrual moliraen^ and the symptoms resulting from this commence with the retnru of the menstrual period after the patient^s recovery from that which was the fons et origo mall. Thus, when the cicatrix results from difficult labour, the first dis- turbance begins some six, eight, or more weeks afterwards. But whenever it commences it is always in connexion with the re-establish- mcnt of this function; the time which elapses between the formation of the cicatrix and the return of menstruation varies according to the severity of the disease or of the operation which w'as the imme- diate cause of its formation. In Case XI., for instance, the symptoms began at the succeeding period, while in Case XIV. three periods elapsed, and in the case of gangrene of the vagina, communicated by M. Goupil, nearly nine months passed before menstruation was at- tempted. There are other points of resemblance bet-ween these first two varieties, viz. : as regards their commencement ; they usually begin with slight symptoms which go on uniformly increasing in severity month by month, and though the earlier symptoms may be milder, and the reaction upon the system at first be less serious, yet these cases are far more mischievous than those of congenital imperfora- tion : for while the latter will allow of a precarious existence often for years ; the former compromise life in a few months. Where there is, instead of complete obliteration of the canal, only a constriction which renders the excretion difficult, but not impossible, as in Case XII., the dangers are then greatly retarded, the reason being that time is given for the development of other phenomena. Those which constitute our third, fourth, fifth, and sixth varieties are distinguished from the two first, by the fact that the retention, instead of being subsequent to a more or less complete and prolonged suspension of the menstrual flow, is generally pre- ceded for a longer or shorter time by dysmenorrhoea ; that is to say, bv transient retention of the catamenial secretion ; this is reco":- iiised each time by the production of a nioi'c or less painful expul- sive efi'ort. The diflerences wiiicli I have pointed out in the intensity and rcguhirity of the retura of tlic dysmenorrhccic accessions, whether 72 MENSTRUAL RETENTION. they are produced each month, or at irregularly lengthened periods, may serve in many cases to distinguish the different contractions one from another. Thus according to the regularity or irregularity of the attacks we may divide cases of obstructive dysmenorrhoea into two groups ; the first, to which tlie name mechanical dijsmoiorrhcea may be given, comprises not only those which result from congenital atresia, to which English authors limit the term, but those also which are determined either by cicatricial contraction, or by increase in the volume of the cervix, or by polypus. They are distinguished from other varieties by the regularity of the monthly return of pain, by its equal severity and duration, or by its regularly increasing severity, the menstrual parturition being accomplished with more or less difficulty according to the amount of obstruction, and the condition of the genital organs. The regularity and persistence of these attacks makes them liable to be mistaken for neuralgic dysmenorrhoea, and the difficulty in diagnosis is increased by the frequent coexistence of a morbid con- dition of the uterine mucous membrane, which destroys the distinc- tive features of mechanical dysmenorrhoea. In the several varieties of dysmenorrhoea symptomatic of inflam- mation of the uterine mucous membrane, the obstacle is due to temporary defective dilatation of the uterine orifice. They are dis- tinguished by the irregularity of the attacks, according to the severity of the catarrhal metritis. When the condition of the uterine mucous membrane has resulted in an hypertrophy of the cervix, the dys- menorrhoeic attacks occur every month, though with varying inten- sity. The differences and irregularities which characterise these varieties make them liable to be confounded with those due to chlo- rosis, ansemia, or hysteria ; the more so as these latter conditions often lead to uterine catarrh, so that it is difficult to discover whether the dysmenorrhoea is due to defective dilatation of the cervico-uterine orifice from the presence of catarrhal inflammation, or whether it is caused by a purely dynamical spasm. The seventli variety differs from all others in this, that the retention follows upon a sudden interruption and cessation of the menstrual flow, whether produced by physical or mental impres- sion. The suddenness of the suppression in the middle of a period, the continuance of expulsive pains, the subsequent distension of the uterus, the occasional escape of a certain quantity of altered CAUSES AND VARIETIES. 73 blood, aud the severity of the symptoms according as the sup- pression occurred on the first or subsequent days, all these have led me to attribute the retention which occurs under these circumstances to a state of contraction of the cervix, analogous to that which occurs during labour. CHAPTER II. SYMPTOMATOLOGY. The sj^mptoms of menstrual retention, tliougli slight at first, especially in the two first classes, are, as I have said, generally related to the quantity of fiuid contained in the uterus. During the first period they are : — the absence of the menstrual flow, a sense of weariness and weight in and about the pelvis, and the recurrence of intermittent pains passing round from the lumbar to the pelvic regions. These pains remain throughout the period, and even con- tinue afterwards when, perchance, expulsive efforts set in, as in Case XXVIII., and bring about a cure of the retention, even during the first period ; but if these efforts fail, the pains in a few days diminish. Sometimes the only appreciable symptom left is a sense of weight in the hypogastrium, which is increased by fatigue and especially by walking. When, after the usual prodroma, the discharge does not come on, the symptoms assume fresh activity. But a variety of circumstances so modify the result that in one case symptoms which occur at the first period may not in others be met with till the fourth. During these periodical exacerbations tlie hypogastric weight increases, and there is painful defaecation and micturition. The uterus enlarges, the fundus rises while the cervix is depressed, its labiee are thickened, and the cavity is dilated. The body also is anteverted. At the same time tumours of greater or less size appear, either in the iliac fossa parallel with the Fallopian ligament, or in the right or left vaginal cul-de-sac. They are connected either with the sides of the uterus or with the posterior surface of the pubis, the movement of the former being communicated to them. They are tender, elastic, and obscurely fluctuating, and as they increase in size the uterus becomes fixed in its normal or abnormal position, according as the tumour is fixed to one or other side. The pains are for the most part irregularly intermittent, spasmodic, and cramj)y, resembling those of labour. They are generally well marked, as in Case XIII., where they simu- SYMPTOMATOLOGY. 75 lated those which the patient had experienced in a previous Labour, and during each expulsive pain the uterus was felt to undergo con- traction, the tumour at the same time becoming sensibly larger and more tender. In Case XXVIII. the resemblance of the pains to those of labour was shown yet more by the fact that they ceased under the influence of laudanum injections, and were afterwards increased by the administration of ergot. When the uterine contrac- tions are unable to overcome the resistance of the cervix, they force the incompressible liquid upon which they act into some abnormal passage, which thereupon finds its way into the peritoneal cavity and sets up inflammation. I may, however, remark, that this is not the usual way in which peritonitis is occasioned in these cases, as we shall see in the Chapter on Pelvi-peritonitis ; it appears to be pro- duced by a sort of reaction upon the peritoneum from the genital organs being distended with the catamenial secretion. Among the remote symptoms, the more prominent are those resulting from the nervous erythisra produced by almost constant suffering. To this cause are attributable the sense of anxiety and impatience, the continued agitation and restlessness, the sense of suffocation, the violent palpitation, or syncope, the hysterical con- vulsions, and other nervous phenomena ; to the same cause are due the loss of appetite without much thirst, the occasional rigor and slightly accelerated pulse. Precisely the same thing happens occasionally in labour, where the nervous system unduly participates in the struggle. When the expulsive effort remains ineffectual, little by little these symptoms diminish with the decadence of the menstrual epoch. The distension of the genital organs, and the difficulty in micturition and defalcation, decreases ; while the tingling sensation in the thiglis, the weight in the hypogastrium, and the intermittent pains, gradually disappear. In like manner the nervous phenomena cease, or are re- placed by others of less importance. This improvement continues up to the return of the next period, when the symptoms reappear with, probably, greater intensity, and seldom cease again so completely, thougli the aggravation of the symptoms is more maiiifest during than after the period. Gradually thc.>^e exacerbations become less s(;vere as the catamenial secretions dimiuiish in quantity, till sometimes they cease altogether, after th(! system has been sorely tried by the long-continued menstrual re- tention. This circumstance, and the changes which take place in the 76 MENSTRUAL RETENTION. effused blood, considerably modify the attendant symptoms. These I shall consider further on in reference to the steps adopted by nature for rendering such a foreign body innocuous ; we shall see that the curative efforts of the organism tend to bring this about in two ways. In the one, the morbid phenomena represent merely an exagger- ation of the ordinary properties of the uterus. In the other, on the contrary, inflammatory action and, after awhile, suppuration, is set up round the tumour, and the foreign body disappears in the process of suppuration. The excitation of uterine contraction gives rise to a discharge of blood which varies according to the duration of the retention, the quantity of the retained fluid, and the amount of relief afforded by it to the congested orgaus. This salutary effort occurs at different periods ; in one case it happens within a few days of the occurrence of retention, in others two, three, four, or more months may elapse. In the majority of cases a hsemorrhage continues more or less abundantly, according to the extent of disease. When the retention has existed for several months, a discharge of blood by drops goes on during the interval, and ceases only when the uterus has relieved itself by a final effort of the last remains of the retention. To this sort of dis- charge M. J. P. Prank gave the name of amenorrhee distillaute.* These peculiarities, no doubt, exercise an influence over the ejected fluid, but it is always difficult to appreciate the circumstances which occasion decomj^osition of a fluid retained in a central cavity : in one case it may occur in a few days; in another not for several months. The latter, however, occurs only in cases of complete occlusion, whether congenital or acquired, where ail contact with air is impossible. The quantity of discharge is also subject to considerable varia- tion, according to individual peculiarities. As a general rule, it is proportionate to the number of periods passed over. Thus in Case XXVII., where only one period had elapsed, the discharge was equal to that of an ordinary period ; while in cases of congenital imperforation, where a great many periods have passed by, the quan- tity of blood evacuated is in general very considerable. It is remarkable also that these sanguineous discharges do not in any way j)rejudicially affect the general health ; and this is impor- tant in regard to diagnosis in those forms of hsematocele in which * J. P. Frank, traduit par Goudareau, he. cit., t. v., p. 229, 234, et suiv. SYMPTOMATOLOGY. 77 tlie intra-peritoTical effusion of blood is the result of a liremorrhagic diathesis. The various discharges of blood to -which women are subject explain the differences in their results. In tlie inenorrhagia which is syni])tomatic either of a diathetic condition^ or of some uterine affection, the discharge of blood which is necessary for the purposes of life, modifies its composition, and thus originates a condition of body exceedingly prone to other morbid pheno- mena. In cases of retention, on the contrary, when the discharge conies on it is mostly of that only which had been retained, and does not therefore seriously affect the constitution. The real cause of tile debility and emaciation which often occurs in these cases is the ])rolonged continuance of pain, and tlie occurrence of inflammation in those parts where the effused blood remains as a foreign body. The discharge of blood which thus happily terminates the retention, is usually accompanied by contractions of the uterus, and resistance is sometimes offered to the process of dilatation of the cervix, which gives rise to a fear lest the blood should escape by some abnormal way. It is under such circumstances that authors have feared rupture of the uterus.^ This fear, it seems to me, is unfounded where the uterine walls are free from any alteration beyond the mere distension; at least, I know of no case in which rupture has occurred when uterine the walls were free from disease, benign or malignant. I cannot conceive how rupture of the uterus could occur under these circumstances, since retention of the menses would dilate all the genital tract, and make of it one tortuous canal, each part of which would be variously distended according to its contractile force. The result would be to drive the incompressible fluid into the Fallopian tubes, the w^alls of which are less resisting. Then the feeble union between the ovary and the tube would be broken down, and through the opening of the latter the retained fluid would escape into the abdomen. This escape immediately gives rise to inflam Illation of the serous surface, and is characterised by some symptoms jieculiar io this variety of peritonitis. Hiere is, first, the time and circumstance of its occurrence ; secondly, the formation immediately after of a pelvic tumour or tumours in close relation to the uterus ; and thirdly, the accession of severe pain in and about the pelvis, especially in the iliac fossae. As a v\\]r, T believe there • Dance, loc. ciL, Archives g^n. de medecme, V^ serio, t. xx. p. 530, et suiv. 78 MENSTRUAL RETENTION. is no rigor, or at least not until some hours after the attack has begun. After a time the pain becomes exceedingly severe, and the patient very restless ; the former is such that no examination can be borne. Soon respiration is quickened, and becomes short, jerking, and tremulous from the pain which movement occasions. I have observed often a peculiarity at this stage in the condition of the abdominal walls — viz., a state of contraction and rigidity, which seems created for the purpose of protecting all parts of the inflamed serous mem- brane against external pressure. After awhile the abdomen becomes tympanitic and greatly distended. The gaseous secretion, as well as the nausea, vomiting, and constipation which are usually observed in peritonitis result from the disturbance which is created in the diges- tive function. The pain which hinders the respiratory movements also prevents the contraction of the intestinal muscles, each move- meat of which is communicated to the inflamed peritoneal covering. The inertia of the intestines suspends the course of the materials they contain, and fseces are no longer ejected. The condition thus resembles that of strangulation. But to return. In enumerating the symptoms I have omitted the loss of appetite and thirst, with the modifications in the pulse and temperature of the skin, all of which, with the altered expression of face and general prostration of vital power, indi- cate the disturbance which the peritonitis has produced in the system. This disturbance is, of course, in direct proportion to the inflammation, but it is remarkable that the general reaction does not come on till some time later; so that its appearance indicates exactly when the affection has ceased to be local and is influencing the whole constitution. Thus, then, we are enabled by close attention to the various symptoms to appreciate the progress of the disease ; — the extreme sensibility and retraction of the abdominal walls indicate inflammation of the parietal peritoneum ; the severity of the disturbance of the digestive canal points to visceral peritonitis ; and, lastly, the general condition of the patient is the gauge as to the influence of the attack upon the entire organism. Distinct as these symptoms are at first, they become after a time so blended together as to be indistinguishable ; but in consequence of their traumatic origin the prognosis is certainly more favourable than in other inflammations of the abdominal serous membranes, as w^as pointed out by Professor ChomeL* Once only have I seen the * Chomel, loc. cit., p. 578. SYMPTOMATOLOGY. 