UC SOUTHERN REGIONAL LIBRARY FACILITY G 000 005 665 5 LECTURES DISEASES OF WOMEN. BY THE SAME AUTHOR— LATELY ISSUED. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Fourth American from the Fifth and Revised London Edition. In one neat octavo volume of6bG large pages, extra clot A, $4.50 ; leather, $5.50. This work may now fairly claim the position of a standard authority and medi- cal classic. Five editions in England, four in America, four in Germany, and translations in French, Danish, Dutch, and Kussinn, show how fully it has met the wants of the profession by the soundness of its views and the clearness with which they are presented. Few practitioners, indeed, have had the opportunities of observation and experience enjoyed by the author. In his Preface he re- marks : " The present edition embodies the results of 1200 recorded cases and of nearly 400 post-mortem examinations, collected from between 30,000 and 40,000 children, who, during the past twenty-six years, have come under my care, either in public or in private practice." The universal favor with which the work has been received shows that the author has made good use of these unusual advantages. Of all the English writers on the diseases of children, there is no one so entirely satis- factory to us as Dr. West. For years we have held his opinions as judicial, and have regarded him as one of the highest living authorities in the difficult department of medical science in which he is moat widely known. His writings are characterized by a sound, practical, common sense, at the same time that they bear the marks of the most laborious study and investigation. We commend it to all as a most reliable adviser on many occasions when many treatises on the same subjects will utterly fail to help us. It is supplied with a very copious general index, and a special index to the formulse scattered throughout the work. — Bostoji. Med . and Surg. Journal, April 26, 1806. Dr. West's volume is, in our opinion, in- comparably the best authority upon the maladies of children that the practitioner can consult. Withal, too — a minor matter, truly, but still not one that should be neg- lected — Dr. West's composition possesses a peculiar charm, beauty, and clearness of ex- pression, thus affording the reader much pleasure, even independent of that which arises from the acquisition of valuable truths. — Cincinnati Journal of Medicine, March, 1866. We have long regarded it as the most scientific and practical book on diseases of children, whioii has yet appeared in this country. — Buffalo Medical Journal. Undoubtedly one of the best books on the subject we have ever seen, and we cheerfully recommend it to the profession. — N. O. Mtd. Record, July 1, 1866. To occupy in medical literature, in regard to diseases of children, the enviable position which Dr. Watson's treatise does on the dis- eases of adults, is now very generally as- signed to our author, and his book is in the hands of the profession everywhere as an original work of great value. — Md. and Va. Med. and Surg. Journal. Dr. West's works need no recommenda- tion at this date from any hands. The vol- ume before us, especially, has won for itself a large and well-deserved popularity among the profession, wherever the English tongue is spoken. Many years will elap.se before it will be replaced in public estimation by any similar treatise, and seldom again will the same subject be discussed in a clearer, more vigorous, or pleasing style, with equal sim- plicity and power. — Charleston Medical Journal and Review. There is no part of the volume, no subject on which it treats, which does not exhibit the keen perception, the clear judgment, and the sound reasoning of the author. It will be found a most useful guide to the young practitioner, directing him in his manage- ment of children's diseases in the clearest possible manner, and enlightening him on many a dubious pathological i)oint, while the older one will find in it many a suggestion and practical hint of great value. — Brit. Am. Med. Jonrual. Dr. West's book is the best that has ever been written in the English language on the diseases of infancy and childhood. — Colum- bits Revietv of Medicine and Surgeri/. LECTURES DISEASES OF WOMEN. CHARLES WEST, M.D., Fellow of the Royal College of Physicians ; Examiner in Midwifery at the University of London; Physician to the Hospital for Sick Children; and formerly Physician-Accoucheur to St. Bartholomew's and the Middlesex Hospitals, irb Inuritan, FROM THE THIRD AND REVISED ENGLISH EDITION. PHILADELPHIA: HENRY C. LEA. 1867. PHILADELPHIA: CAXTOJf PRESS OF SHERMAN t CO. -^v / -/^ TO PETER MERE LATHAM, M.D., PHVSICIAN EXTRAORDINARY TO THE QUEEN, AND FORMERLY PHYSICIAN TO S T. B A R T H L M E W ' S HOSPITAL: WnO FIRST SHOWED ME HOW TO STUDY, AND HOW TO PRACTISE MEDICINE ; WHO HAS OFTEN GUIDED ME BY HIS ADVICE, STILL OI'TENEIl TAUGHT ME BY HIS EXAMPLE ; AND WHO SMOOTHED BY HIS UNWEARIED KINDNESS THE EARLY DIFFICULTIES OF MY CAREER ; TO MY RESPECTED TEACHER, MY GENEROUS FRIEND, I MOST GRATEFULLY, MOST AFFECTIONATELY, THIS BOOK. ADVERTISEMENT TO THE THIRD EDITION. The adoption of a somewhat fuller page than in the pre- vious editions has enabled me to increase the matter without adding to the size of the book. The chief additions will be found under the heads of Uterine Haematocele and Ovarian Disease : but I have care- fully revised the whole work, and added to it wherever larger experience has increased my knowledge. 61 WiMPOLE SrEET, April 30, 1864. ADVERTISEMENT TO THE SECOND EDITION! The kind indulgence with which the first part of these Lectures was received has ah^eady rendered a new edition of it necessary. A shorter time, too, than I feared has sufficed for the fulfilment of my pledge, and the completion of the work. Many subjects that deserve a longer notice are touched on here but slightly, and others of a purely surgical nature are completely j)assed over, for I have not ventured to teach concerning matters with reference to which I feel myself to be still altogether a learner ; while I have always regarded mere compilation, uncontrolled by large experience, as more apt to perpetuate error than to difi'use truth. But I have a more agreeable duty to perform than that of confessing my shortcomings, and pleading in their exten- uation. To one of my colleagues at St. Bartholomew's Hos- pital I have been constantly indebted wherever the aid of the surgeon was necessary; and Mr. Paget's dexterous hand, and sound judgment, and ready friendliness, were always given almost without the asking. Many cases, those es-pe- ADVERTISEMENT. cially of ovarian disease, we observed and treated together; and my opinions have often been modified, and my conduct influenced by his suggestions. My readers will reap the benefit; it is for me, with best and warmest thanks, to ac- knowledge the obligation. 61 WiMPOLE Street, October, 1858 ADVERTISEMENT TO THE FIRST EDITION OF THE FIRST PART. These Lectures are a first instalment towards the dis- charge of that debt which the opportunities of a hospital and the responsibilities of a teacher impose upon me. A second volume, which will treat of all the remaining dis- eases of the female system, will appear, if health and strength are spared me, within three years from this time. I have published this part separately, because I believe that students and junior practitioners stand in much need of that help which, with reference to an important class of these ailments, it may perhaps afford them. To almost all persons there is probably more of pain than of pleasure in looking back upon a work on which much time and labor have been expended ; so wide is in general the distance between the endeavor and its fulfilment. To myself, the consciousness of doubt has often, while engaged upon these Lectures, been very painful, and" the sense of im- perfect knowledge has pressed heavily upon me, and does so still. Xll ADVERTISEMENT. I commend the book, however, to the kindly judgment of my professional brethren, as embodying the results of ten years of observation in the wards of a hospital, and of the honest attempt to gather from each day's added experience something more or better, for the use of those who look to me for help and guidance. WiMPOLE Street, April, 1856. CONTENTS. LECTURE I. FAO£ Introductory. Symptoms of Diseases or Women, . . . .17 LECTURE II. Introductory. Examination of Symptoms, concluded. Modes of Examination, 24 LECTURE III. Menstruation, and its Disorders. Amenorrhcea, 34 LECTURE IV. Disorders of Menstruation. Amenorrhcea concluded. Menorrhagia, 49 LECTURE V. Disorders of Menstruation. Dysmenorrhcea, 69 LECTURE VL Diseases of the Uterus. Inflammation and kindred Processes. Hypertrophy of the Uterus, and Acute Inflammation, . . 82 LECTURE YIl. Inflammatory Affections of the Uterus. Chronic Inflammation AND Ulceration of the Os Uteri ; Examination of Different Opinions on this Subject, 94 LECTURE VIII. Chronic Inflammation and its Results, continued; Treatment of THE Affection; Cases considerkd requiring Local Treatment of Ulceration. Cervical Leucorrhoea, 112 XIV CONTENTS. LECTUKE IX. PAOE Misplacements of the Uterus. Prolapsus Uteri, and the Allied Misplacements of Yagina, Bladder, and Eectum. Their Nature AND Mode of Production, 126 LECTURE X. Misplacements of the Uterus, continued. Prolapsus Uteri, and the Allied Misplacements of Vagina, Bladder, and Eectum. Their Symptoms and Treatment, . . . . . . . 138 LECTURE XL Misplacements of the Uterus, continued. Versions and Flexions. Anatomy and Pathology of Axteversion and Retroversion, and OF THE corresponding FlEXIONS. CONGENITAL OBLIQUITY, . . 159 LECTURE XII. Misplacements of the Uterus, continued. Versions and Flexions: THEIR Symptoms, Diagnosis, and Treatment, 170 LECTURE XIII. Misplacements of the Uterus, continued. Inversion of the Uterus. " Ascent of the Uterus, 187 LECTURE XIV. Uterine Tumors and Outgrowths. Mucous, Fibro-Cellular, and Glandular Polypi. Mucous Cysts of Uterus. Fibrinous Polypi, 205 LECTURE XV. ^ Uterine Tumors and Outgrowths. Fibrous Tumors: their Struc- ture, Pathology, and Symptoms, 216 LECTURE XVI, Uterine Tumors and Outgrowths. Fibrous Tumors, continued: their Diagnosis, and Deviations from Ordinary Symptoms : their Prognosis, 232 LECTURE XVII. Uterine Tumors and Outgrowths. Fibrous tumors, continued : their Treatment, 244 CONTENTS. XV LECTUKE XVIII. PAGE FiBROTis Polypi. Eecurbent Pibroid Tumors. Fattt Tumors of the Uterus. Tubercular Disease of the Uterus, 259 LECTURE XIX. Malignant, or Cancerous Diseases of the Uterus : their Morbid Anatomy, 276 LECTURE XX. Malignant, or Cancerous Diseases of the Uterus, continued : their Pathology, Symptoms, and Diagnosis, 294 LECTURE XXI. Malignant, or Cancerous Diseases of the Uterus, continued : their Treatment, .316 LECTURE XXII. Inflammation of Uterine Appendagp^s, and of the Pelvic Cellular Tissue: Its Causes, Symptoms, and Course, 336 LECTURE XXIII. Inflammation of Uterine Appendages, etc., continued : Exceptional Cases. Treatment of the Affection. Hemorrhage about the Uterus, or Uterine Hematocele, 353 LECTURE XXIV. Inflammation of the Ovaries themselves. The Acute and Chronic Forms of the Disease. Displacement of the Ovary. Note on Hernia of the Ovary and on Cysts of Uterus, 37f LECTURE XXV. Ovarian Tumors AND Dropsy ; their Morbid Anatomy, . . . . 391 f LECTURE XXVI. Ovarian Tumors and Dropsy. Pathology of the Disease furthkr considered : its Course and Causes, -iOi'y LECTUKE XXVII. Ovarian Tumors and Dropsy; thkir SY^u•T0Ms and Diagnosis. Xotk ON Floating Tumors of the Abdomen, 421 XVI CONTENTS. LECTUKE XXVIII. PAGE Ovarian Tumors and Dropsy ; their Prophylactic and Palliative Treatment, 437 LECTUEE XXIX. Ovarian Tumors and Dropsy ; their Treatment, continued : Curative Measures, 450 LECTUKE XXX. Ovarian Tumors and Dropsy ; their Treatment, continued : Extirpa- tion OF THE Disease, 468 LECTUKE XXXI. Diseases of the Female Bladder, 484 LECTUKE XXXII. Diseases of the Urethra and Vagina, 498 LECTUKE XXXIII. Diseases of the External Organs of Generation, 617 INDEX, 539 THE DISEASES OE WOMEN. LECTURE I. INTEODUCTOKY. Keview of subjects already considered in the Lectures on Midwifery — Eeasons for having postponed the Study of the Diseases of Women — Twofold Knowledge requisite for their study — Dangers and mistakes arising from want of it — Illustrative cases. Symptoms of these diseases furnished by disturbance of function, alteration of sensibility, and change of texture. Symptoms of first two classes considered. Gentlemen : Some of you, perhaps, remember that I endeav- ored, at the commencement of my Lectures on Midwifery, to point out to you the various respects in which the generative system plaj^s a more important part in the organism of woman than in that of the man. I called your attention to its constantly recurring activity, as displayed in the periodical return of menstrua- tion, to its fiir-reaching influence as manifested in the various phe- nomena that attend upon pregnancy and labor, and to the impress which the whole body bears of the s[)ecial adaptation of every part for the most complete performance of its functions. I pointed out to you, how, as the child grows, the womb grows with it ; how its lowly organized tissues become developed; its vessels increase in* size ; nerve-matter is deposited Avithin the sheaths, so delicate as to have been almost imperceptible before ; and the uterus becomes at length what old aiuitomists have not hesitated to call it, — Mira- culum iS'aturje. And next I described to you the means by which all the dangers and dilliculties of parturition are surmounted; and then told you how, all the grand functions of the'titerus being thus completed, its tissue undergoes degradation and decay, its vessels shrink, its nerves dwindle to their former .size, all the emunctories of the body bearing their part in the removal of the now useless materials ; while, at the same time, nature labors to form a new uterus, fitted to go once more through the same marvellous changes, and to answer the same important cuds. I 2 18 IMPORTANCE AND DIFFICULTIES entered then into such details, not for the purpose of exciting idle wonder, but in order to lead you to the obvious inference that processes so complicated must be very apt to become disordered ; that it must, therefore, be your duty, and ought to be your pleasure, to acquaint yourselves with them and their disorders ; that you might learn to know what is healthful, to correct what is contrary to nature, or to render ills that are unavoidable as small as possible. Thus convinced, as I trust, of the importance of the study, you have completed the examination into the physiology of the female sex, in so far as the reproductive processes are concerned, and have inquired, moreover, into the various circumstances by which the generative organs are liable to be disturbed in the performance of their highest functions, the signs of such disturbance, and the means whereby it may be remedied. But, as the generative system in woman has functions that it performs independent of those highest offices which it discharges when a germ has been impregnated, and becomes developed to a new being, so their disturbance is not without serious influence on the whole organism. The establishment of the sexual power at puberty, and its extinction with advancing age, both exert impor- tant influence on the constitution ; at both of these epochs there is an increased liability to disease, and at the former a marked in- crease in the rate of mortality. All tlirough the time of sexual viijjor too, a thousand causes mav derano;e the reijular recurrence of the manifestations of its activity, and thereby throw the whole complex machinery of the body into disorder. The disorders of the sexual functions, then, and the way in which they react on the general health, or are acted on by it, call mani- festly for some of your attention; but even when you have famil- iarized yourselves with them moi^t completely, your acquaintance with the diseases of women will be but just beginning, for the organs which subserve these functions may be themselves diseased. These organs, too, are complicated in their structure ; formed of various tissues, but bound together by sympathies so close that one part cannot be the seat of suflering without all suft'ering together; and hence it is often no easy task to unravel the tangled web of symptoms, and to find out where the mischief is, and what it is, to which so many manifestations of disease are due. I have deferred till now inviting you to enter on the study of these afl'ections, on account of the many difficulties by which it is attended, and on account of the need you will find, in pursuing it, of that special knowledge which you have acquired while attend- ing lecture^ on midwifery, as well as of that acquaintance with practical medicine which careful observation in the wards of the hospital can alone supply. Knowledge of both of these kinds is equally necessary ; the want of the one or of the other is the cause of those two errors into which practitioners not infrequently fall. Some men regard the local ailment as everything ; others almost lose sight of its existence, and it is difficult to say which of these two errors is the more miscjiievous. A woman applies to a prac- OF STUDY OF DISEASES OF WOMEN. 19 titioner who is guilty of the first-mentioned error, complaining of painful and scanty menstruation ; he at once adopts mechanical means for her relief. He introduces bougies to widen the canal, and to remove some, perliaps imaginary, contraction of the cervix uteri, by which he conceives the escape of the menstrual fluid to be impeded, and he even incises it to make sure of enlarging its calibre. After undergoing much pain of body, and much distress of mind, the patient finds herself at the end of these manipulations no better than when they began ; the cause of her sufferings lay deeper, and was to have been found in the derangement of her general health, which would have attracted the notice of a better physician, and which well-directed measures would probably have cured. Let me mention another case as illustrative of the opposite error. A patient seeks for relief on account of profuse menstrua- tion, attended with discharge of coagula, but accompanied with little or no pain. General treatment is adopted, the patient is con- fined to the recumbent posture, in a cool and well-ventilated room, astringents are given internally, cold is applied locally, and no sign of disorder of the general health is allowed to pass without appropriate means for its cure ; but yet amendment does not follow, for the bleeding depends upon the presence of a minute polypus, which nothing but careful examination of the uterus could dis- cover. In the one case, a crass mechanical treatment was adopted to cure an affection that depended on the state of the general health ; in the other, general treatment failed to remove symp- toms which careful investigation would have shown to depend upon a local cause. But I need not draw upon imaginary cases in order to enforce the caution that I am desirous of impressing on you ; the records either of hospital or of private practice afford illustrations of it in abundance. A middle-aged woman complained of frequent desire to pass water, and of discomfort in voiding it; she was dyspeptic and out of health. Her urine was tested, and found to contain albumen ; and the irritable state of her bladder was assumed to be dependent on the disease of her kidneys. Treatment improved her general health, but brought no relief to her dysuria. At length careful observation discovered the albumen to be due to the admixture of vaginal discharges with her urine — a not infrequent source of it in women who suffer from leucorrhoea; while examination, which had been delayed too long, detected a small vascular tumor just within the orifice of the urethra, to the irritation produced by which her symptoms were due, as was shown by their immediate disappearance on its removal. A young lady whose health had never been robust, began at the age of twenty-two to menstruate irregularly and scantily, and to suffer at tlie same time from pruritus of tlie vulva. For this symptom various local applications were resorted to, and more than, once she underwent the distress of an examination wliich discovered nothing more than an increased degree of redness 20 ERRORS IN DIAGNOSIS OF DISEASES OF "WOMEN. about the labia and njmphse. At length, with the decline of her general health, she came under the care of another physician, who ascertained that sugar was present in her urine. The pruritus, like the itching of the urethra in the male subject, was the con- sequence and the symptom of the diabetes of which the poor girl eventually died. A woman was admitted into the hospital a few years ago in a state of extreme sutiering ; her countenance was very anxious ; she lay in bed with her knees drawn up, dreading the slightest move- ment ; her abdomen Avas intolerant even of the slightest pressure. She was reputed to have peritonitis, and had been bled for this, as well as abundantly salivated before her admission, yet without relief. But with all this her skin was perspiring, and her pulse was soft, and not increased in frequency. Her history was, that after vague uterine ailments for a month, slie was suddenly attacked by violent pain in the womb, attended witli bearing-down efforts equal in intensity to those of labor. These subsided, but the pain was referred to the bladder, and desire to pass water became very frequent. This too abated, and the next complaint was of violent pain in the shoulder, which was encountered by active measures for the relief of alleged inflammation of the shoulder- joint; and the pain in the shoulder suddenly ceasing, the severe abdominal suffering at once succeeded it. A hot hip-bath gave almost inmiediate relief, though the patient screamed when moved in order to be placed in it ; and a full dose of opium was followed by some hours of quiet sleep. The next day no pain was com- plained of except over the pubes, and this soon disappeared under the use of anodynes; and steel and good food completed tlie cure of a case of hysterical peritonitis. Now these cases, to which it would be very easy to add many more, are all examples of the error of making too little or too much of symptoms indicating disorder of the sexual system. Your general medical knowledge must keep you from the latter; it is my special dutj- to arm you against the former, or rather, as much as in me lies, to defend you from both. With this view I propose to-day to make a few introductory remarks upon the signs and symptoms of disease of tlie generative organs in the female, and on the means of investigating them. There are three modes, in some or all of which these affections manifest themselves — namely, by causing disturbance of function, alteration of sensibility, or change of texture. The ovaries are the grand organs of sexual activity in the female ; and during the whole time that sexual life continues, they are employed in the healthy individual in bringing ova to maturity, and then in extruding them at certain periods when they have attained a state of fitness for further develo[iment, if subjected to the fecundating influence of the semen. Accompanying this in- ternal process, the consequence and the evidence of the local con- gestion which attends it, we observe a periodical discharge of blood constituting menstruation. The regular return of menstruation, SIGNS OF SEXUAL DISORDER. 21 its accomplishment within a given period, attended by a certain average amount of discharge, and by no more than a certain average degree of discomfort, are regarded by women, and with propriety, as "conclusive evidences of the healthy state of the sexual functions. In every inquiry therefore, with regard to supposed disease of the generative apparatus, the mode in which this function is performed must engage your careful attention. You know menstruation to be merely the sign of a more important process going on deeper within the organism. The non-appearance of the discharge, then, or its suppression, suggests at once many important inquiries which must be carefully followed up, till you can return to them a satis- factory reply. Is the system so feeble that, like an ill-thriven plant, its sexual power remains altogether in abeyance ? or are the ovaries themselves diseased ? or does the internal process go on, while yet, owing to some mechanical cause obstructing the escape of the discharge, its outward manifestation is wanting? or is its appearance prevented by some disorder of the general system, or of the uterus, which incapacitates that organ from performing its usual office as a kind of safety-valve by means of which the congested pelvic vessels are relieved of their superabundant blood? Or is perchance none of these suppositions correct, and is the real explanation of the suppression of the menses to be found in a physiological not in a pathological occurrence, and are the symp- toms those of pregnancy, not those of disease ? Such are the important questions which, in every case of suppressed menstrual discharge, you must endeavor to answer, and to which, both for your own reputation as well as for your patient's well-being, it is of the greatest moment that you should return a correct reply. Or, again, your patient sutlers from what she conceives to be ex- cessive menstruation, her health is breaking down beneath it. Whence comes the discharge ? is it due to a state of general pleth- ora, which nature endeavors to relieve by this outlet, though in her endeavors she exceeds the limits of safety? or are the vessels so weak that blood escapes from them with dangerous profusion ? or is the hemorrhage due to neither of these causes, but to a breach of surface, to some ulcer of the womb from which the blood flows, or to some morbid growth, or formidable organic disease, the effect of which is rendered more serious just at those times when the uterus becomes more than usually congested ? These, and similar inquiries, possess a special importance at certain epochs of a woman's life ; for wlion the sexual powers are on the decline, disease is especially liable to be set up, and you therefore regard all menstrual irregularities at that time with closer attention than at any former period. But there are other subsidiary functions perfomtied by the gener- ative organs, the disturbance of which is sometimes the occasion of mere discomfort, at other times the indication of serious disease. These organs present a great variety of secreting surtaces, which furnish matters of various kinds, subserving various purposes. A slight secretion moistens the interior of the Fallopian tubes, just 22 SIGNS OF SEXUAL DISORDER. as it does that of all viscera, and except near the monthly periods of sexual activity, it is by little more than a mere halitus that the cavity of the womb itself is lubricated. The large mucous crypts or glands about its neck furnish a peculiar secretion, which is generally present at all times, though most abundant during preg- nancy. The mucous follicles of the vagina pour out a somewhat copious secretion upon its surface ; and the two glands which are seated one on either side of its entrance, and w^hich, under the name of Duverney's glands, correspond to Cowper's glands in th« male, furnish an abundant discharge at the time of sexual con- gress ; and, lastly, numerous mucous crypts and sebaceous follicles on the nymphae, the interior of the labia, and about the vestibulum, supply a suitable secretion to lubricate those parts. From any or all of these sources secretion may be furnished, excessive in quantity, and more or less altered in character. The secretion may be a mere leucorrhoea, an increased flux from otherwise healthy tissue ; it may be a purulent discharge from inflammation of a mucous membrane, or it may be furnished from an ulcer of the womb ; or, it may not be simple pus, but an offensive sanies from a wide-spread cancer of the organ, or of some part adjacent. Your patient may come to you in complete ignorance as to which of all these is the cause of the affection under which she is laboring : she looks to you for an answer to her doubts, and for relief to her sufferings. Diseases of these organs, however, are associated not merely with altered function, but also with disordered sensibility, and that not only of the part affected, but also of others more or less distant. There is hardly any more fertile source of erroneous diagnosis with reference to the diseases of women than the overlooking the import of some of these alterations of sensibility, and the not connecting with its proper cause the sympathetic affection of some, perhaps, distant organ. If a woman complain of a sense of heaviness in the pelvis, of bearing-down pain, of pain in the loins and about the sacrum, or shooting down the thighs, our attention is naturally directed to the state of her sexual organs, and we are not likely, with moderate caution, to overlook the real seat of her disease. In many cases too, something beyond the seat of the disease may be learned if we notice the character of the pain from which the patient suffers, since this is usually of one kind if inflammation be present, of another if there be cancerous disease, of a third if there be displacement of the womb. These minutise, too, are of all the more importance for us to attend to, since there are no other dis- eases in which that personal investigation by which so many questions can be at once answered is attended by so many diffi- culties, both from the natural repugnance of the patient to submit to it, as well as from the imperfection of our means of examina- tion. But disease of these organs is not seldom attended by pain which is referred not to the real seat of the mischief, but to some other, perhaps some distant part. Women may apply to you who seem ALTERED SENSIBILITY. 23 out of "health, and in whom you may, perhaps, at first, suspect the existence of uterine disease; but they appear annoyed at inquiries with reference to their sexual functions, or perhaps deny, and with perfect truth, the existence of any pain in the uterus, or its imme- diate neighborhood. Perhaps, however, they may confess to pain in the rectum, especially at the time of defecation ; or may speak of symptoms which they refer to hemorrhoids ; or may complain of sciatica, or of lumbago. Always suspect the import of these sufferings ; bear in mind the wide sympathies of the pregnant womb, and keep all your vigilance active ; it is highly probable that these anomalous symptoms will resolve themselves into the effects of uterine disease. Nor are they merely strange and intractable forms of local ail- ment which should call your special attention to the uterus and its functions. The pregnant woman suffers almost invariably from nausea and* vomiting; her appetite often becomes capricious, and her digestive functions are frequently ill performed ; while it is far from unusual for her to have attacks of headache, or of tic-doalou- reux, though she may at other times enjoy a complete immunity from all such ailments. But just as disorder of the functions of other organs not seldom attends upon the physiological processes going on in the womb, so may it follow upon uterine irritation produced by disease ; and a large proportion of the most obstinate forms of dyspepsia, and a still larger number of hysterical and nervous afi'ections, have been excited and are kept up by disease of the womb. In a great many of these cases, minute inquiry elicits evidence of functional disorder of the generative organs, as shown by disturbed menstruation, by leucorrhocal discharges, or by painful sensations, although noiie of these symptoms may have been so marked as to have engaged the patient's notice ; or she may have regarded them as trivial accidents not worth mention when compared with the' other, and to her feelings the more im- portant causes of her sufferings.^ Need I guard myself against being misunderstood — against be- ing supposed to say that, in the management of a woman who is d^'speptic, your attention is to be turned less to the state of her stomach than to that of her womb ; or that, if a woman suffer from neuralgia, you are at once to suspect the existence of uterine disease? I mean no such thing; but what I do mean is, that, in the treatment of diseases occurring among patients of the female sex, you should always bear in mind tliat, besides the ordinary causes of disease common to both sexes, there is another set of causes peculiar to themselves. Whenever, therefore, the ordinary principles of pathology fail to explain, or the ordinary proceedings of therapeutics prove inadequate to cure the ailments of any female 1 In vol. ii of Lisfranc's Cliniqiie Chirurgicalc, 8vo., Paris. 1842, from p. 182 to p. 256, are some remarks, with illustrative cases, on errors of diai^nosis in uterine disease, which, though not free from the characteristic faults of that writer, will yet well repay an attentive perusal. 24 EXAMINATION OF THE ABDOMEN. patient, it behooves you to remember that in her sex, and in its peculiar diseases, you may perhaps find a ckie to the cause of her present symptoms, and discover indications which may show you bow to accomplish their cure. LECTURE II. INTEODUCTOKY. Symptoms of diseaise of generative organs, furnished by alterations of size, texture, or situation, to be ascertained only by examination — General remarks on the subject — Examination either tactile or instrumental — Tactile examination of the abdomen, per vaginam, jier rectum — Instrumental examination, by means of the Uterine Sound ; descri])tion of the instrument, and rules for its intro- duction ; examination with the Speculum ; varieties of the instrument; rules for its introduction ; attempt to estimate its value. There was not time at our last meeting for the due considera- tion of the tldrd and last class of indications of disease of the genera- tive organs — namely, those furnished bi/ alterations of their size, tex- ture, or situation. I must therefore direct your attention to them to-day. It is, I conceive, quite needless for me to preface what I have to say by any remarks upon the importance of these signs, or upon the necessity of ascertaining the presence or absence of any of these changes in a great majority of the cases in which our pa- tient's symptoms indicate some disorder of her sexual functions. The examination, however, by which alone this information can be obtained, must be extremely painful to a woman's feelings, since she is not now, as in the time of labor, impelled by the extremity of her sufterings to submit to anytliing for the sake of relief. She seems, indeed, to be now peculiarly alive to every painful impression ; and while she feels almost overwhelmed by a sense of humiliation at having to undergo an examination, of the necessity for which she may yet feel fully convinced, she will judge with painful minuteness each act of yours — any needless delay, any careless exposure of her person, any apparent want of delicacy or consideration. With the greatest care, indeed, you will not always escape from undeserved blame ; without it, you will perpetually wound your patient's feelings, and if you do not injure your own prospects, you will yet fail to support the dignity of your profession, and will lead to the inference that there is at least one department of the art of healing incompatible with the tone, and manner, and feeling of a high bred gentleman. The familiarity which hospital practice begets with these ailments among women whose sensibilities are not always as keen as those of persons in a higher class of life, or the circumstance that they do not venture to express the pain which want of consideration EXAMINATION OF THE ABDOMEN. 25 may have caused them, leads but too often to carelessness in these respects on the part of men who would yet shrink from the idea of inflicting a moment's unnecessary sutfering upon any one. I am therefore all the more anxious to impress upon you that the delicacy with which you ought to conduct all your investigations into the diseases of women, is not a thing which can be assumed for the nonce, but that it must be the habit of the mind, must therefore have been acquired now during your pupilage, and in the midst of your intercourse with the poor. We make ourselves acquainted with the existence of disease of the generative organs, either by manual examination or by ocular inspection ; and for the purpose of making such investigations with the greater accuracy, we not infrequently employ instruments of different kinds. The simplest mode of examination, and that which causes our patient the least distress or alarm, is that in which we employ our sense of touch alone, unaided by any apparatus what- ever. It is perhaps scarcely necessary for me to remind you that, while it is our duty to use every means essential to the thorough investigation of our patient's condition, it is no less our duty to make no needless examination ; never to use an instrument when we can ascertain all that is necessary without it ; never to resort to ocular inspection when we can feel a reasonable certainty that by the sense of touch alone we have arrived at a true knowledge of the disease. We derive information from our sense of touch when applied either through the abdominal walls, or by the vagina, or the rec- tum. Examination of the abdomen is not always called for; when it appears necessary, it is well to begin with it. For this purpose the patient should lie upon her back, with her knees drawn up so as to relax the abdominal muscles. It is very seldom necessary to apply the hand to the uncovered surface ; the interposition of the patient's shift little if at all interfering with the accuracy of the examination. Care should be taken that your hands are not cold ; if they are, this will not only annoy your patient, but, by exciting contraction of her al)dominal muscles, may seriously im- pede your investigation. Placing both hands upon the abdomen, you make at first very gentle pressure, increasing it by degrees as the patient becomes accustomed to it, and trying to engage her in conversation, and thus to distract her attention, if either pain or alarm should cause her to throw her abdominal muscles into action. You thus make yourself acquainted with the general con- tour of the abdomen, and by examining at either side as well as in the centre, you detect any tumor which may be present there. Su]iposing any such growth to be discovered, you must examine well its form, its size, its attachments, its degree of mobility, and the amount of tendersess or pain which meddling with it occa- sions. Is it due to accunmlation of fjeces in the large intestine; to enlargement of the liver or spleen ; or is it pcrha}»s merely the result of a general fulness of the abdomen produced by flatus in the bowels, or by fat in the omentum or beneath the integuments, 26 SIGNS OF SEXUAL DISORDER. rather tlian the consequence of any definite disease ? If the tumor seem to arise from out of the pelvis, it is most probably formed either by the uterus itself, or by its appendages. If by the former, the chances are that it will be situated in the mesial line of the abdomen ; if by the latter, that it will occupy one or other side, or at any rate that it will be learned to have occupied that situation when first discovered. "Whether it is solid or fluc- tuating, even or irregular, will be other points for you now to make out, and you must then proceed to correct or confirm, by a vaginal examination, the impressions received on examining through the abdominal walls. It is seldom necessary, for the purposes of a vaginal exavnna- tion, that the patient should be in any other than the usual ob- stetric position. On the Continent, where women are generally delivered on the back, they often assume that position whenever the state of the uterus needs investigation. Sometimes, too, when it is wished to appreciate the degree of prolapse or downward dis- placement of the uterus, or to estimate its increase in weight, or when the womb is high up and does not come readily within reach, the examination is made with the patient in the standing position ; I do not think, however, that any of the alleged advan- tages of this attitude are sufiicient to counterbalance its very ob- vious inconveniences. The patient, therefore, lying on her left side, the index finger of the right hand is introduced as for an examination in labor, and as it is slowly carried forward, atten- tion is to be paid to the degree of pain excited in each part of its course. Tlic state of the external organs must be noticed, and then that of tlie vagina — whether it is hot and swollen, or cool and relaxed ; whether dry, or abundantly bathed in secretion. The cervix uteri is thus reached, and you observe whether or no it is tender, what are its length, and size, and texture ; whether the OS uteri is open or closed; whether its lips are small and even, or rough and irregular. You will bear in mind, that after fre- quent childbearing, the cervix uteri is both shorter and broader than in the woman who has never given birth to children (changes which are especially marked in that portion of it which projects into the vagina, and is commonly called the portio vaginalis) ; and that the os uteri is frequently open, so as to admit the finger with but little difficulty. In this case, however, the inner surface of the OS is smooth, and the tissue of the cervix soft and yielding ; while if disease exist, the interior of the os will most likely be rough and uneven, and the substance of the cervix rigid. Some- times a peculiar and almost velvety smoothness is presented by the surface of the os uteri, or the tissue generally has less than its natural firmness ; and any of these peculiarities, or the presence of any foreign body between the lips of the- uterus, should be well borne in mind, in order that you may afterwards compare the in- formation obtained by ocular inspection with that previously gained by the sense of touch. While making this examination, you notice, moreover, the situation of the uterus, whether it still EXAMINATION BY VAGINA AND RECTUM. 27 retains its natural direction, or has come to lie with its axis cor- responding to the axis of the vagina; whether it is bent upon itself, or in any other way misplaced. Examine next whether the uterus is increased in weight ; balance it on your finger, and ap- preciate as well as you can the size and weight of the organ. If you had discovered any tumor by examination through the ab- dominal walls, you should now try to ascertain whether there is any connection between it and the uterus, or between it and any other tumor that you may detect within the pelvis, and whether pressure on the one in any way modifies the position of the other. For this purpose, too, it is advisable to let the patient lie on her back, when, with one hand placed over the pubes, and the finger of the other in the vagina, the size of the womb and the relations borne to it by any tumor can be made out far more accurately than is possible while the position on the side is maintained. When all the above-mentioned points have been ascertained, with as much gentleness as possible, the vaginal examination is over, and there is nothing more for you to notice, except it be the ap- pearance or other characters of the discharge. Sometimes it is expedient to examine per rectum as well as per vaginam ; if either the patient had made complaints of serious pain in the bowel, or if you had discovered a tumor situated be- hind or to one side of the uterus, or if on any account you are anxious to examine the posterior part of the pelvis, or of the uterus itself, as completely as possible. The only caution specially ap- plicable to examination per rectum is, that owing to the interven- tion of the intestine between the finger and the womb, that organ feels much larger than it really is ; besides which, as the finger reaches less readily to a level with the cervix uteri when intro- duced into the rectum than into the vagina, there is some risk of mistaking the cervix for a prominence of the posterior wall of the uterus, or for a tumor in that situation, or for a retroversion or retroflcction of the organ, when, in reality, no morbid condition whatever is present. Of late years it has become customary in many cases to aim at a greater completeness of tactile examination, by means of an in- strument which is called the Uterine Sound. At different times, indeed, practitioners have in some special instance introduced a catlieter into the uterus to satisfy themselves of the size of its cavity, or of the absence of any foreign body from its interior; or have attempted to rectify a retroversion of the unimpregnated womb, by means of an instrument introduced within it.' To 'the best of my knowledge, however, a Frenchman, M. Lair, ^vas the first person who, between thirty and forty years ago, recommended ' Tlic late Professor Osiander, of Gottiiiijjcn, employed his Dilatoriiim Orificii Uteri, which is described in llDsenmcyer's dissertation, jnil)lished at Gottini^en in 1802, on three occasions, to reduce the retroverted unini))r('i:;nated womb. His cases were published in the Medlc'misch Chlnirgische Zrifuni/ for 1808, according to Schmitt, who refers to them in his Essay, Ueber die Zuruckbeuguny der Qebiirmutter, Svo., Wien, 1820. 28 SIGNS OP SEXUAL DISORDER. Bounding the interior of the uterus in order to ascertain whether the cervix is free from all impediments, and whether the cavity of the orfi^an generally is in healthy state. His book is illustrated with drawings of the instruments which he employed for this purpose ;' and he advised that the}^ should be curved like a catheter at their uterine extremity, in order to facilitate their introduction. He recommends, moreover, that the sound should be introduced through a metallic cylinder or speculum, by which the mouth of the womb is to be first brought into view ; a proceeding which, instead of facilitating the introduction of the instrument, must, in many cases, have rendered it altogether impossible. The practi- cal defects of M. Lair's plans prevented their general adoption ; and his recommendations were in consequence soon forgotten. To Dr. Simpson,^ of Edinburgh, belongs the merit, not only of having recalled attention to the subject, but of having also in- vented a Uterine Sound, admirably adapted for the safe and easy exploration of the cavity of the womb. His instrument is made of flexible metal ; and in shape and size closely resembles a sound for the male bladder, having a similar curve, and its handle being flat, and roughened on one side in the same manner. The uterine end of the instrument terminates in a small bulb, to prevent its injuring the interior of the womb, while a notch at every inch serves to indicate the distance to which the sound has entered the womb, and tlius to mark the size of its cavity. A slight prom- inence at two and a half inches shows the average length of the cavitji of the healthy womb, while a deep depression at four and a half inches marks a size, which, except under very special circum- Btances, the organ hardly ever exceeds.^ The mode of using the instrument is sufiiciently simple. Two fingers of the left hand are introduced behind the cervix uteri, as the patient lies on her back or on her left side, and the sound is slid along the fingers till its point reaches the os uteri, when, by depressing the handle towards the perineum, and at the same time carrying the instrument gently forwards, it will enter the uterine cavity. I need not say, that it must never be employed when the least ground exists for suspecting pregnancy; and that in no cir- cumstances must force be used in its introduction. In the majority of cases the introduction of the sound causes some pain, tliough this is generally by no means severe, and is almost always of veiy 1 Nouvelle Methode du Traitement des Ulrh-es, etc., de V Uterus, 8vo., Paris, 1828. Deuxi^me Edition, p. 137. The first edition apjDeared about two years before. * In a series of papers in Londun and EdinbicrgJi Monthly Journal for 1843. 3 Many modifications of the Uterine Sound have been suggested bj'^ Valleix, Kiwisch, Huguier, and still more recently by Dr. Kugelmann, of Hanover. {Ver- handl. d. Gesellschaft f. Gebnrtshulje, Nov. 1861, Zeitschr. f. Gehurtsk, vol. xix, p. 120). This last is very ingeniously contrived with a movable scale which slides on the sound itself, and indicates at the handle the distance to which the instru- ment has entered the uterus, so that the prominence and the notches that interfere with the introduction of Simpson's sound, are done away with. The difficulties in the employment of the original instrument are, however, so slight, and simplicity is of such great value, that I still prefer Simpson's sound to anj' of the other varie- ties of the instrument. EMPLOYMENT OF THE SPECULUM. 29 short duration; and in no instance which has come under my observation, have dangerous consequences resulted from its use, tliough awkwardness and foolhardiness have, I know, done mis- chief with this, as with almost all instruments that have ever been invented. The information which this instrument places within our reach is often extremely valuable ; and of a kind such as otherwise we could not obtain at all, or could arrive at only very slowly, and by frequently repeated examinations. If, in a patient suffering from frequent hemorrhages, we ascertain the uterine cavity to be greatly increased in size, our immediate conclusion is that the womb con- tains some foreign body, as a polypus or fibrous tumor, the pres- ence of which has excited and serves to keep up the bleeding. If we doubt whether a tumor proceeds from tlie womb, or from its appendages, or from some other part within the pelvis, the sound enables us to estimate the weight of the organ, and to strengthen the inference drawn from this experiment, by completely isolating the womb from the tumor, and thus ascertaining positively their independence of each other. Or lastly, if the uterus is bent upon itself either forwards or backwards, the diagnosis of this condition, which once was a matter of much difficulty, is now often arrived at with facility, by introducing the sound with its concavity di- rected towards the swelling we detect per vaginam, and observing whether or no this swelling disappears on turning round the in- strument. I will not now go into further detail on the subject, for I shall hereafter have to refer on many occasions to this valu- able aid to diagnosis. The uterine sound, indeed, is not always applicable ; nor does it, when used, always clear up our doubts ; but I do not remember any instance in which a diagnosis based on the information which it afforded turned out afterwards to be erroneous. The idea of adopting some contrivance by which the condition of the uterus might be examined by the eye was not altogether unknown to the ancients, though for the most part those instru- ments, of which drawings may be seen in old works on midwifery, and which received the name of Speculum Matricis^ were used for dilating the mouth of the womb during labor, rather than for examining its condition in disease.^ An instrument similar in kind, however, appears to have been sometimes employed for the investigation of disease of the uterus and vagina, though it never came into anything like general use. The introduction of the speculum into modern practice as a means of facilitating the inves- tigation of uterine disease does not date further back than the year 1821, when the instrument was first employed by M. Rccamier. This, which was merely a C3'linder, conical in form, rounded off a little at its uterine extremity, and bevelled at its otlu-r end, was next fitted with a small handle by M. Dupuytren, and afterwards 1 Soe some remarks and quotations referring to the early history of the speculum, in Balbirnie, Oryanic Diseases of the Womb^ pp. 41-45, 8vo., London, 183G. 30 EULESFORTHE a plug was adapted to it to render its introduction more easy. Various materials have been used in the fabrication of these in- struments, but we owe the greatest improvement in this respect to Mr. Fergusson of King's College. Instead of employing metal, which is very apt to tarnish, and never has a very powerful re- flecting surface, or glass, which though very useful when caustics are to be applied to the uterus or vagina, since they do not act upon it, is yet liable to be broken, and moreover, owing to its transparency, does not reflect very powerfully, he adopts the fol- lowing plan : A glass speculum is silvered on its outside, by which means the inner surface is converted into a mirror easily kept clean, and on which no caustics can act. The speculum is then enveloped in successive layers of cotton-cloth, each of which is covered with a solution of Indian-rubber, and when the glass has thus received a coating of sufiicient thickness it is varnished, and forms an instrument which is now in general use. Its funnel- shaped termination is intended to provide for the admission of as much light as possible ; a point of the more importance in this country, from the almost universal practice of examining patients on their side, in which posture light has a less ready accesS to the parts than if, as on the Continent, the patient lay on her back. The object of the instrument being slightly bevelled oft' at its uterine extremity, is that the same advantage is thereby secured^ as if the diameter of the cylinder throughout were greater. This sloping oft" of the instrument, however, must not be carried, as some have recommended, so far as to amount to an angle of forty- five degrees, since by so doing the inconvenience is encountered of a fold of vagina falling down in front of the cervix uteri. The specula which I use may perhaps appear to you of an unnecessary length; but you must bear in mind that the vagina is very exten- sile, and that when a speculum is introduced into it, the canal is stretched in length as well as in width, so that the ordinary length of the vagina is not to be taken as the measure for the length of the speculum. I believe the attempt to reach the os uteri fails from the shortness of the speculum oftener than from almost any cause, and quite agree with the opinion of the late Professor Lis- franc of Paris,^ that a speculum ought to be seven inches long. In spite of the general convenience of the cylindrical speculum, however, there are some drawbacks from its utility. Owing to the entrance of the vagina being narrower than any part of its canal, it happens sometimes that a speculum sutficiently small to pass without causing the patient severe pain, is not large enough to bring the whole of the os uteri into view. But even though its whole surface be exposed, yet the cylindrical speculum pressing the lips of the os together may prevent a good view being obtained of its interior, and may thus render the examination incomplete 1 This useful modification of the speculum was, I believe, first suggested by Dr. "Warden, London and Edinbu7-gh Monthly Journal, Dec. 1844. * CLinique Chirurgicale, &c., vol. ii, p. 272. EMPLOYMENT OF THE SPECULUM. 31 and unsatisfactory. To obviate these disadvantages, specula have been constructed on the principle of the old instruments, composed of two, three, or four blades, and so arranged that Ijy turning a screw or by closing the handle, the uterine extremities separate, and thus expose the os uteri to view without any enlargement of the other end of the instrument. The best known of them are the two-bladed speculum of M. Kicord; a three- and a four-bladed speculum manufactured by M. Charriere, of Paris; and a two- bladed speculum invented by Mr. Coxeter, instrument-maker to University College. M. Ricord's instrument, and to a less extent those of M. Charriere, have the inconvenience that folds of the vagina are apt to fall down between the blades, and thus conceal the OS uteri from view. This objection does not apply to nearly the same extent to Mr. Coxeter's instrument; each blade of which being a half-cylinder, does not leave so large a space vacant when it is opened. Two or three different sizes, then, of Fergusson's speculum, and a Coxeter's bivalve speculum — which last it is worth while, for the sake of obtaining a better reflecting surface to have electro-plated — are all the instruments you need for ocular exami- nation of the uterus. On the Continent, the posture usually assumed by a patient when about to undergo a specular examination, is on the back, with the nates resting on the edge of a bed or table, and the legs bent up towards the body, or the feet resting on two chairs, be- tween which the doctor stands. There can be no doubt but that in this position of the patient the os uteri falls more readily within the orifice of the speculum, and tliat light is admitted much more thoroughly than in any other attitude ; but its apparent indelicacy is so serious an objection to it, that except under special circum- stances, it is desirable to introduce the speculum with the patient lying on the left side. In this position, too, unless the os uteri be directed in a remarkable degree backwards towards the sacrum, a very good view can generally be obtained, provided the patient lie with her body directly across the bed, her hips close to its edge, and her thighs drawn up towards the trunk; in the same attitude, indeed, as we should place a person in, on whom we were about to appl}' the forceps in labor. If the patient be not in bed, the same })recautions as to her position must be taken as she lies on a couch or sofa, and a very little care in the arrangement of her dress will prevent any exposure of her person. The speculum, having been previously warmed and lubricated, is then to be in- troduced with the right hand, while with the left the labia and nymplue are separated. Care must be taken that the end of the speculum is passed thoroughly within the opening of the vulva, since, if this precaution be neglected, a little duplicature of the fourchctte is sometimes pushed before the instrument, and much needless pain is caused to the patient. The great obstacle to the introduction of the speculum is met with at the entrance of the vagina, and this must be overcome by gentle effort, not by any- thing approaching to violence. The speculum then passes on 32 RULES FOR THE with facility, and when it has entered for some distance joii with- draw the plug, and possibly find that the os uteri is now within view. You must, however, bear in mind, that the folds of the vagina sometimes hang down at the further end of the speculum, leaving a small aperture between them, which may be mistaken for the OS uteri ; though, on moving the instrument a little, the contour of the orifice will alter, and the vaginal folds dispose them- selves in a difierent form. If, although you have introduced the Bpeculum for some distance, the os uteri do not appear, the proba- bilities are that you have passed beyond it, and that the instrument has gone up into the cul-de-sac of the vagina, behind the neck of the womb. In this case by gently and gradually withdrawing it, the OS uteri will most probably come into view ; if it do not, you may move the speculum slightly from side to side, since it is likely that the uterus is not quite in the mesial line, and that thence arises the difiiculty in getting sight of it. When once you have the OS uteri within the speculum a little manoeuvring will gener- ally suffice to remove an}' fold of vagina which obstructs your view; though, if the neck of the womb be very large, you may be compelled to examine first the anterior and then the posterior lip of the organ ; and in this case you will find a bivalve speculum much more useful than the cylindrical instrument. There are many other little matters of detail connected with the employment of tlie si)eculum well worth the knowing, but to be learned rather by personal observation and actual practice than by any description. ISTeed I say that there are some cases, those of unmarried women, for instance, in which nothing but the most urgent necessity would justify your employing the speculum; others, as the majority of cases of cancer of the womb, in which its use would furnish uo important addition to your previous knowledge ; and still others in which its employment must be postponed, if not actually interdicted — such, for instance, as cases of extreme sensibility of the parts, of inflammation or ulceration of the vagina or of the external organs? Restrictions to its use, indeed, such as these, speak to the common sense and right feel- ing of every one too distinctly for there to be much hesitation in subscribing to them. But, while admitting them, some of you may be inclined perhaps to go still further, and to inquire of me, whether on the whole, the advantages arising from the use of the speculum outweigh the evils resulting from its abuse ; whether it helps us to so much additional knowledge, or adds so much to our therapeutical resources, as to counterbalance all the suflering, both moral and physical, which its employment not infrequently inflicts upon the patient? ISTow if I had a strong opinion on the negative side of this question, I should certainly not have taken up so much of your time in describing the instrument, and in directing you how to use it. The restrictions which my present experience leads me to put upon its employment will be best appreciated when I speak of each disease in the management of which it has been advised to have recourse to it ; and whether my EMPLOYMENT OF THE SPECULUM. 33 views be right or wrong, I do not apprehend much diiRculty in expressing them. To answer the broad question, " What is your opinion of the specukim?" I feel, on the other hand, to be a very difficult matter, and to expose me to much risk of being misun- derstood. I will, however, do my best to reply to the inquiry. Those who first introduced the speculum into practice employed it for two purposes; partly as furnishing a new means of diagnosis, partly as enabling them to adopt various modes of local treatment, which, without it, were impracticable. Now I believe that the advan- tages of those topical medications for which the speculum is needed have been greatly overrated ; though there are some cases, and those such as have proved most rebellious under other plans of treatment, in which these local measures may be resorted to with the most signal advantage. In estimating the value of the speculum as a means of diagnosis, I think that the advances in knowledge of uterine disease, of which it was the indirect occasion, by the impulse which it gave to their study, are sometimes confounded with those positive additions to our information which we owe exclusively to the use of that instru- ment. The former have been very great indeed, and I think candor compels us to acknowledge that they have been due almost exclu- sively to persons who, not content with our previous means of investigating uterine disease, have labored to increase them by the employment of instruments. The latter have certainly been less considerable, but nevertheless the speculum enables us in many instances to decide at once, and with certainty, upon the nature of a case, which otherwise we should have understood only after long and careful watching, to discover some minute polypus which the fingers alone would not have detected, to deter- mine the source of a profuse leucorrhoeal discharge, and to decide whether it is furnished by the cavity of the womb, or by the walls of the vagina; or, from the redness, congestion, or abrasion of the OS uteri to infer the state of the womb generally, and thus to conduct our treatment upon the sure ground of positive observa- tion, not upon bare presumptions. At the same time, however, that I hold the speculum to be in many cases of most essential service, I think that the endeavor of all of us should be to ascer- tain the minimum of frequency with which its employment is necessary. This is to be done not by decrying the instrument, still less by attributing dishonest motives to those who use it, but by soberly and honestly trying to test the value of the information which we derive from it, and learning to discriminate between those appearances which the speculum discloses that are of moment, and such as are of no importance. 84 DISOKDERS OF MENSTRUATION. LECTURE III. MENSTRUATION, AND ITS DISOEDERS. Importance of disorders of menstruation ; their three varieties — Relation of tardy puberty to menstrual disorder. Amenorkh(EA, from local causes, from congenital absence or malformation of sexual organs, from retention of menses owing to impediments to their flow. Amenorrhcea, from constitutional causes — tardy development, influence of pre- vious illness in causing it. Symptoms, chlorosis whereon it depends — state of the blood. Consequences of amenorrhcea. Treatment — principles which should regulate it — attention to general health, to uterine functions. Vicarious hemorrhages, their import, their management. Importance of habit in all ailments of menstrual function. I CALLED your attention, in the first Lecture, to the importance of the menstrual function, and to the frequency of its disorders. I told you that almost every serious ailment of the generative sys- tem, at least during the period of sexual activity, betrays itself by some disturbance of menstruation; and I may further add, that such disturbance is often the first, and sometimes for a considera- ble period the only, symptom of even grave disease. But you also know that disordered menstruation does not invariably depend on local mischief, that derangement of function does i^fOt always im- ply altered structure, but that a woman may menstruate scantily, painfully, or in excess, and yet no part of her generative organs may differ in appearance from those of a person in whom that function has always been performed in the most healthy manner. The disorders of the menstrual function, then, being so numer- ous, so important, and dependent on such various causes, it will be our best course to study them first, and afterwards to examine into other diseases of the sexual system, in which, though disor- dered menstruation may occur as a symptom, it is yet not the only one, nor that which calls for the chief consideration in the treatment of the patient. There are three grand classes, to one or other of which it has long been customary to refer the different disorders of menstrua- tion. Either the menses do not appear at that period of life at which their occurrence is naturally expected, or they become sup- pressed in persons in whom they have already occurred ; or their discharge is attended with extreme pain ; or it is excessive in quantity, or over frequent in its return. I propose to consider in its turn each of these three varieties of disordered menistruation, which have respectively received the names of Amenorrhcea, Dys- menorrhoea, and Menorrhagia. It is, as you know, wisely ordered that the power of perpetuat- ing the species is the last of nature's gifts, and one which she does not accord until the whole system has, in other respects, attained TARDY PUBERTY. 60 nearly to its perfection. Of this new power in woman, menstrua- tion is both the sign and the consequence, indicating; that tlie ovaries have become capable of bringing to maturity the germs, which need only to be impregnated in order to become developed to new beings. In our climate, the date of the first occurrence of menstruation is between the fifteenth and sixteenth year ;' but the changes at puberty in the maiden, like those at dentition in the babe, are not accomplished all at once, but extend over a period of several months, during which disease is more frequent, and as our Tables of Mortality show, more fatal, as compared with the male sex, than at any former time.^ The anxiety with which pa- rents regard the approach of this epoch is, then, not unnatural ; nor is it without good reason that this anxiety is increased more and more in proportion as delay occurs in the appearance of the first menstruation, since, when the menstrual function has been even once properly performed, many of the dangers of puberty may be regarded as already passed. i)r. Whitehead, of Manchester, to whom the profession is in- debted for some very interesting researches into these subjects, as- certained that the risk of some unfavorable accident complicating the first establishment of menstruation is very much greater when that is tardy in its occurrence than when it is premature ; and that in between a third and half of all cases in which it is delayed to nineteen years and upw^ards, its appearance is associated with either local or constitutional disorders — a statement with which my own experience coincides.^ 1 Dr. Whitehead, of Manchester, gives fifteen years six and three-quarter months as the avera!ji;c deduced from 4000 cases, in which he made this point the subject of inquiry. See p. 47 of his Treatise on Abortio7i and Sterility^ 8vo., Lon- don, 1847. 2 Thus MM. Quetelet and. Smits, in their work Sur la Reproduction et la Morta^ lit& de V Homme, 8vo., Bruxelles, 1832, show that while in childhood the mortality of the two sexes has been equal, or that of the male has predominated, the female mortality at once rises between fourteen and eighteen years of age to 1.28 to 1 male death ; sinking again in tlie succeeding four years to the proportion of 1.05 female to 1 male death. * Mr. Whitehead's table, lib. cit. p. 48, yields the following results: First Menstruation. Total Number of Cases. Number Unfavorable. Percentasre of Unfavorable. From 10 to 14 years, . Between 15 ai\d IG, . . " 17 and 18, . . From 19 and upwards, . Total, 1141 1728 892 239 224 324 247 'J 7 19.03 18.75 27.69 40.58 4000 892 22.30 av. In 506 cases in which I ascertained the date of the first menstruation, cither ex- cessive pain, excessive discharge, irregularity of its return, or disorder of the general health, occurred with the frequency shown in the following table. The 36 AMENORRHCEA, The mere circumstance, indeed, of a girl having passed the age at which menstruation usually appears, without performing that function, is not of itself a reason for medical interference. The date of puberty varies very widely, and one woman may menstru- ate at ten, and another at twenty years of age, without the health of either being of necessity impaired. Usually the absence of menstruation in otherwise healthy young women, is associated with the absence of some of the other signs of puberty, indicating a generally tardy sexual development, just as, without apparent cause, one tree will produce blossoms and bear fruit later than another. This, however, is not always the case, and instances are sometimes met with of persons in whom pregnancy has preceded menstruation : completeness of sexual power having existed, though not manifesting itself by its ordinary sign. Such cases were a greater puzzle to physicians in former days than they are to us, who know that the discharge of blood is not the essential part of menstruation, but that the maturation and extrusion of ova may occur independently of it. One instance of it has come under my own notice, in a woman who, never having menstruated, married at the age of twenty, and immediately became pregnant; nor did the menses appear till after the birth of the first child, though she subsequently menstruated regularly, and had a numer- ous family. This, however, is very rare, and there would always be reason to apprehend that a woman who had not menstruated before marriage would remain sterile afterwards. Besides, it is possible that the non-appearance of the menses depends upon some congenital malformation, which might even prove a bar to sexual intercourse, such as absence of the vagina or its imperfect formation. If, then, your advice be asked as to the propriety of any young person marrying who has not menstruated, I should advise you to recommend delay ; and if still further urged, to withhold your sanction until you have ascertained that no serious defect of structure is present. The pain of such an investigation would foil far short of the distress which would be entailed upon all parties, if a woman with some important malformation of her sexual organs were to contract marriage.' conclusions to which it leads are the same as follow from Mr. Whitehead's more extended researches : First Menstruation. Unfavorable. percentage of Unfavorable. Under 15, Between 15 and 17, . . 17 and 19, . . At 19 and upwards, . . Total, 228 220 92 26 41 38 22 11 17.9 15. 23.9 46.1 566 107 25.7 av. ^ An important case illustrative of this subject is related by Dr. Meigs, at p. 119 of his"8ranslation of Colombat on Diseases of Females, 8vo. Philadelphia, 1845. FROM MALFORMATION. 37 Amenoi'rhcea from imperfect formation of the sexual organs may depend either upon causes which altogether prevent the perfor- mance of the menstrual function, or on such as merely interfere with the discharge of the menstrual fluid. Cases of the former kind are fortunately very rare, since, depending on the absence or defective formation of the uterus or ovaries, they are completely bej'ond the reach of remedy ; those of the latter description gene- rally admit of cure. In some of the former class of cases, the sexual character has been altogether imperfectly developed, and the woman has never experienced any periodical occurrence of symptoms such as usually prelude the appearance of the menses,, while in others the women have been liable to periodical attacks of pain in the back and loins, and to all those indications of suffering by which the menstrual flux is often attended, and have presented in their outward form all the indications of perfect womaidiood. It is not easy to account for all of these difterences, since, in some instances, where the sexual character was but imperfectly marked, the ovaries were found after death sufliciently well formed, though the uterus was absent, or merely rudimentary. A few casQS are on record of alleged absence of both ovaries, in spite of the otherwise natural formation of the sexual organs. Such cases, however, are excessively rare, and the probabilities are that in many instances the organs were present, though in a very undeveloped condition. Somewhat less uncommon are the instances of absence of one ovary ; a malformation generally asso- ciated with absence of the other uterine appendages on the same side, and sometimes also with absence of the corresponding kid- ney: a circumstance which will not surprise you if you bear in mind the mode of development of the urinary and generative ap- paratus, and the intimate relation which subsists between them at an early period of foetal existence. Much less uncommon than the absence of either ovary is the persistence of both through the whole or the greater part of life in the condition which they present in inftincy and early childhood, with scarcely a trace of Graafian vesicles in their tissue. This want of development of the ovaries is generally, though not invariably associated with want of development of the uterus and other sexual organs: and I need not say that women in whom it exists are sterile. Two instances have come under my own notice in which there was reason to suppose that some defect of development of the ovaries was present. The first patient was a woman aged forty- three, who had been married for twenty years, but had never menstruated, nor had ever been pregnant. In her case the sexual organs were well formed, though the uterus was small, and sexual appetite existed. The other case was that of a young girl about twenty years of age, wlio was for some time under the care of the late Dr. Roupell, suflcring from those vague symptoms of disorder of the general health which so frequently exist when the appear- ance of the menses is delayed. She presented the generaJi*£igiig of puberty, but her vagina was very small, and her uterus was not 38 AMENORRHCEA, larger than that of a young cliild. I do not know what became of her eventually, but it is quite possible that the evolution of her sexual organs, though long delayed, may at length have taken place, and have been followed by the due performance of their functions. Conditions^ such as these which I have been speaking of interest us rather as physiologists than as practitioners ; we can only guess at their existence, and can do nothing for their remedy. Though not so obscure, still quite as hopeless are those cases in which the uterus alone is absent, or, as is more frequently the case, is repre- sented by one or two small bodies, of the bigness of a bean, or even smaller, made up of true uterine tissue, rudiments, as it were, of the deficient organ. This absence of the uterus may coexist with a perfectly natural condition of the external organs ; .the "\^gina, which is usually much shorter than natural, terminating in a cul-de-sac. The only instance of this malformation which I have seen, existed in a young woman of little more than twenty years of age, who had been married but a few months, and who applied to the late Dr. Hugh Ley, in consequence of some obstacle to complete sexual intei'course. Her appearance was that of a well-developed woman, and her external genitals were quite nat- ural, but the vagina was not above an inch and a half in length, and terminated in a blind pouch, above which no uterus could be felt, neither could any trace of the organ be discovered on exam- ination by the rectum.^ Besides these cases, however, in which the non-appearance of the menses is due to a cause wholly beyond the power of art to remedy, there are others in wliich the ovaries are present, and perform their functions properly, in which the uterus also exists, and the periodical hemorrhage takes place from its lining ; but the effused blood finds no means of escape, owing to congenital closure of the os uteri, or to the absence or occlusion of the vagina. The non-appearance of the menses from any of these causes is unquestionably very rare, and but one instance of imperforate state of the hymen has come under my observation. To judge by the recorded accounts of such cases, however, they all present a certain general resemblance to each other, and are all characterized by the occurrence, at or soon after the ordinary period, of the usual signs of puberty, the appearance of the menses alone excepted. While these are absent, the premonitory symptoms, which in general usher them in, are experienced with even more than ordi- nary severity. These symptoms subside, and again recur after 1 Numerous references to cases of absence of the ovaries, or of their imperfect development, are to be found in Chereau, TraiU des Maladies des Ovaires, Paris, 1844, pp. 73-91 ; and Meissner, Frauenkrankheiten, vol. ii, p. 28 ; and Dr. Thndi- cum, of London, has published in the Monatschrij't f. Oeburtfiku7ide, April, 1855, p. 272, a very careful analysis of twenty-one cases, collected from different sources, in which the uterus was either altogether absent, or merely rudimentary. * Any one who wishes to study the subject of uterine malformations in all its bearii^^ will find ample materials collected in the elaborate work of Kussmaul, Von d^ Mangel, der Verkummerung, roduce the menses w'hcn suddenly checked by cold, or b}' any other cause, we nmst wait patiently till the next menstrual period comes round, unless indeed urgent symptoms supervene, betokening great con- gestion or inflammation of the uterus, and they may require free local depletion, or even venesection, and other active measures to ♦i arrest their progress. With the return of the ensuing menstrual period, the greatest care must be taken to secure the proper performance of the func- tion, by the use of all those means which I mentioned in my last lecture, when speaking of amenorrhoea. The importance of doing this cannot be overrated, since many cases of habitual d^'smenor- rhoea, due probably to a state of chronic irritation or inflammation 1 See on this subject the remarks of M. Parcnt-Diichatelet, — De U Prosiituilun dans la VUle de Paris, vol. i, p. 2'J8. 52 MEItORRHAGTA. of tlie ovaries, date back to some accidental suppression of the menses ; and the suffering has been confirmed by want of due care at the return of the next few periods. It is no part of my phm to occupy your time with passing minutely overground already often trod before; and, therefore, in considering the ditibrent disorders of the menstrual function, I shall content myself with pointing out to you the grand principles by which your management of them must be regulated, rather than attempt to enter into detail concerning any. This being so, we may now pass from the consideration of cases in which the menses have been scanty, or suppressed, or have failed to appear in due time, to the study of disorders of the menstrual function of an exactly opposite character, — to cases of what is termed menorrhagia, or excessive menstruation. This excess of menstruation may show itself either in the great profuseness of tlie flow, or in its long duration, or in its frequent return. It is, as you will find hereafter, by no means a matter of indifference, in wljich of these respects the excessive menstruation first or chiefly shows itself, since from these variations important conclusions may often be drawn, both as to the cause of the ail- ment and its means of cure. It must, however, be borne in mind that menstruation seldom continues long to be excessive in one respect alone; but if the menorrhagia be not speedily checked, the patient will menstruate not only in greater quantity, but for a longer time, and at shorter intervals than natural. Divisions and subdivisions of menorrhagia into man}' different kinds, have been needlessly multiplied. The only classification that seems to me of real practical utility, is that which recognizes two forms, depending, either — 1st, On some cause seated in the constitution generally. 2d, On some affection of the sexual system. This distinction should never be lost sight of in practice, though we may seldom meet with instances in which the actual line of demarcation is drawn with the same precision as we attempt to observe in our nosologies. One caution is, perhaps, worth giving, before I,say anything more about menorrhagia. It is, that every excessive hemorrhage from the uniinpregnated uterus, during the years of sexual activity, is not necessarily menorrhagia. Women themselves are apt so to regard all losses of blood during that period of their life, and practi- tioners are too often guilty of the same oversight. Menorrhagia is an excess of menstrual discharge, an over abundant hemorrhage, the cause of which, in the first instance, is that congestion of the sexual organs which attends the maturation and escape of an ovule from the ovary. As 1 mentioned yesterday, outbursts of bleeding may take place from the wond) in some cases where the menses have been long suppressed, aftbrdiiig relief to the system, or even, by their excess, jeopardizing the patient's well-being, and this with no more real reference to the function of which menstruation is the sign, than exists in a case of hemorrhage from the bowels, or ITS CAUSES TWOFOLD. 53 of bleeding from hemorrlioiJs. In the same way, too, a patient may bleed to death from a cancer of the womb, or from a polypus, or from a fibrous tumor of that organ, and yet such hemorrhage may be no real menorrhagia. In tliis case, again, the distinction cannot always be drawn, for the incipient uterine disease may at first have betrayed its exist- ence by the excessive congestion of the sexual system, and con- sequent abundant discharge of blood at a menstrual period, but, with the advance of the mischief, bleeding may take place at any time, and independent of any special occasion of uterine excite- ment. I need not sa}' that a distinction does not cease to be use- ful because it is not always practicable to make it. But to return,^ menorrJiag ia was stated to depend m some instances on causes acting tJirough the medium of the gerieral system. Thus, for instance, some years ago 1 saw a widow lady of about forty years of age, whose time was divided between a sojourn in this country for two or three months at a time and a residence during the other part of the year in a somewhat damp situation in Ireland. Menstruation was always regular in the time of its recurrence and natural in quantity during her stay in this countr3% but for some two or three years her return to Ireland had been followed by an excessivel}^ profuse discharge at each menstrual period, and by its continuance for more than twice as long as usual ; symptoms which subsided once more after a few weeks' stay in England. Ilowthe change of climate acted in this case it is not possible to say, though illustrations of a somewhat similar influence of locality in modi- fying the uterine functions are for from unusual. Cases are sometimes met with in which an altered state of the circulating fluid, such as even our rough chemistry can detect, co- exists with and appears to be the exciting cause of menorrhagia. In cases of granular degeneration of the kidneys, monorrhagia is far from being of unconmion occurrence. The altered, attenuated 1 Premature menstruation, wenfifmrttio prcpcox, has been classed by some writers as a form of monorrhagia. I have preferred, liowever, passing over the sulijeet, since cases of precocious puberty in either sex concern the pliysiologist rather than the physician. Two remarks only suggest themselves as in ])Iace here. Fir.^t, tiiat those instances in which the sexual system has been stimulated to premature ac- tivity by various injurious influences both physical and moral, are not genuine cases of precocious puberty; and second, that neither are all cases to be so regarded in which once, or oftener, sanguineous discharges have taken place from the sexual organs of infants and very young female children. Cases of genuine precocious puberty, in which the whole body ha? undergone in early childhood tlie various changes that usuallj' take place in later years, and an- nounce the arrival of womanhood, are far less common tlian the numerous refer- ences to be found to their occurrence in medical works would at first lead one to inuigine. A very soimd criticism on many of the earlier cases is to be found in Naegele, Ahhaiulbmcfcn, tfc, aiiH.Hrm Gcbieir (lev KrauIihrJien drs wrihlichen Gmch- lechfen, 8vo., Mainz, 1812, pp. 312-828. Numerous references, though sonie of them are of doubtful autlu-nticity, are to be found in Jleissner, Frntictiknmkheliet) , vol. ii, 8vo., Leipsig, 181"), p. 723-73!l ; and in Uuseh, Das Gesrldrchislvhrn drs Weihes, vol. iv, 8vo., Lc'ijisig, 18-J3, ^ 243, pp. 4V.)-4Ctr^; and, lastly, an interesting case, with very sensible remarks on many jirevious histories of cases of pr(>matuie men- struation, will be found in a small tract of 47 pages, by Dr. Keuter, Leber die Pra- cocltdt der Menstrtiation, Bvo., Wiesbaden, 1846. 54 MENORRHAGIA. blood seems to escape more readily than natural from the uterine vessels when they are congested at the return of a menstrual period ; and three or four cases of supposed disease of the womb have come under my notice, in which the most careful examination could detect no local cause for the profuse menstruation, but in which the urine was discovered to be loaded with albumen. The hint which this fixct suggests as to the expediency of examining the urine, even though no symptoms should seem to point to the ex- istence of renal disease, is worth remembering, and the test-tube will sometimes help to clear up an obscure case of supposed uter- ine ailment. You are not to be specialists, even though chance should lead you to have most to do with one special class of ail- ments, but you are to be physicians, and in proportion as you learn to estimate aright the influence of the disorders of one part on the functions of another, will ^^ou be likely to prove good and suc- cessful practitioners in the treatment even of local diseases. Somewhat similar in their nature are those cases of menorrhngia met with most frequently towards the decline of sexual activity, in which, with general disposition to plethora of tlie abdominal vessels, a sluggish liver, and constipated bowels, menstruation is sometimes irregular in its occurrence, often anticipates the proper date of its return, and is often excessive in its quantity. Such hemorrhages are not of necessity menstrual, tliough tiny" usually take place at or near a menstrual period, the congestion of the womb which then exists favoring the occurrence of profuse bleed- ing at that time from the uterus rather than from any other organ. A tendency to hemorrhage is a frequent attendant on many conditions of debility, and we look, probably with propriety, on some change and deterioration in the circulating fluid as account- ing both for the general feebleness, and for the local accident. In women whose strength has been exhausted, or whose blood has been impoverished by prolonged lactation, the reappearance of tlie menses often takes place with an \indue abundance of discharge, often in such quantity as to constitute real menorrhagia ; while in many instances the long duration of the hemorrhage is at least as trying to the patient as the profuseness with which it flows. Here then is another illustration of menorrhagia from constitu- tional causes. These cases, indeed, are so frequent in their occurrence, and often cause so much anxiety, as to claim a moment's special no- tice. A woman who has reached the period at which menstrua- tion commonly ceases, finds that, independent of any cause to which to attribute it, the flow becomes far more profuse than was its w^ont. It lasts longer, is more abundant during its flow, and often returns more frequently than before ; but it is unattended by pain, and is not succeeded by purulent or mucous leucorrhoea, though a sero-sanguineous discharge not infrequently continues in the in- tervals of menstruation, or is induced l)y very slight exertion. The absence of all local discomfort often leads the patient to postpone any treatment for months, under the impression that the ailment FROIVI CONSTITUTIONAL CAUSES. 55 will soon disappear with the spontaneous cessation of menstrua- tion, until at length the daily increasing weakness, the dyspna^a on slight exertion, the swollen ankles and impaired digestion, urge her to seek relief from symptoms which even then she scarcely connects with the perpetually-recurring bleeding. Such patients come to the out-patient rooms of hospitals, or even present them- selves in the consulting-room of the practitioner, after long delays, with the worn aspect, the pale and sallow countenance which at once raise the suspicion that they are suffering from malignant disease. This suspicion, too, is not infrequently strengthened l)y the statement that the discharge is occasionally fcetid — a condition by no means unusual in cases of long-continued hemorrhage, if the blood is not washed away from the vagina by daily syringing. In every instance of the causeless occurrence of menorrhagia in ad- vancing life, the probable existence of cancer must not be lost sight of, since to that, or to the presence of small fibrous tumors or polypi, the hemorrhage is often due. In these special cases, however, no uterine disease exists, though sometimes, from the perpetual afflux of blood towards it, tlie womb is increased in size. Often the organ is no larger than natural ; it is not hard, nor in any respect unhealthy, and one feels at a loss to account for such grave functional disorder with such complete absence of local mischief. But though in cases such as these the sexual sj'stem is not the part first in fault, yet no serious disorder of its functions can take place, still less can recur frequently, without being accompanied by some sign of uterine ailment. A sense of weight in the pelvis, a feeling of bearing down and sympathetic pains in the back, tell that the uterus is heavier than natural, and that its vessels, from habitual congestion, arc overloaded with blood; while the mucous discharge which persists in the intervals between the menstrual periods is but the effect of the same condition, which, increased at the time of each ovarian excitement, gives rise then to the profuse outflow of blood. Moreover, since the menstrual effort returns every twenty-eight days, the congested womb has not time to re- cover itself between each period. The blood has scarcely ceased to flow before it is again determined to the organ by a renewed ovarian excitement; and, its tissue being looser, its vessels more dilated on each succeeding occasion, allow more and more readily of the escape of blood, till at length no interval is left at all, but the flow goes on constantly, and menstruation is marked only by a larger hemorrhage than takes place at other times. The influ- ence of habit, too, to which I ret'erred when s])eaking of amenor- rhoea, is not less marked in cases of menorrhagia, tending to per|)etuate the evil, and to render its removal difficult, long after the cause to which it was originally due has ceased to be in action. Some inferences api>licable to practice may be deduced from what has already been said. 1st. Tiie importance of determining whether the cause of the menorrhagia is to be sought in the state of the general system or of the sexual orirans. 