79 disease terminate fatally (Case XXI). Still it must be remembered that I have never had recourse to puncturing a hsematocele, as was first recommended by Recamierj* and afterwards by Nelaton,t a practice which I cannot but regard as very serious. To appreciate the prognosis of hfemorrhagic peritonitis we should bear in mind the condition in which that patient was who died under my care; her constitution at the time of the attack was profoundly aflected by a disease of long duration ; she had also at a previous menstrual epoch had an intra-i)eritoneal efi'usion of blood and an attack of peritonitis in consequence which had run a chronic course. In Cases VII. and XV., both of which terminated fatally, similar symptoms ])revailed. In them no operation was attemjjted for the congenital malformation upon which the retention depended, because the peculiarities which existed rendered the prognosis of peritonitis more serious than ordinary. In all these the in- flammation only terminates a life which has for long been com- promised by the defect of the menstrual excretion. Where operative measures which are necessary in cases of congenital imperfora- tion are delayed for a long time, there is always a risk of the blood escaping into the abdominal cavity, and thus of inducing a more severe form of peritonitis ; the reason being, that the delay gives rise to conditions which tend to generalize the inflammation. This, however, does not always take place, for in one of de Haen's cases tlie symptoms though severe foT a time rapidly improved and the patient recovered. There is less fear of a fatal termination in cases of hfemorrhagic peritonitis, when no attempt is made at puncturing ; and when the inflammation is limited to the pelvic serous membrane, the symptoms are still less severe ; indeed, the w'orst are altogether wanting, especially the great sensibility, the tension of the upper part of the a])d()meii, and the vomiting. When these do exist they are but slight and soon cease. When, however, the febrile condition has jKissed off, or exists oidy in the shape of evening exacerbations, the patients are still subject to abdominal pains, which at times are felt very acutely, especially on pressure in the iliac fossae, making it very difficult to institute an accurate examination. • H. Bourdon, Den tumeurs Jluctuantes du hassin (Revne Medicale, juillet, aoftt, septcnibre, 1841, p. 59). t Neliiton, Lemons oralcs faitcs a I'hopititl Saint Louis {Gazette des h6pitaux, H icvricr, 1851, p. Gl, et suiv). 80 MENSTRUAL RETENTION. At this time too we are able to make out the physical signs of the tumour produced by effusion of the menstrual secretion into the abdomen. By its mere gravity it most frequently accumulates in the utero-rectal cul-de-sac : retro-uterine hematocele as it is called. In the absence of any defect of the vagina, such as is ob- served in the several varieties of our three first classes^ and failing any engorgement of the cervix to modify the displacement impres- sed on the uterus by the tumour, the physical signs of hematocele caused by the passage of menstrual secretion into the abdomen are precisely the same as those occasioned by intra-pelvic effusions of blood, from any other cause. This circumstance jastifies my quoting the two cases published by my friend M. H. Bourdon,* to whom undoubtedly belongs the credit of having described the physical signs of the affection now called hematocele. To the two cases contained in his remarkable me- moir on Fluctuating Tmnours of the Pelvis, I shall add a case which M. Denonvilliersf presented to the Chirurgical Society, in order to prove that hcematoceles are situate in the peritoneum, as I have said, and not in the cellular tissue, as M. Vigues % pointed out. Case XXXTV.§ — Sanguineous tumour of the pelvis ; fuctuationfelt hy recto-vaginal examination ; incision of the tumour through the vagina ; cure. A woman, aged 24, had been confined with her second child eight months, when, a month before admission, she was suddenly seized with shivering, fever, abdominal pain, and tension. On admission into the Hotel Dieu, August 1st, 1840, a hard tumour the size of a fcetal head was felt in the lower part and right side of the abdomen ; it was tender on pressure, and sliglitly moveable. On examination per vaginam the tumour was felt in the right recto-vaginal pouch, it was slightly fluctuating. On August 3rd, M. Recamier punc- tured \iper vaginani, and some thick red fluid escaped. The walls of the tumour were thick and firm, almost like fibro-cartilage; upwards of a pint of fluid escaped, and the patient was much relieved. Subse- quently the tumour discharged freely, and then gradually disappeared. * H. Bourdon, Memoire siir les tiimeurs fiuctuantes du bassin (Itevu med. 1841). \ Denonvilliers, Societe de chirurgie, 4 juin, 1851. X Vigues, These inaugurale, Paris, 1850. § Hipp. Bourdon, loc. cit., p. 19. SYMPTOMATOLOGY. 81 She made a good recovery, and left the Hospital thirty-uiue days after the operation. Case XXXY.* — Sangtnneoiis tumour developed between the vagina and rectum ; incisioti through the vagina ; cure. A woman, aged 28, liad had two cliildren at term, and one miscar- riage brought on by violent exertion a short time before admission. For several weeks a bloody discharge followed. On admission into the Hotel Bieii a tumour filling the pelvis was felt compressing the rectum and pushing the uterus forwards ; externally it could be felt as high as the umbilicus, and in both iliac fossae ; it was move- able and deeply fluctuating. M. Recamier incised the tumour per vaglnam, when a quantity of black half-coagulated blood escaped. The patient made a good recovery. Case XXXVI. t — Menstrual retention ; hemorrhagic peritonitis ; spontaneous opening ; death. A woman, aged 29, was admitted into the Hopital S. Marguerite on ^larch 8, 1851. In February of that year she had symptoms of menstrual retention. In March menstruation came on, but was followed by peritonitis. A tumour was then felt in the hypogas- triura and j)er vaginam. On April 11th she passed a large quantity of black coagulated blood per rectum ; on May lOtli a discharge of blood and pus escaped per vaginam ; on the 15th symptoms of pyaemia came on, and she died on the 25th. On post-mortem examination the tumour was seen occupying the utero-rectal pouch ; the ovaries were large, and presented several lacunae 0])ening into the bloody cyst, as if the effusion had owed its origin to these partial ruptures of the ovaries. The Fallopian tubes were rather contracted than dilated. We may observe in these cases, and in those which I shall presently report, that the bloody tumour to which the passage of the men- strual secretion into the abdomen give rise, are characterized — (1.) by the instantaneousness of its development coincident with a catamenial period which is attended by very scanty secretion ; (2.) by its inde- pendence of the uterus, which it displaces from its immediate con- • II. Bourdon, he. cit. p. 81. t Denonvilliers, Gazette des Hopitaux, 14 juillet, 1851. 9 82 MENSTRUAL KETENTION. tiguity ; (3.) by the differences felt in its consistence at different times, owing to the successive changes which take place in the contained blood ; (4.) and lastly, by the periodical intermitteiice of the sym- ptoms, while the affection of which they are the result, instead of improving, gives rise to fresh effusions, each adding to the bulk of the tumour. The combination of these several characters is indispensable for the purpose of accurate diagnosis, and even with them there is the possibility of error. It is necessary always in making an examination to combine abdominal palpation with vaginal and rectal exploration, following the teaching laid down by my ex- cellent friend, M. Bourdon. Examining with the hand placed over the lower part of the abdo- men, we learn that the upper part of the tumour, emerging into the abdomen, is sometimes of so considerable a size that it reaches up to the umbilicus, and is quite independent of the abdominal walls which glide over its smooth and even surface. The upper limit of the tumour is well defined, not only to abdominal palpation, but also to percus- sion, a dull sound being elicited over the entire extent of the tumour ; while inferiorly it is felt buried in the pelvic cavity i the upper strait of which it fills, being immoveable or almost so by the fixity of its base which may be reached by the finger either in the rectum or . vagina. The blood cyst, whether simple or multilocular, forms in the abdominal cavity a tumour of irregular outline, varying according to the circumstances of its development ; it may be either in the middle line, or in one or other of the iliac fossse, or it may be formed of several distinctly defined lobes. This latter condition, which occurred in my first case and in that of M. Satis, which I shall report pre- sently, is almost typical of hsematocele from defective excretion. In outline it resembles somewhat the figure on a club card, as is seen in the annexed drawing. Eig. 1. Tins form is given to it by the convex- ity of the tumours in each of the iliac fossae, Eig. 1. T, which are parallel with the Eallopian hga- ments; between these two tumours in front appears the fundus uteri, Eig. 1. U, which is distinctly sepa- rate from them by a groove. Be- hind the uterus the two tumours appear to meet by the formation of a third lobe, which is pore or less distinctly felt, according as it rises Fig. 1. SYMPTOMATOLOGY. 83 Fig. 2. Fig. 3. above the level of the fundus uteri, which it surmounts as the epi- didvmus does the testicle. When one of the lobes of the tumour is of unequal volume, as the right for example, which often happens, we find in the region beliiud the uterus, which is pushed to the left and slightly twisted, an almost circular tumour rising more or less high in the abdominal cavity. Fig. 2, T. At the lower part of this tumour there is a sort of undefined projection lying behind the Fallo- ])ian ligament, which appears to be formed by the swollen broad ligament, above this rises the tumour which, in the case represented by Fig. 1, was interposed between the two lateral lobes. In Fig. 3, T, tills third middle lobe, being much more developed in comi)arison with the other two, stretches up- wards in the middle line sometimes as high as the umbilicus and pushes the uterus and the two swollen broad ligaments against the pubis. This last conformation is much less frequent when the effusion of blood results from defective excretion, than when it occurs simply as a haemorrhage from one of the generative organs into the peritoneal cavity. It is, indeed, peculiar to tliis menor- rhagic variety of haematocele, which, as I shall show in a succeeding chaj)ter, is the commonest of all. When the upper part of the blood cyst projects into the abdomi- nal cavity and there forms such a tumour as I have just sketched, its lower portion projects in front into the vagina and behind into the rectum where its characters may usually be made out. Sometimes the vagina is so distorted by it that the cervix is reached only with difllculty, being pushed about according to the amount and position of the effusion, whether it be median or lateral. In some excei)tional cases the cervix, as in Case I., is lower than usual, in others it is higher, and is pushed forwards against the pubis. Sometimes the tumour is so low down that the finger must be curved to reach the cervix, in order to dit^cover its relative position and the direction of its cavity, all which is indispensable for interpreting the results of the vaginal examination. When the tumour is median, we find the cer- 92 84 MENSTRUAL EETENTION. vix flattened against the pubis and drawn up ; when it is latero- median the cervix, besides being pushed forwards and upwards, is laterally depressed from that side which is occupied by the tumour, and is thus slightly twisted on its axis with a lateral inclination. These differences do not prevent the cervix from receiving directly movements which are exerted on it by pressure on the fundus ; but pressure on the tumour, when it projects into the abdominal cavity, is not communicated to the cervix. Carrying the finger behind the uterus, we find the latter separated from the tumour by a sulcus, the tumour itself sometimes descending below the uterus into the recto-vaginal pouch as far as the junction of the upper and middle third of the posterior wall of the vagina, sometimes even a little below that. In the latter case it will be felt as a boss, about the size and shape of an egg, easily appreciable both to sight and touch, to the former either by the speculum or by merely separating the labiae with the fingers. Visual inspection, however, is of little service and may well be dispensed with. The bulk of the vaginal portion of the tumour may readily be made out by combining vaginal and rectal examination, while at the same time the latter demonstrates the deformities of that part, which besides being flat- tened from before backwards by pressure of the tumour is sometimes thrown a little to one or other side. Furthermore, we are able to make out that above the cervix the tumour expands so as to be bound only by its containing bony walls, and is incapable therefore of definition in this direction. This defect in delineating the form and size of the tumour, wliich seems, as it were, like molten metal to take the mould in which it is cast, is very important in the dift'e- rential diagnosis of hsematocele from other benign or malignant afiec- tions of the uterus or its appendages. The physical signs described above, which establish not only the existence but the seat, volume, and configuration of the tumour, are much less important than those which indicate that it contains a fluid, and that it is formed by an intra-peritoneal eflusion of blood. To determine these points we must again and again combine abdominal palpation with vaginal examination, for mere vaginal examination as recommended by Nelaton"'^ is very untrustworthy, and can only give evidence to those who have a very keen appreciation of the sense of touch. The settlement of this question is at all times difficult, for * Fenerly, These inauyurale, 1855, p. 13. SYMPTOMATOLOGY. 85 though we may be able to detect a sort of elastic softness, and to re- cognise the kind of vibratory sensation communicated to the finger in the vagina by percussing the tumour in the abdomen, yet this does not determine the question as to whether the collection of fluid is blood, pus, or serum. In the absence of perfectly circumstantial antecedents, more important even for diagnosis than digital examina- tion, there is no one, I believe, who is not, or who may not be at times, deceived in difficult cases. It has happened to me as it has to others; but before recounting my own errors in diagnosis I shall relate a most instructive case where a mistake of this kind was made by M. Nelaton. I extract it from the thesis of his pupil, M. Voisin.* Case XXXYII. — Suppurative pelvi-periioniiis mistaken for a retro- uterine hematocele ; puncture ; cure. M., aged 39, admitted March 5th, 1857, under the care of M. Nelaton. For the last two months menstruation had been scanty, and for eight days she had had severe pains in the abdomen, which she called colic; warm baths gave her no relief. On examination an abdominal tumour was discovered, which was diagnosed as either retro- uterine hscmatocele or peri-uterine phlegmon. The cervix was dis- placed, the uterus being pushed against the pubis. On each side there was nothing remarkable, but, behind, a swelling existed between the vagina and rectum ; it resembled in consistence a bloody tumour, and was moderately soft and tender. To the left of the hypogastrium, a tumour was felt. In the centre the fundus uteri was detected pushed high upwards and forwards. M. Nelaton diagnosed it as a case of retro-uterine haematocelc. On the 13th the patient was worse, the uterus was more displaced upwards and forwards; micturition diffi- cult ; the vagina] mucous membrane was of a bluish colour at the point corresponding to the swelling. On the 16th the pains were 80 severe, and the tumour so largely increased, that M. Nelaton punctured the upper and back part of the vagina and let out a quantity of pus. The patient subsequently made a rapid recovery. In reference to this case I will only add one remark, which is this, that the history of this patient was too incomplete to form the dilTer- ential diagnosis on wjiich M. Nelaton ventured, and which had no foundation as far as can be judged from the report of the case. I • A. Voisin, Thhe inaugurale, 1858, p. 52. 86 MENSTRUAL RETENTION. have selected it from many others of the same nature in order to show that the surgical examination of the tumour cannot suffice to exclude error, however able they may be to form a diagnosis who content themselves merely with the physical signs presented to them. There is a special liability to error when we find that, in the several examinations to which we should submit a patient before coming to any positive opinion, the difi'erences in the tumour are not well marked. One of the most important characters of bloody tumours in general, and hsematocele especially, is the successive modifications which they undergo, and the different sensations detected in conse- quence, especially in their earlier career. Almost immediately after its formation, a hsematocele is both larger in size and more distinctly fluctuating than at any subsequent period. In a few days it becomes somewhat less bulky, and has a sort of gummy consistence ; later still we find fluctuation in some parts, and hard nodules in others ; showing, as was apparent in i\\Q post-mortem examination of my first case, that the separation of the clot into two distinct parts, the one sohd, the other serous, has taken place. But it is not ordinarily in the first month of retention that the separation of the blood into its two parts takes place. As a general rule the tumour remains gummy up to the return of the next m.en- strual epoch, when it undergoes certain modifications according as the retention ceases or not. Whatever may be the future progress of the case, menstruation invariably leads to an accession of pain in the tumour, and to an increase in its size and tension. This period it is important to note as the starting-point of changes, the character of which will be determined by the mode in which menstruation is per- formed ; if it be easy, there will be a general abatement of the sym- ptoms, owing chiefly to the rapid absorption of the fluid. We cannot, however, reckon on the return of convalescence till at least another month has passed, during which the patient should maintain the recumbent posture; the tumour meanwhile diminishes in size from above downwards, and acquires a firmer consistence. If, on the other hand, the catamenial excretion is prevented, the tumour, instead of diminishing, increases, it may be but slightly^ if there be no additional eflusion into the peritoneum ; or it may be considerable and accompanied by a renewal of the acute symptoms. As ail example I may adduce the following case : — SYMPTOMATOLOGY. 87 Case XXXYIIT. — Sudden suppression of menses ; repeiltion of the symjjtoms two years after ; diag^iosis of hamatocele three months after admission into the Hospital ; three months and a-half after that a repetition of the pelvic hcemorrhage into the peritoneal cavity ; spontaneous escape of the blood per vaginam and per rectum ; cure.