56 MENORRHAGIA. 2d. The necessity of bearing in mind that even when the ail- ment depends on a constitutional cause, it will yet be attended by certain local symptoms ; and further, that the latter may persist long after the removal of the former. 3c7. It follows as a corollary from the two preceding statements, that it is essential in every case of long-continued menorrhagia to determine by careful examination the presence or absence of local disease ; and this the rather since tlie early stages of organic uter- ine affections are not only often accompanied by menorrhagia, but also are often unattended by any other symptom. But there is a second class of cases in which menorrhagia occurs as the result of some cause acting directly on the sexual system. We meet sometimes with instances of what seems like a special sus- ceptibility of the sexual system, in which any sudden excitement, even though unconnected with the sexual functions, is followed by hemorrhage lasting perhaps only for a few hours, or for a day, but sometimes continuing longer, and even passing into regular menorrhagia; while in all patients who are liable to this accident, menstruation is almost invarial)ly profuse. A similar effect is pro- duced by causes acting directly on the sexual system ; and hence, while in some cases we find the unaccustomed stimulus of sexual intercourse lead to suppression of the menses, we also observe it in other instances followed by their excess. Menstruation in these cases generally continues to observe its proper periods of return, but lasts on each occasion much longer tlian natural; M'hile absti- nence from intercourse for a season, and moderate use of it after- wards, are almost always followed by the menstruation resuming its natural character. More difficult of cure, however, are those cases in which, from some cause or other, the marriage is sterile, and especially those in which, from disparity of years, or from constitutional feebleness on the husband's part, the act is but im- perfectly accomplished. In these circumstances a sort of chronic ovarian irritation and chronic congestion of the woTnb are kept up, which lead to a degree of hypertrophy of the uterine sub- stance, and to profuse bleeding from its lining membrane. Men- orrhagia, too, not seldom occurs in prostitutes from the constant over-excitement of their sexual organs, and its cure is almost im- possible by any means short of the complete abandonment of their habits. The local causes, however, which may give rise to menorrhagia are manifold. Whatever produces undue ovarian excitement, whatever causes undue uterine congestion, is likely to occasion it, while any circumstance that renders the womb larger, its texture looser, its vessels of greater size tlian usual, by just so much facili- tates its occurrence. Premature exertion after delivery is often followed by hemorrhage. If this hemorrhage is not speedily checked by treatment, and its return guarded against by watchful care, it soon assumes the menstrual type, and soon also becomes excessive in quantity, from the very circumstance that it takes place from an organ in which the processes of involution are as FROM LOCAL CAUSES. 57 yet incomplete, and whose vascular supply is much more abundant than it would be if menstruation were delayed till the lapse of the ordinary period after delivery. From a similar cause the founda- tion of menorrhagia is often laid in a want of due care at the time of the first appearance of the menses after a miscarriage ; an occa- sion, by-the-bye, on which you should not fail to impress on your patient the need for what may seem to be almost exaggerated pre- caution. This condition of the womb, too, sometimes persists for long periods after the delivery or the miscarriage to which it was originally due; or in weakly persons exists even independent of any appreciable cause, and this to so great an extent that the uterine sound may sometimes discover the length of the utei'ine cavity to vary as much as half an inch within the course of a single week. This state of relaxation of the tissue, of the womb likewise coexists very frequently with a granular, abraded, or ulcerated condition of the os uteri; local affections which, slight though they may seem, yet help to keep up an habitual congestion of the womb, and thus furnish an ever present occasion of menorrhagia. Other causes still mio-ht be enumerated as giving rise to exces- sive menstruation, such as blows or other injuries inflicted on the uterus during a menstrual period. INIisplacements of the uterus, as retroflexion or anteflexion, are often associated with it, and various organic diseases, as polypus, fibrous tumor, or cancer, which eventually produce constant hemorrhages, at first manifest their existence in many cases by an increased flow of blood at the ordinary menstrual period. Inflammation of the uterus, especially, I believe, of its lining membrane, has this effect in very many in- stances, and not only produces it on a single occasion, but gives rise to a state in which menorrhagia often becomes habitual. It has also been alleged^ that many cases of obstinate menorrhagia are dependent on a morbid state of the uterine lining membrane, in which it becomes the seat of minute polypoid granulations, whose removal, by scraping away the membrane itself, is essential to the patient's cure. There can, however, be no doubt but that the frequency of these granulations has been greatl}' overrated ; their existence is not referred to by Pichard in his table of ex- aminations of 800 uteri ;^ Rokitansky does not allude to them ; and they did not come under my notice in any one of seventy uteri which I examined carefully some years since at St. Barthol- omew^'s Hospital. There is no doubt, however, of their occasional existence, or of their identity in structure with the uterine mucous membrane itself,^ though, while they have been found in the uteri ' First dopcribcd by M. Rdcamior in tlio JnnrnnI de C/iirin'ffie for 1843. M. Xonat, who onibrafcs M. Kt'caniior's ojiinioiis, and adojtts his praolioc, gives a sketoh of tho litorature of tlie subject at p. 193 of his Traite des Maladies de I' Uterus, 8vo., Paris, 18()0. '^ Apjiondcd to his book, Des abus de la cautei'isaiion, etc., dans les maladies de la mafrice, Paris, 8vo., 1840. ^ Seo th(> account of their microscopic structure by M. Kobin, in the Arc/tives de Medecme, 1847, vol. xvii, p. 411. 58 MENORRHAGIA. of women who had never suffered from any form of hemorrhage, there is no evidence to show that they have any necessary con- nection with the occurrence of menorrhagia, or that menorrhagia, when associated with them is distinguishable by any peculiar S3^mptonis. Tlie supposition that it is.possible to distinguish tliem by exploring the uterine cavity with the curette is ridiculed, fairly enough, by M. Aran/ who criticizes the hazardous proceedings whicli their presence has been supposed to justify, and on account of which I make this reference to a pathological condition in it- self of no great importance. Lastly, various affections of the ovaries are attended by the same result; and misplacement of those organs, their inflamma- tion, and more rarely their degeneration, may be characterized by abundant and over-frequent menstruation. Each of these causes of menorrhagia, however, as well as all the different affections of the uterus itself, must engage our attention at a future day, and may therefore be passed over now without further notice. In entering on the consideration of the treatment of menorrha- gia, it is almost superfluous to observe that this can be by no means uniform, but must dift'er almost as widely as the various causes to which the excessive loss of blood is due. In every instance, however, we have to fulfil two indications, of which sometimes the one, sometimes the other is the more urgent; namely, to arrest the present hemorrhage, and to remove the cause on which it depends. The ])rinciple whicli must guide us in endeavoring to accomplish the latter are too obvious to need more than the very briefest reference. In those patients, for in- stance, in whom the menorrhagia is but a sign and a consequence of general debility, the tonic remedies and ferruginous prepara- tions which tend to invigorate the health and to improve the com- position of the blood, will of themselves have a most powerful influence in checking the excessive discharge at the menstrual period. In some of these cases, too, the menstruation is excessive relatively to the patient's strength, rather than absolutely, com- pared with the quantity of blood lost by women in general at a menstrual period. This is so not infrequently with women in whom menstruation appears during suckling; and in such cir- cumstances, it usually suffices to wean the child, and to give some simple tonic, in order to effect the patient's cure. Less amenable to treatment, of course, are those cases in which the alteration in the circulating fluid depends on some deep-seated cause, such, for instance, as exists in cases of granular degeneration of the kid- ney ; though in such it is at once obvious that our attention must 1 In his Leqons sur les Maladies de V Uterus, 8vo., Paris, 1858, p. 475. "What !" says he, " do they seriously profess to be able to distinguish bj' means of the curette — -that is to say, at the end of a stem a foot in length — these fungosities which measure in every direction three or four millimeters, and which scarcely project one or two millimeters beyond the surface of the mucous membrane; and this, too, in spite of their extreme softness, and of their continuity, without any distinct line of demarcation with the healthy mucous membrane?" INDICATIONS FOR TREATMENT. 59 be directed cliiefly to something more than the mere suppression of the present hemorrhage. Again, the excessive hemorrhage that occurs in connection with a state of general plethora of the abdominal vessels, showing it- self in a disposition to hemorrhoids, a sluggish action of the liver, and a constipated state of the bowels (a condition most frequent towards the decline of the sexual powers), admits less of remedies immediately addressed to the suppression of the bleeding than of attempts to remove it l)y indirect means. These are the cases in which a carefully regulated diet, whence all stimulants shouhl be banished, great attention to the bowels, with the habitual employ- ment of small doses of saline aperients, such as the sulphate of magnesia, the potassio- tartrate of soda, or some of the aperient mineral waters, as the Pullna water, for instance, continued for w'eeks together, will seldom fail to be successful. In such cases, too, as well as in those of younger women, in whom, wnth a gen- eral state of plethora, and rather sluggish condition of the bowels, the menses are with every month becoming more and more pro- fuse, an active aperient taken the day before their expected occur- rence often has a most remarkable influence in restraining the ex- cessive hemorrhage. But there are many cases in which the sexual organs themselves either are the immediate cause of the menorrhagia, or in Avhich changes that they have undergone tend in great measure to per- petuate or to aggravate it. In all the more important forms of uterine or ovarian disease, the menorrhagia is but one out of several symptoms, each of which may claim our attention and necessitate our interference. Here, then, the empirical recourse to measures for checking the hemorrhage maj be either out of place or use- less ; and just as the peculiar state of the constitution calls for consideration in some cases, so the precise character of the local ailment requires investigation in others. Not to enter, however, into details which would occupy much time now, and must yet of necessit}^ be incomplete, I will endea- vor to furnish you with some general rules applicable to cases of menorrhagia in general, and then to give you special directions for the management of those in which the amount of the bleeding, or its persistence, or the state of the patient's health, requires that decided measures should be adopted for its suppression. Under all varieties of condition, there are certain precautions which tlie known liability of any wormian to menorrhagia sluuild lead her to adopt with the return of each menstrual period. First among the rules may be mentioned the strict observance of the horizontal posture, from the commencement of the discharge, and the maintenance of it till the discharge ceases. If with this be associated due care that the bowels are not constipated, and the pelvic viscera consequently not congested at the onset of the pei'iod, it is surprising how many cases of obstinate menorrhagia will be relieved in a very short time, and the hemorrhage restrained within proper limits, and this even though all kinds of remedies had pre- 60 MENORRHAGIA. viously been long and fruitlessly employed. To secure this benefit, however, it is necessary that the precaution be repeated for two or three successive periods, and that afterwards a much greater degree of care should be taken at the return of each menstruation than many women are ready to observe. But while these precautionary measures are alike applicable to all forms of menorrhagia, the management of the case in other respects differs completely, according to whether the hemorrhage assumes an active or a passive character. In the latter case, we employ astringent remedies both generall}" and locally, and this with a confident expectation of success ; in the former, astringents would be out of place, and we rely on antiphlogistic measures, of greater or less activity, according to the urgency of the symptoms. There is one variety of excessive menstruation, dependent on a state of intense uterine congestion, if not on actual inflammation of the womb, in which the profuse loss of blood is associated with general febrile disturbance of the system, with a very distressing sense of weight and bearing down, great abdominal and uterine tenderness, together with pains of a periodical character, like those of threatening miscarriage, or of the early stage of labor. These symptoms, to which the name of metritis Jiemorrhagica has been applied by some continental writers, require both for their relief, as well as for the suppression of the hemorrhage, the abstraction of blood from the arm, or tlie free application of leeches over the low^er part of the abdomen ; measures which are most efficacious if taken just before the occurrence of a menstrual period, or within the first day or two from the commencement of the discharge. But there are besides, other cases, in which, though the symptoms are less urgent, yet any attempt directly to stop the discharge would be equally unsuitable. Such are all those instances of menorrhagia that are associated with a state of general plethora, where a flushed face, and a full pulse, and an aching head, at the commencement of the period, become by degrees relieved as the blood flows, and where the hemorrhage seems to be almost salu- tary, were it not that it tends to become excessive, and tends also to become habitual, persisting long after the cause which first occasioned it has ceased. In these cases a modified antiphlogistic treatment must be pursued; small doses of the sulphate of mag- nesia wdth sulphuric acid, and the tincture of henbane, if much uterine pain be present; or the nitrate of potash, with tincture of digitalis, must be given, and will scarcely ever fail to check the bleeding.^ 1 (No. 2.) R. Mac:nppiiB Sulphatis, . ^iv Acid. Siilph. diluti, . ^:^j Tinct. Hyosciami, . . ^\} Aqu?e Cinnamomi, . . ,^jss Aqirne purje, . . . . ^iv M. ft. mist., cujus sumat cochl. ij am- pla 4ta quaque hora. R. (No. 3.) Potassaa Nitratis, Tinct. Digitalis, SjTupi Limonum, Aquae purse, .5.1 ti^xl % vss M. ft. mist., cujus sumat cochl. ij am- pla 4ta. quaque hora. J TREATMENT OF THE ATTACK. 61 Cases presenting; an active cliaracter, however, or calling for any approach to antiphlogistic measures in their treatment, are decid- edly exceptional. Menorrhagia*ls most commonly met "with in conjunction with a state of debility, and the obvious indication in the miijority of instances is to check the bleeding as promptly and by as direct means as we can. With this view it is desirable, in all cases of passive menorrhagia, particularly when the affection has been of long standing, to employ astringent remedies,* such as alum, gallic acid, lead, or matico, from the moment when the discharge commences, and not to delay their administration until the hemorrhage has become considerable. Of the four remedies which I have just mentioned, the gallic acid and the matico are those in which I have the greatest confidence, while I place the least reliance on the acetate of lead. I do not know, however, of any special indication by which we can judge beforehand of the probability of one or the other remedy proving specially applica- ble in any particular case, but am accustomed to employ each in succession, provided one should fail to produce the desired effect. The ergot of rye is employed by many practitioners in cases of menorrhagia, and this not simply on account of its action on the uterus, but also from its supposed styptic property, I used to think that it was not possessed of any power of arresting hemor- rhage, independent of that which it exerts as an excitant of the muscular contractions of the womb. I hesitate, now, however, to express that opinion so confidently as heretofore, since I have ob- served several instances in which bleeding has been stanched by its employment without any sensible uterine contraction having been produced. If one were sure of always obtaining the drug perfectly fresh, I believe the infusion of o'j of the ergot in .^vi of boiling water, to be its most efficient preparation, wliile the greater number of the essences and tinctures which are in such general use have seemed to be almost equally inert. Of the es- sential principle of the ergot [ergotine) I have no experience; but I believe that it has not justified the high expectations of the 1 (No. 4.) li. Aliiminis, . . . Sulve ill Aqune purse, . adde 3JS M. Tinct. Cinnamomi co. Syrupi Paj)av. alb., ail, . ^^^iv ft. mi.st., cujiis .suiiiat cochl. magna 3tia vel 4ta quaque hora. (No. 5.) R. Acidi Gallici, . . . Synij)i siinplici.s, . . Aed, and the microscopist tells us of a new generation of spindle-sha[)ed cells which he can discover in its tissue, just like those which existed in the organ l)cf(Me i»reg- naucy began, and which remain stationary at the same low stage 100 ALLEGED IMPORTANCE OF of formation, till in their turn excited by impregnation to go through higher phases of development. In these changes the body of the uterus, and the lining of its cavity, bear a far greater part than either the substance of its cervix, or the mucous membrane which lines that canal. The mucous membrane of the body only is developed to the decidua, and it alone is thrown off after delivery; the lining membrane of the neck undergoes much slighter alterations, and is not deciduous. It is in the body of the uterus that its muscularity is most evident; firm fibro-cellular tissue predominates in the cervix, with which are interwoven here and there bundles of narrow, smooth, muscular fibres ; and the stimulus of pregnancy which works such changes in the former situation, brings to pass far slighter alterations in the latter. Though our knowledge is still but imperfect, we yet know some- thing of the results which often succeed to accidents that interrupt the course of pregnancy, and originate the processes of degrada- tion of the uterine tissue prematurely ; or which follow on disease SHCceeding to delivery at the full period. Some of these results were pointed out to you in the last Lecture, when I was speaking of deficient involution of the uterus, and of the evils that may follow in its train ; wdiile I referred to other ailments of a some- what similar character which may come on independent of preg- nancy, as the consequence of some form of irritation or excite- ment of the womb. In nearly fifty per cent, of the patients who applied at St. Bar- tholomew's Hospital for the cure of uterine ailments independent of organic disease, marriage, pregnancy, or delivery was assigned as the cause of the patient's symptoms ; and it is, I think, fair to assume that in this large proportion of cases the disorder was local in its origin, and that the constitutional affection was but the secondary result of its intensity or persistence. Plausible, indeed, as the argument appears, that the performance of functions for the discharge of which any organ is expressly constituted cannot be likely to produce disease of that organ, you yet must not forget those peculiarities of the uterus which render it a probable excep- tion to such a rule, while the fact is also not without its signifi- cance, that of 425 applicants for the relief of non-organic uterine ailments, 404 were married women or widows, and only 2; I un- married.' But while I mention these facts in order to caution you against 1 It is not possible, from the statistics of the out-patient department of a hospital, to deduce anything like a correct estimate of the comparative frequency of difl'er- ent diseases ; and the sources of error are still more numerous in the case of any department of a hospital devoted to the cure of a special class of diseases ; since the more serious of those affections are sure to present themselves at it in a very undue proportion. The statements in the text, then, are not intended to repre- sent the absolute frequency of primary uterine disease, in comparison with cases in which the disorder of the womb is secondary to constitutional ailment, but merely to guard against the assumption that the uterine afi'ection is, in almost all instances, secondary in point of time and subordinate in importance. INFLAMMATION AND ULCERATION OF CERVIX. 101 unflerratiiig the frequencj or the importance of uterine ailments as primary disorders, it is far from my object to lead you to supj^ose either that these disorders have one invariable cause, or that they are the results of one constant pathological occurrence. This, however, or something very like it, has been maintained ; it has been alleged that there is an invariable, or almost invariable cause of these symptoms, — that be the remote occasion of them what it may, inflammation and ulceration of the neck of the ivomh is their immediate cause, — that the key to the right understanding of uterine diseases is to be found in the correct appreciation of the importance of this condition ; and the cardinal point in their treatment consists in the adoption of means for its cure. The ulcerations to which such important results are attributed are for the most part mere superficial abrasions of the epithelium investing the lips of the os uteri, whose abraded surface is of a vivid red color, and finely granular. This granular appearance seems to be due to the papillae that beset the surface of the uterine lips having become denuded of their epithelium; while the larger and more distinct granulations, which frequently bleed readily on, being touched, are these same papillre, not merely deprived of their epithelial investment, but actuality h3'pertrophied.^ In other cases in which the absence of cpitlielium is less complete, the surface seems beset by a number of minute, superficial, aphthous ulcerations, between which the tissue appears healthy, or slightly redder than natural. The ulcerations of the os uteri seldom or never present an excavated appearance with raised edges, as ulcers of other parts often do ; but either their surface is smooth, or it projects a little beyond the level of the surrounding tissue. They are usually, but not constantly, of greater extent on the posterior than on the anterior lip, are sometimes confined to the former, but very rarely indeed limited to the latter. They appear to com- mence at the inner margin of the os uteri, wdience they extend outwards ; and sometimes, though by no means invariably, the short extent of the canal of the cervix uteri wdiich can be brought into view by the speculum, appears denuded of its epithelium. The adjacent parts of the os uteri vary considerabl}^ in their appearance; sometimes their natural pale rose tint is preserved up to the edge of the abrasion, wdiich is marked by a distinct well-defined line, while at other times the whole surface is of a much more vivid red than natural, and the line of demarcation between the abraded and the healthy surface is irregular and indis- tinct, the one encroaching on the other. The orifice of the uterus is generally more open than in a state of health, and the disappear- ance of the abrasion, which always takes place from the periidierj' towards the centre, is accompanied by the gradual closure of the previously patent orifice. The state of the tissue of the os and cervix varies ; sometimes there is a very marked softness of the 1 See the account of their microscopic structure in the chiboratc work of Uennig, op. cit., p. 64. 102 CORRECTNESS OF THESE parts, the condition resembling that of the uterus soon after abor- tion or delivery, while at other times it is much harder than natural ; but it certainly is not at all a common occurrence for extensive ab- rasion of the OS uteri to coexist with a condition of the organ such as would seem healthy to the touch. The secretion from the sur- face varies considerably in different cases, and the chief part of the leucorrhceal discharge from wdiich the patient sutlers is derived from within the canal of the cervix, or from the cavity of the womb, not from the abrasion itself Still, in some instances, those espe- cially in which the ulceration presents a very marked granular character, the discharge derived from this source alone is far from inconsiderable. The degree of sensibility which the ulcerated sur- face possesses also varies greatly ; now and then the slightest touch is extremely painful ; but in the majority of cases, the ulcerated surface is not more sensitive than the adjacent parts, nor is the , neck of the uterus whose os is abraded by any means constantly more tender to the touch than the same part of an organ entirely free from that aflection. Such, then, are the chief characters of the ulcerations, abra- sions, and granulations of the os uteri, to which so high a patho- logical import is attached by some writers. It is alleged in ex- planation and in support of this opinion, that the mucous mem- brane of the cervix uteri, by reason of its vascularity and of the abundance of mucous follicles which are embedded between its duplicatures, is extremely liable to inflamation ; and that this pre- disposition is still further increased by the abundant afflux of blood towards the neck of the womb, as well as by the position of that part of the organ and its consequent exposure to irritation and injury from various sources. This inflamation of the cervix is said to manifest itself by the secretion of an abundant albumi- nous matter from the cervical glands, and by the opening of the otherwise closed os uteri ; as also, in by far the greater number of instances, by abrasion or ulceration of the os uteri, which usu- ally occurs at a very early period. The cervix becomes swollen and congested, and it increases in size ; but while in some in- stances it remains soft to the touch, even after years of disease, its substance becomes more frequently the seat of inflammation, lymph is effused into it, and it is not merely enlarged, but indur- ated — a change which takes place to a greater degree in those who have given birth to children than in the unmarried or sterile. The different extent of the ulceration is the only cause assigiied for the presence of induration of the cervix in one case and its absence in another ; but the relation of the two conditions does not seem to be by any means invariable. The degree to which the ulceration spreads appears also to be uncertain ; in the gi-eat majority of cases it passes more or less deeply into the canal of the cervix, and sometimes occupies its whole extent, th« internal OS uteri, however, forming a barrier to its further progress, and preventing almost invariably its extension into the cavity of the womb. It is then inflammation, with its attendant ulceration of OPINIONS DOUBTFUL. 103 the OS and the cervix uteri, and usually with consecutive indura- tion of its tissue, to which, according to these views, the sufler- ings of the patients are due ; and all the varied disorders of the uterine functions — the pain, the leucorrhoea, the homorrluiges, the sterility, or the frequently occurring ahortions — are attributed to the sympathies of contiguous parts with that small portion of the womb which is the seat of disease. Ulceration, too, when once it has occurred, is alleged to have scarcely any tendency to heal ; while so long as it remains there may perhaps be a lull in the patient's sulferings, and some temporary mitigation of her symptoms; but there can be no real cure until the time when, the period of sexual vigor having expired, the organs which sub- served it pass into a common state of atrophy ; while cure, even then, is uncertain, and the consequences of disease outlast, by no means rarely, the uses of the part. As uterine pathology is sim[)lified beyond expectation by the discovery of an almost invariable cause of the most diverse symp- toms, so uterine therapeutics also are made easy, according to the writers whose opinions I am relating, by one remedy being found almost always applicable for its cure, be the duration of the disease or its severity what it may. If the evil be slight, its removal will be speedy; if severe, a longer time will be required: but to modify the vitality of the part by caustics is the one unfailing indication; and, this accomplished, the ulceration and the inflam- mation and its results disappear together, and the sufferings of years are thus almost infallibly got rid of in a few weeks, or at latest in a few months. There are, indeed, some cases of slight mischief, which rest, antiphlogistic treatment, and vaginal injec- tions, may cure; but these are rare. There are also some circum- stances in which the local abstraction of blood may be of service; but what caustics to use, how often to repeat their ap[»lication, how to prevent or to remove those inconveniences which sometimes result from their employment, are questions discussed as of chief importance ; since to these remedies all other local measures as well as general trejitment are but secondary and subservient. Having now detailed these opinions, and pointed out the prac- tical consequences which flow from them, I nmst occupy the remainder of this Lecture in the endeavor to set before you as briefly as possible the reasons which lead me to reject the opinions as erroneous, and to caution you against the practice which they are supposed to warrant. Among the arguments by which these views have been sup- ported, is one derived from the assumed greater vascularit}' and higher vitality of the cervix than of the body of the uterus, and its supposed consequent greater liability to become the seat of in- flammatory mischief. But not only does a simple examination of the womb sufiice to show that blood is distributed in greater abundance to the body than to the neck of tlic organ, l)ut a con- sideration of the relative share of the body and of the neck of the womb in furnishing the menstrual discharge, or in the changes 104 CORRECTNESS OF THESE which pregnancy and delivery bring with them, must lead, I think, inevitably to the opposite conclusion. Nor, indeed, with reference to these points, are we confined to inferential reasoning, but the advanced stage which cancerous disease of the neck of the womb not seldom readies before either general illness or local suffering betrays its existence, leads to the same conclusion, \vhile everv-day observation has shown that the cervix uteri may be forcibly" dilated, may be incised, its tissue may be burnt w^ith the strongest caustics, or with the hot iron, or portions of it may be removed with the knife, with an impunity wholly incompatible, as I cannot but conceive, with the assumption that the part is one endowed with high vitality and delicate sensibility. The results of post-mortem examinations have been appealed to by the opponents of these views in order to negative, by the rarity with which ulceration of the os uteri was observed, the idea of its important share in the production of uterine ailments. To my thinking, however, the very frequency with which this condi- tion is discovered, furnishes a still more cogent reason for regard- ing it as of comparatively little moment. In seventeen out of sixty-five instances in which I examined after death the uteri of women who died of other than uterine affeptions, or in rather more than a fourth of the total number, abrasion or ulceration of the OS uteri w^as present.^ But though so often met wnth, this ulceration w^as usually very limited in extent, and so superficial as to be unassociated with changes in the basement membrane of the affected surface, and exercising so little influence on the state of the uterus in general as to be unconnected, in a large number of instances, with changes either in the interior of the womb, or in its substance; while induration of the uterine tissue and disease of the lining membrane of the womb were found independently of it or of each other. As far as it goes, the evidence of anatomical investigation appears to me unexceptionable. It shows the absence of any necessary connection between ulceration of the os and those other changes of the uterine tissue which have been alleged to be dependent on it, and suggests the probability that an afi'ection which was be- tokened by no marked symptom during life, and is found asso- ^ Table showing the Chief Results of the Examination of Sixty-five Uteri. Uterus healthj' in 36 " diseased in ... .29 Ulceration of os uteri — " existed alone in . . . . . . . .11 " with diseased lining of uterus in . . . . .3 " with induration of walls of uterus in . . . . 3 17 Induration of walls of uterus, without ulceration of os, . . .5 Disease of lining of uterus, without ulceration of OS, ... 7 Total of diseased uteri, . . . . .29 For the exact particulars of most of these examinations, as well as for the details of the argument condensed in this lecture, I must refer to my Croonian Lectures, On the Pathological Importance of Ulceration of the Os Uteri. 8vo. London, 1854. OPINIONS DOUBTFUL. 105 ciatcd with no important alteration after death, must itself be of no great moment. All additional reason for suspecting that the importance of this condition has been overrated, is furnished by what we observe in cases of prolapse, or procidentia of the womb. From tlic una- voidable irritation to wliich it is exposed, the neighborhood of the OS uteri becomes in these circumstances almost invariably ulcer- ated, and this ulceration is usually both extensive and inapt to heal. Now, though the relations "^of the procident womb differ materially from those of the organ while still in situ, though its sensil)ilitie8 are unquestionably much blunted by its change of position, yet the general absence of any abundant discharge either li-oni the cavity of tlie w^omb, or from the canal of its cervix, as w^ell as of the other symptoms supposed to characterize inflamma- tion of the neck of the womb, cannot but raise a presumption unfavorable to the opinion that ulceration of the os uteri is the all-important aft'ection wliich it has been assumed to be by some writers. If, however, we grant that between the procident uterus and the organ still in situ there are differences sufficient to prevent our a[)plying rigorously to the one conclusions drawn from the other, there is yet another source wdience evidence may be de- duced to show that the os and cervix uteri are less susceptible to disease, and that disease has less disposition to increase and to assume a serious character than has been sometimes imagined. There is no class of persons in whom to such a degree as in pros- titutes we meet with the conditions best calculated to inflict local injury on the neck of the uterus. It would therefore be reasona- ble to expect, if the susceptibility of the cervix uteri have not been greatly overrated, that in these women we should discover with remarkable frequency and intensity an ulcerated condition of the OS uteri, an indurated and hypertrophied state of its cervix. Moreover, as an hypertrophied cervix uteri returns, even in favor- able circumstances, extremely slowly to its original size, there would be many occasions in which the chronic effects of bygone inflammation must be evident in those who had devoted them- selves for months or years to a vicious life. Observations, however, seem to show that, be the causes of ul- ceration of the OS uteri, of inflammation, hypertrophy, and indur- ation of its cervix what they may, sexual excesses, at any rate, have no great share in their production. I found some years ago, on investigating this subject, that in twenty-seven out of forty women admitted into the venereal wards of the hospital, the os and cervix uteri were quite healthy. In ten more the only mor- bid condition was a mere excoriation not above a line in breadth, partially or completely circumscribing the os uteri, but associated with no other change of its tissue. ^In the remaining three the ulceration was more extensive, but in one only of these (and she a woman who had given birth to children) were the lips of the os uteri at all enlarged, while in no instance was there any such 106 CONCLUSIONS WITH REFERENCE alteration of the texture of the part as to deserve the name of induration. The conclusion which we are warranted in drawing from the inquiry, as far as we have hitherto pursued it, would seem to be, that the coiulition of so-called ulceration or abrasion of the os uteri is far from infrequent, even in cases where no uterine symp- toms were complained of during life; but that it is usually un- associated with other important afiections of the uterus such as may be supposed to be the effect of inflammatory action : and further, that such affections do not seem to be readily excited by causes acting on the neck of the womb, either when displaced or when the organ is in its natural position. We are bound, however, to go a step further, and to inquire whether, in the case of persons suffering from uterine ailments, there are such differences either in kind, degree, or duration of the symptoms, according as ulceration of the os uteri is either absent or present, as would enable us to connect with it certain definite consequences, or to say that it tends to certain definite results such as do not otherwise occur. Considering that in the opinion of some writers,^ so large a • Dr. Henry Bennct, at page 36 of his Treatise on Infammntion of the Vtenis, &c., 8vo., ;\d edition, London, 1858, makes this statement. In accordance with this view, too, he observes at page 6, that " in nearly five cases out of six of uterine disease, in which chronic discharges, mucous, puriform, or sanguinolcnt, or other well-marked uterine symptoms, are present, there is inflammatory ulceration of the cervix." His theoretical opinions, however, seem to be undergoing modifications more considerable than he himself is fullj- aware of. In his Review of the Present State of Uterine Pathology, which appeared in the //(7nce< during the spring of 1856, and which was afterwards published as a separate work, he denies having "ever looked upon it as a disease per se, having a separate existence — a separate patho- logical entity;" apparently forgetting statements such as those which 1 have quoted, and also the no less significant fact that 226 out of the 359 pages of which the first part of his book is composed are occupied with the consideration of inflauimation and ulceration of the neck of the womb; only 37 with the study of inflammation, acute or chronic, of the bodj' of the organ. In this Review, too, afiections of the body of the uterus are recognized, though only incidentally, in a manner suggestive of a f requeue}^ and importance much more considerable than would be inferred by readers of his larger work, while he altogether abandons the doctrine on which so much stress has been laid of the special importance of ulceration of the os uteri. I inferred it to be usually of little moment, because, whether it be present or absent, "a very great degree of resemblance exists between the two classes of cases: women of the same age, in similar circumstances, presenting the same symptoms, leading to the same results, having the same duration, and attended with similar structural changes, whether ulceration of the os uteri is present or absent." Dr. Bennet concludes. Review, p. 31, that the " two groups of patients were laboring in a great measure ifnder the same disease, only manifesting its existence in one group by one mode of expression, in the other group by another mode of ex- pression." The indiscriminate use of caustics will probably not very long outlast the recognition of the fact that ulceration of the os uteri is but one mode of expression of uterine disease ; in other words, an accident — not an essential char- acter. Dr. Bennet, indeed, considers this conclusion valueless; to my mi/id it is one of great practical moment, and one which appears to me to be already bearing fruit. Having had occasion thus to refer to Dr. Bennet, I cannot let pass the opportu- nity of avowing my sense of the obligation under which he has laid the profession in this country, not only by the attention which he has drawn to the subject of uterine disease in general, but also by many of his own observations, and especially TO THESE OPINIONS. 107 proportion as 81 per cent, of all women presenting symptoms of uterine ailment are suffering from inflammatory disease of the tissue or canal of the cervix uteri, and 70.4 per cent, likewise from ulceration of the os uteri, this inquiry can scarcely he expected to be difficult to answer.' The evidence in support of the importance as well as of the frequency of these affections may fairly be ex- pected to be overwhelming; and the symptoms of ulceration of the OS uteri to be characteristic, either from their peculiarity or their severity, or from both together; and to differ in important respects from such as attend upon those uterine ailments which are unassociated with that condition. There is not time in a course of Lectures on the Diseases of Women to carry you step by step through the whole of this inquiry, which some years since I made the theme of my Croonian Lec- tures. It must suffice then to say, that, dividing all cases in which the alleged symptoms of uterine ulceration were present into two classes, according as examination with the speculum discovered that condition or showed it to be absent, I endeavored to ascertain wliether sterility is more frequent, whether the rate of fecundity is lower, and whether abortion occurs oftener in the one class of cases than in the other? Whether menstrual disorder is more common, more severe, or different in kind; whether leucorrhcBa is more abundant, or furnished from a different source ; or whether pain is less tolerable when the os uteri is ulcerated than when tliat condition is absent? And lastly, whether similar or different causes produce the uterine affection in the two classes of cases; whether the duration of illness is the same ; whether the structural alterations of the womb are alike or diverse ? Each of these questions was made the subject of special inquiry, and the general results, from which more extended observation has not led me to differ, may be summed up as follows : 1st. Uterine pain, menstrual disorder, and leucorrhoeal dis- charges — the symptoms ordinarily attributable to ulceration of the OS uteri — are met with independently of that condition almost as often as in connection with it. 2(1. These symptoms are observed in both classes of cases with a vastly preponderating frequency at the time of the greatest vigor of the sexual functions, and no cause has so great a share in their production as the different incidents connected with the active exercise of the reproductive powers. But it does not appear that ulceration of the os uteri exerts any special influence either in causing sterility or in inducing abortion. 3d. While the symptoms are identical in character in the two classes of cases, they seem to present a slightly increased degree by his remarks on the subjoct of uterine displacements, and on the diagnosis of uterine cancer. 1 Hcniiii;, op. cit. p. 08, found the proportion to be 17 per cent., and in 9 only of tiic 17 did the morbid condition of the os coexist with leucorrha-al discharge from the cervix. 108 LOCAL TREATMENT of intensity in those cases in which ulceration of the os uteri exists. 4th. In as far as could be ascertained by careful examination, four-fifths of the cases of either class presented appreciable changes in the condition of the uterus — such as misplacement, enlarge- ment, and hardening of its tissue, while frequently several of these conditions coexisted. An indurated and hypertrophied state of the cervix uteri was, however, more frequent in connection with ulceration of the os uteri than independently of that condition. 5th. The inference, however, to which the last-mentioned fiict would seem to lead, as to the existence of some necessary relation — such as that of cause and effect — between ulceration of the os uteri and induration of its cervix, is in great measure negatived by two circumstances. 1. That in numerous instances an indurated cervix coexisted with a healthy os uteri. 2. That while in many of the cases in which induration of the cervix existed, the ulceration of the os was very slight, induration was entirely absent in other instances where the ulceration was noticed as having been very extensive. Since, then, we find that a very great degree of resemblance exists between the two classes of cases; that women of the same age, in similar circumstances, present the same symptoms, leading to the same results, having the same duration, and attended with similar structural changes, whether ulceration of the os uteri is present or absent ; it may fairly be inferred, that ulceration of the womb is neither a general cause of uterine disease, nor a trust- worthy index of its progress; and it follows, I think, as a necessary corollary that the endeavor by local remedies to remove this con- dition of the OS is not the all-important ohject in the treatment of uterine disease which the teaching and the practice of some physicians Avould lead us to imagine. But opinions, such as these which I have expressed, are met not infrequently by the statement, that recover}^ from various uterine ailments is daily seen to follow the employment of caustic and the application of various local remedies exclusively directed against ulceration of the os uteri. Now, though I may not fully acquiesce in this statement, it would be worse than idle to deny that, in many instances, the application of caustic to the os uteri has been succeeded by the restoration of the patient to health. The fact, however, admits of a solution, and one involving a principle which finds its application in the treatment of many diseases besides those which are peculiar to the female sex. It should be borne in mind that in connection with this mode of treatment various other measures are of necessity adopted eminently calculated to relieve many of the slighter forms of uterine ailments. The married woman is for a time taken from her husband's bed ; the severe exertion to which eitlier a sense of duty urged or a love of pleasure prompted her, is discontinued; while rest in the recumbent posture places the uterus and the SOMETIMES MISCHIEVOUS. 109 pelvic viscera in just that position in which the return of blood from them encounters the smallest difficulties. The condition of the bowels, probably before habitually neglected, is now carefully regulated; and the patient's diet, bland, nutritious, and unstiinu- lating, often differs widely from that with which, while all her functions were overtaxed, she vainly strove to tempt her fading appetite. Add to this, that the occurrence of the menstrual period is carefully watched for; that all precautions are then redoubled, and each symptom of disorder, such as on former occasions had been borne uncomplainingly, though often not without much suf- fering, is at once encountered by its appropriate remedy; w'hile, generally, returning convalescence is met in the higher classes of society by a quiet visit to the country, or to some watering-place, in pursuit not of gayety but of health ; and we have assembled just those conditions best fitted to remove three out of four of the dis- orders to w^hich the sexual system of woman is subject. But the very simplicity of these measures is a bar to their adoption ; for it is a matter of constant observation, that the rules which common sense cannot but approve, but which seem to require nothing more than conmion sense to suggest tliem, are just those to which our patients least readily submit. The case is altered, however, wdien the same rules are laid down, not as the means of cure themselves, but only as conditions indispensable to the success of that cauter- ization which, repeated once or oftener in the week, is the great remedy for the ulceration that the doctor has discovered, and which he assures his patient, and with the most perfect good faith, produces all the symptoms from which she sufiers. The caustic used in these milder cases is the nitrate of silver; the surface to wdiich it is applied is covered by a thin layer of albuminous secre- tion not easy to remove completely, and which serves greatly to diminish the powers of the agent, while the slightly stimulating action that it nevertheless exerts seldom does harm — sometimes, I believe, does real good, though no more than might have been equally attained by vaginal injections, or by other similar reme- dies, which the patient might have employed without the inter- vention of her medical attendant. It would, however, be a matter of comparatively little moment whether the views which I believe to be erroneous were so or not, if their reception involved nothing more than an over-estimate of the value of certain therapeutical proceedings which may in reality be unessential to the patient's cure. But their evil, if they be erroneous, is of a far graver kind, and the manner in which they act injuriously on the patient is not hard to understand. No one engaged in the practice of medicine but must have been often struck with the important part which the sexual system plays, unconsciously to herself, in almost all the diseases of women. The frequent sadness and low spirits in celibacy, the grief, the almost shame, of childless marriage, depend on causes more dee|)ly seated than reason can dispel, and are familiar to us as often stamping a peculiar character on the diseases of our patients. To the same 110 USE OF CAUSTICS cause is clue the nervous susceptibility whicli women often mani- fest on the least symptom of ailment affecting their uterine system ; to control which, and to prevent the disposition to unconscious ex- aggeration of their symptoms, becomes often one of our most im- portant, and at the same time one of our least easy duties. Any course of proceeding, then, which, without the most urgent and absolute necessity, directs the patient's attention in the slighter ailments painfully and frequently to her uterine system, is in the highest degree objectionable. The patient recovers from her ill- ness, but with the impression that all the sensations that for weeks, or months before, she had experienced were exclusively due to the local disease which had called for local remedies. On the first re- turn of any symptoms resembling them, all her apprehensions are revived lest the same painful investigation, the same distressing manipulations as before, should be again required. The fact that it needs but to watch the beatings of one's heart for a few minutes, in order notably to quicken its pulsations, and to become painfully conscious of its action, is one of the most familiar illustrations of that influence of attention upon the functions of the body, of which, both in health and in disease, we see so many instances. Diges- tion watched through its difierent stages with the not unnatural anxiety of a dyspeptic invalid, often leaves him a hypochondriac, unable to take other than certain articles of diet, and those cooked in some peculiar fashion ; while in many instances, neither in the food itself nor in its mode of preparation.is there any reason to be found why that alone should be tolerated by his fastidious stomach. More or less discomfort — often, indeed, nmch positive pain — at- tends in the great majority of women upon the performance of the menstrual function, precedes or follows it. These pains are now thought to be of more importance than before; their occurrence is watched for, the sufl'ering of one month is weighed against that of the month before, as the woman thinks she finds in its increase or its diminution grounds for hope or for apprehension. But the sen- sations thus attended to increase in intensity and in persistence ; the slight ailment, which but for the coming evil that it is supposed to portend, would in a few days be forgotten, is noted with anxious vigilance ; and the more it is observed, the more it seems to grow; the patient fears she never will be well again, and at length makes up her mind once more to go through the same treatment as be- fore relieved her, though it brought to her the painful revelation of the grave cause on which her suflfcrings, once thought so little of, in reality depended. Such persons among the poor come to our hospitals, and on questioning them as to their ailments, they at once, and without waiting to describe their symptoms, say that they are suflering from ulceration of the womb ; though on exami- nation one finds no traces of it, or at most a little redness of the edges of the os uteri ; or it may be even that slight abrasion which I trust that I have shown to be as trivial in importance as it is fre- quent in occurrence. But though they have no serious disease, they are not the less, or perhaps one might say all the more, real AND ITS EVILS. Ill suiFerers, and sufferers most difficult to cure. The treatment they perhaps are once more subjected to serves but to confirm the mor- bid habit of mind which has been gradually increasing upon them, and destroying both their present happiness and their capacity for it in future years. But though it is my conviction that, in the great majority of instances in which the nitrate of silver is applied to the os uteri, the proceeding is simply superfluous, it yet would not be right to leave unnoticed other cases in which, the neck of the womb being more or less enlarged, stronger agents are employed. On these occasions the caustic potash is generally used, and by some with the- view of destroying outright a certain portion of the enlarged cervix; by others, with the intention of getting rid of the enlarge- ment by means of the inflammation which it sets up in the uterine tissue. With whichever object resorted to, the proceeding is con- fessedly devoid neither of suffering nor of danger. If the caustic be introduced, as is usually done, within the cervical canal, it is allowed that the pain produced, and which sometimes lasts for two or three days, is very intense, causing nausea or sickness, and sometimes even syncope, or occasioning extreme depression, pros- trating a patient so completely as to render her unable to quit her bed or sofa for several days. Thus much for the present eflect of this remedy, for which its strongest advocates can scarcely lay claim to such an ei)ithet as jucunde. But it does not fare better with it as far as cito is concerned. The application of the potassa fusa so as to produce an eschar, implies a subsequent course of treatment with frequent applications of the nitrate of silver for a period of about forty days, at the end of which time, the action of the remedy being supposed to be exhausted, unless the patient is cured, it will be necessary to repeat the same treatment again and again. This treatment, too, it will be observed, confines the patient dur- ing the whole time that it is in progress to her room, and almost to her couch, and entails upon her the necessity of one or two ex- aminations with the speculum every w^eek during its continuance. But if it can be said to act neither cito nor jucunde, it might be hoped that this mode of proceeding had at least the third merit of tuto ; but it has not. The tendency to contraction or obliteration of the cervical canal after these proceedings is very considerable, and is referred to as even a frequent occurrence ; while inflamma- tion both of the uterus generally, and of its appendages, is a con- tingency far from uncommon. Of the last of these accidents I have seen several instances among patients at the hospital, who, previous to their coming under my care, had been treated with the stronger caustics for ulceration of the os uteri. I will not attempt to follow the advocates of this practice through the explanation which they give of its mode of action ; and tlie rather, since where some see a healthy stimulus to the affected tissues, others discern what they consider to be a dulling, stupe- fying influence, as they term it, weakening the vital foire; while throughout the language used with reference to this subject there 112 EVILS OF USE OF CAUSTICS. is a mingling of metaphor with scientific termhiology, from which it is extremely difficult to arrive at a clear notion of what is meant. I do not doubt but that by either mode of applying the caustic potass, the cervix uteri may be reduced in size; but my dissent from the practice is founded on the fact that it has none of the three recommendations of painlessless, speed, or safety; while my own experience would lead me to believe that when adopted it is usually either out of place or superfluous. During the presence of any active symptoms of inflammation, such a proceeding as the destruction of a portion of the uterine tissue by caustics cannot but be perilous; after their removal the womb will return slowly, often indeed but imperfectly, to its previous size. This return, however, does take place, as far at least as my experience goes, in the immense majority of cases, and takes place as surely, and not much, if at all, more slowly, under just those conditions which best promote the general health, as under a course of treatment which, apart from other evils, confines a woman for weeks and months to her chamber and her couch, to the grievous impairment of her general health, and the utter ruin of her cheerfulness, as on several occasions I have had the opportunity of observing. Moreover, very wide variations in the size of the womb seem to be equally compatible with the healthy performance of its func- tions, while the special tendency which it exhibits in any circum- stances that produce congestion of its vessels to increase in size must never be forgotten in estimating the pathological importance of hypertrophy, either of the whole or a part of the organ. In this opinion, too, I am further strengthened by the fact that some of the most marked instances of enlargement of the neck of the womb, with increased hardness of its tissues, which have come under my observation, occurred in cases where there was no trace of ulceration either of the os uteri or of the canal of its cervix. But I must stop here, and reserve for the next lecture the en- deavor to show what opinions seem to me better substantiated, and what practice more judicious, than those which I have hitherto been engaged in criticizing. LECTURE VIII. INFLAMMATORY AFFECTIONS OF THE IJTEEUS. Chkonic Inflammation and its Eesxjlts, continued. Evidence of general de- pendence of symptoms on affection of body of uterus, and independence of ulceration of os — illustrative cases. Objections answered. Hypothesis of primary affection of cervical canal considered ; and reasons assigned for dissenting from it. Treatment of these cases; depletion, sedatives, use of mercurials, use and selection of tonics. Vaginal injections. Exceptional cases requiring local treatment of ulceration. Cases of cervical leucorrhcea ; their nature and treatment. The last Lecture was occupied almost entirely with the endeavor to point out the fallacy of a certain hypothesis which professed to AFFECTIONS OF THE UTERUS. 113 explain the occurrence of menstrual irregularities, leucorrhoeal dis- charges, and uterine pain, by referring them to a single cause, and regarding them as the invariable, or almost invariable, conse- quences of inflammation of the cervix and ulceration of the os uteri. It remains for us now, however, to inquire to what other cause or causes these symptoms may be attributed, and to ascertain, if possible, in what circumstances the local affection of the os uteri is to'be regarded as occasioning special aggravation of the patient's symptoms, and as calling for special local treatment. In the course of former lectures many remarks have been already anticipated, which might otherwise find here a most appropriate place. It can, indeed, scarcely be necessary to repeat what I have already said with reference to the connection of menstrual irregu- larity and leucorrhoeal discharges with hepatic disorder, or Avith the gouty or rheumatic diathesis. Such conditions are of them- selves amply sufficient to account for symptoms which the patient may refer to the womb ; and so long as they are unremoved, it is idle, or worse than idle, to attempt a cure by local treatment. But there is, besides, a large category of cases in which the symptoms date back to pregnancy, delivery, or miscarriage, and in which the enlargement of the uterus, as well as the history of the patient, point to a purely local cause of the ailment. In these cases, however, it is the body of the womb which is the part most affected, since as it bears the greatest part in all the changes that pregnancy brings with it, so any defect in the involution of the organ will leave its body more enlarged, the lining of its cavity more vascular, than are the walls or the lining of the cervical canal. Often, indeed, but by no means always, enlargement of the neck of the womb accompanies enlargement of its body, but the former is- not the occasion of the latter, — is, I believe, secondary in the order of time, and subordinate in point of importance.^ In 40 per cent, of all the cases that came under my observa- tion, the patient's history went back to one or other of these last- named exciting causes ; for, indeed, it is not possiljle to conceive of a state of things more favorable than they to the supervention 1 "While those shoots •were passing through tlie press, Scanzoni's elaborate treatise on chronic intlammation of the womb [Die ch7-onische Me(ri/is,Svo., "W'icn, 18G3), came into my hands, thoiigii too late for me to make that uir(jicnl Trnnsnctiomt ; ami aftorwanls l>y Dr. Tylor Smith, in his work on Lemorrltica, 8vo.,' London, 1855. ]\[. Iliignicr was, to th(^ best of my boliof, the person who in his Lectures at the llo/ufal tic I'Ourcine, published in the Gazette den Ilupitaux, for 1847, clearly enunciated the opinion that the main source of leucorrhcea was to be .sought in aftVction of the glandular apjiuratus of the cervix uteri, and sujiported this view by very cogent argument, though, for tlie reasons assigned in the text, 1 have ventured to dissent from the conclusion at which both he and other subsequent writers hiive arrived. 2 Op. cit, p. 18. 118 . HYPOTHESIS OF EXCLUSIVE AFFECTION hastily ; and this is all the more likely to he the case if the point on which they rest is one which it is almost impossible to determine with certainty by actual observation. I do not for a moment doubt the frequent, perhaps even the constant admixture of secretion from the glands of the cervix with that from the cavity of the womb in ordinary leucorrhoea ; I believe that in some cases which will be hereafter noticed, such secretion makes up by far the greater amount of the discharge. There are some considerations, however, which, in the absence of any means of positively deter- mining during the lifetime of our patients whether a discharge poured out from the os uteri is furnished from the cervical canal, or from liigher up in the hody of the uterus, or from both, should make us hesitate to assign so little importance to aiFections of the uterine cavity in the production of leucorrhoea and kindred dis- ordei^. Some of the most cogent of these have been already so fully detailed, that it seems almost superfluous to refer once again to the changes tbat succeed delivery, in wbich the mucous mem- brane of the cavity of the womb bears so much greater a part than that of the cervix, and continues to pour out a muco-purulent secretion long after all sanguineous flow has ceased. The history of an ordinary menstrual period affords another illustration of the same fact. The mixture of mucus and epitlielium, which at its commencement and end constitutes the greater part of the men- strual flux, is not only assumed to be furnished from the congested mucous membrane of the body of the uterus, but on examination after death may be seen not only in its cavity, but even distending the whole length of the Fallopian tubes. ^ Whence, too, but from such a source could it flow, as it sometimes does in the healthy subject for twelve or twenty-four hours after the cessation of all admixture of blood, since the secretion formed in tlie cervical canal must be removed at the commencement of each menstruation, and the periodical functions of the two parts of the womb are assumed to be performed at dift'erent times? Nor must it be forgotten, that the mucous membrane of the uterine cavity is provided with appro- priate glands, to furnish such secretion, almost infinite in number, curiously convoluted to increase the extent of their surface, and susceptible of a peculiar hypertrophy more remarkable than any which is observed to take place in the glands of the cervix. Ob- servation also not infrequently discovers the membrane of the uterine cavity abundantly moistened with secretion, while now and then accident and disease bear testimony to the same fact, as in the case of the inverted uterus, of which one of the most con- stant symptoms, next to the profuse hemorrhage, is the abundant leucorrhoea ; or of the inflamed lining membrane of the womb when some accident preventing the escape of the secretion, the 1 It seems indeed doubtful whether affection of the Fallopian tubes does not play a far more imywrtant part than we have been accustomed to suppose, in the pro- duction of many of the ailments of the female sexual sj'stem. See Hennig's re- marks on the preponderance of .catarrh of the tubes, over similar affections of the body or neck of the womb, or of the vagina. — 0/». cit., p. 28. OF CERVIX UNTENABLE. 119 cavity of the organ has been found distended by an accumulation of pus.' Rejecting, then, the supposition that the symptoms we have been considering are in general due either to ulceration of the os uteri, or to some affection of the glands of its cervix, we come now to inquire into their most appropriate treatment. This, as you will readily understand, differs widely, according as the symptoms have anything of an active character, or, on the other hand, are purely chronic, though in both cases the indications to be met are but few, and the means to be employed abundantly simple. So long as acute symptoms are present, or whenever they reappear in the chronic stage of the disorder, local leeching generally affords more speedy and more decided relief than any other remedial means. The leeches should be applied to the uterus itself; not above four in number at a time ; nor is it in general expedient to repeat their application above once in a week or ten days. Another precau- tion to which your attention has already been called, consists in never leeching the womb w^ithin four or five days of a menstrual period, lest the regularity of that function be disturbed, either by being brought on prematurely, or (which, however, is much less frequent) by its occurrence being postponed for several days. The pain which is left behind after menstruation in some of these cases — in those especially in which the discharge is scanty — is often very greatly relieved by the ap})lication of a few leeches as the period passes oft'. Next to the abstraction of blood, the mitigation of suftering by direct sedatives claims our attention. After what has been said in former Lectures on this subject, I will now merely remind you that when sedatives may be long needed, the milder the preparation, and the smaller the dose, the less will be the risk of injury to the health from their continuance. The backache is often relieved by counter-irritation to the sacrum, which is usually more efhcient than plasters of opium, or belladonna ; while its good eftects, also, are in general less transitory. As suitable a preparation for this purpose as any is a croton-oil liniment, com- posed of one part of croton oil to ten of the simple camphor-lini- ment, which should not be rubbed into the sacrum, but merely applied with a sponge twice a day ; and while thus employed will somewhat irritate the skin, but without producing any trouble- some pustular eruption. ' Thore are many such ca.«es on record. In one, the particulars of which arc detailed at p. 79 of my Croonian Lectures, and referred to at p. 91 of Lecture VI, a mere fli-xnre of the neck of the \v<>inb had prevented tlie escape of fluids from its cavity, and it was distended by the accumulation of pus witiiin it to the size of a hen's egjij. The history of cases of inversion of tlni womb, as detailed, for instance, in Cross's monoifraph on that subject, rejiresents jirofnse leuc<)rrba'a as one of its nevcr-fiiilini; symjitoms, sometimes indeed, thouijii l)v no means always, succeeded by a serous discharije, almost continuous in its flow, which takes tlie |ilace at leniith, almost or alt<)a;ether, of the previous hemorrha2;es. The ]irnfus(' loss of blood which accompanies in many instances the small mucous polyju of tiie cervix, is, on the other hand, ample evidence that hemorrhai^e may follow irritation of the neck of the womb, as well as mucous discharge, irritation of its body w fundus. 120 TREATMENT OF SYMPTOMS The same means as relieve the uterine pain, seldom fail to dimin- isli the irritability of the bladder by which it is often attended, and which, after the first more acute sjnnptoms have passed away, is very generally associated with abundant phosphatic deposits in the urine. Small doses of hydrochloric acid, with "tincture of hen- bane and the extract and decoction of pareira, are the most ser- viceable. So long: as there is much pain or much uterine tender- ness, no local applications nor vaginal injections will be of service, except such as are simply soothing, as tepid water; and for the same purpose the tepid hip-bath may be found of benefit. While these measures are employed, absolute rest for a time is needed, though it must never be forgotten, in the treatment of uterine ailments, that there are certain positive evils to which prolonged rest exposes a patient, both by the general interruption of her health, and also by the almost inevitable direction of her thoughts, during the days of seclusion from her ordinary pursuits and ordi- nary amusements, to the seat of suffering. At the same time much prudence is necessary in breaking through restrictions ; and even for months after the patient is convalescent, the approach of a menstrual period, the presence of menstruation, and the first few days after its cessation, are seasons when every precaution must be most strictly observed. If promptly met, the symptoms sometimes pass away gradually, but uninterruptedly ; though the tendency to relapse which each menstrual period brings with it, or which some very slight impru- dence suffices to occasion, is one of the most disappointing features of these cases. After several such misadventures, we find the uterus not only enlarged and less movable than natural, but its tissue generally feels harder, and the cervix in particular presents this character. Leeches will still do something in many instances towards removing this condition ; though it is' in general inexpe- dient to apply more than two at a time, and the result of their emploj^ment must settle the question as to the frequency of their repetition. In these cases the bichloride of mercury steadily em- ployed for many weeks has seemed to me preferable to any other remedy, exercising a decided influence in reducing the enlarge- ment and diminishing the induration of the organ, while it neither irritates the bowels nor affects the mouth, as other mercurial prep- arations, nor disorders the digestion, nor produces sleeplessness, both of which evils are incidental to the employment of iodide of potassium. I prefer giving it in the form of pill, with a few grains of extract of hemlock, and if this be taken in the course of dinner or luncheon, all risk of irritating the digestive organs is avoided, a matter of no slight importance, where, as in these cases, the appetite is fickle. Some kind of tonic is often needed, and few are so little likely to disagree as the liquor cinchonse. If the bowels become constipated, or the liver gets out of order, accidents very apt to liappen, suspension of the tonic for a day or two, and an aperient with two or three grains of blue pill, or a pill containing OF CHRONIC UTERINE INFLAMMATION. 121 a grain and a half of gray powder, of watery extract of aloes, and of extract of henbane, will usually remove the symptoms. Pain in either iliac region is a very frequent attendant on this condition. A small blister will generally eiiectuall}' relieve it; or if the pain be scarcely so severe as to necessitate the cm])loyment of a remedy from which patients usually shrink, a liniment of belladonna, aconite, and soap liniment, maybe employed instead.^ Long after other symptoms have passed away, or have at least been very greatly mitigated, there remains a disposition to exces- sive menstruation, and also to profuse leucorrlucal discharges, due, I believe, to the persistence of congestion, not of the uterine sub- stance only, but of the lining membrane of the womb in particular. This is a state of things for which chalybeate preparations are generally the best remedy, and I know none better than the com- pound sulphate of iron, sulphate of magnesia, and sulphuric acid, which I mentioned some time ago.^ Another remedy which I have tried with advantage on Dr. Tyler Smith's recommendation, as specially adapted to cases where menorrhagia is a prominent symptom, is a compound of alum with sulphate of iron. He speaks of a compound salt^ which he has employed for his hospi- tal patients ; but even in the rough form of extempore prescrip- tion, it has seemed to me very useful. But, besides internal medicines, various external remedies, such as hip-baths and vaginal injections, may be emplo^-ed with advan- tage in the more chronic stages of this affection. It is true that we who now believe the main source of the discharge in these cases to be not the vagina, but the uterus, cannot anticipate so much good from their use as was reckoned on l)y our predecessors, who imagined that the fluid injected into the vagina came into direct contact with the secreting surface whence the leucorrhoeal discharge was furnished. Still, mere purposes of cleanliness furnish one very obvious reason why injections should be employed in every case of abundant leucorrhoea ; while in addition it may be borne in mind, that almost always, when the ailment is of long standing, a part of the discharge is poured out from the vaginal Avails, and some also from the follicles of the cervix, on both of which it may be expected that the medicated fluid will act more or less ener- getically. The injection also will serve to give tone to the relaxed vagina, and thus to counteract the disposition to prolapsus, which is an almost constant sequela of uterine inflammation, while if fluid be used abundantly, or its injection continued for several 1 (Xo. 10.) R Extr. Bollaclonna3, ^fis Tiiict. Aconiti (Fleming's), . . . ,::;iv Lin. Sa|)onis, CO., 3Js.< — M. ft. Lininiontum. For this very useful formuhi I nm indebted to a jmper of Dr. Oldliam's, " On the Use of IJichlorido of Mercury in Hypertrophy of the Uterus," Guy's Hosjniul lie- ports, 2(\ Series, vol. vi, pt. i, p. IGl. 2 See Formula No. 1, p. 46. ' The Putliology and Treatment of Leiicoii'haay 8vo. , 1855, p. 11)3. 122 • TREATMENT OP THE LEUCORRHCEA. minutes at a time, it is also not without decided influence on the body and cavity of the womb themselves. For any such ends to be gained, however, it is essential that injections be employed much more eiEciently than can be done by means of the ordinary syringes, or of the India-rubber bottles which are commonly used. Dr. Evory Kennedy's ingenious syringe, or even the cylindrical pump syringe, which is a more convenient application of his original idea, both require a degree of strength of hand which few women possess ; but a recent modification of the ordinary syringe, which I have seen at Mr. Ferguson's, instru- ment-maker, of Giltspur Street, furnished with a foot, that keeps it steady without the use of both hands, appears to me to obviate every difficulty that was experienced in the use of the other instru- ments. Still more efficacious, however, is the douche, which indeed I am accustomed to employ very generally in hospital practice, in all cases where the uterine cavit\' appears to be the source of the discharge. The only drawback from its use is, that there is a kind of fuss in getting it ready, which induces me in private practice usually to substitute for it the hip-bath. By dissolving a quarter of a pound of alum in the water of the bath, a very good astrin- gent is obtained. If the patient is apprehensive of taking cold, the bath may at first be warmed to about 70° ; and by degrees its temperature may be reduced till it is taken quite cold. The morn- ing is the most convenient time for using it, and the patient should remain in at least ten minutes, in order to derive any important benefit. With reference to vaginal injections, the point of most impor- tance in their composition is, that they should be inexpensive and readily prepared by the patient herself. The dilute lead lotion, which can be readily made from the Goulard extract, lotions of zinc, or of alum, all have their advantages ; while two drachms of tannin, and half an ounce of alum dissolved in a quart of water, form as powerful an astringent as the decoction of oak-bark and alum lotion, which requires much time for its preparation.^ Though in the great majority of instances these measures suffice for the gradual recovery of the patient, yet to this rule there are occasional exceptions, and local applications are sometimes neces- sary to bring about the healing of an ulcerated or abraded condi- tion of the OS uteri, which may have persisted, unafiected or but little modified, by the general treatment. The vivid red appearance of the os uteri, associated with more 1 A peculiar form of uterine leucorrhoea, limited in its occurrence to the aged, and associated with dilatation of the cavity and atrophy of the walls of the uterus, has heen described h}- Dr. Matthews Duncan, in the Edinhirgh Medical Journal, March, 1860. Its characteristic symptoms appear to be peculiar lumbar and pelvic pain, accompanied by a sense of constriction, and the discharge of muco-pus. Its cure seems to require the dilatation of the contracted internal os by the sound, and the application of nitrate of silver to the interior of the womb. I believe that I have met with this condition on one or two occasions, but the patients having their minds relieved with reference to the existence of uterine cancer, preferred putting up with the discomfort to submitting to treatment for its cure. LOCAL TREATMENT OF ULCERATION OF OS. 123 or less extensive abrasion of its surface, and a slightly granular appearance, which is not infrequently met with during the more active stages of these affections, for the most part alters its char- acter, loses its vivid color, and finally disappears under tlie local depletion which the state of the uterus generally calls for. Some- times, however, it continues, its granulations become large, soft, very vascular, and bleed easily, while the surface furnishes a very considerable quantity of glairy discharge. In this case the os and cervix uteri are usually tender, sexual intercourse is painful, and is often followed b}^ a little bleeding. This condition, like that swollen and granular state of the palpebral conjunctiva witli which we are familiar in the purulent ophthalmia of young children, is generally much benefited by extensive scarifications, which may be followed by the daily application of powdered alum on a piece of cotton-wool, or by the introduction of a piece of cotton-wool soaked in a strong solution of alum. By means of a piece of thread tied to the cotton-wool it can be removed by tlie patient herself in the course of a few hours, though it must always be introduced through the speculum. In the greater number of instances, the state of the os uteri becomes so much improved in four or five days that this mode of treatment may be then dispensed with, and the sedulous employment of strong astringent injections will usually suffice to complete the patient's cure. When tliis is not the case, but the morbid condition still continues, more powerful applications may be needed. The nitrate of silver is not in gen- eral suitable in these cases, for its application is often followed by pain and also by bleeding. The acid nitrate of mercury, both in this instance, and also whenever a strong caustic is required, has seemed to me the most useful ap})lication ; and with moderate care its employment is unattended by risk. When it is used, however, the patient must lie on her back, and one of Coxeter's bivalve speculums being introduced so as thoroughly to expose the os and include the cervix, a little cotton-wool must be carefully disposed all round the edge of the speculum, so as to .'ibsorb any of the superfluous acid, and to prevent it from running down outside the speculum, and thus injuring the vagina. A brush can easily be extemporized by trimming a little piece of cotton-wool after it is placed in the holder, and the whole diseased surface may then be painted over wnth the caustic, which immediately forms upon it a white eschar. A piece of dry cotton-wool now pressed against the part will absorb any superfluous caustic: the little strips placed around the edge of the speculum may then be removed and the speculum withdrawn. An additional precaution, however, which it is well to take, consists in introducing, before the withdrawal of the speculum, a piece of moistened cotton-wool up to the os uteri, whence it may be removed in the course of a few hours by the ])atient. It is seldom that either pain or bleeding follows this application ; and at the end of a Aveek the eschar will usually be separated, the surface will be found to have lost its fungous char- acter, and cicatrization to be commencing at its edges. A zinc 124 TREATMENT OF ULCERATION OF OS. lotion of about five grains to the ounce, or the bhick wash em- ployed as a vaginal injection twice a day, will now generally be sufficient ; but sometimes the surface puts on an indolent character again, and it may then be expedient to touch it once or twice with the nitrate of silver, and I have occasionally found it necessary to repeat the application of the nitrate of mercury. Another state which I have but rarely met with, but which seems usually to call for caustic applications, is one in which the os uteri is the seat of a distinct ulcer, with sharply cut edges, its surface apparently a little depressed below the adjacent tissue, partially covered by a thin layer of dirty yellowish lymph, but red and bleeding on its removal. This condition has usually come under my notice in women whose previous history afforded evidence of syphilitic infection some months before, and it has generally dis- appeared rapidly under one or two applications of the nitrate of mercury. Besides the two above-mentioned conditions of the os uteri, which are those that oftenest seem to call for caustic applications, I have in other instances employed them almost empirically, where I have found ulceration or some allied morbid condition of the os uteri to exist independent of any appreciable disease elsewhere, or where a morbid state of the os has persisted after the other symptoms of uterine ailment have been subdued. Neither the one nor the other of these cases has, however, seemed to me of frequent occurrence. Although I expressed my dissent from the opinion that the sole, or indeed, in the majority of instances, the principal source of leucorrhffial discharge, is the follicular structure of the cervix uteri, it yet must not be forgotten that a very copious secretion may l)e poured out from that part, and that, in some instances, as, for example, in pregnancy, the discharge may be almost exclu- sively derived from it. The whole glandular apparatus of the cervix uteri undergoes a remarkable development during pregnancy, and exercises its secretory function with an activity which contrasts re- markably with its non-gravid condition ; and then also many of the mucous folicles attaining an unusual size without opening and giving exit to their contents, form those bodies which are usually known under the name of the I^abothian bodies."^ But besides pregnancy, tliere are some other conditions, not very clearly understood, though generally, I believe, connected with some previous irritation of the body of the uterus itself, such as miscarriage leaves behind, or as may be produced by habitual 1 Further incidental remarks on the much debated question of the nature of these Nabotliian bodies will be found in Lecture XIV, under the head of "Glandular Polypi, and Mucous Cysts of the Uterus." It may suffice now, how- ever, to state that the reasons for regarding them as the obstructed mucous follicles of the cervix, which are assigned by M. Huguier, at p. 258 of his paper " Sur les Kystes de la Matrice," &c., in voL.i, of the Memoires de la Soc.ietc de Chirnrriie, -seem to me quite conclusive. The same view of their nature is taken also by Dr. Hennig, o}^. cit. p. 63. TREATMENT OF CERVICAL LEUCORRHCEA. 125 scxnal excesses, as in the case of prostitutes, in wliich the cervical ghands become enlarged, and pour out an abundant transparent, albuminous discharge. In some instances, the discharge collects witliin the cervical canal, and escapes in gushes at short intervals. In other cases the discharge is continuous, and may be seen issu- ing in great abundance from the os uteri, which is usually found open, its lips large but soft, and not tender, and a granular or abraded condition of their surface as often absent as present, while the body of the organ is in general quite movable, and not larger than natural. Between this condition and that in which there is a positive cyst formation in the substance of the cervix uteri, the ditferencc is, I believe, rather of degree than of kind. The dis- tinction between leucorrhoea from this source, and that Avhich is furnished from higher up in the uterine cavity, is furnished by the abundance of the discharge in the former cases, its peculiar transparency and tenacity, and the frequent presence of the Ka- bothian bodies on the lips, or about the edges of the os. In this case, too, in spite of the long continuance of the leucorrha'a, it is generally unaccompanied hy the graver forms of functional dis- order of the uterus, such as menorrhagia, dysmenorrhea, and ovarian pain; while it is not infrequently associated with a state of irritation of Cow^per's glands, which pour out an increased dis- charge, or even w^ith obliteration of their duct on one or other side, and accumulation of their contents so as to form a small encysted tumor at the inner and lower part of the labium. I believe this ailment, which is essentially chronic in its course, to be of rare occurrence. It certainly, in its severer forms, is very difficult of cure, and though rather an annoying infirmity than a serious disease, I have seen one case where the complete failure of the patient's health seemed to be due entirely to the abundant secretion, which no means succeeded in checking. The treatment which these cases require is almost entirely local. Something may be done by astringent lotions of various kinds, and es})ecially by such lotions wdien employed by means of the douche ; though you must not forget that the douche is inappli- cable whenever a sus})icion is entertained of the existence of preg- nancy. Astringent hip-baths, too, are of service; while during the persistence of the discharge, it is expedient that sexual inter- course be but rarely indulged in. I have found benefit in some cases from the introduction of dossils of cotton-wool steeped in solution of tannin, or covered with powdered alum, and ap[)lied by means of the s[)eculum to the OS uteri ; but I have made less use than perhaps I ought to have done of tlie injection of astringent fluids into the cervical canal itself A very convenient contrivance for this purpose, con- sisting of a very small elastic bottle attached to a carved silver canula, is to be had of all instrument-makers. In some obstinate cases I have cauterized the whole of the interior of the cervix with nitrate of silver, by means of Lallemand's portecaustique, but without advantage. It seems as if in these cases the action 126 PROLAPSUS UTERI. of the nitrate of silver was expended on the copious secretion, and scarcely reached the cervical follicles themselves. Something may probably be done to avoid this evil, by the employment of the douche, or of very abundant vaginal injections to clear the canal of the cervix to some extent just before the caustic is em- ployed. I am disposed to think, however, that in the most obsti- nate cases it may be expedient to adopt a suggestion of M. Iluguier, of which I have but small experience, though I have followed it with benefit on two or three occasions. He is accus- tomed^ to scarify the interior of the cervical canal with a small, curved, narrow-bladed, blunt-pointed bistoury before introducing the caustic. The previous scarification exposes the more deep- seated follicles, which would otherwise altogether escape the action of the remedy ; and while M. Huguier states that he has never known any mischief follow this proceeding, he has by its repetition two or three times eflected the cure of cases that resisted every other mode of treatment. ^LECTURE IX. MISPLACEMENTS OF THE UTERUS. Prolapsus Uteri. Reasons for the mobility of the uterus, and consequent variety of misplacements to which it was liable. Various degrees of prolapsus, and arrangements by which its occurrence is o{)posed ; its causes, tendency to in- crease, changes in the uterus, and in adjacent parts. Complete Prolapse, or Procidentia. Prolapse of the Vagina ; — its relation to prolapse of the womb — may occur in connection with hypertrophy of walls of canal ; peculiarities of this form, and hypertrophy of cervix uteri which it produces. Prola]ise of anterior, and of posterior wall, with descent of bladder and of rectum : its causes, character, and mode of production. Among the many wonderful adaptations of means to an import- ant end with which the study of anatomy makes us acquainted, not the least remarkable is the contrivance by which the uterus is sus- pended in the pelvic cavity, so movable as to escape any rude shocks from without, or any inconvenience from the varying con- ditions of the surrounding viscera, and yet so tethered to its place as to insure its enlargement going on, if pregnancy occurs, in such a direction as shall avoid needless discomfort to the person, or pressure upon, and disorder of the functions of other organs. But this very mobility, without which pregnancy would be a season of uninterrupted suftering, and even sexual intercourse almost im- possible, naturally exposes the womb to the risk of changes in its position, such as may themselves become the source of inconve- 1 See the third of his "Lectures on Uterine Catarrh," in Gaz. des Hojntaux, 1847, p. 379. PROLAPSUS UTERI. 127 nience, and as call more frequently than almost any uterine ail- ments for medical interference. It is obvious enough, that an organ suspended within a capacious cavity by means of supports which are themselves yielding, must be very likely to be displaced by comparatively trivial causes. In the case of the uterus, too, the risk of its displacement is further increased by the circumstance, that its weight and size are subject to variations, and that the very causes wliich tend to render it heavier and larger than natural, liave often the further eflect of diminishing the powder of those supports by which it is retained in its natural position. The tendency to misplacement, too, is further encouraged by the pressure from above of the superincumbent viscera, and by all those muscular exertions which a person cannot avoid making in walking, in lifting weights, or even in efforts at defecation. All these causes, indeed, tend to produce displacement in one direction — namely, downwards ; and accordingly, in all but some very rare instances of uterine misplacement,^ the organ is thrown lower down than natural, though there are some causes which likewise incline the fundus of the uterus either backwards or for- wards, and thus produce its retroversion, or anteversion, instead of its simple prolapse. Prolapse or descent of the womb is so much the most common form of misplacement of the organ, that I will first notice it and those allied conditions in which either the rectum or the bladder becomes prolapsed, dragging in some cases the uterus with it, and will afterwards call your attention to those modifications of its situation in which its fundus is either thrown backwards or tilted forwards. Prolapsus of the womb, then, which is a common result of any cause that either increases the weight of the oro:an or diminishes the strength of its supports, may exist in three different degrees, for which different names have been proposed, but which it will, I think, be most convenient to designate simply as the Jirst, second, and third degrees of prolapse. In prolapsus of the first degree, the organ is merely situated lower than natural, but still preserves its proper direction, its axis corresponding with that of the pelvic brim, and this even though it should be so low that its cervix rests upon the fioor of the vagina. In prolapsus of the second degree, the uterus is situated with its fundus directed backwards, its orifice forwards, so that its long axis corresponds with the axis of the pelvic outlet. In prolapsus of the third degree, or, as it is often termed, jjrccidentia of the uterus, the organ lies more or less completely externally, hanging down beyond the vulva, though it generally 1 The protornatural elevation of the uterus is not only a rare condition, but also one which of itself gives rise to no peculiar or characteristic syni|)tonis. Some remarks on its diagnostic import in douhtful cases of affection of the uterus or its appendages will be found in Lecture Xlll. 128 MEANS BY WHICH admits of being replaced within the vagina, if not of being alto- gether restored to its natural position. Now the first question that suggests itself to us with reference to this accident, concerns the manner in which it is brought about, and the mechanism which must be disordered before its occurrence becomes possible. The ofl-hand reply, that the womb is main- tained in its natural situation by its ligaments, and that their weak- ening and stretching are the cause of its prolapse, is neither minute nor correct enough to be of much service to us in practice. The w^omb is not merely suspended in the pelvis by the duplicaturcs of peritoneum within which it is contained, but is also supported in its place by the vagina, on which it rests as on a firm though elastic stem. The vagina is yielding enough to allow of the voluntary efforts depressing the womb to the extent of half an inch or an inch, but immediately these efibrts cease, the organ would in the healthy state resume its former position, while any further descent of the womb would be at once resisted by the duplieatures of peritoneum, which would be put on the stretch. In the liealthy virgin, however, the support afforded by the vagina is very consid- erable ; for instead of being a wide canal with membranous walls far distant from each other, as it appears in so many anatomical drawings and preparations, its two w^alls lie in close contact with each other, and thus form an almost solid stem for the uterus to rest upon. The curved direction of the vagina further lessens the chances of misplacement of the womb, while at either extremity the vagina is strengthened by its connection through the medium of the pelvic fascia with the bladder and rectum above, and by the sphincter which surrounds it below, as well as by the other muscles of the pelvic floor, and by the perineal fascia, between the two layers of which those muscles lie. By these arrangements the very beginning of prolapsus is in the healthy virgin altogether prevented ; but let habitual leucorrhoea relax the vaginal walls, or frequently recurring menorrhagia dimin- ish their resistance, just as the loss of blood robs all tissues of their natural resiliency, and you will at once see that the first step towards the production of prolapsus uteri is already taken. While all things were in a state of health, the connection of the vagina with the rectum, and thereby with the posterior pelvic wall, would have been the first to ofler resistance to the further descent of the womb. If the parts, however, are lax and yielding, this slight resistance will soon be overcome, and the anterior attachments of the vagina not affording any more serious obstacle, the upper part of the canal will become inverted as the uterus descends, and will readily allow it to occupy a position from an inch to an inch and a half lower than its natural situation. In many instances the organ remains in this position, its cervix a little above, or even resting on the posterior vaginal wall, for its further descent is opposed by the various duplicaturcs of its peritoneal investment. First, the posterior part of the broad ligaments, and the utero-sacral ligaments must be put on the stretch, and then the middle part of PROLAPSUS IS PREVENTED. 129 the broad ligaments, before any considerable stress will be expe- rienced by the utero-vesical ligaments, or by the anterior fold of the broad ligaments, and it is to tlie circumstance of the posterior attachments of the uterus tying it down so much more closely than the anterior that we must in groat measure attribute the tendency of the fundus uteri to fall back into the hollow of the sacrum in every case of prolapse of the organ. The round liga- ments of the uterus have no share in preventing descent of the womb ; their office seems to have reference to the development of the organ during pregnane}' rather than to its situation in the unimpregnated state, and the organ must not merely be prolapsed, but must be procident far beyond the external parts, before the round ligaments can be at all put on the stretch, or can be in the least affected by its changed position. As has been already mentioned, descent of the uterus is not often the consequence of mere weakening of its supports, but in the great majority of instances the same cause as diminishes the resistance increases at the same time the superincuml)ent weight. The leucorrhoea or the menorrhagia which deprives the vagina of its tone, is often associated with actual uterine disease, and the organ, enlarged by clironic inflammation or its consequences, is more prone than in a healthy person to sink below its natural position. Such is the history of most of the cases in which ])ro- lapsus uteri takes place in unmarried women, or in those who have not recentl}' given birth to children ; and in such cases, with the cure of the intlammation and the reduction in bulk of the hyper- trophied organ, the vagina will once more regain its proper tone, and the womb, which had been situated only an inch or an inch and a half from the vulva, will, as it were spontaneously, resume its {tropor position high up in the pelvic cavity. In most cases, however, it is not in single but in married women that prolapsus takes place, and in them it very generally succeeds to aljortion or to labor. Everj'thing in these circumstances con- spires to favor the occurrence of the malposition, for the womb is greatly increased in weight at the very time when the vagina has lost most of its power of resistance, while the duplicatures of the peritoneum have been so recently put on the stretch by the die- tended uterus as to be but little able to prevent even the more advanced degrees of misplacement. In not a few instances, too, the tendency to this accident is still further increased by the per- ineum having been lacerated, and by the wliole posterior wall of the vagina having thus been deprived of its natural sup]M)i-t by the tearing of the fascia and muscles of the perineum, an accident which has the additional effect of giving to the canal a perpen- dicular instead of a curved direction. The general rule of the coexistence in cases of ju'olaj^sns uteri of increased weight of the organ with diminished power of its sup- ports, is not, however, without occasional exce]>lion. Even in a previously healthy person, a sudden and violent eti'ort, such as the attempt to lift a heavy weight, may sometimes cause the uterus to 9 130 VARIOUS CAUSES OF PROLAPSUS UTERI. prolapse beyond the external parts, just as in another person, or in the other sex, a similar effort might produce a hernia. But while such cases call for no further remark, the occasional occurrence of prolapsus of the womb in old age, in spite of a healthy or even of an atrophied condition of the organ, and in the absence of an}^ ex- citing cause, requires some explanation. This explanation, indeed, is not far to seek, for it is furnished by circumstances peculiar to that period of life. With the advance of years the fat and cellular tissue which give their rotundity to the labia, and which form a sort of cushion about the entrance of the vagina, become entirely removed ; and instead of the vulva being closed, it is scarcely con- cealed by the shrunken parts. The fat of the perineum is removed; the levator ani becomes atrophied and feeble, and the vagina grows shorter as well as smaller, while it loses its muscularity, and the peritoneal duplicatures lose their resilience. The womb may now almost spontaneously become prolapsed, since, though shrunken instead of being increased in size, it has almost completely lost the support which kept it in its proper position.^ This somewhat tedious explanation of the different conditions under which prolapsus of the uterus is commonly brought about, shows, I think, clearly why it is that the fundus of the womb is so disposed to fall backwards, why every prolapsed womb is to a great extent retroverted also. You see that the anterior uterine liga- ments do not tie the organ so closely in its place as the posterior, and that consequent!}' the liability of the womb to retroversion must always be much greater than to anteversion. You see also how it comes to pass that the uterus, when once prolapsed, is always extremely likely to remain so. The vagina having once yielded so as to allow of the descent of the womb, can hardly be expected to recover its tone while the patient is going about her ordinary avocations, and the uterine ligaments, subjected to dail}^ stress, can scarcely do other than yield. But not only is the spontaneous cure of a prolapsed uterus thus rendered very unlikely, but the condition has a constant ten !ency to pass from bad to worse, and for this simple reason, that the pressure of the intestines from above is always helping to increase the descent of the uterus, always "fill- ing up the space which that descent leaves vacant in the pelvis. The prolapse of the posterior wall of the vagina, if at all consider- able, is daily aggravated by the efforts at defecation, and thus the womb, pressed on from above by the intestines, is at the same time drawn downwards by the vagina. The close connection between the cervix uteri and the neck of the bladder is a temporary obstacle to the complete descent of the womb, while at the same time it favors the retroversion of the organ ; but if at length this yields, the urine accumulating in the bladder distends its fundus and the anterior vaginal wall into a pouch which drags down the uterus 1 By far the best account of the mechanism of prohipsus uteri, and which I have followed in the text, is given by Kiwisch, Klinische Vort7-dge, od edition, vol. i, p. 171. CHANGES WHICH RESULT FROM PROLAPSUS UTERI. 131 in front just as the prolapse of the rectum drags it down behind; and the organ now soon comes to lie beyond the external parts; the case being thus converted into one of procidentia of the uterus, or of prolapse in the third degree. But this misplacement of the womb does not happen, or at least occurs comparatively seldom unaccompanied by other alterations both in the organ itself and in the surrounding parts. The womb, subjected to constant and unusual irritation, obeys the law which we observe to be exemplified in almost all the affections to which it is liable, and increases in size by a process of simple hypertro- phy, that ditiers from the enlargement of pregnancy only in the somewhat greater density of the tissue. Tlie neck of the womb is the part in which this alteration chiefly takes place; for it is the neck which is exposed to the most, and the most constant irrita- tion. This enlargement, too, occurs both in length as well as in thickness ; so that the neck of the womb may not only be found nearly of the thickness of the wrist, but also greatly elongated, and the os uteri be thus approximated to the pelvic outlet, not simply by the general descent of the womb, but also in great measure by positive growth of its neck. The lips of the uterus become enlarged, together with the rest of the womb, and the small transverse aperture which in women who have borne chil- dren should represent the orifice of the womb, becomes converted into a wide opening, situated deep in between projecting lips, whose surface, irritated and excoriated, presents, in parts at least, a vivid red, finely granular surface, covered by a copious albumin- ous secretion. How much this enlargement of the womb must lessen the chances of the organ resuming its proper situation in the pelvic cavity, is obvious without any remark of mine. There are limits, however, to tins increase of the womb, which seems to be most considerable while the organ, though occasionally or partially procident, yet admits of being replaced in the vagina; and in these circumstances I once found the neck of the womb measure eight inches in circumference an inch above the os uteri. In this instance, however, the patient had nine months beibre given birth to a child; and the uterus, both at that time and also for three years previously, liad been occasionally procident; so that its enormous enlargement was probably partially due to the im- perfect involution of the organ after delivery. At first it seems almost impossible that so enormous a mass could pass out of the vulva, and be replaced without difficulty, unless the perineum were altogether destroyed. In not a lew cases, however, of procidence of the uterus, the whole pelvic floor completely loses all power of resistance ; so that, though quite uninjured, itofi'ers not the slight- est obstacle to the misplacement or reposition of the womb ; an occurrence, which as might be expected, is most frequent in cases where the accident has followed soon after delivery at the full period, when the parts are already stretched and weakened by the passage of the fcetus. In the course of time the occasionally protruding womb comes 132 CHANGES WHICH OCCUR to He constantly beyond the vulva, though this procidentia may still for years continue to be onl}^ partial ; the fundus and a portion of the organ remaining within the pelvis, while the neck and lower part of its body are external. In most instances, however, so con- siderable a degree of descent of the womb is before long converted into its complete procidentia ; the vagina becoming inverted, and forming the outer walls of a tumor, at the lower part of which the Vomb is situated. So long as the procidentia is incomplete, this tunlor is somewhat pyriform in shape, its base being directed up- wards ; but afterwards, as it increases in size, it assumes an oval form, owing to more or less of the bladder being drawn down into it in front, and of the rectum also, in many cases, behind. Its bulk is also further swelled, in numerous instances, by the small intestines sinking down into the sac, and thus adding to its size till it equals or exceeds that of the adult head. In a preparation now in the museum of St. Bartholomew's Hospital, the external tumor measured seven inches and a half in length by thirteen inches in circumference, and was found to contain, in addition to the uterus and its appendages, the bladder, and a portion of the rectum ; no less than five feet eight inches of the small intestines. The uterus itself, as the above-mentioned case well illustrates, forms in many instances only a comparatively small portion of the large external tumor which often exists in cases of complete prgci- dentia. The susceptibilities of the organ seem indeed to be much diminished, and with them its disposition to hypertrophy when it has come to reside habitually out of the pelvic cavity. Sometimes, indeed, as in the case just referred to, the womb appears actually diminished (it measured in that instance less than two inches from its orifice to its fundus), and I believe that the difficulty which may be experienced in the replacement of long-standing i)roci- dentia of the uterus seldom if ever arises from the size of that organ. The bulk of the tumor, and the difficulty of its replace- ment, depend chiefly upon two causes. Of these the one consists in the enormous hypertrophy which the vaginal walls undergo. Not only does their mucous membrane lose its ordinary character, and become covered by a layer of cuticle like that of the skin, to protect it from the various sources of irritation to which it now becomes exposed, but the walls themselves attain a thickness of as much as half an inch, and present a dense muscular structure. The other cause of the bulk of the tumor, and of the difficulty of replacing it, arises from the presence of the intestines in the sac, which seldom reside there long without inflammation of their peritoneal covering being set up; not^of so acute a character, in- deed, as to produce formidable sjmiptoms, nor even as always to cail for treatment, but matting their difl'erent coils to each other, and tying them firmly to the interior of the sac. This latter cause of difficulty in the attempt to return a procident uterus must not be lost sight of, even though no intestines should seem to have descended into the external tumor itself, for the same slow form of peritoneal inflammation may glue them to each other and to IN PROCIDENTIA OF THE UTERUS. 133 the walls of the pelvic cavity, and thus efFectnally close np the walls against all endeavors to replace the womb. In the eases which we have hitherto studied, though tlie point of departure of the whole evil consisted in a weakening of the vagina, yet that step once taken, the prolapse of the womb miglit be re- garded as a primary occurrence, the organ in its descent dragging down the vagina with it. There are, however, other cases in which the displacement of the womb is entirely a secondary atci- dcTit, following on a giving way of the anterior or posterior vaginal wall, which becomes prolapsed, and in its prolapsus draws down the uterus. It is thus, for instance, that prolapsus uteri is some- times brought about in cases of ascites, the pressure of the fluid gradually distending the recto-vaginal pouch, till it may even cause the posterior wall of the vagina to protrude externally. A similar effect is sometimes produced in cases of long-continued constipa- tion, in which the accumulation of faeces in the rectum l)y degrees distends the intestine into a pouch which projects into the vagina, while still more frequently the anterior vaginal wall gives way from the retention of urine in the bladder, and thus produces in the course of time a similar descent of the womb. There is, be- sides, a form of vaginal prolapse due apparently to hypertro{)hy of the walls of tlie canal, in which the position of the adjacent viscera is not altered, tliough the os uteri is not infrequently found lower down than natural, owing to the prolajjsed vagina dragging at the cervix, and exciting the part to overgrowth by the constant irritation which it thus maintains. Strictly speaking, these different affections of the vagina should be reserved for our consideration by and by; but there is such a general similarity between their symptoms and those of prolapsus of the uterus, and so close a correspondence between thej)rinci- ples of treatment applicable to them, that we may very well sacri- fice systematic arrangement to practical convenience. First, now, with reference to prolapsvs of the vagina unaccom- panied by misplacement of the other pelvic organs, I have already mentioned that it seems to depend in the first instance on a sort of hypertrophy, as the result of which it cannot well be contained within its proper limits, but a fold of it comes to protrude beyond the external parts. Such an hypertrophy of the vagina takes place during pregnancy, for not only does the womb groAv to keep pace with the development of the fnetus, but the vagina grows too; longitudinally, to allow the womb to ascend high u\) above the pelvic l)rim; transversely, to afi(>rd space for the ])assage of the child in labor, room for which could not be obtained by any mere stretching of a membranous canal. When labor is over, the vagina, in common with the uterus, ought to diminish in size by a removal of much of its old material. Sometimes, however, just as we have already seen in the case of the uterus, this involution is imi»erfect, and the vagina then remains longer and wider, and with its walls thicker than they should be, and as soon as the pa- tient begins to move about again, or to niake any exertion, a 134 PROLAPSE OF VAGINA. portion, often the whole cylinder of the loM^er part of the vagina, hangs down outwardly, an accident all the more likely to take place if the perineum has been injured, or if the levator ani and the tiiscia at the pelvic floor have lost, as they are wont to do, much of their power of resistance by frequent childbearing. Why it is that sometimes the vagina continues thus hypertrophied while the involution of the uterus has gone on properly, I cannot say, though of the fact itself there can be no doubt ; for one meets occasionally with cases in which the uterus, still suspended by its ligaments and by the folds of peritoneum, is little if at all lower than natural, and little if at all altered in size, while the vagina is so wide as readily to admit several fingers, and its folds hang down loosely to or even beyond the orifice of the vulva. Although this prolapsus of the vagina is usually a primary af- fection, and attributable to the consequences of pregnancy and childbearing, yet this is not so invariably. The prolapse of the vagina appears to be in some instances consecutive to descent of the womb,^ but the affection being neglected, the tissue of the protruding portion of vagina may become hj^pertrophied, and the ailment which was secondary in importance, may by degrees be- come of greater moment than the misplacement of the womb, and morf" difficult to remedy. Though not quite constant, yet the exceptions are but few to the rule that considerable or long-standing prolapsus of the vagina will produce hypertrophy of the cervix of the uterus; not of that por- tion only which projects into the vagina or portio vaginalis, as it is termed by continental writers, but of the whole uterine neck, of which a specimen (Series xxxii, 30) in the Museum of St. Bartholo- mew's Hospital, afibrds a striking illustration. Even more remark- able instances of this kind are on record, one of the first of which was described by Morgagni,^ and attention was drawn some few years afterwards to their practical bearings by Levret.^ He clearly pointed out the differences between those cases in which the ap- proach of the OS uteri to the vulva is mainly due to overgrowth of the cervix, and the others in which it is entirely the result of the descent of the womb. His remarks, however, were lost sight of, and it was with no previous knowledge of them that Virchow,* ' Eemarks made by Professor Kiwisch, Klinische Vortrage, vol. ii, 2d edition, 1852, p. 413. 2 Morgagni, De Sedihus et Can.sis Morborum, folio, Venetiis, 1761, 2d vol., Epist. 45, Art. 11, p. 204. Morgagni regarded the hypertrophy of the cervix in this case as consequent on the prolapse and hypertrophy of the vagina. "Evidens est, vagina9 adeo crassae pondere deorsum tractiim fuisse uterum, cujus fundus aliquanto inferior fuisset, nisi cervix jam inde ab initio, ut puto, ea esset laxitate, ut so prse cseteris distrahi, distendique in raram istara longitudinem sineret. " 3 Journnl de Medecine, Chiru?-gie, etc., par M. A. Roux, vol. xl, Oct. 1773, p. 352, " Sur un allongement considerable qui survient quelquefois au col de la Matrice." Attention was called to this state, with a completeness of detail which leaves but little to be added, by Prof. Stolz of Strasbourg, in Journnl Hebdomadaire, vol. vi, June 10, 1859, p. 356, where, however, by a misprint, the date of Levret's paper is given 1775 instead of 1773. ^ Yirchow, in Verhandl. der Gesellschaftf. Geburtsh. in Berlin, vol. ii, 1847, p. 205. PROLAPSE OF BLADDER. 135 some few years since, described this occurrence as a peculiar form of prolapse, under the name of prolapsus uteri ivithout descent of the fiuiduH. Still more recently the subject has been brought into undue prominence by the assertion of M. Huguier,^ that prolapsus of the uterus is a condition that scarcely ever exists; but that cervical hypertrophy lias been almost invariably mistaken for it, and that consequently not the supi)ort of the womb, but the re- moval of the elongated cervix, is the ])roceeding to which one ought to have recourse. Like most extreme statements tliis of M, Iluguier, is contradicted by general observation.^ Still it is well for you always to bear in mind, not only that hypertroph}^ of the uterus tends to favor its prolapse, and that the prolapsed uterus tends to enlarge still more, but also that long-standing prola])Sus of the vagina is almost alwaj'S associated with a condition of the cervix uteri which closely simulates ordinary prolapsus, but which, as you will hereafter see, must be clearly distinguished from it, since those attempts at mechanically rectifying the supposed mal- position which would be of service in true descent of the womb, must here be useless, and sometimes may even aggravate the suf- ferings of the patient. Of much more frequent occurrence are those cases in which the prolapse of the vaginal wall is partial, involving its anterior or posterior part only, and deriving, in the great ma,jority of ins "'.^ices, its chief importance from the altered position of theadjacent organs, which descend into the pouch thus formed, and constitute what have been termed by many writers vaginal rectocele and vaginal cystocele. In those cases where the anterior vaginal wall gives way, forming a pouch into which more or less of the bladder descends, it is not easy to sa}^ what is the first step in the occurrence ; whether the vagina draws down the bladder with it, or whether the distended bladder ])uslies before it the vaginal wall. It is an accident, how- ever, which in the unmarried is even more rare than prolapse of the womb, and its occurrence is traced back, in by far the majority of those who suffer from it, to a miscarriage or labor; to a time, in short, at which all the parts were loose, and had lost the power of resistance, while the vagina as well as the uterus was liyper- troi)hied, ;ind had to undergo that process of ]iost-puerperal involu- tion to which I have had such frequent occasion to refer. Some- times, indeed, though rarely, the patient gives a history of the sudden formation of a swelling at the anterior part of the vagina during some unwonted exertion, just as the womb itself occasion- 1 Tn a memoir road bofore tho. Academy of Medicine on "Marcli 8, ISHO, and |)iil)- lished in vol. xxiii of the Memoir es de V Academic — " Siir les aiiongements iiypi-r- tro])liiques dn col do rut^nis." * See especially the discussions to which this paper p;ave rise, as reported in the Bulletin de VAcndemie, vol. xxiv, p. 072, 727, 771. 704; a pa]);'r by Scan^oni, at p. 820 of the 4th voliiine of his lieiJn'if/e zur Oehirtslmmle ; Aran. <>p. ril., p. 10.14; McClintock on Disrnsex of Womrn, 8vo., Dublin, ISC.:?, p. ')S : and Mayer, Klinisc/ie Mitthedumjen aus dem Gebiiie drr Oi/nii/.n/ni/ie, 4to., 1 Heft, IJerlin, 18G1, p. 33. 136 PROLAPSE or BLADDER ally becomes prolapsed in similar circumstances; while it is easy to understand bow a comparatively small prolapse may be con- verted into a large one during some violent effort when the bladder is full, and consequently exposed to all the force of the diaphragm and abdominal muscles pressing downwards. The union' is so much more intimate between the anterior vaginal wall and the bladder, than between the posterior vaginal wall and the rectum, that we scarcely ever find the vagina alone becoming prolapsed, and dragging itself away from the bladder in the same manner as, in prolapse of its posterior wall, it often be- comes separated from the rectum. Further, that part of tlie blad- der which adheres to the vagina includes the orifice of both ureters and the whole of the trigone, extending, indeed, somewhat beyond its limits on either side, so that the urine, as soon as secreted, col- lects in tliis situation, and tends constantly to distend it into a pouch, whose dimensions increase all the more rapidly since its enlargement is not opposed by the weight of the superincumbent intestines and the antagonism of the abdominal muscles, both of which have to be overcome as the distended bladder rises out of the pelvic cavity. A slight pouch then is first formed in the anterior vaginal wall, scarcely perceptible when the bladder is completely empty, but tense and elastic when filled with urine, though admitting even then of being partially or completely removed by firm pressure upon it, and disappearing altogether if. while this pressure is being made, a catheter is introduced into the bladder. In the course of time the small tumor, whose anterior border was felt a little be- hind the symphysis pubis, enlarges, now and then forming a kind of diverticulum,^ with a narrow neck and long pedicle, but oftener producing a globular swelling, which fills up the canal of the vagina, and projects more or less bej'ond the external parts, when it becomes covered by the same investment of ordinary skin as clothes the tumor in prolapsus of the uterus or vagina. The weak- ening and giving way of the anterior vaginal wall, however, sel- dom attain any very great degree without producing likewise some prolapse of the uterus, though the extent of this is by no means constant. Whenever the uterus does not readily yield to the traction made on it by the prolapsed bladder, the anterior lip of the organ becomes hypertrophied, and projects far beyond the posterior; in a similar W'ay, though not to tlje same degree, as w^e .have already observed to be the case with the whole of the neck of the womb, in cases of prolapse of the w%ole circumference of the hypertrophied vagina. The dragging of the prolapsed portion of the bladder upon the 1 The exact relations of these parts are nowhere so well described as by Dubois, Traite de V Art des Accouchemens, pp. 190-199, and pp. 234-243; nor so well de- lineated as \>y Kohlrausch, Z«me, Sfe.,der Beckenorgane, 4to., Leipsic, 1854. 2 As in a case described by Madame Lachapelle, Pratique des Accouchemens, vol. iii, p. 387, in which the prolapsed bladder was driven down in this form before the fcetal head, and beyond the external parts. AND RECTUM. 137 neck of the organ naturally interferes with the functions of the part, and produces frequent desire to pass water, as well as in many instances inability to retain it. Another eviP which occasionally results from it (l)ut wliich I have failed to observe in the few cases where I have been present at a posf-mortetn examination of women who suffered from prolapsus of the bladder, probably from want of directing special attention to the point), consists in a degeneration of the kidneys themselves. The ureters being not only drawn down and stretched, but also in some instances even pressed ui)on as the pouch of prolapsed bladder projects under the symphysis pubis, the urine with difficulty tlows along them ; and both they and the pelvis of the kidneys themselves become dilated, with a corresponding atrophy of the secreting substance of these organs. Prolapse of the posterior vaginal wall is in its slighter degrees of more common occurrence than prolapse of the anterior, and when the perineum has been torn in labor, scarcely ever fails to take place. It does not, however, constantly bring with it prolapse of the rectum in the same manner as the giving way of the anterior vaginal wall is constantly associated with prolapse of the bladder, since the loose cellular tissue which connects them allows of a tolerably ready separation between the two canals, and the rectum ma}' still retain its natural situation. If, liowever, the laceration of the perineum has been considerable, or if, independent even of any such condition, the bowels have been habitually allowed to be constipated, the lower part of the rectum bulges out into acuhde- sac, in which fecal masses become retained and indurated, causing, in addition to the ordinary annoyances of prolapsus, much discom- fort, sometimes even much sufiering, in the act of defecation. It is to the influence of constipation in producing this ailment that must be attributed the comparative frequency with which it is ob- served, independent of pregnancy and childbearing ; and its im- portance arises in great measure from its aggravating that state of the bowels to which its original occurrence was mainly due. 1 Ileferred to, both by Kiwis-ch, lib. cit, vol. ii, p. 422; and by Vircliow, loc. cit, p. 209 ; by the latter of whom it is more fully described. 138 SYMPTOMS OF PROLAPSUS UTERI. ^ LECTURE X. MISPLACEMENTS OF THE UTERUS. Prolapsus Uteri. Sj^mptoms of its first and second stages; pain, its causes and character, disorder of uterine functions, and of general health Symptoms of third stage; influence of misplacement on adjacent organs; difficulty of return of long-standing procidentia. Peculiar symptoms of prolapsus of bladder and rectum described and explained. Treatment of Prolapsus varies according to its cause and degree. Cases requiring or not requiring mechanical support, distinguished; pessaries, their uses and varieties; external supports and bandages. Management of Procidentia; cautions as to replacement of uterus; treatment of ulcerations of its surface. Operations for its permanent cure considered. Irre- ducible procidentia; extirpation of womb. After the stud}- of the manner in which some forms of mis- placement of the uterus and parts therewith connected are pro- duced, we come next to inquire into the symptoms to which those misplacements give rise. The symptoms depend partly on the changes in the relations of the various organs produced b}' their altered position, or by the altered position of the womb itself; partly on direct dii^turbance of the uterine functions, and partly, too, on the sympathy of distinct organs with the ailments of the womb itself. I^one of these symptoms, however, are constantly proportionate in severity to the degree of misplacement, so that one woman will sutler most acutely from comparative slight descent of the womb, while another will pursue laborious avocations, ap- parently little distressed by a prolapsus so considerable that the uterus is with difHculty retained within the canal of the vagina. As a general rule, the patient suffers most in those cases in which the occurrence of prolapsus has been somewhat sudden, and in w^hich it does not succeed to previous delivery or miscarriage. The reasons for this are obvious enough ; the dragging at the uterine ligaments and duplicatures of peritoneum must be much more painful when they have been suddenly stretched, than when, already loose and yielding, they give way under the weight of the uterus which they are prematurely called upon to bear. Hence it is that comparativel}^ slight prolapsus in the unmarried is often attended by far more distress than a much greater amount of dis- placement in women who have given birth to children, and that the degree of suffering which is sometimes experienced after a night's dancing, or a fatiguing ride on horseback, seems to point to an ailment far more serious than slight descent of the womb. Women designate the peculiar pain which they experience in cases of prolapsus uteri by the expressive terifi, "bearing down ; " a sensation as though the pelvic viscera were about to fall out ; and to this is often added on very slight exertion, such as in walk- ing, in lifting anything, or on altering the posture, a sharp pain, due to a momentary increase of tension of the uterine ligaments, SYMPTOMS OF PROLAPSUS UTERI. 139 which compels the person to stand still, and often to bend slightly forwiirds, so as to remove as far as possi])le all pressure from above, and tlins to await the cessation of the i)ain. The effort at defeca- tion is often extremely painful, from tlie very circumstance that it puts all those ligaments upon the stretch, while, when the womb has descended so far that its cervix habitually rests upon the floor of the vagina, there is frequently superadded a sense of desire to empty the rectum, a sort of tenesmus which is verj- dis- tressing. The uterus, too, becomes now exposed to shocks from various external causes from wliich it was before defended ; and sitting on a hard seat, or placing herself in any posture in which the perineum is pressed on, causes the patient extreme pain, so that she is compelled to study her attitudes, and carefully to adjust her position. With these discomforts there is almost always asso- ciated more or less of that pain in the back which is the nearly constant attendant upon uterine ailments of every kind; and in some instances there is also an extreme degree of tenderness or sensitiveness in the hypogastric region, which is not aggravated by slight pressure on the surface, or by gentle friction over it, but on the contrary is often much relieved by it. This abdominal pain is no more special to prolapsus than is the lumbar pain, but both seem due to the radiation of painful sensations from the uterus itself, along the different nervous branches and twigs with which it is either directly or indirectly connectly; and hence we find it in many cases of uterine cancer, as well as in dysmenorrho^a, and in very many other chronic ailments of the uterus. Another very distressing sensation often experienced quite in the early stage of uterine prolapsus, and before there is any interference with the position of the bladder, is a very frequent desire to pass water, which the patient is compelled to do every half hour, though with very little relief. In unmarried women, when the uterus has descended so as to lie in the axis of the pelvic outlet, there is besides much distress produced by the os uteri pressing against the hymen ; but all of these discomforts are mitigated, many of them cease altogether when the patient lies down. Pain, however, is not the only symptom of prolapsus of the womb. ■ The organ thus misplaced is irritated, and leucorrhoeal discharges are an almost invariable attendant upon the ailment, while, from the same cause, the menstrual flux becomes more pro- fuse, lasts longer, or returns more frequently than natural. The blood flows back from the misplaced womb with more than ordi- nary difhculty, a state of habitual congestion is maintained, which in some instances relieves itself from time to time by profuse losses of blood, though in spite of them the irritated congested organ tends to increase in size, and the womb, thus larger and heavier than natural, becomes less and less likely to resume its natural situation. The disorders of the general health that accompany prolapsus of the womb have nothing in them that is characteristic, but con- sist of that class of symptoms which attend upon so many uterine 140 SYMPTOMS OF ailments, and among whicli dyspeptic disorders have a very large share, owing to the peculiar sympathy that subsists between the stomach and the womb. Constipation of the bowels may, however, be mentioned as an almost constant attendant upon prolapsus, due in part to the distress which in the early periods of the affection accompanies the effort at defecation ; in part also to the mechani- cal impediment which the pressure of the cervix uteri on the rec- tum frequently offers to the passage of the fseces. In the u})per classes of society, the symptoms of prolapsus are almost invariably met by approj)riate treatment in the early stages of the affection, so that in them it seldom passes the first or second degree of misplacement. There may, however, be exceptions to this rule, in cases where the perineum bas been extensively torn and the vagina has consequently been very much and permanently weakened. The atrophy of advancing age being equally inci- dental to all, the uterus may even in the wealth}^ come down so low as to protrude partially beyond the external parts. Xow and then, too, even in young w^omen, tlie perineum after childbirth seems so completely to lose its resiliency as to afford little or no support to the vagina. A small knuckle of the posterior vaginal wall soon becomes prolapsed, so as to project between though not beyond, the labia ; it here becomes irritated ; and irritated, it soon becomes hypertrophied. The edge of the yielding perineum is dragged down by the vagina, or if an examination be made, is easily carried before the fingers, and seeming thus to constitute a part of the vaginal wall, the sensation of the perineum having been nearly destroyed, is most deceptive; and sometimes the eye alone can determine whether this is so or not. Now, in this case the vaginal support of the uterus being completely lost, though the mischief is not irreparable, as it must be when the perineum is torn, external prolapse of the uterus may take place. The sudden occurrence of external prolapse, or procidentia, when it happens during some violent exertion, or when it takes place all at once during some change of posture a short time after parturition, or in the effort at defecation, is attended by much local distress, and much constitutional disturbance. In by far the majority of cases, however, the womb becomes procident ordy very gradually; at first but a small part of the organ protruding, and that only occasionally, and then more of it coming down, and for a longer time, till at last the whole womb lies usually, or con- stantly, beyond the external parts. With tliis change of position of the organ there is a change of symptoms; often, indeed, a marked remission of some of those which were the most distress- ing; for the sensibilities of the womb appear to be greatly blunted when once it becomes an external organ, and injuries and interfer- ences which it could not bear while in its natural situation seem to be of but small importance when it has left the pelvic cavity. The alleviation of the patient's symptoms, however, owing to the cessation of the vaginal leucorrhoea, and the gradual ])lnnting of the uterine sensibilities, is generally more than counterbalanced PROLAPSUS UTERI. 141 by the supervention of suffering from other sources. With the increase of the procidentia of the uterus, the position of the other pelvic organs becomes more and more disturbed ; the bhidder is drawn down into the pouch in front, and the natural relations of the urethra are often so altered that the canal runs perpendicularly downwards, instead of in a horizontal direction. This misplace- ment necessarily brings with it much difficulty in emptying the bladder, while accompanying it there is generally a fre- quent desire to void the urine, and by these two symptoms the patient's life is rendered miserable. In a similar manner, though not so invariably, the rectum is drawn down behind, and difficult defecation is thus superadded to the other symj^toms. Nor is this all, but the descent of the small intestines into the pelvic cavity to occupy the space which the uterus and adjacent viscera have left vacant there, disturbs their proper functions, and gives rise to various sensations of pain and discomfort in the abdomen, and to these is not infrequently added the distress from inflammation of the peritoneum, a chronic form of which seldom fails to be set up. The external tumor is itself the source of much distress. In spite of the thickening of its tegument, the irritation produced by exposure to the air, and by all the forms of external injury from which it is impossible to shield it, as well as by the passage of the urine and fteces, seldom fails to produce iilceration of its surface. This ulceration generally occurs m large patches upon the most exposed parts; as, for instance, at the sides, where the tumor is exposed to friction by the thigh; below, where it is rubbed when the patient sits or lies, and at the upper part, where it is apt to be made sore by the passage of the urine. The ulcers are seldom deep, but are usually irregular, with raised edges and an indolent surface, and are very indisposed to heal. The os uteri, too, from its position at the lower part of the tumor, and its consequent ex- posure to irritation, as well as from the delicacy of the membrane in this situation, is almost always the seat of an ulcer or excoria- tion. This ulceration is often of considerable extent;' not simply from the circumstance that the lips of the os, partaking of the general hypertroiohy of the w^omb, present a large surface, but also because the continual dragging of the inverted vagina tends to draw the lips of the uterus upwards and apart from each other, and thus produces a ver}' considerable eversion of the mucous membrane of the cervical canal, which soon becomes excoriated. The replacement of the uterus restores the parts to their natural relations, and the large external ulceration passes almost out of sight into the canal of the cervix. The existence of prolapsus uteri, though no bar to conception, often renders pregnancy a period of very considerable suil'ering. The slighter degrees of descent of the womb, indeed, are often 1 This fact, of the correctness of which any one can readilj' satisfy himself, was, to the best of my knowledge, first noticed by Scanzoni, in a note ut page 178 of the 4th edition of vol. i of Kiwisch, Kdniscke Vorirdge. 142 SYMPTOMS OF cured by pregnancy, since the uterus as it enlarges gradually as- cends in the pelvis ; and the temporary relief thus afforded may be rendered permanent by care during gestation, and a long ob- servance of the recumbent posture after delivery. Wlien the mis- placement, however, is considerable, and especially when the uterus has already been partially procident, the effect of the en- largement of the womb is to make it descend still lower, so that a consideracle portion of its lower segment, as well as its greatly enlarged cervix, protrude permanently during a great part or the whole of pregnancy. All the symptoms to which prolapsus ordi- narily gives rise are experienced in these cases in an aggravated degree, and miscarriage not infrequently takes place, partly owing to the disturbance inseparable from the misplacement of the womb, partly owing to the want of space in the pelvis for the further en- largement of the organ, which is unable to rise as it ought to do into the abdominal cavity. In some few instances, however, pregnancy runs its course undisturbed, in spite of a great degree of prolapsus; and cases are on record in which the uterus has descended furthef and further till a great portion of it hung down between the thighs ; but the development of the foetus has, never- theless, gone on in this unnatural position ; and others, still stranger, in which coitus has been practised immediately through the os uteri, and impregnation and undisturbed gestation have followed in spite of the existence of irreducible procidentia. The causes have been explained which tend to oppose the return of any long-existing procidentia of the uterus ; and the same causes, though operating in a less degree in simple prolapsus, yet often interfere with the complete restoration of the womb to its normal situation. By degrees, indeed, a woman not infrequently gets habituated to the discomforts of her position, till at length she seems to be but little inconvenienced by them, and this even in cases of external procidentia of the womb. To this, liowever, there are many exceptions ; and the ulcerations of the surface of the procident organ sometimes become very extensive, assume an unhealthy condition, and partial sloughings of the integument take place ; or the mass having been unreturned longer than usual, it becomes swollen, tense, and painful, and all attempts at replacing it prove unavailing. The extreme pain, which in some of these cases attends upon any endeavor to replace the womb, is often due to some degree of inflammation having been set up in the perito- neum lining the pouch into which the intestines descend, at the upper and back part of the prolapsed womb, or of the peritoneal investment of the intestines themselves ; and death may in these circumstances take place, wnth many symptoms of the same kind as attend upon fatal strangulated hernia. Of the two varieties of vaginal prolapsiist in which its posterior or its anterior wg^ll is displaced, the latter gives rise to by far the more important symptoms. Some degree of prolapsus of the pos- terior vaginal wall exists, indeed, in very many cases of laceration of the perineum ; and a painful dragging sensation on assuming VAGINAL PROLAPSE. 143 the erect posture, leucorrlioeal discharge, and discomfort from the projection between the labia of a small pouch of vagina, are gener- ally experienced, though by no means in a measure always pro- portionate to the amount of misphicement. To these are super- added all the inconveniences of constipation, and the distress arising from the impaction of scybala in the rectum, whenever the lower part of the intestine itself becomes dragged down and pro- lapsed ; while, whenever the ailment is of long standing, or con- siderable in degree, the uterus is usually drawn down also out of the pro})er position. The prolapsus of the anterior vaginal wall, attended as it is by descent of the bladder, is accompanied bj'a peculiar dragging sen- sation at the umbilicus, which is distressing in proportion as the bladder is full ; is lessened, or ceases altogether, when that viscus is completely empty. This sensation has been referred, and probably correctly, to the stress upon the suspensory ligament of the bladder, which must be dragged on more and more in proportion as urine accumulates in the prolapsed pouch of the organ. The patient ex- periences, moreover, a constant desire to pass water, which very frequent micturition fails to relieve, unless pressure be made from below against the pouch of prolapsed bladder, so as completely to empty the organ. To this becomes superadded in many instances, in the course of time,' an altered condition of the urine, which is turbid, ropy, sometimes ofl'ensive, and loaded w'ith phosjihates; owing, in part, to its retention in the prolapsed pouch of the blad- der ; in part, also, to irritation propagated to the kidneys them- selves. • It can scarcely be necessary to say that in these cases the ordinary symptoms of vaginal prolapse will not be wanting; while reference h-as already been made to the peculiar eifect of descent of the bladder in causing hypertrophy of the anterior lip of the womb, and afterw^ards in occasioning the organ to prolapse. The characters of prolapsus of the uterus or vagina are so well marked, that w'ith the most ordinary care it must be nearly im- possible to mistake their import. We may, therefore, pass at once to the examination of the treatment best suited to effect its cure. Here, however, we at once meet with vary contradictory oi)inions and assertions, for while some writers advocate the general em- j»loyment of mechanical means to keep the misplaced organs in their proper position, others deny their utility, and allege various arguments ngainst them. Witliout entering into the controversy, we must bear in mind, what the disputants have too often forgotten, that })rolapsns of the womb occurs in very ditierent circumstances; and that its treatment, to be appro{)riate, must differ too. Some- times it is the result of causes which add to the weight of the uterus, and thus render its ordinary supports unequal to maintain it in its proper position, while in other instances a weakening of 1 To this CHiisp of alteration of the urino attention was first called by the late Dr. Guiding Bird, in a jiajier published in Medical Times a>ui Oazelie, 1853, Jan. 1, p. 11. 144 TREATMENT OF tlie supports themselves, by accident or disease, is the first step towards producing the misplacement; and according as the one or the other of these conditions predominates will the use of mechani- cal means be expedient or undesirable. Thus, for instance, time, and care, and judicious management generally sufltice to remove that form of descent of the womb which succeeds to miscarriage or to labor, wherein the as yet iniperfect involution of the organ, and its consequent increase of weight, are the main causes of its misplacement, while mechanical contrivances are always needed when the support which the vagina should afford has been destroyed by extensive laceration of the perineum, or greatly enfeebled by the atrophy of old age. The first inquiry, then, which we ought to make in every case of prolapsus uteri concerns the cause to which the misplacement of the organ is due ; and we must therefore endeavor to ascertain the precise condition of the patient's liealth previous to the occur- rence of those symptoms for wliich she now seeks our help. In married women we shall often find the commencement of the evil referred to some miscarriage or labor; in the unmarried, to exer- tion too severe or too prolonged at a menstrual period, and subse- quently aggravated by a like want of care at each successive return of the menses. Rest in the recumbent position, strict attention to the condition of the bowels, the cold hip-bath, and astringent vaginal injections, will usually suffice for the cure of such cases; and as the hypertrophy of the womb gradually subsides, so will the organ by degrees regain its proper position. Neglect of due precaution at the menstrual periods, leading as it often does to the minor degrees of uterine prolapse, becomes associated, also, with enlargement of the womb, which disappears, together with the malposition, under the same treatment as is appropriate in those cases where the ailment succeeds to delivery. Here, however, especial care is needed, at the return of each menstrual period, to counteract the tendency of the womb to become again displaced — care, too, which it is often very diflicult to induce our patient, who probably feels but little discomfort, to observe. It is by such care, however, rather than by much positive treatment, that we can best succeed in putting a stop to that over-profuse menstruation which is very frequently associated with even the minor degrees of pro- lapsus. The misplacement of the organ exposes it to irritation ; the irritated and congested organ becomes somewhat increased in size ; and from its vessels, larger and more numerous than when the organ was in its natural position, blood flows more freely, and all the more so if the patient retains at these times the erect pos- ture, or pursues her ordinary avocations. In many other conditions the uterus grows larger and heavier than natural, and in some of them, the disposition to prolapsus is even greater tlian when the size of the organ is due to the incom- pleteness of its puerperal involution. The womb, though left after delivery much larger and heavier than natural, is not the only part hypertrophied ; but its supports, albeit overstretched and conse- PROLAPSUS UTERI. 145 quently enfeebled, have grown too, and are larger and more power- ful thiin in the unimpregnated state. If, however, the increase of the womb is due to some other cause, such as the congestion of habitual monorrhagia, or the enlargement which attends upon chronic inflammation, prolapsus of the organ will be still more likely to occur, since its increase of weight will have been un- associated with any corresponding development of those parts by which it is retained in situ. The prolapsus here is purely second- ary; the enlarged womb may even require local depletion tnberg) that it can very seldom happen for a case to occur in which the far more uncertain and more hazard- ous operation is indicated. In not a single one indeed of the rather numerous in- stances of uterine prolapse which have come under mj"^ care, since the performance of the operation which I have related, have I found it necessary to resort to episi- orraphy, f(jr in every one suitable pessaries, generally that of Zwanck, retained the prolapsus just as well as the most successful operation could have done." I may add, that during the last three years of my connection with !St. IJartliolomew's Hospital, I did not meet with a single case of prolapsus which a Zwanck's pessary faih'd to retain. 1 See some recent cases referred to in the discussion on M. Huguier's paper, by M. l)ej)aul. Bulletin de I'Academie, vol. xxiv, p. 682. 2 Ojj. cii. p. 150. 158 OPERATIONS FOR THE CURE OF PROLAPSUS. bladder in front, while the hemorrhage, always profuse, can scarcely fail in some instances, to endanger life. Moreover, the very conditions in which the need of relief is most urgent, are those which, according to M. Huguier, forbid the per- formance of the operation, inasmuch as he says, that "a capacious pelvis and a large opening of the vulva, more or less laceration of the perineum, and considerable relaxation of the soft parts at the pelvic floor, absolutely contraindicate it."^ I would confidently ask, how many are the patients suffering seriously from the symp- toms of uterine prolapse, in whom some one or more of these conditions are not present, and in what persons but those whose sufie rings are most severe, should we be justified in setting their life upon the cast by the performance of an operation which rests on a false hypothesis, which is not proved to be permanent in its results in many of the cases where it has been performed, and which can be but moderately perilous only in the hands of those who maybe possessed of the exceptional dexterity of M. Huguier?^ The annals of medicine contain the history of some few extra- ordinary cases in which the uterus, having long been procident, being quite irreducible, and having been attacked by inflammation which terminated in gangrene, has been removed with no ill effect by means of the ligature and knife. I have no personal experience of such cases, though a patient was once sent to me at St. Bar- tholomew's Hospital to have the procident uterus extirpated. The procidentia, however, was not irreducible ; the uterus was not the seat of any dangerous inflammation, and the woman within the previous year had given birth to a child. I need not say that the operation was not performed, but the womb, being replaced within the pelvis, was retained there by means of an Ashburner's band- age, and the patient. was sent back to the country in a state of comparative comfort. I do not know, however, but that instances may occur justify- ing this proceeding, and further, would remind you that the womb, when long misplaced, loses much of that sensibility which char- acterizes it when in its natural position. The inverted womb has on many occasions been safely removed by ligature, and one of the few instances of successful extirpation of the cancerous uterus was that recorded by the younger Langenbeck, in which his father performed the operation on a womb that for years had been proci- dent beyond the external parts.^ There would be two great risks to be avoided in such a proceed- ing : the one would be that of opening the peritoneum, the other that of wounding the bladder, which viscus in almost all cases of 1 Ibid.,Y>. 166. 2 The criticisms of M. Depaul in the discussion at the Academy of Medicine, those already referred to by Scanzoni in vol. iv of his Beitrdge on this and the analogous operation of Professor Braun, of Vienna, and in the 3d edition of his LehTbnch, published in 1863, pp. 143-147, may be consulted by any one who is desirous to pursue this subject further. 3 De totius uteri exiirpatlone, auctore M. Langenbeck, 4to., Gottingse, 1842. RETROVERSION OF THE UNIMPREGNATED "WOMB. 159 considerable or long-standing prolapse, descends far down in tlie front of the tumor, and without much care would be very likely to be injured. LECTURE XI. MISPLACEMENTS OF THE UTEKUS. Versions and Flexions of the Uterus. Ketroversion of the Womb ; knowledge of its existence in unimpregnated state comparatively recent. Its causes, and mode of its occurrence. Illustrative cases. Anteversion often confounded with anteflexion. Flexions or Uterus — probably more frequent than misplacements of whole organ — always take place at one point, and why ; comparative frequency of ante and retroflexion. Absence of disposition to spontaneous cure; existence of adhesions and of atrophy of uterine wall. Influence of flexions on uterus in other respects, hypertrophy of womb; constriction of internal os, «&c. Obliquity fi-om congenital malformation. "When speaking about prolapsus uteri, I explained to you how it occurs that descent of the womb is always associated with a dis- position to retroversion of the organ; or, in other words, to a fall- ing back of its fundus into the hollow of the sacrum. Such minor degrees of retroversion, however, are of comparatively trivial im- portance, and whatever symptoms they may occasion are entirely lost in the general consequences of the downward displacement of the womb. Cases, however, especially of late years, have engaged the atten- tion of practitioners, in which, though the womb may be some- what lower than natural, yet it is not only, nor even principally, to this displacement that the patient's symptoms are due, but rather to a falling of the fundus uteri downwards and backwards into the hollow of the sacrum, accompanied with a corresponding elevation of its cervix, which is directed upwards and forwards against the symphysis. To Dr. William Hunter we owe, if not the first men- tion, at least the first clear description of this retroversion of the womb as an accident liable to happen in the early months of preg- nancy ; and since his time no treatise on midwifery has failed to mention its occurrence, and to delineate its symptoms in colors even darker than are always needful. But though it would seem natural to anticipate that this acci- dent should not always be limited to the pregnant state, but might also sometimes hap})en in any other circumstances which rendered the womb heavier than natural, and its supports more lax, yet it was long before this was recognized as a general fact, and the few instances of the displacement which were from time to time re- corded by continental writers were regarded as rare and excep- tional occurrences. The minute detail of four cases of this mis- placement of the unimpregnated womb, by Professor Osiauder, of 160 CAUSES OF Gbttingen, in the year 1808, then in the zenith of his reputation, did much towards directing attention to the subject. It was not, however, until some years later that the publication of the essays of Professor Schweighauser,^ of Strasburg, and of Professor Schmitt, of Vienna,Mully established the frequency of the accident, and furnished a description of its symptoms so minutely accurate as to have left little room for the additions of subsequent observers. The researches of these German writers attracted but little atten- tion out of their own country; and retroversion of the womb, as well as the opposite condition of its anteversion, were regarded by medical writers, both in France^ and England, as ailments ex- tremely unusual in the unimpregnated condition of the womb. In the year 1848, however, a paper was published in the Dublin Journal of Medical Sciences, by Professor Simpson of Edinburgh, on retroversion and other misplacements of the unimpregnated womb — accidents to which he had already drawn attention five years before at a meeting of the Medico-Chirurgical Societj^ of Edinburgh; and since that time the danger has been lest the im- portance and frequency of these conditions should be overrated, rather than lest they should be underestimated.^ One of the results of close attention being directed to the situa- tion of the womb in the pelvic cavity, has been to show that the organ is liable in this respect to very great varieties ; that not only may its fundus fall backwards into the hollow of the sacrum, or forwards against the symphysis pubis, but that it may also in- cline towards either side ; and that moreover its body is liable to be bent upon the cervix, constituting a new class of misplacements called flexions. There seems also to be reason for believing that the difteront varieties of flexions of the womb, as its retrojiexion and antejlexion, are of more frequent occurrence than the corre- sponding alterations in position of the whole of the organ which are known as retroversion and anteversion. Fewer difiiculties present themselves in the way of understand- ing the mode of occurrence of retroversion than of the other above- mentioned misplacements of the womb. It has already been seen that the tendency of the womb, when at all enlarged, is not only to sink below its natural position in the pelvic cavity, but at the same time to fall with its fundus backwards towards the hollow 1 Schweighauser, Aufsdtze uher einige Ger/enstdnde der GehurtshuJfe, 8vo., Niirn- berg, 1817, cap. xxviii, p. 251; and Das Gebdren nach der beobachteten Natur, Strasburg, 1825, 8vo., p. 234. 2 Bemerkungen iiber Zuriickbeugung der Gebdrmutier bei Nichtschwangeren, 8vo., Wien, 1820. 3 From this statement, however, it is only just to except the name of M. Velpeau, who was led by his own observation long since to appreciate the frequency and importance of flexions of the uterus, and to devise means for their cure. See p. 14 of a small tract of his. Maladies de I' Utertts, 8vo., Paris, 1854. * Opinions at variance with those of Dr. Simpson were however expressed by several writers, as, for instance, by Dr. Bennett, Dr. Oldham, and Dr. Matthews Duncan, of Edinburgh, who, though difl'ering from each other in some respects, yet all formed a low estimate of the importance of mere versions or flexions of the uterus, and dissented from the employment of mechanical means for their removal. RETROVEESrON OF THE WOMB. 161 of the sacrum, in consequence of the utero-sacral ligaments con- fining it more closely to the posterior part of the pelvis than do the utero-vesical ligaments to the anterior pelvic wall. Aloreover, enlargement of the womb, whether from the presence of fibrous tumor, or dependent on simple congestion and consequent liyper- trophy of the organ, or resulting from its imperfect involution after delivery or miscarriage, is almost alwaj's much more con- siderable at its posterior than at its anterior wall, and the womb in consequence naturally falls towards that side which is the heavier. The ordinary distension of the bladder, too, necessarily tends to throw the uterus into the posterior half of the pelvis ; and if the utero-vesical ligaments be at all yielding, as they must be in cases where some degree of prolapsus exists, the same cause must also dispose the fundus of the organ to fall backwards; while the inclination to the malposition will be increased by a loaded state of the bowels such as exists habitually in many persons. When favoring causes such as have been just referred to coin- cide, retroversion of the womb may take place either gradually, or as the result of some sudden accident which violently increases the uterine misplacement, and throws the fundus of the organ downwards and backwards into the hollow of the sacrum. It is thus suddenly that in the majority of instances retroversion of the pregnant womb takes place — an accident, the comparative rarity of which is, I apprehend, to be accounted for mainly by the cir- cumstance that not only does its physiological enlargement equally extend to the whole of the organ, but also that the size and strength of its ligaments increase with the added weight which they have to bear. But while, owing to this wise provision, the pregnant womb rises gradually and safely out of the pelvic cavity, the hypertro- phied organ, or that whose involution is imperfect, or in whose substance tumors are developed, being destitute of such duly in- creased supports, sinks down far lower than natural in the pelvis. The sudden eftbrt and consequent violent misplacement which we generally find to constitute the history of retroversion of the enlarged and pregnant womb, are sometimes equally marked in the case of the non-gravid uterus, showing that the mode of oc- currence of the accident is identical in both instances. Thus, a woman aged thirty, whose second and last labor had taken place sixteen months before, while reaching over the fire to remove a heavy tea-kettle, was suddenly seized by violent pain referred to the back and the umbilicus, and became for a time unable to pass her urine, and thougli she afterwards voided it, yet it was with pain and difiiculty, and defecation also was attended by pain. On examination per vaginam the finger came in contact with a firm, but slightly elastic, globular tumor, which felt about half the size of an orange, and occu[)iod the posterior half of the pelvis, having driven before it the posterior vaginal wall, while the rectum could be traced |)assing behind it. The situation of this tumor was not exactly in the mesial line, but it occupied rather more of the right than of the left half of the pelvis, while the os uteri was situated. 11 162 CAUSES OF high up, immediately behind the symph^'sis pubis, but a little to the left of the mesial line. I may remark, in passing, that to this slight obliquit}^ of the retroverted uterus it is due that the urethra and neck of the bladder not infrequently escape that pressure which would otherwise be unavoidable ; and thus it happens that difficulty of micturition is, in many instances even of retroversion during pregnancy, by no means so prominent a symptom as the statements in most systematic treatises on the diseases of women might lead one to expect. There was, besides, in the left iliac region, a firm slightly movable tumor, whose surface was a little irregular, as if nodulated, and pressure upon it was communicated to the tumor in the pelvis. Inquiry ascertaining that the patient's bowels had long been in a constipated condition, it was assumed that while the sudden exertion had retroverted the uterus, the accumulation of fpeces in the sigmoid flexure oY the colon and in the upper part of the rectum had prevented its spontaneous re- placement. Enemata and purgatives were employed, and in the course of seven days the womb, which was not much larger than natural, had completely regained its proper position, while a vague sense of some swelling in the posterior part of the pelvis was as- certained to be due merely to the existence of very great hyper- trojihy of the walls of the rectum, a condition which is by no means uncommon in cases of long-standing habitual constipation. It is not thus suddenly, however, that retroversion of the unim- pregnated uterus usually occurs. In th(^ majority of instances the accident may be traced back to labor, menstruation, or miscarriage ; to some condition, in short, which combines considerable enlarge- ment of the womb with weakening of its supports. A patient was received into St. Bartholomew's Hospital, on account of what was alleged to be a tumor in her womb, and suflering from frequent hemorrhage, from pain in the sacrum and hypogastrium, and from painful and difficult defecation. All these symptoms dated from a miscarriage at the third month, which had occurred six weeks before. The uterus was completely retroverted, the os being di- rected forwards and somewhat upwards, while an elastic, globular, slightly tender tumor occupied the hollow of the sacrum. The uterine sound entered for five inches and three-quarters, with its concavity directed backwards, and on turning the instrument round, the tumor completely disappeared. Rest was followed by cessation of the hemorrhage, the use of the cold douche led to some diminution in the size of the uterus, though it was still as much retroverted as ever, when the outbreak of small-pox in the ward compelled the patient's discharge from the hospital in less than three weeks after her admission. Just two years later, the patient came once more under my notice. She had in the interval been pregnant several times, but had on each occasion miscarried early, while, when not pregnant, she had suffered much from menorrhagia. The uterus was no longer so enlarged as before, though of greater size than natural, but its misplacement was just as considerable ; still, however, ad- RETROVERSION OF THE WOMB. 163 mitting of momentary removal by means of the sound, but almost immediately falling back into its former position. If this person had not been exposed to the risks of becoming pregnant, there can be no doubt but that the involution of lier womb would have taken place much more completely; though even then the mis- placement would almost certainly have continued unrelieved, and accident might then have discovered a small and otherwise healthy uterus completely retroverted, with no other clue to the cause of this occurrence than would have been furnished by the history of a miscarriage, succeeded by long-continued hemorrhage some years before. The state of the womb during menstruation is similar to its con- dition after miscarriage, and favors in the same manner, though of course in a less degree, the descent of the organ or its retrover- sion, while in every form of misplacement of the uterus the ten- dency of things is to a deterioration rather than to an improvement. The accumulation of urine in the bladder, the distension of the rectum with fseces, have a disposition to aggravate the misplace- ment, while the stretched ligaments and the lax vagina have no power of spontaneously recovering their tone, and of thereby favor- ing the replacement of the womb. With the return of each men- strual period, too, the uterus for the time grows heavier, and subsides further and still further back in the pelvis, till at length its retroversion becomes complete. Nor must it be forgotten that in some at least of the instances of this and of kindred misplace- ments, any permanent improvement is effectually prevented by the formation of adhesions between the fundus of the uterus and the surface of the adjacent intestines. Such attacks of circum- scribed peritonitis as to produce these consequences were first noticed by Madame Boivin' as a cause of abortion, and she appears, indeed, to have exaggerated both their frequency and their import- ance. They are, nevertheless, of considerable moment, and none the less for the circumstance that they are by no means constantly accompanied by symptoms so severe as to force themselves on the patient's attention. Their occurrence, and the consequences which they leave behind, sufficiently account for the immobility of the retroverted uterus in some instances, for its difficult replacement and immediate resumption of its malposition in others. Although I have spoken first of retroversion of the w^omb, yet the opposite state oi anteversion of the unimpregnated organ earlier attracted attention, and was described by Levret' with character- istic accuracy. In this condition the fundus is directed forwards against the symphysis of the pubes, and its orifice backwards into the hollow of the sacrum. How this accident comes to hapjien, and to happen even with considerable frequency, is certainly not easy to understand. The very form of the pelvis, as observed by 1 Rec.herc.hen nnr une des causes les plus frequentes, et la moins coniiue de I'Avoi-te- ,neni, 8vo., Pnris, 1822. ^ "8iir un deplaconiont particulior do la matrice, dont los autcurs n'ont point parle," in lioux, Journal de Medecine, etc., Sept. 1773, vol. xl, p. 209. 164 ANTEVBRSION the late Professor Kiwisch/ while it favors the production of retro- version, is opposed to any such misplacement as the anteversion of the womb, while the accumulation, of the urine in the bladder and of the fseces in the rectum, the former takino; place from below upwards, the latter from above downwards, alike tend to prevent and remove it. There is, besides, no such pouch of peritoneum in front of the uterus as exists behind it, allowing space for the descent of the fundus uteri, and for its residence in this unnatural situation. In spite, however, of these conditions, which would seem to oppose the occurrence of anteversion of the uterus, it is yet met with in many instances, though I believe less often un- associated with previous enlargement of the organ than the oppo- site state of retroversion. Thus in fourteen out of twenty cases of anteversion or anteflexion of the womb there was marked en- largement of the organ, while the history of the patients further warranted the belief that the misplacement was in these instances secondary to other much longer standing diseases. Such I believe to have been the cause of the misplacement of the womb in a patient whom I saw four years after her delivery, which had been succeeded by phlegmasia dolcns, and symptoms of uterine inflam- mation so severe as to have confined her to her bed for three months. Such possibly was tlie real history of a woman who had lived three years in sterile marriage, and who was attacked suddenly during menstruation, ten months before I saw her, by severe pains in the abdomen, followed by temporarj^ cessation of the menses, by great pain in the hypogastrium, difficulty and pain in micturition, and symptoms like those of severe vaginitis, and who had ever after experienced attacks of violent parox3'smal uterine pain. Her uterus was both hard and enlarged, the fundus resting against the symphysis, and the os in the hollow of the sacrum. Some- times, moreover, one meets with an increased degree of obliquity of the womb, though short of actual anteversion, which appears to be the almost mechanical result of sexual intercourse. When in connection with this exaggerated obliquity of the womb, there has also existed some congestion of the organ, such as is not un- usual, particularly in sterile women, the misplacement is then often associated with symptoms of uterine disorder, which prob- ably are due less to it than to the gorged state of the bloodvessels with which it is associated. Still there are instances, though of far less frequency than those above referred to, in which there is no evidence of previously existing disease, but where the anteversion of the womb was apparently a primary occurrence. It was so in the remarkable case which first drew the attention of Levret' to this malposition. In this instance, the fundus of the anteverted womb was taken for a calculus in the bladder, and the patient died from the effects of lithotomy performed under this erroneous idea. In this instance, it is expressly stated that slight engorgement of the anterior wall 1 Op. cit, vol. i, p. 235. 2 l^^c. cit, p. 269. OF THE WOMB. 105 of tlie uterus, and a somewliat unusual shortness of the round ligaments, were the only appreciable causes of its malposition. A woman, aged thirty, the mother of four children, the last of whom was born three 3'ears before she came under my observa- tion, had ever since experienced some, though inconsiderable, abdominal pain. A few days before I saw her, however, while turning a mangle, she felt a sudden pain over the pubes, which extended over the whole pelvic region, and on making an exami- nation, the uterus was found remarkably anteverted, the os being in contact with the anterior wall of the sacrum, and the fundus resting against the inner surface of the sympliysis. It seems diffi- cult here to avoid connecting the symptoms suddenly supervening during exertion with the misplacement of the womb. Still harder does it appear to me to be able to account for the malposition of the organ in an unmarried ladj'^, aged thirty-four, whose menstrua- tion had been habitually scanty, and who had suiFered for eight months before she came under my care fi'om hemorrhoids, ac- companied by profuse loss of blood. For four months she had also experienced abiding aching pain in the hypogastrium, with frequent and painful micturition. Her uterus was lying almost horizontally across the pelvis, its orifice being directed backwards, and to the left, and this to so great a degree as to render it almost impossible to touch the small circular os, while the fundus was situated in the .same manner forwards and to the right. . Be the explanation of cases such as the above what it may, — and I confess myself unable satisfactorily to solve all the difficulties which they present, — there can be no doubt but that, in the greater number of instances of alleged version of the womb either forwards or backwards, the organ is really flexed, or bent upon itself; and further, that not infrequently the two conditions coexist, the whole womb being thrown more forwards or more backwards than natural, while, in addition, the body of the organ is bent upon its cervix. As far as the symptoms are concerned to which they give rise, these varieties of misplacement present but little differ- ence; but the distinction deserves to be borne in mind, since it throws light on the manner in which the accident is in many in- stances brought about. The point of flexion of the uterus, whether it is bent forwards or backwards, appears always to be the same — namely, the point of junction between the body and neck of the womb, or, in other words, a spot corresponding to the intorual os uteri; so that the organ assumes a shape closely resembling that of a chemical re- tort. Various reasons have been assigned for the constancy with which the organ is found to bend at this one situation ; and various theories, such as an assumed atrophy of one part of the uterine walls and engorgement of its fundus while the cervix remains un- altered, and other suggestions less plausible, have been ])roposcd in explanation of the fact. But these conditions arc by no means invariably present even in cases of most marked flexion of the womb, and must therefore be rejected as inadequate to account 166 FLEXIONS OF THE UTERUS: for its taking place at the same situation in all cases. The only explanation that I know, against which no such objection can be raised, is that propounded by Professor Vircjhow, of Berlin,^ and which is based on the anatomical relations of the organ. He points out the fact, that while the neck of the womb is tirmly connected with the posterior and lower part of the bladder, its body is per- fectly movable ; the point to which the peritoneum descends in the utero-vesical pouch corresponding exactly to the situation of the internal os uteri, and, consequently, to the spot where the fixed cervix passes over into the movable body of the organ. The posterior surface of the cervix uteri, though somewhat strength- ened by the cellular tissue which surrounds it, is by no means so firmly fastened as its anterior surface ; while the pouch of perito- neum descends much lower down behind it, and is even on a lower level than the summit of the roof of the vagina. If, now, any cause interfere with the ready mobility of the l)ody of the womb, while the attachments of its cervix retain their firmness and resistance, a bending of the one part on the other must of necessity take place ; a bending which may occur either forwards or backwards, find thus constitute either anteflexion or retroflexion. With refer- ence to the production of the accident, it is probably a matter of indiftbrence whether its cause is one that operates gradually and continuously, or suddenly and with great force — a violent exertion may therefore produce it ; and just as much may the slow action of adhesions tethering the fundus of tlie womb either to the blad- der or the rectum, and compelling the organ in the course of time to yield at its weakest point — namely, at that which corresponds to the junction of the body and neck of the organ. This explanation will account equally for the occurrence of anteflexion and of retroflexion. Of the two misplacements, the former is alleged by Rokitansky, and by other morbid anatomists, to be the more frequent ; and observations during life confirm, on the wliole, the correctness of this statement. In my own notes, indeed, I find the particulars of forty-three cases of retroversion or retroflexion, and of only twenty of anteversion or anteflexion ; but these results are at variance with those of some most trust- worthy observers, and I believe they are due to the circumstance, that in the early period of my observations I often failed to mark the slighter degrees of anteflexion. Valleix, in his valuable lec- tures on this subject,^ gives thirty-five deviations of the uterus for- wards, and thirty-three backwards ; Dr. ]Mayer,^ of Berlin, met with sixty-three cases of the former, and sixty-four of the latter ; and MM. Bernutz, Goupil, and Gosselin found a greater or less decrree of flexion or version of the uterus forward, in 106 out of 1 Ueher die Knicknngen der GebdrrmiUer ; in the Verhandlunyen der Gesellschaftfiir Gebu?-ts/nllfe, vol. iv, 1851, p. 80. * Des Deviations Vterines, 8vo., Paris, 1852, see p. 27. 3 As stated by Dr. Eockwitz, in Verhandl. der Gesellschaftf. Gehurtsh., vol. v, 1852, see p. 85. THEIR MODE OF OCCURRENCE. 167 163 women who had never given birth to children.^ This hitter statement, however, represents the frequency of tliat physiological curvature of the womb which, while it exists in the child and in the unmarried womttn, ceases after childbirth, or is even replaced by a disposition to version or flexion of the fundus backwards. A condition met with in two women out of three can scarcely be other than natural ; and while I may have often overlooked it, I believe that I do not err in regarding it as usually of but small importance. The older opinions on this subject, indeed, are in conformity with the conclusions which I have arrived at, and I believe them to be correct, as far as any such degree of misplacement is con- cerned, as would manifest itself by sj'mptoms during life ; while the whole subject of uterine versions and flexions lias been of late much obscured by the confounding together of the natural and the morbid degrees of these misplacements. There can be no doubt, indeed, but that slight degrees of anteflexion of the uterus are frequently overlooked during life, since not only does the finger come less readily into contact with the parts in the anterior than with those in the posterior half of the pelvis, but further, unless the bladder be completely empty, the tumor of the anteflexed womb is scarcely perceptible. A slight flexion of the womb forwards is, however, a natural condition, as is exceedingly well shown in Koldrausch's beautiful delineation of a section of the pelvic viscera.^ " The uterine canal," says he, "is not straight, but slightly curved, like an italic /, and the whole organ has in its natural position a slight flexure, being curved at first a little backwards, then bent more considerably forwards." This curve, Ijiowever, is no longer apparent after childbearing, while, besides, any cause which pro- duces enlargement of the womb, brings with it those influences that tend to favor retroversion or retroflexion of the organ. The explanation that has been proposed of the invariable occur- rence of flexion of the uterus at the same point, suggests the reason why the ailment has no tendency, or scarcely any tendency, to spontaneous cure,. and explains why the misplaced womb remains misplaced for years. Two conditions, moreover, tend to give to the misplacement a permanent character, of which one is the pres- ' See notes 3 and 4, at p. 465 of vol. ii of Bornutz and Goupil's Clinique Medi- cale sw les Maladies des Femmes, 8vo., Paris, 18C2. - Zur Anatdniie, etc., der Bec.ke7inj-f/nne, 4to., Leipsig, 1854. In a paper read before the Medico-Chirurcical Society, and afterwards published in the Dublin Medical J<»t7-na.l, August, 1857, Dr. Bennett gave the results of his own investiga- tions on the living subject, which led to precisely the same conclusions as those arrived at by Kohlrausch. The observations of Boullard, contained in his thesis, which apjiearod in 1853, who believed that a degree of anteflexion of the uterus, far excci'ding any gentle curve, was the really normal state of the uterus, have been sliown by Depaul (Gazelle des Ilopitaux, No. 36, 1854), to be vitiated by the circumstances in wliich they were made, and that purely cadaveric causes are chiefly inHuential in producing great flexions of the organ, and especially flexions of the fundus forwards. Boullard's statements, however, though they exaggerated the degree of the natural curvature were correct as to the fact of its general exist- ence, and deserve the praise which attaches to i>riority of observation. 168 ANATOMICAL RESULTS ence of adhesions binding down the fundus of the uterus, either to the rectum posteriorly, or to the bhidder in front; the other is the wasting of that wall of the uterus towards which the flexion has taken place, and which must necessarily render the organ in- capable of retaining its natural position, even though it were pos- sible to replace it completely. Of these two conditions the former is, I believe, the more frequent, and therefore the more important. Such adhesions are expressly mentioned in many of the cases where, on examination after death, flexions of the womb have been discovered, and I can speak to the extreme frequency of adhesions, false membranes, or other indications of bygone in- flammation about the womb or its appendages, since I met with them in twenty-two out of sixty-six cases in which I examined the uteri of women who had died of some other than uterine dis- ease. There appears to be some uncertainty as to the date of the occurrence of atrophy of the uterine wall, and also as to the degree in which it takes place. I found no trace of it in a case where the uterus was greatly anteflected, and where the existence of marked uterine symptoms for man}' years rendered it probable that the condition was of long standing; and it is expressly stated by Dr. Kockwitz' not to have been present in the case of a woman whose uterus had been completely retroflected'for a year by the presence of an ovarian tumor. On the other hand, Virchow de- scribes the gradual wasting of the muscular substance at the point of flexion till nothing is left but a small quantity of flaccid, slightly fibrous, cellular tissue; and in a very useful essay on the subject, Dr. Sommer relates some post-mortem examinations in which this atrophy of the uterine wall was very remarkable. The eflcct of such a change in the uterine wall is twofold. On the one hand it weakens the tissue at one point, and thus incapaci- tates the organ for maintaining its proper position ; on the other it shortens the wall towards A\hich the flexion exists, and thereby insures still more eftectually the permanence of the malposition ; and no one who is familiar with uterine ailments, and has felt the bent uterus resume its malposition immediately on the removal of the sound by which it had just been rectified, but must believe that such wasting of one uterine wall must exist in a very large number of instances. A frequent, though by no means an invariable result of long- standing flexion of the womb, and one which must be borne in mind as explaining some of the symptoms to which it occasionally gives rise, is a contraction of the internal orifice of the womb. This constriction too, is, at any rate in Virchow's opinion, not a merely mechanical approximation of the two sides of the canal by the bending of the organ, but is in many instances due to an organic narrowing of the passage, produced by the constant irritation of the mucous membrane at this spot, and its consequent thickening. 