* A woraarij aged 43, began to menstruate at 13_, was married at 22, and had fifteen children. In 1849 symptoms of menstrual re- tention came on. In 1851 she was admitted into St. Louis for the same symptoms, when a tumour was discovered in the abdomen, and since then she has not been well, but has had no miscarriages. In October 1853 she had severe pain in the left iliac fossa, and deep in the pelvis, attended with swelling, tenderness on pressure, &c. On admission, January 2nd, 1854, there was great pain, tender- ness and swelling over the left iliac fossa and down the left side of the pelvis and vagina. Across the abdomen fluctuation was felt, but not very distinctly. The uterus was prolapsed and pushed forwards and to the right. Fluctuation was distinct in the upper part of the vagina in the posterior cul-de-sac, and a little to the left of the cer- vix. The tumour could be felt distinctly fluctuating between the vagina and rectum. On January 17th smart hsemorrhage occurred from the vagina, which lasted eight days, and considerably reduced the size of the tumour. By the middle of February she had greatly improved. On April 15th she was taken with violent rigors followed by fever; for which twenty leeches were ordered. On the 16th there was great pain and vomiting, and the tumour greatly increased in size. On the 22nd another attack of haemorrhage per vaginam occurred with great diminution in the size of the tumour and a cessation of the severer symptoms. On the 30th diarrhoea came on, with bloody evacuations, and a still further diminution in the size of the tumour. From that time she made a good recovery. I will only remark in reference to this case that the absence of sufficiently circumstantial antecedents forbids any positive diagnosis of menstrual retention, though the history presents many analogies to the first case of that kind recorded in these pnges. In both we see a woman who has had many jiregnancies, and who seems previously to • Fcucrly, These inanyurule, Paris, 185."), p. 53. 88 MENSTRUAL RETENTION. have suffered from hgematocele in connection with her menstrual troubles. At the end of those troubles, which unfortunately we had not the opportunity of observing, another attack of intra-peritoneal haemorrhage occurred, for which the patient entered the Hospital some time after. As in the first case the symptoms diminished and the bloody tumour lessened after the expulsion of clots of altered blood from the vagina, which evidently came from the uterine cavity, and, as the history showed, the expulsion corresponded exactly with the menstrual period. Just as in Case I. this escape of altered coagula, followed by a long-continued discharge of blood, led to a deceptive kind of convalescence, inasmucli as at the following catamenial period there was an absence of any menstrual excretion. Then, all at once, as in my first case, at a date exactly correspond- ing to that when, sixty days before, the expulsion of clots took place in lieu of the ordinary menstruation, the bloody tumour suddenly in- creased in size and was accompanied by peritonitis. These cases of hsemorrhagic peritonitis from effusion into the ab- dominal cavity, do not ordinarily occur, as I have said, till some time after the first catamenial migration. If both the secretion itself and also the molimen which precedes it, are wanting, the catamenial epoch is unattended by any symptoms until the time when the return of the function occasions such an excitement in the tumour as is pro- portionate to the difficulty of excretion. On the other hand, when the secretion is scanty, the case may lapse into a chronic form, the tumour loses its sensibility, its volume diminishes, absorption pro- ceeds gradually, and general improvement takes place up to the next catamenial period, when similar symptoms are reproduced, and be- come more marked each time. An example of this chronic form is seen in the following case of M. Velpeau. Case XXXIX.* — Difficult menstruation ; symptoms resulting Jbr eighteen months ; intra-pelvic blood tumour diagnosed before punc- turing ; iodine injection ; cure. A lady, married two years, was never quite regular after her marriage. Abdominal pains began soon after, she lost health, and for one year and a half was under various plans of treatment, when she came under my care, and I diagnosed a collection of fluid in the * Velpeau, Recherches anatomiques, etc. sur les cavites closes {Amiales de la chirurgie fran^aise et etrangere), Paris, 1843, t. vii. p. 430. SYMPTOMATOLOGY. 89 pelvis behind the uterus, and in the right iliac fossa. This I punc- tured, and afterwards injected with iodine. She ultimately made a capital recovery. In spite of the many gaps presented in the history of this case, I have, nevertheless, reported it, because the details which it contains demonstrate the length of time during which the case was in pro- gress, a fact of rare occurrence in the history of hgematocele. And, moreover, the date of the publication of this case, immediately after that of the memoir of M. H. Bourdon,* proves incontestably that Professor Velpeau,t long before the pretended discovery of hsemato- cele in 1849,:{: had made out, during life, the diagnosis of intra-pelvic blood tumours, and had formulated the treatment which appeared to him the most opportune under the circumstances. It is seldom that these tumours remain thus stationary; the excitement of the return of menstruation generally gives rise to inflammation, which, if it be not excessive, leads to a slight ulcera- tion of the inferior wall of the tumour, and thus occasions the escape of the contained blood. This may take place either by the rectum and vagina simultaneously, as in Cases XXXVI. and XXXVIIL, or by the rectum or vagina singly, as in the following case, which is further remarkable, inasmuch as the opening in the tumour appears to have been produced simply by the irritation caused by the pre- sence of the blood acting as a foreign body. Case XL.§ — Menstrual suppression ; symptoms increasing in severity for four months; admission into the Hospital sixteen months after ; diagnosis of hamatocele ; spontaneous opening of the tumour three months after per vaginam ; rapid diminution of the tumour ; cure. L., aged 28, began to menstruate at 15, was pregnant at 18. In August, 1853, menstruation ceased, without giving rise to any abdominal pain, and since then to the present time, February, 1854, it has not returned. In December last micturi- tion became difficult and defcecation painful ; soon after which she had an attack of hsematuria, which lasted a month ; at iirst • H. Bourdon, lor. cit., 1841. + Velpeau, loc. cit., 1843. X Nelaton, Kli'mnnln iIp jiatholofjie rhiniryirale, t. v. p. 220, Paris, 1859. § Fericrly, 'I'hese inauy urate, p. 5(5, Paris, 1855. 90 MENSTRUAL RETENTION. she thought her urine was coloured by menstrual fluid. After this she had increasing pains in the abdomen. On examination^ February 8th, 1854, a tumour was felt on the left of the uterus, soft and very tender to the touch, though the uterus was not so. The cervix was pushed back, and in the utero-vaginal cul-de-sac a tumour was felt similar in all respects to that in the abdomen. The dia- gnosis made by M. Nelaton was that of recto-uterine hsematocele. On May 27th there was a discharge of black foetid \Aoo^per vaginam, and it was then discovered that the tumour had burst into the vagina. Tlie discharge continued for some time, and the patient ultimately got well and menstruated regularly. The spontaneous opening of a bloody tumour, whether into the rectum or vagina, or both, and the expulsion therefrom of the menstrual secretion, either alone, as in the preceding case, or mixed with pus, is generally followed by rapid improvement. Not only does the tumour speedily diminish in size, but if we are content not to enlarge the opening, as in Case XXXVI., the local excitement soon calms down, the whole mischief disappears, and the normal excretion takes place. When this happens the pelvic cyst cicatrizes, and all local inflammation subsides. It must, however, be added, that occasionally, by mere con- tiguit}^ the inflammatory action extends to the rectum, and sym- ptoms resembling those of dysentery come on. They are still more marked when the tumour opens into the bowel ; but, at the same time, any one conversant with true dysentery would not be likely to confound the two diseases. Nor can I agree with M. Voisin"^ in his estimate of the resolvent action which this inflammation exercises upon the haematic tumour. As a rule, rupture into the bowel is more hkely to occur where the inflammation of the cyst is so severe as to simulate inflammation of the broad ligament. This happened in the following case of M. Satis. f "& Case XLI. — Menstrual suppression followed hy peritonitis ; return of menstruation and suhsequent suppression ; development of a tri-lohed liypogastric tumour projecting into the vagina behind the cervix ; infiammation of the tumour ; expulsion per rectum for a * Voisin, loc. cit., p. 37. + Satis, lliese inaugurale, p. 89, Paris, 1847. SYMPTOMATOLOGY. 91 fortnigJi I of clots and purulent matter; circumscribed induration of right broad ligament ; disappearance of the rest of the tumour. J. D., aged 25^ began to menstruate at 15; had always been regular, and the discharge somewhat abundant. Two months before admission menstruation was suddenly suppressed, and was followed by severe pain in the abdomen, with swelling in the hypogastrium. She did not quite recover from this; but some weeks after leeches were applied to the thighs to provoke menstruation. This had the desired effect ; but again it stopped suddenly, with increased pain, for which she was admitted August 12th, 1845. There -was then severe pain in the abdomen, hips, and loins ; a swelling existed at the lower part of the body, and in each ihac fossa, rising in the median line to five fingers' width above the pubis, it was smooth but very tender. She was bled to eight ounces, baths and poultices were ordered. On examination the cervix was found to be drawn up, and the body of the uterus so considerably increased in size that it formed a tumour in the middle of the abdomen, it was painful to the touch, and was fixed between the two lateral tumours. These were continuous behind the uterus; no fluctuation could be felt ; no dis- charge ^^r vaginam. On the 20th the bowels were relaxed, the motions being mixed with blood and pus. The tumours after this were somewhat smaller and less painful. For twelve days the dis- cliarge of pus and blood from the bowel continued ; there was none from the vagina. Gradually the tumours disappeared, the pains ceased, and the patient made a good recovery. The symptoms in this case as regards their severity may be said to hold a middle place between the acute and chronic, the blood ex- pelled presented the usual, and one may say the pathognomonic characters, though its expulsion took place in an abnormal way. The mixture of a large quantity of pus with it showed that the containing cysts had undergone a more than usually severe inflammation. In this case the inflammation was, as it were, accessory, it ran its course unpcrceived in the midst of more striking symptoms consequent upon the catamenial retention. On the other hand, in the interest- ing cases for which we are indebted to M. Satis,* the inflammation waa the prominent symptom and so masked the expulsive effort as to attract all attention, and led M. Satis to refer the symptoms • Satis, he. oil., p. 83 ct suiv ; 89 et suiv. 92 MENSTRUAL RETENTION. to that alone. M. Satis would liave us believe that the mere absence of the catamenial secretion is the cause of all the morbid phenomena, that in fact it is simply a physiological disturbance. But this theory overlooks the fact, that when suppuration takes place blood, both fluid and coagulated, is foand in the midst of the pus, as was seen in the discharge which came away for a fortnight in the last case. The presence of these clots negatives M. Satis' opinion, and establishes that which I have sought to explain. In the case just cited, severe symptoms, which may legitimately be referred to an attack of hsemor- rhagic peritonitis followed, the first attack of menstrual suppression. The severe pain in the lower part of the body extending soon over the whole of the abdomen, which was increased by pressure or movement, and continued for several weeks, accompanied by a smart attack of fever, and lastly, the shape of the abdominal swelling, all indicated the existence of that afl*ection; especially as the same symptoms were observed in my first case, where the diagnosis was verified by 2i post- mortem examination. In Case. XLI the patient was still sufi'ering from peritonitis when the first catamenial period came on without producing any important result, owing no doubt to the fact which I have before observed, that the absence of this function when the system is disturbed from any other cause, is productive of no very evil results. Subsequently the inflammatory symptoms improved, and at the second menstrual period a discharge came on after the application of some leeches, this soon stopped again and was followed by an increase of the hypogastric swelling, the middle and larger portion of which was, according to M. Satis, formed by the enlarged fundus uteri, while the lateral tumours occupied the broad ligaments. This distension of the genital cavi- ties, following immediately upon the suppression of the menstrual flow, was accompanied by continual, but occasionally increasing, pain, resembling those expulsive pains noticed in all the preceding cases. These uterine contractions remained powerless, and a new phase of the disease occurred. While the uterus slightly diminished in bulk, the engorgement of the iliac swellings increased, they became hard, tender, painful to the touch, and hot. Soon lancinating pains were felt in the swelUng of the left broad ligament, pus and blood ]^^?,bq^ per rectum, and under the influence of this sanguino-purulent discharge, the uterus and swelling of the right broad ligament sensibly diminished in size, while that of the opposite side remained painful, hot, and tender, and continued to be the seat of painful twitchings. For about a SYMPTO]MATOLOGY. 93 fortniglit the discharge continued^ and during this time the pains recurred and again diminished with the return of the discharge. Then the suppuration and discharge of coaguhi, ceased, and con- valescence was estabhshed. From tliis time the uterus and right broad Hgament returned to their normal condition. Not so the left, which was more acutely inflamed, and remained considerably indurated. The patient left the Hospital, having had no discharge from the vagina, but cured in appearance, though she remained beyond doubt exposed to a repetition of the same occurrences. Unfortunately we do not always get this happy termination, on the contrary, the patient for a time seems to improve, but relapses into a state of hectic fever, consequent on suppuration, and gradually sinks. This occurs either when the pus cannot find an outlet externally, as in Case XII., or when the rupture of the sanguino-purulent cyst is unaccompanied by any colliquative discharges, as in the following case, the post-mortem examination of which I made with my colleague M. Lailler, to whom I am indebted for the unfortunately not very complete account obtained during life. Case XLII. — Menstrual suppre>ision of eight months' standing; hectic fever; death. Fost-mortem examination ; complex pelvic-tumour ; composed of\. four cysts formed in the left Fallopian tube, which was obliterated in three pjarts and filled with bloody detritus ; 2. a large tri-lobular cyst formed by the broad ligament and the parietal peritoneum and filled with sanious matter and fibrinous masses, communicating on the one hand with the perforated small intestine, on the other, with the rectum, also perforated •,2>. by two intra-pelvic serous cysts arising from the right atrophied ovary, free below and within, and apparently of old standing. Q. F., aged 21, was admitted June 9th, 1847. She had not en- joyed very good health ; at the age of 20, she had a violent attack of cohc, with distension of the abdomen, nausea, and the formation of a tumour in the right iliac fossa, which had remained for tlie last fourteen months. She recovered from the acute symptoms, and the swelling decreased somewhat, but pains in the loins and in the iliac fossa contirmed. In October last she was seized with severe pains in the limbs and body, coincident with the non-appearance of menstru- ation. Since then there has been amcnorrlujca, and for the last two months diarrhnca. She died on the 18th of June. On making t\post- 94 MENSTRUAL RETENTION. mortem examination, there was found to be general peritonitis proceed- ing from a perforation of the intestine. The vagina and cervix uteri were normal. The uterus was normal in size, but flattened. The uterine orifices of tlie Fallopian tubes could not be made out, but on the left side four small cjsts were seen placed side by side, between the bladder and left border of the uterus ; they were evidently formed from the left Tallopian tube which was obliterated in three parts of its length. They contained a thick grumous material, and were lined with mucous membrane. The outermost cyst was in part formed by the ovary. The right side contained a large tri-locular cyst, the locules freely communicating ; the middle one was connected with the bowel and with the rectum. These cysts were chiefly formed out of the riglit broad ligament, and were filled with a sanious fluid, at the bottom of which was a body resembling very much an atrophied ovary. Between these two groups of cysts was a third, situate in the middle line, but having no communication with them; it was composed of two small serous cysts, having the left ovary for a base; the walls were thin and transparent^ and the contents nothing but serum. The circumstances which in Case XII. and in the preceding, led to a fatal termination, may be regarded as quite exceptional. This remark applies equally to the case recorded by M. Bouvyer,"^ where * Bulletins de la Societe anatom. de Paris, xxx® annee, 1855, p. 388 : — Di/smenorrhoea ; menstrual siipjxrossion ; application of leeches and re-es- tablishment of the Jloio. The following month renewed suppression ; on admission recent hcematocele ; increase of the tumour at the following period ; treated homceopathically ; slight improvement, followed by colliqua- tive diarrhoea ; death. Tost-mortem examination ; intra-peritoneal blood- cyst attached to the left ovary ; ovaries healthy. S., aged 25, married, had never been pregnant. Menstruation began with pain ; the discharge clotty ; for several months she vomited blood before the periods. In September, 1854, these troubles increased, and the pain preceding menstruation was so severe that fifteen leeches were applied to the hypogastrium. This gave great relief. No tumour was dis- covered in the pelvis. Three weeks after, menstruation again came on with great pain, and she was admitted into the Hospital Beaujon. There she remained from September 24th to December 20th. Soon after admission a tumour was discovered, the size of a fist, a little to the right of the hypogastrium. It was difficult to reach the cervix, which was situated above and behind the symphysis pubis. The uterus not much enlarged was immoveable, and in the posterior cul-de-sac was a SYMPTOMATOLOGY. 