1 Loc. cit., p. 82. 2 Z(i)' Lelwe des Infractionen und Ftexionen der GehiirmuUer, 8vo., Giessen, 1850. OF FLEXIONS OF THE WOMB. 169 Any positive obliteration of tlie internal os, however, which Vir- chow has sometimes met with in aged persons, is not merely a very rai-e occurrence, but is probably due in large measure to the natural tendency to closure of the internal os in old age, and which the flexion of the uterus, though it may have increased, has not originated. One or two other consequences of flexion of the w^omb deserve mention, though I believe that the degree to which they exist ad- mits of very wide variation. The body and fundus of the w^omb are very apt, as the result of their altered position, to become the seat of congestion ; a congestion that may be very intense,' and with the existence of which it is reasonable to associate the dis- position to menorrhagia that is so prominent a feature in many cases of this kind. Moreover, a part that is the frequent seat of congestion tends to enlarge, and hence the misplaced body and fundus of the womb often become hypertrophied, wdiile the difii- culty of escape of the secretions, when the angle of flexion is very acute, helps to increase the dimensions of the uterine cavity, a re- sult of the occurrence of which the uterine sound informs us in a very large number of instances. The condition of the cervix uteri is seldom natural, but there is generall}' a profuse secretion from its glandular apparatus, while the edges of the os uteri are usually red, and their epithelium is often al)raded, a condition dependent doubtless on the state of general irritation of the cervix. To the touch the margins of the OS rarely present any marked deviation from a healthy condition, while the os itself (at least in retroflexion, concerning which my observations are more numerous than concerning anteflexion), is often open so as to admit the tip of the finger. The anterior lip, too, in cases of retroflexion, is usually shorter than the posterior — an alteration of the natural relations probably due, as Sommer suggests, to merely mechanical causes, and to the dragging out of its ]>lace of the lip on that side which corresponds to the convexity of the flexed womb. In tlie cases to which reference has hitherto been made, the uterine misplacement would seem to be an acquired condition, though one coming on at different periods of life, and under the influence of causes which, sometimes at least, are obscure. There are other instances, however, in which obliquity of the uterus for- wards, backwards, or to eitlier side, is the result of conqenital mal- formation, associated with marked difl'erence in the length of the womb and broad ligaments on the two sides, or dependent on un- equal development of the two halves of the womb itself. In one instance in which I found the womb, in an unmarried girl, aged eigliteen, oblique in form, and inclined towards the right side, the left ligamentum ovarii was 1.2 inch fin length, while that of the right side measured only .6 of an inch ; and in the body of another 1 As in tlio drawing of the antefloxed uterus at figs. 5 and G of plate ix of Boivin and Diiir^'s Atlas. 170 MISPLACEMENTS OP THE UTERUS. unmarried girl, aged nineteen, likewise free from all trace of uterine disease, the womb was unequal in size, its right corner being .3 of an inch higher than the left. Professor Tiedemann,^ who was the first to call special attention to this condition, has published in his treatise on the subject several drawings, which represent very extreme degrees of uterine obliquity and malfor- mation. There is nothing to surprise us in the occasional want of symmetry of an organ formed as the uterus is, in great measure, by the coalescence of two lateral halves or cornua. At the same time it seems very doubtful whether such inequality of the womb gives rise to any symptom, or whether in the event of pregnancy and labor occurring, it produces any of those formidable results whicli Deventer and other practitioners of midwifery a hundred and fifty years ago referred to obliquity of the uterus ; opinions which even at the present day are not altogether exploded. I refer to these conditions now chiefly for the purpose of impressing on you the by no means needless caution, that since uterine obliquity may depend on causes wholly beyond remedy, so prudence dic- tates that when it gives rise to no symptoms we should abstain from all endeavors at cure, which, to say the least, are needless, which very likely may be fruitless, which possibly may prove very mischievous. LECTURE XII. MISPLACEMENTS OF THE UTERUS. Versions and Flexions of the Uterus. Symptoms. Conflicting opinions concerning them ; how they may to a certain extent be reconciled. Alleged symptoms not always due to misplacements. Evidence of statistics; production of symptoms connected with other causes acting on the womb. Enumeration of symptoms, and separate examination of each. Diagnosis. Use of the sound. Treatment. Historical sketch of opinion and practice on the subject. The uterine supporter; reasons for rejecting mechanical contrivances, and for preferring palliative treatment. Plan of treatment described. "We have hitherto been occupied with the examination of the nature of the various versions and flexions of the uterus, and have had occasion, in the course of this inquiry, to notice conflicting opinions and opposing statements which it was very difficult, wliich it was sometimes indeed quite impossible, to reconcile. Such dis- crepancies become more numerous and more frequently irrecon- cilable as we pass to the study of the symptoms which these mis- placements produce, and to the consideration of the treatment that they require. The symptoms are by some described as being 1 Von den Duverneyschen Drilsen des Weibes, und der schiefen Gestaltunr/ iind Layc der Gebdrmutter , 4to., Heidelberg, 1840. SYMPTOMS OF FLEXIONS OF THE WOMB. 171 both numerous and characteristic, and the appropriate treatment' is by them alleged to be both simple, safe, and successful; while others deny that the malpositions taken by themselves produce any symptoms, and assert that tlie proposed treatment, while attended by very considerable risk, is wholly inadequate to the removal of the evil which it is intended to cure. Each of these opinions, too, is maintained by men equal in the eminence of their position, in their practical experience, and their good faith.^ The alleged results of these uterine misplacements maybe briefly stated to consist in disor(|er of menstruation, wdiich is usually both excessive and painful, in leucorrhocal discharge, in pain and diffi- culty both in defcci\tion and micturition, and in pain in the pelvis generally, though usually most severe in that part of the pelvis towards which the fundus uteri is turned or flexed, while sterility is a farther consequence stated to be produced by flexions of the womb in a very large number of instances. In these symptoms it is obvious that there is much that of itself cannot be regarded as pathognomonic of one uterine aflection rather than of another, since they constitute just that train of ailments which, in varying combinations and with varying intensity, we meet with in almost every disorder of the womb. To this, however, it would not be right to attach much importance, since the uterine ailments that manifest themselves by some one characteristic symptom, or by characteristic combinations of symptoms, are very few indeed. Just as sickness may depend on sympathetic disturbance of the stomach during pregnancy, or on irritability of the organ conse- quent on some exhausting disease, or on the presence of sarcinpe in its cavity, or on the development of cancer in its walls, so may the same symptoms depend in one case on trivial disorder of the womb, in another on its incurable disease. The symptoms are like the alarm-bell, which gives notice of a something wrong, and serves to awaken attention ; it is not fair to expect that they should at once inform us not merely what part sufters, but what the exact cause is on which those sulFerings depend. Another circumstance, however, has been much insisted on as proof of the unreality of the alleged symptoms of tliese misplace- ments — namely, that in many instances where accident has re- vealed the existence of uterine misplacement, the functions of the womb were ])erformed in all respects naturally and painlessly. But from this fact we must be careful not to draw too wide an inference, for even the early stages of uterine cancer ]^ass not in- fre((uently unrevealed by any symptoms of disorder of the womb; and fibrous tumors often attain a great development before their existence is suspected, or a lull of their symptoms takes place so complete and of such long continuance that careful examination alone convinces us of the persistence of the evil which had pro- 1 Tlio pnljlisliod report (if tlie discussion at Paris on tiiis subji'ot, coiitaiMcd in the liiillrtin Or I'AcadSinie de Meile.cine for 18r)3-r)4, vol. xix, pp. 778-97(j, is a most reniarlcahle illustration of the extent to which, in an uncertain science, ditJerenco is possible. 172 IMPORTANCE OF FLEXIONS duced them. There is a French phrase which expresses excellently well the character of those in whom both these misplacements and other uterine ailments are generally attended by the most urgent symptoms: they are persons quis'ecoutent vivre, — who watch them- selves live ; and the ailments of which another would be barely conscious, are to them sources of exquisite torture. The ailment may be a real one, and yet it may be the wiser and more hopeful course to try to remedy the state of constitution which exaggerates the patient's suft'e rings, rather than to meddle with the local affec- tion that excites their present manifestations. But there are facts of a different kind which show that the im- portance of these ailments has probably been overrated; and they are furnished by cases where the removal of the misplacement, though no other uterine ailment was discoverable, has not been followed by any mitigation of the patient's sufferings; as well as by others in which the symptoms once present have ceased, in spite of the persistence of the misplacement. A woman, aged twenty- two, had been married four years, during which period she mis- carried four times; on the last occasion, at the sixth month, seven months before coming under my care. She suffered from the date of her last miscarriage from pain, leucorrhcea, and profuse men- struation, accompanied by discharge of coagula; and on examina- tion her uterus was found retrofiected, the fundus being directed not only backwards, but also to the left side. Twenty-seven months after her last abortion she became pregnant, but the misplacement continued during the early months of pregnancy, as was ascertained by examination. She gave birth to a live child at the full period of utero-gestation, and expressed herself as feeling afterwards per- fectly well ; but her womb was still retrofiected, and I found it occupying its old position fifteen months after her delivery, or four years and a quarter after the miscarriage to which she originally referred all her sufferings. A woman, twenty-eight years old, had been married nine years, had given birth to one child in the second year of her marriage, and five years before I saw her had undergone some operation for the removal, as she said, of a uterine tumor. Ever since this operation she stated herself to have suffered from leucorrhoeal dis- charge, with pain of a burning character in the neighborhood of the uterus, much aggravated by defecation or by sexual intercourse, and being especially severe at the menstrual periods. The peri- neum was somewhat torn, the uterus low down, its orifice circular, with perfectly smooth edges, and its posterior lip was connected firmly to the posterior vaginal wall, and cicatrices ran from it for some distance to the left side of the vagina.^ The uterine sound entered easily with its concavity directed backwards for two inches 1 It is not without interest, as illustrative of the futility of many of the sugcces- tions made for the cure of these ailments, to notice the existence in this case of that very condition of adhesion between the cervix uteri and the vaginal wall, on tlie production of which by surgical interference M. Amussat has insisted as so im- portant a means of cure. OF UTERUS OVERRATED. 173 and a half; on turning it round the tumor completely disappeared. For the first four or five' days after the replacement of the uterus the patient expressed herself as feeling much relieved; but her symptoms then returned, and have continued just the same as before for four years and a half, during which time I have had the opportunity of frequently examining the condition of tlie uterus, and have always found it occupying its natural position. But be the value of cases such as these what it may, as proving on the one hand that flexions of the womb do not of necessity give rise to any suffering, and on the other, that the removal of a flex- ion of the organ may not be followed by the least relief to a pa- tient's distress, the fact still remains, that misplacement of the womb is in very many instances accompanied by various uterine ailments, such as were not experienced before its occurrence. The question, however, suggests itself with reference to these cases, as to whether their history presents any peculiarity which would war- rant our believing.that the symptoms are due not simply to the mis[)lacement, but to some other morbid condition witli which the misplacement is associated, or to the two causes together ? Xow, there are circumstances which appear to favor the opinion, that in the majority of instances the symptoms are due not to misplace- ment alone, but to misplacement accompanied by some other mor- bid state of tlie womb. The fact, that of 131 instances of version or flexion of the womb,* 115 .occurred among married women, 16 only among those who were single, tends to connect it with the performance of the liigh- est functions of the sexual system — with pregnancy, delivery, and their consequeuces. This view is further confirmed by the cir- cumstance that the age at which the majority of women sufter from its symptoms coincides with that period of life at which those functions are in most active exercise. Valleix states that the majority of his patients referred the commencement of their ail- ments to between the ages of twentj^ and thirty years ; while the fact that forty-nine out of the sixty-three patients of whose cases I have preserved a record were under forty years old at the time of their coming under my cai'c, points in the same direction. Moreover, in thirty-four out of fifty-seven cases of married women referred to by M. Valleix, and in twenty-one of my fitty-eight (or twenty-one of forty-six, if for the moment twelve cases where marriage liad proved sterile are omitted), the patients referred the commencement of their ailments to delivery or miscarriage ; to a time, in short, when the womb was larger, heavier, and more alnindantly supplied with blood than at other seasons, when its recently stretclied supports were less able than at other times to keep it in its proper position, and when those attacks of circum- scribed peritonitis, by which adhesions are ])roducod between it and the adjacent parts, are specially likely to occur. The case ' The above numbers are derived from the sixty-eight cases of Valleix, with sixty-three of my own. 174 / SYMPTOMS OF UTERINE related in the last Lecture (p. 162) shows how in these conditions the enlarged uterus may be retroverted, and shows further how, in spite of its gradual reduction in size, the misplaceuient may still continue ; its symptoms /.aggravated after each fresh miscar- riage, which reproduced, though in a slighter degree, the same train of evils as attended the first occurrence of the accident. Ot the remaining thirty seven' patients, three had fibrous tumors in the uterine walls, so that the misplacement of the womb might be regarded as in part due to their presence, while in a fourth there was a small tumor, probably ovarian, behind the uterus, which not merely retroflected it, but having become adherent both to the womb and to the rectum, prevented the uterus from resuming its proper position even after the tumor, in which suppuration took place, had discharged its contents by the bowels ; and in a fifth the misplacement was apparently consequent on the formation ot an abscess between the uterus and rectum, by which the organ had been retroverted and finally bound down by adhesions in its unnatural position. Four patients, one of whom was unmarried, referred their symptoms to a menstrual period, which had been attended by an unusual amount ot suflering, and one dated them from intemperate sexual intercourse. Once the symptoms suc- ceeded to an attack of vaginitis, which was most likcl}- accom- panied by peritoneal inflammation, since the anteflected womb was bound down in its unnatural position ; and in one more, in whom the enlarged and anteverted womb was similarly fixe.d in the pelvis, there was a history of abdominal pain and tenderness occurring causelessly five years before. Six times the accident seemed to have succeeded to some sudden violent exertion, and in one instance (that in which the symptoms persisted after the removal of the misplacement), the patient dated her suftering from some operation performed five years previously, apparently for the removal of a polypus. There still remain twenty patients, con- cerning the cause of w'hose ailments no adequate explanation is given. It is not without interest, however to observe that in al- most all of these cases, the symptoms had come on very gradually, and the misplaced uterus was in the great majority of instances much enlarged. The subsidence of the symptoms and the diminu- tion in size of the womb took place simultaneously. Sometimes as the organ grew smaller, it resumed its natural position of its own accord, while in other cases it remained misplaced, but there did not seem to be any invariable connection between the com- pleteness of the patient's recovery and the return of the womb to its proper situation. It seems, then, that in by far the greater number of instances, the development of all the symptoms of flexion or version of the uterus coincided with the operation of some cause that increased the size of the w^omb, or produced congestion of the pelvic viscera; and further, it may be added, that the almost immediate relief which followed rest, local depletion, and the due regulation of the bowels, seems to show that to these associated ailments, rather FLEXIONS ACCOUNTED FOR. 175 than to the mere misplacement of tlie womb, the patient's siifierings were to be attributed. IN'ot infrequently, however, the relief, though striking, was of short duration ; and the patient had not long followed hpr usual avocations,,or not long returned to her husband's bed, before many of her former symptoms returned. But tliis is by no means peculiar to misplacement of the womb ; for we SCO illustrations of it in the increased suffering which, in almost every uterine ailment, attends upon the menstrual period, and iu the aggravation of all previous uterine discomfort, which in many women succeeds to marriage, and which is sometimes the occasion of ailments being brought to light whose very existence was pre- viously unsuspected.^ A woman, aged thirty-five, was admitted into St. Bartholomew's Hospital, and gave the following history of herself: She had been married eleven months, but had never been pregnant. Previous to her marriage her health had been good, with the exception that menstruation, though regular, was always very painful. Since her marriage, however, she had suffered much from constant aching pain round the loins, felt most in walking, and constant desire to pass water, while her menstruation had become very frequent in its return. On making an examination, the os uteri, which was small and circular, was found directed backwards ; while above the anterior wall of the vagina a tumor of a rounded form was felt pressing forward against the bladder, and could also be dis- tinguished by means of a sound introduced into that organ. I imagined the body to be formed by the anteflected uterus; though, after careful and repeated examinations, in the course of which I endeavored successfully to introduce the uterine sound, I changed this opinion, and came to the conclusion that it was a fibrous tumor growing from the anterior uterine wall. Whichever view be cor- rect, the case equally well illustrates the fact that a uterine ailment may remain quiescent, as far as the production of symptoms is concerned, for an indefinite period, while yet it may be the cause of much suffering, if any accident gives rise to an increased afflux of blood towards the womb. Bearing in mind, then, their compound origin, we may next inquire into the nature of the symptoms that usually accompany veik^ions or flexions of the womb. In the two instances where the misplacement occurred suddenly as the result of over-exertion or straining, much pain was at once experienced, and was referred to the neighborhood of the uterus; while in the case of retrover- sion there were considerable difficulty in micturition and frequent 1 This estimate of the ordinarily small importance of simple uterine flexions coincides very closely with the conclusions at which Scanzoni ha.s arrived, and wiiich he holds so decidedly that he jirints in large type in the third edition ol" his boOk. '' P'lexions of the uterus are never of much imjHirtance, nrvcr give rise to serious evils, except when some other atfection of the uterine suhstance is associated with them."— 0/>. cit., p. 90. The conclusion, too, to which ^V. Hernutz is con- ducted by his and M. Goupil's elaborate investigation is, that "uterine deviations, with till.' exception of descent and prolapsus of the organ, giv(> rise, when uncom- plicated, to no kind of functional disorder." — Op. cit., vol. ii, p. 717. 176 SYMPTOMS OF UTERINE desire to pass water. In other cases, however, the supervention of the symptoms was gradual ; discomfort ahout the pelvis accom- panied by unusually profuse, and often unusually painful men- struation, being the symptoms which first excited the patient's notice, and by their persistence and their increase, compelled her to seek for relief. The following were the more prominent symptoms in the sixty- three cases of version or flexion of the uterus of which, down to the present time, I have preserved a record : In the total In twenty of them the uterus was sixty three cases. auteverteii or anteflexed. Menorrhagia, .... 20 3 Dj-smenorrhoea, .... 20 8 Leucorrhoea, .... 25 8 Pain, or other discomfort 1 ni 7 in micturition, . . / Pain, 51 17 Difficult or painful defe- } 24 3 cation / Of the above sixty-three patients, fifty-eight were married, of whom twelve were sterile. The remaining forty-six, of whom all but one were under forty years of age, had given birth to one hundred and twenty-four children, and had had forty miscarriages; numbers which yield results ditt'erent but little from those which we meet with among persons afllicted with uterine disease in general ; and whose labors amount to 2.7, their miscarriages to 0.47 to a marriage, while one in 8.5 of the total number proves sterile. The above enumeration of symptoms, and of their comparative frequency, which tallies in the main remarkably with the state- ments of M. Valleix on the subject, must be sufiicient to show that either the misplacement itself, or the state of the uterus associated with it, is adequate to produce much positive sufiering and much functional disorder. The pain which was experienced in all but twelve of my cases, and in sixty-four out of sixty-five of those of M. Valleix, varied much in its intensity. It was a constant sense of pain and aching in the back and loins, and of pain shooting down the thighs ; often, though not always, accompanied by a sense of bearing down, and by sensations of the same kind a^ in general attend ordinary descent of the womb, though more dis- tressing in their character. In very many sexual intercourse was attended by great pain, while the sufiering it produced had led in some instances to its complete discontinuance. Those patients in whom the abiding pain was the most considerable sufiered also from occasional attacks of paroxysmal pain, which was sometimes of extreme intensity, and had the character of hysterical colic such as one meets with occasionally in various uterine ailments, and such as is especially associated with dysmenorrhoea. I have not been able to ascertain that there is any constant relation between the direction in which the womb isfiexed and the seat of the pain in the anterior or posterior part of the pelvis, though difficult and FLEXIONS ACCOUNTED FOR. 177 • painful defecation appears to be much more frequent in cases where the womb is retroflexed or retroverted than in those where it is turned or bent forwards. I doubt, however, very mucli the extent to which any of these symptoms can be referred to the mere mechanical effects of the clisphacement of the womb, for in five out of the fourteen cases in which difficult micturition attended misplacement of the womb backwards, the organ was retroflexed and not retroverted, and consequently the bladder was subjected to no kind of pressure ; while, moreover, in thirteen cases of ver- sion or flexion of the womb forwards, the bladder was relieved without cither pain or difficulty. Pain and difficulty in defecation, too, are by no means such constant attendants upon retroflexion as might be reasonably expected if they depended upon a simply mechanical cause. The symptom was, indeed, for a long time regarded as of purely mechanical origin, and the presence of mucus in the evacuations was looked upon as conclusive evidence of the irritation of the bowel by the misplaced womb. Further observa- tion has shown, however, that this symptom is by no means con- stant in cases even of very marked retroflexion ; that further, it is often absent in cases where the growth of fibrous tumors from the posterior wall of the uterus exerts very considerable pressure on the bowel, while it is far from uncommon in various uterine ail- ments attended with much irritation of the neighboring viscera, even though unaccompanied by any enlargement or misplacement of the womb. The same fact holds good still more absolutely with reference to constipation, for the retroflected fundus is never found so to compress the rectum as to interfere with the easy intro- duction of the finger into the bowel, and consequently cannot mechanically prevent the escape of its contents; while further, no accumulation of ffeces is found to take place above the fundus of the womb ; and lastly, constipation, even more obstinate than that observed in these cases, attends upon a large number of ailments, especially of an aneemic or hysterical kind, in which there is no local affection of the uterus. The leucorrhoea, the dysmenorrhoea, and the menorrhagia, though of very frequent occurrence, are perhaps less characteristic than the symptoms already enumerated, inasmuch as they are frequent attendants upon so many uterine disorders. It is, however, worth notice that the forty instances of disturbance of the menstrual function occurred in thirty-nine different persons ; but I am not prepared to state that there was greater flexion of the womb where the menstruation was most painful than in other cases, or more marked enlargement or ap- parent congestion of the organ where the menstruation was most profuse. Lastly, with reference to the influence of these conditions on fecundity. Of the fifty-eight married women one had become a widow, and one had passed the childbearing age, before any symptoms of uterine ailment appeared, while in seven the symp- toms were of less tlian a year's duration, and consequently there 12 178 UTERINE FLEXIONS: had not been time for the influence of the ailment in this respect to become evident. Of the remaining forty-nine, six gave birth to live children at the full period, after the womb had been misplaced; and one of this number had five live children at the full term of utero-gesta- tion, in spite of the existence for fifteen years of all the signs of retroflexion of the uterus. In one of the above six, pregnancy was preceded by the replace- ment of the organ ; but in the other five, not only was the womb misplaced at the time of conception, but was ascertained to con- tinue so after delivery. Five having previously given birth to living children, miscarried after the development of symptoms of uterine misplacement; and in one of the number miscarriage had twice occurred, and in an- other eleven times, while twenty-one, having previously given birth to one or more living children, had passed more than a year since the commencement of the symptoms without conceiving. In six of this number, however, though still within the childbearing age, conception had not taken place for from two to five years previous to the commencement of tiie symptoms of misplacement of the womb. The above detail of symptoms shows, I think, that while versions and flexions of the womb by no means invariably produce either local suftering or functional disturbance, their presence or absence is yet far fron) being a matter of indiftcrence, and we must admit them as constituting a distinct class of by no means unimportant ailments of the womb. But even though they were themselves of but little moment, it would nevertheless be very necessary that we shouhl learn to dutinguhh them from other and more serious uterine ailments, with which some of thcin are, on a superficial examination, very likely to be confounded. With ordinary care, indeed, any misplacement of the whole uterus, assuming, as it usually does, the form of retroversion, can scarcely be overlooked or mistaken, for the fundus uteri thrown backwards, and often downwards, into the hollow of the sacrum, and the mouth of the womb directed forwards, and tilted upwards against the symphysis of the pubes, are characteristic indications of the change in its position. The sources of fallacy are, however, far more numerous in those cases in which the organ is flexed and its body is bent upon the cervix, producing a tumor which may be mistaken for ovarian disease, or for a fibrous tumor of the uterus, or for one of those extravasations of blood around the substance of the womb, to which, under the name of uterine h?ematocele, atten- tion has of late years been especially directed. In cases where the uterus is bent forwards, the sources of error are less numerous than in cases of its retroflexion, and I am not aware of anything except a fibrous tumor of the anterior uterine wall which is likely to throw uncertainty upon our diagnosis, though I have found the discrimination between flexion of the womb and the presence of a fibrous tumor in its wall to be sometimes so difficult as to be THEIR DIAGNOSIS. 179 almost impossible. The tumor formed by a flexion of the womb usually begins immediately above its cervix, and the substance of the organ may be traced passing over into it. At the same time no enlargement of the uterus can be felt by the finger carried in front of the cervix in cases of retroflexion, or behind it in cases of anteflexion, while if the patient lie upon her back, and pressure is made with one hand over the pubes and the other in the vagina, the absence of any pelvic tumor may in general be readily ascer- tained. Moreover, in many instances, pressure with the finger in the vagina upon the uterine tumor imparts to it a degree of mobility without at all altering the position of the cervix, such as would not be possible in the case of a fibrous outgrowth from the organ. This, however, is not always practicable ; for on the one hand, the tenderness of the flexed womb not infrequently prevents any steady pressure upon it being borne by the patient ; and on the other, steady and long-continued pressure does not always modify the position of the organ, — and this even though no morbid adhesion connect its fundus with adjacent parts. In a very large number of the doubtful cases we should remain in uncertainty for a very long time, and come at length to a hesitating decision, if it w^ere not for the help afforded us by the uterine sound. If this instrument is introduced with its concavity directed either back- wards or'forwards, according as the tumor is situated in front of the cervix or behind it, and if it be then gently and carel'uUy turned round, we shall find that the tumor, previously so distinct, will completely disappear, though often to be immediately repro- duced with the same character, and of precisely the same size as before, the moment that the instrument is withdrawn. The sound affords at the same time the opportunity of ascertaining the per- fect mobility of the uterus, and the absence of any such increase of its weight as the existence of a tumor in its walls must of necessity occasion. Valuable, however, as is this means of diagnosis, it is yet not without some sources of fallacy, while its emploj-ment leads occa- sionally to no satisfiictory results. The instrument will sometimes not pass beyond the internal os uteri ; and though pressure upwards against the tumor, so as to lessen the bend of the cervical canal, not infrequently enables us to introduce it, yet this is not always the case ; and I need not say that force is never allowable in order to overcome the difficulty. But even in these cases, the absence of any considerable sense of weight when the organ is poised upon the instrument strengthens the presumption against the existence of any uterine tumor. Further, a fibrous tumor projecting into the recto-vaginal pouch may present many of the characters of the retroflected womb, while tlie fact that such a growth not infi-e- quently flexes the organ, and causes it slightly to deviate from its natural direction, increases the probability of error. ■ If, too, on turning round the sound after its introduction, the handle of the instrument be much de])ressed, its other end will of course be cor- respondingly raised, and a uterine tumor being thus carried out 180 DIAGNOSIS OF of easy reacli of the fingers, may apparently disappear, and the case be thus mistaken for one of simple flexion of the womb. The safeguard against this error is found in the precaution of not other- wise altering the position of the sound, when the instrument is turned round. The existence of adhesions, indeed, prevents any attempt at replacing the flexed womb from being successful, and thus deprives us of one means of diagnosis, though even in such cases the direction in which the sound enters with facility, and the fact that in no direction but that one will it enter at all, are not without value. Ovarian tumors are almost always larger and more spherical than the retroflected fundus uteri, and the finger will in general detect the body of the uterus driven forwards by the tumor, while with the finger of one hand in the vagina, and the other hand over the pubes, the practitioner will in general be able to satisfy himself as to the exact relations of the organ, even though attempts to introduce the sound should not be successful. The same statement aUo holds good with reference to uterine hsemato- cele, and further, the tumor which it produces does not usually present the same degree of resistance as the retroflected uterus. One of the largest uterine hsematoceles, however, which has ever come under my notice had produced complete retroversion of the organ, and thus rendered diagnosis very difficult. In such a case, and indeed in others where tumors have flexed the womb, or have much altered its position, the risks of error are very great indeed. I do not mean to claim for the sound the advantage of always enabling us to come to a correct conclusion, but only to express my conviction that it is a very valuable help to diagnosis, and that it restricts the doubtful cases within very narrow limits, and enables us in the great majority of instances to express ourselves at once and positively with reference to questions which otherwise would often be very obscure. Lastly, we come to the consideration of the appropriate treatment of these misplacements; a question which has received two difl'er- ent answers, according as practitioners have confijied themselves to the endeavor to remove those ailments with which the malpo- sition was associated, and to which the symptoms appeared to be directly due ; or, as they have aimed at something more, and have attempted to restore the uterus to its right position, and to maintain it there by mechanical contrivances. Of the continental writers who first called special attention to these misplacements of the womb, Schweighauser contented himself with the employment of remedies calculated to remove the constipation, and to relieve the congestion of the pelvic viscera, and states, that having accom- plished these objects he found that the uterus returned invariably to its proper position ; and Schmitt also coincided, in the main, in the same opinion. A view, in many respects similar, has been ably aidvocated by Dr. Oldham,^ who regards the misplacement of the womb as being invariably the secondary consequence of its 1 Guy's Hospital Rejwrts, second series, vol. vi. FLEXIONS OF THE UTERUS. 181 enlare^ement, and insists on the special advantages of the use of the hichloride of mercury in removing this condition. Schmitt attempts in his essay to discriminate hetween cases of primary misphicement of tlie womb, and those in which its altered position is secondary to some enlargement, or to some inflammatory affec- tion of the organ. He never employs any means for the purpose of replacing the womb so long as either constitutional disturbance or local tenderness of the uterus is present, and recognizes the frequency of spontaneous re]>lacement of the womb after their removal ; for accomplishing which he trusts, like Schweighiiuser, chiefly to rest, and to the due evacuation of the intestinal canal by the regular administration of saline aperients. If the misplace- ment should still continue, or if the case was already chronic in character at the time of its coming under treatment, he apiiroves of careful attem})ts being made to replace the womb. These at- tempts consist in pressure upon the fundus with the finger in the vagina, or sometimes in the rectum, and he throws out the sugges- tion that possibly in some instances a contrivance employed by Professor Richter, of Moscow,' for replacing the womb retroverted in pregnancy, may be of service. As a subsidiary means tending to promote the replacement of the organ, Schmitt further recom- mends that the patient should lie upon her side with the hips raised, an attitude to be changed oidy for that on the abdomen, and that she should carefully avoid lying on the back; recommen- dations, all of which are much insisted on by many practitioners at the present day, who place their patients on the prone couch in every case of retroversion or retroflexion of the womb. Lastly, whenever the disposition to retroversion of the v»'omb continues in si»ite of treatment, lie employs one of Levret's disk [lessaries, made with an aperture sufliciently large to admit of its embracing the neck of the womb ; following in this Levret's own directions as laid down in his pa[)er on anteversion of the womb.^ This essay of Schmitt's, to which the particulars of nine cases are appended, and which is even at the present day by far the most complete and most valuable contribution to our knowledge of the subject, continued to be the guide of practice in Germany until the publication of Dr. Simpson's ingenious observations. Dr. Simp- son not only drew attention in this country and in France to the frequency of these misplacements, which had previously been so much underrated, but he also insisted on their mechanical rectifi- cation as the most important means of removing their symptoms, and suggested a novel contrivance both for replacing the womb and for maintaining it in its position. His first proposal, to replace the womb by means of the uterine sound (an instrument which owes almost all its practical utility to 1 See Kichler's Synopsis Praxis Medico-ObHietricicp, 4to., Mosqua;, 1810, plato ii, p. 70, for a description of this instniinont, which was composed of a oiirvtd stem of wood, terminated by a kind of plufr, wliich was covered with a cushion, and was intended to answcsr the jturpose of a loni; and strong finger in replacing the womb. * Already referred to in Journal Ue Medccine, etc., p. -80. 182 FLEXIONS OF THE UTERUS. the alterations wliicli lie lias made in its form), seems to have heen anticipated by Osiander in 1808,^ who describes the introduction of a slightly curved instrument into the retroverted Vonib, by turning w^liich round, the fundus uteri was at once restored to its proper position. Osiander's suggestion, however, was disregarded, and his facts were discredited and soon forgotten. Velpeau claims^ the invention of a pessary with a somewhat elastic stem projecting from the centre of a semicircular disk. The disk being turned forwards in cases of retroversion, and backwards in cases of the opposite kind of misplacement, the tendency of the elastic stem would be gradually to restore the womb to its proper position, and gently to maintain it there. His trials, appear, however, by his own admission, to have been but few, and their results were not encouraging. Dr. Simpson, believing that in the great majority of instances the symptoms associated with misplacement of the womb, and also the changes which the organ may present, are mainly dependent on its malposition, insists on the reposition of the womb, and on the employment of mechanical means to secure its continuing in its place. He proposes to accomplish the first object by means of the uterine sound, and the second by means of a wire stem intro- duced into the cavity of the womb, and maintained there by suitable contrivances. This instrument underwent several altera- tions in Dr. Simpson's hands, and although it has since been modified by the late Professor Kiwisch of Prague, yet Simpson's uterine supporter, with the improvements devised by M. Valleix, of Paris, appears to me to be by far the safest, and the best adapted for its purpose. Dr. Simpson's paper was not accompanied by any detail of cases, and contained scarcely any hint as to possible dangers or difi&culties in the employment of his instrument. The attention of practi- tioners in this country had been called by him to an ailment, the possible occurrence of which they had previously scarcely recog- nized, while the simplicity and ingenuity of his proposed means of cure recommended it to almost universal adoption. Some doubts, indeed, were expressed on theoretical grounds, as to the probable result of maintaining a foreign body for weeks or months together in the uterine cavity. These were, however, silenced for a time by the detail of cases by different writers, in which the instrument was worn for a long period, not only without injury, but with very obvious advantage. Still, by degrees, unfavorable results began to be more generally heard of ; much uterine pain, almost constant leucorrhoea, associated with a distressing sense of pruritus; menor- rhagia, and hemorrhage between the menstrual periods, were found to be of no very rare occurrence. The advocates of the mechanical treatment of these ailments, too, became in time impressed with 1 Med. Chir. Zeiiung, 1808, vol. iv, p. 170, as quoted in a note at p. 54 of Sclimitt, op. cit. 2 Lib. cit. p. 102. OBJECTIONS TO THE UTERINE SUPPORTER. 183 the necessity for greater caution. They not only removed the in- strument at the menstruiil periods, which at first they were not accustomed to do, but tried to liabituate the womb by degrees to its ])resence, introchicing it at first for an hour or an lionr and a half at a time, while some even recommended that it should on no occasion be allowed to remain longer than three or four hours within the womb. Inconveniences such as these, the incomplete- ness of the patient's temporary recovery in some instances, the fre(iuency of her relapse in many more, the occurrence of serious inflammation of the wojub, or of dangerous peritonitis, and some instances of death from the use of the instrument, have now led to its almost universal discontinuance. It is probable that in a few years more the uterine supporter and its uses will have become mere matter of history. It would not, however, be right at present merely to condemn it without at the same time assigning the reasons which appear to have led most practitioners to abandon it. 1st. The safe employment of the instrument requires that, as a general rule, its use should be continued for only a very few hours at a time ; a necessity which implies that every woman who is submitted to this mode of treatment shall undergo two vaginal examinations every day, the one for the introduction of the instru- ment and the other for its withdrawal. 2d. The quietude which its use imposes, and the restriction to which the patient is compelled to submit in order to avoid severe sufiering and the risk of serious danger, are at least as absolute in their kind and as irksome to be borne as those which any other mode of treatment involves, while it is necessary to continue them for a*s long a time. 8(1. In spite of all precautions, the treatment is generally painful, often dangerous, sometimes fatal ; and the untoward accidents have not been by any means constantly attributable to want of prudence cither on the part of the practitioner or of his patient. 4th. Cure, even by the long-continued employment of this means for several months, is uncertain, while relapses are very frequent after the mechanical support is discontinued ; besides which the permanent cure of the misplacement is far from being always followed by the cessation of the symptoms.' ^ To meet assertions by mere counter-stntement is invidious, and carries no convictions to those whose opinions difter from our own. I will therefore adduce here the testimony of two men wliose position and character entitle their opinion to especial weiejht. In the discussion before the Academy of Medicine at Paris, M. Dubois stated that he had himself treated more than twenty patients by means of the uterine supporter, which in some instances vv.'is worn for several months, but tiiat the misjilacf'ment re|)r(>duci>d itself within a very short time after the removal of the instrument; and that hr. had mach; a similar ohservatioti in tlie cast? of many patients who, havinuj been thus treated by 31. Valleix antl Dr. Simpson, had been dismissed by those ejenthmien as cured. Professor Scanzoni, in a note appended to the fourth edition of Kiwisch's work on the Dlfseases of Women, which he edited after the author's death, makes thcfol- lowini^ statement : " The observation of fifty-six cases of flexion of the uterus during the past four 184 TREATMENT OF On these accounts, though I have tried the uterine supporter in a few cases, I have now for some time quite given up its em- ployment, and content myself with a mode of treatment, which, though it seems to promise less, yet almost always affords great relief, while in a large number of instances it quite removes the patient's sufferings, and is not infrequently followed by the com- plete rectification of the position of the womb. I believe, too, that even they who were the most strenuous advocates of the uterine supporter in this country have silently almost renounced its use ; and M. Aran^ states that M. Valleix, who strove with so much abilit}' to introduce it in France, '' had towards the close of his life, almost completely abandoned its employment, substituting for it the replacement of the womb with the uterine sound, fol- lowed by the introduction of an air pessary either in front of the womb or behind it, according to the direction in which the flexion had taken place." The principle upon which I act in the management of these cases amounts pretty much to this : that to the best of my power I take care of the general symptoms, and leave the misplacement to take care of itself. In a very large number of instances the misplacement succeeds to delivery or to miscarriage, and the womb is, as might be anticipated, in a state of imperfect involution. In these circumstances rest for a season in bed or on a couch, occa- sional leeching if there be much tenderness of the organ, and the strictest attention to the condition of the bowels, which should be kept freely open by moderate doses of saline ap*erients, seldom fail speedily to relieve the congestion of the womb and of the pelvic vessels, and to place the organ in the most favorable condition for the accomplishment of those processes by which its bulk may be reduced. With the approach of each menstrual period, precau- tions should be redoubled, for menstruation is very often excessive in quantity, and also irregular and over-frequent in its return ; anticipating the proper time of its reappearance, and, moreover, after its apparent cessation coming on again causelessly or on the slightest occasion. In proportion as this evil is chronic, may we use more decided means to check it. The sulphuric acid and sulphate of magnesia if the bowels be at all constipated, the sul- phate of alum if that condition do not exist, or the gallic acid or infusion of matico, rnay be given internally, accompanied, if there years compels me to express my decided conviction that the mechanical treatment of this affection so elaborately set forth by the author is either useless or positively mischievous." After adducing some reasons for this opinion, he concludes: "I will merely add, that since I have quite discontinued leaving the sound in the uterus, emploj'ing the uterine supporter, and so on, and have contented myself with the use of cold vaginal injections, with the antiphlogistic treatment of any chronic uterine inflammation, and the application of caustic to any ulceration of the OS uteri, and with the endeavor to remove the chlorotic symptoms which are seldom absent, I have been much better satisfied with the results of my treatment than I was at the time when I allowed myself to be seduced into the application of a variety of mechanical contrivances." — Op. ci^., vol. i, pp. 135, 136. 1 Op. cit, 1015. UTERINE FLEXIONS. 185 be niueli pain, with the tincture of henbane, or of Indian hemp, neither of which has the same tendency as opium to produce coiistii)ation. Cold enemata twice a day may be employed after the second or third day of the discharge, and in more ol)fetinate cases, even vaginal injections of matico or alum. I have not, however, ventured upon those intra-utcrine injections or cauteriz- ations of the inner surface of the womb Avhich Kiwisch sometimes resorted to, both during the presence of the catamenia and also in the intervals between their flov/. In almost all cases of these ailments, a state of general debility, often of very considerable anajmia, is present, and chalybeate remedies are therefore nearly always of service. As a general rule, there is none more suitable than the combination of iron with an aperient salt, which I recommended to you when speaking of the management of cases of menorrhagia.^ It is obvious, however, that 3'our prescriptions may here, as in other cases, require to be varied according to the idiosyncrasies of your patient or the pecu- liarities of her case. After the general uterine tenderness has been diminished if necessary by previous leeching, recourse may be had with advan- tage to the cold douche, which both restrains hemorrhage and leucorrhoea, lessens congestion, and tends to bring about contrac- tion of the lax tissues of the enlarged womb. Sometimes, how- ever, the douche occasions pain ; and Avhen this is the case, the cold hip-bath, cold sponging of the loins, and cold vaginal injec- tions may be substituted for it, since, though less efficacious, they exert a similar influence. Pain, referred to one or other ovarian region, and varying in severity much and causelessly, is a very frequent attendant on these malpositions of the womb. It is generally much relieved by counter-irritation, by means either of small blisters not kept on for a sufficiently long time to produce vesication, by the em- ployment of a croton oil liniment, which must be applied by means of a piece of sponge, not rubbed into the part ; or by the use, if the skin be very irritable, of the milder liniment of aconite and belladonna.^ As in the course of other uterine ailments, so in these, there are occasional attacks of violent paroxysmal pain, which, though not limited in their occurrence to the menstrual periods, are more apt to come on at those times, and sometimes call for immediate relief. The local application of chloroform often gives ease ; and the mitigation of suticring which it jtrocures frequently continues. I have, however, in a few instances, known the j»ain to be more severe and more lasting than tiie remedy so ajiplicd could remove; and when that is the case, its present intensity may be relieved by inlialation of chloroform, and its return prevented or mitigated by the occasional use of opiate enemata, or by the administration of camphor and morphia, or camphor and bellatlonna, which 1 See Forinula No. 1, p. 4G. * See Formula No. 10, p. TJl. 186 TREATMENT OF FLEXIONS OF THE UTERUS. last remedy, though somewhat uncertain, is often of very great utility. But you may inquire whether in these cases I reject not only the use of permanent mechanical supports for the uterus, but also the employment of mechanical means for its replacement? Now, I believe that, with the exception of those rare instances in which the misplacement is the result of some sudden shock or violence, mechanical interference is rarely desirable ; and that the womb will of its own accord gradually revert to its proper position, or, continuing misplaced, will cease, when its attendant ailments liave been removed, to give rise by its mere misplacement to any incon- venience. While, therefore, I use the sound as a means, and I believe a very valuable means, of diagnosis, I do not resort to that frequent replacement of the organ by it which has been adopted by some practitioners, who yet hesitate to leave any kind of sup- port permanently within tlie uterus. I do not follow this plan, because, while suffering occasionally remains for a considerable time after the introduction of the instrument, the womb almost invarial)ly ftills back again to its previous unnatural position alter its withdrawal. There has been much debate about the use of pessaries in these cases, since, while still employed by some practitioners, they are decried as altogether unserviceable by others, and chiefly by the advocates of the intra-uterine supporter. It must be confessed that they are very imperfect means of support; but, nevertheless, I have seen much relief from their employment in cases of retro- flexion and retroversion of the womb. They serve to keep the uterus comparatively fixed in the pelvis, and spare it from many of the painful shocks to which the organ is otherwise almost unavoidably exposed when the patient begins to move about, and especially when she sits. They moreover diminish, in many instances, the painful straining eftbrts at defecation ; a fact which shows how much more that ailment partakes of a neuralgic char- acter than of that of a disorder due to mechanical causes. The kind of pessary which has seemed to me usually most serviceable is one of Indian-rubber, of an oval form, inflated with air, which, being introduced in the cul-de-sac between the uterus and the rectum, serves to support and to keep steady the fundus of the womb. The recent employment of vulcanized Indian-rubber and gutta percha for these purposes, and the various modifications of these instruments which the new materials have rendered possible, may probably lead to the invention of some useful varieties of pessary adapted to the peculiarities of difl:erent cases. One of these I must mention, since it acts on a difl'erent principle from others, and promises, as far as my limited experience of it at present enables me to judge, to be very serviceable in some cases of retroversion or retroflexion of the womb. The idea of the instrument is, that misplacement of the womb may be corrected by affording support to the vaginal wall, and thus rendering it unyielding. Under the name of the lever pessary, it was, I believe, INVERSION OF THE UTERUS. 187 first suggested by Dr. Hodge of Philadelphia ;^ but a preferable form a|)pears to me to be that devised by my friend Dr. Priestley, and which may be obtained of all instrument-makers. It consists of a frame of gutta percha, of the tliickness of an ordinary goose- qnill, or a little thicker, about five inches long, twisted into some- what of a fiddle shape, its upper end about an inch and a half broad, its two limbs approaching till they unite in a sort of button, and the whole instrument having a gentle curve like that of an italic /. The instrument is introduced with its broad end in the cul-de-sac between the uterus and rectum ; while to the button at the otlier end, projecting beyond the vulva, are attached four vulcanized Indian-rubber straps, which are fastened to a belt that surrounds the abdomen. These straps, indeed, are by no means constantly necessary; and I have found the pessary, when em- ployed without them, sometimes keep in its position very well, and aflbrd great comfort to the wearer. LECTURE XIII. MISPLACEMENTS OF THE UTEKUS. Inversion of the Uterus, generally occurs during labor ; sometimes spontane- oush'; symptoms usually very formidable. Its ebronic form ; tendency of it to destroy life; occasional exceptions to this rule; alleged spontaneous replace- ment of uterus. Diagnosis, and management of accident when recent; state of womb modifies chances of replacement, which are very small, except when attom]it(d immediately. Chronic Inversion, its management; extirpation of uterus ; causes modifying suc- cess of operation. Errors of diagnosis, how to avoid them ; further cautions as to best mode of operating. Inversion from Polypus. Practical cautions respecting it. Ascent of Uterus ; its various causes and diagnostic value. Those forms of uterine misplacement to which our attention has hitherto been directed, claimed our notice as much from the frequency of their occurrence as from the importance of their symptoms. We found them to be the occasion of discomfort of various kinds, and not seldom the exciting cause of much dis- turbance of the uterine functions; but in scarcely any instance were they of themselves dangerous to life, while they moreover always admitted of much palliation, often indeed of complete cure. We have now, however, to turn to the study of a form of uterine misplacement, which, though, happily of very rare occiirronee, is one of the most grievous accidents which can befall a woman, inas- much as its almost invarial)le tendency is to destroy life, while the remedy to which alone we can resort in the greater number of cases for its cure is an operation of a most hazardous kind, one 1 On Diseases Peculiar to Women, 8vo., Philndelphia, 18G0, p. 830. 188 SYMPTOMS OF wliicli mutilates the patient, and renders her forever incapable of performing the functions of her sex. Inversion of the uterus, the turning of the organ inside out, is an accident clearly impossible in the natural condition of the nnim- pregnated womb ; it being obviously essential for its occurrence that the organ should have attained a certain size, and that its walls should be comparatively yielding. It is indeed only at an advanced period of pregnancy that these conditions are generally met with, and only during labor that an exciting cause is likely to be superadded capable of producing the misplacement ; but at that time violent traction at the funis by some unskilled practi- tioner, before the detachment of the placenta, may mechanically invert the womb, or the organ may by its own contractions invert itself, just as the intestine does in cases of intussusception. The late Mr. Crosse of Norwich, in his v^ry elaborate Esmy on Inver- sion of the Uterus^ which unhappily he did not live to complete, states^ that in 350 out of 400 cases of inverted uterus of which he had found mention, the accident occurred as a consequence of par- turition ; and there can, I think, be no doubt but that the real proportion of cases in which it is traceable to this cause is much higher than seven to one. Of the remaining fifty cases, forty were said to, have occurred in connection with the presence of a polypus in the interior of the womb, the accident sometimes taking place spontaneously, in other instances resulting from traction at the outgrowth in some attempt to accomplish its removal. Almost all of those rare cases in which the uterus is alleged to have become inverted independently of either of the above causes, are deficient in such details as are needed to substantiate their correctness, and doubt may be reasonably entertained with refer- ence either to the accuracy of the diagnosis, or else as to the truth- fulness of the history related by the patient.^ Enlargement of the uterine cavity, however, associated with some cause capable of exciting contraction of its fibres, may be looked on as the two conditions essential to the inversion of the organ ; and where these two coexist, as in Dr. Thatcher's case of enlargement of the womb from hydatids,^ there the possibility of inversion taking place must be conceded. ISo instance has come under my own observation of uterine inversion in the recent state, and indeed the annals of the Dublin Lying-in Hospital and those of the London Maternity Charity sufliciently illustrate the rarity of the accident, since it was not 1 Part ii, p. 70. ^ Baudelocque's remarkable case of alleged inversion of the womb in a girl fifteen years old, who suifered from menorrhagia, appears to me to be one in which "We may be allowed to entertain some doubt as to the accuracy of the diagnosis ; while nothing can be vaguer than the history of Lisfranc's patient [Clinique Chirurgicale, vol. iii, p. 380), whose symptoms are said to have existed five years before she came under his observation. 3 As narrated in Crosse's Essay, part i, p. 57. INVERSION OF THE UTERUS. 189 once met with in a total of more than 140,000 labors/ Its symp- toms, as detailed in works on midwifery, are so appalling and so characteristic, that it would seem almost impossible either to over- look or to misinterpret them. Sudden collaj^se, accompanying abundant hemorrhage, associated with disappearance of the tumor formed by the uterus in the abdomen, and the presence of a large spherical body either just within the vagina, or projecting beyond the external parts, are the ordinary indications of the womb having been inverted; and the occurrence even of some of these accidents in the third stage of labor, or just after the detachment of the placenta, ought at once to excite the suspicions of the attendant with reference to their almost invariable cause. In spite of this, however, in a very large proportion of instances in which inversion of the uterus in the chronic state has come under observation, the accident, though clearly tracea])le to delivery, has been overlooked at the time of its occurrence, and almost the only opportunity of replacing the womb has thus been lost. Three cases of inversion of the uterus in the chronic state have come under my own observation ; but in none of them was the condi- tion discovered until some months after the patient's delivery. The history given of herself by one of these patients, who fourteen months after her delivery was admitted under my care into St. Bartholomew's Hospital, was, that the detachment of the placenta, which she believed was eftected by the hand, was accompanied by hemorrhage so profuse as to occasion syncope ; and she was told by the nurse that the womb was brought down and projected ex- ternally, but was apparently replaced by the gentleman in attend- ance. Nothing furtlier of any consequence transpired for a week from this time, when on sitting up to have a motion the body again projected externally, but was once more replaced by the nurse, since which time it had never again protruded beyond the vulva. In the case of the second patient the placenta was removed by hand ; and after a period of insensibility, which lasted for two days, inflammatory symptoms came on, but no circumstance awakened suspicion as to the existence of inversion of the uterus. In the third case the placenta came away spontaneously; the hemorrhage does not appear to have been very profuse; and severe expulsive pain was the most prominent symptom for the first two months after the patient's delivery. In other instances there have been even fewer symptoms to engage attention, and nothing has been observed except some hemorrhage succeeding the spontaneous expulsion of the placenta, until the return and the persistence of the bleeding have led to a vaginal examination and to the discovery of the then almost remediless displacement of the womb. In these cases there can be no doubt but that the uterus has inverted itsolf, and that this accident has been brought about, not by simple want of contractility of the organ, but by ' Tlfirdy and IVIcClintock, Prndirnl Oharrraiions in ^^!lhl^!fr>•J/. p. 223; find l?ains- bothfini, Obstetric Medicine, «Scc., 3d od., p. 719. 190 SYMPTOMS OF the irregular and unequal contraction of its different parts; a state of comparative relaxation of the os and cervix coexisting with vio- lent action of its fundus.^ The only circumstance, indeed, which tends to prevent our receiving this as the ordinary explanation of the occurrence of inversion of the womb during labor, is its not happening in institutions such as the Dublin Lying-in Hospital, in which the last stage of labor is wisely conducted; while spontane- ous inversion of the organ would obviously be nearly as liable to happen among patients in a lying-in hospital as elsewhere. Profound shock to the nervous system and profuse hemorrhage are, as has already been mentioned, the two characteristic symp- toms of inversion of the uterus. Dr. Radford has shown, however, that except in cases where the placenta was still partially adherent to the womb, the hemorrhage is by no means so formidable as might beforehand be anticipated, and that the shock to the sys- tem is independent to a great degree of the loss of blood. If these immediate dangers are surmounted, the patient's subsequent his- tory seems to be liable to considerable variation with reference to the period at which formidable symptoms reappear, though the symptoms themselves are very uniform in their character. The state of the uterus, too, differs in a way which greatly modifies our prognosis; the organ remaining in some instances compara- tively soft and 3'ielding, admitting of being indented by the finger, and consequently allowing of attempts at its replacement being made with a fair prospect of success; while in other cases it be- comes at once small and firmly contracted, and bids defiance to every effort to rectify its position. I do not know how to account for these difterences in the state of the womb, though their im- mediate cause must consist in the absence of, or at least in the very imperfect involution of the organ in one case, and the rapid' and complete accomplisliment of it in another. Those cases where the uterus remains soft and flaccid, and capable of replacement, are, however, exceptions to the general rule, as might, indeed, be inferred from the rarity of the instances in which, after many days, or even after many hours, the accident has admitted of remedy. In the majority of instances the con- traction of the uterus occurs very speedily, and is so firm that the inverted organ has sometimes been mistaken for the head of a second foetus, while the processes of involution usually go on as completely as in the womb when in its natural position. This 1 This mode of production of inversion of the womb during labor, first recog- nized by Saxtorph, Gesmnmelte Schriften, 8vo., Kopenhagen, 1804, p. 301, has been fully and ably set forth by Dr. Kadford, Dublin Journal for 1837, Nos. 34 and 35; and is now generally received as a frequent, if not the most frequent, mode in which it is brought about. Dr. Simpson, in expressing his adhesion to Dr. Kad- ford's views — see his Obstetric Works^ vol. i, p. 817 — refers to two cases in which inversion of the uterus, with expulsion of the child, took place after the mother's death. Both of the cases are very marvellous. Bcerner's patient, indeed, had reached the full period of pregnancy ; but she whose history is very imperfectly recorded hx Klaatsch, was only in the fourth month; and the inversion of the womb is alleged to have occurred in the second night after her death. One is at a loss as to the inferences to be drawn from histories so wonderful. INVERSION OF THE UTERUS. 191 fact is attested by the numerous preparations of chronic inversion of the womb, in which, as in one in the Museum of St. Bartho- lomew's Hospital, the organ is so small that the 0})ening of the pouch which it forms would not admit anything larger than a quill, while its dense tissue seems at first scarcely compatible with the outpouring of so abundant a discharge of blood as that under wliich the patient sank. In many instances hemorrhage has continued to flow at sliort but uncertain intervals from the moment of the occurrence of the accident, but to this there are occasional exceptions. In one of the cases wdiieh came under my observation, a very slight occasional discharge of blood was all that occurred for several months after the patient's delivery ; she having suckled her child for thirteen months. At the eleventh month, however, the ovaries resumed their function, and the menses were extremely profuse. On their next return the bleeding was still more abundant, and thirteen months after delivery the flooding w^as alarming from its quantity, and w'as intermingled with large coagula, which were discharged without any sufl'ering. Even before the hemorrhage became pro- fuse the patient sufl'ered from ordinary leucorrhoeal discharges, which afterwards continued in the intervals of menstruation. 13y degrees tlie intervals become shorter, the hemorrhage more pro- fuse, and the leucorrhoeal discharge lost its character of a mucous secretion, and became more serous. At last, when well-nigh drained of all her blood, the red color almost completely disap- peared from the discharges, and for the last two or three months of her life there was a constant flow of serum, but the positive hemorrhage was very small. A sense of bearing down, and the occasional appearance of the inverted womb externally on walk- ing or any exertion, so long as the patient was able to follow her usual avocations, were her only other symptoms, and, indeed, the only ones which are common in these cases. There are, however, some instances in which the inverted womb, from hanging. exter- nally, has been exposed to injury, and become ulcerated; and others in which the violent constriction of the inverted body of the womi) by the os uteri has produced gangrene of tlie organ. ^ Such being the consequences that follow the inversion of the uterus during labor, it is obvious that they tend of necessity to a fatal issue, and that the question is not so much how, as how^ soon a case will terminate. Mr. Crosse,^ whose industry has thrown so much light on many subjects connected with this accident, states, that in seventy-two out of one hundred and nine iiital cases, death took place within a few hours, in eight w'ithin a week, and in six more within four weeks. Tlic immediate danger, however, being surmounted, there follows during lactation an interval of compara- tive safety and of cessation of serious symptoms, which reap})ear 1 Sevi'ial rcttTonces to this occurrence are givuii bv Crosse, o/j. cjV., part ii, j.. Ill, Notes 104 and 1U5. 2 Op. clL, }). 170. 192 SPONTANEOUS CURE OF INVERSION. when snckling is over. It appears that of the remaining twenty- three patients only one died at the fifth month, and then, as the result of an operation which had an unsuccessful issue, one died at eight months, three at nine months, and the others at various periods of from one jenr to twenty years. These latter cases of great prolongation of life, in spite of the persistence of inversion of the womb, lead us lastly to notice those rare instances in which life has not only continued for many years, but in which serious symptoms have been altogether absent. Of these the most remarkable history is that recorded by Boivin and Dug^Sji of a woman who was brought to one of the hospitals at Paris six days after a labor in which her womb had become inverted. Repeated eflbrts were made by M. Dubois, as well as by Madame Boivin herself, to replace the womb, but without success, and no symptoms being at the time present, the patient returned into the country by diligence on the eighteenth day after her delivery. N^othing more was heard of her till five years afterwards, when she presented herself to Madame Boivin, with her uterus still inverted, though of smaller size than before. Some sense of dragging at the groins, a frequent desire to pass water when she was up and exerting herself, and a discharge of a reddish mucus recurring every fifteen or twenty days and lasting for a few hours, were the only symptoms from which she suffered. She was in- commoded, however, by having grown enormously fat, and ex- pressed anxiety at the non-appearance of her menses. Two cases are related by Lisfranc;^ the one that of a woman who died at the age of seventy years, of inflammation of the lungs ; and the other that of a person forty-eight years okl, whose only uterine symptoms were slight leucorrhoea, and dragging sensation at the loins, and whose uterus, on her death from enteritis, was also found completely inverted. In neither of these cases, indeed, was there any satisfactoryhistory of the manner in which the accident took place; but the existence of inversion at the examination after death, and the absence of symptoms of it during the lifetime of the patients, are both clearly substantiated,^ Stranger still than the above are cases in which the uterus is alleged to have spontaneously replaced itself. The possibility of the spontaneous replacement of a partial inversion of the w^omb during labor must be admitted, and can even be understood ; an occurrence stated by Saxtorph^ to have taken place in a patient whose uterus he endeavored in vain to replace ; and being thus compelled to leave the case to nature, the organ recovered in a few days its natural position. But there are other instances in which spontaneous replacement of the completely inverted womb is stated to have occurred many days, or even months or years, after de- livery. It is difficult to know what opinion to form concerning » Op. cit, vol. i, p. 245. 2 Qp. cit , vol. ii, pp. 379-383. 3 References to other similar cases are given by Meissner, op. cit., vol. i, p. 743. < Gesammelte Schriften, 8vo., Kopenhagen, 1804, p. 307. DIAGNOSIS OF RECENT INVERSION. 193 these cases; in some the accuracy of the diagnosis appears very doubtful, and in others the details given are far too meagre to warrant any conclusion with reference to their real nature ; while unquestionably no such exceptional occurrences sliould be allowed to influence our treatment of any case which may come under our care.^ Questions of obstetric practice do not fall within the scope of these Lectures. I shall therefore say very little with reference to the management of these misplacements of the womb in their recent state, but shall pass almost at once to the consideration of the diagnosis and treatment of the accident in its chronic form. In the recent state the diagnosis of inversion can seldom be obscure. There are instances, indeed, in which it has been over- looked or mistaken, or in which the inverted uterus has even been torn away under the supposition that it was the placenta; but such errors imply a depth of ignorance and folly, upon which all rules and all experience would alike be wasted. There seem, how- ever, to be cases where, some short time after the detachment of the placenta, the womb has become of its own accord partially inverted, or depressed at its fundus, and where, while much de- pression and some hemorrhage have existed, there has neither been a tumor to be felt per vaginam, nor disappearance of that which the uterus should form in the abdomen. This partial in- version, too, tends to increase, so that the depression of one day may amount (to borrow Mr. Crosse's terminology) to introversion on the next day, and to complete inversion on the third. I do not know that more is needed to preserve from this error than a knowledge of the possibility of falling into it, and of the conse- quent necessity of ascertaining in every instance where causeless depression and causeless bleeding follow the last stage of labor, not only that the uterine tumor still remains in the abdomen, but also that it retains its proper size and contour. When the accident does occur before the detachment' of the placenta, the whole weight of evidence is, I think, in favor of re- moving the placenta before endeavoring to return the womb; and the non-occurrence of serious bleeding in many instances of recent inversion of tlie womb after the separation of the placenta, strongly corroborates the accuracy of the views as to the source of hemor- rhage in labor, which, though so clearly explained by Dr. Simp- son, have been much misunderstood and misrepresented. There is some discrepancy between the directions given by 1 The most satisfactory of those cases is Dr. Thatcher's, referred to by ^Ir. Crosse, op. cit., p. 170, note. But in tliis instance the uterus had resumed its proper posi- tion at the end of a month. The ease related by Dailliez, .S'^r le /{runrKemrnt de la Matricc, 8vo., Pari.-;, ]803, p. 33, corresponds mueli more nearly with one of polyjius than of inversion ; and of Dr. Meigs's two cases the former is very 3,p. 85. There are, besides, seven unsuccessful cases in addition to those referred to by Mr. For])os, namely : Symonds, Medical Gazette, "Nov., 1830. Mcerholdt, in Salomon's dissertation, De uteri inversione, &c., Dorjmt, 1830, re- ferred to by ]}reslau, p. 40, No. 49, in his table. Coates, Association Medical Joarnal, July, 1855. Covelier, Presse Medicale, and Schmidt, JakHiilcher, July, 1852, p. 182. Dr. Putnam, referred to by Dr. C. Lee, loc. cit. Dr. Channing, ilMd. Aran, op. cit., p. 914. 198 EXTIRPATION OF INVERTED UTERUS. own experience towards a solution of the question. It may, how- ever, be worth notice that in one only of the five cases of excision of the uterus did any considerable bleeding occur; in one of the instances which terminated fatally, death was occasioned by peri- tonitis alone ; in the other, in spite of the employment of the ecraseur, abundant hemorrhage into the abdominal cavity was the occasion of the peritonitis under which the patient sank. The dread of hemorrhage which so long deterred practitioners from excising polypi, has been learned by experience to be in great measure an exaggerated fear ; while the risk of inflammation of the womb from the inclusion of some of its fibres within the liga- ture has been found to be very real. It is deserving of considera- tion whether, when the inversion is of long standing, the uterus small and firmly contracted, and the diameter of the peritoneal pouch consequently scarcely larger than a crowquill, while the sensibility of the serous membrane has been lessened by the long- continued change in its relations, the risk attending the excision would not be smaller than tliat associated with the ligature of the uterus. The employment of the ecraseur would probably be pref- erable to the application of the ligature, or it might be resorted to, as in Dr. McClintock's case, after the previous employment of the ligature. The fact that the ecraseur is not an absolute safe- guard against hemorrhage does not negative its employment, but nierely suggests the necessity for much care, and for working the instrument extremely slow. As might be anticipated, the result of the operation is to a very considerable extent modified by the period at which it is under- taken. If performed soon after delivery, while the womb is still comparatively large and vascular, and its sensibilities acute, the prospects of success are smaller than if the misplacement had be- come a chronic evil before any kind of interference was resorted to. Table shoiving the period after delivery at ivliich the inverted uterus was extirpated in fifty -five cases. Patients Patients Total. Under 1 month, recovered. died. 4 3 7 Between 1 and 2 months, 3 3 " 2—6 " 3 "3 6 " 6 — 12 " 2 4 6 " 12 — 18 " 10 2 12 " 18—2 years, . 1 1 " 2—3 " 5 5 " 3— 4 " 2 2 " 4— 5 " 4 4 " 5—6 " 2 2 " 6— 7 " 2 2 After 12 years, . 1 "2 i 1 1 1 1 2 "14 "... "15 "... " many "... '. 41 14 55 DIAGNOSIS OF CHRONIC INVERSION. 199 It is perhaps deserving of mention, tliat in one of the cases where tlie operation was successfully performed within a month after the patient's delivery, the uterus was in a state of gangrene, and that in two others it lay beyond the external parts, a position which I need not remind you, considerably lessens its sensil)ility. The remaining case was one in which the operation was performed by an ignorant midwife with a razor, and is an illustration of the wonderful power of repair, even of most fearful injuries, which nature exerts occasionally, rather than an example that can serve for our guidance in practice. In some of the fatal cases put on record, and probabl}^ also in others which have not been published, inversion of the uterus has been mistaken for polypus, and the error has only been discovered after the supervention of formidable symptoms of peritoneal inflammation, or after the death of the patient. It hence becomes a matter of considerable importance to ascertain the nature of the case before any operation is attempted, lest it should unexpectedly api)ear that the ailment, instead of being one the removal of which is attended but by moderate risk, is in reality one whose cure is unavoidably accompanied by most imminent hazard. A want of caution on the part of the practitioner is obvious in most instances of inverted uterus, in which an error of diagnosis has been committed. But still the diagnosis has now and then been rendered extremely difficult by the firm contraction of the OS uteri around the inverted body of the womb, which is thereby compressed so as to resemble the pedicle of a growth proceeding from within the uterine cavity, and thus closely to simulate a polypus. The history of the patient in such a case, even if accu- rately ascertained, is not absolutely conclusive, inasmuch as uterine polypus may complicate pregnancy, and may both give rise to hemorrhage after delivery, and also to a tumor, felt on vaginal examination. The comparative sensibility of a polypus and of the inverted womb does not furnish any trustworthy criterion ; for the sensibility of that organ is in many instances very low, and was so in all the cases that came under my observation ; while it may further be added, that there is no such dift'erenco between the appearance of the tumors as can be relied on in forming a decision. Mr. Arnott suggested to me some years ago a means of distin- guishing between the two, which appears quite worthy of being borne in mind. Let the finger be introduced into the rectum, and carried up as high as possible. On turning it round, if the uterus be inverted, the finger will have been carried above it, and will easily ascertain the absence of the organ from its natural situation in the i)clvis. If, on the other hand, the vaginal tumor is a polypus, the uterus will probably be found enlarged, and at any rate occupying its proper position. The uterine sound furnishes us with another valuable aid in doubtful cases. If a polypus is present, the uterine cavity will be found enlarged, so that the sound will pass flirthcr than natural, and a sense of weight will 200 EXTIRPATION OF THE UTERUS also, most likely, be experienced; and b}^ these two means of examination combined, I believe that in all cases of inverted uterus after labor, an erroneous diagnosis may be avoided. It now remains for me to ofter a few suggestions with reference to the only means by which the almost inevitable results of irre- ducible inversion of the womb can with certainty be obviated; and these, consist, as you know, in the extirpation of tlie organ, either by the knife or the ligature. It is almost superfluous to say that, inasmuch as there are some few instances on record in which inver- sion of the womb has not been followed b}^ the serious results to which it usually gives rise, so nothing but most obvious danger to the patient's life will justify the performance of an operation so hazardous as the extirpation of the womb. But further, the occur- rence of severe hemorrhage, and the apprehension of its increase at each return, will not sufiice to render an operation expedient within a few months after deli very, since the chances ofthe patient's recovery appear to increase in proportion as the accident is of long standing. Since also .in some instances in which the function of the ovaries has been kept in abeyance by lactation, but little loss of blood has occurred for several months after delivery, it would seem desirable that every woman sulfering from irreducible inver- sion ofthe uterus should be encouraged to suckle her child, in order that time might be gained for the occurrence of as complete an in- volution of tlie uterus as possible before its removal is attempted. "When the frequency of the return of the hemorrhage, or the abundance of the losses of blood, has shown the necessity of inter- ference, it yet is not desirable to select the time when hemorrhage is going on for the operation, inasmuch as such times usually cor- respond with a menstrual period, and the uterine sensibility is generally greatest at those seasons. In spite of the general pro- priety of this rule, however, it may be borne in mind that if hemorrhage at any such period should threaten life, and should not be restrained by styptics or by the plug, a ligature may be applied as a temporary expedient with great probability of the loss of blood being thereby restrained,' even though the ligature should be removed some hours afterwards. In the use of the ligature something seems to depend on the kind of material employed. Both silk and whipcord appear to irritate considerably; and Dr. Johnson, of Dublin, who has had greater success in this operation than an^^ one else, prefers a liga- ture of well-annealed silver wire and dentist's silk twisted together, as being more readily loosened if too tight, and as causing less irritation than ligatures of other kinds. It has sometimes been attempted to obviate the risk of inflammation by applying the liga- ture at first so tightly around the inverted womb, as at once and completely to strangulate it. This proceeding, however, whilst it 1 This result occurred in Dr. Johnson's second case, with the effect of checking the bleeding, five weeks before the organ was actually extirj'tated. See his paper in vol. iii of Dublin Hospital Rejwrts. * BY THE KNIFE OR LIGATURR. 201 causes intense suffering, does not appear to have tlie desired effect ; and a preferable plan seems to be that of applying the ligature com- paratively loose, and of tightening it gradually day by day as the patient is able to bear it. The great prostration and severe pain which usually attend the first application of the ligature would probably be obviated in great measure by the administration of chloroform; the subsequent supervention of inflammatory symp- toms seems to require the immediate slackening of the ligature, and may necessitate its complete removal. After the ligature has about half effected the division of the part, there appears to be no sort of ol)jection to the completion of the operation by the knife or scissors; but the double operation of applying a tight ligature, and immediately excising the womb, does not seem to be as safe a proceeding as either the ligature or the knife alone. I have already expressed mj^ opinion, however, that the substitution of the ecraseur for the knife, and its employment after the previous application of the ligature, w^ill be found, as Dr. McClintock's cases w^ould lead one to believe, to be the safest mode of proceeding. A few words must still be said about those cases in which the presence of a polypus in the cavity of the womb has led to the in- version of the organ ; an accident which, though probably not rarer, has yet been less frequently noticed than the inversion of the womb after labor. Tlie large size of the outgrowth, the presence of more tumors than one, together with the origin of the pol^'pus from the fundus of the w'omb, arc the conditions which have been met with in the majority of instances where this acci- dent has happened. These, however, are by no means of constant occurrence ; for a very small tumor has sufficed to invert the Avoml),' while the insertion of the pedicle of the polypus into the fundus of the uterus is common to the greater number of these growths; and the large size of the tumor or the presence of several tumors, is by no means unusual, without any disposition to inver- sion of the w^omb. The accident seems to have taken place wnth polypi of all descriptions ; with soft, malignant, or pseudo-malig- nant tumors, as well as wnth those of a ffbrous texture, or which might be supposed to be actual outgrowths of uterine tissue; and I am not aware that in any instance the observation has been made of any peculiar relation subsisting between the substance of the womb and that of the tumor. In most of the instances, I believe, in which any definite history has been given of the pa- tient's previous condition, violent ex})ulsive pains are stated to have preceded the inversion of the wondj. I need scared}' say, however, that violent expulsive efforts are too frequent a concom- itant of the escape of a polypus into the vagina to have much diagnostic value; while in a remarkable case that came under my ' Of wliii'li H ninarkal)!!' illustrntion is c;iven hy ^Ir. Crosso, op. cit, p. 47 and pinto viii, from a prc^paration in the Musoiiiii of the Royal College of Surijeons in i)ul)lin ; the tumor which had produced com^ilotc inversion of the womb very little exceedin}; a chestnut i-n si/.o. 202 ASCENT OF THE UTERUS: own observation, the escape of the polypus, and the inversion of the womb took place at a time when the previously severe pain had almost completely subsided. In other respects, the symptoms attendant upon inversion of the uterus complicating polypus present nothing at all peculiar — leucorrhoea, menorrhagia, and exhausting hemorrhages occurring in cases of ordinary fibrous tumor or polypus as frequently, and to as great extent, while the womb retains its proper position, as when the organ is inverted. In a practical point of view, that which it behooves us to bear in mind is, first, the possibility of this accident occurring in any case of polypus growing from the cavity of the womb, and the especial reason for suspecting it when any consitlerable or long-continued expulsive efforts have preceded the escape of the polypus into the vagina: second, the expediency, before tjdng or excising any poly- pus, which either is very large, or the development of which has been accompanied by such symptoms, of ascertaining by means of the sound the exact dimensions of the uterine cavity, that we may not unwittingly divide or tie the substance of the womb instead of the pedicle of the tumor. If it be ascertained that the womb is inverted, I should imagine the proper course would be to excise the polypus suflBciently low down to avoid all risk of seriously wounding the uterus, and then to endeavor to replace the organ : an attempt the impracticability of which seems to have not infrequently been assumed on insufficient grounds, and which was accomplished in my own case with the greatest facihty. Lastly, it must be borne in mind that the uterus may be in- verted by the tractions made at a polypus in the endeavor to drag it down sufficiently low for its excision. I do not think, indeed, that there is much risk of this in the case of polypi of ordinary size ; but the cases related by M. Amussat, and one which occurred still more recently in the practice of Mr. Johnson, of NorAvich,* show that when the tumor is of considerable size this accident is very likely to occur. A word or two, before concluding this Lecture, may be added concerning a form of uterine misplacement of no practical moment, except as sometimes helping to throw light on the nature of a patient's ailments, otherwise perhaps obscure. The ancients con- ceived, as probably you know, that the peculiar sensation of choking, the globus hystericus, from which women often suffer, was due to a positive ascent of the wornb from its natural situation in the pelvis. In order to expedite its return to its proper place, they were accustomed, by a quaint combination of reward and punishment, to employ aromatic fumigations to the vulva, while fetid gums and other ill-savored medicines were given by the mouth. This practice, with many other absurdities of bygone days, is exploded, but a vestige of the theory still remains behind, 1 See Crosse, op. clt., p. 52. ITS CAUSES AND IMPORT. 