95 granular disease of the kidneys occurred in the course of the febrile attack. It is as difficult to understand the significance of this occur- rence as is that of disease of the liver which sometimes occurs in the course of suppurative pelvi-peritonitis. Moreover M. Bouvyer's case isintcrestingj inasmuch as the homoeopathic system of treatment \vas adopted. I may add too^ that if the method of treating hsema- toceles by puncture has been unfortunate in its results in a large number of cases, a system of purely expectant treatment, such as homoeopathy, cannot be more favourable, inasmuch as it allows the occurrence of a series of symptoms as grave as those to which punc- turaour continuous with that in the hypogastrium ; it was independent of the uterus, non-iUictuating but resisting, not solid; it was in front of the rectum. A clotty sanguineous discharge was taking place. Treatment consisted of baths, poultices, leeches, and saline purgatives. She was then treated homoeopathically by M. Tessier ; the fever abated, the tumour rapidly increased in size and became very tender, the pains increased ; deftecation became extremely difficult and painful. The tumour rose above the umbilicus, and her condition became alarming; there was fever, vomiting, and hypogastric tenderness. Suddenly, early in Decem- ber, and without any treatment, the symptoms abated, the tumour diminished iu size, the pain also ; but the latter soon returned with increas- ed fever ; diarrhoea also came on, and she then insisted on leaving the Hospital. Three days after she took two ounces of castor oil, which made her much worse, and she was admitted into Hotel Dicu, January 5th, 1855, in a state of extreme prostration and stupor with intense headache, hot skin, thirst, &c. ; diarrhoea frequent, abdomen distended and painful, coutrh and profuse expectoration. January Sth. — Somewhat better. A tumour was felt in the hypogastric arid umbilical regions, formed of two distinct parts — the larger situate iu the middle line, the smaller in the right iliac fossa— hard, resisting, non-fluctuating, dull on percussion ; the cervix was directed to the left side. In the posterior cul-de-sac a large tumour was felt, which seemed to be intimately connected with the body of the uterus and continuous with the non-fluctuating hypogastric tumours ; urine acid, albuminous. She rai)idly becaine more prostrate ; diarrhcea and vomiting increased, and she died on the 9th. Poat-mortem examination. — On opening the abdomen, the intestines were seen to be pushed upwards by a large tumour situate in the pelvis and right iliac fossa. It was globular, and measured six and a-half inches in dia- meter. Its walls were thick and resisting, and its cavity contained clots of black blood ; it was situate to the right of the uterus, the interior of which was quite healthy ; the ovaries were also healthy. In front of the left ovary was the cyst before-mentioned ; the timiour seemed to be intra-peritoneal. Both kidneys were affected with Bright's disease. 96 MENSTRUAL RETENTION. ture itself can give rise. Happily, however, there are few physicians who have the sad courage to submit their patients to such medica- tion ; and this is why a fatal termination is seldom to be expected, even where the blood cyst becomes the seat of inflammation suffi- ciently severe to transform it into a purulent cyst. When the cyst has been opened, either spontaneously or artificially, we generally find that for a long time after we get symptoms of diarrhoea, or dysentery, owing to the extension of inflammation to the rectum. After a time this improves, and is succeeded by constipation and colic which continues for some time. The return to health is there- fore very gradual and tedious, because though the menstrual reten- tion is perhaps relieved, some mischief in the generative organs remains and disturbs the digestive functions. Notwithstanding the tediousness of the convalescence, we may still regard the prognosis of hsemorrhagic pelvi-peritonitis as very favour- able, at least relatively. Possibly the gravity of these inflammations of the serous membranes depends upon the nature of their exciting cause. Hgemorrhagic peritonitis is undoubtedly less severe than that caused by the eff"usionof other fluids, because blood is less irritating; and besides, after various transformations it may disappear by absorption from the cavity which it has inflamed, or it may be isolated and form a serous cyst which remains without producing any evil result. In regard to the prognosis and the results which may follow the organization of these false membranes, I may remark, that they sometimes form bands which unite to the different parts of the parietal peritoneum, sometimes to the uterus, more often to the ovaries, and still more often to the Fallopian tubes. In this way are produced the various displacements of the ovaries and tubes, as well as some uterine deviations, which not only lead to much inconve- nience and to sterihty, but often to fresh attacks of peritonitis. Moreover, not only does the peritoneum take on inflammatory action, but the Fallopian tubes also become inflamed by the pro- longed detention of blood in their cavities. Phlegmons also of the broad ligaments may result in the same way, at least such appears to have been the result in the following case : — Case XLIII."^ — Menstrual suppression recurring eight times, and each time followed hy a swelling in the iliac fossa — six times in the * Satis, loc. cit., p. 83. SYAIPTOMATOLOGY. 97 left, ticlce in the right side, attended in each case by a discharge of ptis per rectum ; amenorrhoea ; enlargement of the left broad liga- ment ; scant!/ sanguineous discharge from the vulva; purulent ei'«c? r - 212 PERI-UTERINE HEMATOCELE plainly marked, the blood was on its way through the Fallopian tubes, its clot being attached to the uterine cavity. In Barlow's case, the oviduct was filled, and the blood was escaping into tlie peritoneum. Hence we conclude that a hsemorrhagic discharge from to the uterus, may be a cause of haematocele. It is also probable that the ex- tent to which blood passes along the Fallopian tube is dependent on the duration and extent of the metrorrhagia, which is sometimes considerable, even before the hsematocele takes place, as we see in the case quoted below. "^ In the cases of Dr. Barlow and M. Prost the metrorrhagia followed abortion, so that menstruation had nothing to do with the hsematocele. We must then consider that the pelvic effusion resulted accidentally from repletion of the Fallopian tubes, reaction being set up by the distending fluid. Looking also at M. Laboulbene's case, where tubal metrorrhagia occurred with variola fifteen days after the menstrual period, it appears that hsemorrhage from the genital organs * Obs. de M. Heurtaux, publiee dans la These de M. Voisin, obs. xii. p. 116. G., aged 38,was admitted into the Hopital Lariboisiere, August 17tb, 1857. She had been ill two months and a-half. Ten days after a menstrual period i she had an attack of haemorrhage, which lasted twenty days. She then began to suffer hypogastric pains, which became so severe she was obliged to take to her bed. There were no rigors, vomiting, headache, nor fever. Two i days after a swelling was felt in the pelvis, and then she had shivering fol-j lowed by heat. Leeches and poultices were applied. Thehaemorrhage stopped] for a few days, but came on again, and was continued. She was very weak] and anaemic ; complained of vertigo, frequent and difficult micturition and constipation. The abdomen was tender on pressure, and there seemed to be] two tumours, the one on the left, reaching as high as the umbilicus, and occu- pying the iliac fossa, was of cartilaginous hardness. The other on the right, I not quite so large. Both were absolutely dull on percussion. Per vaginam\ they were round, moderately hard, projecting from the posterior wall of the vagina and nearly obliterating that canal. The cervix was pushed! forwards and upwards behind the symphysis pubis. Ordered belladonnal externally ; opium internally. Subsequently she was leeched and poulticed with benefit. The men-' strual period passed without effect. At the end of a week oedema came oni in the left leg and slightly in the right. A week after this the tumour had] sensibly diminished in size, especially on the right, where there was much] less tenderness ; per vaginam the tumour was about the same, except that it was softer and apparently finctuating. Mercurial inunction with bella- donna was ordered. On the 23rd of September it was noted that thej FROM METRORRHAGIA. 213 iudepeiideutly of menstruation is sometimes tlie exciting and proxi- mate cause of haemorrhage into the peritoneum. It seems that from the cases quoted by Dr. Barlow and M. Prost that pregnancy and menstruation only act secondarily in the production of metror- rhagic hfematocele in those cases where diseases such as variola, scarlatina, rubeola, purpura, black jaundice, &c., exist. The term " catamenial haematocele," introduced by Trousseau, is therefore incorrect ; at the same time I do not deny that haematoceles, like the '^floodings^' which take place in the haeniorrhagic diathesis, more frequently occur at a " menstruar' period than during an inter- val. But this does not prove that the physiological action, though a determining cause, is the exciting cause. Menstruation is not a disease ever ready when unexpected to cause a hsematocele. Nor will relapses, even if they were frequent instead of being as they are very rare,^ authorise such a conclusion. tumour in the left iliac fossa had almost entirely disappeared. She had had dysenteric diarrhoea for some days past. Per vaijinam the tumour could not be felt. The patient was greatly exhausted. From this date to the 20th of October she continued to decline. The diarrhoea was almost incessant; bed-sores and abscesses formed and were opened. She gradu- ally sank, and died on the 20th of October. On making a post-mortem examination, the uterus was seen to be semi- rotated, and to be kept in its mal-position by adhesions to the rectum. At its left angle a small hard oval tumour was seen to be attached by its an- terior and inner extremity; it was continuous with the Fallopian tube. Behind the uterus was a cavity, bounded below by the utero-rectal rw^-(/e- aac ; and above by the fundus uteri and rectum. It contained three diver- ticula, one towards the vagina, the others to the iliac fossae. Its contents were principally altered blood. On incising the tumour before-mentioned, it was found to contain the same kind of fluid in a sort of vascular cavity. In front and to the inner side it communicated with the uterus. The fim- briated extremity of the left tube could nowhere be found, but by passing a probe along the lower extremity of the dilatation, it penetrated into the retro-uterine cavity before-mentioned. On the right the adhesions made it equally difficult to discover the Fallopian tube of that side, but when found, its cavity was also dilated, though to a less extent than the left. The right ovary could nowhere be found, but the left, flattened and indurated, was discovered ;in the midst of the adhesions. The rectum gave evidence of the dysenteric symptoms, but the other organs were healthy. * .VI. Voisin {Traite de Phematocele, p. 242) quotes such a case, but with^ out a bibliographical reference. 214 PERI-UTERINE HEMATOCELE M. Trousseau declares iu his lecture, that there is often a predis- position to these hsematoceles, just as there is to gout or rheumatism. I am wilhng to admit it, and beheve that there is generally some disease, either latent or active, of which the effusion is an accidental consequence. But we need not enter upon the consideration of this predisposi- tion, for it differs in each of the varieties of metrorrhagic hsematocele, as a special disease, unknown before our time, and deserving a distinct place in nosology. The frequent recurrence of some morbid symptom shows, indeed, the existence of disease of some kind; but it does not make it necessary that that morbid phe- nomenon which is merely a symptom, should be erected into a disease per se ; particularly when the metrorrhagia occurs in diseases, like chlorosis and anaemia, which are characterised bv alternations of symptoms. Nor should mx confine our attention merelv to the menstruation: we must seek a link higher up in the chain of events, and endeavour to find out the disease which is the cause of the perversion of the sanguineous exhalation. It is here, I , think, that the predispo- sition which M. Trousseau very rightly considers of such great therapeutical importance is to be found. The difference after all is not very great between ]^. Trousseau's opinion and my own'. His judicious observations in the Chapter on the Treatment of Metrorrhagic Chlorosis by iron,^ may be applied to metrorrhagic hseraatocele. Still less does my opiQion differ from that of M. PQech,t so far at least as I can judge from the abstract idea which, though not precisely formulated, appears to be the foun- dation of his Paper on Hasmatoceles. But to return now to the consideration of metrorrhagic hoema- toceles occurring in various pyrexial conditions. Their practical importance is unfortunately somewhat restricted, for the recognition of haematocele is, under these circumstances, only of value in reference to the prognosis which it seems indeed to make yet graver. In these cases, and especially in that brought forward by Dr. Barlow, we can readily recognise the relation which exists between the haematocele * Trousseau et Pidoux. Traite de therapeutique. t A. Puech. De Vhcematocele, chap. v. p. 47 et suiv. Montpellier, 1858. FROM IMETRORRHAGIA. 215 and the metrorrhagia, and between this latter and the disease which originates the hcemorrhagic diathesis. The following propositions seem to me clearly to flow from a consideration of these re- lations. First, that in metrorrhagic hfematoceles the effusion of blood into the pelvis occurs simply as a result of the distension either of one or both of tlie Fallopian tubes by a morbid excretion from the uterus, or from the uterus and Fallopian tubes together. Secondly, that these haematoceles, though more frequent at the menstrual periods, do not necessarily depend on the catamenia flow- ing in a wrong direction, but they may originate in local hsemor- rhage of any kind. Thirdly, that whether supervening upon a period, or during the interval, they are only secondary phenomena, which may result from many and various diseases. The aflection, therefore, is only a sym- ptom, it cannot be considered as a distinct disease, and it does deserve the title of "catamenial hfcmatocele.^" It may be thought that these conclusions should have been post- poned until we had discussed all the various pathological conditions under which intra^pelvic effusion, somewhat unfortunately called hrematocele, has followed metrorrhagia; my object is to avoid the confusion arising from the term. The second group of metrorrhagic hpematoceles includes all those which occur in flooding after childbirth, I need not discuss Kuysch^s opinion as to the possibility of the lochia })assing through the Fallopian tubes into the abdominal cavity, which Fred. Hoffman,* Stahclin and Hallerf admit, but Wciss,| Bandeloc(pie,§ Jacque- mierjl and Scanzoni^ reject. Those who object to this say that in these cases it is the rupture of some vein which escapes notice that gives rise to the intra-pelvic efl'usion. We will only remark that the cases of Dr. Barlow and M. Prost are in favour of the former • F. Hoffman, Opusc. pfilhol. prat., p. 338, quoted by Scanzoni, loc. cit., p. 313 t Stahelin et Haller, ride Haller, lor. cit., t. viii. p. -155. X Weiss /;/ Haller, loc. cit. § Bandelocque. Traite cles hemorrhagies uterines, p. 80. Paris, 1831. II Jacquemier. Loc. cit., Archives de med., 3® serie, p. 324. ^ Scanzoni. Loc. cit., p. 313. 216 PERI -UTERINE HEMATOCELE opinion, and against the latter. The hsematocele in the following case of Dr. West was not, I think, consequent on venous rupture. Though very laconic, the report is interesting as a puerperal case of effusion treated successfully by puncture. Case XIII.* — Premature labour ; continuance of sanguineous discharge for six weeks ; formation of retro-uterine tumour ; puncture ; cure. A married woman, aged 33, had an abortion, and exerted herself two days afterwards. At the end of six weeks the sanguineous dis- cliarge, which had not stopped since the miscarriage, increased a good deal, and continued for twelve weeks. At the end of that time a retro-uterine tumour the size of an apple was discovered. A puncture was made and a quantity of red fluid let out. A discharge of this kind continued for three weeks, and was followed by complete dis- appearance of the hsematocele. The brevity of the report forbids comment. We cannot deter- mine whether the metrorrhagia resulted from abortion, or whether it was a symptom of inflammation occasioned by the exertions of the patient. Were the profuse lochia and consequent hsematocele due to pelvi-peritonitis ? We cannot tell. Suffice it to say that the case, at least, contradicts the assertion of M. Laugier, that abortion is not a cause of hsematocele. It shows that the effusion of blood was, if at all, only indirectly connected with menstrual action. The discharge was persistent and profuse before the period, and was due either to the hsemorrhagic form of the miscarriage, or to the genital organs being morbidly affected by the exertions of the patient. The tJdrd group of metrorrhagic hsematoceles comprises the largest number of cases. This frequency arises from the fact of the comparatively frequent occurrence in young women of hsemorrhages symptomatic of peri-uterine phlegmons, which M. Nonat justly re- gards as a most important genital affection, inasmuch as the knowledge of it entirely regulates the study of gynaecology. Unfortunately, notwithstanding the efl^orts of M. IS^ouat and myself, the differential diagnosis of the complex affection to which I have given the name II West. Diseases of Women, p. 452, 3rd ed., 1864. FROM IMETRORRHAGIA. 