203 for it is alle2:ecl by some continental writers^ that contractions of the uterine ligaments, or as some say of the peritoneum, raise the womb from its proper situation, and thus supply a positive mecliani- cal cause for the unpleasant sensations about the pelvis, of which hysterical patients frequently complain. For my own part, I neither admit the explainition, nor do I believe the fact. It is also said that the greater difficulty with which the os uteri is reached in the aged than during the years of sexual vigor, and the narrow- ing of the upper part of the vagina which is then observed, are due to an actual elevation of the organ in advancing years. This, however, again appears to me in the highest degree problematical. We know that the uterus wastes ; that the projection of the cervix into the vagina also disappears from the same cause ; that the vagina, too, becomes atrophied, and that if the uterus, owing to the weakening of its supports, do not sink down, and so distend the vagina, the calibre of that canal will become much narrower than it was before. I am cpiite at a loss to understand what causes operating in old age can tend really to raise the uterus higher than it was before ; nor, in fact, am I convinced that such an elevation of the organ actually takes place. But, though ascent of the womb does not call for notice as a condition of itself producing any definite symptoms, it is yet of importance to bear in mind the difterent circumstances in which we are likely to find the organ occupying a higher situation than usual. 1st. It is a physiological attendant upon pregnancy, from about the fourth to the eighth month, is especially marked in first preg- nancies, is sometimes so considerable as to render it a matter of extreme difficulty to reach the os uteri. With moderate attention, however, to the patient's history, and consideration of all the cir- cumstances of her case, the peculiarities presented by the pregnant OS uteri will seldom fail to keep the practitioner from error. 2d. When any considerable degree of pelvic contraction exists, the want of space often obliges both the uterus and bladder to remain above the pelvic brim, a circumstance to which much of the difficulty of the operation of craniotomy is frequently due. 3d. In cases of inflammation of the pelvic cellular tissue, or of that between the folds of the broad ligament, the uterus is often found very high up, so that its orifice is reached Avith difficulty. This change in the position of the organ, too, is not necessarily due to the formation of a tumor lower down in the pelvic cavity, forcing it above its natural situation, though it may of course be produced in that way ; but it may depend on a positive dragging of the womb upwards by the inflamed tissues. 4th. In a large number of instances of ovarian dropsy, the cj'st, as it rises out of the pelvis, draws the uterus with it, sometimes even considerably above its natural position. In cases where a 1 Busch, Gcschlechtslcben dcs Weibcs, vol. iii, p. 473. 204 ASCENT OF THE UTERUS. question arises as to whether an accumulation of fluid in the ab- dominal cavity is due to ascites or to ovarian dropsy, the relations of the uterus often assist us in arriving at a correct conclusion, for the organ which is usually drawn upwards in ovarian dropsy is generally depressed below its ordinary situation in cases of ascites. More frequently it happens that doubt is entertained as to the nature of a non-fluctuating tumor, concerning which it is uncertain whether it is uterine or ovarian. Any considerable ele- vation of the uterus is much more frequently due to degeneration of the ovary than to tumor of the womb. 5th, and lastly. In a few instances, flbrous tumors of the uterus as they increase in size raise the organ more and more out of reach. Nothing, indeed, is more common in cases where the uterus is the seat of several fibrous tumors, some of which have attained to a considerable size, than to find the organ so much deformed that the os becomes situated high up behind one or other side of the ramus of the pubis. But besides those cases in which the firm irregular outgrowths felt per vaginam leave no room for un- certainty, there are a few exceptional instances in which a single fibrous tumor in the uterine wall, without producing any deformity of the organ appreciable per vaginam, raises it in the progress of its development. high out of the pelvic cavity. In this process, however, the greatly elongated cervix uteri scarcely participates in the growth of the body of the organ, but becomes mechanically stretched till it attains sometimes the length of several inches.^ As a result of this the lips of the os uteri become extremely thin, or disappear almost entirely, leaving the os a funnel-shaped entrance with almost membranous margins to the elongated and narrow cervical canal. "When drawn upwards by the enlarged ovary, the traction is exercised on the body, not on the neck of the womb, and hence no change is produced in the character of the lips or OS uteri. With these hints, not without their use perhaps in the diagnosis of uterine afiections, we may take leave of the subject of malpo- sitions of the womb, and must at the next Lecture commence the study of another and most important class of its diseases. 1 As in the very remarkable case described and delineated by Professor Walter, of Dorpat, in which the cervix was two inches and three quarters long, and scarcely any indication of the uterine lips was perceptible. See p. 10, of his Essay Ucber Fibrose Korper der Gebdrmutter, 4to. , Dorpat, 1852. UTERINE TUMORS AND OUTGROWTHS. 205 LECTURE XIV. UTERINE TUMOKS AND OUTGEOWTHS. Their occurrence connected with tendency of uterus to hypertrophy generally. Outgrowths of the mucous membrane, or Mucous Polypi ; their simplest form. Ii^ihro-Cellular Polypi. Glandular Polypi from hypertrophy of uterine follicles. Cystic enlargement of follicles of cervix, or Mucous Cysts of the Uterus. Symptoms of these afiections: nature and source of the hemorrhage they occasion. Diagnosis. Treatment. Fibrinous Polypus, its nature; analogy to other chronic effusions of blood. Note on some other alleged varieties of polypus. In the course of the foregoing Lectures I have referred over and over again, with an iteration tliat can scarcely have failed of being wearisome, to the ready increase of the womb under the influence of very various exciting causes. We have seen that in- flammation going on to the production of its ordinary conse- quences — suppuration, or the eflrusion of lymph — is of very rare occurrence. Abscess of the womb is one of those accidents so uncommon, that when met with it seldom fails to be recorded among what the old writers used to term Curiosa Medica; and the eifusion of lymph into the tissue of the organ has been assumed in accordance with certain physiological or pathological hypotheses rather than actually demonstrated. It is indeed scarcely ever, except after labor or miscarriage, when the tissue of the womb passes physiologically through changes such as those which inflammation tends to work, that the diseased process manifests itself in its acute forms, or with dangerous severity, while, even then, the serous investment of the organ, or the lining membrane of its veins, is generally the part which shows marks of the most serious mischief. Often, too, the signs of inflammation appearing at these times, turn out to be symptomatic less of aft'cction of the womb itself than of its ap- pendages or of the cellular tissue in its vicinity, or connecting together the different pelvic viscera. At the same time, however, we And that the causes which elsewhere might issue in inflamma- tion produce in the case of the womb its overgrowth. It increases from that frequent afflux of blood towards it which jiroduccs many forms of menstrual disorder; it remains pennanently in- creased from deflcient involution after labor; it enlarges, if flexed or misplaced, and its prolapsus causes it in many instances to attain to more than double its ordinary size. But not only is hypertrophy of the M'omb more frequent than the hyi»ertrophy of any other organ, but each of its conqionent tissues is liable to a similar overgrowth — not regular indeed, and equable, but in [)arts, here and there, constituting tumors and out- growths, which are met with in this oftener than iu any other 206 UTERINE TUMORS AND OUTGROWTHS. part, and of which frequency the physiological peculiarities of the womb furnish the only explanation. The mucous membrane of the uterine cavity undergoes, as we have already seen, an occa- sional hypertrophy in some menstrual disorders, but becomes eventually cast oft" in accordance with the laws which regulate its development iu a state of health and uuder the influence of preg- nancy. But the mucous membrane of the cervix also sometimes becomes hypertrophied, and such hypertrophies are not decidu- ous, but assume the form either of a distinct fold at the orifice of the womb,^ or more frequently of distinct small pendulous out- growths. Now and then, the admixture of a larger quantity of cellular tissue than usual gives to these growths a more consider- able size than they attain to when composed exclusively of mucous membrane. Sometimes the same process of overgrowth aft'ects the celluUir structure of the neck of the womb, and then a peculiar form of outgrowth is produced, termed the glandular or ceHular pol^q^as of the cervix uteri. If one of these follicles alone in- creases at the expense of the others, and without a corresponding hypertrophy of the cellular structure or mucous membrane, there are then produced those cysts of the neck of the womb whose nature and origin were once so little understood. Lastly, if the same process involves the uterine substance itself, we then meet with the so-called fibrous tumors of the womb, which, identical with it in their intimate structure, differ only in this, that they are not developed in accordance with the general contour of the organ in which they arise; but, springing from various centres, grow with no symmetry towards its outer or its inner surface, and produce symptoms which vary according to their scat and the vigor of their growth. With reference to these and other varieties of growths from the womb, it is not altogether without importance to observe that the time of their appearance is just that at which all the physiological changes in the organ go on with the greatest activity, and that they are rarely met with either in the season of decrepitude or of early youth. The same fact, too, holds good to a great extent with reference to another great class of ailments of the uterus; those, namely, of a malignant character. These, also, occur chiefly in the season of sexual activity, and seem to be connected, as in the case of the female breast, with the wide fluctuations in growth and in activity which succeed each other in those parts within very brief intervals. Having thus thrown out a suggestion that may perhaps explain in some degree the singular liability of the womb to various tumors and outgrowths, I propose to examine each kind in succession, beginning with those of simplest character, namely outgrowths 1 As well delineated by Dr. Tyler Smith in pi. ix of his Essay in the Med. Chir. Transactions, vol. xxxv. MUCOUS POLYPI. 207 from the uterine mucous membrane; the mucous j^ohjin of most writers on the diseases of women. ^ These generally appear as small outgrowths from the folds of the so-called arbor vitce, varying from a third to half an inch in length by about three lines in thickness ; the pedicle by which they are connected with the mucous membrane being generally exceedingly slender, though at the same time very short. It would seem as if they were originally duplicaturcs of the mucous membrane, of equal thickness throughout, and as if tlie gradual constriction of their pedicle were the process by which nature gets rid of them, just by the same means as those by which the loose cartilages in the knee-joint are by degrees detached from their connection with the synovial membrane whence they originally sprang. They are usually of a bright rose tint, abundantly sup[)lied with a delicate network of vessels, and consist exclusively of mucous membrane with a very small admixture of cellular tissue. The seat of these little bodies is nearly always the cervical canal, from any part of which they may arise, though they are usually nearer the external than the internal os uteri, and now and then I have found a single growth of this kind in the uterine cavity, but quite at its lower part. Though generally pediculated, as just now described, they are now and then sessile, of a flatter form, and adherent along the whole of one of their surfaces to the mucous membrane. Occa- sionally, too, they do not assume the form of distinct outgrowths, but a[)pear like hypertrophied folds of the arbor vitse, bearing the same relation to the walls of the cervix as the attached carueae columnfe do to the parietes of the heart. Sometimes these growths are solitary, but it is at least as fre- quent for two or three of them to be found in the same patient; they have a disposition also to be reproduced ; or at least succes- sive growths form, so that it is not unusual for a patient from whom they have once been removed to require a repetition of the operation after the lapse of a few months. I have known them coexist with fibrous tumors of the uterus, but do not imagine that this was the result of more than a mere coincidence, and have never seen reason for regarding them as the precursors of malig- nant disease, though the late Dr. Montgomery, of Dublin,- be- lieved this to be not infrequently so in the aged. Those outgrowths, which are simple excrescences from the mu- cous membrane, never exceed the very small dimensions which 1 have just specified. Sometimes, however, a larger quantity of cellular tissue enters into their composition, and they then acquire a much larger size, and bang down beyond the os uteri into the vagina. They are often the size of a small fig, of a flattened form, and are found to be made up oi jihro-cellular tissue, having an in- 1 liha papillary polypi of Hirsch, whose Essay Ueber die Hisiolopic und Foiinen der Uterns-Pijlypen, 8vo., Giessen, 1865, is a valuable contribution to this depart- ment of morbid anatomy. 2 In a very valuable paper on "Polypus of the Uterus" in the Dublin Journal of Medical Science for August, 1846. 208 CYSTS OF THE CERVIX UTERI. vestment of mucous membrane, while they do not proceed exclu- sively from the cervix, but have their origin also sometimes within the cavity of the womb. IMore frequent than these are polypi of a more complex structure, into the formation of which there enter not merely the mucous membrane of the uterus or its hypertrophied iibro-cellular tissue, but also the large mucous follicles of the cervix. These polypi assume different forms, being sometimes pediculated, and the pedicle is occasionally of considerable length; at other times they appear as continuous outgrowths from the inner surface of one or other uterine lip, most commonly, I think, of the anterior. On dividing them, their most striking peculiarity is at once seen, for they are found to contain a large quantit}' of tenacious, transparent, albuminous matter, precisely similar to that which is secreted by the Nabothian glands. Sometimes, when the growth is still small, vesicles varying from the size of a pea to that of a kidney-bean, filled with this albuminous matter, compose the great bulk of the tumor, their walls still partially transparent, but readily distin- guishable beneath the delicate mucous membrane with which the whole is invested. In other instances, however, and generally whenever the bigness of the growth exceeds the size of the first joint of the thumb, the vesicles are not so distinct, though the structure is equally characteristic. In the midst of the succulent fibro-cellular tissue which enters into the composition of tlie tumor, there are numerous canals, whose walls are of a denser structure, arranged longitudinally, side by side, some of them communicat- ing with each other towards the pedicle, but not by any cross branches. These canals are all directed towards the surface of the tumor, where some of them terminate in blind pouches. Others end in openings mostly of an oval form, and invariably smaller than the calibre of the tube itself. Their length is not quite uni- form, and hence it results that the tumor has a peculiar, uneven, almost lobulated surface, closely resembling in this respect the appearance of an hypertrophied tonsil. They are filled with the same albuminous nuitter as in the smaller outgrowths is contained in the vesicles I mentioned, and the origin of both appears to be the same, namely, the mucous follicles of the neck of the womb. The long pedicle with which these growths are sometimes fur- nished' does not contain any of the hypertrophied follicles, but is composed entirely of fibro-cellular tissue. Usually, however, the pedicle is very short, and the point of origin of the gro^^i;h low down in the cervical canal. Though freely supplied with vessels, these growths do not in general present any considerable vascularity of the surface, which may be stated on the authority of Virchow,^ to be composed of very dense cellular tissue, covered by a thick layer of tessellated epithelium, 1 See Boivin et Duges, Maladies de V Uterus^ &c., Atlas, pi. xvii, fig. 2, and pi. xix, flg. 2. 2 In the Archiv. fur Pathol. Anatomie und Physiologie, vol. vii, 1854, p. 164, and plate ii, figs. 5 and 6. A very good description of the general characters of this SYMPTOMS OF MUCOUS POLYPI. 209 Lastly, in connection with this class of ailments, may be men- tioned the occasional enlargement of the follicles of the cervix uteri, unconnected with any outgrowth of its proper tissue, or any hyper- tropliy of its mucous membrane, but assuming the form of ci/sts, whose development takes place at the expense of the uterine sub- stance. Sometimes, too, though I believe not in the majority of cases, these cysts or vesicles are altogether new formations; and are not produced by the mere enhirgement of occluded follicles. Such, at least, is the conclusion which Hie examination of their structure by the microsco[)e leads us to adopt. In examining the uterus after death, it is by no means unusual to observe several vesicles of the size of a pea imbedded between the folds of the arbor vit^e, but scarcely, if at all, projecting beyond the level of the mucous membrane. This size, however, may be greatly ex- ceeded. In the uterus of a woman, aged twenty-nine years, which presented no other appearance of disease, all the Nabothian glands were much enlarged, and the whole cervical canal was filled with their secretion; while at the upper jDart of the cervix uteri was one of these cysts as large as a kidney bean, distended with albu- minous matter, and having by its increase produced the absorption of almost the whole of the uterine wall, which was scarcely a line in thickness. The cyst had produced a degree of bulging out- wardly of the attenuated uterine wall, such as must have been obvious during life, and b}' which I believe that, on one or two occasions, I have recognized this affection, which might, but for other symptoms, be taken for a solid tumor of the neck of the womb.^ Though I have met with many more cases in practice, yet I have preserved notes of only twenty-three instances of these varieties of uterine polj'pi, a circumstance readily explicable by the speedy and complete removal of the ailment by a very slight and simple opera- tion. Of the twenty-three cases, five occurred in single, eighteen in married women, of whom twelve had given birth to children at the full period, one had aborted several times, and five had never been pregnant. The age of the youngest patient was twenty-three, that of the oldest fifty-seven ; and the average age of all was forty years. The symptoms which induced the patients' to seek for medical aid had existed for periods varying from three months to four years; and were in every instance very similar in kind, though varying greatly in degree. Either leucorrhoeal discharge, or hemorrhage, or both existed ; to which bearing-down i)ams were sometimes, though by no means constantly, superadded. Once or twice I have accidentally discovered small polypi in kind of polypus and a diagram of its structure were given by Dr. Oidliani in Guy's Hi)fi])Hal Reports, 2d scries, vol. ii. It has also been well described by Huguier in the Memoiri-s de la Sndefe de Cfiinirgie de Paris, vol. i, 1847, p. 35. ' An extremely elaborate jiapcr on this subject, with several illustrative drawings, has been published by M. Huguier, in the lirsl volume of the Memoirci de la Sucieti de fViirnn/ir, pp. 241-295, and plates i-iii. The other portions of this Essay will call for notice hereafter. 14 210 SYMPTOMS OF MUCOUS POLYPI. cases where they had produced no sj^mptoms whatever. This, however, is unusual, for hemorrhage is very generally present, though its amount seems to be in great measure dependent on the relation the polypi bear to the cervical canal ; being usually much more considerable if the growth is inclosed within the lips of the OS uteri, than if it projects beyond them and hangs down into the vagina. This, indeed, is what might be expected beforehand, and it serves to explain thejiistory which patients occasionally relate of themselves, that the hemorrhage which at one time had been profuse has at length greatly diminished, or even altogether ceased. The influence of these small poh'pi in producing uterine irritation is sometimes exemplified hy their giving rise to considerable en- largement of the neck of the womb, and a degree of hardness con- sequent on engorgement of the part from the considerable afilux of blood thither; a condition that may lead the practitioner, unless on his guard, to overlook the real nature of the ailment, and to suppose that he has to do with hypcrtro^Dhy and induration the result of some bygone inflammation of the neck of the womb. This same fact also explains why it is that a comparatively large polypus hanging down into the vagina may be unaccompanied with bleeding, while an extremely small outgrowth still included within the neck of the womb may occasion very formidable hemor- rhage. These simple facts point, 1 believe, to the solution of a much mooted question ae to the source of the hemorrhage in these and other varieties of uterine polypi and tumors. The growths are themselves well supplied with vessels ; if wounded they bleed ; if excised, the hemorrhage which takes place from their pedicle is sometimes considerable, has even been known to prove dangerous; but yet all evidence goes to prove that it is rather from the womb itself than from the outgrowth that the principal bleeding flows, and that the hemorrliage is proportionate, less to the size of the outgrowth than to the intimacy of the relation between it and the womb. Of this I saw some years ago a very remarkable exempli- fication. A woman came under my care who for three 3'ears had suflered from very profuse hemorrhages, which had ceased without known cause for three months before I saw her. The non-appear- ance of the menses for the same period did not engage my attention as it ought to have done ; and I accordingly excised a fibrous polypus the size of a small hen's egg, which grew by a short pedicle from the inside of the cervix uteri. Very profuse bleeding followed the operation, but no other untoward sj- niptom ; and within six months more the patient was confined at the full term of pregnancy. I do not relate the case now for the sake of the moral to be drawn from it with reference to the absolute necessity of care in your diagnosis, though in this respect it comments on itself, but because it illus- trates exceedingly well the source whence the most abundant hemorrhage flows. For three years the polypus had irritated the womb, and blood had been abundantly poured out. Pregnancy took place, there was increased flow of blood towards the part ; THEIR DIAGNOSIS. 211 tlie poly[)US must have gained rather than lost in vascularity, but no bleeding occurred. The uterine cavity was now lined with decidiia, and its cervical canal was occupied by the mucous plug poured out from the J^abothian glands, and thus sheltered from irritation, the hemorrhage from its surface ceased, and leucorrhoea alone continued the evidence of the presence of the tumor. The structure of the })olypus has, however, something to do with the nature of the symptoms, with the gccurrence, and still more with the amount of the hemorrhage. Those polypi which present the compound structure due to enlargement of the Xabothian glands, are always attended by profuse leucorrhoea, a circum- stance easily ex}>licable if we bear in mind that the formation of the outgrowtli is associated with a state of hypertrophy and over- activity of the whole secreting apparatus of the neck of the womb. Their vascularity being less than that of the small mucous polypi, they are also more frequently unaccompanied with bleeding, while, as might be expected, the hemorrhage is usually absent when they assume the form of outgrowths from the inner surface of one or other uterine lip, since in that case the cervical canal escapes almost entirely from direct irritation. I do not know whether these growths have any special influence unfavorable to conception, though there is no cloubt but that the very nature of the sjanptoms to which they give rise is of a kind to lessen the probabilities of a woman becoming pregnant. I once excised a polypus, composed of enlarged ISTabothian glands, of the size of a sugared almond, from the anterior lip of the uterus of a young woman who had lived for more than eighteen months in sterile marriage, but who became pregnant within a month afterwards, and was delivered of a living child at the full period, liere, however, the relations of the tumor were such as mechani- cally to narrow, and almost to occlude the uterine orifice. The enlargement of one or more of the follicles of the cervix, so as to form distinct cysts in the uterine substance, is of rare occur- rence. In the few instances of it which have come under my observation, a profuse albuminous discharge, unchecked by treat- ment, or even by the free application of the nitrate of silver within the cervical canal, has been invariably present. On one or two occasions I have felt at the upper part of the cervix a small nodule which might readily be takCn for a small fibrous tumor, but which may be known by its yielding slightly on firm pressure, and by its size not being invariabl}^ the same at different times. I liave not found these cysts associated with menorrhagia, though that symptom was present in some of the cases related in M. Iluguier's essay on this afiection. I do not know of any special difficulty attending the diagnosis of these outgrowths, nor of any particular rules which can be laid down for the avoidance of error. Tiie very small jtolypi are some- times scared}' perceptible by the finger, and I have already referred to the enlargement of the cervix wliich they occasionally jn'oduce, and which is lilsfcly to mislead the unwary. The only rule that 212 TREATMENT OF SMALL POLYPI. can be given for practical guidance, is, however, this : that in no case of long-continued menorrhagia should we be content with mere digital examination, but should invariably employ the specu- lum ; and further, if no satisfactory conclusion be thereby arrived at, we should dilate the os uteri with sponge tents, in order that the cervical canal may be brought within reach both of examina- tion with the finger and with the speculum. If these precautions be neglected, the patient whom we have failed to relieve may place herself under some more careful practitioner, who will at once detect the cause of her symptoms, and cure her by an ex- tremely simple operation. For the most part, nothing is more easy than the removal of these small outgroivths. The smallest may be removed by laying hold of them with a pair of long forceps, and twisting them off, while those which are somewhat larger, after being twisted to check the risk of bleeding, may be cut otf with a pair of scissors. The bivalve speculum should always be employed in doing this, and both forceps and scissors are made for the purpose, so con- structed as to be readily worked within the speculum. To attempt their removal by means of forceps or scissors simply guided by the hand, is at best but a bungling mode of proceeding, while besides, the risk of hemorrhage is much greater than it would be if, after the removal of the polypus, the part whence it sprang were touched with the solid nitrate of silver, a precaution which I now never omit. Sir C. Locock^ has described a sort of long gouge, which he has contrived, with much ingenuity, for tlic removal of small polypi of the cervix uteri ; but these bodies, often so small as to be scarcely distinguishable by the finger, are also far too movable to be readily detached by any instrument introduced, as this must be, pretty much at a venture, and I have found it, on trial, practi- cally useless. In the case of the sessile outgrowths, which I spoke of as occasionally resembling, in their rehitions to the uterine walls, those of the carnese columnse to the heart, I have a])plied the acid nitrate of mercury by means of the speculum, and by this proceeding destroyed the outgrowths, and arrested the bleeding. In the case of the larger growths, made up either of fibro- cellular tissue, or of hypertrophied uterine follicles, I also employ the speculum if practicable. If the outgrowth be too large to come readily within the blades of the speculum, while its struc- ture is too frail or its pedicle too thin to allow of its being seized and drawn down by means of the Museux hooks, I employ a pair of forceps similar to those used by surgeons for operations on the tongue, with rackwork at the handles to insure the firm closure of the instrument. In all operations of this kind it is a great convenience to have the forceps or hooks made with a lock like that of the midwifery forceps, by which means each blade may be introduced separately, may be carried higher up along the pedicle of the growth, and made to seize it more firmly than can 1 Medico- Chimrg leal Transactions, vol. xxxi, p. 171. REMOVAL OF SMALL POLYPI. 213 be done if the blades are united, and liave to be separated after their introduction into the vagina. ■ The polypus being laid liold of by this instrument, a pair of curved, blunt-pointed scissors may easily be carried up to divide the pedicle, while any hemor- rhage that may follow will usually be checked with ease by the application of nitrate of silver through the speculum, and by the subsequent introduction of a piece of cotton-w^ool soaked in the tincture of matico, and which may be easily withdrawn after a few hours by a thread previously fastened to it. The question of the comparative merits of the ligature and of excision can scarcely be raised with reference to these small polypi, since the latter proceeding is so simple and easy, and with due care is not attended by any serious risk of hemorrhage. The forcible avulsion of polypi is a rough and hazardous proceeding, a relic of barbarous surgery; while their strangulation by means of pecu- liar constructed forceps' appears to me to be possessed of no advantage over the use of the ligature. Slight as in most cases the operation for the removal of these outgrowths is, it is yet a matter of prudence to keep our patient in bed for one or two days after its performance. On the only occasion in which I neglected this precaution, and allowed a woman from whom I had removed a small vascular poly[)US iu the out-patient room to return home, an attack of peritonitis came on which necessitated her reception into the hospital, where, however, the disease speedily yielded to appropriate remedies. Since I became acquainted with the essay of M. Huguier, I have not met with any of those enormous cystic enlargements of the uterine follicles whose nature was described a short time since. I applied, in the few instances which had come under my notice, the solid nitrate of silver abundantly within the cervical canal, but with scarcely any benefit. M. Huguier, however, has adopted, and with marked success, the simple plan of scarifying the interior of the neck of the womb previously to applying the caustic, by which means the cysts are emptied of their albuminous contents, and the caustic comes to act immediately upon their secreting membrane. Allied to these outgrowths in many of the symptoms to which they give rise, though differing in their essential characters, are those accumulations of blood within the uterine cavity where it undergoes certain changes and a kind of imperfect organization, which have received tlie name of fbrinoiis poh/pi. The late Pro- fessor Kiwisch,^ who was, to the best of my knowledge, the first 1 A procooding first suggested by Sir Cljfirles Bell, in his Pri»r!ptrs nf Opcrnfive Siirf/r7-7/, and renewed with some nindificutions recently by M. Geii>^oul, fif Lyons, in a pamphlet entitled Nouveau procedi pour operer les Polypes de Matricc, Lyons, 8vo., 1851. 2 In the first edition of his Klinische Vorti-a/je, &e., published in 1849, vol. i, p. 420, ^ 222. He made no addition to the account there given in the sub.i, already re- ferred to,aretlie results of thi^ microscopic cxaniinntiun of tive different specimens, by Professer Uidder, ? 20, pp. 37-41 ; and lastly, the results of some other exami- nations are given by Paget, op. cit., vol. ii, pp. 135, 13G. 218 FIBROUS TUMORS: the bigness of a large pea or of a kidney bean, and seldom pro- ject so far as to form more than the half of a much-ilattened sphere. In other instances, they proceed from the thickness of the uterine wall, and may then either grow outwards towards the peritoneum, or inwards towards the cavity of the womb, though the former is by far the more frequent occurrence, and is so doubtless for the obvioug reason that in that direction the tumor encounters the least resistance to its growth. Such tumors sometimes attain the size of a goose's egg, of a large pear, or even a greater bulk, and are connected with the uterus by a thick pedicle into which uterine fibres enter, though, unlike the tumors that grow towards the cavity of the womb, they do not receive an investment from its substance. The tumors that thus grow outwardly from the uterine walls are often present inconsiderable number, as maybe seen, for instance, in a preparation in the Museum of St. I>artho- lomew's Hospital, where twelve of these growths may be counted projecting from the surface of the womb, though its interior is quite free from disease. When they grow internally, they are sometimes positive outgrowtlis of the uterine tissue, while even when this is not tlie case, their relations to the womb are gener- ally very intimate.' They receive an investment of uterine tissue, and are often much more abundantly supplied with blood than any other varieties of these growths ; points, all of which are of very great practical moment, modifying the patient's symptoms, and influencing also our conduct. Whatever be their point of origin, those growths usually tend, as they increase in size, to be- come distinctly pediculated. To this, however, there are occa- sional exceptions. The firm, very slightly vascular tumor, with concentric arrangement of its fibres, remains imbedded in the uterine substance and covered by its investment of cellular mem- brane, witliout any disposition to project into the interior, or to protrude at the exterior of the organ. In some cases, too, the more vascular variety of fibrous tumor, with a very elastic and very succulent tissue, becomes developed in the thickness of one or other =uterine wall, attaining the size of the fcetal head, or even a greater bulk, and producing very great enlargement of the uterus, but retaining its spherical form, and continuing imbedded in the substance of the organ rather than projecting from it in either direction.^ The influence which these growths exert upon the uterus varies to a very remarkable extent, but is in proportion to the intimacy of the relation between the tumor and the womb, rather than to the mere size to which the tumor itself attains. When situated external to the womb, and growing into the peritoneal cavity, the 1 The Museum of St. Bartholomew's Hospital contains two specimens illustrat- ing exceedingly well the difference between the outgrowth and the tumor, for which purpose they are diagrammatized, by Mr. Paget, op. cii., vol. ii, p. 131, figs. 11 and 12. 2 A condition admirably represented in Wenzel, Krankheiten des Uterus, folio, Mainz, 1816, plates vii and viii, x and xi. THEIR INFLUENCE ON THE UTERUS. 219 tumor often acquires an enormous size, and tlie womb is, as might be expected, much elongated, and strangely deformed; but never- theless is not in general much increased in bulk. On the other hand, the development of a siugle tumor within the substance of the womb brings about an increase of its size, a thickening of its walls, and a development of its tissue very similar to those which take place during pregnancy. Of this fact a preparation in the Museum of St. Bartholomew's Hospital affords a very remarkable illustration. Imbedded in the anterior wall of the uterus is a fibrous tumor, no larger than an unshoUcd almond, and of such slight vascularity that the injection which has deeply colored the parietes of the womb has not entered the vessels of the tumor. This small growth, however, has so stimulated the uterus that it has grown to a length of five inches, and its walls are at least an inch and a quarter thick. In like manner, the growths which project into the uterine cavity bring with them a remarkable in- crease of the womb, and this not due to the mere distension of the organ by the substance contained within its cavity, but to the actual growth of its tissue and unfolding of its muscularity, such as takes place in pregnancy, and even in those rare cases where the development of the ovum goes on external to the womb itself. In these cases, however, the womb, after a certain period, con- tracts upon and expels the tumor or polypus from its cavity, or the tumor passes out of it quietly and imperceptibl}^, with which occurrence the further increase of the organ not only conies to a standstill, but its size diminishes, so that not infrequently a large polypus maybe found connected with a uterus whose dimensions fall below the natural standard. Hence it is that the instances in which the womb acquires the largest size are not those in which the tumor hangs down by a pedicle into its cavity, but those in which its development takes place into the substance of one or other uterine wall ; and the organ thus increased in bulk some- times attains the size of a child's head; and its cavity as measured by the uterine sound, may be found to equal four, five, or six inches in length. It is a matter rather of idle curiosity' than of practical utility to determine the number of these growths that may exist in any one uterus, or the size to which they may attain.' They are seldom eolitary, sometimes they are very numerous ; and they are usually present in the greatest number on the peritoneal surface of the womb, while it is rare to find more than one projecting at the same time into the cavity of the organ. This, however, is prob- ably due to the circumstance that there is not room for more than one tumor at a time within the cavity of the womb, for it is not a very uncommon thing, some months after the removal of one growth, to find another occupying the same situation, producing ' Walter's Dissertation, already quotccl, ^§ 11 and 12. and pp. 27-30; and Jlcisg- nor, op. cit., vol. ii, pp. Ki-lfl, contain references to the most rcniurkablc cases of largo or numerous fibrous tumors. 220 NUMBER AND SIZE OF FIBROUS TUMORS: the same symptoms, and calling once more for a recourse to the same operation. With reference to the size of these growths, we encounter wide diiFerences again in this respect, instances being on record of their attaining to such dimensions as to weigh even eighty pounds; and the Aveight of the growth in the remarkable case delineated by Walter was seventy-four pounds.^ These unquestionably are quite exceptional instances, but they are worth bearing in mind, as show- ing that in a diagnostic point of view the mere size of the tumor is not to be relied on in discriminating between growths from the uterus and those proceeding from the ovary. There are very few ailments in the course of which nature does not make some eftbrts, often, indeed, imperfect and unsuccessful efforts, at cure. In the case of fibrous tumors, there are five dif- ferent modes in which this attempt is made. Either the pedicle undergoes a process of gradual attenuation, and then gives way, the tumor thus becoming detached from the uterus; or more rarely, a portion of its investment becomes ulcerated or dies, and the growth graduallv shells out from the sheath of cellular membrane which contained it; or a change takes place in its substance, the exact nature of which is not quite understood, it becomes disintegrated, dies, and is got rid of piecemeal; or a different change occurs, similar to what we see in other morbid products, — the tumor undergoes the cretaceous transformation, and though not elimi- nated from the womb, it ceases to stand in any vital relation to it, and the symptoms Avhich it once produced diminish, or altogether disappear. Nothing can be simpler than the j^rocesses by which these tumors, when growing within the uterine cavity, may become detached from their connections and eventually expelled, though m}^ own experience does not lead me to believe that any of them are of frequent occurrence. It may happen, however, either that the pedicle, by constant traction of the growth, becomes thinner and thinner, till at length it gives way, or that the margins of the OS uteri, tightly constricting, strangulate it, or that in its violent expulsive efforts, the uterus snaps the slender stalk of the out- 1 Op. cit. Though in this case the whole tumor was of solid texture, still in some instances the enormous dimensions of these growths have been due to cyst formation, and the accumulation of a large quantity of fluid in their interior. This fluid has sometimes amounted to many pints, and the distinct fluctuation to which it gave rise has led to the disease being taken for ovarian dropsy, and to the patient being tapped for its relief. No instance of it has come under my own observation ; but the impression left on my mind, by reading the various recorded cases of it, is, that the disease is essentially different from ordinary fibrous tumor, since, in addi- tion to one or two cysts of very great size, a number of small cysts seem always to have been present in their immediate vicinity, and entering into the structure of the more solid portions of its growth. The cases, in short, seem to be instances of fibro-cysHc disease of the uterus, and as such call for special investigation, rather than ordinary fibrous tumors, in whose substance cysts have accidentally formed. See, in addition to the references given by Paget, op. cit., vol. ii, p. 138, Kiwisch, op. cit.., vol. i, p. 455, and Chiari, op. cit., p. 404. THEIR SPONTANEOUS CURE. 221 growtli.^ This detachment of the tumor, by the giving way of its pedicle, is not limited to cases in which it grows into the cavity of the womb, but is also occasionally, though very rarely, observed in instances where the tumor has sprung from the peritoneal sur- face of the womb. In the only case of the kind which has come under my own notice, the tumor had arisen from the posterior uterine wall, and had projected into the interspace between the uterus and rectum, which continental writers commonly speak of as the space of Douglas. Though perfectly detached from the uterus, however, the tumor, which was of the size of a wahiut, had not fallen loose into the peritoneal cavity, but was held in its position by false membrane passing between the uterus and rectum; and I believe that in almost all recorded instances of the complete detachment of a fibrous tumor from the outer surface of the womb, the outgrowth has been retained in a similar manner close to the part whence it originally sprang. Another mode by which fibrous tumors are sometimes got rid of, is the disintegration of their tissue, and tlieir subsequent ex- pulsion. Tliis process seems to be one of death of the tumor; but the mode in which it is brought about is not by any means clearly understood. It is not a process of inflammation, nor one of its ordinary results. The fibrous tumor, when attacked by inflamma- tion, presents a vivid rose-red color, and shows a greatly increased vascularity; while local pain and the general signs of inflammation attend the process during the patient's life. The disintegration of the tumor, on the contrary, takes place unattended by symp- toms which could lead to a suspicion of what is going on; and the outgrowth becomes soft, and breaks down into a dirty putri- lage. This change is not very unusual in the lower part of fibrous l^olypi, when they project through the os uteri into tlie vagina. Tlie mucous membrane covering this part becomes ulcerated, and being thus deprived of its most important source of nutrition, the adjacent portion of the tumor loses its vitality; the cellular tissue binding the bundles of its fibres together, dies first, and such a growth may sometimes be found firm and solid, and presenting all the ordinary characters of a fibrous tumor at its upper part, but lower down split up into a number of shreds or packets of fibres connected together by a dirty decaying matter. By degrees, these firmer fibres themselves soften, and the process of decay ex- tending further and further, the whole growth may come away imperceptibly; or, on attempting to remove the polypus, we may be sui'prised to find that what had once been a very firm mass, is now so soft that the hooks by which we endeavor to draw it down, tear out — that nature, in short, has anticipated us, and that in a few more days or weeks she will have completed her operation. 1 A very clabornte paper on this suhjoct, containing an enumeration of twenty- four cases, collected from ditVerent sources, was publisiied by M. Marchal do Calvi in the Annates de la Chirurgie, August, 1843. 222 ' SOFTENING OF FIBROUS TUMORS. It is not, however, in these cases only that the death of a fibrous tumor takes place. The same process may go on in the tumor, while still completely within the cavity of the womb, and while still of inconsiderable size. On examining the womb of a woman sixty-three years old, and who was not known to have suffered from any symptoms of uterine disease, the organ was found de- formed by eight fibrous tumors growing from its outer surface, which altogether made up a mass three times the size of the healthy womb. One of these tumors, as large as a pigeon's egg, was connected with the posterior uterine wall only by peritoneum and a very slender pedicle of cellular tissue, and would probably in a very short time have become completely separated, while many other tumors were undergoing the calcareous change, and were thus in process of cure. On laying open the cavity of the womb, it was found to bo occupied by a growth of the size and shape of a sugared almond, 1.25 inch long by .9 of an inch broad. On its free surface it was covered by the uterine mucous mem- brane; but it was imbedded for about a fourth of its thickness in the uterine wall, from which it was separated by a distinct envel- ope of dense cellular tissue, such as surrounds fibrous tumors in general. It was of a dark, almost melanotic color, through the greater part, thongli not the whole of its substance, and looked as if blood were infiltrated into the substance of a softening fibrous tumor; for enough of its tissue still remained to show its real nature, even irrespective of the evidence aftbrded by numerous small fibrous tumors, varying in size from that of a pea to that of a bean, which were imbedded in the uterine walls. Hnd this person lived a little longer, one of two things would doubtless have occurred, — either the elements of the softened out- growth would have been absorbed, or its cellular investment would at some point have given way, and a slight discharge, apparently of coagulum, would have been the sole evidence of the ailment from which the patient had suffered, and of the means by which nature had wrought for its removal. AVhether without any such previous change in its tissue, fibrous tumors are ever completely removed by absorption, is a question that I am unable to answer from my own observation. I should quite believe in the possibility of the occurrence, though my impression is that softening and disintegration usually precede the removal of the tumor, and that almost invariably it is not absorbed, but is expelled in its softened state, and piecemeal, from the cavity of the womb. Whether in health or in disease, there is a general analogy between nature's modes of proceeding, even in cases apparently the most diverse, which it is both interesting and instructive to study. The tuberculous bronchial gland is softened, its invest- ment is absorbed, a communication is opened with the air-tube, and the diseased matter is expelled; or when this cannot be accom- plished, another change in its element takes place; the gland shrinks, its substance grows harder and harder, chemical activities THEIR CALCIFICATION. 223 are set to work, and a few masses of calcareous matter unexpect- edly discovered close to the bronchi of some person who liad died in a good old age, tell, not infrequently, that in his youth he was the subject of a disease which usually tends to destroy, and to destroy speedily, those whom it attacks. Just the same kind of changes occur in fibrous tumors of the womb. We have already studied the process of softening, by which their removal is sometimes brought about: a process of hardening by calcareous deposit in their substance is still more common. This deposit sometimes takes place merely in the \)e- ripher}' of the tumor, which thus receives a calcai'eous investment or shell, its interior remaining unaltered. This, however, is very unusual, though it is less rare to find incipient calcification of the interior of the tumor, while the change of its surface is complete. The most common form is that in which irregular masses like coral are deposited in various parts of the tumor, whence they may be separated by maceration, or which make up in the case of the smaller tumors almost the entire mass. Now and then, too, this alteration goes on to the same extent even in the larger growths, and they become converted into a substance of stony hardness, which, as is the case with a tumor in the Museum of the Middlesex Hospital, may receive as smooth a polish at the hands of the lapi- dary as any geological specimen. The growths which proceed from the outer surface of the womb, where nutrition is usually the least active, are those in which this change most commonly takes place. Still the rule is by no means without exception, as a tumor projecting into the cavity of the womb sometimes undergoes this alteration, and being at length expelled from the uterus, constitutes the so-called osseous concretions,' the origin and nature of which were once a puzzle to observers. It is, I imagine, almost super- fluous to say that these tumors contain none of the elements of true bone, that the change which takes place in them is unaccom- panied by the formation of bone cartilage ; that in short it is due to a chemical rather than to a physiological process, and like the so-called ossification of the arteries, is an evidence of enfeebled vitality, not of active nutrition.^ The only other*question of importance concerning the pathology of fibrous tumors of the uterus, is that of their relation to ma- lignant disease, and the possibility of their degeneration into carcinomatous structures. Nothing but the imperfect means of observation possessed in former days would have allowed this ques- tion to remain so long undecided ; but while hard cancer was be- lieved to be a common form of uterine disease, and every induration 1 There are some sjood drawings illustrative of those changes in (ihrous tumors in Hooper's Morbid Anaiomy of the Humfin Ufcrxs, 4to., London, 18o2, ])hitc vii. " See on this subject the remarks of Professor Bidder at p. 42 of Walter's Dis- serfaflon, who believes in the occasional presence of true bone ; wliile Henle also, AUcjeincinc AiKiioiuic, \). 8n'.t, stales that he has diseovrred cartilage corjiuscles in them ; a statement which Vogel, in Wagner's Hatidbuch der Physinlogic, vol. i, p. 823, does not corroborate. 224 ' INFLUENCE OFAGEON of the cervix was regarded as scirrhous, it is not surprising that hard tumors should have been believed to be at least of kindred nature. It may, however, be now positively asserted that no such degeneration of a fibrous tumor ever talq^s place ; and further, that though fibrous tumors do not exclude carcinoma, they yet are not associated together with any special frequency.^ Fibrous tumors are generally regarded, and I believe with truth, as the most frequent of all organic diseases of the womb, though I cannot pretend to state the fact numerically, for the reasons which have been already referred to as vitiating the statistics of hospital practice. Strange as it seems, too, the results of post- mortem examinations are confiicting; on the one hand we have the statement on Bayle's authority, that every fifth woman, after the age of thirty-five, lias fibrous tumors in her uterus; and on the other hand, the allegation of M. Pichard,^ that they were met with only seven times in 800 examinations made by himself or by M. Lair.^ Mr. Pollock,^ in a paper read before the Mcdico-Cliirur- gical Society, states that of 583 uteri examined by himself and his predecessor at St. George's Hospital, 265 were diseased, and in thirty-nine of them fibrous tumors were present, while cancer ex- isted in only thirty-eight. The value of these statements is, how- ever, not a little diminished by their referring to females of all ages, from birth up to old age. Ecpially unsatisfactory are the data given by MM. Braun and Chiari,^ according to whom out of 2494 post-mortem examinations of both sexes, twenty-five instances were found of the presence of fibrous tumors of the uterus. Of seventy instances in which 1 have examined the uterus of women who died after puberty of other than uterine diseases, seven pre- sented fibrous tumor of the uterus. From these data we arrive at nothing more definite than the general conclusion that fibrous tu- mors of the uterus are very frequent, probably more frequent than cancerous disease of that organ. The data of which we are possessed with reference to the age of patients affected with fibrous tumors, though very scanty, are yet more satisfactory, because more definite. Twenty-four post- mortem examinations of Braun and Chiari, and nine cases of my 1 Dr. Lee, in his CHnical Reports of Uterine and Ovarian Diseases, relates one case of the coexistence of a calcareous fibrous tumor and malignant ulceration of the uterine cavity, p. 176, Case V; and one case of the presence of the two has come under my own notice. Chiari's figures, indeed, would lead to the belief that fibrous tumors of the womb are associated with a special liability to malignant disease, since in twenty-live examinations of patients sufiering from them, two presented also cancer of the womb, one cancer of the mamma and lung, and six cancer of other organs, op. cit., p. 404. I know of no other data, however, which would lead to the same conclusion. 2 Diet, des Sciences Medicales, 8vo., Paris, 1813; Article Corj^s Fibreux de la Matrice, p. 73. 3 Des Abus de la Cauterisation, ^-c, dans les Maladies de la Matrice, 8vo., Paris, 1846, Table at the end. * Lancet, Feb. 7, 1852, p. 155. Klinik der Geburtshiife und Gyndkologie, 2d part, Erlangen, 1853, p. 397. PRODUCTION OF FIBROUS TUMORS. 225 own, yield the following result as to the age of the subjects in whom the tumors were found: 2 age not stated. 1 was aged 24 years ; and she died of puerperal peritonitis. 3 were aged between 30 and 40 years. 14 " " 40 " 50 " 4 " " 50 " 60 " 7 " " 60 " 70 " 1 " " 70 '• 1 " " 80 33 In many of these cases, however, the tumors had doubtless ex- isted for many years, and we are therefore concerned rather with the age at which patients first complain of those symptoms to which fibrous tumors give rise, though even then the disease itself has probably existed in many instances for months, or even years, before it attracted notice. Braun and Chiari have stated the ages of thirty-seven patients who applied for relief at the great hospital at Vienna on account of fibrous tumors of the uterus not including polypi ; and if to these be added ninety-six cases wdiich have come under my own observation, w^e obtain a total of one hundred and thirty-three, of which — 26 were between 20 and 30 years of age. 44 " 30 " 40 " 47 " 40 " 50 " 15 " 50 " 60 " 1 " 72 years. 133 The above proportions differ in no important degree trom those obtained by Malgaigne' on a comparison of fifty-one cases of fibrous poly})US of the uterus, from wdiich, if twenty-two cases of my own be added, we obtain the following result : From 26 to 30 years 4 " 30 to 40 " 24 " 40 to 50 " 30 " 50 to 60 " 7 " 60 to 70 " 3 " 70 to 74 " 5 73 If, however, instead of taking the age at which the patient first applied at the hospital, we draw our conclusions, as we ought ratlier to do, from the period at which the symptoms characteristic of the disease first manifested themselves, it will be seen that fibroustuniors and fibrous polypi are an aftection incidental to the 1 Dcs Polypes Uierins, Thise dc Concours, 4to., Paris, 1833, p. 12. 15 Age of patients. First came und( Under 20 years, . Between 20 and 30 years, 11 a 30 " 40" II 40 it 40 " 50 II 50 II 50 " 60 (I 15 Above 60 years 1 226 SYMPTOMS OF season of sexual vigor much oftener than to the period of its decline. 26 48 34 5 1 117 117 It has hecn asserted on Bayle's authority that single women are more liahle to these tumors than those who are married, but my own observation does not bear out the statement ; for of ninety-six women affected with non-pedicuhited fibrous tumors, eighty-two were married; or incUiding the cases of fibrous polypi, of one hundred and eighteen, ninety-nine were married. The prepon- derance of married women is so considerable as to show, I think conclusively, in spite of the comparative smallness of the numbers, that the non-exercise of the sexual functions has no influence in predisposing to the disease. Taking leave, then, of that attempt to ascertain the cause of this affection, which in the case of all diseases we are so disposed to make, and from which we so seldom arrive at any satisfactory result, we may now pass to the very important inquiry concerning the consequences that these tumors produce and the symptoms that they occasion. First of all it may be premised that sometimes these tumors are attended by no symptoms at all ; that they exist for many years without producing any inconvenience whatever. Illustrations of this fact are attbrdcd us by the discovery of fibrous tumors after death in the uteri of women whose sexual system had never shown any sign of disturbance; by our accidentally ascertaining their presence when examining a patient for some other purpose ; or by the sudden supervention of symptoms calling our attention to the state of the womb, and revealing the existence of a large fibrous tumor, whose o-rowth must have been e-oins: on for vears. As might be expected, the constancy of the symptoms is generally proportionate to the intimacy of the relation l)etween the tumor and the uterus. The growths which proceed from the outer sur- face of the womb often produce no symptoms except such as are due to their mechanical pressure upon adjacent organs ; whilst those which are imbedded in the uterine substance almost always disturb the functions of the organ, even before they have attained any considerable size ; and the polypi or growths which occupy the cavity of the womb attract attention almost from the first by the hemorrhage which they occasion. Some relation, too, subsists between the general activity of the sexual sj-stem and the exercise of its highest functions on the one hand, and the severity of the symptoms of fibrous tumor on the other. It is thus that in v»'omen advanced in life, and whose menstruation has ceased, the effects FIBROUS TUMORS. 227 of fibrous tumors are usually less serious than in younger women. It is thus, too, that these growths may produce so little incon- venience as to be scarcely suspected so long as a woman remains single, but may become the occasion of much suffering as soon as she" marries, and as sexual intercourse occasions the frequently increased afflux of blood towards the womb. The bearing of these facts upon our prognosis and treatment must be sufficiently obvious even now, but will be still more apparent after we have examined the symptoms of this affection more in detail. Those fibrous tumors which hang by a pedicle into the uterine cavity, and which are commonly called uterine polypi, are attended by one invariable and characteristic symptom, — viz., hemorrhage. Since, then, their diagnosis is comparatively easy, and since their treatment differs from that which is generally practicable in the other forms of fibrous tumor, we will postpone their further con- sideration for the present; and my remarks will be understood to have reference to those varieties of fibrous tumor which are either imbedded in the uterine substance, or which project from its peri- toneal surface. Menstrual disorder, uterine hemorrhage, pain, dysuria, and more rarely difficult defecation, are the more im- portant symptoms of fibrous tumors, though from being present in various degrees, and in varying combinations, they often leave room for much doubt as to the nature of the affection to which they are due. The following are the principal results deduced from a compari- son of ninety-six cases of fibrous tumor of the uterus, of which I have preserved a sufficient record : In eight of the ninety-six cases menstruation had already ceased when the patients came under my observation, but in two of them considerable hemorrhage occurred from the uterus at irregular intervals, in two such hemorrhage occurred in bi\t small quantity, and in four it did not take place at all. In thirty more cases the menstrual function was not disturbed at all, and in twenty-four of them there was no intercurrent uterine hemorrhage at other times ; but in six patients hemorrhage occa- sionally took place, which, however, had no relation in the time of its occurrence to the menstrual function. In the remaining fifty-eight cases menstruation was more or less seriously disturbed, being Excessive, in 30 cases. " and painful, "10 " " " irregular, . ..." 5 " Painful, "5 " " and irregular, <' 2 " Irregular, "2 " Scanty, . "4 " 58 It appears {hen that in forty-five out of eighty eight cases in which menstruation had not ceased, it uas either excessive in quantity, or over-frequent in recurrence, or both; while in fifteen 228 INFLUENCE OF FIBROUS TUMOKS instances tlie function was performed with excessive pain ; and only in four instances did the quantity of blood lost at the period fall below that to which the patient was accustomed when in health. In forty-four cases hemorrhage from the uterus occurred at other times than those of menstruation ; an accident which took place After the cessation of the menses, in 4 cases. Coincided with menorrhagia or over-frequent menstrua- tion, "32 " " " painful menstruation, "2 " " " " and irregular menstruation, . . " 1 " " " irregular menstruation, "1 " " " no disorder of menstruation, . ..." 4 " 44 In sixty-five cases, pain was complained of at other periods than those of menstruation. This pain varied greatly in its severity, its situation, and its continuance; some patients describing it as a burning sensation, others as a sense of bearing down, while others again seemed to suffer from it in paroxysms of almost intolerable anguish. This pain in thirteen of the sixtj'-five instances coin- cided with painful menstruation ; but in four cases of dysmenor- rhoea, pain was not experienced at other than the menstrual epochs. Menstruation had already ceased in six of the cases in which pain was experienced, and in the remaining forty-six was performed without suffering, and in nineteen of the number, without dis- order of any kind. There were, moreover, thirty-five instances in which the patient suffered from dysuria ; either from pain in voiding urine, or from difiiculty in its discliarge, or from frequent desire to pass it; while four times complaints were made of difficulty in defecation : but none of these sensations could be referred so distinctly to the seat of the tumor or to its size as might beforehand have been expected. The influence of fibrous tumors in modifying the rate of fecun- dity is very remarkable, and shows itself both in diminishing the number of conceptions, and also in increasing the i:)roportion of pregnancies which come to a premature termination. Of the ninety-six cases on which these observations are founded, eighty- two were those of married women ; of these twenty were sterile, while the remaining sixty-two had given birth to one hundred and twenty-four children, and had miscarried forty-eight times. Thirty-one of the sixty-two had had but one pregnancy, which in the case of twenty-one had gone on to its full period ; in ten had terminated prematurely by miscarriage. It is true that five women had given birth to three children each, four to four, three to five, one to eight, one to nine, and one to eleven, respectively; but in all but three of these instances, the tumor either grew from the fundus, or was situated external to the posterior uterine wall, and, as far as could be ascertained, did not involve the substance of the womb. "We shall hereafter see that even when proceeding ON MENSTRUATION. 229 from this situation, fibrous tumors of the uterus often render pregnancy, and labor, and the puerperal state, periods of great hazard ; but it is eas}' to understand that when the growths pro- ceed from the exterior of the womb, they may not interfere with the mere term of utero-gestation. The symptoms of fibrous tumors for the most part come on by degrees, so that the patient cannot narrowly define the commence- ment of her ilhiess, but speaks of a gradual increase in the abun- dance of her menstruation, or of the discomforts which attend it, or of some painful sensation at first scarcely perceived, becoming by little and little more and more importunate, until at length, when driven to seek relief, she first became aware of the existence of the tumor. To this rule, however, exceptions are by no means uncommon ; m\d in twenty-one of ninety-six cases the symptoms came on suddenly, some grave accident at once forcing itself on the attention of the patient, who had previously imagined herself quite well. In eleven of these twenty-one cases, it was hemor- rhage, in five inability to void the urine, such as to call for the use of the catheter, which first excited the patient's alarm, and five times it was intense abdominal pain, though it by no means follows that the first symptoms should continue throughout the most prominent. Lastly, I may add that in eleven instances the accidental discovery of a tumor in the abdomen, was the first in- dication that the patient received of the existence of an affection which for years must have been in slow course of development. If, now, we endeavor to picture to ourselves the history of a case of fibrous tumor of the uterus, we shall, I think, find our sketch to be sometliing of the following kind : A person, probably a little past the prime of womanhood, but at an age at which the sexual functions are still actively performed, becomes causelessly the subject of menorrhagia, which may or may not be attended with pain. The hemorrhage is at first readily suppressed by rest and ordinar}' precautions, but it afterwards returns on every slight exertion, and at length comes on without any cause at all, or con- tinues from one menstrual period to another, so that the patient loses all count of the proper mcnstraal epochs. She does not experience that general constitutional disturbance which almost always accompanies idiopathic menorrhagia, but sufi'ers merely from the loss of blood and its direct results, while in the intervals between the attacks of bleeding, she is seldom troubled by leu- corrhoca, and never by any ofi'ensive discharge. Cou])led with the hemorrhage, sometimes from the very first, generally witliin a few months from its outset, various sensations of pain or dis- comfort are experienced in the lower part of the abdomen, and the neighborhood of the womb. Among these sensations of dis- comfort, that of a frequent desire to pass water is one of the most frequent. The abiding pain is seldom of great intensity; unlike the pain of chronic uterine inflammation, it is not such a^ to render sudden changes of posture, the sitting on a hard seat, or jolting on a rough road almost intolerable ; it does not even preclude 230 CONDITIONS OF THE UTERUS sexual intercourse. On the other hand, it is not a sharp lancin- ating pain like that of carcinoma, but is a dull aching, or burning, or throbl)ing, not in general very difficult to bear, though now and then there are associated with it occasional attacks of suttering evidently neuralgic in character, intense in their severity, and generally accompanied by violent expulsive eflbrts. Any symptoms of this kind should raise a suspicion in our minds as to the probable existence of a fibrous tumor of the uterus, while neither the comparative youth nor the advanced age of the patient, neither the sudden supervention of the symptoms, nor their very slow development, should be allowed to negative this suspicion, or to bias our minds with reference to a question which a careful examination can alone decide. In any such case, and indeed in every instance where there is the least possibility of«the existence of a tumor of any kind, it is necessary to begin by a careful ex- amination of the abdomen. The tumor formed by a fibrous growth is generally very firm, nodulated, and uneven, seldom mesial, but so often situated considerably to one side of the abdomen, that its position alone is not of much value as a means of discriminating between it and tumor of the ovaries. The latter may, however, generally be distinguished by their smooth surface and spherical contour, as well as by a certain degree of elasticity, which is usually distinguishable in them, even though they should yield no distinct sense of fluctuation. On making a vaginal examina- tion, the condition will be found to vary very much, according to the position and relations of the tumor. If any tumor can be felt in the abdomen, the first point to ascertain is the relation borne by it to that of the uterus, to determine whether pressure on the one is immediately conmiunicated to the other; since thereby some clue may be obtained as to the probability of its connection with the substance of the womb on the one hand, or with the uterine appendages on the other. The ovarian tumor, when once it has risen out of the pelvis, almost always draws the uterus up with it, while this change of position seldom takes place when the growth proceeds from tlie womb itself. The posterior uterine wall is the most common seat of fibrous tumors, inasmuch as they were present there in thirty eight out of ninety-six cases ;^ and in twelve of the number could not be discovered in any other part of the uterus that was accessible to examination. Hence we gen- erally find a firm body often, but not always, uneven, occupying more or less of the posterior part of the pelvic cavity, carrying the uterus forwards towards the symphysis pubis, and frequently more or less completely retroverting the organ; in which case it is usually displaced from the mesial line, so that the os uteri is to be found near to the pubo-iliac synostosis on one or other side. 1 The result thus obtained bj' examination during life tallies tolerably closely with that arrived at by Mr. Lee, from a comparison of various preparations in the Museums of the metropolis; who found that in twenty-two out of seventy-four cases the growth sprang from the posterior wall of the body or neck of the uterus. See Saflford Lee, On Tumors of the Uterus^ 8vo., London, 1847, p. 2, table i. IN CASES OF FIBROUS TUMOR. 281 The OS uteri itself is generally small, circular, and healthy; the tissue of the cervix smooth and healthy, or, at the most, only somewhat turgid and hard, from the frequent afflux of hlood to- wards the organ. If the tumor be very small, springing from just behind the cervix, the diagnosis between it and retroflexion of the uterus is a matter of much difficulty, and harder still is it to make out the distinction between anteflexion of the uterus and a fibrous tumor of its anterior wall, the possibility of which must not be lost sight of in the confessed rarity of its occurrence. If the tumor is within the uterine cavity, or imbedded in its walls, the results of an examination will of course be different; the uterus will be found larger, heavier, and less movable than natural; its lower segment may be distended by the tumor, and in that case will not be unlike the form which is assumed by the pregnant womb, though the lips of the uierus, instead of present- ing the development characteristic of the gravid state, wnll be found mechanically thinned by the pressure of the tumor. The cervix uteri, too, in such cases not infrequently disappears long before the growth has attained such a size as by its prominence in the abdomen to simulate the state of the womb when gestation is half completed. If, however, the tumor does not thus project into tlie uterine cavity, its diagnosis will be much more difficult, for a large, a somewliat hard, and a but partially movable uterus, will l)e all that is at first apparent, all perhaps that even a repeated examination may discover. Still, even here, the unaltered orifice of the womb, the absence of tenderness of its cervix, and of any thickening about the roof of the vagina, will suffice to show that neither has inflammation of its appendages fixed the organ in its position, nor has inflammation of its substance or its cervix in- creased its size and weight. The sound may also show the cavity of the uterus to be elongated; and I believe that an enlarged, and heavy, and somewhat hard uterus, coupled with the causeless oc- currence and frequent return of uterine hemorrhage, while the OS and cervix uteri are healthy, are almost always characteristic of fibrous deposit in the uterine substance. It is, I imagine, scarcely necessary to say that not infrequently we come to this opinion rather by the exclusion of all other possible sources of similar symptoms than by the positive evidence afl:brded by any single sign pathognomonic of this affection. It must remain, however, for our task at the next Lecture to pass in review the various anomalies in the symptoms of fibrous tumors of the uterus, and to study the different circumstances which may render our diagnosis difficult or doubtful. 232 DIAGNOSIS OF FIBROUS TUMORS LECTURE XVI. UTERINE TUMORS AND OUTGROWTHS. Fibrous Tumors ; — their diagnosis, and exceptional character of their symp- toms in some cases. Occasional difficulty of distinguishing between them and ovarian tumors. Menstrual irregularity and subsequent sudden hemorrhage has raised suspicion of miscarriage. Sudden suppression of urine in some cases ; its import. Difficulty of distinguishing between flexions and tumor of the uterus. Possibility of mistaking for cancer. Cases characterized by in- tense pain. Diagnosis between pregnancy and fibrous tumor, and difficulty of discovering former when complicated with latter. Prognosis ; progress generally slow ; illustrative table. Influence of pregnancy and labor; dangers which attend them, and why. We have hitherto looked at the symptoms of fibrous tumors of the uterus only as they appear in the simplest cases, with nothing to obscure or distort their characteristic features. In the study of all diseases, however, our concern is at least as much with the exception as with the rule ; and if we would not fall into gross errors, we must be as ready to undo the tangled web, and to find in the midst of it the clue that may lead us right, as we should be quick to follow the signs which point out the plainest path, and render even a moment's doubt .almost impossible. Some of the rarer cases, then, must next engage us ; and I must try, even at the risk of wearing out your patience, to describe some of the many circumstances which may cause us to hesitate in the diagnosis of fibrous tumors of the uterus. In enumerating the symptoms of this afi^'ection, it has already been mentioned, that while hemorrhage very often attends it, the occurrence is by no means constant. It may, however, happen that missing on some occasion this, which is one of the most characteristic signs of the disease, we may begin to doubt its nature, and to question whether the tumor which we discover is not connected with the ovary rather than with the womb itself, I do not know any certain means of avoiding error in such cases, but refer to them for the sake of impressing on you the fact, that the mere absence of hemorrhage, or even a condition of scanty menstruation, does not negative the possibility of the existence of fibrous tumor ; just as, I may add, on the other hand, very profuse hemorrhage sometimes occurs in instances where the tumor is unquestionably connected with the ovaries. The kind of difficulty which presents itself in some instances in distinguishing between tumors of the uterus and tumors of the ovaries, and the considerations which guide us to a solution (pos- sibly indeed not always a correct one) of the question, will perhaps be best understood by the following sketch of the history of a woman, aged thirty-nine, who was admitted under my care into St. Bartholomew's Hospital, in April, 1851. She had been married twenty years, but for eighteen had been a widow, her only child OF UTERUS. 233 Laving been born a year after marriage. Her menstruation, which commenced at fourteen, had always been regular, and unattended by any considerable inconvenience, while it had at no time been excessive. She first noticed a swelling in the right side of the abdomen between three and four months before she came under my notice ; and this tumor had since gradually increased in size. Since she first perceived the tumor, she had had two or three attacks of pain in the back, followed by retention of urine ; while her bowels were often constipated, and she frequently required aperient medicine. Her general health, however, was not seriously impaired. The abdomen measured thirty-six inches and a half at the umbilicus, forty-one inches and a half two inches lower down. The abdominal integuments were loose, and contained a good deal of fat. A solid movable tumor occupied the abdomen, extend- ing from low down on the left side of the pelvis, across the mesial line, reaching on the right side to an inch and a half above the umbilicus, and to within three inches of the right crista ilii, but not dipping down into the right side of the pelvis as it did on the left. This tumor was solid, non-fluctuating, and its surface was somewhat nodulated. At its upper part, and at the right side near the umbilicus, one portion of the tumor, a sort of oflshoot as it seemed, was movable upon the other larger part of the growth. On examining per vaginam, the finger at once came upon a firm globular tumor occupying the pelvic cavity, and dipping down to within an inch of the outlet. At the anterior and right part of the tumor a depression could be felt, somewhat like the os uteri, though the finger could not be made to enter it ; but in no other situation could the least trace of an opening be discovered. A grooved needle was introduced with some difiiculty per vaginam into the tumor, but no trace of any fluid was obtained. In this case the circumstances which favored the supposition that the tumor was ovarian, were its large size, the alleged rapidity of its growth, the fact of its situation not being mesial, and the absence of uterine hemorrhage during its growth. On the other hand, the mere size of the tumor is not conclusive, since, as you know, a fibrous tumor of the uterus sometimes attains to enormous dimensions ; while further, the early stages of its growth might all the more readily be overlooked, owing to the large quantity of fat in the abdominal walls. Moreover, in spite of the frequency of uterine hemorrhage as a symptom of fibrous tumors of the uterus, it is an accident by no means of constant occurrence, and in some of the largest fibrous tumors that have come under my notice, the only symptoms produced have been purely mechanical. It is very unusual to find so large an ovarian tumor without some sense of fluctuation ; the uneven nodulated surface, and the mobility of one portion of the tumor upon the other is, moreover, consonant with what one observes in tumors of the uterus rather than in those ot the ovary. The results of vaginal examination, the solid tumor, the altered condition of the lower segment of the uterus, the \ 234 DIAGNOSIS OF FIBROUS TUMORS. absence, or at least the impossibility of discovering the os uteri, unless it were represented by the small depression which I have mentioned, and lastly, the result of puncture with the exploring needle, all seem to warrant the conclusion that the tumor was uterine, and not ovarian. In addition to these means of diagnosis, which will be found more or less applicable in other cases, the position of the patient during a vaginal examination is a matter of considerable importance. If a woman assumes the usual attitude, the tumor naturally falls towards the left side, carrying the uterus with it. To ascertain correctly the relations between the womb and the tumor, the examination should be made with the patient lying on her back, even though it should be necessary, as very probably it may be, for th'e sake of making a complete examination, to alter her position, and to place her afterwards on her side. I should perhaps add that the diagnosis between uterine and ovarian tumors is sometimes still more obscured by the presence of fluid in the abdominal cavity. Some degree of ascites is indeed far from unusual in cases of ovarian disease ; but its coexistence with fibrous tumor of the uterus is so rare that it may possibly be forgotten. Twice, however, I have had occasion to tap the abdomen in cases where a tumor was supposed to be ovarian, and it was only on a careful examination, after the evacuation of the fluid, that its real nature became api)arent, and that the tumor was ascertained to be connected with the uterus, and not with the ovary. Since, then, the two conditions may be present, it is wise to abstain from forming a positive opinion as to the nature and relations of any solid tumor which may be felt in the abdomen when much distended b}- fluid, and to wait till tapping has re- moved the fluid, and rendered the tumor accessible to a thorough examination. Another deviation from the ordinary characters of the disease is seen when its symptoms set in with great suddenness, those symp- toms being generally either hemorrhage, or retention of urine. The sudden hemorrhage is sometimes assumed to be due to niis- carriage, and this upon grounds as slender as a mere impression upon the patient's mind that she was pregnant, often indeed a hope, rather than a belief, that this was the case. The great safe- guard against this class of mistakes consists in never taking a patient's statement as to the existence of pregnancy for granted, but in always questioning her closely with reference to the date of her previous menstruation, and the evidence of her alleged con- dition ; and if this be done, it will not infrequently turn out that an assertion made most positively, is nevertheless unsupported by a single tittle of proof. But further, the hemorrhage excited by a fibrous tumor is usually more profuse than that of an early abor- tion — is often unattended by pain, while when pain is present, it is not of the same kind, nor do the pain and the bleeding cease at the same time as they do when miscarriage has occurred. The causeless return of the bleeding in cases of fibrous tumors, gene- SUDDEN ONSET OF THEIR SYMPTOMS. 235 rally removes the doubt wliicli miglit have been felt ; while if au exaiiiination be made per vaginam, though in both cases the womb will be heavier than natural, yet the developed lips of the os, its patulous condition and soft texture, after a recent miscarriage, differ much from the firm tissue of the neck of the womb in the other case, its undeveloped lips, its small and scarcely open orifice. The other mode in which the symptoms sometimes suddenly manifest themselves is in the supervention of great difficulty in voiding the urine, or in the occurrence of retention of urine such as to necessitate the use of the catheter. The occasional retention of urine is an occurrence by no means infrequent, independent of organic disease, in women of an hysteri- cal temperament, and cannot of itself be regarded as characteristic of any one affection in particular. It is, however, well to l)ear it in mind, as being sometimes the first indication of the existence of fibrous tumors of the uterus, while both it and dysuria, and very frequent micturition, are less frequent attendants upon ovarian tumors, except in those cases in which both ovaries are afi'ected, and one occupies the pelvis, while the other fills the cavity of the abdomen. The reason for this difterence between ovarian and uterine tumors is, I believe, to be found in the tendency of the tumor of the ovary to rise out of the pelvic cavity, while the fibrous tumor of the uterus still continues in its original situation ; and, as it enlarges, either presses against the neck of the bladder, or carries the uterus more and more forwards till it comes to press U[)on that organ, to irritate it, and even mechanically to interfere with the discharge of its contents. This interference with the functions of the bladder is usually most remarkable in those instances in which the tumor proceeds from the anterior surface of the uterus; and I relate the following case both in illustration of this fact, and also of another to which reference has already been made, namely, the manner in whicli some unwonted cause of uterine congestion may at once call into painful distinctness a train of symptoms previously little felt, per- lu4»s even scarcely suspected. A woman, aged thirty-five, married for eleven mouths, but who had never been pregnant, was admitted under my care in Decem- ber, 1852. Previous to her marriage, liabitual dysmenorrha^a had been the only form of ill health from which she had suffered,' but since then she had been troubled with frequent desire to jjasy water, and constant aching i>ain in the loins, aggravated by walking. The urine was either natural, or else threw down a precipitate of the lithates. The case seemed at first as though it were simply one of uterine congestion after marriage, and local leeching brought slight and temporary relief to the symptoms. On exami- nation per vaginam, however, the os uteri was found to be directed much backwards, — it was very slightly 0[)en ; while a tumor of a rounded form was distinctly felt in front of the cervix, pressing immediately against the bladder, and the sound introduced into the bladder encountered this same obstacle to its introduction, 236 DIAGNOSIS OF FIBROUS TUMORS whicli was overcome only after a little manipulation, though no evidence was obtained at any time of the existence of disease of that organ. The position of the os uteri, and the circumstance of its almost complete closure, while in cases of flexion of the womb it is nearly always open, were two of the reasons which led me to regard the case as one of uterine tumor, not of anteflexion of the uterus. In other instances of tumors of the anterior uterine wall, I have observed a nearly equal degree of irritability of the blad- der, but coupled with hemorrhage and other characteristic symp- toms of fibrous tumors of the uterus, which in this case were absent. The discrimination between fibrous tumors of the posterior uterine wall and retroflexion of the uterus, is often attended by at least as much difficult}^ as that between the two opposite states of anteflexion and tumor of the anterior wall. Tliese cases illustrate one remarkable fact, to which reference has already been made when I was speaking of flexions of the uterus, namely, the want of any constant relation between the amount of mechanical pres- sure on the rectum, and the degree of difficulty in defecation. Sometimes, indeed, the presence of a tumor so large as almost com- pletely to fill the cavity of the pelvis, will be attended by scarcely any difficulty in the expulsion of the freces, while in another case, a growth of but small size will be accompanied by pain and difii- culty in emptying the bowel, and the presence of mucus in the evacuations will give unmistakeable proof of the irritation to which it has given rise. The comparatively slow growth of a fibrous tumor, and the time consequently given for the adaptation of parts to their new relations, no doubt goes far to explain the gen- eral absence of any serious difficulty in defecation ; it occurred only in four of the ninety-six instances on which my remarks are founded. Nothing, however, is more variable than the amount of pain attendant upon uterine ailments; and causes acting through tlie medium of the general system, as well as others more local in their influence, often excite intense suffering from some disease of the womb which had existed for months or years before without occasioning severe pain, perhaps even without producing serious inconvenience. Neither the amount of pain, nor the degree of difficulty in de- fecation, can be taken as affording an}' clue to the solution of the question, whether we have to do with a retroflected womb, or with a fibrous tumor of the posterior uterine wall. The exact relations of the tumor, the fact of the tissue of the cervix uteri passing over into that of the tumor, — a characteristic of flexion of the womb which the experienced touch will generally be able to appreciate, — the state of the os uteri, and the results of the intro- duction of the uterine sound, which will remove the misplacement and inform us of the weight of the uterus (supposing always that we can introduce it, though that is sometimes impracticable), are generally sufficient to keej) us from error. In spite of all care, however, we may sometimes meet with cases in which we shall FROM CANCER OF THE UTERUS. 