217 of pelvi-peritonitis, is so difficult that it is impossible to state posi- tively that the title of liaematocele which has been given to it is legitimate. We can, indeed, onlj accept as positive proof the evidence of sight, when, the tumour being punctured, or having ruptured spontaneously, blood escapes. Hence it is, that while ap- parently rich in the number of such cases, we are in reality poor, from the want of more definite diagnosis. Still, I believe, that the two following cases, though insufficient to settle all the questions connected with this subject, are yet, so far as they go, conclusive as to their individuality as specimens of this variety. Case XIY."^ — Abortion at second month. Abdominal pains eight days after. A month after utero-rectal blood tumour ; incision ; cure. E. G., age 35, admitted into the Hopital S. Antoine, October 13th, 1848. She began to menstruate at 15, and was always regular. Has had four children after natural labours ; six weeks ago she mis- carried at the second month, and has not menstruated since ; a week afterwards she had pains in the loins and thighs, a sense of weight in the back passage, and painful menstruation; she took an aperient, and blistered the abdomen. She has had rigors, colic, and nausea. On admission she was pale, had a quick pulse, thirst, nausea, and abdominal tenderness ; defsecation was impossible ; and there was severe pain in the pelvis and rectum. A painful, slightly moveable fluctuating tumour could be felt jyer vaginam in the utero-rectal cul- de-sac ; per rectum it could be felt anteriorly; the cervix was lifted up and pushed against the pubis. In the next few days the tumour became more and more apparent, more evidently fluctuating, the abdomen more tender and distended; the tumour was therefore punctured per vaginam,, and a pint of black, viscid blood escaped ; this materially diminished the tumour, and gave the patient great relief. A discharge of this kind of fluid continued for several days, a good deal coming away. On the 26th of November she left the Hospital well, having menstruated normally a fortnight before. Case XV. t — Menorrhagia folloioing labour ; sudden suppression and • Vigu^s. These inaug., p. 49. Paris, 1850. f Voisin. These citee, obs, vii , p. J. 218 PERI-UTERINE HiEMATOCELE symptoms of peritonitis ; a fortnight after a large Timnatocele teas discovered. Puncture, free discharge of blood per vaginam three weeks after ; cure of the hematocele, hut persistence of the me- norrhagia. L., age 31, admitted into the Hopital des Cliniques May 2nd, 1856, under the care of M. Nelaton. She began to menstruate at 13, married at 15, had her first child at 16^, and has not been pregnant since. Since her confinement menstruation has been much more profuse, so that she has only been well eight days between ; moreover, there has been a good deal of pain during menstruation on the right side; Three weeks ago, during menstruation, she was seized with an acute pain in the right side of the stomach, and at the same time some clots passed per vaginam ; soon after a tumour was observed in the right hypogastrium. On admission she was very anremic, and was sufi^ering acute pain like that of labour ; the abdomen being too tender to admit of examination. An enormous fluctuating tumour was seen to occupy the hypogastric region, especially on the right side, and to extend into the pelvis ; the vagina was short, the cervix uteri forwards ; it was small and flattened. Behind, an elastic tumour, the size of an orange, and continuous with that felt in the abdomen, could be detected. The posterior wall of the vagina was of a violet colour. Leeches were applied to the anus, baths and opium were administered. On the 7th, the pain being very acute, the tumour was punctured, and a quantity of blackish, red fluid escaped; this gave instant relief, so much so that on the 9th the patient wished to go home. On the 15th the pain and the size of the tumour increased. On the 28th a large quantity of coffee-coloured fluid, upwards of a pint, escaped. On the 31st the tumour was very much smaller and less tender, and next day she left the Hospital. Not a trace of the tumour, which three days before had been so considerable, could be felt abdominally. On the 4th tlie cervix uteri was depressed and forwards ; the fundus to the left. A firm, indo- lent, flattened mass could be idi per vaginam. The discharge con- tinued during the next few days, and gradually became mixed with pus ; ultimately it was merely serous, and finally it stopped, leaving the patient quite well. She was still subject to menorrhagia. In the last case, the metrorrhagia and consequent intra-pelvic FROM METRORRHAGIA. 219 effusion resulted, I think, from some old undetermined affection of the genital organs. Haemorrhages are often due to the anremia they induce, though the first of the series may have a purely local origin, and though remote and perhaps no longer in existence, patients are wont to attribute the subsequent discharges to the same cause. Simi- larly, we must not attach too great weight to accidental circum- stances in the production of hsematocele ; the influence of excessive venery has been much exaggerated. It may probably cause flood- ings, and produce intra-pelvic effusion, but iti these patients either the debauch brings into action some anterior disease, or they are constitutionally hsemorrhagic. These are important j)oiuts in prac- tice. We sometimes see hsematocele supervene in that form of me- trorrhagia which may be termed cachectic, as it comes on in diseases which deteriorate the constitution, and induce a tendency to hseuior- rhacre, the converse of that manifested in fevers. The anaemia which is very common in women who indulge in venereal excesses is of this kind. The fourth group of metrorrhagic hsematoceles are character- ised by some cachexia, whether that be simple anaemia, the result of losses of blood or defective hygiene; or whether it be in- duced by chlorosis, hysteria, &c. The case of M. Aran comes under this head if we accept his diagnosis, but unfortunately we feel bound to object to it. The symptoms and the autopsy point to inflammation of the ovarian cysts and neighbouring peritoneum which followed venereal excesses, and was relieved by antiphlogistic treatment. M. Goupil* has published a similar case, and my friend M. Aran another,t though I regret that I cannot accept his • Goupil. Bulletins de la Societe medkale d' observation, decembre, 185G. f Obs. de M. Aran, Lemons cUniqucs sur Ivs maladies del'iiterus, 3" partie, obs. xxi., p. 7G9. A woman, 213 years of age, came under my care the 20th of Auecially in the umbilical region. She was cold, pale, the lips blue, the pulse small and frequent. She complained of extreme pain in and about the umbiHcal region. In this state she remained for six hours, when she expired. On^o^^-mor^ew- examination it was found that the cause of death was rupture of the right Fallopian tube, which contained a very small f(]ctus. In this case the first symptoms were immediately followed by death, as, indeed, almost always happens, whether the cause be trau- matic, as from a blow, a fall, or dancing, &c., or spontaneous, either from distension of the Fallopian tube, or ulceration consequent on inflammation, as happens in the case of certain aneurisms. Death seems to be due to the quantity of blood poured out; both Littre and Duverncy speak of it as very great, and Velpeau has calculal ed it at many pounds. The amount of the hicmorrhage bears no relation to the extent of the rupture or perforation. In the cases whicli occurred spontaneously, the opt iiiiig would hardly admit of • Extrait de Dczeinicris. Grosnessea ertra-uterines {Journal des connais- sances tnedico-chirurf/icales, t. iv. p. 210). 246 INTRA-PELVIC HEMORRHAGE the head of a pin or a grain of wheat, according to Santorini* and Dr. Koner.f As death follows so rapidly in these cases that the haemorrhage has not time to become encysted I need not dwell longer upon them. It is remarkable that in general death ensues even more rapidly in these cases than in those which constitute my next variety, where the foetal cyst is ruptured, and the fcetus or placenta finds its way into the peritoneal cavity. The symptoms here are very marked ; there is horrible pain, clearly defined by the patient, then syncope, fainting, rigors, and lastly, all the signs of profuse internal haemorrhage, followed rapidly by death. Very often these signs follow an attack of metrorrhagia of varying duration, either after some traumatic cause or spontaneously. The patients generally believe themselves to be two or three months ad- vanced in pregnancy. This is a point of great importance, which I shall again refer to in the cases which come under my fifth head. Section IV. — intra-pelvic hemorrhage from rupture oe the rCETAL CYST. The examples of rupture of the Fallopian tube which we have just studied belong either to the tubal, tubo-interstitial, or tubo-abdo- minal varieties of extra-uterine pregnancy. But rupture of the foetal cyst, with intra-peritoueal haemorrhage, may happen in all varieties of extra-uterine pregnancy, though the numerical proportions of each are very different. Thus, if we say that nearly every case of extra-uterine pregnancy ends by rupture of the foetal cyst, we shall find, on taking each variety separately, that this termination is, in tubal pregnancies, almost constant ; in certain ovarian pregnancies it is frequent ; but in the pelvic sub-peritoneal, and tubo-ovarian forms it is very rare ; and in tubo-abdominal, and true abdominal preg- nancies it is quite exceptional, * Case taken from Biancbi De naturali in humani corpore vittosa morbosa- que generatio, p. 152. t Case of Dr. Koner (extracted from Moreau op. cit., p. 19). A woman died with symptoms like those of arsenical poisoning. At the post-mortem examination great effusion of blood was found in the abdomen to have issued from two apertures, hardly large enough to admit the bead of a pin in a tumour which was formed at the extremity of the left Fallopian tube. On opening this tumour a two months embyro was found; the uterus was triple its ordinary size, and lined with decidual membrane. FROM RUPTURE OF THE FCETAL CVST. 247 The rarity of this termiuation in the latter kmds induces me to transcribe the following case by M™*^ Lnchapelle. Unfortunately we cannotj from the details of the autopsy, determine exactly whether the pregnancy was abdominal or tubo-abdominal, but the latter seems the more likely. Case YI.* — Extra^^derine gestation ; spontaneous rupture; death. T., aged 24, pregnant for the second time at the 6th mouth, was admitted into the Maison d' Accouchement, November 2nd, 1816. At the 2nd month of gestation she had a fall, which brought on a discharge of blood from the vagiiui, this stopped and came on again several times. She also experienced abdominal pains, varying both in degree and duration. A surgeon whom she consulted, stated that she was not pregnant, that her symptoms were due to the absence of men- struation, and ordered leeches and medicines to bring it on. Not getting any better, she was admitted into the Hotel Dieu, where the same opinion was given, and similar treatment was adopted. Not deriving benefit, she left the Hospital and came into the Kosplce de la MaternitS. On examination, the cervix was found to be normal. On its right side a large, immoveable, solid tumour was discovered. The pain and discharge of blood contiiuied ; the abdomen became more tender; the pulse was small and frequent; the extremities cold ; and she died on the 4th of November. On post-mortem examination, a considerable quantity of blood was found in the abdomen. In the right lumbar region was seen a male foetus, well formed, and apparently at about the 6th month of ges- tation, its face was turned to the right side of the spinal column. In the umbilical and left lumbar regions, a thick, solid cyst existed, it was adherent all round ; at its upper and right aspect there was an irregular rupture ; in its interior was a foetus with its envelopes entire. In the right iliac region, and in the upper part of the ptlvis, was the uterus, pushed on this side by the cyst. It was larger than nor- mal, but otherwise presented nothing remarkable. The right ovary and tube were healthy. The left tube contained the foetus, and tlic left ovary was lost in the general mass. In this case we may observe from the outset the various couq)li- • Madame Lachapellc. rrutique des accouchement s, i. iii. p. 117. 248 INTRA-PELVIC HEMORRHAGE cations which usually accompany extra-uterine pregnancies. The advanced period of gestation, six months_, is also a point worthy of notice, for generally the rupture of the cyst takes place at the second, or before the fourth month. The difference in the time appears to depend on the greater or less distensibility of the cyst, and its development jf^f/zY jassu with the foetus. This distensibility of the cyst is still more apparent in tubo-ovarian pregnancies, though they seldom terminate in this manner. In the following case the rupture appears to have supervened on some special circumstances, and was not a natural or necessary termination. Case VIL* — Metrorrhagia following a blow on the aidomen during pregnancy ; inflammation ; death. Post-mortem examination. — Extravasation of blood into the abdomen ; rupture of the cyst of a tubo-ovarian pregnancy. A woman, aged 32, mother of five children, received in the second week of her sixth pregnancy a severe blow in the abdomen, which was followed by syncope, and symptoms of inflammation, but not abortion. Metrorrhagia supervened, and haemorrhage, under which the patient died. At the post mortem examination a good deal of fluid and coagu- lated blood was found in the abdomen, and a foetus of about ten weeks' growth. The fundus uteri rested against the pubis, and the cervix against the sacrum, the displacement being caused by a tumoui- situate on the left of the uterus. Violent inflammation had existed in the tumour which was formed by the ovary, the Fal- lopian tube, and the broad ligament. The fimbria of the tube were adherent to the ovary, the two having formed a cyst, the distension of which had ended in rupture. It is difficult to decide whether the rupture of the cyst in this case was due to the blow on the stomach, or to the natural progress of the pregnancy, complicated by inflammatory action. But the likelihood of such a termination happening in this very rare form of extra-uterine pregnancy, is shown in the case of Reiss.f Although the question of ovarian pregnancy is still unsettled, and * These de M. A. Moreau, Paris, 1853, p. 13. From the Dublin Jour- nal of Medical Science, 1833. f Observation consignee dans Moreau. These, 1853, p. 15. FROM RUPTURE OF THE FCETAL CYST. 249 even its existence contested, we may at any rate affirm that some of these cases have ended by rupture of the cyst and intra-peritoneal hsemorrhnge, though we do not feel called upon to decide whether the fcetus was developed in the very tissue of the ovary,* or in the separated vesicle, or in the periphery of the gland which produced the germ.t Case YIII.| — Severe pain occurring in the right hypogastrium at the third month of gestation; death. Post-mortem examination — fcetus found in the abdomen adherent by the cord to the right ovary, ichich was ruj^tured. A woman, aged 34, had had three children prematurely, and was pregnant the fourth time. The condition being accompanied by extreme prostration and a good deal of pain on the right of the pelvis. At the end of the third month she expelled j!9g;* vaginam a mole, the size of an tg^. Six days after this she experienced most agonising pain in the liypogastric region, accompanied by severe vomiting, and soon after this she died. On examination a male foetus was found in the right iliac fossa, but still attached to the right ovary by the umbilical cord. The ovary itself was ruptured on its under side. The organs on the left side were healthy. The uterus was much thickened, and large enough to admit a foetus of three months : such an one was found in the abdomen. The case of St. Moressy is quite analogous to that of Professor UcelH ; though the detailed symptoms are less complete, it seems to show quite as plainly that the ruptured foetal cyst was formed at the expense of the ovary. § These ovarian pregnancies are extremely interesting, they are not at all common, and they do not ordinarily terminate by rupture. * Dezeimeris. Journal des connaissances medico-chirurgicales, 1837. f Velpeau, op. cit. X Bibliotheque niedicale, t. xxxviii. p. 265, et Dezeimeris, op. cit. p. 236. § Observation de M. de Saint Moressy, medicin dc Riherac en Saintonge, 1662 {danK Diiverneg, (Euvres anfitomirjiics, Paris, 176}, t. ii. p. 3o0). A lady had borne eight children, when, after an interval of five years, she became pregnant for the ninth time. At the tliird month she became very weak, had colicky pains, with symptoms of approaching labour, and died in nine hours. On opening the abdomen a large quantity of blood was found edused, and in removing this a male foetus about an inch long 250 INTRA-PELVIC HEMORRHAGE Such is not the case, however, with tubal pregnancies; these are not only very common, for, according to Murat, Baudelocque saw five examples in three months ; but they generally end by rupture of the foetal cyst. This fact has long been observed, and some remarkable instances are quoted by Mauriceau* and Duverneyf. As everyone has read of these cases I report two only, which seem to offer some special points of interest. The first case is the only one I know of in which rupture of the Fallopian tube, and the escape of the foetus into the abdomen accom- panied by intra-peritoneal haemorrhage, was followed by encysting of the foetus together with the effused blood, in a word by a haemato- cele, and later by intestinal fistula; death not ensuing until six months after the commencement of these complications. Case IX.J — A woman, aged 20, was admitted into Guy^s Hospital, suffering from very obscure and anomalous symptoms. She had been ill six months, but the last three weeks she had been much worse. Had passed a good deal of brown coagulated substance from the bowels. She had dyspepsia, and suff'ered from abdominal pain. She died seventeen days after admission. On post-mortem examination nume- rous adhesions were discovered, some of which were of long standing. On the left side these were so numerous, that they formed a complete cavity between the curve of the colon, the rectum, the bladder, and anterior and lateral walls of the abdomen ; in this cavity a fcetus with its placenta was found of about three months' development. The cavity communicated by two openings with the rectum and iliac curve of the colon. The uterus was healthy and contained no chorion. One of the tubes formed a thin sac, in which the foetus had evidently been developed. In the following case, taken from the thesis of M. Siredey, we have, on the contrary, an example of rupture of the Eallopian tube in tubal Avas disco \ored. It was found afterwards that the right ovary was ruptured ill its length, and that the foetus had been developed therein. * Mauriceau. Des maladies des fenunes (jrosses, 5^ edition, t. i. p. 86. f Duverney. Q^uvres anatomiques, t. ii. p. 512, 1701. X Obs. extraite du Journal des connaissances medieo-chirurgicales, t. v. p. 6. Des grossesses extra-uterines, par Dezeimeris ; indiquee comme provenant de Bright, obs. extr. dans Froriep's Notizen aus dem Oebiete der Natur und Heilkunde, t. xxiv., et Kleinert's Re^iertorium, avril, 1830, p. 94. FROM RUPTURE OF THE FCETAL CYST. 251 pregnancy, terminating fatally in eight- and-forty hours, without any encysting having taken place. In tin's case the rupture took place in the fourth or fifth week after conception, which is much earlier than we observe it in spontaneous rupture; excessive fatigue also brought on metrorrhagia the first day after conception ; we may, therefore, regard this as the predisposing cause, while excessive coitus seems ultimately to have ruptured the cysfc, and so acted traumatically. Case X.* — Old-standing pen-metrltls ; hihal pregnancy; venereal excess ; intra-peritoneal hcemorrJiage ; death in forty-eight hours. A. L., aged 28, was admitted into iYieHojrital S.Antoine 12th of August, 1859. Has enjoyed good health. She began to menstruate at 15. Was married at 17, and has had two children. Suffered a good deal from leucorrhaa during lactation. Was treated with steel chiefly. Three years after her accouchement she consulted M. Valleix, who recognised a displacement of the uterus, and she used a pessary, but has never since been really well. After her second pregnancy she had peritonitis, and was treated by leeching and mercurial and belladonna ointment. This sallivated her. Sexual intercourse was painful. Has suffered from indigestion and flatulence. She has been worse since the 9tli of August. In the evening of the 11th her pulse was small, 120, skin hot, thirst, vomiting, abdominal distension and pain on pressure. Twenty-five leeches were applied, poultices and Neapolitan ointment, with opium pills internally. On admission there was a good deal of fever; increased sensibility of the abdomen and pelvis ; the eidarged cervix uteri was pushed posteriorly, the uterus itself being anteflexed, and adherent on the right. She left the Hospital, and was readmitted on the 11th of November. The day previously she over-exerted herself, and at night, wliile in great pain she had sexual intercourse six times, after wdiich she fainted. On admission the pulse was 150 small, the extremities cold, the surface pale ; the cervix uteri was forwards; in the posterior riil- de-sac was a body which felt like the fundus. The general symj)toms were those of internal haemorrhage, but no ha^matocelc could be detected. Rectal examination was very jiaiuful. Ordered opium and wine. She died on the 15th. Sircdey. Thhe inangurale. Paris, 18G0, p. 98. 252 INTRA-PELVIC HEMORRHAGE On post-mortem examination, tlie abdomen was much distended, and on opening it a quantity of black liquid blood escaped. The pelvis was full of blood. The viscera generally were in an ex-san- guine condition. The uterus was lying in the hollow of the sacrum, and in front of it was a large quantity of blood. The left tube and ovary were adherent together, and rested against the left lateral half of the uterus, the tube being in front and below the ovary. The free orifice of the tube was not obliterated, and on pressing it some black fluid escaped. False membranes united the ovary and Fallopian tubes to the broad ligament of the same side ; they were much thickened. The ovary measured an inch and a half in length, and one inch in thick- ness. On the right side the ovary and tube were firmly united together, forming, with the uterus, a solid mass. The ovary was fully two inches long, and its pedicle short ; the Fallopian tube of that side was thickened. The tumour contained some black blood, and a substance which at first looked like the debris of altered placenta. M. E-obin considered that the embryo was from three to six weeFs growth. At the junction of the cervix and body of the uterus it was soft and flexible, and in its interior had all the ap- pearance of the gravid state. This case demonstrates that efl^usions of blood, however profuse, when seated in the true pelvis do not yield the indications of a tumour until the process of encysting has taken place, and formed a kind of solid base. In fact the author of the above case, though aware that internal haemorrhage had occurred, could not find any tumour. This fact has an important bearing on diagnosis, and I have selected this case for this special reason^ from numerous examples of rupture of the foetal cyst in tubal pregnancy. Interstitial tubo-uterine pregnancies terminate by rupture of the foetal cyst, even more frequently than do tubal pregnancies. Dr. Meniere^ considers this their constant termination ; but Dr. Payan's case, though also fatal, differs somewhat. M. Jacqueraierf indeed thinks that women have sometimes sur- vived the bursting of the cyst into the uterine cavity. I am not * Meniere. Archives generales de medicine, 1'" serie, 4*^ annee, t. xi. p. 169. t Jacquemier, Manuel des accouchements, t, i. p. 373, FROM RUPTURE OF THE FCETAL CYST. 253 acquainted with the facts on which he bases this opinion, and am obliged, like Dr. Meniere, to consider the rupture of the cyst if not the constant at least the almost constant termination of this variety of extra-uterine pregnancy. Usually this occurs from the first to the third month of pregnancy, sometimes without appreciable cause, as in the remarkable cases of Dance,'^ Auvity (reported by Dr. Meniere), and Gaidef ; sometimes from an external cause, blows or a fall, as in the case which we report of Alvers (de Breme). Case XI.| — A woman, aged 36, had a fall down stairs at the third month of her second pregnancy, September 19th, 1811. She became almost insensible from the fall, but managed to perform most of her ordinary duties that day. Syncope soon came on, and ske was admitted ; the journey to the Hospital causing extreme pain. She died next day. Four days after, the post-mortem examination was made. The abdomen was filled with blood, and in the midst of the clot a small foetus was found, apparently about nine weeks old. The uterus had all the appearance of gestation. The ovum had developed in that part of the Fallopian tube which adjoins the uterus, and this had caused such distension as finally to lead to rupture of that part. No trace of the membranes could be discovered. In these different cases, comprehending nearly all the varieties of extra-uterine pregnancy, rupture of the cyst has occurred at very difi'erent stages ; if, however, we do not reckon the extreme cases where rupture took place at one and eight months, we shall see that it almost always happens between the second and fourth months, and this is a point of importance in diagnosis. All the patients were multipara;; they all, except the one in Case X., p. 251, thought themselves pregnant, either from stoppage of the menses or from some other symptom of gestation. A few of these pregnancies run a regular course, but they mostly show some irregularity, as malaise, debility, bad health, pains * G. Breschet. Memoire hi a V Academic des sciences, 1825. f Obs. de M. Gjiidc, service de M. Ray or, Bci-ue medicale, t. xx. j). 321. X Obs. tiree de Dezeinieris. Journal des connaissances mddico-chiruryi- cales, t. ix. p. 243. 254 INTRA-PELVIC HEMORRHAGE about the abnormal seat of the pregnancy, sometimes various iuHam- matory attacks, evidently coinciding with the peritoneal lesions observed at the post-mortem examination, metrorrhagia almost always slight but continual, and, at times, increased in quantity. I lay the more stress on this metrorrhagia, as it is compara- tively infrequent in those cases of extra-uterme pregnancy which ter- minate in a cure, and is still more rare in the first months of normal pregnancy. The rupture then most frequently happens about the time when the metrorrhagia has diminished or quite ceased, often spontaneously, and without any known cause : at other times it follows some trau- matic injury, as a blow on the stomach (Case YIII. p. 249), a fall down a staircase (Case XI., p. 253), excessive fatigue or venery (Case X., p. 251). The actual ruj)ture is usually announced by sharp, often agonising, pain at the hypogastrium, followed immediately by one or more ter- rible fits of syncope, often of long duration, and sometimes repeated : then general rigors supervene, the belly becomes tympanitic, or changes its shape if the pregnancy is slightly advanced : excessive debility, fainting, often vomiting, and sometimes convulsions herald death, which takes place in a short period, varying from eight, ten, or twelve hours to three or four days, the patient not losing con- sciousness. In a very few exceptions the hsemorrhage stops, the product becomes encysted, and life is prolonged for some weeks or months (Case IX., p. 250). The rupture of the foetal cyst sometimes happens less abruptly, and the events take a less rapid course, the perforation being occasionally preceded by pain for some hours or days. Thus, in Albers' case, after tlie fall the patient lost consciousness, and in spite of her altered expression and appearance, and the persistent pains in tlie abdomen and at the sacrum, she continued to work about her house the whole day ; it was not until the evening that a sudden fit of syncope and icy chills were followed quickly by death. It is evident that the intra-peritoneal haemorrhage took place at this last moment, and it is a plausible hypothesis, though it cannot be actually demonstrated, that the pains in the belly and sacrum, as well as the loss of consciousness which followed the fall, are referable to separation of the ]jlacenta and haemorrhage, which at first distended and finally ruptured the cyst. WITHIN THE FCETAL CYST. 255 In some cases, on the other hand, the successive events have taken place more slowh^j and been observed more complete!}'. Repeated hsemorrhoges have occurred in the foetal cyst, and a tumonr has been formed which as the cyst distended burst into the peritoneum or brought on death without opening into the abdomen. These facts demonstrate one of the modes in which foetal cysts rup- ture. We must not, however, imagine that they always terminate in this way ; on the contrary, there is so much difference between the progress and duration of the symptoms in those cases where intra-cystic haemorrhage occurs slowlv and at successive bursts, and those where it terminates as in the preceding cases, that I have thought it best to describe them separately, and to group them under the fifth head. Section V. — ixtra-pelvic hemorrhage within the fcetal cyst. This division is the more justifiable, because in the case where the intra-cystic hsemorrliage ended with the rupture of the fcetal cyst, the longest period of the disease was wliere one or more hsemorrhages took place into the cyst, while the rupture was only the termination of a series of well-marked events. Besides, we shall see that this end is not absolutely necessary. In some cases it seems to have been determined by accidental circumstances, and sometimes after a considerable interval. This stage of the disease, during which liEcmorrhage occurs in the cyst without causing rupture deserves the more attention, as the effused blood always becomes encysted, contrary to what we have observed in the preceding cases. It forms a tumour, which by its seat, its form, and its character, presents more or less completely the physical characteristics of peri- uterine liBcmatocele. We may remark also that these tumours have frequently during life, and even sometimes at the post-rnortem examination been mistaken for hgematoceles, although they differ so widely in tlieir symptoms, as well as in their mode of formation and their etiology. Therefore, though the diagnosis may be difficult, it can generally be worked out. In cases of this kind the tumour will be either intra- or extra- peritoneal, according to the seat of the extra-uterine pregnancy. The case of M. Nonat (Case II., p. 238) has already given us an example of haemorrhage into a sub-peritoneal foetal cyst without rupture of the cyst. The following case, published by M. Gallard, is one of those rare examples of intra-cystic haemorrhage occurring in the course of sub- 256 INTRA- PELVIC HvEMOERHAGE pelvi-peritoneal pregnancy. The cyst^ in truths ended by rupturing into the peritoneum ; but this events supervening on the action of an injection made into the cyst, must not be attributed either to the spontaneous progress of the disease, or to a fresh liaemorrhage : for, on the one hand, only sanguineous serum was found in the peritoneum, and, on the other, the clots of blood in the tumour were all similar, and seemingly not referable to successive hsemorrhages. A perusal of the case will enable us to form an opinion on these points. Case XII. — Extra-uterine pregnancy ; metrorrhagia ; retro-tderine tumour ; puncture and injection ; peritonitis ; death ; post-mortem examination. M. R., aged 32, was admitted into the Hopital Beavjon, November 3rd, 1854. She had always enjoyed good health. At 14 she began to menstruate without difficulty, and since then she has continued regular, but has had occasional pains in the loins and pelvic regions, which at times have required the use of leeches. Twice, these attacks were more serious, and were accompanied by abdominal distension, fever and delirium, but yielded to local depletion. Menstruation has always been quite regular since her marriage. Early in August menstruation came on scantily, accompanied by uterine colic and lumbar pain ; these symptoms continued for three days, tlie discharge being almost nil ; and were succeeded by an attack of metrorrhagia. The pains then ceased, but the haemorrhage continued for a month, and was increased in September ; the abdomen was neither painful nor tender, and there was no vomiting or fever. At the end of September the pain became much more severe, but was relieved by purgation, the discharge continued and the abdomen increased in size. Early in October the pains and the hsemorrhage were renewed, and ice was applied to the vagina to check the latter ; this it did, but only at the cost of increased suffering. By the latter end of the month all seemed to have passed off again. But, on the 29th she took a long walk, and was extremely fatigued in the evening ; the pains returning again with great severity though the discharge kept off. From that time up to her admission, this was in general all the treatment that had been adopted, rest, light diet, emollient applica- tions and injections. On the 5th of November it was noted that the abdomen was distend- ed as large as at the seventh month of gestation ; tender, tympanitic at WITHIN THE FCETAL CYST. 257 the upper partj dull at the lower^ -where also a noii- fluctuating tumour could be felt^ not adherent to the right iliac fossa ; the cervix was not largCj was directed to the left and in front behind the pubis ; the posterior cul-de-sac was occupied by a tumour, soft and fluctuating, not tender on pressure, nor hot ; it was continuous with that felt in the hypogastriura ; the uterine sound was not used ; there was no- thing remarkable about the patient's general condition. On the 6th M. Eobert punctured j!?^??- vaginam the fluctuating part of the tumour. A small quantity of fluid blood escaped, and con- tinued to do so during the day, to the evident comfort of the patient. Next day it was injected with warm water, which brought on ex- treme suffering in the hypogastrium. The injection was accordingly suspended, and eight leeches were applied ; she had rigors and vomit- ing, and the pain continued ; ten leeches were then applied, followed by mercurial inunction, and calomel internally, but she died in a few hours. At the post-mortem examination the abdomen contained a good deal of bloody serum. A tumour existed in the right broad ligament, pushing the uterus to the left. Behind the uterus was a cyst con- taining a foetus of about five or six inches in length. It must have been a six-months fcetus at least ; it was soft and even putrified. Besides this there was another tumour behind the body and cervix- uteri, and extending as far as the tumour in the broad ligament ; it was spongy, infiltrated with blood and seemed hke placenta. The fimbria of the right tube, the ovary, a'nd the peritoneum of the recto- vaginal cxd-de-sac could not be made out. All the surrounding cellular tissue was hardened ; the left ovary was sound. MM. Toucher and Guyot drew the following conclusions from this case : — 1 . That the tumour situated in the right broad hgament was the placenta and that it communicated with the cyst behind the uterus. 