237 find it a most difficult matter to arrive at a certain diagnosis. Need I say that the importance of a correct diagnosis consists, in these cases, not in its leading us to the adoption of any special plan of treatment, but rather in its enabling us to remove much needless anxiety, to assure our patient that there may be some misplacement of the womb, but that there is no disease of the organ, nor any reason for anticipating an increase of suffering, still less for apprehending a painful and lingering illness. The history alone of fibrous tumor may often raise the suspicion that the patient is affected with cancer, for pain and hemorrhage may both be present, and the health may give way under their continuance, while it needs but inattention to cleanliness, and the allowing the coagula to remain in the vagina and decay there, in order to produce the third symptom, — offensive discharge, which is so often looked upon as almost pathognomonic of malignant disease of the womb. A vaginal examination, however, seldom fails to clear up all uncertainty ; so little is there in common be- tween the small os, the thin and undeveloped lips which coexist with fibrous tumor, and the gaping oj-ifice, with the thickened, hard, irregular, and nodulated lips that characterize cancer of the womb. Error, however, is still possible, and Dr. ^lontgomery, in his valuable paper, to which reference has already been made, men- tions some instances where the pressure of a fibrous tumor just about to project through the os uteri against tlie lower segment of the womb, and the consequent alteration in the condition of the cervix, had led to the mistaken supposition that cancer existed. Care ought to prevent you, I think, from falling into this mistake. More difficult, however, is the diagnosis between cancer of the body of the uterus and fibrous tumor of the organ ; and tlie risk is considerable, in spite of much watchfulness, of your taking the more for the less serious disease. When speaking of cancer of the womb, I shall shortly have occasion to refer again to this sub- ject. At present it may suffice to say that the more rapid progress of the malignant disease, the persistence, tliough not of necessity the greater abundance, of the hemorrhage, and the want of mo- bility of the uterus, though its size be not such as to occupy com[)letely the pelvic cavity, are some of the more important characters by which we may usually recognzie that rare aflection — cancer of the body of the womb. Though not likely to induce any positive error of diagnosis, there is yet another deviation from the ordinary symjitoins of fibrous tumors of the uterus, which calls for some notice. It ha)»pens now and then that they are accompanied by attat-ks of pain of such intense severity as to be almost unbearable, the ]>ain being evidently neuralgic in character, ceasing abru])tly, returning causelessly, and being but little amenable to any kind of treat- ment. These attacks do not seem to be dependent on the size of the tumor, nor on its situation, and are certainly not connected with any special pressure exerted l)y it on any organ, or on any 238 DIAGNOSIS OF FIBROUS TUMORS set of organs. lu one case, in which it continued for years to return occasionally, a sense of weight and burning referred to the womb being experienced in the intervals, the tumor was imbedded, as far as could be ascertained, in the posterior uterine wall. Men- struation was irregular, but profuse ; its occurrence had no inilu- ence either in increasing or in lessening the uterine pain. The patient was at different times under my care with little benefit, and many trials were made of preparations of iodine, without her being able to continue the remedy. At length, after the lapse of four years, she became able to take iodine without the disturbance of health which it had previously occasioned, and after about six weeks' continuance of it, both the abiding and the paroxysmal pain were greatly lessened, though the condition of the tumor remained unaltered. The other case was one of a still more remarkable character. A stout, tolerably healthy-looking woman, but whose somewhat bloated face confirmed the suspicions which her calling as the wife of a publican excited, presented herself one morning at the out- patient room of St. Bartholomew's Hospital. At that time her appearance and manner presented every sign of most intense agony; drops of perspiration stood on her forehead, her skin was cold and clammy, and her pul«e feeble. With these manifestations of extreme suftering, there were associated a disposition to weep, and also a good deal of globus hystericus. After being some little time in bed, the intense pain subsided, and she then gave the fol- lowing account of herself: She was thirty-three years old, had been married seventeen years, had given birth to one live child at the eighth month, and had miscarried three times at early periods ; twelve years having elapsed since her last miscarriage. The cata- menia had always been regular in their return, but for the last two years the discharge had been more profuse than before. For six- teen years she had had occasional attacks of pain similar to those from which she suffered when she came under my notice, but the attacks had always been mitigated by cupping and leeching. For eight years, however, the pain had returned regularly immediately after tiie cessation of menstruation, and had continued for about a week after each period, the paroxysms returning every two hours, and lasting from half an hour to an hour. Her health was gene- rally best for a week before, and sometimes during menstruation, though the pains had greatly increased in their severity, and were sometimes brought on by exertion, or by sexual intercourse, while rest in the recumbent posture always relieved them. The patient complained besides of a sort of cramping pain during micturition, and of diflicult defecation, as if from some substance contracting the passage for the fseces. When the pain came on she sat up in bed, swaying herself from side to side, weeping loudly, complaining of pain like the throes of labor, and also of a choking sensation, all of which subsided by degrees in the course of about half an hour. The abdomen was full ; its size, which was considerable, was partly due to fat with which the integuments were loaded ; WHEN ATTENDED BY INTENSE PAIN. 239 on laying the hand npon it, spasm of the abdominal muscles was immediately excited ; and this for some minutes prevented tiie attempt to determine whether any tumor was seated there or not, though after a time this was settled in the negative. The uterus was situated low down in the axis of the pelvic outlet; its anterior lip was three-fourths of an inch longer than the posterior ; the tissue of the cervix was healthy, the os circular, and slightly open.. Behind, and to the left of the uterus, and extending also slightly in front, was a firm uneven nodulated tumor, tender on pressure, connected, though apparently not very intimately, with the uterus, but which w^as ascertained by repeated examinations, and by evidence of the uterine sound, which discovered the cavity of the organ to be four inches and a half long, to be in reality an outgrowth from the womb, and not a tumor simply connected with its appendages. At first quinine was given in large doses and at short intervals, but with little effect; and I may state my general impression, that quinine oftener fails to arrest uterine neuralgia than to relieve pain seated in other systems of nerves. Afterwards the pain was kept in check b}^ opium, and the patient left the hospital relieved, but not more than might be expected from quiet, a regulated diet, and the anticipating each attack of suffering by appropriate treatment. The most frequent and the most important exceptional peculiari- ties of these growths have now been passed in review ; but refer- ence ought perhaps to be made to the distinction between fibrous tumors and pregnancy, and to the discrimination of pregnancy when it coexists with tumors. Of the two, I believe the latter to be far the more difficult ; and, indeed, when we find the size of the womb obviously increased by fibrous outgrowths, it is almost a pardonable error to attribute to them the whole increased bulk of the organ, and to lose sight of the possibility of a ph3'siological cause having a share in the production of the enlargement. No direction can be laid down such as will always keep from error : the best safeguard is perhaps to be found in our making it a rule for our guidance, in ever}' case of doubtful tumor, to prove the non-existence of pregnancy before advancing a step further in forming a diagnosis. It is to be remembered, sadly strange as it may seem, that there is scarcely any disease, however forinidal)le or however loathsome, in spite of which sexual intercourse and conception may not take place. Vesico-vaginal fistula, the most repulsive disease of the external organs, cancers of the vagina or of the uterus, are far from proving the bar to cohabitation that might be ex[)ected — a cohalntation often on the woman's part suljmitted to with pain of body and anguish of mind ; for, indeed, it is in her sex, much less often than in our own, that "the Centaur not fabulous" finds its aptest illustrations. Ileferencc has already been made to the different condition of the womb in pregnancy from that which it presents when enlarged by fibrous tumor; and the dissimilar state of the lips and orifice of the womb, and the different consistence of its eidarged lower 240 DIAGNOSIS OF FIBROUS TUMORS. segment, will generally suffice to keep the attentive observer from error. It is, indeed, from relying on the evidence furnished by some one or two symptoms of pregnancy, and not taking into due consideration the counterproof alForded by other symptoms, that mistakes are almost always committed. The uterus is found en- larged, and its lower segment expanded ; movements supposed to she foetal are felt by the patient, and a sound resembling the uterine souffle is perhaps detected, and the existence of pregnancy is at once assumed; no account being taken of the occurrence of hemor- rhage, of the non-development of the uterine lips, and of those other phenomena which ought to have excited suspicion ; — which, duly weighed, might have at once proved the case to be merely one of uterine tumor. It is well to bear in mind that, although always of rare occurrence, it yet happens more frequently in cases of fibrous tumor than of any other uterine ailment, that a sound is perceptible closely resembling the uterine souffle, and corre- sponding with it in situation, and in the extent of surface over which it is heard.* The caution which this fact suggests must not be lost sight of in any case of doubtful pregnancy. The complication of fibrous tumor with pregnancy may inter- fere very seriously with the detection of that condition, partly by the misplacement of the womb which it frequently produces, the consequent alteration in the form of the organ, and the difficulty that it may give rise to in attempting to reach the os uteri ; and partly by the impediment which the deposit itself may oiler to the occurrence of the physiological changes in the orifice, neck, and lower segment of the womb. Some time since a case was under my observation in the hospital, in which I overlooked the existence of pregnancy; and I will re- late to you some particulars of it, as illustrating the circumstances that may conspire to throw you off your guard, and to obscure almost completely the usual symptoms of pregnancy. A woman, aged thirty-eight, who had been married twelve months, but had never been pregnant, stated that she had had tolerably good health, and had menstruated regularly until seven weeks before slie applied for admission, when the discharge sud- denly ceased after exposure to cold. Four months before I saw her she first perceived a hard, painless swelling, about the size of an egg:, below and to the right of the umbilicus, and this increased until it had attained half its subsequent size, without any disturb- ance of her health. Since the cessation of her menses, she had suflered from pain in the back and loins, which, slight at first, had * In "Walter's remarkable case, to which reference has already been made, a loud souffle contributed for a time to obscure the diagnosis. Several instances of loud uterine souffle coexisting with uterine tumor, and independent of pregnancy, are re- lated by J. A. H. Depaul, TraiU d' Auscultation Obstetricale, 8vo., Paris, 1847, pp. 209-222. I have observed it in one only out of the ninety-six cases on which these remarks are founded. In this instance, too, error was scarceW possible, for the sound was accompanied by a distinct fremissement, and both it and the tremor seemed to be seated in the left epigastric artery and its branches. DIAGNOSIS OF FIBROUS TUMORS. 241 by degrees become very severe, and at length compelled her to seek for medical advice. Leeching and rest had relieved her pain, but the tumor gradually increased in size. Three weeks before her admission, a discharge, said to be menstrual, again made its appearance, and continued I'or a week, when it ceased for two days, but then returned, and was still going on when tlie patient came under my care. The abdomen was occupied by a tumor, which was not sym- metrical, but more prominent on the right than on the left side of the umbilicus, reaching up to about its level, extending to within about an inch and a half of the left crista of the ilium, and com- pletel}' occupying the right iliac region. It was hard, unyielding, seemed about the size of an infant's head ; was tender on pressure upon its most prominent part. On examining per vaginam, the linger came at once upon a spherical body, occupying the posterior half of the pelvis, and pressing the neck of the womb closely against the symphysis pubis. This tumor, which was firm though somewhat clastic, began immediately l)ehind the cervix uteri, which was about half an inch long, the lips soft, and the os open enough to admit the finger, while the cervical canal was not closed, nor could any mucous plug be detected in it. After the patient's admission, there was very little hemorrhage from the uterus, but she had frequent attacks of very violent pain of an expulsive character. Opiates mitigated the severity of these attacks and controlled their frequency, and at the end of a month the patient left the hospital much relieved, her abdomen measuring thirty-three inches at the umbilicus, as on the day of her admission. A month after she left the hos[)ital she was prematurely confined of a still-born child at about the sixth month of utero-gestation, and her recovery after her lal)or was retarded by an attack of uterine inflammation, of which the patient spoke as having been very severe. Nine weeks after her delivery I again saw her, and found her uterus low down and fixed in the pelvis, the enlarged, elongated, and much thickened cervix being closely in apposition witli the anterior pelvic wall, while a large tumor connected with, and growing out of the posterior uterine wall, com[)letely filled the pelvic cavity, and greatly contributed to the immobility of the organ. It were time wasted to dwell at length on the causes which rendered the diagnosis of pregnancy so difiicult in this case, or which indeed prevented any suspicion of it being entertained. Unsuspected by the patient herself, some of its symptoms were doubtless unnoticed by her; while the continuance of a discharge like that of the menses, its subsequent suppression for a short period, its reappearance and persistence for three weeks before she was received into the hospital, all seemed more like the evi- dences of disease than any of the ordinary results of pregnancy. Examination, too, detected a tumor occupying the pelvic cavity, and which was clearly a fibrous outgrowth. This very tumor pre- vented the ordinary changes in the lower segment of the uterus 16 242 PROGNOSIS IN FIBROUS TUMORS: from taking place, and thus led to the belief that uterine disease, and disease alone, existed. You know, however, that a correct diagnosis implies, not simply the discovery of the patient's dis- ease, but the formation of a right joclgment concerning that patient in all respects. The public feel as little respect for an in- complete diagnosis as for one that is altogether wrong. It is not possible, with reference to any disease whose progress is so variable and course so uncertain as that of uterine fibrous tumor, to make any general statement concerning the prognosis that we should form, for the contingencies are very numerons by which the patient's condition may be modified. Thus much, how- ever, may be stated : that apart from the risks attendant on preg- nancy and labor, fibrous tumors do not tend generall}', nor ever rapidly, to the destruction of life, though they undermine a person's health, and must often make her an easy prey to any intercurrent disease. In only one out of the ninety-six cases on which these observations are based did the patient die of hemorrhage, and the fatal event in this instance occurred nine years after the appear- ance of the first symptoms of the disease; while in the other two fatal cases death was due to uterine and peritoneal inflammation after delivery. The subjoined table which shows the duration of the symi)toms at the time when the patients first came under my observation, illustrates the comparatively slow course of the affection. The symptoms had lasted less than . 1 year in 23 between 1 and 2 years in 8 II 2 — 3 " 5 i< 3 4 " 13 (I 4 — 5 " 10 <( 5 — 6 " 9 . 300 ; Lever, ibid. vol. vii, pp. 98-103 ; and some remarks by Dr. Simpson which first appeared in the Edhibiin/h Monthly Journal, August, 1817, and are re- published at p. 833 of vol. i, of his collected Obstetric Works, 8vo., Edinburgh, 1855. TREATMENT OF FIBROUS TUMORS. 245 of the day before ; witli no prospect indeed of return to liealth, but with a decline so tardy, marked by so few events, that the shadow on the dial seems scarcely to go down at alh Fortunately, in the present case, the disease often has pauses in its course, which, though uncertain alike in their occurrence and their duration, are yet frequent enough to lend a little brightness to the patient's prospects. These, too, are still further clieered by the rare accident of a perfect recovery being now and then brought al)Out by nature's hands ; wliile concerning it we can fore- tell so little, that every patient may witli almost equal reason hope that she herself will prove the happy exception to the general rule. We have already seen enough of the conditions that favor the development and growth of fi])rous tumors, to be able to infer the nature of those precautions by which their increase may be re- tarded. We find their growth to be more rapid, and their symp- toms generally to be more formidable, during the years of sexual activity, than after the time when those functions have ceased ; while pregnancy and its consequences are not only attended by certain positive dangers, but appear to be accompanied by a greatly accelerated rate of increase of the disease. Hence it may be re- garded as a fortunate circumstance when the symptoms of this affection come on comparatively late in life, and we then venture to hold out to our patient the expectation of amendment taking place when menstruation ceases. Hence, too, a more encouraging prognosis may usually be expressed in the case of an unmarried woman, or of a widow, than of one who is still cohabiting with her husband. Apart, indeed,, from the occurrence of pregnancy, there can be no doubt but that mere sexual intercourse is injurious to patients with fibrous tumor, and that the congestion of the uterus and pelvic viscera, and the increased vitality of the sexual organs which the act induces, favor its increase. If then your patient be a married woman, it is your duty to acquaint her with this fact ; it is not generally your duty to do more ; for often there are complicated questions iDoth moral and physical involved, which 3'ou must not ignore, but into which, unasked, you have no right to intrude. But while you must to a great extent leave this matter to be settled by your patient, there are some other points concerning which your advice cannot be out of place. Independent of the risks of hemorrhage which attend it, the menstrual period is always unfavorable to this class of patients, and the more quietly you can succeed in conducting them through it the better. Ab- solute rest through the whole of each period is of great importance; while, if much hemorrhage or severe pain accompanies it, the pa- tient should remain in her bed for the first forty-eight hours, and should not move further than to her sofa during the whole of its continuance. If it sets in with severe pain, associated, as is usually the case, with abdominal tenderness, a few leeches over the hypo- gastrium, or the tender part of the tumor as felt through the ab- domen, will often be of service, but the caution which I have 246 TREATMENT OF FIBROUS TUMORS: already given as to the inexpediency of leeching the uterus just before the commencement of a menstrual period, holds good in this case. Both the pain and the hemorrhage are often nmch lessened, not only by keeping the bowels acting with regularity at all times, but also by giving an aperient just before the dis- charge commences. If menstruation should be very excessive, the case must be treated just like any other case of menorrhagia, and in anticipation of profuse loss of blood, astringents may be employed from the very first day of the discharge appearing, Not infrequently there is a disposition to intercurrent hemorrhage be- tween the periods, which may in man}' instances be warded oif by complete rest at the time, by the avoidance of all stimulants, by salines and sedatives, such as the citrate of potash with tincture of henbane, and by the a[)plication of a few leeches to the abdomen, if the tlireatcnings of loss of blood are accompanied with much pain. I do not think that in cases of fibrous tumor of the uterus very much is gained by the application of the leeches directly to ^the w'omb itself, though in simple hypertrophy of the organ that constitutes our most efficient mode of treatment. Sometimes, however, when menstruation is scanty, and, as is then generally the case, painful ; or when there is considerable uterine tender- ness, and a \niffy or indurated condition of the cervix, much is obtained by this measure. I believe, however, that then it is the general state of the uterus, rather than the tumor of the organ, which is benefited. Much standing, much exertion, and especially much walking, are all objectionable, for all tend to produce and to keep up a congested state of the pelvic viscera. If these, how- ever, be interdicted, and the patient be thereby condemned to a sedentary life, it is obvious that to maintain her health she must adopt a mild, unstimulating diet, that she must live more sim[»ly, even more abstemiously, than before. On the degree to which you can command your patient's confidence, and can induce her to adopt this somewhat self-denying kind of life, and on the extent to which she has fortitude to persevere in it, month after month, even year after year, will depend the measure of her health, her comfort, and her powers of usefulness. It would profit but little to repeat all that lias been said before when treating of dysmenorrhoea and of excessive menstruation ; for the rules then given and the remedies then suggested api)ly equally to the mitigation of pain or the suppression of bleeding when dependent on fibrous tumor. It may not, however, be super- fluous to add, that the steady observance of the hygienic rules which I have laid down is of more importance than the mere use of medi- cines for the permanent mitigation of either of these symptoms. But it may be asked whether there is no remedy that exerts a specific influence on the growth of these tumors, — none by which we can obtain their absorption, or at least feel sure of putting a stop to their growth ? I very much fear that no such remedy exists, or at least has been at present discovered. Mercurial prep- arations most certainly have no such influence ; and the alleged USE OF IODINE. 247 powers of iodine seem to have been very miicli overrated, for in a very large proportion of the instances in which it has been perse- veringly employed, no effect whatever has appeared to follow its administration. The disintegration of the tumors, and their ex- pulsion, have never, in my experience, succeeded the continued use of preparations of iodine, but have taken place unexpectedly, and independent of any assignable cause. Still it is possible that the rapid increase of these growths may be sometimes restrained by this agent, and I therefore employ it as our best, though but an uncertain remedy, and with a yearly lessening faith in its efficacy. To gain an3-tlnng by it, indeed, it is essential that its use should be continued for many months ; and, in order to this, the patient must be brought very gradually under its influence, since large or frequently repeated doses often disorder the digestion, occasion slee})lessness, or produce a febrile condition, which compels the discontinuance of the medicine. I seldom give more than one grain of the iodide of potass with twenty minims of the syrup of iodide of iron, twice a day ; and though in addition I generally recommend the inunction of an iodine ointment over the tumor, yet this is rather as an additional means of impregnating the system with iodine than on account of any marked local influence which its employment in this manner has seemed to me to exert. The introduction into the vagina of balls of iodine ointment, for the sake of the supposed local action of the remedy on the tumor, does not appear to me to have evidence in its favor sufficient to counterbalance the obvious disadvantages attendant on constant local medication of the womb, and the daily introduction of irri- tants into the vagina. The same kind of objection, with the additional drawbacks attendant on the proved in efiicacy of mercu- rials, attaches to the local use of the unguentum hydrargyri, and its injection, as has been recommended, into the cavity of the Avomb. The bromide of potassium has been spoken of as of sujierior efficacy to the salts of iodine. I cannot say whether it de.-erves this character or not ; but it certainly has the advantage of being better tolerated, and for a longer time, by the patient. It must also be remembered that the waters of Kreuznach' in Germany, 1 Dr. Siitro, in liis work on the German Mineral Waters, London, 1851, gives at page 2uG the f(jllowing result of an analysis by Professor Lijwig of Zurich, of the contents of sixteen ounces of the water : 72.88 chloride of sodium. 13.38 " calcium. 4.07 " magnesium. 0.62 " potassium. 0.()1 " lithium. 0.27 bromide of magnesium. 0.03 iodide 1.09 carbonate of lime. 0.01 '< baryta. 0.10 magnesia. 0.15 oxide of iron. 0.02 pho.sphate of alumina. 0.12 silica. 04.02 248 TREATMENT OF FIBROUS TUMORS: which have acquired considerable reputation for the special in- fluence which they are supposed to exert over enlaro;ements and fibrous tumors of the uterus, contain salts of bromine in much larger quantity than those of iodine. I am much at a loss, how- ever, as to how far the alleged influence of these waters on fibrous tumors is a real one, and must confess that in no instance have I seen any marked diminution of a tumor result from their use, still less have I known a tumor become absorbed or disappear. The waters are no doubt possessed of great potency, and in many scrofulous and secondary syphilitic aft'ectious prove of much service. The mode of their employment, too, is very energetic, so tliat failure cannot be attributed, as when the waters are used in this country, to the imperfection or insufiicienc}^ of their application. For six or seven weeks the patient spends three-quarters of an hour daily in a bath, the strength of which has been increased by the gradual addition of from twenty-four to thirty pints of the mother lye, or liquor which remains after evaporation of the water, to four hundred pints of the water. Besides this, twice a day for an hour together, warm fomentations of the mother lye are ap- plied to the abdomen, and these fomentations are increased in strength until they produce a burning sensation, and an eruption of pimples on the surface. The patient, in addition, takes the waters internally, and employs an enema of two ounces of the water, with twenty to thirty minims of the mother lye, every day after the bowels have acted. This treatment is continued until constitutional symptoms, indicative of what is regarded as satura- tion of the system with the remedy, are produced ; and then, after a pause of three or four weeks, a second similar course of four or six weeks is undergone, and this plan is repeated in many instances for two or three successive summers.^ If to this energetic treatment there be superadded the observance of all those subsidiary measures, often too hard to enforce in other circumstances, but which seldom fail to be attended to when a patient leaves her home and places herself for some months under the care, not of an ordinary practitioner, but of one who seems to preside as a sort of genius of the place over the wonder-working spring, we certainly have all those conditions assembled from which most striking results might be anticipated. My own con- clusions, however, are fully borne out by the greater experience of Scanzoni,^ who says that he "does not believe that by these means any important diminution of a real fibroid tumor has ever been effected." It seems, too, from the statement of Dr. Prieger himself, a gentleman who first brought the waters of Kreuznach into notice, and who for many years practised there with well-merited reputa- tion, that by far the greater proportion of cures occurred in his 1 For this account of the plan pursued at Kreuznach I am indebted to a letter from Dr. Engelmann, who has practised there for many years, and has written a little book on the use of the waters in secondary syphilitic atiections, — The Baths of Ki-euznach, 8vo., Frankfort, 1852. 2 Op. cit, p. 237. USE OF KREUZNACII WATERS. 249 experience in cases of simple hypertrophy of the uterus, and not of fibrous tumors of the or2:an. My own observation confirms Dr. Prieger's statement. I have seen simple enlargements of the uterus consequent on chronic inflammation of the organ, or a deficient involution after delivery or miscarriage, much reduced in bulk; and I have also seen the womb in whose substance fibrous tumors were imbedded grow smaller, not from reduction of the tumor, but from lessening of the hypertrophy of its tissue, to which the tumor had given rise. With this improvement, too, in the local condition, there has been a lessening of the discomforts from which the patient pre- viously suffered. I do not know, however, that I have seen this relief, in cases of fibrous tumors, persist for long after the patient's return home, on her attempt to resume her previous mode of life; nor have I found it to be more complete or more lasting than I have seen follow in other instances from obedience to simple rules deduced from general principles of treatment. Still, when our remedies are so few, we cannot well afltbrd to dispense with any, even though their virtues may he questionable; and I often sanc- tion, or even suggest a visit to Kreuznach, though accompanying it with a liint that relief of discomfort, rather than absolute cure, is all that I can promise from the experiment. I should also say that of late years the Kreuznach salt and the mother lye have been imported into this country; and patients anxious to make trial of their virtues can obtain them from most of the principal chemists in London. They are employed either in liip-baths, or in the form of epithems worn over the lower part of the abdomen, and I have known patients obtain relief from both of these proceedings. I doubt, however, whether the latter does more than act as a moderate counter-irritant, and whether the comfort afforded by the former is not due as much to the soothing influence of the warm water as to the medicinal action of the salt which it contains.^ If medicine, however, is so slow, and confessedly so uncertain in its action upon these growths, are they, you may inquire, equally beyond the reach of surgical interference? Such of them as s[)ring from a distinct pedicle, and hang down into or beyond the uterine cavity, admit of removal either by the knife or the ligature; and concerning these fibrous polypi I shall have some- thing to say presently. The non-pediculated growths, with tlie study of which we are now occupied, and those pedunculated tumors that spring from the outer surface of the uterus, arc almost or altogether beyond our reach. A few cases are on record whore the abdomen has been laid open, and the extirpation of a fibrous tumor from the outer surface of the uterus has been attenqited, and even actually accomplished. In most of these cases the ' ()no pintof tlin mothor lyo and one jioiintl of common salt in an ordinary lii]>- batli ofSii" is a .eviffii'icntly close imitation of tho baths of the mineral s)>rin^ itself, dift'eiin<^ from it chiefly in beini:!; stronger than the baths are at Krouznach, in which the whole body is immersed. 250 TREATMENT OF FIBROUS TUMORS: operation was undertaken with the impression that the tumor was ovarian, and in all instances but one, which is reported by an American surgeon, Dr. Atlee, its completion was followed by the patient's death. It is a proceeding to be altogether deprecated, difficult to accomplish, almost certainly fatal if concluded, sur- rounded by dangers which wisdom cannot foresee, nor skill avert. It would perhaps not be right to pass quite so sweeping a con- demnation on another operation which, since its first performance by M. Amussat, has had several imitators, and which consists in the enucleation of fibrous tumors of the uterine walls by an incis- ion made through the os uteri, or the lower segment of the womb. No one can have noticed the extremely loose connection between the uterus and fibrous tumors imbedded in its substance, without the feasibility of an operation for their removal occurring to his mind, and it was suggested, on theoretical grounds, by M. Velpeau, some years before the idea was put in ju-actice in 1840 by M. Anmssat. The results of it, however, are by no means encourag- ing, so long as we limit our inquiry to cases of enucleation of inter- stitial fibrous tumor of the body of the uterus, for twenty-eight operations yield fourteen deaths to fourteen recoveries, while in four of the latter tlie operation was incomplete, and a portion of the tumor was left behind.^ If now to the published mortality 1 The followinc: references include all the cases with which I am acquainted that strictly belong to this category: STJCCKSSFUL CASES. Amussat, 2 cases, reported in full in Exnrninnieur MSdicale, Feb., 1843. Maisonneuve, 2 " Bulletin de I' Acad, de Med., xiv, 722; and Gazette des Bopitait.v, Dec. (i, 1849. Grimsd.ale, 1 " Liverpool Medico-Chirurqical Journal, Jan., 1857, p. 54. Teale, 1 " Medical Times, March 22, 18-36, p. 28-3. Atlee, 7 " Timnsaciiona of American Medical Association, \o\.y\,\>. ^io^. Davis, 1 " Transactions of the Obstetrical Society, vol. ii, 18G1, p. 17. — 14 cases. FATAL CASES. Boyer, 1 case, Revue Medicate, March, 1845; death in 6 days. Berard, 2 " Bull, de la Societe Anatomique, 1842, j). 82 ; death in 5 weeks ; in his other case mentioned by Jarjavay, death took place in 2 days. Maisonneuve, 1 " Bulletin de la Societe de Chirurgie, vol. i, pp. 458, 474. M. Maisonneuve does not himself mention the death of the patient, but the fact is mentioned by .Jarjavay, who states that death took place at the end of a month. See the translation of his thesis, " Des Operations aux Corps Fibreux de I'Uterus," in vol. vii, of the Analekten fur Frauenkranliheiten, p. 426. Chiari, 1 " Klinik der Geburtshiilfe, &c.. p. 408; died in 36 days. Baker Brown, 2 " Medical Times, July 2-5, 1857; death of one in 30 hours, of the other in 13 days. Atlee, 5 " Loc. cit. The date of death was 1 month, 11 daj's, 5 days, 7 weeks, and 20 days respectively, after the first operation was attempted. Simpson, 1 " Ed. Monthly Journal, March, 1848, and republished in the Obstetric Memoirs, p. 118; died in 6 days. Self, 1 " — 14 cases. The temptation to suppress due mention of cases having an unfortunate issue THEIR ENUCLEATION. 251 we make some atldition, — and I fear it ought to be a very large one, — for suppressed, or at least for non-reported cases, we arrive at a result wliicli compels us to class the operation among the most hazardous in surgery. These risks, too, be it observed, are incurred not in the case of a disease surely and rapidly destroying life, but of one that runs a slow course, that often comes to a standstill of its own accord, and that almost always atfords a pros- pect of months or years of valetudinarianism indeed, but still of life, wdiich the operation may cut short in a few days. Success, on the other hand, by no means necessarily frees the patient from her ills, for fibrous tumors are but seldom solitary, and the removal of one may but serve to bring to light the existence of another beyond tlie reach of surgical interference. In the performance of the operation itself, the main difliculties seem to arise from the size of the tumor, the inadequate si)ace afibrded by the opening of the os uteri, which it has generally been necessary to incise or to dilate forcibly, and from a thinness of the uterine parietcs, so extreme as to necessitate the most cautious manipulation, lest the peritoneal cavity should be opened in the endeavor to extract the tumor. It must, indeed, be imposrsible for any one to read the particulars of operations such as those of Amussat and Boyer, where the patient was more than two hours under the hands of the surgeon ; or of that of Maisonneuve, in which the hemorrhage that immediately followed it was very alarming, without feeling much hesitation as to the propriety of ex})Osiiig a person to so great a risk for advantages so uncertain. It is not^ however, the loss of blood, for that is not in general con- siderable, nor the immediate eifect of the shock, which is most to be apprehended, for no patient appears to have died from hemor- rhage, and only two from the direct shock, and one of these paticjits had already been exhausted by frequent operations. Peritonitis, phlebitis, and pj-iemia, the consequences of violence done to the uterus of women exhausted by large and frequently repeated flood- ings, are dangers from which but few have altogether escai)ed ; under which I fear that correct statistics would show that most have succumbed. scorns almost insurmonntublo, while it vitiates all the conclusions whicfi wc may attempt to draw from the statistics of those adventurous operations. Thus, in the discussion that arose at the iSociet^ de Chirurgie, on Dec. 5, 1849, with reference to M. ]\Iaisonneuve''s third and fatal case, tliat j^entleman himself mentioned having seen a " i,'ood number" of unsuccessful attempts at enucleation of tilimns tuinors, all of whicii had a fatal issue; while M. Huuuier relates an instance where death took place twrevent, which are known to have modified his own practice, and which migiit attbrd lessons so well worth learning to others. 252 TREATMENT OF FIBROUS TUMORS: The amount of difficulty in the performance of the operation, and the degree of risk which it will entail on the patient, can scarcely be estimated beforehand; and of this it would not be easy to give an apter illustration than is furnished by my own unsuc- cessful case of attempted enucleation of a fibrous tumor. The patient was thirty-nine years old, the mother of three chil- dren. The first symptom of her disease ha'd appeared a year before, when she had a sudden attack of most profuse hemorrhage, which returning thrice at intervals of a fortnight, reduced her to a' state of extreme exhaustion. The enlarged uterus was only with diffi- culty felt by the hand over the pubes ; its enlargement was due to the presence of a tumor as large as an orange, imbedded in the anterior uterine wall, which had distended the os uteri to aljout the size of the top of a wine-glass, but did not project beyond its margins, the surface of the tumor being adherent to the anterior uterine lip. The uterine sound appeared to circumscribe more than half of the growth. The moderate size of the tumor, the open state of the OS uteri, and the circumstance tliat so large a portion of the tumor was unattached, seemed both to Mr. Paget and mj^self to render the case one in which, if hemorrhage returned dangerously, enucleation might be attempted. For a few months no consider- able bleeding took place ; but then the hemorrhages returned ; and ten months after the patient first came under my notice, the operation was attempted, the tumor apparently retaining very nearly its original size and relations. A pair of hooks were firmly fixed in the tumor, and by their means the uterus was drawn down near to the vulva. The anterior uterine lip was then dissected off from it, and as far as the finger could reach the shelling of the tumor out of its investing membrane was easily accomplished. The hand was partly introduced into the cavity of the womb, and the detachment of the tumor posteriorly was accomplished ; but no efibrt succeeded in reaching high enough in front to complete its separation. Attempts were made in vain to separate the growth by traction, or to invert the uterus so as to bring it within reach of the finger, but in vain ; and the operation was left incomplete after the enucleation of about four-fifths of the tumor had been accomplished. Before abandoning the attempt, however, incisions were made in various directions into the substance of the growth, in the hope that its vitality might be destroyed, and that event- ually it might be got rid of in a state of disintegration. The operation lasted about an hour, very little blood was lost in its performance, but the patient suffered much, and was left in a state of great depression, which seemed to require the liberal employment of stimulants. As this condition subsided, the com- plaints of abdominal pain became greater, and the tenderness more exquisite, on which account two dozen leeches were applied on the third day after the operation, and mercurials were given which produced salivation in five days, marked relief of all the symptoms taking place about the same time. A profuse, fetid, and very THEIR ENUCLEATION. 253 acrid discharge came on soon after the operation, and continued for more than a month, causing the patient much distress h}' ex- coriating the vulva and nates; but though the whole of the tumor disappeared, it was but once that a very small portion of it was discovered in the matter which flowed from tlie vas-ina. The operation was performed on December 21st; by January 5tli the patient seemed to be in a state of safety; and before the end of the month she was able to walk about the ward. On February 11th she complained of some increase of pain in tlie left iliac region, which subsided on the application of half a dozen leeches; and which seemed the less to call for any serious anxiety, since the patient a few days before had menstruated scantily, though naturally. In the afternoon of February 14th, how'cver, the patient, who had been up and walking about in the morning, was seized with a violent rigor and a return of pain, which once more subsided completely on the application of a few leeches, and the administration of an opiate. On the 20th she was so well that she was about to leave the hospital the next day; but at two o'clock in the morning w^as attacked by violent shivering, intense ab- dominal pain, and those indications of collapse which accompany peritonitis from intestinal perforation, and died at four o'clock in the afternoon of the same day. After death, all the evidences of recent acute peritonitis Avere discovered, wath a considerable quantity of a sero-purulent fluid ; which in the pelvic cavity was found to consist almost entirely of pus. This pus seemed to proceed from the cellular tissue between the uterus and rectum, though the abscess there did not appear to have been large. The matter had escaped into the peritoneal cavity through several small openings formed by sloughing of the serous membrane in that situation. The uterus Avas healthy ; the upper part of its cavity retained its ordinary appearance, but a little above the os there existed a cavity formed at the expense of the uterine wall, which was here less thick than elsewhere. This cavity, which was evidently the bed whence the tumor had been removed, measured 1] inch in its lateral diameter, half an inch in dc])th, and the same in its antero-posterior diameter. It was lined by soft, pale granulations, and no trace of the tumor was to be seen in it. But for the bursting of this abscess into the peritoneum this case would have been numbered among the successes. The fatal accident, it is true, was one of very rare occurrence, unlikely to happen again on another occasion, but it is this very liability' to rare accidents which foresight cannot anticipate nor skill piwent that serves to distinguish these exceptional proceedings from those operations whose indiciitions can be clearly detined and their dangers accurately estimated, and A\hieh htll within the more legitimate domain of surgery. It seems to me worthy of consideration how far the mere ineising fibrous tumors, so as to destroy, or, at any rate, greatly to impair 254 TREATMENT OF FIBROUS TUMORS: their vitality, might be substituted for the more hazardous attempt at their entire enucleation. In the case just narrated, this might have been done without the infliction of any such violence on the uterus as was inseparable from the attempt at the complete re- moval of the tum.or ; and some instances have since been recorded, in which the gouging out a portion from the centre of a fibrous tumor of the uterus has proved successful.' The great hazard attending this, as well as all other operations on the sexual organs of women, is that of the supervention of pysemia; and it must not be forgotten that the previous exhaustion of the patient by frequent hemorrhages renders her specially liable to this acci- dent. But while the hazard attendant on operations for the enucleation of interstitial fibrous tumors of the uterus, when still imbedded in the walls of the organ, is so extreme as to render them generally inadmissible, and to remove them to thiit class of exceptional pro- ceedings which the special condition of the patient, and the unusual dexterity of the surgeon alone justify, there is a class of cases in which the attempt at the removal of these growths maybe admis- sible. Such are those instances, some ot" which are recorded by Lisfranc,- where a small tumor was imbedded in the substance of the uterine lip, and its removal could consequently be efl:ected without any violence to the cavity of the womb. A case of this kind was recently under my care in St. Bartholomew's Hospital. The tumor, which weighed 2} ounces, and which presented all the ordinary characters of a fibrous tumor, was imbedded in the posterior lip of the uterus of a patient aged forty-seven. An in- cision was made by Mr. Paget along the whole posterior surface of the uterine lip, and was carried forwards to the margin of the os. The growth was tlien shelled out by the finger with the greatest ease, except at one small point at its front and upper part, where it adhered firmly to the uterine tissue, but was detached by a few strokes of the bistourj'. No hemorrhage of importance, nor any bad symptoms, followed the operation, and the patient left the hospital quite well in a fortnight. The operation, too, is comparatively free from danger in those cases where the tumor has approached the pedunculated form, and has consequently been easily reached through the widel}' open or easily divided os uteri, or perhaps has admitted of still readier removal, owing to its having passed beyond the orifice of the womb, and come to lie almost completely within the vagina. The operation here would seem to stand on much the same footing with operations on pedunculated tumors or polypi ; and the de- tails of cases such as those of Dr. Pancoast,^ Mr. Teale,^ Dr. Gil- ' Baker Brown, Ohstet. Trajisact., vol. iii, p. 67. 2 Cliniqiie Chirurgkale, &c., vol. ii, pp. 172, 173, 178, 179. 3 Boston Med. Journal, Oct. 9, 1844. * Med. Times, Aug. 20, 1853 ; und Ibid. March 22, 1856. THEIR ENUCLEATION. 255 bert,' and M. Langeiibcck.^ appear to bear out the correctness of a supposition wbicli lias all tlicoretieal probabilities in its favor. Absolute safety, bowcvor, cannot be claimed even for tbis simple operation. I performed it once on a patient wlio bad long sntlered from afibrons tnmor, whicb, growing somewbat in a polypoid form, bad on tbree previous occasions been partially removed. At length spontaneous inversion of tbe uterus took place, and tbe tnmor witb tbe inverted womb was now easily drawn by a pair of mid- wifery forceps beyond tbe vulva. Tbe mass, weigbing six ounces, was readily sbelled out of tbe uterine tissue by tbe baiid, and scarcely an}^ blood was lost in accomplisbing this; the inverted womb being afterwards readily replaced. Seventeen days after- wards tbe patient died of pyoemia; a large coagulum, in which pus cells were abundantly present, filled tbe inferior vena cava, and there were purulent deposits in the lungs, spleen, and left kidney, though tbe large uterus, its appendages, and its veins, w^ere perfectly healthy. There is still one resource left us in cases where the hemorrhage produced by a fibrous tumor is very formidable and uncontrol- lable, while the patient's condition forbids tbe adoption of any grave surgical proceeding. This consists in making free incisions into the os uteri, and great diminution of the bleeding seems al- most always to have resulted from it,^ though I confess tliat I do not understand the mode in which this efiect is to be explained. I once had recourse to it with partial success; but the patient^ already much exhausted, sank a few weeks after under the slight 1 Boston Med. Journal, vol. xxxi, p. 350. For this last reference, and also for calling my attention to Dr. Atlee's cases, I am indebted to some very interesting jiapers by Hutchinson, in the Medical Times, July 25 to August 15, 1857. Four of the cases, however, which he includes in his table being those of operations on two patients with recurrent fibroid tumor of the uterus, appeared to me to be out of place there, and for the reason assigned in the text; the seven cases just referred to seemed to require to be ranged in a diiierent category from that to which operations on interstitial fibrous tumors belong. This division appears to me to convey a juster impression of the sources of danger from tbe operation tlian one based on the mode of its performance. In many, enucleation by the induction of gangrene was attempted, only because primary enucleation had been attempted and failed. The verjf uncertainty in cases of interstitial fibrous tumor as to which operation will be practicable, or whether both may not alike prove impossible, constitutes to my mind the great objection to these proceedings. The' real question is ob.scured, if stated so as to seem one concerning the comparative merits of two kinds of operations. ■■^ Deidsche Klinik, 1859, p. 1^_^ Three cases are related, one of which does not belong here, since the operation was performed as a matter of neci'ssity during labor, when the patient was already nuich exhausted, and death was attributable to the delay rather than to the operation. The other two cases, which bad a suc- cessful issue, illustrate the indications for the performance of the operation, which M. Langenbeck defines as being "The youth of the pat'ent, the dangerous nature of the hemorrhage, and the seat of the tumor in the substance of either lip or of either wall of the cervix uteri, so that it can be reached by the knife, without forcibly drawing down the womb." Two other additional cases by M. S.iiit<-;s.m and 31. Janger, both of which had a favorable issue, are related in Schmidt's Jahr- burJicr, 1858, vol. 100, p. 41. ^ Sec some cases recorded by Dr. McClintock, op. cit., p. 147. 256 MANAGEMENT OF LABOR hemorrhage which still continued, and sj-mptoms of pjcemia for a few days preceded her death. In conclusion, and before taking leave of the subject of fibrous tumors, a few remarks must be made on the management of cases in which they occur as complications of pregnancy or labor. It happens occasionally, as in a case which some years since came under my own observation, that the pelvic cavity is found at the commencement of labor occupied by a large and firm tumor, the existence of which had not been betrayed previously by any s^mip- toms whatever of uterine disease. In some of these cases the Csesarean section has been performed, but I am not acquainted with any instance where a favorable result has followed the operation when rendered necessarj'- by uterine tumor. The presence of the growth both interferes with the due contraction of the womb, and thus exposes the patient to great risk of hemor- rhage, and also, if this danger be surmounted, seems to insure the supervention of inflammation of the uterus and peritoneum of a kind so perilous, that in every recorded instance it has hitherto proved fatal. Unfortunately the cases are but very few in which extirpation of the tumor is possil)le, for, in comparison with any operation by which the peritoneal cavity is laid open, that would seem to bo far less hazardous. The successful removal of polypi during lal)or, and the extirpation of large fibrous tumors of the pelvic walls,' encourage to such a proceeding; but the only in- stances with which I am acquainted of the actual enucleation of a fibrous tumor from the uterus itself during labor, are related by M. Danyau,^ AI. Langcnbeck,^ and Dr. Keating.^ M. Danyau's patient Avas thirty years old, had given liirtli to three children, after ^easy labors, and had reached the end of her fourth pregnancy, though slight hemorrhage had been going on for three weeks. Forty hours after the escape of the liquor amnii, a foot of the child was felt presenting, while the pelvic cavity was almost com- pletely filled by a tumor which seemed to be formed by the thickened posterior lip of the uterus, and which did not leave a space of above three-quarters of an inch to an inch and a quarter between itself and the symphysis pubis. The child having been ascertained to be dead, and no question therefore arising as to the performance of the C^esarean section, M. Danyau, having consulted 1 A.s in the remarkable case related by the late Professor Burns of Glasgow, in his Midwifery^ eighth edition, 8vo., London, 18-32, p. 33. 2 Gaz. des Hopitaux, No. xlii, 1851 ; and iSchmidt's Jahrbucher, vol. Ixxi, August, 1851, p. 190. ^ Loc. cit., p. 3. * Americnn Journal of Med. Sciences, May, 1858 ; and Schmidt, vol. 100, p. 40. I purposely do not go into the consideration of those cases, of which several are on record, with varying results, of the extirpation of polypi or of non-pediculated tumors soon after delivery, for I have no personal experience on the subject. My leaning, however, would be to non-interference with them in the puerperal state, unless symptoms urgentlj' called for an opposite course, since I should fear that the greater facility of their removal would be more than outweighed by the greater risk of purulent absorption afterwards. WITH UTERINE TUMOR. 257 Avith Professor Dubois, carried a bistoury on two fingers of liis left hand througli tlie os uteri, whicli was open to tlie size of tlie top of a small wine-glass, made a longitudinal incision through the anterior and upper part of the tumor, and then succeeded with two fingers of the right hand in shelling it out of the uterus, and removing it from the pelvis. The tumor weighed twenty ounces seven drachms; its longest diameter was five inches and three- quarters ; its shape conical, with the apex downwards. The ex- traction of the child was easily accomplished after the removal of the tumor, and the patient recovered without any bad symp- toms, though a considerable quantity of venous blood escaped at the commencement of the o[)eration, when the tumor was first cut into. The patients of M. Langenbeck and of Dr. Keating were less fortunate. The former, exhausted by the previous long dura- tion of labor pains, died within twenty-four hours, while the latter was attacked by puerperal phlebitis, which proved fatal on the eighth day. In all cases, however, where it is practicable, operations on the parturient uterus are to be avoided, and the first thing to ascertain with reference to any tumor is whether it admits of being moved out of the Jiclvic cavity, since, if that can be done, it is obviously attended with the least possible hazard. In my own case it was readily accomplished; and there can be little doubt but that the same proceeding would have been successful in the case well described and delineated by Dr. Etlinger,^ in which Professor Kilian of Bonn performed the Caesarean section on a patient whose pelvis was occupied by a fibrous tumor that grew by a rather broad peduncle from the posterior surface of the womb. This person died forty-eight hours after the operation, from the effects^ of the hemorrhage which attended it. My patient survived till the sixth day, and I cannot but attribute her death to an attempt which was made (injudiciously on ni}' part) to puncture the tumor before trying to awry it above the pelvic brim. There waa no general peritonitis, but the wound in the tumor was gaping widely ; the tissue about it was of a black color, and discoloration exten- ded thence inwards towards the centre of the tumor. The dark portion of the tumor was softened, but the rest of it was of a vivid red color, and neither it nor the other tumor, which was about the same size, namely, that of the head of a foetus at seven months, presented any trace of that general softening and disintegration which have been alleged to occur in these growths after delivery. The intestines in the left iliac fossa were nuitted together by ivcent l3'mj)h, and about four inches of thon, just where they lay in c(Ui- tactwith the i)unctured tumor, was much congested, quite rotten, and their ])osterior part was converted into a large greenish-black slough. This slough corres[)onded to a large slough on the outer and upper part of the punctured tumor. The other tumor was 1 Etliiiger, Ohservatiojies Ohsietricicp, 4to., Bonniv, 1854, soo pp. 50-50, and plates i and ii. 17 258 MANAGEMENT OF LABOR WITH UTERINE TUMORS. of a rose tint ; the uterus, wliicli presented some half-dozen small tumors about the size of peas on its surface, was, in other respects, perfectly healthy. It seemed, in short, as if the puncture of the tumor had been the point of departure whence all the subsequent mischief proceeded.' In all instances, then, the endeavor to carry the tumor out of reach should precede any attempt at reducing its bulk by puncture. In the event, however, of the former failing, the apparent solidity of the growth must not be taken as warrant sufficient for dispens- ing witli the trocar, for a cyst, if very tense, either from the ac- cumulation of fluid within, or from any very great pressure upon it from without, will often yield, even to the well-practised finger, scarcely any sensation by which the nature of its contents can be suspected Lastly, I am disposed to think that in almost all of these cases it will be preferable to turn the child rather than to make any at- tempt at extracting it with the forceps; and even if the want of space be very great indeed, craniotomy, followed by turning (and little though it may be used in this country, I cannot refrain from adding the use of the cephalvtribe to break up the base ,of the skull), will, I doubt not, enable us to carry to a safe conclusion a case which at first appeared to ofifer no alternative but the per- formance of the Ciiesarean section. At the close of the last Lecture, I stated my dissent from the opinion that there is a constant, or at least a general tendenc}' on the part of these tumors to pass into a state of softening, or disin- tegration during pregnancy. I do not therefore conceive that the induction of premature labor, and still more of abortion, simply because a fibrous tumor is connected with the uterus, is either necessary or justifiable. The presence of a fibrous tumor so en- croaching on the pelvic cavity as to render labor difficult or dan- gerous, is of course an indication for the operation ; so also may perhaps be the experience of a previous delivery which had been' followed by symptoms of uterine inflammation. The mischief, however, dates, I believe, in all instances, not from any particular epoch of pregnancy, but from the expulsion of the ovum when- ever that occurs; and the greater hazard attendant upon labors at the full period, is due to the greater violence undergone by the uterus and the tumor during the passage of the foetus in ad- vanced than in early pregnancy. Each case, then, must be con- sidered and treated on its own merits ; the mere fact of a pregnant woman having a fibrous tumor of her uterus, cannot be taken as a sufficient indication for the induction of abortion or of premature labor. 1 A second case, almost identical in its features with the foregoing, and, like it, having a fatal termination, came under my notice in 1862, and has been report.ed by. Dr. 3Iadge, in the fourth volume of the Obstetrical Transactions. UTERINE TUMORS AND OUTGROWTHS. 259 LECTURE XVII I. UTERINE TU-AIORS AXD OUTGROWTHS. FiBRors Polypi ; their structure, vascular supply, and source of liemorrliage which attends them. Their symptoms. Operations I'or their removal ; com- parative merits of ligature and excision. Management of labor complicated with polypus. Rkcukkknt Fibroid Tumors of Uterus. Their rarity ; illustrative cases. Fatty Tumors of Utkrus. Tubercular Degeneration of Uterus. Its characters, seat of the disease, and connection with general tuberculosis. It still remains for us to consider that variety of uterine fibrous tumor wliicb grows from the inner surface of the womb, or which less frequentl}' spi'inging from eitber lip, hangs down by a stalk or pedicle into tlie cavity of the uterus, or into the cana] of the vagina. Tlie impropriety of the term Polypus, as applied to these solid growtbs, need not occupy us now; it is sufficient that it has been universally adopted, and is so well understood, that no one will be misled by the incorrect terminology. In general structure these tumors are almost identical with those we have hitherto been studying; the only important dili'er- ence, perhaps, being, that whereas the growth in all the former cases was distinct from the uterine tissue, even though imbedded in it, or projecting from it, some polypi are positive outgrowths of uterine tissue, their texture and that of the womb 'itbelf being inextricabl}^ interwoven.^ Even in these instances, however, the substance of the growth is usually firmer, denser, and less vascular than that of the adjacent uterine wall ; while on the other hand, the pediculated fibrous tumor is generally, when growing from the interior of the womb, more succulent and better su}iplied with blood tlian similar tumors whose position and relations are different. The pedicle of these tumors is composed of uterine sub- stance mingled with more or less dense cellular tissue, and though generally single, is sometimes formed by the coalescence of two or three bundles of fibres springing from different, though nearly adjacent, ])arts of the womb. A layer of uterine substance is con- tin ued from the pedicle for a varying distance along the tumor, sometimes investing it completely, at other times only in part, as the cup surrounds the acorn, or the calyx the petals of a fiower. Besides this, the polypus is always covered by the mucous mem- brane of the uterus, which becomes firmer and denser than natural, both it and also the muscular fibres of the womb itsolf undergo- ing development somewhat in i)roportion to that of the tumor. The tumor can often be shelled out of its coverings just in the 1 As in a ]iri'parati()n in tlie M usciim of St. Barthr)lomew's riospitnl, sketched and referred to b}' Paget, op. cit., vol. ii, p. 131, tig. 11. 260 FIBROUS polypi: same manner as an ordinary fibrous tumor may be enucleatccl from its investment of dense cellular tissue ; but this is not invariably the case, and the connection between the substance of the polypus and the membrane that surrounds it is now andthen very i)itimate. The vascular supply, as already stated, is more abundant than that of other fibrous tumors, though it may generally be observed that neither the arterial trunks entering the tumor nor the veins leav- ing it are proportionate in size to what might be anticipated from the quantity of blood in its substance. Some part of its supply of blood alrfo comes to the polypus through the mucous membrane by wdiich it is invested, though even in tliis no considerable ves- sels are in general perceptible. This comparatively small apparent supply of blood to these tumors, coupled with the fact that they always give rise to very profuse hemorrhage, while such hemor- rhage is always arrested by a ligature applied jrouud their peflicle, have contributed to form a problem in uterine patholog}-, wliich, till within a recent date, received very conflicting and very un- satisfactory solutions. The profuse bleeding which is excited alike by non-pediculated fibrous tumors, and also by the very minute vascular polypi of the organ, seems to show that it is rather from the irritated mucous membrane of the uterus than from the surface of the tumor itself that the bleeding flows. The same fact, too, is further illustrated by facts such as the following : A woman, aged forty-six, was admitted under my care into St. Bartholomew's Hospital. She was a single woman, and, with the exception of a sense of weight at the lower part of the abdomen, since the cessation of her menses at the age of forty-three, liad had good health "till three weeks before she came under my notice. She was then suddenly attacked by profuse hemorrhage, and at the same time a tumor had partially forced its way through her vulva. The loss of blood had continued more or less since, and the patient, at her admission, seemed very much exhausted by it. This tumor, which at its lower part was already in a state of super- ficial slough, was a fibrous tumor which measured seven inches in length by four in diameter at its widest part, and w'eighed one pound one ounce and a half. It was connected by a small and short pedicle with the posterior lip of the uterus ; an arterial trunk about the size of one of the digital arteries seemed to be the source whence its supply of blood w'as derived; though it pre- sented an unusual degree of vascularity, and its lower part, which had projected beyond the vulva, and had been subjected to pres- sure, w^as so intensely congested as to have an almost apoplectic appearance. Now this large and vascular growth had gone on, doubtless for years, increasmg in size, and yet producing no symp- toms, giving rise to no hemorrhage, until having partially escaped beyond the vulva, it began to drag upon the womb, to pull it down- wards, and to irritate it, and then all at once, from the womb itself, for there was no appearance of bleeding from any part of the sur- face of the tumor, sudden and most formidable hemorrhage broke forth. The suspension of bleeding by the application of a ligature SOURCE OF IIEM0RRHA(;E, 2G1 around tlie pedicle of a polypus does not of necessity imply that the source whence the heniorrhaire proceeded is thus mechanically shut off, but is also inteHigible*x)n the supposition that the ligature interrupts the vital relations between the tumor and the womb, and thus renders the polypus a far less powerful excitant of the uterine mucous membrane than it was before. No stronger proof can be aflorded of tlio difference between a vital and a mere mechanical stimulant of the uterus than is given by the compara- tive impunity with which, in many instances, the metallic stem of the uterine supporter is borne within the cavity of the womb, as contrasted with the almost irrestrainable hemorrhages that are often excited In* even the smallest vascular polypi. Fibrous l>olypi are susceptible of the same kinds of changes as may take place in fibrous tumors elsewliere situated. I am not aware, however, of their undergoing that atrophy which occa- sionally occurs in other fibrous tumors of the uterus, while cal- careous deposits in their substance are excessively rare. On the other hand, both oedema of their substance, and the extravasation of blood into their tissue, are far from being of unusual occurrence; and when tlic}^ have passed through the os uteri into the vagina, the membrane covering their lower surface not infrequently becomes ulcerated, or passes even into a sloughing condition, which may extend to the adjacent substance of the growth. They do not, however, so far as I know, ever shell out completely from their investment as some other fibrous tumors now and then do; and when S[>ontaneonsly detached and expelled, their natural cure is brought about by their pedicle giving way. Formed, as these polypi usually are, within the cavity of the uterus, their influence upon that organ seems to depend somewhat on the situation whence they spring. Thus if it arise low down in the cervical canal, the tumor soon grows beyond these limits, and hanging down into the vagina, may acquire a considerable size without exerting much influence on the womb itself, neither disturbing its functions nor producing any consideralde hyper- trophy of its tissue. On the other hand, those polypi which are developed from some point high up in the womb, naturally remain within its cavity till they have acquired a consideral»le size, and thus give rise to enlargement of the organ, and to thickening of its walls. There seem, however, to be considerable diversities between the relations which the polypus continues to bear in different cases to the organs within which it is developed. In the great majority of instances, before it has acquired the size of a small apple, tlie OS uteri, against which the lower |)art of the polypus lies, gradually dilates to allow its passage, and the growth is then found hanging down into the vagina, its pedicle embraced, though but seldom tightly constringed, by the orifice of the womb. Sometimes, liow- ever, I know not why, this process is eftected much less quickly; the margins of the os uteri do not yield so as to allow of tlie easy exit of the polyjuis, but violent uterine action is set up, and under efibrts like those of labor, and which recur in paroxysms, and 262 SYMPTOMS OF FIBROUS POLYPI: tlien subside, and again recur after a lapse, perhaps, of many days, the polypus is literally born. It is usually under these vio- lent throes that the womb, as was 'Explained in a former Lecture,* sometimes becomes literally inverted, or turned inside out ; an accident which is brought about less by the mere mechanical action of the weight of the tumor than by the eflbrts which it excites in the muscular tissue of the womb. When once in the vagina, the growth of the polypus still goes on, and probably even more rapidly than before, since it is no longer subjected to the same degree of pressure as while it was within the uterus. For the most part, however, the symptoms to which it has given rise have been so serious as to lead to its early detection, and it is removed before it has acquired any very for- midable dimensions.^ If it be allowed to sojourn for any time in the vagina, that part of the tumor to which the air has access seldom fails to become ulcerated, while it is further by no means unusual for the adjacent surface of the vagina to become likewise inflamed and ulcerated, and for adhesion then to take phice between the two. A similar occurrence happens occasionally, though much less often, between the tumor and the lining membrane of the uterus itself; and either of these accidents may make the diagnosis obscure, and must render all forms of operative interference un- usually difficult. The two grand symptoms of polypus uteri are hemorrhage and leucorrhoea, symptoms which go on increasing in severity and continuance until, if tlieir cause be undiscovered or unremoved, they will at length exhaust and destroy the patient. At first the seasons of menstruation are those when the hemorrhage takes place, the periods lasting longer, returning sooner, and being ac- companied with a more profuse loss than was their wont, while abundant leucorrhcea persists in their intervals. Then the periodi- city of the hemorrhage ceases, for its presence becomes general, or constant, and it is at leYigth found impossible to keep any account of when menstruation last took place, or when it may next be ex- pected. A constant sense of bearing down may be experienced, or some mechanical inconvenience or other, from the pressure of the poly- pus, if large, upon adjacent parts; or expulsive eflbrts may some- times occur; but they are by no means constant; and the last- mentioned symptom in particular is met with only in a small minority of cases. It has been said that the escape of coagula of an annular shape, due to their being formed around the pedicle of the polypus, is characteristic of this aftection. This, however, is one of those plausibilities which savor more of the study than of 1 See Lecture XIII, on Inversion of the Uterus, p. 187. 2 I have already mentioned one case where the polypus weighed 1 lb. IJoz. An instance is related by Heyfelder, Studieji im Geblete der Heilwissenschnfi, 8vo, Stuttgart, 1838, vol. i, p. 269, of a polypus which weighed 1 lb. 3 oz. 7 d'r. ; and numerous references are given by Meissner, op. cit., vol. i, p. 838, to cases of polypi of enormous dimensions. THEIR DIAGNOSIS. 263 the bedside, and experience does not confirm the statement. The only rule, indeed, which I can give you as to the diagnosis of polypi is, that whenever hemorrhage, having taken place cause- lessly at one menstrual period, recurs equally without cause at the succeeding one, you should on no account omit making a vaginal examination. The tumor projecting through the os uteri, encir- cled by its lips, and passing up into its cavity, perhaps boA'ond the point to which 3'our tliiger can reach, can scarcely be mistaken for anything else, except, perhaps, for the inverted uterus, the distinc- tive characters of which I have already endeavored to point out.^ Neither, indeed, can the nature of those polypoid growths which proceed from one or other lip of the uterus be doubtful, since the OS uteri will be perceptible either in front of the growth or behind it. , In cases where tlie polypus lias not 3'et passed through the os uteri, the diagnosis may be very difficult, for hemorrhage and leucorrhoeal discharge are common to many uterine ailments, while the growth itself may not be sufficiently large to produce any marked increase in the size of the wondj, still less to expand its lower segment. In doubtful cases the uterine sound is often of much service, since as, by means of it, we ascertain either that the uterine cavity exceeds its natural dimensions, or is limited to them, so the presumption in favor of the presence of some tumor in the womb is either greatly strengthened, or altogether refuted. Sometimes,however, the introduction of the sound is very difficult, or, from its extremity impinging on the body of the tumor, is altogether impossible; while even at the best, though the sound may raise our presumption of the existence of a polypus almost to a certainty, we are not thereby at all assisted towards its removal. Tiie ingenuity of Professor Simpson,^ however, has furnished us, in the sponge tent, with a means by wliich we can readily dilate the OS uteri sufficiently to make a careful examination of the interior of the womb, and to perform any ojieration which the tumor may call for, almost as easily as if it had already descended into the vagina. This brings me, in conclusion, to consider the best means of removing these ilbrous polypi of the uterus, for I will not waste your time in repeating again all the measures by which you must try for the moment to stanch the profuse hemorrhage to which these growths sometimes give rise. Now there are two ditlerent proceedings, each of which has been strenuously advocated by some persons, and equally strongly reprobated by others.^ One of these consists in strangulating the growth by means of a ligature, the other in its excision with the scissors or some other cutting instrument. The apprehension of dangerous bleeding from the 1 See p. 199. 2 On the Defpcfion, i\c., of hitra-}iferine Polypi, \n Ed. Mont/ih/ JoKinnI, Ann. 18.")0, and Obstetric Memoirs, vol. i, p. 1*22. * See a pa|)er by Dr. Simpson, Obstetric Memoirs, vol. i, p. 150, strongly con- demnatory of the u.-^e of the ligature. 264 COMPARISON OF LIGATURE removal of polypi, to which mistaken anatomical views in a measure contributed, led to the adoption of the ligature in the first instance; but 'its use has now, with propriety, been almost uni- versally abandoned. The reasons for the discontinuance of its employment are, that the application of the ligature is almost always tedious, often difhcult; that while in the case of the smaller polypi and of those with thin pedicles, its employment is super- fluous, its action when the pedicle is thick is both slow and uncer- tain, and it of necessity condemns the patient for days to all the discomforts arising from the decay of the strangulated tumor. But further, the operation is attended not merely by discomfort, but also by positive danger, partly from the tissue of the uterus itself being almost unavoidably included in the ligature, partly from the risk of phlebitis being set up by the absorption of the putrid debris of the decaying polypus. That these dangers, too, are far from being imaginary, you may satisfy yourselves by visit- ing any of the anatomical museums of tliis metropolis, all of which I think you will find contain specimens of polypi partially detached, or of uteri from which the growth had been quite sepa- rated by ligature, but in which the supervention of inflammation had destroyed the patient. The reason alleged for the preference of the ligature to the excision of l>olypi is the risk of hemorrhage attending the latter operation. My own experience of twenty cases of excision of fibrous polypi unattended by hemorrhage, is too small to be of much weight; but Velpeau' states that no instance of troublesome hemorrhage occurred to him in twenty cases in which he excised polypi ; Lisfranc^ states that he met with it in but two out of 165 cases; and Dupuytren^ also in l)ut two out of nearly 200; while they all refer to instances of phlebitis, or of peritoneal inflamma- tion leading to a fatal issue after the operation by ligature. There are, indeed, a few instances on record of inflammatory symptoms succeeding to the excision of polypi, just as there are a few in which dangerous hemorrhage has followed their removal by liga- ture ; and in one instance under my care, 'peritonitis came on on the fourth and terminated fatally on the tenth day, after the easy excision of a small fibrous polypus. I believe that on the whole the advantages of the former operation greatly preponderate ; that it is much easier, much more speedy, and much safer ; and that the cases are very few in which it will not be found the better pro- ceeding. In this opinion, too, there is an almost unanimous con- currence on the part of those whose experience has been most extensive;^ though in order to guard against the possibility of hemorrhage occurring, some few, as for instance M. Aran,^ prefer, 1 Medecine Operaioire, t. iv, 2d ed., p. 391. 2 dhdrpie Clilrurgicale de la Pitie, t. iii, p. 210. ^ Schmidt, Jnhrh.^ vol. ii, p. 90. ■• It may .=iifi5ce to refer to the names of Scanzoni, Aran, and McCliiitock, in siijiport of this statement. * Oj). clt., p. 87o. AND EXCISION OF POLYPI. 265 wlierever it is practicable, to apply the ligature, and tlien, either at once or very soon after, to excise the growth. Considering the opinion which I entertain concerning the com- parative merits of the operation by ligature and that l)y excision, it can scarcely be expected that I should enter into any lengthened details with reference to the former mode of extirpating iiolyj)!, or the different instruments which have been invented for the purpose. It may suffice to say that on the wliole Gooch's double canula, with the contrivance invented by Laundy, the instrument- maker in the Borough, for tightening the ligature, appears to me the most easy of application, and most generally suitable ; though nothing can better illustrate the great difficulty often experienced in tying polypi than the number of the instruments which have been devised with this end.' The excision of polypi is very seldom indeed attended by much difficulty, or even by so much pain as to necessitate the use of chloroform, though, if the patient be nervous, there can be no possible objection to its employment. The patient being placed on her back, with the feet resting on a stool, and the knees sepa- rated and firmly held apart by assistants, a pair of Museux hooks are to be carefully carried along the index finger of the left hand of the operator as high as the pedicle of the tumor. They nnist then be carefully sei^irated ; two fingers of the left hand guarding their hooked extremities until they are sufficiently far a})art to allow of the pedicle being seized by them firmly. If the polypus be but small, a single pair of hooks will suffice to hold it securely, and the poljqius may now be steadily but gently drawn down be- yond the external parts, or at any rate close to the vulva, when its stalk may be divided by a pair of stout, curved, probe-pointed scissors, similar to those wliicli surgeons use in operations on the tongue. If, however, the first pair of hooks be not fixed very firmly, or if the tumor be of considerable size, so as not to yield to traction readily, it may be expedient to introduce a second or even a third pair of hooks before nudving any extractive efforts. In this case it is often convenient to introduce each hook and fix it separately, which is easily enough done, by having the instru- ment made as my former colleague, Mr. Arnott, was accustomed, with the two halves separate, but capable of being united by a lock like that of the common midwifery forceps. Even when thus contrived, how^ever, if the polypus be large, so as nearly to fill the vagina, a sharp hook cannot be carried high up so as to hiy hold of its iiedicle without a u'ood deal of risk of getting entangled as it is passed, or of prickling the operator's fingers severely. A' metal sheath which I have had made for covering these liooks, and wdiich can be immediately dislodged, as soon as they have 1 An olaboratc critiquo of the difl'crent instrumonts for tying ]ioly]>i is given by Kilian, Opcra/ion.slc/ire f. Gcbnrl.HhUlfcr, 2cl ctl., Bonn, 1852, part ii, j.p. '-'08-248. Dr. Gooch himself describes his own cannla and its mode of apjilieation at pp. 2r)n-2Gr) of liis \vorl< on the Dixcnse.t of Wvinen, so ch'arly, that no better rules can be laid down for the uso of the ligature. 266 RULES FOR THE been carried to the part of the tumor into which it is wished to fix them, very readily overcomes this difficulty. Steady traction seldom fiiils to bring the growth within reach of the scissors, though I have known it to be requisite to employ the midwifery forceps to bring a large polypus through the vulva. Lisfranc was accustomed, in cases where there was much difficulty in dragging down the polypus, to fix the hooks into the lips of the uterus, and then to make traction directly on the womb itself. Neither this proceeding, however, nor that of incising the perineum in cases where the large polypus could not pass the narrow vulva, and which has the authority of Dupuytren in its support, seems to me ex|»edient. The division of a large polypus, and its extraction piecemeal, has been proved by experience to be unattended by any of those risks of hemorrhage which were once apprehended from the em- ployment of cutting instruments in any way for the extirpation of these tumors; while various practitioners have invented curved knives or cutting hooks for the division of the pedicle of polypi which could not be drawn down with facility. Thus M. Vel[>eau^ employs a knife eight or ten inches in length, curved at its point, which is blunt, and has a cutting edge only on one side. With this instrument he divides the pedicle of the polypus, which is kept on tlie stretch by an assistant grasping it with a pair of Mnseux hooks. A very ingenious, though perhaps rather complicated knife, the blade of which is fixed at right angles with the handle, and is introduced defended by a sort of sheath, like that of a bistoire cache, was invented and used in a case where the polypus was very large, and its pedicle very thick and solid, by Dr. Herrich, of Ratisbon,^ while more lately Professor Simpson, of Edinburgh,^ has employed an instrument not unlike the sharp hook employed by midwifery practitioners for decapitating the foetus. The in- strument seems in his hands to have answered very well, though one might have feared that the sharp edge being on the same i)lane with the handle of the instrument, it would have cut too obliquely for the ready division of the pedicle. Though thus generally applicable, there are, however, a few con- ditions in which excision of polypi appears to be inferior in safety to their removal by ligature. The forcible drawing down of the uterus in cases where a polypus is contained within its cavity, in order to obtain access to the growth, is inevitably accompanied with a degree of violence which is avoided in the application of the ligature. The employment of the steel wire rope instead of the old whip-cord ligature, and tlie application of the principle of the ecraseur, as in the instrument invented by Dr. Braxton Hicks,* 1 Bull. Gen. de Therapeutique, vol. xiv, Paris, 1838, p. 1856 ; and Meissner, op. cit., vol. i, p. 864. 2 Ueher Gebdrmutter Pobjpen imd deren Aysrottung, 8vo., Regensburg, 1846. 8 Edi7i. Monthly Journal, Jan. 1855, and Obstetric Worka, vol. i, p. 150. * See the description and drawing of the instrument in Transactions of the Obstet- rical Society, vol. iii,p. 346. EXCISION OF POLYPI. 267 deprives the ligature of the danger which used to accompany it, since by this means the pedicle of the outgrowth may be cut through in a few minutes. In cases of very large polypi, in which there is no space for the application of other instruments, this cutting ligature may ah^o probably be employed with safety.* By whatever means a polypus is separated from tlie uterus (polypi of a malignant character of course excepted), the pedicle withers, and the growth is not reproduced. This fact, which was once regarded as suggesting a problem of difficult solution, is not hard to understand, if we bear in mind that the pedicle is formed of uterine tissue. On the removal of the growth, the stimulus to hypertrophy of the uterus is withdrawn, the whole organ returns by that process of involution of which we see so many illustrations to its natural dimensions, while the pedicle of the polypus, having no longer any office to perform, is completely removed. Other modes of getting rid of fibrous pol_ypi have been occa- sionally resorted to, but it is scarcely necessary to do more than enumerate them. Torsion is but rarely applicable, for the pedicle is usually too thick and too firm to admit of the growth being thus removed. If the polj^pus be small, and its stem slender, there can, however, be no objection to it, while it unquestionably has the great advantage of doing away almost completely with all risk of bleeding. The forcible tearing away or avulsion of the growth has nothing whatever to recommend it; it is uncertain, painful, and hazardous. The destroying the vitality of the polypus by forcible compression, either of the whole mass, or by an instru- ment strangulating its pedicle, as practised by M. Gensoul, of Lyons,^ appears open to all the objections that may be alleged against the ligature, without any compensating advantage. Some reference ought, perhaps, to be made to the occasional complication of pregnancy or labor with polypus of the uterus, before we take a final leave of this subject.^ There seems to be good reason for believing that polypi participate in the general development of the uterus during pregnane}', and tluit a growth previously very small may attain to a very considerable size during gestation. They do not, however, in general produce mai"ked symptoms during pregnancy, nor do they tend to interfere with its natural progress. After the commencement of labor their in- jurious effects become manifest, since they sometimes present a 1 Dr. G. Simon, who has done so much for tho improvement of operative sur- gery in tho diseases of women, suggests a very ingenious mode of obtaining access to the pedicle of very voluminous polyju. This proceeding consists in making a deep transverse incision as high as |)ossible into the body of the polypus, and tln-n dissecting off its capsule from half the circumference of the growtli. If ii<>\v the polypus is seized with hooks, and steady traction nnide ui)on it, Us films will don- gate to such an extent as to allow ready access to the pedicle, though before, while the mass retained a more globular form, it might have been altogether out of reach. [Afo7infschnft f. Grhiirtskuiulc, vol. xx, p. 4(;7.) ^ '■^ Nouveau Proce((6 pour operer les Po/i/pes de Mntrice, 8vo., Lyons, 18.")1, p. 11. 8 A very able essay on this subject, which will well repay perusal, was published by Dr. Oldbam in the Guy's Hospital Reports, 2d series, vtd. ii. 268 * RECURRENT FIBROID TUMOR. meclianical obstacle to the passage of the cliild, and at other times give rise to untoward consequences after its expulsion. Of these, one of the most frequent is hemorrhage ; the polypus within the uterine cavity interfering with the due contraction of the organ, just as the portion of adherent placenta does in cases of its disrup- tion. The other risk is that of violent and uncontrolUible uterine action being excited, and exhausting the patient by its severity and continuance, as, for instance, in tlie remarkable case related by Dr. Gooch,^ in which, after delivery, a polypus weighing three pounds fifteen ounces was expelled beyond the external parts, and the patient died while her medical attendants were still uncertain as to what her ailment was, and what should be done for her cure. In spite of these contingencies, however, the general rule, and one concerning the wisdom of Avhich there can be no doubt, is not to meddle with a uterine polypus either in labor or after delivery, unless the symptoms are so serious as to leave us no alternative. The ground for this rule is furnished by the risk of hemorrhage if the polypus be excised, and of phlebitis from the absorption of decaying a^iimal matter if the growth be removed by ligature ; while the vascularity of the polypus, and probably its size, will rapidly diminish as the involution of the uterus goes on, and the whole organ grows less and less susceptible as the date of delivery becomes more distant. It is therefore better during labor to extract the child, and after- wards to check hemorrhage, and by opiates to still any violent uterine efibrts, if possible, rather than by attempting the immediate removal of the polypus, to expose the patient to hazards so serious and so difficult to obviate. If, however, interference become urgently necessary, I think that I should, even in these cases, prefer the excision of the polypus, with the present risk of hemor- rhage, to the somewhat tardier, but, I apprehend, graver dangers attendant on the use of the ligature. There still remain a few varieties of uterine disease, concerning which something should be said, before we pass to the study of those malignant aflcctions of the womb, that constitute the most painfully important of all the ailments of the female sexual sys- tem. To a brief notice of these I propose devoting the remainder of this Lecture ; and first, I will describe a very rare form of tumor of the womb, which resembles in its character what has been termed the Recurrent Fibroid tumor. In the eighth volume of the Transactions of the Pathological Society- there are recorded by Mr. Hutchinson the particulars of a case in which a tumor formed within the uterine cavity of a middle-aged unmarried woman, and gave rise to floodings large ill amount and frequent in their return. At the end of twenty- three months an attempt was made to remove the tumor, which sprang from within the uterus by a pedicle as thick as the wrist, whence a mass as large as three fists projected into the vagina, 1 On Diseases of Woinen, &c., p. 281, case vii. * Page 287. RECURRENT FIBROID TUMOR. 2G9 wlnle the uterus itself was felt as large as a cliild's head above the } tubes. The soft texture of the tumor prevented it from being lirmly fjrasped, and the operation was discontinued after only a com[»arativeIy small portion of the mass had been detached. The bulk of the tumor, however, subsequently sloughed awa}', and at the end of a month no trace of it could be discovered, nor any enlargement of the Avomb detected. For the next three months the patient continued so to improve that it was hoped a perfect cure had been effected; but at the end of six months the growth was reproduced, though it had not quite regained its former size. A second operation was now performed, and the hand introduced into the uterine cavity broke down the tissue of the tumor, which it was found possible only very imperfectly to remove. Temporary improvement again followed, but in three months more the tumor had grown again, and was attended by its old symptoms. Attempts to destroy its tissue by caustic injections caused much suficring and did little good, and death took place two jears and ten months after the commencement of the patient's illness. The uterus was about the size of two fists, and contained a white soft growth, attached by a very broad base to the fundus and posterior surface, its free extremity hanging down in a pol}'- poid shape close to the os. The mucous lining of the cervix, though congested, was healthy. The uterine walls were much thickened in those parts to which the tumor had no attachment, but were thinned, evidently by its infiltration, at the base of the growth. On a microscopic examination the tumor was found to be com- posed of a fibroid tissue, and of a softer material made up of round nuclear bodies, of transparent molecules, and of some fusitbrm cells. Both its microscopic character as well as the history of the disease seem to remove the tumor from the class of malignant growths, and Mr. Hutchinson's own interpretation of its nature as belonging to the class of recurrent fibroid tumors is doubtless correct. In his paper on the enucleation of fibrous tumors, Mr. Hutch- inson refers to a case of Dr. Atlee's, as probal)ly belonging to the same category with the one just related. The account given by Dr. Atlee,^ however, is too vague to enable one to form any very accurate judgment of the structure of the growth, though its ri\\nd reproduction after removal renders his opinion in the highest de- trrce ])r()bable. A case has also come under in}- own observation, that belongs to the same class, and the details of which, as will be seen, harmonize very closely with the history of Mr. llutclnnson's jiatient. A young unmarried woman, aged twent3'-tlirec, who had always had good health, and since her fourteenth year had menstruated scantily, but without pain, every three weeks, was kicked on the lower [)art oi" hei' back during a menstrual jteriod in July, 18')2. ' Tronsndions <>f Atncrican Medical Associaiion, vol. vi, p. 570, ciisc iii. 270 RECURRENT FIBROID TUMOR. This kick was followed. by frequent abundant discharges of blood from the vagina, and towards the end of September by pain, referred to the loins and hypogastrium, and by a sense of bearing down, which, however, was not aggravated by moderate exertion, nor relieved by the recumbent posture. The discharges, which had reduced her to a state of great weak- ness, were described at the time of her admission into the hospital on October 1st, 1852, as being habitually offensive, consisting sometimes of fluid blood, often intermixed with large coagula, but being at other times greenish and watery. On examination the os uteri was found widely open, and a polypus, apparently of the size of a pigeon's egg, protruded through it, Ijut the finger could not be passed high enough up to reach the point of its insertion. The hooked forceps introduced to draw it down, tore out from its substance, which was found to be remarkably soft ; but a portion as big as an egg having been removed, a large mass was still left behind in the uterus. No hemorrhage followed this first operation, which was attempted on October 4th; on the 10th, the ergot of rye having been given in the interval in the hope of forcing the tumor lower dc^wn, the sound passed fou-r and a half inches, and the finger detected a rough mass, not unlike placenta or very old clot, firmly adherent to the walls of the uterus, which was perfectly movable in the pelvis. On November 11th a second attempt was made to remove the tumor, the patient having in the interval sutt'ered nmch fi-om hemorrhage, and having also experienced considerable pain. The attempt, however, issued in the removal of but a very small portion of the tumor, whose texture again broke down, while its attach- ment to tlie posterior and lower part of the uterus was too broad to allow of a ligature being placed around it. On December 2()th, a third operation was attempted; a fourth on January 5th; a fifth on February 21st; and a sixth on March 8th; the growth being partly torn away by the fingers, in part scraped from the interior of the uterus by a blunt knife, whose blade was fixed at right angles to its handle. After each operation masses of the tumor came away, and it was estimated that altogether the quantity removed in and after the several operations amounted to about six ounces. On April 11th, the sound still entered three and a half inches, showing that thongh the size of the uterus was dimin- ished, it had not yet returned to its natural dimensions ; while, though the os was closed, so that the exact state of things could not be nscertained, I yet feared the reproduction of tlie tumor, for I had been struck by the circumstance that in spite of its laceration and of the forcible avulsion of portions of it at each operation, it yet, on ever}^ repetition of the proceeding, presented the same smooth surface. Microscopic examination of the portions of the tumor showed its texture to be made up of imperfectly formed fibres, and of an RECURRENT FIBROID TUMOR. 271 ao;greg-ation of cells resembling those of inflammatory lympli, or granulation cells. In April the patient left the hospital, but at the end of June she had a most alarming hemorrhage, during which large portions of the tumor were discharged, intermixed with coagula. At the beginning of August she was readmitted, and the eidarged uterus was now felt distinctly over the pubes, while on a vaginal exanu- nation its lower segment was felt much distended. The os uteri was dilated with sponge tents, and as much of the tumor as could be removed in fragments was extracted, though the quantity did not much exceed six drachms. The muriated tincture of iron was now injected into the broken-down issue, in the hopes of thus ex[)editing its destruction, and this was repeated thrice between that time and the 17th of October. The patient, however, dreaded these injections very much on account of the severe pain which they occasioned ; while chloroform produced so much and such abiding sickness and (Repression, that it was not possible to have recourse to its use. In December, 1853, an attack of hemorrhage was accompanied by the expulsion of six ounces of the tumor; and on the loth of that month a large portion was removed ; and on February 20th, 1854, a ninth ancl last operation was performed. The suflering caused by each operation, not so much at the moment of its per- formance as subsequently, when much al)dominal tenderness was always experienced, and a great degree of constitutional dis- turbance was produced, coupled with the necessarily incomi)lete character of each operation, and the extreme rapidity with which the growth was reproduced, led me from this time to abstain from all interference. It would be tedious to relate minutely the sub- sequent history of the patient, wlio, in the autumn of 1857, was still able to follow a sedentary occupation, and to walk half a mile in order to show herself to me at the hospital. She had had many attacks of profuse hemorrhage, one of which, in May, 1856, very neaiJy proved fatal, and was followed for weeks by alarming de- ])ression, with severe abdominal pain, which was kept under only by large doses of morphia; and by profuse, extremely ottensive watery discharges. The outline of the abdominal tumor, too, could be felt above the umbilicus, the abdomen measuring at that point thirty-two and a half inches; while per vaginam a lobulated soft growth extended through the widely-dilated mouth of the womb. In spite of the decided increase of the abdominal tumor, however, the patient's condition steadily improved, after her re- covery from the hemonhage in May, 1850, since which time no considerable loss of blood occurred, though the abdomen remained extremely tender; and the patient, in spite of added strength, remained pale as a marble statue. On Decend)er 20, 1857, she re-entered the hos[tital for the last time, not sutfering indeed from any return of her uterine symp- toms, but from pain, which she conceived to be rheumatic, in her neck, and from cough brought on by exposure to cold a week 272 RECURRENT EIBROID TUMOR. before. Some swelling was perceptible on the right side of the cervical vertebrae, and light was thrown on its probable nature in the course of a few days by the occurrence of numbness of the right arm and leg, and difficulty in moving them. l!^ext, power over the left arm and leg became similarly impaired ; and the urine was voided involuntarily as well as unconsciously. The respiration, too, was labored to an extent which auscultation did not account for; and the strength daily declined, though without suffering, and death took place qnietly on the 3d of January, 1858 ; nearly six and a quarter years from the commencement of the patient's illness. The following account of the appearances after death is from the notes of my friend and colleague, Mr. Callender. The rarity of the case furnishes my excuse for relating it in such detail: On opening the sac of the peritoneum, a large oval tumor, in front of which lay several coils of small intestine, was seen occupying the left iliac fossa, and extending upwards to about the level of the middle of the left kidney. It was invested by a thin transparent membrane, which di})ped in between the convolutions that divided the tumor into lobes of unequal size. The tumor was of a white or pale straw color, slightly vascu- lar, a few large bloodvessels ramifying over its surface. It grew from the posterior wall of the uterus, to which it was connected by means of a broad base, two inches and a half thick, by one and a half in length. The tumor itseli' measured five and a half inches in breadth. The uterus occupied the entire pelvis, and rose to some height above the level of its brim. Its walls were only a quarter of an inch in thickness, and the os uteri was so di- lated by a tumor which projected through it, that it was impossible to determine exactly where the uterus ceased and the vagina be- gan. - The uterus thus attenuated was stretched over a large tumor which occupied its interior. This tumor was attached by a broad base to the posterior uterine wall, where it was continuous with the growth which projected into the iliac fossa, while anteriorly and "at the sides it was perfectly free. Independently of this, a few isolated nodules Avere connected with the right side of the uterus, and projected upon its inner aspect, involving the mucous and submucous coat. The lobed surface of the tumor was free from any irregularities such as might have been expected from the previous operations. The lobes were more marked and more irregular on the anterior and lower portion of the tumor than elsewhere. It measured seven and a half inches in length, by five inches in breadth. These tumors presented throughout the ordinary characters of recurrent fibroid growths, being composed of narrow, elongated, caudate, and oat-tosits in tlie mucous membrane are alone apparent, while when the disease is far advanced (and it was so in the two cases which came under my own observation), not only is the mucous membrane completely destroyed, but the deposit encroaches on the substance of the womb, its cavity is enlarged by the abundance of the morbid substance, and its v/alls are thickened; changes that in some instances have been known to occur to a very considerable extent. In the great majority of cases the tubercular deposit does not extend beyond the cavity of the uterus, though sometimes a similar matter is found distending the Fallopian tubes, and tubercular degeneration of the ovaries now and then coexists with the disease of the interior of the womb. Either of these occurrences is, how- ever, more frequent than the extension of the disease to the cer- vical canal; and Rokitansky' states that it scarcely ever appears there as a primary deposit. Occasionally one sees in the living subject, on the surface of one or both lips of the uterus, deposits of a yellow color, of the size of a split pea, or smaller, having altogether the appearance of small deposits of yellow tubercle, and which on being pricked give issue to a small quantity of matter of the consistence of pus, or rather firmer, and having a granular appearance under the microscope. These deposits have been alleged to be tuberculous; and the high authority of the late Professor Kiwisch^ may be adduced in support of that opinion. I am familiar with the appearance, but am not altogether con- vinced of its tuberculous character, and am rather inclined to con- 1 Pnihol Anatomic, 3d ed., 1861, vol. iii, p. 498. ' Op. cit. vol. i, p. 558. TUBERCLE OF THE UTERUS. 275 sider it as cine to hypertrophy of some of the ISTabothian follicles, with obliteration of tlieir orifices and alteration of their contents. At any rate, thoug-h small slightly excavated ulcers are now and then left behind, I have never been able to trace any connection between this appearance and any form of destructive ulceration of the cervix. The disease seems to be always secondary to tubercular deposit elsewhere, and even then to be of rare occurrence, though perhaps less so than it was believed to be by Louis,^ who did not estimate its frequency higher than one and a half per cent, of all cases of tubercle in general. M. Kiwisch- states, that at Prague it was met with once in every forty cases, or, in other words, with a frequency of two and a half per cent. ; and I know of no other statistics bearing on the subject. The following table deduced from data furnished by Kiwisch and a recent very painstaking writer on the subject, Dr. Geil,^ furnishes some information not without its value. Tubercular deposit in the uterus was met with — In 6 subjects between 10 and 20 years. "22 " " 20 — 30 " "15 " " 30 — 40 " "10 " " 40 — 50 " " 7 " " 50 — 60 " " 6 " " GO — 70 " " 2 " " 70 — 80 " Total, 08 In forty-five of the cases collected by Dr. Geil, the seat of the aflection is distinguished — Uterus alone affected, 1 case " and fnbp9 / with affection of peritoneum, . 19 cases ' \ without " " . 12 " Uterus, tubes, / in form of an aphthous process, 2 cases and vagina, . \ " true tuberculous ulcers, 1 case Tubes alone affected, 8 cases Eight tube alone, 2 "■ Total, 45 Amenorrhoea or dysmenorrhoea, often associated with leucor- rhocal discharges, are the s/jmptoms which are ordinarily observed in connection with uterine tuberculosis. Pain appears to be an exceptional occurrence, and when present, neither to be an early 8ym];)tom, nor commonly to attain to any great severity, though now and then, as in the interesting case which came under my own ^ Recherchcn sur la Phthisic, 2d ed., Paris, 1834, p. 142. 2 Op. cit., p. 559. 3 In an inaugural dissertation, published at Erlangen in 1851, and of which an abstract is given in Schmidt's Jahrhiirher, March, 1852, ]>. 324. Some additional cases, whirl), however, throw no fresh light on the subject, will be found in the abstract of a paper by M. Crocq in Archives de Med., 1800, vol. ii, ji. 215; and in another by M. Paulsen, in Schmidt's Jahrbiicher, 1852, vol. 80, p. 222. 276 CANCER OF THE UTERUS. notice, and which was described by Mr. Tomlinson of Burton-on- Trent, at a meeting of the Obstetrical Society, pain may become very severe. In many instances no symptoms have attended the aftection during life, while those which have jost been enumerated present, as I scarcely need to say, nothing pathognomonic of this peculiar disease. Indeed, if we bear in mind that tuberculous affections of the womb appear to be almost always secondary to extensive deposit of tubercle in other organs, we are led to the practical inference that, in cases where phthisical symptoms are present, there is every reason for interfering as little as possible for the removal of amenorrhoea, or other irregularities of the menstrual function, and especially for abstaining from much local treatment of any other uterine ailment that may occur.^ LECTURE XIX. MALIGNANT OE CANCEROUS DISEASES OF THE UTERUS. Hopelessness of the subject, but importance of questions involved itiits study ; erro- neous opinions formerly held concerning it. Definition of Cancer ; its varieties. Scirrhus extremely rare ; its anatomical characters. Medullary Cancer; its nature, mode of occurrence of ulceration, Its rapid progress; abortive attempts at cure, and advance of the disease. Hypertrophy of uterus in its course ; changes in its walls ; its interior ; on its surface. Extension of disease to vagina and bladder. Exceptional cases; cancer of body of uterus; cancerous polypi. Alveolar cancer. Epithelial Cancer ; its general characters; its relation to medullary cancer ; essen- tial identity with Cauliflower Excrescence. Ulcers of the os uteri ; the so-called Tuberculous Ulcer ; Corroding Ulcer. Frequency of secondary afiections in cases of uterine cancer. In the study of the diseases which have hitherto engaged our attention, we have never entirely lost a sense of hopefulness. Either medicine might cure the ailment, or surgery might remove 1 Twice have I met with symptoms of disease of the womb which I regarded as tuberculous, bvit had no opportunity of verifjnng my diagnosis by a post-mortem examination. The patients in these cases were aged 35 and 53 years respectively. The younger had given birth to children ; the elder had not married until late in life, and had never been pregnant. Theyounger patient was in a state of advanced phthisis, with cavities in the lui)gs; the elder had had symptoms of consumptive disease in early life, and percussion was dull and respiration feeble in the left infra-clavicular region. In both patients leucorrhceahad preceded any other local symptom ; in both this discharge came from the interior of the uterus, was thick, tenacious, yellowish in one case, greenish in the other ; had a peculiar faint smell, but not the offensive odor of cancer. In neither was there any hemorrhage; and menstruation, which still continued in the younger patient, had in her become ex- tremely scanty. Pain had come on gradually, had increased slowly, but amounted at last after the lapse of a year, to intolerable ceaseless anguish. There vv^as some tenderness over the uterus, which was somewhat enlarged ; but there was no hard- ness about the cervix — no unhealthy condition, either to the touch or eye, about the mouth of the womb. The symptoms were not those of cancer of the body of the uterus, but they resembled not a little those described by Mr. Tomlinson. I do not know how long either of these patients lived, but I know that it was more than two years. CANCER OF THE UTERUS. 277 « it; or at the very worst, so much might be done to retard its prog- ress, and to alleviate the siifFerings Avliich it occasioned, that lite was in many instances but little, if at all shortened ; was sometimes even scarcely embittered b}' its presence. In passing now, however, to the investigation of the malignant diseases of the womb, of cancer and its allied disorders, we shall find but few of those mitiii-atins: circumstances which lessen the darkness of the picture in the case of many other incurable affec- tions. Pain, often exceeding in intensitj- all that can be imagined as most intolerable, attended by accidents which render the sufferer most loathsome to herself and to those whom strong affection still gathers round her bed ; the general health broken down by the action of the same poison as produces the local suffering, and all tending surely, swiftly, to a fatal issufe, wliich skill cannot avert, from which it can scarcely take away its bitterest anguish : such are the features in the picture which I must now call on you to contemplate, and that not hurriedly, nor for a moment, but most carefully and deliberately, and in all its various aspects. There are indeed many reasons which prevent our passing over the subject of uterine cancer (as we might be glad to do) with but a passing notice. The frequency of the disease forbids it, for scarcely any age is free from its attack, while it is doubtful whether any other form of organic affection of the womb is met with so often, and it is certain that there is no other so fatal. The dread most naturally felt, lest this symptom or that symptom should portend the outset or imply the existence of cancer, forbids it ; for we are called on over and over again to remove the ai)prehen- sions of women whose fears have been excited by some uterine ailment, perhaps of no great moment, but out of which they have shaped to their affrighted fancies all the hideous featui'es of an incurable, an almost unbearable disease. Need I say, then, how much it imports that we should be able to remove such a})prehen- sions when causeless, not by holding out vague hopes or uncer- tain expectations, but by positive assurances founded on large and accurate experience, and, as far as may be, on certain knowl- edge ? To those practitioners and writers, both English and foreign, who have taken the most active part in the study of the inflamma- tory affections of the neck of the womb, and whose investigations have led them (as some believe, and I confess m3-self tohe of that number) to an exaggerated estimate both of their frequency and of their importance, we yet owe a debt of gratitude for the light which they have thrown on this disease, which outweighs many overstatements and cancels many errors. Cancer of the uterus used before their time to be described as a disease slow in prog- ress, continuing in its first quiescent stage of scirrhus not only for months, but for years, and then, excited by one knows not what cause to activity, passing into the state of ulcerated carcinoma, and thus at its close quickly destroying the patient. It sufficed, then, for the neck of the wond) to be hard and painful, and some- 278 VARIETIES OF CANCER. ^ what enlarged, for the suspicion of malignant disease to be enter- tained, and for years of causeless anxiety to be entailed upon the patient. Such and such like were the results which followed from confounding the consequences of inflammation and of kindred processes, with the changes which the deposit of the elements of cancer brings about in the aifected part. It is scarcely necessary to define eancer, but if some definition must be adopted, I know of none better than Mliller's •} " Those growths may be termed cancerous which destroy the natural struc- ture of all tissues, which are constitutional from their very com- mencement, or become so in the natural process of their develop- ment, and which when once they have infected the constitution, if extirpated, invariably return, and conduct the person who is affected by them to inevitable destruction." Taking this defini- tion, however, as, on the whole, the best that can be given, we must still bear in mind that morbid anatomy and chemical research have both, within the five and twenty years that have passed since it was framed, tended to show great diversities between the dilfor- ent forms of carcinoma, and to show also that many of those which aflect the womb are local in their origin and continue so through much of their progress ; and that probably if we could always dis- cover the existence of the disease early, we often need not despair of its cure. No form of carcinoma seems to be peculiar to the uterus, though they do not all occur with anything like the same frequency. Fungoid or medullary carcinoma is by far the most common ; next in frequency maybe classed the epithelial varieties of the disease, if, indeed, it be not more correct, as some men of high authority believe, to refer them to a separate category distinct from genuine cancer. Next to them, but divided by an interval which widens in exact proportion as fresh evidence is brought to bear on the subject, may be classed scirrhus, or hard cancer; while almost as rare, or, perhaps even more uncommon, stands the colloid, or alveolar variety of the disease. The only attempt with which I am acquainted at a numerical estimate of the comparative frequency of scirrJnts, or hard cancer^ and other varieties of malignant disease of the womb, is tlie state- ment by the late f*rofessor Kiwisch,^ that about three of every ten cases of cancer of the womb are scirrhous. This estimate, however, in all probability much overrates the frequency of scirrhus ; and I cannot but think that many instances of firm medullary cancer have been regarded as scirrhus, and this not only by less compe- tent observers, but even by Kiwisch himself He goes on to say " that with the commencement of the softening of fibrous carci- noma, the peculiar characters of the growth progressively disap- pear ; it grows like medullary cancer, becomes more vascular, and is easily broken down ; contains a pultaceous, brain-like substance, ' 0?i Cancer, &c., English translation, 8 vo., London, 1840, p. 28. 2 Op. cit, vol. i, p. 518. SCIRRHOUS CANCER. 279 and the ulcer which forms upon it presents precisely the same ex- ternal appearance, and the same characters as those which result from the breaking down of medullary cancer." The great authority of Rokitansky' may further be adduced in support of the opinion that "fibrous cancer is of extreme rarity;" while, on the other hand, "medullary carcinoma occurs with the greatest frequency." To say after this that I have not met on a post-mortem examination with any example of genuine scirrhus of the uterus, considering how few comparatively are my o[>portunities for observation after death, may seem almost an idle impertinence. It is more to the purpose, however, to add that my friend Mr. Paget informs me that he has not met w'itli any instance of it, while any one who carefully examines the preparations in our anatomical museums will find that this disease, once said to be so common, is in reality but seldom met with. It is perhaps not irrelevant to mention, that of one hundred and seventy cases of uterine cancer of which I have a record, the disease appeared from an examination during the patient's life to be of the medullary kind in a hundred and thirty-seven, epithelial in tw^enty-eiglit, epithelial and fungoid combined in two, and colloid in two, while in only one instance did I recognize the character of scirrhus, though I have seen some cases of alleged scirrhus in which the history of the patient and the result of long-continued observation, plainly showed the name to have been misapplied, and the enlargement and induration to be due to causes of a perfectly innocent kind.^ In spite of ditferences on other points, all observers are agreed that the neck of the womb, or rather that part of it which projects into the vagina, the portio vaginalis, is the point at which cancer generally commences, and to which, for a season, it is confined. Its mode of commencement differs, according as the disease belongs to the epithelial or to the medullary form. In the first case, the papilhc of the os uteri seem to be the point of departure of the evil, and a large, gi-anular, sprouting outgrow'th not infrequently projects into the vagina, while still the subjacent tissue is but little involved. In the second case, the morbid deposit takes place in the substance of the part, enlarging, but thickening far more than lengthening it, increasing the size of the lips of the uterus, ren- dering them hard and tense, though still not without a certain elasticity, and at the same time irregular and nodulated ; while as they enlarge they usually gape, and leave the mouth of the womb and the lower part of its cervical canal more widely open than in a state of health. On making an incision into the parts which have thus lost their ordinary characters, the place of the natural structure of the uterus 1 P(iihit\t>(j\srlie Ajintnmie, vol. iii, p. SriO. 2 I am well aware that this superfitial kind of oxaniinntinn which nlono is prao- tioftlilf during lifo, is almost valueless towards the decision of a question concerning which much difference of opinion exists, even among the most niorl)i(l anatomists, such as Virchow and lioUitansUy. The rarity of true scirrhus is the one point concerning wliich all are agreed. 280 ULCERATION OF is found to be more or less occupied by a white, firm, semi-trans- parent deposit, which in some parts seems infiltrated into the proper tissue of the womb, in others has entirely taken its place. This deposit is always more abundant near the mucous surface of the organ than towards its outer vjaW ; and a thin layer of mus- cular substance may often be detected beneath the peritoneal in- vestment of the uterus, even when the conversion of its tissues into cancerous structure has been most complete. It is very seldom that after death one finds notliing more than this substitution of cancerous deposit for the proper tissue of the womb. In the great majority of cases softening takes place, even while the part involved is but a comparatively small portion of the womb ; softening is soon followed by death of the mucous mem- brane of the OS uteri; an ulcer forms, a ragged uneven sore, with raised, irregular, hardened edges; and a dirty putrilage covering its uneven surface, takes the place of the smooth but enlarged lips of the organ. Or, if the disease go on still lurther, the \]\)S, of the womb and its cervix are altogether destroyed, and a soft, dirty white flocculent substance covers the uneven, granular, and hard- ened substance, which alone marks their former situation. These ulcerations, when once formed, increase with great rapid- ity, a fact of which I have more than once seen remarkable illus- trations. A patient, aged forty-nine years, was admitted under my care into St. Bartholomew's Hospital, whose symptoms con- sisted of hemorrhage, at first profuse, afterwards occurring fre- quently and withont cause, though in less abundance, and with it some pain in the back had of late been associated. The uterus was low down, quite movable in the pelvis, and not much enlarged. The posterior lip was thin, and seemed healthy, the anterior Avas thick, hard, and nodulated, thongh tlie mucous membrane covering the surface of both appeared healthy under the speculum. Twelve days afterwards the examination was repeated, and the advance of disease within this short time was very remarkable. The posterior lip was now no longer thin and natural, but thickened, puckered, and uneven, and the inner surface of the anterior lip Avas irregidar, as if from ulceration, while the introduction of the speculum showed the surface to be uneven, ragged, black, and bleeding. I have seen other similar cases, but none in which the occur- rence of ulceration w^as so sudden, or its subsequent progress so rapid as in this instance. It is not easy to account for the occur- rence of ulceration in all instances. Commonly it is preceded by softening of the morbid deposit, but this is by no means constant, for in the very instance which I have related, and in others too, in which it has been possible to fix the date of the ulceration, and to trace its subsequent progress, the cancerous substance round the ulcer has been, and has still continued firm. Mere rapidity of growth, too, does not of itself produce ulceration, for some in- stances of rapidly growing medullary cancer of the womb excite our suspicion, and yet obscure our diagnosis by the absence of ulceration even up to a late period. All that we can venture to MEDULLARY CANCER. 281 assert with reference to the subject is, that in all forms of cancer of the Avomb (with the exception, perhaps, of that of its body), ulceration and the formation of an open sore take place sooner or later; and further, that this ulceration may occur in one of two ways,^ either proceeding from within outwards, in which case it is preceded by softening of the cancerous tissues, or from with- out inwards ; the vitalit}' of the investing membrane of tlie uterine lips being destroyed first, just in the same wa^^ as the vitality of the skin is sometimes destroyed over a cancerous tumor of the breast. A few days often suffice to give to the ulceration the dimen- sions and even the depth which it may be found to retain for months subsequently. The patient, indeed, grows worse, the dis- charges continue, composed of pus from the ulcerated surface, fetid from the admixture with it of dead and decaying materials, tinged with blood from the giving way of some of the vessels distributed to the granulations, while every now and then abun- dant hemorrhages break forth, profuse enough, perhaps, to excite a})prehensions even for the patient's present safety. If we ex- amine, we find sprouting granulations or positive fungous out- growth from the surface, and, then, after a time, the fungus dis- appears, the surface feels less uneven, the edges less unhealthy, and we can almost persuade ourselves that here and there a process of cicatrization has begun. And yet healing does not take place. " The cancer sore does not heal, because its base, the cancer substance, is not cicatrix tissue, and consequently can form no scar, and the apparent scars Avhich now and then form are never lasting. It does not heal, because the outgrowth is constantly going on ; it does not heal, because no skinning takes place upon its surface; and, lastly, it does not heal, because the new-formed tissue speedily dies again. "^ IS^ew formation and death of the newly-formed tissues go on in constant succession; a series of abortive attempts at cure, such as prevent the rapid extension of the ulcer, such as cheer the patient with delusive hopes of re- covery, such as sometimes mislead the unwary, even among mem- bers of our own profession , and such as, I blush to say it, furnish the wretched charlatan with a fair pretext for the most despicable of all falsehoods ; for those with which, for his own behoof, the doctor (lares to impose on the credulity of his patient. Slowly, however, though the disease may sometimes seem to advance, it yet does advance, cancerous deposits extending from the cervix into the substance of the body of the uterus; the new- ' Sf(>, with rofcroiioo to this subject, Paffot, op. cif., vol. ii, p. 884. 2 Bnu'li, Uebcr die Diet ff nose der bosartiyen Gesc/nciitnte, 8vo., Mainz. 1847, p. 454. Tho few isohited instance.s of spontaneou.s cure of cancer limited to X\w poriio vagi- nnlis do not invalidate the general truth of this statement. Sucli a cure takes place, accordini^ to K. 4i)."), by a proees.s of slounliinn' ulceration ; the consc(iuiMit loss of substance leavini; a funnel-shaped scar, witli its i\\w\ directed ui)\varils towards the internal orifice of the uterus. See a case of Scanzoni's, op. cit., p. '2S2; and some remarks of Wagner, Der Qcbdr- inutlcrkrebs, 8vo., Leipzig, 1858, i>. 27. 282 CHANGES IN THE UTERUS formed tissues dying, and dying; on the whole to a greater extent than they are reproduced, until at length the lips of the os are quite destroyed, the portio vaginalis of the cervix is destro^-ed too, and a widely gaping opening, with thick, hard, and irregular edges, is all that is left to mark the point where the womb begins, and the canal leading to it ends. Often, though not invariably, a step preliminary to this occurrence is the formation of adhesions be- tween the lips of the uterus and the contiguous surfaces of the vagina. Sometimes these adhesions are limited to one lip, often they involve both, and to them is in a great riieasure due that ap- parent shortening of the vagina which is very marked in many cases of uterine cancer, and which does not at all imply the pre- vious occurrence of any descent of the womb. In the softer kind of medullary cancer, in which this condition is met with most frequently, and in the greatest degree, the surface of the portio vaginalis and the walls of the vagina become sometimes so completely fused together that a mere thickened ring is all that indicates the situation of the mouth of the womb. Even this, at length, becomes indistinct, owing to the extension of the cancer- ous disease along the vaginal walls, and the finger at last diseov^ers no distinction between the uterus and vagina, but finds only that the uneven walls of the canal end in a cavity filled with a dirty putrilage. Sometimes, indeed, this fusion between the two surfaces does not take place, but nevertheless the vagina becomes almost always implicated in the advance of the disease. Cancerous deposit takes place in its cellular tissue, confined at first pretty much to the roof of the vagina, where it produces that thickening, hardness, and resistance, which render the cancerous womb less movable. than natural. With the lapse of time the deposit both becomes more considerable at its original scat, and also extends further and further along the canal, shortening as well as thickening it, while general hypertrophy of the tissues tends to the same result. Nor is the disease confined to the substance of the vagina, but it aftects the mucous lining in almost every instance, and this, as might be expected, most remarkably in the immediate vicinity of the womb. The whole mucous membrane, indeed, is often red and inflamed, but as the neck of the uterus is approached it is also found soft- ened and thickened. Small spots of whitish cancerous deposit, from the size of a pin's head to that of a barley-corn, not unfre- quently beset the upper part of the canal, and unhealthy, super- ficial ulcerations, usually irregular in form, and having a transverse direction, are often present. These ulcerations are said by M. Lebert* seldom to have a cancerous base, and are probably due in great measure to the acrid nature of the discharge in which the upper part of the canal is almost constantly bathed. What ren- ders this opinion the more probable is, that in cases of epithelial 1 Op. cit, p. 230. WITH THE ADVANCE OF CANCEK. 283 cancer in which this discharge is often absent, the ulcerations are also commonly wanting. It is almost needless to say that while disease advances at the lower part of the uterus, the rest of the organ is not left in a healthy state. If life is sufRciontly prolonged, the deposit by degrees extends further and further upwards, till even as high as the ligaments of the ovaries, or sometimes higher still, the walls of the organ are thickened by infiltration of cancerous matter, or are completely converted into it. This, however, is not the only cause of that enlargement of the whole uterus which is met with in almost ever}'^ case of carcinoma. In other organs of the body, the advance of cancerous deposit, and the wasting and disappear- ance of the proper tissue of the part, go on simultaneously and in equal proportions. In the case of the uterus, however, that dis- position to growth and development of which we have seen so many illustrations, shows itself even during the progress of ma- lignant disease. The walls thicken in parts which the cancer has not yet reached, for the increased afflux of blood brings with it an increased activity of growth, and even in those situations where the malignant deposit is abundant, there remains up to a late [)eriod a layer of muscular fibre bounding it externally; the product, as I imagine, of new formation, not simj)ly the residue of the original parietes of the organ. But though the cancerous disease, either for the reason which I have assigned, or on some other account as yet inexplicable, seldom reaches to and involves the external surfiice of the womb, its mucous lining has no such immunity from disease. Its con- dition, however, is very variable. Sometimes nothing more is apparent than a general and intense redness of the interior of the womb; but much more frequently the uterine lining membrane is covered by a dark offensive secretion, and is beset here and there by small white deposits of cancer. If disease is more advanced, the mucous membrane is absent, at any rate from the lower part of the uterine cavity, and the surface is uneven and granular from the infiltration of cancerous deposit into the uterine tissue. On one occasion, too, T found the wdiole interior of the womb lined by a white membraniform layer of cancerous deposit, beneath W'hich its substance was irregular and granular, as if ulcerated. This partial destruction of its mucous lining, and this granular state of its interior, occasion that roughness which the finger so constantly perceives when introduced within the orifice of the cancerous womb. There is, however, besides, in many instances of uterine carcinoma, a distinct polypoid cancerous outgrowth, which s[)rings from low down in the cavity of the womb, or from the upper part of its cervix, seldom attaining any considerable size, but varying from month to month, and usually disappearing altogether as ulceration advances, and as the uterine structure is with its advance mor(> and more extensively destroyed. Besides these, which are usually but temporaiy phenomena, there are dis- tinct malignant polypi, concerning which I must say more pres- 284 CHANGES ON EXTERIOR OF UTERUS ently, but about which it may suffice now to mention that they may be formed independently of disease of the os or cervix uteri, thongh those parts, too, become almost invariably involved in the progress of the cancerous growth. If now from the substance of the womb and its interior we pass to the study of the alterations which cancerous disease brings about on its external surface, we shall find occasion to notice many im- portant changes, though none perhaps so striking as those which we have already observed. Many circumstances concur to pro- duce that firm fixing of the uterus in the pelvic cavity which is observable in almost every instance of carcinoma of the medullary kind, except in its very earliest stages. It is partly brought about by a chronic form of peritonitis, which is generally, though not constantly limited to the parts in the immediate vicinity of the pelvis, and which glues the womb to the rectum and bladder. This, however, is not its only cause, but infiltration of cancerous matter between the uterus and adjacent parts, and between the folds of the broad ligament, tends to fix it in the pelvis, and to form it and the parts connected with it into one immovable mass. These deposits usually take place on the visceral surface of the peritoneum, and are sometimes so extensive as to be the apparent occasion of a degree of wasting of the womb itself, Avhich I have once or twice found, in the midst of abundant medullary deposit, small and shrunken, and its outer surface rough, as if partially eroded or destroyed by the morbid structure. While these deposits are but inconsiderable, they may still be seen in small patches beneath the peritoneum ; but with their increase the peritoneum too becomes involved, and at length is undistinguishable in the midst of the large mass of cancerous disease which conceals the uterus and its appendages from view. In cases where these deposits are most abundant, it is by no means unusual to find softened cancerous matter in the pelvic cavity, or between the folds of the broad ligaments ; while sometimes the intestines are matted together above the pelvic brim, so as to form the uj^per wall of an irregular cavity lined with cancerous matter, while now and then a real fecal abscess is produced by tlie extension of the disease to the intestines, and their consequent perforation. More frequent than the actual destruction of the peritoneum by deposits of cancer beneath it, is the occurrence of numerous small masses of the same substance on its outer surface. These are sometimes flat and sessile, like small tubercles distributed over it; at other times they are connected with the serous membrane by a small and slender membranous pedicle, similar to that by which small fibrous outgrowths are not infrequently attached to the fundus and adjacent parts of the womb. On two occasions I have also found, in the midst of the cancerous substance Avhich enveloped the uterus, serous cysts of the size of a filbert, contain- ing a rather deep straw-colored, transparent serum, their walls thin, their outer surface free, theirinner connected with the uterus itself by the interposition of a layer of cancerous substance of WITH THE ADVANCE OF CANCER. 285 uncertain thickness. In one instance, five cysts were present, and the material which surrounded them, and Vvhich al.-o had matted together the uterine appendages, was intermingled fat and cancer substance. In the other case, there was only one cyst, but it also was surrounded by a very abundant deposit of cancer. These cysts showed no sign of endogenous growth in their interior, but appeared to be simple serous cysts, such as sometimes form on the exterior of the uterus, independent of any other disease. I am therefore uncertain in what relation they stood to the cancer- ous deposits, whether in that of mere accidental complication, or whether the connection between the two was more intimate.' Reference has ah'eady been made to the formation of adhesions between the uterine lips and the vaginal walls, and it is obvious enough that when this takes place, the extension of disease to the substance of the vagina is almost sure to follow. It is matter of observation, however, that the anterior vaginal wall and the bh^dder are much more frequently involved by the advance of uterine cancer than are its posterior wall and the rectum. It has been attempted to explain this occurrence by the assum])tion that cancer oftener attacks the anterior than the posterior lip of the uterus ; but facts do not bear out this assertion, and my own ex- perience, indeed, would lead me rather to the conclusion that cancer is oftener limited to the posterior, and that certainly the disease of the posterior lip is often further advanced than that of the anterior. The intimate connection between the neck of the womb and the bladder, parts which are separated only by the intervention of a fold of the pelvic fascia, while posteriorly the peritoneum descends even below the level of the commencement of the portio vaginalis, accounts much more satisfactorily for the more speedy infiltration of cancerous matter into parts contiguous with the front than with the back of the organ.^ Though, perhaps, not strictly in place, it ^vill 3'et be convenient to add a few words more about the afi'ection of the bladder in cases of uterine cancer. It is by no means unusual, independent of any trace of cancerous deposit in the organ, to find the mucous mem- brane of the bladder intensely congested and of a deep red color, sometimes inflamed, even ulcerated, pus covering its rugre, and all the coats of the organ thickened, showing, what indeed the dysuria 1 In all the cases of serous cysts of the uterus described by Huguier in his very Talual)ic Es-say in vol. i of the Menioires de V Acadeinie de Cliirnrgie, chap, ii-, pp. 2!t")-32.j, and plates iv and v, the cysts were sub-peritoneal. Those which I ob- served in the two cases above described were similar to the cy.st.s delineated by Bt)ivin and Dugfes in plates xiv and xxxiii, tig. 1, of their ^1^/as, but of which they give no particular descrijition. ■^ AVagner, o]). cit., pp. 4'.) and 60, gives the proportions as 38 per cent, of the former to 10 per cent, of the latter. Jlis data, however, bring out a fact for which I was not prepared — namely, the much greater frequency of recto-vaginal than of vesico-vaginal fistula as the result of cancerous disease. It ajipears that while there were but twenty-eight cases of vesico-vaginal listula in eighty-three instances of cancerous disease? of the bladder, tlstulous communication with the vaginft existed in twenty-four out of thirty-three cases in which cancer had implicated the rectum. 286 AFFECTION OF THE BLADDER IN CANCER. during the patient's life but too constantly announces, how close the sympathy is between the bladder and the womb. The mode in which the first anatomical evidence of positive disease of the bladder appears is not constant. Sometimes the mischief seems entirely to proceed from without inwards, and then at one spot, where the bladder and vagina are closely united, the mucous membrane of the former viseus may present a slightly flocculent appearance. If touched, it will be found to be softened ; if pressed ■ on with a probe, it will give way ; the cancerous deposit has gradu- ally destroyed all the intervening tissues, and a few da^'s more would have sufficed for the production of a fistulous opening. In other instances, disease attacks the bladder, secondarily indeed, but independently of mere extension to it by continuity of tissue. Deposits of cancer, in the form of small flat whitish tubercles, take place beneath its mucous membrane; not limited to that part where the uterus or the vagina and bladder are in immediate con- tact, though generally much more abundant there than elsewhere. These tubercles enlarge somewhat, though they do not coalesce nor attain any considerable size, but they destroy the mucous membrane above them, while that of the rest of the organ is gener- ally inflamed, thickened, and sometimes even ulcerated. When the fistulous opening has once formed, the bladder undergoes all those changes that attend a vesico-vaginal fistula, however pro- duced, only aggravated by the constant advances of the disease by which the fistula was occasioned. But to return to that more special study of cancer of the womb itself which is our present business, I may observe, that though the descri}ition of the disease already given holds good to a great extent of all tbrms of uterine cancer, there are some varieties of the disease in which deviations occur from its most common course. It has been stated as a general rule, that cancer begins in the neck of th« womb, and this statement is open to almost as few exceptions as the directly opposite one with reference to the exclusive seat of fibrous tumors in the body of the organ. In three, liowever, out of one hundred and seventy cases of uterine cancer, the disease occupied the body of the organ, and ran its course to a fatal issue without the occurrence of ulceration of the os uteri, or of any change in its condition, such as during life could lead to the suspi- cion of its being the seat of malignant disease, though its tissue was found after death infiltrated with cancerous deposit. In all of these cases the enlargement of the uterus was very considerable ; in one it measured five inches in length, in a second six inches, and in the third was nearly as large as the adult head. Tliis in- crease of size was due in two of the cases to the extreme thickening of the uterine walls by infiltration of cancerous deposit, which in one had converted the whole organ into a tolerably uniform mass of soft, indistinctly fibrous tissue, of a dirty grayish-white color, soaked in a dirty serum, very soft, but tearing most readily in a longitudinal direction, while no trace of mucous membrane was discoverable, nor any remains of uterine cavity beyond half an CANCER OF THE BODY OF THE UTERUS. 287 inch from the orifice of the womb, which was small and circular, and outwardly presented no evidence of disease. In the other case, the walls of the uterus were similarly thickened, though in a less degree, and the uterine cavity was not obliterated, but a mass of soft medullary cancer, of the size of a walnut, projected into it, springing from a little above the situation of the internal os uteri. Externally, the lips of the os uteri were healthy, their surface per- fectly smooth and of a vivid red color. This character continued to just within the cervix, but there the mucous membrane at once became roughened, of a red color, with dead-white spots of can- cerous deposit showing through it everywhere/ A similarly hcahhy state of the os existed in the third instance, in which the uterus measured five inches in length. The organ in that case was surrounded by a mass of softening carcinomatous matter, but its walls were not infiltrated with malignant deposit. The in- creased size of the womb, indeed, was due to expansion of its cavity; not at all to thickening of its walls; but their inner sur- face presented a very remarkable appearance, being everywhere beset hy small warty growths, or irregularities, among which were one or two rather larger than the rest, but even these did not ex- ceed the size of a pea. These granulations were quite sessile, and the surface altogether looked more like that of a clu'onically ulcer- ated bladder than of a part the seat of morbid deposit. In the substance of these granulations no distinct cancer-cells were found, but at the fundus of the uterus, where the walls were generally very thin, there was an aperture of communication large enough to allow the finger to pass between the cavity of the womb and the mass of carcinoma which surrounded it. Here, too, the uterine wall was softened and disintegrated, and seemed infiltrated with the same kind of matter. Besides these cases, two others out of the total one hundred and seventy presented a great preponderance of disease in the interior of the womb, though the lips were not in a healthy conditii)n. It was clear, however, in both instances, that the mischief had })ro- ceeded from within outwards, not in its usual course; and I am dispos<:H;l to think that the conmiencement of cancerous disease in the interior of the womb, instead of about its orifice or in the sub- stance of its neck, is not of that extreme rarity which is generally supposed. Lastly, in connection with those cases in which the os uteri esca[)es the cancerous deposit, or l^ecomes afiectcd only second- arily, some mention must be made of those rare instances in which poljipi of malignant structure grow from the interior of the uterus, independent of previous disease of its orifice, lleference has already been made to the frequent formation of polypoid out- 1 A brief but intcrosting (Icscriiitioii of t by deep fissures into loludes of various sizes, all of which, however, seem to be connected together at their base, though the fissures are so deep, and their directions so various, that it is seldom pos- sible, when the growth is of any size, to distinguish between them and the os uteri itself The dimensions of these growths are not in general the same througliout, but they spring from the surface 1 I have rotainod the term cancer as appliod to these varieties of malifcmmt dis- ease of the uterus, beeaiis(! I do not feel myself competent to form an ind«'|ifndent opinion with reference to what is still a moot point between the hii;hest authorities; and bicause the general tendency of epithelial and cancroid diseases of the womb is to become associated durin<; their projL|:ress with medullary cancer ; r)ften. indeed, they lose their own distinctive features completely, mergiiiij; them in those of ordinary' uterine carcinoma. 19 290 CHARACTERS OF EPITHELIAL CANCER. of tlie OS uteri by a short tliick pedicle or stem, the elongated and hypcrtrophied cervix, and then expand below into that peculiar cauliflower-like shape from which their name has been derived. Even the most careful examination generally breaks down some of the tissue of the growth, and produces hemorrhage ; but if, in spite of this, the finger be carried down to its base, the substance will be found to become much firmer, and at the same time to be possessed of a degree of sensibility which, though but low, is much greater than that of the more depending part of the tumor. Sometimes the outgrowth is confined, at any rate at its commence- ment, to one lip, and may attain a considerable size before the other is involved in the disease.' This is more likel}^ to occur if the posterior tlian if the anterior lip is aft'ected, and for the ob- vious mechanical reason which accounts for every large polypoid outgrowth being flattened on its anterior surface, spheroidal on its posterior. The hollow of the sacrum allows more room for the development of any outgrowth than is afforded by the compara- tively^ flattened anterior half of the pelvic cavity bounded by the rami of the pubes. Though the vagina does not by any means escape from a par- ticipation in the disease, and a granular or papillary structure may be felt sometimes extending over its roof, and for some distance along one or other wall, yet this is by no means con- stant; and so long as the disease retains its original characters well marked, the disposition to involve adjacent parts is far less than in ordinary uterine cancer. The tendency, however, to pass into ordinary medullary cancer, or to become associated with it, is very strong; while we find that the tumor itself undergoes the same processes of alternate partial death and partial reproduction, as we have noticed in other forms of malignant disease. Usually tlie outgrowth in the course of time disappears in part, and the irregular, sharp-cut edge of the os, whence it grew, is at first felt granular and uneven within, but afterwards grows thicker and nodulated, assuming by degrees all the characters of a part which has from the first been the seat of medullary cancer, while the walls of the organ and its interior likewise undergo just the same changes. Between this disease and genuine cauliflower excrescence the differences appear to be of degree rather than of kind. In the latter, indeed, the eidthelial cells which compose it are of the cylindrical form, but its more obvious peculiarities consist in the larger size of its vessels, in the greater delicacy of their walls, and in their being covered by a thin investment, not bound to- gether into a comparatively solid mass by connecting tissue, but "hanging in fringes almost like a mass of uterine hydatids;"^ 1 Of which there is a very characteristic drawing in Boivin and Dug^s' Atlas, plate xxiv, fig. 1. 2 This not inapt comparison is made by Virchow in his description of the micro- scopic structure of these grf)wths, in the VerhandL der Phys. Med. Ge^ellschafi in Wurzburg, vol. i, p. 110, whic!- harmonizes with and completes previous observa- I INTRACTABLE ULCERATIONS OF THE UTERUS. 291 while the base of cancer substance, which in the more solid growths is deposited very early, in the delicate and vascular cauliflower excrescence is not formed till a much later period, or even not at all. Their intimate structure, however, and their microscopic elements are just the same, and both consist of hypertrophied papillae, composed of epithelial cells richly supplied in their in- terior with large and delicate vessels, and covered with a thickened layer of epithelium. The enormous looped capillaries of the cauli- flower excrescence explain the abundant hemorrhages and the profuse serous discharges that attend it, while the absence of that solid structure which is found in other forms of epithelial cancer accounts for the peculiarly favorable results tluit have followed its extirpation, and also for tlie fact that after its removal a few shreds are all that remain of what had seemed to be a large and firm tumor. Ditference of opinion exists as to the exact nature of those intractable ulcerations of the os and cervix uteri, which, in accord- ance, as I believe, with the preponderance of authority on the subject, I have referred to epithelial carcinoma, but which are alleged by some very competent observers to be tuberculous. "When speaking of uterine tubercle, I made mention of numerous small deposits of a yellowish color sometimes met with on the surface of the os uteri, and which, if punctured, or if their con- tents escape spontaneously, sometimes leave behind small slightly excavated ulcers. Their tuberculous character did not, however, appear to me to be clearly substantiated, since I had never ob- served any general fusion of the deposits, and consequent breaking down of the tissue of the cervix. M. Lisfranc, however," has de- scribed a condition which has never come under my own notice, but which has been seen and described by M. Robert,- M. Pichard,^ and others, who relate cases illustrative of its character, and wlio refer it to the breaking down of tubercular deposits in the sub- stance of the cervix. " These tubercular ulcerations of the cervix uteri," says M. Robert,* " may be recognized by their excavated base, their grayish appearance, and the presence of a caseous matter in the midst of the muco-purulent discharges which come from the interior of the cervix. They may also be known by the presence in the cervix of tumors of uncertain size, of a rounded form, at first firm and with no change of -color, afterwards soft, whitish, yielding to the pressure of the fingers, and giving an indistinct sense of fluctua- tions. Very i)mcnt of the womb is less and less perfectly accomplished, and the feeble 300 SYMPTOMS OF UTERINE CANCER: uterine action of the multipara, the greater comparative frequency of hemorrhage after delivery, and even of rupture of the uterus in women who have given birth to several children, than in those who are in labor for the first time, are but so many different illus- trations of the same fact. It is not therefore the woman who has never conceived, hut she Avhose uterus has oftenest undergone all the changes which the puerperal state brings with it, — the fatty degeneration of its fibres, the wasting of its tissue, the most pro- found disturbance of its nutrition, — in whom this disease of per- verted, imperfect nutrition is most frequent. Nor is the fact without its significance as illustrative of the same law, that in 18 out of 110 women living in fruitful marriage, in whom cancer of the womb came on before the fiftieth year, or, in other words, before the period of sexual vigor was passed, the very moment at which the important changes of tlie puerperal state were going on, the very time when the nutrition of the womb was most dis- ordered, should have been that at which, one might almost say out of which, this disease, so insidious and so fatal, was developed. One }»oint still remains for notice with reference to the produc- tion of cancer — namely, the infiuence of hereditary predisposition in favoring its development. In the case of cancer generall}', the influence of constitutional taint has been ascertained to be very real ; nor docs it appear to be less so in the case of cancer of the womb, though the number of observations bearing on the subject is perha[)S too small to warrant a positive opinion. Of^ 160 cases of cancer of all parts, collected by Paget,' 2t), or 1 in 6.1, presented the history of hereditary cancerous taint; and the same fact was ascertained with reference to 14 in 102, or 1 in 7.2 of the cases referred to by Lebert.^ Lebert found evidence of hereditary ten- dency to cancer in 2 out of 13 cases of cancer of the womb;^ and it existed in 8 out of 49 cases, or in 1 out of 6.1, in which I made this point the subject of inquiry. In 1 of the 8 cases the patient's father had died of cancer of the throat ; in 2 the mother; and in 4 the sister had died of cancer of the womb, and in 1 the sister had died of cancer of the breast. There are three symptoms of cancer of the womb so almost in- variable in their occurrence that the merest tyro would not fail to mention them, and the man of greatest experience would still enumerate them as its grand characteristics. Pain, and hemor- rhage, and vaginal discharge often coexist in the advanced stages of the disease, and one or other of them is present from its com- mencement, or furnishes us at least with the first evidence of its existence. The once common error, however, which confounded under the name of scirrhus a variety of uterine ailments that had no real relation whatever to malignant disease, led to equally serious misapprehension of the import of these symptoms. Hemor- rhage was supposed to be the invariable evidence of ulceration having occurred, while pain and constitutional disorder, and 1 Op. cit., vol. ii, p. 538. 2 Op. cit., p. 134. 3 Ibid., p. 273. " 77 u 4f..3 " 23 l( 1^.8 " 15 (( 9.0 PAIN. 301 sundiy forms of functional tlisturbance, both of the womb and of adjacent viscera, were imagined to characterize tlie first or so- called scirrhous stage of the disease. In 166 cases the first symptom of cancer was stated by the patient to have been In 30 instances, or 18.0 per cent., pain of various kinds, and of various degrees of intensity. ' hemorrhat^e, generally profu.se, without pain. ' hemorrhage, accompanied by jiain. ' pain and leucorrhoja, or watery discharge, sometimes offensive. " 21 " 12.6 " leucorrhcea, or other discharge without pain. Each of these symptoms deserves a more careful examination; and, first, with reference to the pain. Both at tlie commence- ment, and through the whole course of the disease, this varies greatly in situation, in character, and in intensity; and there is no one kind of pain which can be regarded as peculiar to uterine cancer in any stage of its progress. Under the term pain, too, must be included various uneas}^ sensations experienced during the act of defecation or micturition, the result sometimes doubt- less of the disease having at an early period afi'ected the bladder or the bowel, but oftener the consequence of the congested state of the pelvic vessels, or of that sympathy between the womb and other pelvic organs, of which, in the course of all uterine ailments, one meets with so many illustrations. ' As a general rule, the pain of the early stage of cancer is not severe; it is by no means constantly' referred to the uterus, but is more often s[)oken of as backache, or pain in the loins, wearying by its constancy rather than by its severity. "With this is associated in some instances pain in the In-pogastrium, usually of the same dull character; but hyi)0- gastric pain alone, and unaccompanied by backache, is decidedly unusuah Lancinating pain, decidedly referred to the uterus, is not common at an early stage of cancer, neither is the organ in general tender to the touch, and in not a few instances even sexual intercourse does not appear to be attended by any special suffering. As in other forms of uterine disease, pain is occasionally referred to one or other iliac region, and, like ovarian pain in general, is marked by a teiidency to exacerbation in paroxysms. In those cases in which the disease sets in with menorrhagia, the excessive loss of blood is often accompanied with much pain ; but, as appears from the table, the majority of cases of hemorrhage at the outset of* cancer are characterized by the absence of pain; while the ces- sation of the previously profuse bleeding is often associated with the setting in of juiin, from which the patient was }>reviously free. With the advance of the cancerous disease, pain in general increases much in severity, though there is no invariable rule which determines either the amount or the seat of the chief sufier- ing; while, in by far the greater number of cases, the severest pain is experienced long before the patient's death, and the last months of existence, when all the evidences of the cancerous 302 CAUSES OF PAIN IN CANCER. cachexia are most marked, and the strength is daily declining, are happily not in general agonized by intensity of snfiering such as had been previously endured. The causes, however, which con- tribute up to a certain point to increase the patient's sufterings as her disease advances are many, while all the old sources of distress continue. Pain referred to the uterus is now often superadded to the former pain in the back and tlie abdomen ; and this pain, though constant, has its exacerbations, in which it becomes utterly intolerable, is sometimes described as a burning pain, sometimes as a stabbing pain ; while, when most intense, it is a horrible agony, which can be likened to no otlier sufl'ering, of which words seem unable to convey any idea. Every night generally brings with it increase of suffering; but the tits of the sharpest pain are uncertain in their occurrence, and appear to come on without any exciting cause. Sometimes the severer pain precedes an outburst of hemorrhage, and then the bleeding gives relief for a time ; but in many instances this is not the case. Besides the old h3'pogas- tric pain, from which the patient often suiiers in the earlier stages of this disease, there are now frequent attacks of circumscribed abdominal pain and tenderness, indicative of the peritoneum covering the pelvic organs having been attacked by inflamma- tion, and such inflammation comes and goes several times in the course of the disease. The advance of the disease from the uterus itself, along the walls of the vagina, adds much to the patient's sufterings, and does so especially when the anterior vaginal wall is thus aftected. In this case the infiltration of cancer into the tissues at the upper part of the vagina interferes with the return of blood from parts quite uninvolved in the disease. Hence the great swelling of the urethra, which may oftoi be felt of the size of two thumbs all the way from the symphysis pubis to the bladder, and hence in a measure the frequent desire to pass water, the diffi- culty in voiding it, and the occasional inability to retain it, which so greatly harass patients with cancer in the womb. But other causes besides tend to aggravate this symptom. It is, as we saw when studying the morbid anatomy of cancer of the womb, by no means unusual for the bladder, independent of the extension to it of malignant disease, to be the seat of intense congestion, or of inflammation going on to the deposit of lymph on its rugre, or to actual ulceration of its mucous membrane. Moreover, the ex- tension of cancer from the uterus or vagina into the bladder is usually accompanied by much severer sufiering than is experi- enced in primary malignant disease of that organ, while, whftn once utero- or vagino-vesieal fistula has been formed, sufferings from a new source are entailed upon the patient. In some in- stances, too, when there is much deposit of cancerous matter about the bladder, one or other ureter is obstructed, though not in general absolutely closed, and it becomes much dilated, run- ning a tortuous instead of a straight course, while its walls are greatly thickened ; and the kidney itself, owing to the difficulty in the performance of its functions, and in the escape of its contents, PAIN SOMETIMES ABSENT. 303 wastes, its glandular strncture almost completely disappearing, its calicos being dilated into a number of sacculi, distended by a urinous fluid.' In a minor degree, tliis occurrence is by no means unusual, and to it must, I tliink, be attributed a measure of tlie backache and of the dysuria from which patients with uterine cancer suft'er. And now, before passing to the examination of another symp- tom, something ouglit to be said with reference to those few ex- ceptional cases in which cancer of the womb runs its course entirely, or almost entirely, without pain. It cannot be too con- stantly borne in mind, that in many instances the three grand s\'mptoms of cancer, — pain, and hemorrhage, and offensive dis- charge, — are not present at the same time. The disease often sets in with hemorrhage, and often while the bleeding lasts no 2)ain is experienced, nor is any fetid discharge perceptible. At a later stage the bleeding ceases, the pain then becomes severe, and the discharge offensive, and continues so to the end, though the pain frequently subsides, sometimes altogether ceases long before the patient dies. Most of the errors in the diagnosis of uterine cancer which have come to my knowledge have arisen fromforgetfulness of this tact; and the absence of pain or of fetor of the discharge has been assumed to negative the possibility of cancer in spite of the clearest evidence afforded by vaginal examination of its ex- istence. It is, however, a very rare occurrence indeed for pain to be absent through the whole course of cancer, though by no means uiiusualfor the disease to have made great progress befoie any suffering is experienced. Though not invariably, yet in the majority of cases, it is the epithelial variety of cancer which is distinguished by this absence of pain. Still, in some of the soft varieties of medullary cancer, I have observed the same thing. One [)atient, a young woman, aged thirty, was not aware of the existence of any serious disease until a profuse discharge of blood took place on one occasion during sexual intercourse; and 1 knew another who imagined herself to be suffering merely from menor- rhagia, to have had intercourse with her husband, and not to have supi)osed her ailment to be serious till abortion at the sixth week of her pregnancy destroyed her by the hemorrhage which accom- panied it. In both of these cases the disease was of the medul- lary kind. The most remarkable case, however, which I have met with, and indeed the only instance in which no pain at all -was experienced, was that of a woman aged thirtj', who had men- struated irregularly for three years, though without any sym[»toni of local ailment, and had recovered but imperfectly from her sixth labor fourteen months before she came under my notice. Kleveu months betbre I saw her, she had sudden and very jiroiuse hemor- rhage, which continued for eight weeks, and was then succeeded 1 Si'f, for remarks on this condition of the kitlnoy, Cruviilhior, Ann/nniir I'l/f/m- l'>f/i'/i'ij vol. ii, p. o70, and Atlas, livraison xxvii, jil. ii, fig. '2; and alst) Wagner, oj>. cii., p. 111. 304 HEMORRHAGE by abundant transparent non-offensive discharge. From that time until her reception into the hospital, the hemorrhage or the watery discharge had been constantly present, and the patient was ad- mitted, in a state of extreme exhaustion, on the 15th of July. Rest and astringents checked both the bleeding and the discharge, and food and wine restored her strength so far, that on the ^Oth she ^vent home to arrange some domestic matters, but on my representation of the serious nature of her disease, she returned on the 5th of August. Hemorrhage recurred the next day, and continued for ten days, but on the 21st she was so far recovered, and had regained so much strength, that all my persuasions to induce her to remain were inefiectual. She went home; on the 1st of September hemorrhage returned, and of this she died on the 5th, having throughout had no other sense of discomfort than some diliiculty iu micturition, from which she had suffered for two years, and which was not at all increased in severity by the super- vention of the cancerous disease. jS'cxt on the list of symptoms stands hemorrhage ; and contrary to what is still laid down in some books, bleeding, so far from being a proof that the disease has reached the stage of ulceration, is often the earliest sign of its existence, since it is mentioned in forty-six per cent, of the cases as preceding any other ailment. A simihir error, as you scarcely need to be reminded, was once gen- erally current with reference to hemorrhage from the lungs in phthisis. The haemoptysis, Avhich we know to be in many instances due to congestion of the lung, and to be the herald of coming mis- chief, w^as supposed to be the proof of irremediable injury already inflicted, of the giving way of a vessel in consequence of its being involved in the spread of the ulceration. The same explanation as accounts for the bleeding in the one case may be admitted as interpreting it in the other; ajid the practical inference to be drawn from this fact, concerns the extreme importance to be at- tached to causeless hemorrhage from the w^omb, the urgent need for making a vaginal examination by which we may detect some forms at least of malignant disease, at or near their outset, at a time wdien remedies can retard their progress, when surgery may perliaps altogether remove them. Ilospital practice gives so little opportunity for tracing cases of chronic disease from their commencement to their close, that I can give no definite statement as to the general relations borne by hemorrhage to the other symptoms of cancer throughout its whole course. The form in which the bleeding first shows itself is very various. Sometimes it is a draining of blood, not profuse but continuous, resembling the discharge at an ordinary menstrual period, except that it may not have come on at the right epoch, and that it generally continues for a longer time, until it excites anxiety by its persistence, or in other instances by the frequency of its return. It sometimes assumes these characters in the aged, in whom all the sexual functions have long ceased, but wdio at first regard the reappearance of a sanguineous discharge with a sort of IN UTERINE CANCER. 305 half complacency, as though it were an evidence of their rejuven- escence ; but it is not in the aged alone that this form of hemor- rhage takes place. It is, however, more common for hemorrhage to take place either at a menstrual period, or a day or two after its cessation ; but though an ill-marked periodicity is generally ob- servable in all hemorrhages from the womb, whatever be their cause, and whatever the age of the patient in whom they occur, it is certainly unusual for menstruation in cases of cancer to con- tinue regular in its return. Sometimes menstruation anticipates, at other times there is a fortnightly hemorrhage, the dischai-ge at each period presenting an equal claim to be regarded as menstrual; but it is not often that the proper period continues to be recogniz- able after two or three returns of bleeding. A few cases occair of a single profuse outburst of blood, not followed by any return of hemorrhage, or merely by the occasional admixture of sanguineous fluid with tlje discharge which takes place at other times. Pro- fuse lochial discharges have once or twice passed, according to the patient's statement, into a hemorrhage which has been the first evidence of cancerous disease ; but, of course, the cases in which this is observed are rare and exceptional. In the early stages of cancer, the bleeding is, as tlie table shows,* most frequently unaccompanied by pain, though to this there are some exceptions. With the advance of the disease, pain is gen- erally associated with the hemorrhage ; for with the exception of cases of epithelial cancer, in which the delicate vessels give way under the slightest cause, congestion of the womb generally pre- cedes each outburst of bleeding, and is relieved b}^ its occurrence. The source of the hemorrhage continues to be the same after ul- ceration has taken place as it Avas before, and the blood is furnished much less by the diseased surface than by the whole mucous mem- brane of the womb. The expulsive uterine pains which in many instances accompany the hemorrhage, are due to the same cause as in ordinary menorrhagia — namely, the formation of coagula within the cavity of the womb, and the eflbrts of the womb to exjicl them ; efforts which are all the more painful, owing to the resistance which they encounter from the unyielding tissues infil- trated with cancerous matter. There is no strongerevidence that the ulcerated surface furnishes but a small part of the bleeding tlian is afibrdcd by its invariable diminution, often by its complete cessation in the advanced stages of cancer, while in not a few in- stances in wliich the process of ulceration has l)een most raj)id. and the destruction of tissues most extensive, there has been but little bleeding, or the hemorrhage has been entirely confined to the outset of the disease. A woman, aged thirty-eight, came into St. Bartholomew's Hospital to die of cancer of the womb, and sank on the second day after her admission. The jiosterior lip of her uterus was comitletely destroyed, and the finger i»assed up at once into its cavity, whence there projected an irregular, spiouting 1 See p. 301. 20 306 HEMORRHAGE AND DISCHARGE growth. The anterior lip of the uterus was firmly adherent to the anterior vaginal wall, along which the cancerous disease had ex- tended to within an inch of the vulva, while the lip itself was irregular, thickened, and in great measure destroyed by ulcera- tion. A single attack of hemorrhage lasting for five hours, was the index of the commencement of her illness eight months be- fore. Abundant and often fetid leucorrhoea had been present for many months, but no blood appeared at any time in the discharge, except on the single occasion which I have mentioned. Lastly, with reference to the discharges in cancer cases. They difier much in different forms as well as in different stages of the disease. An increased mucous, or muco-purulent discharge, is by no means uncommon in the early stages of medullary cancer, de- pendent on the general congestion of the womb, which, as we have seen, accompanies the disease at its outset. This discharge is not in general offensive, but sometimes patients will complain of an offensive discharge as having been the first symptom of the disorder, and this in cases where it cannot be doubted but that no breach of surface at the time existed. In this, however, there is nothing remarkable; offensive leucorrhoea accompanies uterine congestion and uterine inflammation in many instances, or results in cases of mcnorrhagia, or of polypus, or of fibrous tumor, from the decomposition of blood which has been poured out ; and our patients, at any rate, are not to be expected to discriminate be- tween bad odors from one cause or from another. With the ad- vance of the mischief the discharge becomes almost always un- mistakably offensive, though the variations in this respect are even in the same case not a little remarkable. It has been seen that portions of the diseased structure not infrequently slough off", and are detached from time to time, leaving behind, when they are separated, a comparatively clean surface, on which for a time a, sort of attempt at healthy granulation may be perceptible. While the tissues are dying and being renewed, the discharge from the cancer will generally be a dirty, highly offensive sanies ; after they have been completely thrown off" the secretion may be but scanty, puriform, and comparatively inoffensive; while in almost every case, supposing proper precaution to be taken by syringing the vagina, and by due attention to cleanliness to re- move the secretion completely and frequently, the offensiveness of the discharge will depend in very great measure on the activity with which the processes of sloughing and separation of portions of the cancerous substance are going on. When the disease is in a comparatively indolent state, as it sometimes continues for months before the death of the patient, who sinks in that case under the cancerous cachexia rather than under the advance of the local mischief, the discharge is often neither very profuse nor very offensive. In the indolent state of the disease, too, the se- cretion has seldom anything of the purulent character which is observable when ulceration and its allied processes are going on actively, but is usually watery, sometimes blood-stained, at other IN UTERINE CANCER. 307 times comparatively transparent. In epithelial cancer, also, the discharge is generally serous, and often almost inodorous, it being rather a secretion from the surface than the result of any decom- position and destruction of tissue. This same absence of any marked offensive odor continues likewise very frequent!}' even after ulceration and destruction of substance have commenced in an epithelial cancer, though, as its characters become merged, as they often do, in those of medullary cancer, the discharge almost always acquires a much worse smell than before. In cases ap- proaching to cauliflower excrescence, where the patient dies of hemorrhage, and also in cases of the so-called corroding ulcer of the OS, the discharge continues inofi'ensive even to the last. These, however, are exceptional cases, and in no way interfere with the correctness of the general rule, that offensive discharge is one of the symptoms of malignant disease scarcely ever absent in some part of its course. One or two |)ractical inferences may be drawn from what has been stated, which it will be worth while always to bear in mind. First of all, the presence or absence of offensive discharge must in no measure be allowed to influence us in deciding on the ma- lignancy or non-malignancy of any disease of the womb. Mere irritation of the organ from inflammation or congestion may be associated with it, decomposition of blood within the sexual organs may occasion it, or the decay and disintegration of a fibrous tumor or polypus. On the other hand, the discharge from an epithelial cancer is often for a long time inoffensive, and sometimes continues so throughout, while in other cases the presence or absence of an offensive character in the secretion, may depend upon whether the disease is in an indolent or in an active state. Even in the latter case, if an examination be made just after the dead tissues have been thrown off* it may be found that no bad smell is given out by discharges which but a lew weeks before were intolerably offensive. It would, I apprehend, answer no really useful end were I to endeavor to group together those symptoms which we have hith- erto examined, and out of them to form a general portraiture of uterine cancer. The degree in which each symptom is manitested, the order in which the symptoms succeed each other, the time during which they are associated, the increase of one and the diminished urgency of another, all vary so much in different in- staDces that no general description could be applicable in all its details, and I therefore forbear from an attempt which might mis- lead, and could scarcely instruct you. Hitherto, however, no mention has been made of the signs of general constitutional disorder which sooner or later manifeet themselves in almost every case of cancer, whether of the wondj or of other organs, and which add much to the patient's distress. The cancerous cachexia, v.'hich is absent only in some few in- stances of epithelial carcinoma where death takes }i1ace from pure loss of blood, is something more than the mere antemia produced 308 CANCEROUS CACHEXIA. by bemorrliage, or by tbe exhaustion that follows long-protracted suffering. "The fount of all the blood is touched corruptedly ;" food does not nourish, the strength fails, the body wastes, the stomach refuses to perform its proper functions; nausea distresses the patient, or sickness wears her, and the red, raw, glazed, or aphthous tongue indicates bat too clearly the state of the digestive mucous membrane, and explains the urgency of that thirst which drink cannot quench, which it is so often scarcely able even for a few moments to allay. The state of the bowels is frequently an additional source of trouble, constipation alternating with diarrhoea. The former condition is frequently induced in measure by the mechanical obstacle which the enlarged and hardened womb offers by its pressure on the rectum to the passage of the faeces, and is still further maintained by the lack of muscular power in the in- testines themselves, which are no longer able by vigorous peristaltic movements to propel their contents. When once diarrhani comes on, the same want of power allows it to continue till the intestinal canal is completely emptied, while to the same cause may be in a large measure attributed the flatulence which often distresses the patient, producing much abdominal pain, and not infrequently issuing in an attack of diarrhoea. The sleep is always disturbed and unrefreshing; opiates indeed may relieve the pain, but they often aggravate the other ailments; the patient feels too ill to sleep, or if she dozes, the parched mouth and burning throat awake her, or else the sense of utter prostration and exhaustion, and the sufferer returns to consciousness with the feeling that but a little more, and the sleep would have ended, as indeed it does not very rarely, in death. In this state I have on five occasions known convulsions to come on, which ended in coma, and in three of the cases the coma ended in death, which took place twice in twenty- four hours, and once at the end of eight days. These head symp- toms, however, are not by any means indicative of actual disease of the brain, for two of the patients being examined after death, no trace of miscliief was discoverable there ; and two others having rallied from the convulsions, lived for many months, while the hemiplegia which in one instance had followed the fits disa[)[)cared by degrees, but completely. In a sixth case great impairment of sensibility of the left side occurred causelessly, and disappeared in the course of a few days, a month before the death of the patient, during whose illness no other sign of cerebral disturbance was observed. The cause of these cerebral symptoms is obscure. The only explanation of tlieni with which lam acquainted is that sug- gested b}^ AI. Aran,^ who regards them as dependent on hydrone- phrosis, and the consec^uent abolition of the function of the kidney. I do not know how far the recovery for a season of patients in whom these symptoms have occurred, and their subsequent death from the ordinary progress of carcinoma, may be fairly regarded as militating against this theory. In two instances of extreme 1 Op. cit, p. 968. CANCEROUS CACHEXIA. 309 hydronephrosis, produced by tlie pressure of the cancerous womb on the uterus, no sign of head-disturbance preceded death; and in the two who died there is no account of remarkable hydronephrosis having been discovered at the post-mortem examination. But these are exceptional cases, and death is not in general pre- ceded by any marked cerebral symptoms. The powers of life by degrees wear out, the local mischief often remaining for weeks or months quite stationary, and when at last the patient dies, it may be dithcult to say why death came just when it did, why, with disease so far advanced, it did not come sooner, or why, life having lasted so long, it should not have continued still for a few days or a few weeks longer? In one case, indeed, the general poisoning of the blood gave rise to the symptoms of py?emia which ushered in the patient's death, though, singularl}^ enough, previous to her fatal illness the signs of the cancerous cachexia had been by no means extreme. She was fifty-six years old, the S3'mptoms of uterine disease liad existed for only four montlis, and the mischief was so almost exclusively limited to the uterine cavity, that a moment's hesitation had been felt as to whether the disease was really of a malignant character. At the time of her admission slight feverish symptoms were pres- ent, which at the end of a week became more intense, and were associated with pain in the upper extremities preciselj' like that of rheumatism. This pain continued, though it did not increase in severity, but the fever rapidly assumed a typhoid character, the pulse rose to 140 in the minute, the tongue became dry, and on the sixth day she died. This case, indeed, stands alone in my experience, though there is a great difference in the intensity of the symptoms of cancerous cachexia and in the rapidity of their course, while no constant relation appears to exist between the amount of tlie local disease and the amount of constitutional disorder. When most rapid, liowever, the constitutional symptoms still nearly alwaj'S continue of a passive kind; and even the peritoneal inllammation which has been referred to as a not infrequent cause of hypogastric pain, and as producing adhesions between the pelvic viscera, does not seem to have any tendency to assume an active character, and does not materially contribute to shorten the patient's life. The diarrhoea often has this tendency, sometimes assuming a dysenteric charac- ter, and being found after death associated with great congestion of the rectum and lower part of the large intestine, and great en- largement of the solitary glands. It is very unusual for great local pain to attend the last few days of the patient's life, and in the very few instances in which I have ob^^erved it, it was associated with the development of cancerous disease in the abdomen, and did not appear to be attributable to the affection of the womb. Two deviations from the ordinary course of cancer must be noticed before we leave the subject of its sym]itoms. Kefercnce has already been made to the occasional absence of one or other of those symptoms which are usually regarded as characteristic of 310 ACUTE CANCER. tlie disease. But there are also occasional instances in "whicli not merely one customary symptom is absent, but in which all the symptoms are so little marked as to throw the nature of the disease completely into the shade. It is not very unusual for patients to apply for the cure of supposed menorrhagia, in whom examination ascertains the existence of far-advanced cancer of the womb; but the most remarkable case of the latency of all its symptoms which has come under m^-own notice is the following: A woman, aged forty-five, who was following the occupation of a cook, came to me at the Middlesex Hospital, complaining of constipation, and of some uneasiness in defecation, which she attributed to piles. She had no hemorrhage, and no uterine pain, and it was only on closely questioning her that she admitted the existence of slight leucor- rhoea. There were no hemorrhoids, nor was there any disease about the rectum, but the uterus was large, less movable than natural in the pelvis, its anterior lip hard and nodulated, its pos- terior destroyed by ulceration. For more than three months she continued to come backwards and forwards to me, and during the whole of this time she retained her place, expressing great relief from simple aperient medicines which I had prescribed for her.