2. That the internal surface of this cyst was lined with a shining layer of membrane, whether peritoneum or chorion could not be de- termined. 3. That the right tube was obliterated at about two inches from the corresponding cornu, but where the ovary and fimbria of that side were it was impossible to say. 1 consider the title of intra-cystic hasmorrhage fairly given to this case. For, on the one hand, the smooth polislied membrane whicli lined the internal surface of the cavity, and which, no doubt, represented the chorion, abundantly proves that the haemorrhage 258 INTRA-PELVIC HEMORRHAGE took place in the cystitsolf : on the other hand, the situation of tlie tumour formed by the placenta in the right ligament, and tlie col- lection of blood which was contained in the recto-vaginal wall, show that the tumour was sub-peritoneal. Lastly, M. Gallard, avIio quite recognised the situation of the mass, traced the communication of this cyst with the peritoneal cavity by a rent situate behind the left horn of the uterus. It seems plain then that in this case the locus hcemorrhagicus was, as the author of the case himself points out, sub-peritoneal and formed by the fretal cyst itself. Moreover, the symptoms seem especially to point to this situation. And although the mucous membrane of the vagina did not present the abnormal colouring which some physicians describe as a symptom of hoematocele, and especially of sub-peritoneal hdematocele, yet the pe- rineum became prominent like that of a w^oman in labour, and by a combined rectal and vaginal examination, it was felt, that the two layers of the recto-vaginal wall were separated nearly uj) to the perineum. This is never observed when effusion takes place into the recto-uterine cul-de-sac of the peritoneum. At the same time the patient had not the so-called peritoneal aspect ; the countenance ex- pressed suffering, but was not anxious, the skin was warm, slightly feverish, while the pulse was strong. These characters clearly indicate that the case was not one of intra- peritoneal effusion. We also see that syncope and peritonitis, which are indicative of rupture of the cyst, did not come on until after the injection of warm-water into the blood-cavity. The last two phenomena are the only events observed in the fol- lowing case, borrowed from M. Pize, which, although incom])lete, shows clearly, that in some of these cases the haemorrhage furnished by the placenta may occur in gushes, just as in some cases of internal haemorrhage during ordinary pregnancy, and may even cause rup- ture of the maternal cyst without tearing the proper enveloping membranes of the fcetus. Case XIII."^ — Extra-uterine gestatio7i ; acute per itonitis ; swelling in the right iliac fossa ; effusion of Hood into the peritoneum ; death ; post-mortem examination. A w^oman was admitted into la Charite under the care of M. Piorry, suffering from sub-acute peritonitis. A tumour could be * Bulletins cle la Societe anatomique, annee 1853, p. 40. WITHIN THE FCETAL CYST. 259 felt in the right iliac fossa. She died five or six: days after admission. At the post-mortem examination blood was found effused into the peritoneal cavity ; there was no pus or false membrane. A large tumour was found in the right ovarian region^ formed of stratified coagula, ruptured at one poiutj whence the blood had escaped, looking in short very much like a ruptured aneurism. At the top of the tumour was a cyst containing a perfectly formed foetus, of about the tenth week. The uterus presented all the appearance of the unimpregnated state, and certainly contained no decidua. The left tube and ovary were healthy. The right ovary was lost in the mass of coagula, &c. ; the uterine orifice of the right tube was com- pletely closed. The case was, I believe, one of tubal gestation, taking the following course : a fecundated ovule was developed in the right tube ; this led to a great afflux of blood to the part, and the vessels ruptured from simple distension. The haemorrhage being at first slow, the blood coagulated as it flowed, then a more violent loss came on, and the half-organised fibrous cyst ruptured, the blood escaped into the peritoneum, and death ensued. This case, as there is no history attached, is only of use to show the way in which some of these haemorrhages are produced, and how we may sometimes fail to recognise the placenta at the post-mortem examination, owing to its disorganisation, and thus be led to a false interpretation of the symptoms. This happened in the following case. As far as I know, it is the only example in which haemorrhage into an intra-peritoneal foetal cyst was observed during life, and it is precisely on account of this fact, and of its situation in the recto- uterine cul-de-sac, that the tumour formed by the extra-uterine preg- nancy might have been readily taken for a retro-uterine hacmatocele. Case XIV.* — Tuho-ahdominal jircgnancy ; metrorrhagia ; successive hemorrhages into the f<£tal cyst ; pjcritonitis ; probable rupttire of the cyst, and fatal hcemorrhage, Q. M., aged 32, was admitted into the Ilopital de la Pitie on the 18th of March. She began to menstruate at 15, and had five chil- dren, the last two and-a-half years ago. On the 20lh of January, 1853, being a week behind her monthly period, a severe ha'uiorrhage * Obs. dc M. Gaube. Bulletins de la SociSte anatomique, 28" ann6e, 1853, p. 120. s 2 260 INTRA-PELVIC HEMORRHAGE came on, and continued up to the time of lier admission into the Hospital. Prom the 18th to the 20th of March the bleeding became more severe, and was attended by a good deal of pain. The uterus on examination was found to be low ; the labiae large, congested and heavy; cervix open. On the 1st of April twenty leeches were applied to the hypogastrium with marked benefit. On the 2nd a tumour was felt all round the uterus^ compressing the bladder, and rising an inch, or an inch-and-a-half above the Fallopian ligament of the left side. Thirty leeches were applied. April 3rd, tenesmus; the tumour increasing ; no fluctuation. 4th, diarrhoea. Pulse, 128, feeble; abdomen distended. Diagnosis; probably retro-uterine blood tumour with partial peritonitis. The patient gradually got worse, and died on the 8th. 0\\ post-mortem examination some small clots were found in the abdominal cavity. The pelvis -was entirely filled with a tumour, which rose above the pubis in front, and the sacrum behind ; on the anterior part of it was the fundus uteri. The ovary on the right side, shghtly enlarged, was in contact on its posterior aspect with the Fallopian tube. The body of the uterus w^as larger than usual. Its lining membrane was perfectly natural, both as to thickness, colour, and structure. The orifices of the tubes, especially the right, were dilated. Behind the tumour before-mentioned, which was mostly covered with peritoneum, was a large pouch, and ofi^ this was a smaller cul-de-sac between the root of the uterus and the anterior part of the tumour. A crucial incision was made over the anterior and upper part of the tumour, which exposed a red mammillary- looking mass, easily separable from its containing sheath. Further examination discovered a foetus within this, and so proved that what had been supposed to be a retro-uterine tumour was in reality an extra-uterine pregnancy. A large quantity of coagula coexisted with this. The foetus was placed to the left side, and was flattened between the cyst wall and a large clot ; it measured about four or four and-a-half inches, and was perfectly formed for a foetus of about three months, which corresponds with the time (January) when menstruation ceased. At the point wdiere the dilated right Fallopian tube joined was an opening of about three-quarters of an inch, through which the dilated tube might be inflated to the size of a turkey's egg, and was of a bilobular shape. On opening the tube some coagula were found in it, which clearly explained the WITHIN THE FCETAL CYST. 261 mechanism of the hoemorrhage. The orifice of tlie tube, as well as its interior, was lined with a thin delicate^ but very red, mem- brane. The point to be determined, was whether the bloody tumour and the foetus were beneath the peritoneum, or were inside that membrane. M. Nelaton did not at the last believe it to be sub- peritoneal, though at first he did — this was before seeing the foetus. And the very slight resistance which existed at the upper and lateral part of the mass led me to the same conclusion. More careful dissection of the lower parts satisfied me that this was correct. There are two points to be noticed more particularly in this case. 1 . The absence of any rupture of the Fallopian tube discoverable at Wie post-mortem examination; and 2. The presence of hsemorrhage within the tubo-abdominal foetal cyst. This last point is shown by the smooth polished membrane which enveloped both the clots of blood and the foetus ; by the umbilical cord retaining its insertion in a kind of appendnge continuous with the enveloping membrane ; and lastly, by the preservation of the peritoneal recto-uterine cul-de-sac, which, to the right and left of the tumour, at its lower part, admitted the finger, and w^as quite free from any adhesions, so that M. Gaube was able to dissect the peritoneal layer and follow it to the posterior wall of the uterus. That the pregnancy was tubo-abdominal is shown by the fact of the dilated right Fallopian tube ; by the existence of the fine membrane forming the cyst, the rupture of which opened the communication between the collection of blood and the Fallopian tube ; and, lastly, by the development of this cyst which, though delicate, was strong, and had contracted only slight adhesions with the intestines which readily yielded to gentle traction. The details of the post-mortem examination do not show whether there had been a rupture of the cyst, and consequently we cannot determine the source of the internal hsemorrhage which, as it hap- pened on the very morning the patient died, left a layer of bloody coagula covering the upper surface of the stomach and intestines. From the doubt which exists as to the seat of the haemorrhage we compare this case with those of MM. Nonat, Gallard, and Pizc,"^ and we shall find that there is an exact resemblance be- * The following case would lead us to suppoic that'thc rupture of the cyst preceded the hfRmorrhape by eight days, but the details are 262 INTRA-PELVIC HEMORRHAGE tween them^ both in their pathological anatomy and in their sym- ptoms ; and on these points they differ entirely from rupture of the Fallopian tube or of the fcetal cyst. If we study these cases together it will aid us to diagnose between them and haematoceles with which they have hitherto been confounded. I do not attach much importance to the question of the signs of pregnancy, for all the cases are silent on this point. But we should not therefore conclude that they did not exist, for they do not appear to have been looked for, and they certainly are present in analogous cases which I have reported. The cessation or delay of the catamenia is, however, a point to be noticed, it varied from three to seven days, and in one patient after a delay of this kind hcemorrhage succeeded, and she fancied abortion had taken place. We ought, however, in strictness, to speak of sup- pression rather than of retardation of the menses ; for these metror- rhagias which are so common in extra-uterine pregnancy are not men- strual at all, and ought not to be confounded with that flux. As long as the losses continue, sometimes more, sometimes less, they are accom- panied with Httle or no pain, but when a considerable loss occurs, then sharp pains like those of labour follow, but they do not occur regularly. Further, we find that at the seat of pregnancy there was a fixed pain more or less sharp, with some swelling situate either outside the uterus (see Case II.), or adjacent to that organ (Case XIV.). The sharp pains in the lower belly usually come on just as the loss of blood diminishes, and sometimes only when it entirely ceases ; they are generally quite local, not acute, in no case are they very extreme, nor are they accompanied by either syncope or faintings, which is the more remarkable as I have constantly noticed this sym- ptom in ruptures, both of the cyst and of the Fallopian tube. About this time the tumour enlarges, and its volume increases ; it extends too brief to admit of certainty, I abridge its report by Vieussens [Ilistoire des maladies internes. Toulouse, 1775, t. iii. p. 17). A multipara, aged 30, not suspecting that she was again pregnant because she had some losses of blood from time to time, was seized with syncope, failing pulse, and cold sweats. She recovered in two days after appropriate remedies, when eight days later she was again seized with vomiting, syncope, cold extremities, and died in five hours. At the itost-mortevi examination the uterus was in an unimpregnated condition, the belly was half filled with blood, clotted and fluid, amongst which a two months foetus was found. WITHIN THE FCETAL CYST. 263 usually more to one side than the other; and f^omctimes at the beginning it only occupies one side. It increases in volume some- times rapidly and at once (Case XIL), sometimes by successive bursts as it were (Case XIV.). But the pale, altered expression, and the frequent pulse are not remarked, until the size of the tumour is considerable. Still later, the characteristic phenomena of peritonitis either general or local supervene, and always after the formation of the tumour; in M. Aran's case at two days; in M. Gallard's case at six days, and after the injection of water into it. It is of importance to note the period when these symptoms appear; there is tympanitis, dyspnoea, frequent and small pulse, vomitings, and abdominal tender- ness; these generally show themselves after the tumour has developed : while, on the contrary, in cases of intra-peritoneal hoematocele and pelvi-peritonitis, they always precede its formation. These symptoms may, however, improve, no matter how gi'ave they may be at first, as in the case of M. Aran : possibly even a cure may result, though I can- not quote an example. I need not stay to discuss the termination of these cases, because in all of them death has occurred, though in different ways. In one, for instance, the fatal issue was brought about by rupture of the cyst and genertil peritonitis, the result of injections into the tumour; in two other cases death ensued from intra-peritoneal haemorrhage, in one of which the cause was rupture of the ovary, in the other it was unknown ; in the fourth case the rupture of the foetal cyst was the result of haemorrhage into the cyst, and general peritonitis preceded death. The physical signs furnished by abdominal palpation and vaginal examination, by which we estimate the volume, consistence, and situation of the tumour are important ; though the information they aflbrd is not of so much value as one would suppose, they vary a good deal according to the scat of the cyst. Thus, in M. Aran's patient, the physical signs furnished per vaginam, though indistinctly marked, showed at the first a tumour situate more to the right side, and forming a kind of roof in the pelvis, which increased from time to time. In Hie case of M. Gallard, on the contrary, prior to any peritoneal complication, it was found that the tumoiu- had dissected th(; rectcj-vaginal wall and extended nearly down to the perineum, pushing the neck of the uterus upwards and forwards behitul the puhis. 'i'his is plairdy not tlie form usually taken by peri-uterine hacmatocele, but in the first of these two cases the physical characters were not sufHcient by themselves to form a diagnosis. I n the second, 264 INTRA-PELVIC HEMORRHAGE. on the contrary, they sujSicecl to show that the tumour was sub-peri- tonealj a character alone sufficient to lead us to a diagnosis, for we have already seen that sub -peritoneal blood tumours, called, whether rightly or wrongly, hsematoceles, belong either to normal or abnormal pregnancies. Amongst other physical signs I shall only observe, that in all the cases of extra-uterine pregnancy the uterus was larger than normal : but I do not attach much importance to this, becanse it is a thing difficult and sometimes impossible to be certain of. But though I do not consider either the form of the tumour or the other physical signs at all pathognomonic, yet it is evident that they differ widely from hsematoceles in the pre-existence of symptoms peculiar to pregnancy, in the antecedent metrorrhagia, the slight premonitory symptoms, and the existence of a large tumour before any peritonitis appears. Lastly, the absence of syncope, the slow progress of the disease, the non-occurrence of the signs of internal haemorrhage, distinguish these cases from the other termina- tions of extra-uterine pregnancies. I CHAPTER IT. DIAGNOSIS. It has usually been thought impossible to diagnose extra-uterine pregnancy during the first months of gestation. I think^ however, that an attentive study of the different cases will enable us to lay down some rules of diagnosis. We find generally a combination of signs, none of which by themselves are pathognomonic, but which leave no room for doubt when taken together. The grounds for this diagnosis are, the ordinary signs of pregnancy, especially the suppression of the menses ; the existence of metrorrhagia, usually persistent; the increased volume of the uterus; and lastly, the presence of a peri-uterine tumour. Undoubtedly the concurrence of these two sets of symptoms should at least make us suspect the existence of extra-uterine pregnancy, and this suspicion will grow into a certainty when the complications of rupture and internal hgemor- rhage supervene. I attach great importance to the phenomena which precede these haemorrhages, and which alone help us to a correct diagnosis. Almost all the patients whose cases I have quoted believed them- selves to be pregnant, sometimes even against the opinion of the physician (Case VI., 247) nor ought we to refuse a certain value to this belief, for most of these women had already had several children. So general indeed was this impression among the j)atients, that there were only four who had not suspected or rather harl not declared themselves to be pregnant."'^ In all but two the menses were suj)))rrssed, but the existence of metrorrhagia induced the belief that uienstruation was only delayed, because the points in which the one differs from the other were not • We do not here reckon the two Casps X. and XHI. vvliose historirs are altogether imperfect. 266 INTRA-PELVIC HEMORRHAGE. taken into account, especially the defect of periodicity on which Madame La Chapelle wisely lays stress. In only two of these patients, as I have said, menstruation was not suppressed (Cases II. and XII.) ; the explanation however, is easy, for in both, the rupture of the cyst or of the ovarian veins happened in the fourth or fifth week after conception ; moreover, both these women had metrorrhagia from the commencement of their pregnancy, and in their case this was suspicious. Indeed, these losses have always, and with good reason, been regarded as affording evidence of extra-uterine pregnancy: in the cases I have reported metrorrhagia was so frequent that it may almost be considered as constant, since there were but six cases in which it was not noted. Its long duration, the quantity at times, its want of periodicity, the little influence of rest or remedies upon it, the absence of those nervous phenomena which usually accompany menstruation, and the presence of pain, which increases in proportion to the profuseness of the bloody dis- charge ; these will generally prevent our confounding it with ordinary menstruation. It is unnecessary to remark upon the well-known signs which in- duced these patients to consider themselves pregnant. In some, all the usual signs of pregnancy were present, even in those where they had not been suspected, or where the physician had neglected to look for them. Besides the state of the breasts, the disturbed di- gestion, &c., it is generally found that the uterus is enlarged, and this in conjunction with other symptoms, rather suggests the idea of normal pregnancy, were it not for the fact, that at the same time a tumour can be made out either annexed or adherent to the uterus, and very frequently as it developes it thrusts the uterus more or less out of its normal direction. This tumour is so palpable to a practised observer that it has been made out even in a pregnancy of barely a month, as in the case of M. Siredey (Case X.). But the finding of a tumour pos- terior and adherent to the uterus, though separated from it by a groove, had in that case little diagnostic value, because the patient had only just recovered from peri-pelvic ])eritonitis, a condition Avhich, as we shall see, would yield very much the same symptoms. Though this sign taken by itself has but small value in this par- ticular case, its significance is much more important when associated with other signs, especially with the qoexistence of metrorrhagia. DIAGNOSIS. 267 occurring for nearly a montli in a woman who had no " show " either before or during the course of the pelvic peritonitis. I am inclined to lay great stress upon this ])oint because I regard the establishment of an extra- or peri-uterine tumour before the occurrence of any symptom of internal hcEuiorrhage as a cardinal fact in diagnosis, the only one indeed by which we can distin- guish haematoceles of this kind from those which take place in the course of normal pregnancy ; but fortunately this sign is not abso- lutely needed in practice. We have seen that, ordinarily, internal haemorrhages occur in extra-uterine pregnancies during the first, sometimes in the second or fourth, months ; whereas the few exam- ples of hfematocele occurring during normal pregnancy have taken place eitheir in labour or during the latter months of gestation, and consequently at a period when there was no difficulty iu diagnosing the existence of pregnancy ; but with the exception of two cases, I have never met with these complications coincident in point of time with the menstrual period, which is the time when haematoceles so generally occur in the unimpregnated condition, and in all kinds of pelvi-peritouitis. But even these two exceptions lose much of their value, because in the one (Case X.) rupture was the result of excessive coitus, and in the other (Case II.) the intra-peritoneal haemorrhage was occasioned by rupture of the ovary, not of the foetal cyst. I may add also that, except in the last case, the complications we are considering supervened only on the diminution, and often only on the complete cessation, of the metrorrhagy, which hns wrongly been supposed to be menstrual. Pain is the only premonitory symptom of rupture. This pain, which has existed from the commencement of the pregnancy — far more acute than the ill-defined sulfcrings which women in general experience — remains usually in the same situation. Preceded or accompanied by pains in the back it is sometimes compared to a cord drawn across, sometimes to colic, sometimes to labour pains, in a word, without any special character, it is always excessively severe. Some- times it comes on an hour or two before the rupture takes ])lace, but more often it occurs exactly at the time, and is accompanied by a sym])tom which seems to be constant, no matter where the seat of rupture, wh(;thcr vein, tub(!, or f(ctal cyst; the symptoui to which 1 refer is, syneojjc. Whatever he llie catif^c of this pliciioniciioii, whether we ascribe it to the acute pain caused by the rupture, or 268 INTRA-PELVIC HEMORRHAGE. to the great rapidity witli which the profuse loss of blood takes place, we find it existing in all cases of rupture ; whether in normal or abnormal pregnancy, or even in tlie unimpregnated state. Sometimes this syncope happens only once, but more often it is repeated, sometimes it is very prolonged, and complicated with debility and faintings. It is the first in the series of events which announce with certainty internal haemorrhage, and is speedily followed by a small and frequent pulse, loss of colour, chilliness, sometimes convulsions, all of which precede the close of life; these last events, however, only point to more or less profuse internal haemorrhage, while syncope furnishes other important diagnostic indications. It is generally wanting in the hsematoceles which occur in the unimpregnated, provided they are not occasioned by rupture of ovarian varices, or of the Fallopian tube, or of the ovary. We are thus enabled clearly to differentiate between the hsematoceles which we are now studying, and those of the metror- rhagic kind with which, by the presence, in both cases, of antecedent or concomitant uterine haemorrhage, they may easily be confounded. It is, as a rule, absent also in haematoceles from faulty menstrual excretion, but these cases will hardly give rise to any confusion ; for if on the one hand the absence of the catamenia and some gastric disturb- ance raise a suspicion of pregnancy, on the other hand, the absence of any coloured discharge will prove the difference between them and haematoceles symptomatic of extra-uterine pregnancies, as these almost always give rise to lengthened metrorrhagy. There are, more- over, many other characteristic points in which the two affections differ : for example, the anaemia which is but slight in the first is, on the contrary, excessive in the second. The peritoneal complications, most severe in hsematoceles from faulty excretion are less marked, sometimes even there is no time for their appearance in the second kind, as we shall see presently. Lastly, syncope will help us to distinguish ruptures of the foetal cvst from intra-cystic haemorrhage, for as in the latter the haemorrhage occurs more slowly, neither syncope nor even fainting results. The face becomes pale and loses its colour very slowly. Indeed, in M. Gallard^s case, the value of this differential sign is proved by experiment, as absolute fainting only happened at the moment that the injection of warm water into the cyst caused its rupture, though there was no fresh haemorrhage. It would therefore seem that in this case the syncope was dependent rather on the rupture than on the abundance or rapidity of the loss of blood. DIAGNOSIS. 269 I shall not discuss farther the diagnostic value of the signs of peritonitis since they are only seen in those relatively rare cases where death occurs slowly. Still it is worth remarking that in these cases the peritoneal complications are much less intense than one would, at firsts have fancied ; and the presence of blood in the peritoneum does not give rise to those formidable symptoms which are produced by effusion of the fluid of hydatid cysts^ of pus, or of altered blood as Professor Trousseau has accurately remarked. These symptoms, moreover, do not differ at all from those observed in other kinds of haematoceles or in pel vi- peritonitis, and are only of use diagnostically when the time of their appearance is taken into account. In fact, in those rare cases where life is prolonged sufficiently for inflammation to occur, the effused blood becomes encysted, and a tumour is formed which, whether it contains only blood, or a foetus as well, may be a source of error. There is indeed no difference in situation, form, or physical characters between this tumour and that of simple hsematocele ; for which it might be mistaken, if the antecedents and progress of the disease were not duly weighed. We must therefore remember that in these cases the tumour always follows the peritoneal complications. It is not formed, as the case of M. Siredey (Case X.) clearly proves, until the peritoneal adhesions have made a kind of cyst around the clot and formed a resisting envelope, without which the most profuse effusion of blood will not yield the sensation of a tumour to the touch, however careful the observer may be. This special characteristic of blood effusions, viz., that no distinguishable tumour is formed until after the peritoneal complications, is common alike to the other varieties of hoDmatoceles and to pelvi-peritonitis, but it is altogether wanting in intra-cjstic haemorrhages, for in these cases, on the contrary, the increase of the tumour often precedes by many days the development of peritonitis. In some cases the sensation of a tumour may give rise to the opposite error, and lead us to consider the tumour formed by the fcetal cyst itself as a hsematocele following the rupture of an extra-uterine pregnancy. There is a liability to this error in those cases where the foetal cyst, owing to its position between the uterus and the rectum, presses on the bowel and bladder, and gives rise to symptoms pecu- liar to haematoceles as in the foUowijig case. 270 INTRA-PELVIC H^MOERHAGE. Case XV."^ — MetrorrJiafjia for three months ; hypogastric pains ; difficult micturition and defacation, vomiting, Sfc. ; hi/poffastric tumour comptressing the rectum J death; post-mortem examination; intra-perito?ieal haemorrhage ; extra -uterine gestation. A woman, aged 39, was taken ill on the 29tli of October, 1712, having previously had a bloody discharge for three months. She complained of great pain in the lower part of the body, difficult mic- turition and defsecation, with vomiting, fever, &c. On examination a tumour was felt in the hypogastrium very tender to the touch ; an aperient was ordered and some embrocation for the stomach. On the third day of the attack there was smart fever, a pinched expression, and cold clammy sweats. At first it was thought that these symptoms were indicative either of pregnancy, the child being dead and putrid, or that the uterus contained some decomposed blood. The patient denied being pregnant and on examination no sign of pregnancy existed : meanwhile the urgency of the symptoms increased, and the patient died on the fourth day of the attack. On opening the abdomen a quantity of blood was found in the hypogastric region, and on clearing this away a large tumour was dis- covered in the lower part of the abdomen. Having opened the tumour I was greatly surprised to find that it contained a foetus. It was situate more to the left than the right side, the placenta being in the former position, the uterus contained nothing but a few drops of blood ; the left ovary and Fallopian tube were firmly adherent to the membrane which surrounded the child; the placenta was also ad- herent : I separated the orifice of the left Fallopian tube with great care, and on blowing into the tube, the air passed through into the uterus ; the right ovary and the other organs were in a healthy condition. Not knowing the symptoms which induced Duverney to suspect pregnancy in this case, in spite of three months^ haemorrhage, I cannot say whether it could have been diagnosed. Moreover, the reticence in the commencement of the report, so contrary to Du- verney's usual custom, prevents one from putting much reliance on the denial of the patient. I regret extremely that Duverney has not pointed out the Duverney. (Envres anatonnqiies, t. ii. p. 357. DIAGNOSIS. 271 peculiar kind of sensation Mliicli this enormous tumour formed by tlie foetal cvst gave rise to. An intlication the more important, as the tumour, which was neither hard nor painful to the touch, occupied exactly the same situation as a hematocele would do. It was per- ceptible in the hypogastric region, it compressed the rectuui and uterus, and thrust the latter forward. Some of the symptoms might also lead to an error in diagnosis, such as the difficulty of micturition and defcecation, the impossibiHty of relieving it, and the spontaneous pain and nausea. We may also note that the patient had no fever, that for three months she had had uterine haemorrhage, and that it was only on the third day after the commencement of the symptoms, and after the establishment of the tumour, that the signs of internal haemorrhage were manifested. This mode of progression, altogether different to that of haeraatocele, ought to have banished all idea of that kind. Moreover, the absence of syncope precluded the supposition of rupture of the foetal cyst ; and though we are ignorant of the source of the intra-peritoneal haemorrhage, we know at least that neither the foetal cyst nor the Fallopian tubes presented any rupture. This case, while it shows some of the difficulties we have to con- tend with, indicates how far we may hope to arrive at a fair dia- gnosis by the study of the different syn)ptoms, and especially of their order of occurrence jointly with the antecedents. CHAPTER III. PEOGNOSIS. While the difficulty^ and often the impossibility of getting an exact history frequently jjrevents us from arriving at a full knowledge of the nature of a given case, we have, unhappily, no need of the like in- formation to guide us in the prognosis. MM. Litti-e and Duverney did not hesitate in the cases I have reported to prognosticate a fatal issue. In fact, all the cases that I have quoted have terminated in death ; generally it has taken place in a few hours or days, and though death has been delayed for six months, as in Case IX., it is wholly exceptional. Nevertheless, Murat,"^ Cazeaux,t Chailly,J and Jacquemier,§ have pointed out the possibility of a happier result; and I have thought it right to examine the facts on which they found this opinion. Murat indeed quotes two cases to support this view ; one by Jacob {London Journal), which I have been unable to find, the vague de- tails of which do not seem to me authentic : the other by Bianchi,|| which is placed in the note below, though it is susceptible of a very different interpretation from that the author has assigned to it. * Diet, en 60 vols., art. Grossesse extra-uterine. t Cazeaux. Tj-aite pratique des accouchements. X Chailly. Traite pratique de I'art des accouchements, 2^ ed. p. 136. § Jacquemier. Manuel des accouchements, t. i. p. 381. !l Case by Bianclii. De naturali in humano vitiosa morhosaque genera- tione. Historia externce in ovario graviditatis indeque ventralis externce in Taurinetisi Jemina. A woman became pregnant for tlie tbird time, the abdomen enlarged more on the right side than in the mesian line, the pregnancy went on to the ninth month, when labour pains came on ; the foetus was distinctly felt through the abdominal walls, but no delivery followed. After a short time the woman resumed her occupations, and the menstrual flux returned. She contracted venereal disease, and died about fifteen years after the preg- PROGNOSIS. 273 "We see here a case of abdomiiml j)iegnancy, the foetus dviiig at the uiuth mouth, while the mother keeps her heakh ; but there is not a symptom to justify the diaguosisof a rupture of the foetal cyst, and the report of the post-mortem exaiuinatiou fifteen years Later, shows that the cyst coutaining the mummifu d foetus was intact. The following case of Duverney reported by Bianchi * has been considered an example of recovery after rupture of the cyst, but the translator is in error. "In the tubal conception, which M. Duverney met with and described, the foetus underwent many changes and the tube dilated more and more, but foetal laceration and effusion of blood did not follow (as the mother, on the evidence of the writer, died from fever brought on by quite another cause), because the foetus was slowly absorbed just like a dead body laid up and dried, and the tunics of the (Fallopian) tube in the pregnant woman gradually becoming indurated, not only resisted rupture, but perhaps by continued pressure absorbed the growing foetus.^'' This quotation seems to leave no doubt on the matter, since it is there stated that the tunics resisted rupture, and Bianchi adds in the same chapter that tubal i)rcgnancy, followed by rupture of the Pallopian tube, is always fatal. Moreover, if we read the original case of Duvcmey,t we do not see any question raised either about rupture of the cyst or hasraorrhage. It is but too true, then, I fear, that we are authorised in saying that all the cases of intra-peritoneal haemorrhage arising from extra-uterine pregnancy end in death. Some cases, nevertheless, as Case IX. for cxami)lc, would give one slight hopes of a happier termination. Lastly, the long continuance of the disease in the cases comprising our fifth variety, its nature, atid the example of the case of M. Clallard, are proof of the possi- bility of a cure ; in this case we can well understand that the iidie- rent difficulty in diagnosis may often cause us to doubt the existence of such an event, though we are unable to quote an example. nancy. On oj)eninf:; the abdomen the omentum was found united to the peritoneum by new delicate membrane as far as the pul)cs; next came a hard, dense, leathery membrane within which lay a faHns with one loot and Icf^ in a cyst, evidently llic right ovary. • IJianehi, dji.