^ I do not know her subsequent history, but the practical infer- ence from cases such as these is, that we must take nothing for granted, that a very little warrants suspicion, and I may add, that we must not place im}ilicit reliance on our patients' statements when they deny the existence of some symptom which is either known, or popularly believed to be of evil import. They earnestly desire its absence ; they will not allow themselves to believe in the existence of what they so intensely dread. • The other variety of cancer is an acute form of the disease^ winch. I believe to be very rare, but which runs its course with much febrile disturbance, and with symptoms of an active character such as may be taken by the superficial observer for those of inflamma- tory mischief. It is a form which I have seen only in ^oung persons, and soon after delivery or miscarriage. In one instance, a woman who had miscarried at four months, and had had a single profuse attack of hemorrhage two months before she came under my notice, was received into the hospital in a state of profuse sali- vation, in consequence of mercury given her for the cure of alleged uterine inflammation. The disease, of which she soon died, was cancer in a state of far-advanced ulceration; but there had been so much febrile disturbance and so much abdominal pain as to throw an intelligent practitioner off his guard, and to lead him to neglect what might seem the very obvious duty of making a vaginal ex- amination. Another case somewhat of the same kind I have also seen, in which the disease ran its course in three months and seventeen days; its commencement being reckoned from the date of the patient's delivery, previous to which she was not aware of any symptom of uterine disease. In this case the patient died in 1 A case of the kind is related by Dr. Simpson, op. cii., p. 190. LABOR COMPLICATED WITH CANCER. 311 a state of coma wliioli had sncceeded to convulsions, and her state, even at the time of her admission, was one of very great urgency. She, however, had a hot skin, and a furred tongue, and a rapid pulse, with considerable abdominal pain, and I can readily con- ceive that at its outset these symptoms might, as in the other case, have led into error. We have already seen that on the one hand the presence of a disposition to cancer does not interfere at all with a woman's fer- tility, and on the other, that the changes that succeed to childbirth seem to ftxvor the advance of the disease. It now remains for us to look at the influence which cancerous disease of the womb exerts on the process of labor itself, when ^ woman so afflicted has the misfortune to become pregnant. Tlie evidence of statistics bears out fully what one would anticipate to find, and sliows that the rugged and thickened os uteri dilates slowly, painfully, and imper- fectly ; that it is often rent during the parturient efforts, and that formidable hemorrhage takes plac«, or dangerous inflammation succeeds ; and that sometimes so insurmountable are the obstacles, that the child cannot pass at all, and tlic mother and her unborn babe either perish together during the parturient efibrts, or that gestation is prolonged far beyond its ordinary term, and that death at length takes place without any decided effort having been made by the uterus to expel its contents.^ Table showing the Result of Seventy-five Cases of Cancer of the Neck of the Womb complicating Labor. Died in or Recovered Authority. Total Cases. very poon from the effects after I^abor. of Labor. 2 Puchclt, , . . 31 18 13 3 Oldham, . . . 5 2 3 ■• Cormack, . . 1 1 5 Simpson, . . . 2 2 4 ^ Arnott, .... 6 2 ■^ Scanzoni, . . . 4 4 8 Dorrinirton, . . 1 1 9 Kiwisch, . . . 4 4 '" Menzies, 20 10 10 •I Spiegelbcrg, . . 1 ... 1 75 41 34 1 As in Dr. Monzios' very remarkable ca.se recorded in G/asr/ow Midical Joitrnal, vol. i, p 129. July, 1853. '■^ De Tiimorihun in Pe/vi, &c., 8vo., 1840, cap. iii and iv. 8 Lonilun Journal of Medicine, 1851, p. 204, and (tui/'h Ilospifnl Reports, 2d ^orica, vol. vii, )). 427. " London Joiirnnl of Miulicine, 1851, p. 212. 6 Op. cit., p. 648. 6 jV(v/. Chir. Trans., vol. xxxi, p. 37. ' Lehrhnrh der Geburt.'i/iUlfe, vol. ii, 258. 8 Prov. Med. Journal, Oct. 7, 14, 21, 1843. 9 Op. elf., vol. i, p. 540. '" Menzies, Inc.. cit. In Menzies' table of 27 cases are incliidcd those of Dcnman, contained in Pnchelt's table, and some cases of Oldham and Simpson, which are separately referred to by me. These being omitted. 2lt cases remain. " Monatschrijtf. Oeburisk., Feb. 1858, vol. xi, p. 110. 312 DIAGNOSIS OF UTERINE CANCER. In Seventy-two Cases the Fate of the Children is mentioned. Authority. Total Cases. Dead. Born alive. Puchelt, . . Oldham, . . Cormack, . . Simpson, . . Arnott, . 30 5 1 6 2 4 1 4 18 1 19 4 2 2 twins 4 1 4 11 11 1 1 4 1 "i 1 Scanzoni, . Dorrino-ton, . Kiwisch, . 3Ienzies, Spiegelberg, . 72 47 26 Hereafter%ve must return to the subject, in order to inquire into tlie means wliicli will give ns the greatest chance of carrying the mother and her child safgly through these dangers. For the present, it is enough to have adverted to them, and to have shown their nature and extent. In the foregoing lectures I have occasionally noticed the main distinctions between innocent and malignant diseases of the womb, and it may at first sight appear needless to enter into details con- cerning the diagnosis of uterine cancer, since its characteristics are so well-marked as seldom to leave room for doubt, or to allow the possibility of error, except to the grossly ignorant, or the wil- fully careless. But though this is usually the case, yet it does sometimes happen that error is fallen into by persons who can neither be charged with want of knowledge, nor with want of care, and such error most frequentl}' takes the form of regarding an innocent disease as one of malignant character, and thus entails much needless anxiet}^ on the patient 'and her friends. At a time when induration of tlie cervix uteri was commonly supposed to be due to scirrhous de[)Osit, this mistake was much more frequently com- mitted than it is at the present day ; but even now the practical error survives, as is its wont, the pathological blunder in which it originated. Hence it becomes by no means superfluous to lay it down as a rule, so far as I know without any exception, that long-standing induration and hypertrophy of the cervix uteri, with or without superficial abrasion, but unaccompanied by thickening of the roof of the vagina and by diminished mobility of the uterus, are due to chronic inflammation, not to cancerous deposit. So great is the importance of distinguishing between these two conditions, that it may be worth while, even at the risk of being tedious, to contrast them with each other : DIAGNOSIS OF UTERINE CANCER. 313 In InflamiMatory Induration. The history of the patient's ailments generally goes back for a period of several years, and her symptoms have come on gradually. A tedious labor, or an imperfect con- valescence from labor or rniscarriiige, is very frequently referred to as the com- mencement of the patient's ailments. Pain is a more constant and an earlier symptom than hemorrhage. Menstrua- tion is often scanty ; hemorrhage, if it occurs, observes a monthly or sometimes a fortnightly type, is very seldom per- sistent, and is almost always attended by much sutl'ering. The cervix uteri is always tender, often exquisitely so; the mobility of the uterus is but little modified ; the enlarged lob- ules of its lips radiate from the orifice. Ulceration of the os uteri is eitlier a sim])le abrasion of the epithelium, or a red surface of a finely granular, velvety texture, sometimes raised a little above the level of the adjacent part, never de- pressed beneath it. The margins of the ulcerations are always smooth and regu- lar, and the discharge is sometimes puru- lent, oftcner glairy, occasionally a little blood-streaked, hardly ever offensive, and furnished more from the interior of the uterus than from the ulcerated sui*- face. In Uterine Cancer. The average duration of cancer does not exceed eighteen months, and the first symptoms are generally sudden in their occurrence. Though cancer occasionally develops itself out of labor or miscarriage, yet such cases are so rapid in their course as to render mistake impossible. Hemorrhage is an earlier, and in the first stages usually a more urgent symp- tom tban pain. It is causeless, sudden, often persistent, not governed by the menstrual type, and the season of flood- ing is generally one of mitigated suff"er- ing. The cancerous cervix is often but little sensitive ; the mobility of the uterus is early interfered with ; the enlarged lob- ides of its lips are irregular in their position, and not divided by fissures ra- diating from the orifice. ' Cancerous ulceration is never a simple abrasion, but either a sprouting, coarsely granular outgrowth with everted edges, or an excavated ulcer with a dark sur- face, and jagged margins; often partially covered by a dark-grayish slough. The discharge, which is furnished from the diseased surface rather than from within the uterus, is either thick, yellow, puru- lent, highly offensive, or thin, serous, often blood-stained, never transparent and albuminous. Attention to these distinctions will, I believe, suffice almost in- variably to prevent the confounding of mere chronic induration and hyi)ertrophy of the uterus with nuilignant disease. I have however, met with two instances in which the diagnosis between the two conditions was extremely difficult, and in which time alone reYnoved suspicions that had appeared but too well founded. Both of these cases presented considerable resemblance to each other ; and the symptoms, which came on in both some mouths after delivery, were probably due in reality to a condition of im- perfect involution of the uterus. In both instances profuse hemor- rhage burst forth suddenly, endangering the patient's life, and being in one case restrained only by the use of the plug. The uterus was in both cases greatly enlarged, its lips were swollen and everted and its orifice was open, so that its condition closely resembled that of the womb affected by fungoid cancer; while the serous discharge which flowed in the intervals between the attacks of hemorrhage gave out that offensive odor commonly regarded as almost pathognomonic of malignant disease. The nature of the case, too, was, with one of the patients, rendered the more doubtful by the circumstance that she, being turned forty years of age, having given birth to her last child eighteen moiitlis before, and having weaned it seven months, had yet had no return of 314 DIAGJSrOSIS OF UTERINE CANCER. menstruation, while her health was failing, and she had snfFered much from dull lumbar pains. In this case, which I had frequent opportunities of watching, the hemorrhage recurred at irregular intervals for between two and three months, when it ceased, leav- ing the patient completely, exhausted. Slowly she regained her strength ; and at the end of another three months the menses re- turned naturall3\ After having twice recurred at their proper periods, the menses once more disappeared ; their cessation, how- ever, was accompanied by the signs, not of disease, but of preg- nancy, which terminated in. the birth of a living child at the seventh month of utero-gestation. Very serious hemorrhage at- tended the labor, but convalescence was uninterrupted, and no sign of cancerous or other uterine disease has reappeared, though the patient has now entered her forty-ninth year, and the menses are becoming irregular in their return, preparatory no doubt to their final cessation. In this instance I was not alone in the unftivorable opinion which I entertained of the patient's prospects; but looking back upon the case, now that time has corrected my judgment, I can recall to mind that there was a uniformity in the enlargement of the uterine lips, and in the degree of their hardness, which is not usual in fungoid cancer, and that tliere was an absence of that nodulated character which is generally obvious in the uterus affected by malignant disease. Between iibrous tumors of the uterus and malignant disease of the organ, a vaginal examination usually enables us readily to dis- criminate. Still it must not be forgotten that in those compara- tively rare cases in which the body of the uterus is affected by cancer while its orifice is free from disease, we may find a tumor perceptible in the abdomen, coupled with marked increase in the dimensions of the uterine cavity, and sometimes with irregular thickening in the substance of one or other uterine wall, closely resembling that produced by the presence of a fibrous tumor, while sometimes a distinct outgrowth is perceptible through the OS. Our diagnosis, however, will usually be directed aright, by the health being more impaired, and the local suffering more persistent than is usual in a case of fibrous tumor; by the loss of mobility of the uterus being more considerable than even its in- creased size would account tor; and by the extreme vagueness in the outline of any tumor proceeding from the uterine walls. Reference has already been made' to the possibility of mistaking a fibrous tumor just passing through the os uteri for cancerous disease of the organ ; and I have known the disintegrated slough- ing surface of a pedunculated fibrous tumor or polypus hanging down into the vagina to be taken for advanced ulcerated carcinoma of the neck of the womb. Such an error, however, ought not to be committed, for on a careful examination, the absence of the os 1 See p. 237. DURATION OF UTERINE CANCER. 315 uteri from the lower end of tlie tumor, its oval or pyriform sliape, its smooth and uniform surface at those parts which are not in a state of ulceration, and the possibility in almost every instance of reaching one or other lip of the os, if the finger is carried high up along the tumor, will reveal the real nature of the case. One point only still remains to be noticed in order to complete our history of cancer of the womb, and that refers to its duration^ which seems, indeed, to be shorter instead of longer than that of many other forms of the same disease. In twenty-two instances I was able to fix accurately the dura- tion of uterine cancer, and found that it was — Under 4 months, in 1 case 5 " " 3 " " 6 " « 1 laccd under the so- called hunger cure — tliat is to say, her food has been reduced to the smallest quantity on which life can be maintained; and this with the result which the empirical trial of remedies almost always merits, almost always attains. The hemorrltage is usually the first symptom which so excites the patient's alarm as to induce her to seek for medical aid. But unfortunately, ere then the disease has often made considerable advances, and its nature is already but too evident. The hemor- rhage at the outset of the disease being, as already explained, due to congestion of the womb, our first endeavor must be by every means to abate it, and thus to i)revent. if possible, the return of the l>leeding. It is self-evident, that with this object in view, every direct excitement of the sexual organs must he injurious, and hence there can be no exception to the rule which interdicts marital intercourse whenever there is the least suspicion of cancerous disease. The state of the bowels is the next point to attend to ; and they must be kept freely open, if possible, by mild saline aj)erients, which unload the hemorrhoidal vessels, as well as prevent the accumulation of feces in the intestinal canal. A mild, unstimu- lating diet is equally important, and I have no doub^t but that in 318 TREATMENT OF THE HEMORRHAGE. the early stage of cancer an opposite plan is injurious to the pa- tient's general health, and indirectly accelerates the advance of the disease. "When to these precautions are added the avoidance of all active exertion, and the most absolute rest at the return of each menstrual period, I fear there is little more within our power. The local employment of depletion, which has been recommended in the early stages of cancer, is very rarely admissible, and I am not disposed to advise that the blood should ever be drawn from the uterus itself, but rather from the hypogastrium or the groin, since I have known very serious difficulty occur in arresting the bleeding from leeches applied to the neck of the womb in these cases. At a later period of the disease the hemorrhage may be so pro- fuse as to call for direct restraint, and the necessity for immediately checking it is of course urgent in proportion to the degree of anae- mia which already exists. The gallic acid is of all astringents that which has least often failed me; but in order to obtain decided effects from it, it should Ije given in doses of six or eight grains every four hours. The infusion of matico, as a local ai)plicati()n, is also of much use in some of these cases; but the numagemont of the injection can never be safely intrusted to the patient, who either employs it i n effect n ally, or else causes herself much suffering by striking the neck of the womb in her endeavors to introduce the instrument far enough into the vagina. There are obvious difficulties in the way of plugging the vagina in cases of ulcerated carcinoma; and, indeed, the mode in which the profuse bleedings usually take place, by sudden outbursts of hemorrhage, followed by a long pause, is that against which such a proceeding is least of all calculated to guard. In some cases of soft medullary cancer, or of epithelial cancer, when the continuance of hemorrhage be- comes a very serious source of danger to the patient, we may break down the tissue with the finger, and then inject into the midst of it the tincture of the sesquichloride of iron. The bleeding vessels are thus destroyed, and the coagulation of the extravasated blood by the chemical agent prevents the occurrence of any further hemorrhage, while the whole mass which has been thus treated sloughs away in the course of a few days, leaving behind a healthier surface, or one at any rate less disposed to bleed. This proceeding, which was to the best of my belief first recommended by Kiwisch,^ is not accompanied by much pain, nor has it, in my experience, ever been followed by serious constitutional disturbance, while the improvement which for a time succeeds the checking of the previous drain upon the system is often very remarkable.^ Kiwisch 1 Op. cit, vol. i, p. 547. 2 In the Lancet for December 29, 1855, is a very remarkable case related by Dr. Boulton, of Horncastle, in which the breaking down of the ti.ssue of a large epithelial cancer of the cervix uteri, and the arrest of the subsequent bleeding by caustics, of which the muriated tincture of iron appears to have answered best, had been persevered in for five years, not only with great improvement in the patient's condition, but, as would seem, with the final result of completely destroying the disease, of which for sixteen months previous to his communication the os TREATMENT OF THE PAIN. 319 also speaks of the employment of the actual cautery as a very effi- cacious means of restraining bleeding, in cases where the surface is of too firm a texture to be broken down. I have not tried the actual cautery specially for this purpose, though I believe that in some cases of uterine cancer I have obtained by it much tempo- rary improvement, both in the general health of tlie patient and in the condition of the ulcerated surface. Of this, however, more hereafter. The pain is, of all the symptoms, that from which the patient most earnestly prays for relief, while, unfortunately, we are often but little able to afford it. There is a permanent pain, or at least a permanent sense of discomfort, which most women ex[)erience, and besides, there are occasional paroxysms of severe suffering from which some are fortunately exempt. The backache, the pain in micturition, and the distress in defecation, are usually to be relieved rather by attention to the functions of the bladder, and the state of the bowels, than by direct anodynes. The Vichy water as a drink, the extract and decoction of uva ursi, with small doses of liquor potassa and tincture of henbane, often give aiiuch relief to the irritable bhidder which troubles the patient in the early stages of cancer, while, at a later period, when organic mis- chief has commenced there, and the urine is loaded with i)ho8- phates, small doses of hydrochloric acid, with the extract and decoction of pareira, will in their turn be of service. The establish- ing a habit of regular action of the bowels will save the })atient from many of the distressing bearing down sensations from which she had previously suffered. Mild laxatives, such as the confection of senna, or very small doses of castor oil, are generall}^ best for this purpose; enemata are not in general expedient, for their administration is often very painful, owing to the presence of hemorrhoids, while the pressure of the distended rectum against the womb sometimes brings on ver}- /Severe suiiering. Plasters of belladonna, or opium, applied to the back or above the pubes, sometimes relieve the permanent pain in those situations, while any casual aggravation of it is often mitigated by the local appli- cation of chloroform, or of cotton-wool soaked in a liniment of equal parts of chloroform and oil, ^nd covered over with oiled silk to prevent evaporation. The longer the patient can dispense with the habitual enqiloy- ment of anodynes, the better is it for her general health. In time, however, they are sure to become necessai'y, and the need for them is usually first experienced at night, for almost always at that time the pain becomes more severe than it had been during the day. Whether em[>loyed at night, however, or given more frequently, it is always desirable to begin with the mildest form of narcotic, and to pass only by degrees, and as each in turn ceases to be effi- utori liad prosontod no trace. In a siibsoaper con- tains few definite details with reference to its employment. Some trials have since been made of it in Paris,^ the action of the remedy still appearing to be uncertain, and its effect now and then to be that of aggravating instead of mitigating suffering, while in a few instances headache, drowsiness, and depression followed its em- ployment, though not to a serious degree, and subsiding spontane- ously in a few hours after the discontinuance of its use. According to M. Bernard, who has written most fully on the subject, the un- pleasant symptoms were less frequently produced, and in a slighter degree, in cases of uterine carcinoma, than in those in which the vapor was applied for the mitigation of pain consequent on con- gestion or inflammation of the womb. In some instances the continued emplo3'ment of the gas for some ten minutes twice a day during several weeks was followed not only by a great miti- gation of suffering, but also by a great improvement in the state of the womb itself and by a partial cicatrization of the ulcer. In otlier cases, however, the local condition remained unchanged, though for a time the health improved in proportion as the pre- viously severe pains were lessened. ' Nothing can be simpler than the mode of applying the gas. In a glass vessel capable of containing a pint, and such as is used for the disengagement of gases, either carbonate of soda and tartaric acid, or chalk and sul})huric or muriatic acid, or carbonate of soda and bisul})hate of potass maybe placed, and water being added in quantity sufficient to cover them, the gas maybe conducted through an elastic tube into the vagina, while a cloth applied to the external parts \y\\\ prevent its too rapid escape. M. Bernard, who uses 25 grammes of bicarbonate of soda, and 20 grammes of bisulphate of potass, or about 5vi of the former to 5v of the latter, estimates the ([uantity of gas disenle operation of plugging the vagina is not infrequently performed. 1 For a description and drawini;; of this instrument, soc INIfisrs's translation of Colombiit's work on Diseases <>/ Women, 8vo., Pliiladcdphia, 1845, p. 351. '•^ In drai^i^incj down the uterus, however, much caution must be observed ; since, as Scanzoni mentions, op. cii., p. 2G4, it is by no means unusual for adhesions, the result of peritonitis, to form between the uterus and adjacent parts, even in tlie early stages of canc(*rous disease of the womb. If these adiiesions were torn or violently stretched, fresh inflammation of an acute kind would not fail to be .^et up ; and Si'aiizoni even relates an instance in which a rent in the perit<>nrum behind the uterus, two inches in length, was produced during llie erturts to draw down the womb in order to remove its cancerous cervix. ' Ohs/efric Memoirs, p. 180. * Pauly, op. cit., p. 473, asserts that hemorrhage proved fatal within twenty-four hours to three out of nine cases in which he assisted >[. Lisfranc. Such a result, however, is quite out of proportion to the general e.xjierience in this matter. 332 AMPUTATION OF THE CERVIX UTERI. Except during labor, it cannot be thoroughly clone without the use of the speculum. The comparatively narrow vulva and entrance of the vagina render the introduction of the tow or cotton-wool a very tedious process ; and the lower part of the canal is already filled, while its wider and extensile upper portion is so little dis- tended that ample room is left for the accumulation of a large quantity of blood between the uterus and the plug, until at length under some efibrt at vomiting, or some sudden movement, an enormous coagulum and the plug are expelled together, and the bleeding breaks out afresh. The question is not, however, whether the excision of 'the neck of the womb in these cases is unattended by immediate risk, but whether such risk is greater than would attend any other opera- tion performed for the same purpose ? That dread of hemorrhage which has led some practitioners to prefer the ligature to the kniie for the removal of polypi, has also had much influence in pre- venting the excision of the cervix, and has consequently led to the restriction of attempts at cure to those softer varieties of epithelial cancer, in the removal of which, as of true cauliflower excrescence, the ligature is available. 1 employed the ligature with advantage, and without the occurrence of any alarming symptom, not indeed for the cure of the disease, but for the re- moval of an enormous mass of epithelial cancer, which, sprouting from the cervix uteri, occupied and distended the whole vaginal canal. In another instance, however, of less extensive disease, in which I saw tlie ligature employed in the hope of eftecting a cure, the patient died of phleljitis; and Dr. E. Watson,^ who has col- lected such scanty statistics as can be brought to bear on the sub- ject, gives the following result of his inquiries. Of seven patients operated on by ligature, one died four months after of inflamnui- tion of the womb, which threatened to prove immediately fatal, and probably would have done so but for the removal of the ligature on the sixth day after its application. In every one of the others the disease speedily reappeared, but the life of one of the number was saved by the excision of the remainder of the cervix, an operation which was performed by Dr. Montgomery of Dublin. Of nine patients in whom the cervix uteri was excised, none died from the immediate effects of the operation ; the disease returned in three; in five the cure was permanent; and the con- dition of one patient was doubtful, since her history was not brought down later than the eleventh day. Excision of the part seems to me the preferable proceeding, because it is applicable to cases where the ligature cannot be employed, because the present risk which attends it is, to say the least, not more considerable, while the prospect of a permanent cure is far greater. This opinion seems, too, to be that of the profession generallj'; for while, as far as I am aware, no fresh instance has been recorded of the employment of the ligature since the publication of Dr. 1 Monthly Journal, Nov. 1849, p. 1183. LOCAL EMPLOYMENT OF COLD. 333 "Watson's paper, there are many additional cases of tlie removal of the diseased cervix by excision. " Since the date of Dr. Watson's paper, many attempts have been made to combine the permanent advantages of the operation by excision with the greater present safety of the ligature by the use of the ecraseur. It seemed, Ijowever, as if this change in the mode of operating did but substitute a new danger for the old one, and one so grave as to more than counterbalance the safeguard whicli the ecraseur afibrds against hemorrhage. The instrument ap[>cars so apt to draw within its chain parts not involved at the time of its first application, that the peritoneum has on several occasions been wounded in the attempt to amputate the neck of the womb. This ol)jcction was recently urged against it at a meeting of the Berlin Obstetrical Society, by Dr. Mayer, who referred to an in- stance in which this accjident had occurred to a patient of Pro- fessor Langenbeck; and Dr. Biefel on the same occasion mentioned a case of fatal injury to the bladder and peritoneum by the instru- ment.^ A case of injury to the vagina, and protrusion of the intestine through the opening, is likewise related by Dr. Breslau,- but his patient happily survived, as also did another whose case came to my knowledge, and in whom a portion of the peritoneum behind the uterus was removed with the diseased cervix. It has been proposed by M. Simon, of Darmstadt,Mn order to avoid this danger, that in all cases where the uterus admits of being drawn down beyond the external parts, a needle, or two needles, should be thrust through the neck of the womb, and the ecraseur should be a[)plied below them. He rejects the ecraseur, however, abso- lutely in all cases where the uterus cannot be drawn down ex- ternally, though it is doubtful whether, even here, Dr. Braxton Ilicks's wire ecraseur or jSIiddledorflfs application of the red-hot galvanic wire may not stand us in good stead, and avoid the risk of hcmorrliage without substituting for it a new peril. The cases in which any of these proceedings are applicable, must obviously be comparatively few and exceptional; since the disease admits of being extirpated only when comparatively limited in extent, and at a comparatively early stage of its progress. Is there then no resource in these circumstances but to watch the daily advance of the evil; or can anything be done to retard, if not to cure, to alleviate the patient's suffering and to postjione for some weeks or months the inevitable result? Dr. James Arnott,'* to whose ingenuity we owe many very important suggestions in medicine and surgery, believes and adduces evidence to show that by the systematic application of a very low temperature to i)arts affected with cancer, the |)ain of which they are the seat may be greatly diminished, the advance of the disease may be consider- ' MonnUrhr.f. Oeburfsk., Miirt-h, 1858, p. lr,9. ' Sciinzurii's JJciiriif/e, vol. iii, 'NVufzlnirg, 1858, p. 80. " Monalsriirlft f. Gehiirfn/^iDule, vol. xiii, pp. 418-484. * On the TreMimeni nf Cancer by the regulated application of an Amxsthetlc Tem~ jteraturc, 8vo., London, 1801. 334 APPLICATION OF CAUSTICS ably retarded, and ulcerations of their surface may even be made to assume a comparatively healthy character. Practical difficulties in the way of applying the freezing mixtures so often as might be desirable, have interfered with the trial of his plans upon a large scale in our hospitals, while some degree of disappointment has been experiencecl in consequence of the proved inadequacy of cold to annul the pain of surgical operations in other than a very few instances, and those of the very simplest kind. ISTotwithstanding a very kind letter of explanation which Dr. Arnott was so good as to send me, I have yet found very great difficulties in the attempt at employing freezing mixtures in cases of uterine carcinoma. The necessary removal from bed to a couch, the discomfort of the position, the almost impossibility of preventing the patient's person from becoming wet, and the tenderness of the vagina and external parts produced by tlie frequent introduction of a large speculum, which, even when of great size, seldom embraces the hypertrophied cervix completely, have precluded my making such a number of trials of the agent as would alone warrant me in speaking with any measure of confidence as to its powers. Other agents, more potent and more easily applied, have been used in cases of uterine cancer, but with results so indecisive that opinion is still much divided with reference to the propriety of their employment. In coming to a conclusion with reference to the use of any of these remedies, the object with which in each instance it has been liad recourse to must not be lost sight of I have already mentioned, that a strong solution of nitrate of silver applied to a cancer of the womb, in some stages of the disease, both diminishes the excessive fa;tor of the discharge, and also ex- pedites the separation of sloughs from its surface, aiding in this manner the attempts at a cure, which, though abortive as far as permanent recovery is concerned, are yet most welcome pauses in the course of the disease. For this pur[>ose, I believe a strong solution is of greater service than the solid nitrate of silver, prob- ably because in this form the remedy penetrates more thoroughly into the affected tissue. I have also sometimes employed the acid nitrate of mercury to check those granulations which in cases of uterine cancer not infrequently si»rout from the interior of the cervix, and I think that in both of these wa3'S the use of caustics has been advantageous as a palliative, not as a curative proceeding. There are some forms of external carcinoma, in which the em- ployment of the more powerful escharotics, as the chloride of zinc, has been of great service; but I need scarcely remind you that the benefit derived from such agents has depended almost entirely on the possibility of completely destro^-ing the affected tissue, and that, as a general rule, its partial destruction has been followed by a more rapid development of the disease than before. JSTow, in the case of the uterus, it is obvious that the thorough applica- tion of any deliquescent substance is impossible; that the risk of injuring adjacent parts must lead to the inefficient employment of the caustic, and consequently to the aggravation instead of the AND THE CAUTERY IN CANCER. 335 amendment of the disease. Tliis circumstance leaves us no alter- native l)ut to resort to the actual cautery in any case in wliich it is intended to do more tliau modily the state of the surface of the alfected parts. The idea of the operation is much more formid- able than its reality, for it is not very painful in itself, while it can always be performed under chloroform; and the only real danger attending it, that of injuring adjacent tissues by the radiation of the heat, can always be etfectually guarded against by the use of a boxwood speculum. I have not myself used it, or seen it used sufficiently often to have formed a very decided opinion with reference to the an)0unt of benefit wliicli may be anticipated from it; but I feel satisfied that there is no danger to be apprehended in its employment, and that it does not tend to make matters w^orse. Generally there is a vei-y decided, though often very temporarj' mitigation of the patient's previous sufferings, an improvement wliich has seldom outlasted the separation of the eschar. A diminution in the quan- tity and foetor of the discharge has generally continued for a longer time, but I cannot say that as yet I have been able to attribute to it any delay in the progress of the evil, partly, perhaps, from not having re[)eated it sufficiently often, and in still greater measure prol)abIy from the disease being already- far advanced when the patients first came under my care. I believe, however, that like other proceedings intended to effect the real cure of cancer, the actual cautery is seldom indicated except in cases of the epithelial form of carcinoma, for in that alone is the mischief at all likely to be confined wdthin limits which we can hope to reach by any local treatment. These remarks are, I know, anything but detailed enough to furnish a safe and sufficient guide as to when and how, and how often, this kind of interference is likely to be useful, or ma}' even, by good fortune, prove actually curative. They are merely sug- gestive of the direction which your observations should take, and in which your efforts should be made. Your duty and mine is, not to sit down in apathetic indifference, doing nothing, trying nothing for a patient's cure, because her disease is one which hitherto has proved almost invariably mortal; but rather, patient- ly, carefully, with much distrust of our own powers, much watch- ful scrutiny of our own motives, to apply ourselves to the trial of every means by which suffering may be mitigated or life pi'o- longed. To this our common humanity prompts, our obligatitjiis as medical men compel us. It is to misinterpret both very griev- ously, if we not merely content ourselves with doing nothing, but take shelter under noisy censure of the conduct, and unchar- itable construction of the motives, of those who read their duty differently. 336 INFLAMMATION OF THE LECTURE XXII. DISEASES OE PAKTS CONNECTED WITH THE UTEKUS. INFLAMMATION AND ITS RESULTS. Inflammation of Uterine Appendages: of the Cellular Tissue. Causes of affection ; generally consequent upon delivery or abortion ; its various seats, and modes of termination ; affection of the peritoneum in its course, general tendeucj^ to end in suppuration. Morbid appearances. Relation of this affection to inflammation of the ovaries ; its analogy to other in- flammations of the cellular tissue. Symptoms; mode of attack twofold. Formation of abdominal tumor ; occurrence of suppuration, but chronic character of the abscess; various outlets by which it discharges itself. Diagnosis of the affection. Characters of intra-pelvic tumor ; its similarity to uterine haeniatocele. General sketch of its symptoms and course. There are many phrases wliich, though still daily used in medi- cal writings, express not merely the opinions but also the errors of a bygone time. It is tluis with the term uterine ajjpendages, long applied to parts connected with the womb, some of which, indeed, are secondary to it in importance, and subsidiary to its functions, but others are physiologically of higher moment than the uterus itself, and originate those acts to whose due performance the womb does but minister. I have no fear, however, lest by retaining the phrase appendages of the uterus, or by speaking to you about their diseases, I should be suspected of ignoring the othce of the ovaries, or of implying that they are of less importance than the womb in the sexual sys- tem of the woman. I shall be understood to use the term merely as a convenient epithet, expressing without waste of words the broad ligaments of the uterus and all the various parts and struc- tures contained within or intimately connected with them; parts whose physiological import just now concerns us less than do the ailments to which they are liable. When speaking of the diseases of the uterus itself, we con- sidered iirst those which are the result of inflammation ; and it will. I think, be convenient still to retain the same arrangement, and before passing to other subjects to study the inflammatory af- fections of the appendages of the womb. These admit of being classed under two heads, according as the inflammation attacks the ovaries themselves, or as it is chiefly limited to the cellular tissue in the immediate neighborhod of the womb. In the latter case the symptoms are of course modified according to the precise seat of the mischief, which, tliough most frequently involving the cellular tissue between the folds of the broad ligaments, sometimes attacks that which intervenes between the womb and the adjacent viscera, or extends to that lining the pelvic walls, or even to that which lies between the outer surface of the peritoneum and the abdominal muscles. UTERINE APPENDAGES. 337 Inflammation of the cellular tissue in the neighborhood of the womb takes place as a consequence. of abortion or of delivery much more frequently than from any other cause. The e^reat tendency that it has, too, to terminate in suppuration, familiarized practi- tioners of midwifery from a very early period v^'ith it; or at least with the abscesses to which it gives rise, though misconception long prevailed with reference to their nature. They were generally innigiued to he secondary deposits, the result of a supposed metas- tasis of the milk, or of an outpouring of its elements when i»resent in too great abundance in the blood. It was imagined, too, that this occurrence sometimes took place in one situation, sometimes in another, and the most various sequelse of delivery were attrib- uted to this as their remote occasion ; a theoretical error, which as Puzos' essay, " Sur les Depots Laiteux,"^ abundantly proves, did not at all interfere with the most accurate description of some of the most important ailments of the puerperal state. With advancing knowledge the erroneus theory was discarded, but the inflammatory affections of the uterine appendages ceased to attract attention, or were passed over as occasional complica- tions of puerperal fever, until attention was once more drawn to them quite recently by the essays of Doherty, Churchill, and Lever, in this country,^ and by those of Grisolle, Marchal de Calvi,^ and others, in France. Even at the present time, how- ever, and in spite of the recognition of these ailments as attend- ants on the puerperal state, their occurrence independent of preg- nancy and its consequences has scarcely been appreciated as generally as it deserves, and it is this circumstance which is my chief reason for bringing the subject now under your notice. An attempt has been made by some writers to discriminate between inflammation of the uterine appendages occurring after delivery, and the same atiection when coming on in other circum- stances. I do not think, however, that this distinction is called for either by the symptoms of the disease, or hj the treatment which it requires in the puerperal state, though the peculiar con- dition of the uterus at that time often imparts to disease in its vicinity a more acute character than would be presented by the same ailment at another season. The subjoined table shows very clearly the influence of labor and its consequences in giving rise to inflammation of the appen- dages of the womb, and of the cellular tissue in their immediate vicinity. It shows, too, that almost invariably, even when labor did not precede the attack, some accident induced it, which acted immediately on the womb, such, for instance, as miscarriage, or disorder of the catamenia; while the cases were only 7 in o'J, in 1 In his Traite rics Acc(mc/iemr»s, 4to., Pari?, 17-jO. Soo especially pp. nTjO-SCG. « Dxhl'm Journal, vol. xxii, 1843, p. 191); Ibid., vol. xxiv, 1844, p." 1 ; and Guy'a IIoHp'ilnl Reports, Second Series, vol. ii, 1844, p 1. 3 Archivrs Gen. de Meilrcinr, Third Series, 1830, vol. iv, pp. 34, 137, 293; and Des Abcis I'Ideffinoneux Intra- Pel vicns, Svo. , Paris, 1844. 22 338 CAUSES OF INFLAMMATION wliicli the attack was not brouglit on by some local ailment of tlie sexual system. Occurred after Delivery in 32 cases. " " Abortion, 11 " " " Disorder of Catamenia, . . . 7 " " " Seduction, and some probable violence to Uterus, ... 1 " " " Ulceration and Intiammation of Uterus, 1 " " " No ailment of Uterus, ... 7 " 59 In 10 of the 32 cases in which the affection succeeded to de- liveiy the patients were primiparse ; or if to my own cases those of Lever, of Marchal de Calvi, and of McClintock^ be added, 56 out of 112 cases were those of women who had been delivered for the first time. The supposition, however, which this i'act might seem to suggest, that protracted or difficult labor specially predis- poses to this ailment, is scarcely borne out by further inquiry ; since in 21 of m}' 32 cases, and in 7 out of 8 of those recorded by Br. Lever, labor was in all respects natural. In 4 of my cases it was protracted, though in none was instrumental interference neces- sary; in Lever's case turning was performed on account of arm- presentation ; in 1 case of mine extensive laceration of the peri- neum seemed to have been the point of departure of the whole of the subsequent inflammatory mischief, and in the remaining 4 labor was attended by profuse hemorrhage, an accident which also complicated one of the cases of tedious labor. From these data all that we can venture to affirm is the preponderance of frequency with which the accident occurs in primiparae, and an increase of liability to its occurrence when labor is more than usually pro- tracted, or when it is accompanied by hemorrhage. M. GrisoUe expresses his belief that the omission on the part of the mother to suckle her infant is one of the most powerful predisposing causes of the disease, and this opinion is in the highest degree probable ; but in this country it is so universally the practice for women, especially among the poor, to suckle their children, that none of my observations bear at all on that point. The nature of the influence of abortion, of disorder of the cata- menial function, or of other accidents which directly interfere with the sexual organs, is too obvious to call for explanation. Why under the influence of such causes a woman should be seized in one case by violent general peritonitis, in another by an ailment chronic in its course, and seldom dangerous to life, it is perhaps impossible to explain. In so far, however, as this disease is a con- sequence of labor, it must be borne in mind that it is essentially different from any of the complications or sequelce of puerperal fever. Puerperal fever is a disease of the whole constitution, asso- ciated with important changes in the circulating system, probably 1 0/J. cit., p. 3. or UTERINE APPENDAGES. 339 with otlicr alterations too, which we have not at present the skill to discover; but the local mischief which may be found after deatli was no more its occasion, than are the ulcerations of Peyer's glands the occasion or the essence of typhoid fever. In puerperal fever, there may be evidence of injury to the uterus, or to its ap- pendages, or to its vessels, or to tlie peritoneum, but there is this and something more; and this something more, the divinum ali- quid, TO Osuiv of Hippocrates, has puzzled our philosophy, eluded our research, and outwearied the speculations of the most inge- nious theorists who have labored vainly to unriddle its nature. Hence it is, however, that these inflammations of the uterine appendages, or of the adjacent cellular tissue, do not usually come before us in cases where puerperal fever has threatened life, for that disease either destroys the patient speedily, or with the abate- ment of the general disturbance of the system, the local evil, unless the mischief done was irreparable, abates too, and soon disappears completely. This ailment, on the other hand, begins as a local affection, its early symptoms are often so slight that it is overlooked for days or Aveeks togetlier, the constitution s^-mpathiz- ing just in proportion to its extent and intensity, and general health returning as the consequence of the mitigation or of the cure of the local disease. There does not seem to be any rule that determines absolutely either the part which shall be the seat of inflammation, or the course which that inflammation shall run, and whether it shall issue in suppuration, or may by good fortune terminate in resolu- tion. The cellular tissue anywhere in the neighborhood of the womb may be the seat of the mischief, though that contained within the folds of the broad ligament is attacked, as the sub- joined table shows, far more often than the same structure in any other situation, or 38 out of 59 times.' The tendency of recent investigations, too, is to show that here, or rather in the ovary and Fallopian tube of one or other side, is the almost invariable starting-point of the mischief, be the parts eventually involved in it what they may. The inflammation further seems to extend from the appendages of the womb to the peritoneum lining the pelvis ; it often ties down the a[ipendages behind the uterus, or forms adhesions between them* and the in- testines, or mats together the intestines themselves, while matter is sometimes formed in the irregular cavities left between adjacent suriaces of the peritoneum, or of the ialse membranes which con- nect diflerent parts together. The importance of this pelvi- pe7-itonitis, as he terms it, has been much insisted on by M. Bernutz,^ who seeks in it for the adequate explanation of all the 1 I must bo allowed to correct an inadvertence on the jiart of 31. Arjin, who, op. cif., p. G80, note, states that I sjlcfje tlie tissue between the uterus and rectum to be the most frequent seat of this ati'cction. The statement in the text is word for word the same as in the previous edition. '■' In the Ardilvcn de Medccine, ]\[areh iind Ajiril, 1S.")7, and afterwards at very great length in vol. ii of his and ]\I. Guuiiil's work, Sitr Ics Maladies dcs Fcmiiies, already referred to. 340 INFLAMMATION OF CELLULAR TISSUE. S .^ 8 ^ s ><5 CO l-H 1-1 1-4 CI 3^ .S . . — <- -S = 3 = = §.a t *; D c:^ 3 •«! o s 55 .— I ^ C^ CO tq 1-1 CO tr.-3 , ? .2 = - SS^ •'S — i^ o -^ - - « SHARE BORNE BY PERITONITIS. 341 phenomena, both local and general, which have usually been sup- posed to depend on inflammation of the cellular tissue about the uterus. He would propose this solution not of those cases only in which the parts at the side of the womb are the seat of this affection, but for those also (14 out of every 59 cases) in which the inflammation appears to be seated between the uterus and rectum, for here, too, the matting together of the intestines may form a tumor in the recto-vaginal pouch, which may present the characters supposed to belong to pelvic abscess. When, however, he denies the possibility of inflammation of the cellular tissue about the uterus, with the exception of that contained between the folds of the broad ligament, he goes furtlier than I am at present prepared to follow him. In 4 out of my 59 cases tlie tissue intervening between the uterus and bladder was the seat of inflanmiation, which in 3 of the cases went on to suppuration, and the matter so formed twice escaped spontaneously, and once was evacuated by means of a trocar introduced through the anterior vaginal wall. To these cases it is obvious that the explanation of M. Bernutz cannot apply, nor do I think it holds good with reference to many instances of retro-uterine tumors; while, with reference to the broad ligament itself, M. Bernutz admits the possibility of inflammation and suppuration involving the tissue between its folds. The inflammation is in mau}^ instances not limited to its orig- inal seat, but extends, and that not always by direct continuity of tissue, to the cellular tissue lining the pelvis, or attacks that which is interposed between the abdominal muscles and the peri- toneum, constituting the external peritonitis of some writers. In these cases, too, the mischief may recede from the parts which it originally attacked, and the gravity of the secondary aihnent may entirely obscure the perhaps transitory aflection in which it originated, a supposition that will probably apply to not a few of the" instances in which affection of the pelvic cellular tissue and that external to the peritoneum has seemed to be idiopathic. Like other inflammations, so these sometimes pass away, and leave no trace. Oftener they issue in the production of per- manent swelling and induration, due either to the results of the local peritonitis, or to actual thickening of the cellular tissue which has been the seat of the attack ; or, lastly, they may end in the formation of pus, and probably in its discharge through the rectum, vagina, or bladder, or now and then in its escape into the cavity of the abdomen. This termination by suppuration aii}iears to be very frequent in the case of those inflammations which succeed to delivery or abortion. I And it noted as having hajiiJcncd in 23 out of 43 instances in which the inflammation succeeded to delivery or abortion ; and the large experience of Br. McClintock' leads to the same conclusion, since he met with it in 37 cases out of 70. My own impression, too, formed chiefly on bygone hospital » Oj). cit, p. 9. 342 POST-MORTEM APPEARANCES OF experience, is that the same rule holds good even in those cases where the disease occurs independently of puerperal causes My table shows 9 instances out of 16 as having terminated by suppura- tion, and in this respect agrees with the statement of M. Grisolle, who found it take place in 88 cases out of 51. General experience, however, it must be confessed, does not bear out these statements. M. Aran demurs to their correctness,^ and M. Gallard,^ in a very carefully written essay, regards the occurrence out of the puerperal state as so rare as to have been met with only in 4 out of 53 cases. I have no longer the opportunities of large hospital observation by which to control and correct my own impressions ; but it seems to me probable that the cases which came under my notice in a small Avard for admission into which there were many applicants at St. Tjartholomew's Hospital, were of a severer kind than those which formed the basis of M. Gallard's thesis ; and further, that many of the slighter forms of what M. Bcrnutz terms pehi-peri- tonitis may have been taken into account by observers recently, though they would not have entered into their calculations some few years ago While I indicate, then, as I have already done with reference to other questions bearing on this subject, the differences of opinion which prevail, I am not at present in a position to modify my original statement, that the occurrence of suppuration, or, at least, of oedema, with infiltration of sero-purulent fluid, is in all these cases the rule rather than the exception, and this even though no discharge of matter should at any time take place externally. The extreme rapidity with which a tumor forms so as to be de- tected through the abdominal walls, or to be felt in other cases in the vagina, is explicable only by the sudden pouring out of fluid into the loose cellular tissue; while its varying extent, its ill- defined edges, its occasional disappearance from one side and reappearance on the opposite, all serve to show that, whatever may have been its starting-point, the mischief does not in general seriously involve the substance of any solid organ such as the ovary, and consequently to explain the completeness of the patient's recovery, and the subsequent integrity of all her sexual functions, even when the attack has been most severe and the symptoms have appeared most formidable. The original seat of the mischief in the cellular tissue imme- diately adjacent to the uterus is illustrated by the subjoined case, where I had the opportunity of observing after death the process by which nature had eft'ected the cure of an inflammation of the cellular tissue contained Avithin the folds of the left broad liga- ment. The person on whom this observation was made was a 3^oung woman who died of abscess of the liver fourteen months after her recovery from inflammation of the uterine appendages of the left side. The results of examination when she was originally admitted into the hospital, six weeks after her delivery, were as 1 Oj}. cit., p. 707. * Du PJdegmon Peri-uUrin, 4to., Paris, 1855. INFLAMMATION OF CELLULAK TISSUE. 343 follows : the abdomen generally was soft and painless, but imme- diately over the symphysis, extending about two inches above its level, and about the same distance transversely, was a firm, globular enlargement, very slightly movable, tender on firm pressure. The vagina was hot, its anterior wall from about half an inch from the orifice of the urethra was swollen into a distinct elastic tumor, which gave the sensation of containing fluid, and projected so as to contract to half its ordinary dimensions the calibre of the canal. In this tumor, which was not modified by the introduction of the catheter, the anterior lip of the uterus was lost, while the posterior lip was small and natural. The right side of the uterus was free from any unnatural condition, the swelling existing to the left and anteriorly. The uterus and tumor, when pressed on, moved together, but their mol)ility was very small. In a few days the tuinor felt per vagi nam was greatly lessened after a profuse discharge of pus, and when the patient, after six weeks' sojourn, left the hospital, there was said to be no other morbid condition than a thickening at the left side of the uterus, by which it was almost completely fixed in the pelvis. The appearances found after death explained this thickening, and accounted for the non-mobility of the womb, for the folds of the broad ligament, from the upper part of the vagina to the lower surface of the ligamentum ovarii, inclosed a mass of dense cellular tissue of almost cartilaginous liardness, crying under the knife; dense white bands intersecting each other in all directions, and having a firm, yellow fat between them. Tliis mass was closely adherent along the whole leftside of the uterus, though the uterine tissue was in no respect implicated in it. The left Fallopian tube was tied at two or three points by long adhesions to the ovary and its ligament, and the ala vespertilionis on that side was thickened and uneven, as if from old deposits of lymph. The Fallopian tubes were pervious, and the ovaries w^ere quite healthy, and contained several Graafian vesicles. Between the aft'ection we are now studying and inflammation of the substance of the ovaries themselves the difi'erences are obvious and manifold. The extreme rapidity with which matter is formed, and the large quantity of it which is secreted in so short a time, are not compatible with the seat of tlie di.'^ease in the substance of an organ furnished as is the ovary with a dense fibrous capsule, which, though elastic and admitting of vast expansion in the course of time, is yet not capable of yiekling so as to allow of the accu- mulation of a large quantity of matter in a few days. The ter- mination of ovaritis by supjiuration is, I believe, quite excejjtioiuil. In the puerperal stiite it is the [)eritoneal investment ol" the ovaries which is usually affected; while when inflammation even of the acutest kind attacks the substance of those organs, and ending in the formation of matter proves speedily fatal, it does not lead to any great increase of their size, but to sottening and complete dis- integration of their tissue. When, in other circumstances, large collections of matter form within the ovary, their origin is usually 344 ANALOGIES AND SYMPTOMS traceable to some cyst in whose wall inflammation has been acci- dentally set up; and such ovarian abscesses generally remain for a long time as distinct, well-circumscribed tumors, whose contents are very slow in making their way outwards. Generally, indeed, ovaritis is not only a far more chronic evil than inflammation of cellular tissue about the womb, and is attended by pain of a very diflerent character, but the enlargement of the organ is almost always inconsiderable, and its situation is often inferred from pain produced by pressure at one spot rather than clearly pointed out by any considerable increase of its dimensions, while the thicken- ing and hardening of the vaginal walls, scarcely ever absent from that side of the canal on which the atfection of the cellular tissue is situated, is never met with in cases of simple ovarian inflam- mation. The analogies of this affection are, I believe, rather to be found among those inflammations ol'tlie cellular tissue which, succeeding to operations, advance with great rapidity, and terminating soon in the formation of enormous quantities of matter, constitute one of the most untoward of those accidents by which the skill of the surgeon is disappointed of best merited success. The rapid forma- tion, and occasional rapid disappearance of the swelling, show, if further proof were wanting, that it is not due to changes in the solid tissues of any organ, but rather to osdenia or the infiltration of a loose tissue with fluid. This fluid, too, like that which is formed in other inflamnuitions of cellular tissue, is not at first genuine pus, but a thin sero-imrulent matter, and often still retains this character long after it has been formed in quantity sufficient to impart to tlie finger a most marked sense of fluctuation. These characters then correspond to those of difi'use cellular inflammation, or "acute purulent oedema," as it has been well termed by the distinguished Russian surgeon, Pirogoft".' It we take this view, which he indeed suggests, even the most anomalous features of the affection will become comparatively easy to under- stand. We shall not be sur}»rised that the disease should occur in the weakly rather than in the strong, tliat previous hemorrhage or other debilitating influences should favor its development, that while often attended b}' comparatively little local sufiering, it should yet run rapidly through its earlier stages; but still now and then come suddenly to a standstill, and that all trace of it should then quickly disappear. Since we know, too, that tlie seat of the mischief is not in the sexual organs themselves, but only in their connective tissue, we shall find nothing difiicult of explanation in the re-establishment of menstruation, or in the recurrence of preg- nane}', or in the regular performance of all the generative func- tions, even after symptoms which had seemed most formidable, and had appeared as though they must imply that injury had been done passing the power of nature to repair. In those cases in which the affection succeeds to delivery or 1 Klinisclie Chirurgie, Drittes Heft, 8vo., Leipzig, 1854, pp. 3G-54. OF THE AFFECTION. 34§ abortion, its mode of attach Reems to he twofold. Either it sets in witli well-marked symptoms of constitutional disorder, such as general feverishness and heat of skin, sometimes, though not olten, preceded by shivering, and accom[)aiiied by abdominal i)ain, which is seldom very intense; or else it comes on gradually, the local evil being developed almost imperceptibly out of a state of incomplete convalescence; while it is quite an exceptional occur- rence for severe puerperal peritonitis to precede the inflammation of the uterine cellular tissue. In the majority of instances th§ tenderness and pain, though referred chiefly to the lower part of the abdomen, are not at lirst distinctly limited to one or other side, and not infrequently the discovery of swelling, induration, or even of a definite tumor in one or other iliac region by the medical attendant, is the first circumstance which directs the patient's notice to one spot as the special seat and source of her sufterings. The sym[itoms of general constitutiomd disorder, even when most marked at the outset, very rarely go on increas- ing in severity with the progress of the local mischief, but, hav- ing set in on the second or third day after delivery, subside at the end of a fortnight or three weeks. This subsidence of the s3-mp- toms often takes place quite independently of the employment of any medical treatment; but the apparent convalescence tlms established is not only imperfect from the first, but becomes every day more and more interrupted, as the local ailment advances, and now, if not earlier, distinctly manifests itself by abdominal pain, by painful micturition or defecation, or by some other symp- tom which clearly points to its situation. It depends upon the situation of the affected parts, whether or no any tumor is perceptible externally; for while always more or less manifest in cases where the parts contained within the broad ligament are the seat of inflammation, it is generallj' absent when the mischief is limited to the cellular tissue between the uterus and bladder, and always when it is confined to the parts in or about the recto-vaginal septum. Tlie somewhat vague character of the symptoms in many of these cases, and the too common neglect of vaginal examinations, lead in cases of this description to very frequent mistakes as to the nature of the patient's ailment, and mistakes all the less excusable since there are few ailments whose diagnosis is more simple if the investigation is properly conducted. It is not easy to say at how early a period alter the commencement of the attack a swelling forms, so as to be detect- able on examination ; but my impression is, that tliough often not discovered till after the lapse of many days, it usually occurs very speedily. Careful examination even two or three days after the symptoms began, will generally ascertain the existence of fulness in one or other iliac region, will find that on ];»ressure there the complaint of })ain is greater than elsewhere, and that percussion in that situation yields a dull sound, and conveys a sense of solidity not perceptible on the other side. In such circumstances, local depletion will not only aflord immediate relief to the patient's 346 TENDENCY TO EARLY sensations, but that relief will be accompanied by a disappearance of the swelling so complete and so speedy as to raise a momentary doubt in our minds as to whether the impression of its existence was not a mistake. The doubt, however, would be unfounded : the swelling was very real, due possibly to cedema of the cellular tissue, in which, but for our treatment, suppuration would soon have taken place, as indeed it does in the great majority of cases, and then condemns the patient to a tedious illness, and a tardy convalescence. The same rapid formation, and rapid disappear- ance of the swelling, receive another illustration in cases where a sort of metastasis of the inflammation takes place, or where, to speak more correctly, the mischief, originally situated on one side, attacks without apparent cause the other also ; and the new com- plaints of pain in a ditierent situation are accompanied by tume- faction there, which may be very temporary ; or may, if the in- flammation there advance, become as solid, and prove as perma- nent as that on the other side. It is not possible to fix the precise limits of time within which resolution ot the swellings may take place. My impression, however, is that the period is very short, and that after the lapse of a few days at furthest, the changes are far too considerable for any ra])id cure; and that pus is early formed, though the processes by which it makes its way to the surface are generally very tardy, and those are slower still by which, without any escape of matter externally, its complete ab- sorption is now and then eftected. The formation of matter is by no means invariably followed by any marked increase in the suf- ferings of the patient; and it is surprising how the constitution bears its presence even in considerable quantities, the mechanical inconveniences produced by the pressure of the abscess being not infrequently those from which the patient suflers most, and which drive her at length to seek for medical assistance. Thus, a young woman, aged twentj-five, was admitted in the year 1849 into St. Bartholomew's Hospital, having been ill since her delivery seven months before. On the ninth day after her confinement she was attacked by abdominal inflammation, the more acute symptoms of which subsided under depletion, and she attained a state of imperfect convalescence. She went about some other household duties, though with difficulty, and even cohabited with her husband in spite of the i)ain by which sexual intercourse was attended. When she sought for admission into the hospital it was on ac- count of increased difiiculty in micturition, and frequent desire to pass water. On exiiminatiou of her abdomen an oval tumor was discovered in the mesial line reaching midway between the symphysis pubis and the umbilicus, and produced by a collection of pus in the cellular tissue between the uterus and bladder, ten ounces of which escaped on a puncture being made into it through the vagiinil wall. The patient alleged that the tumor had existed only for three weeks ; a statement which can scarcely be received as correct, since she had never thoroughly recovered from the illness which followed her delivery ; but which may be accepted as evi- OCCURRENCE OF SUPPURATION. 347 dence that the abscess had produced no special effects, till by its increased size it began mechanically to occasion discomfort, and to interfere painfully with the functions of her bladder. Another illustration of the same fact may be adduced in the person of a young woman in whom constipation from the fourth to the eighteenth day after her first confinement was followed by inflammation of the cellular tissue behind the rectum. The action other bowels was from this time attended by great pain, and cos- tiveness alternated with diarrhtca, the evacuations being not infre- quently intermixed with pus. In spite of these symptoms, how- ever, she gradually regained her general health, and menstruation returned, though not regularly. Seventeen months after her con- finement she had been visiting the Crystal Palace, in Hyde Park, and while returning home in an omnibus, the jolting of the vehicle occasioned the sudden bursting of an abscess, and the discharge of about three pints of matter streaked with blood per anura. For the next three months from that time, more or less copious puru- lent discharges took place from the bowel, behind which the ab- scess whence it proceeded was situated, forming there a tumor of about the size of a small apple. Occasional local leeching and the most sedulous attention to the state of the bowels were suc- ceeded by the cessation of the discharge, and the ultimate com- plete disappearance of the tumor, of which six years afterwards no trace existed. The presence of any collection of pus so considerable as that which existed in these two cases is decidedly unusual ; but though the size of the abscess is not in general very great, it not infre- quently passes into a chronic state, and emptying itself, for the most part, through some narrow passage of communication, into the bowel, the patient continues for months or years liable to occa- sional discharges of pus per anum, the commencement of which dates back to some attack of inflammation of the cellular tissue years before. In the case of a poor woman who died after long suflTering from ulceration of a quasi-malignant character about her urethra and rectum, a collection of matter was found in the midst of the thickened and condensed cellular tissue by the side of the rectum, and between it and the uterus. This abscess, too, was lined b}' a membrane so distinct, so smooth and polished, as for a moment to raise the question whether it was not a distinct cyst in which suppuration had been accidentally excited. A patient was some years ago under my care in whom inflammation of the cellu- lar tissue between the uterus and rectum having gone on to suppu- ration, it was considered expedient to puncture the tumor which was found in the vagina Not more than two ounces of soro-puru- lent fluid were evacuated b}' this proceeding, but from the punc- ture flowed for the ensuing seven weeks many ounces of pus ilaily, its quantity, however, diminishing, and the discharge at length completely ceasing as the patient advanced towards recovery, and as the swelling behind her womb diminished. In another instance, occasional discharges of matter took place from the bowel, and 348 DIAGNOSIS OF DIFFERENT pus was often intermixed with the faeces, five years after the first symptoms of inflammation of tlie cellular tissue about the uterus, the chronic results of which were still evident in a tumor which was closely connected lioth with the rectum and the womb. Tliese chronic abscesses generally contract, and the fistulous passages which lead to them become by degrees obliterated, but exceptions to this now and then occur, two of which have come under my own notice, and Dr. Simpson^ has reported some very interesting cases where permanent fistulous communications have formed between the abscess succeeding to inflammation of the pelvic cel- lular tissue, and the bladder, uterus, or intestinal canal. Often, though perhaps not always, the formation of abscesses having so chronic a character as those to which reference has just been made, might be prevented if the nature of the ailment were recognized at the commencement. The ch'ngnosis, too, is not at- tended by much ditficulty if only it is borne in mind that whenever after delivery or miscarriage ill-defined febrile symptoms occur, accompanied by abdominal pain, inflammation in the vicinity of the uterus is probably present, and this even though the constitu- tional disturbance should not be considerable, nor the pain expe- rienced by any means severe. If now the inflammation is seated in the broad ligament, there will at first be found in one or other iliac region a vague sense of fulness; percussion in that situation yielding a dull sound, and pressure being painful; and afterwards a more definite swelling. At no time, however, is this swelling so circumscribed that its border can be distinctly traced, nor is it movable like a fibrous tumor of the womb, or an enlarged ovary, but it is felt like a hard mass, extending laterally to the inner surface of the pelvic wall, and firmly adherent to it, reaching down into the pelvic cavity so that its lower border cannot be felt, while its upper and inner margin are both but vaguely marked; the thickening in those situations seeming rather to pass away by degrees than suddenly to cease. The dimensions of this swelling are always much more considerable from side to side than from below upwards; dittering in this respect from tumors of the uterus or ovaries; its surface is even, but extremely hard; it seems very superficial; the abdominal walls are not readily movable over it, but often seem as though they were adherent to it. This, too, they doubtless are in some cases, but the same sen- sation is very often communicated to the hand in instances where there is no reason whatever for supposing that adhesion has taken place between the opposite surfaces of the peritoneum, while fur- tlier, the rapidit^^ with which in some cases the apparent union is dissolved, shows that it must have depended on some cause of a much more temporary nature. My impression is, that it is in a measure due to oedema of the cellular tissue between the abdom- inal muscles and the peritoneum; a condition which not infre- quently terminates in suppuration, and thus constitutes what has 1 Obstetric Memoirs, vol. i, p. 232. FORMS OF THE AFFECTION, 349 been termed external 'peritonitis, but which hi many cases is but an attendant on inflammation of the more deeply-seated tissues, increasing as that advances, remaining stationary wlien that ccmies to a standstill, and rapidly disa])pearing as that begins to subside. An obvious lessening of the general fulness of the abdomen, and a sense of mobility of the abdominal walls over the tumor, is one of the first signs of the patient's amendment, and one which often long precedes any alteration in .the size or contour of the swelling ; while next, as its size lessens, the previous adhesions between it and the pelvic wall become less firm, and its chief connection is felt to be not with tlie side of the pelvis, but with some body at its centre ; in other words, with the uterus itself. Up to the last, the indistinctness of outline which has been already noticed as characteristic of these swellings continues to distinguish them, and a vao-ue sense of fulness in the iliac region remains long after all other evidence of their presence has ceased. When suppuration takes place, the matter makes its way out- Avardly through the vagina, or through the intestinal canal, in almost all cases in which the inflammation is limited to the parts contained within the broad ligaments. In those cases, however, in which the pelvic cellular tissue is implicated, the matter not infrequently makes its way round between the muscles and the external surface of the peritoneum, and the abscess points and discharges itself through the abdominal walls somewhere in the course of Poupart's ligament, or a little below that situation. It sometimes happens, however, that even after fluctuation has be- come distinctly perceptible through the abdominal walls, the abscess eventually bursts either through the vagina or the rectum, and in one instance a communication formed apparently al)out the situation of the sigmoid flexure of the colon ; and after the escape of matter by the bowel, air was for many days distinctly perceptible in the sac of the abscess. In cases of uncomplicated external peritonitis, and also in those where inflammation in this situation occurs simultaneously with that of more deep-seated parts, the tendency naturally is to the escape of matter externally. The swelling in cases of external peritonitis is harder and tenser than when the mischief is more deeply seated, the integuments become red, shining, and brawny, and this condition extends lower down than when the inflamma- tion is seated in the parts within the folds of the broad ligament, and reaches quite into the inguinal region. The quantity of matter formed in these cases usually amounts to several ounces ; the abscess pointing at one spot, and the whole of its contents escaping at a single aperture. Sometimes, however, in cases where inflammation of the uterine or pelvic cellular tissue is present, the tissue external to the pcritcmeum becomes aftected secondarily ; not by direct extension of the mischief to it, but rather l)y a s^rt of sympathy, and in this case two or three small circumscrihed collections of matter are not infrequently formed, each of which may require to be separately evacuated. 350 DIAGNOSIS OF THE AFFECTION. An examination per vaginam throws additional liglit upon the case, except of course in those instances in which the external sur- face of the peritoneum is alone affected. The vagina is hot, and puffy, and tender ; and, according to the seat of the inflammation, either its anterior or its posterior wall is felt to he thickened, and hard like brawn ; and the uterus itself is fixed hy this thickening of the vagina more or less completely in the pelvis, and at the same time is carried hy means of it higher up than natural, so as not to come as readily as usual within reach of the exploring finger. As the cellular tissue within the folds of the broad ligament is oftener affected than that in any other situation, so it is at the roof of the vagina, towards one or other side, and commonly extending some- what round behind the uterus, that these characters are most marked. Soon, too, a distinct tumor is perceptible in addition to the general thickening, swelling, and hardness of the vaginal wall, and the swelling, if considerable, pushes over the uterus towards the opposite part of the pelvis. If seated at the side it does not in general dip down dee])ly into the pelvic cavity, and though it ma}' he seized between the hand externally, and the fingers in the vagina, the state of the abdominal integuments, and the thickening of the roof of the vagina interfere with the accurate determination of its size and contour. If the mischief extends, as often happens, either in front or behind, a definite swelling is very likely to be formed, and this swelling is usually larger and more distinctly circumscribed when situated behind the uterus than when occupy- ing the cellular tissue in front of the organ. If the cellular tissue between the uterus and bladder, and along the anterior vaginal w^all, is the seat of the inflammation, we may then find the hardened, thickened, tumefied state of the vagina reaching down to its very outlet, and the os uteri pushed quite out of reach by a swelling in front of it, not distinctly circumscribed, but passing over into the substance of the thickened anterior vaginal wall. If au}^ laige quantity of pus is formed in this situation, it does not commonly seem to increase very much the size of the pelvic tumor, but forms a distinct, well-defined swelling between the uterus and bladder, which rises up out of the ])elvic cavity, and may be felt through the abdominal walls, occupying the situation, aiul having much the contour of the half-distended bladder. It is when seated behind the uterus, on the other hand, that tlie occurrence of suppuration is apt to give rise to the most definite pelvic tumor ; for there is in this situation a greater obstacle than elsewhere to the extension of the swelling upwards out of the pelvis, while the cellular tissue in the recto-vaginal septum is looser and more abundant than anywhere else in the immediate vicinity of the uterus. Here then matter very speedily forms, and gives rise to a swelling which oc- cupies the whole posterior part of the pelvis, bulging out into it, just as an ovarian tumor is apt to do when seated in the recto- vaginal pouch, but more elongated in form, less globular, and while generally tense, yielding usually at one spot, perceptible through the vagina or through the rectum, a peculiar boggy sen- ITS ORDINARY COURSE. 351 sation, suggestive of a thinning of its covering having taken place there, and of matter being likely to escape in that situation. The OS uteri, too, will be found to be carried out of reach more com- pletely than it would be by an ordinary ovarian cyst of equal di- mensions, and the tumor itself to reach lower down, nearer to the orifice of the vulva, since, it is not a mere swelling seated in the recto-vaginal pouch, but is ibrmed in the substance of the septum itself, where the matter naturally gravitates lower and lower. I do not know of any error which with moderate care can be committed as to the nature of these swellings, except in the rare cases of extravasation of blood into the cellular tissue behind the uterus, uterine hcemafocele, as it has been called; and in them the tumor very closely resembles that produced by suppuration in the same situation. The suddenness of the attack of uterine ha^ma- tocele, its independence of delivery or abortion, and the general absence of thickening and hardening of the vaginal wall around the swelling, will, I should imagine, usually enable us to discrimi- nate between them; while happily there is no serious practical error to which a mistaken diagnosis would give occasion. It is scarcel}' necessary to trace the further prof/rens of these sioellivgs, except perhaps, to add two cautions: first, that the sense of fluid being contained within them is not infrequently deceptive, so far at least that it would seem to imply in many instances the existence of a state of general oedema of the cellular tissue, and not such a definite collection of matter as could be evacuated by the trocar; and, second, that even after the actual evacuation of pus, tliere is seldom that immediate and great diminution of the swelling which we might beforehand anticipate; but the thickening of the cellular tissue which remains behind is not only considerable, but is many months before it is entirely removed. The sym[)toms of the disease, even after it is fully established, and after the formation of a distinct tumor has taken place, are not in general of a very definite character. The patient's condition is one of weakness, illness, feverishness, with evening exacerba- tions, restless nights, and morning remissions, rather than one either of very great local suft'ering or very urgent constitutional disturbance, though when the atfection has lasted very long, and is telling severely on the patient's powers, diarrhoea not infrequently comes on, and tlie fever assumes a marked hectic character. The local suffering varies much, according to the part which is chiefly aftected; the sense of bearing down being most distressing when the recto-vaginal tissue is involved, and the frequent uccmI of micturition most troublesome when the tissue between the uterus and bladder is the seat of inflammation. In all instances, how- ever, the bladder sympathizes more or less with the inflammation in its vicinity, and some degree of dysuria and over-frequent micturition are symptoms scarcely ever absent. While in all cases, be the exact seat of the mischief what it may, there is more or less pain referred to the pelvis, more or less tenderness on pressure upon the abdomen, the amount of severe suft'ering varies 352 ORDINARY COURSE OF THE AFFECTION. very considerably, and varies, too, without any very obvious cause. A dull pain, a sense of weiglit, and a burning sensation seem to be constant, while very severe snliering is often produced by the attempt to stand, or even to sit up. Sometimes, too, independent of any exciting cause, paroxysms of pain occur, of extreme vio- lence, which last for an hour or two, and then subside, returning the next day, or sooner, being equally violent, and passing off again of their own accord. The severest suftering generally takes place before the presence of matter in the swelling has become distinct, while afterwards, during the long period which oiten elapses previous to the contents of the abscess finding an outlet, though the constitutional disorder may become more serious, the local" pain generally abates. With the escape of the matter the relief obtained is usually far more decided, though this seldom occurs in a sudden gush, so as to give instant ease, but the aperture of communication with the abscess being very small, the matter for the most part escapes only in small quantities; or being poured out into the rectum, collects there till a few ounces have accumulated, and are expelled during some etfort at defecation; while for days or weeks afterwards pus is intermingled with the faeces, or a small discharge of it precedes their passage. In cases where the cellular tissue between the folds of the broad ligament is the seat of the inflammation, as well as in those where the tissue behind the uterus is affected, the escape of the matter generally takes place through the rectum ; very rarely indeed through the vagina. The aperture of communication with the bowels is usually low doAvn, though above the internal sphinctei', and though conmionly too minute to be detected, its situation may be guessed with tolerable accuracy, as the finger discovers some spot in the swelling where its parietes are soft and jnelding. Once an iliac abscess on the left side, in which fiuctuution was distinctly perceptible, while the redness of the abdominal integuments, and their firm connection with the swelling, led one to expect that it would discharge itself externally, burst into the intestine, and the communication was free enough to allow of the entrance of air into the sac of the abscess, in which situation crepitation continued for days to be distinctly felt. In the meantime suppuration went on in the tissue beneath the ab- dominal muscles, and a distinct abscess formed there, which was afterwards evacuated by the knife. Twice also I saw an abscess' discharo-e itself throuo-h the bladder, though this occurrence was not final in either case; for in the one an abscess formed exter- nally, and in the other it burst likewise into the intestinal canal, and the patient sutfered for several weeks irom diarrhoea, with discharge of pus per anum. In these cases, however, and also in others in which after an abscess has pointed or has actually burst in one situation, matter afterwards makes its escape in another, it is, I think, very doubtful whether both discharges took place from the same source, or whether there have not been two distinct ab- scesses perfectly independent of each other, and one anterior to the other in the date of its formation. The disposition of this EXCEPTIONAL CASES. 353 affection not simply to extend by direct continuity of tissue, but also to attack similar structures even when not immediately con- nected, is a feature of the complaint to whicli reference has already been made, and one which adds much to its gravity, and imposes on us the necessity of watching our patients most sedulously for a long time after they have seemed to be fairly in the way to con- valescence. The gradual progress of the patient towards recovery during the continuance of discharge from the abscess, and the slow processes by which the thickening and induration of the affected parts are by degrees removed, are unattended by symptoms calling for special description. Their history is one of a convalescence as irksomely slow in some instances, as in other cases where the mischief having been seen and understood, and appropriate treatment having been early adopted, it is surprisingly rapid. The disposition to relapse, too, to the reproduction of fresh mischief in its old seat, or to the kindling of inflammation in some part previously unaffected, is never to be lost sight of, both as governing our prognosis and as regulating our treatment. LECTURE XXIII. DISEASES OF PAKTS CONNECTED WITH THE IJTERUS— INFLAM- MATION AND ITS RESULTS, AND KINDEED TEOCESSES. Inflammation of Utekine Appendages : of the Cellular Tissue. Exceptional cases, consequent on ])ei-itouitis without special uterine disorder ; im- ))ortant, but apt to be overlooked. Treatment in recent stage, care during convalescence. ^ In chronic stage; question of puncture, delay generally advisable ; treatment of sequelaj. Hf-morrhage about Uterus, or Uterine Hematocele. Seat and causes of extravasation of blood. Sjnnptoms and course, changes in the eft'used blood ; cases in illustration. Diagnosis; from extra-uterine pregnancy, from retrover- sion of the uterus, from pelvic abscess, from ovarian tumor, and from fibrous tumor of the uterus. Prognosis and causes of death. Treatment ; comparative merits of interference and exi:)ectancy. In all the cases of inflammation of the cellular tissue in the vicinity of the uterus which engaged our attention in the last lecture, the disease was spoken of as succeeding to delivery or miscarriage. In such cases the disorder of the puerperal processes by which it is accompanied usually gives to the attentive observer early notice of its occurrence. The affection may, however, come on quite inilcpendently of puerperal causes, and may sometimes, though I believe rarely, be wholly unconnected with any previous disorder of the uterus, or with any previous disturbance of its function^. In cases of this last description, the local ailment seems usually to develop itself out of the symptoms of a general peritonitis of no very great severity, which, though relieved by treatment, have 23 354 EXCEPTIONAL CASES. not altogether disappeared, but liavc become limited in extent, and have been referred to the uterus and the pelvic region, where a careful examination discovers just the same changes to have taken place as succeed to inflammation in the puerperal state. A woman aged thirtj^-nine, married twenty-one years, thrice pregnant, her youngest child being eleven years old, was attacked, while following her occupation at a mangle, by sickness, retching, and pain in the abdomen, severest at its lowest part. She kept her bed for a week, then attended at the out-patient room of the hospital for ten days, during which time leeches were applied to the abdo- men ; and being afterwards admitted as an inpatient, she was further depleted, and subjected to a mercurial treatment, by which her mouth was made slightly sore. Her severer symptoms were relieved by these means, but as she was not cured she was trans- ferred to my care at the end of ten days more, or just a month from the commencement of her illne^roportion as the symptoms of constitutional disorder abate, the swelling itself in some instances diminishes in size, till at length an indistinct thickening is all that is left behind. But still this is a more lavorable issue than we often meet with, or than we can ever venture to count upon, where a distinct tumor has formed. Olten, though some abatement of 358 QUESTION OF PUNCTURE the general sj^mptoms takes place, tlie tumor enlarges, becomes tenser, and feels more elastic ; a vague sense of deepseated fluc- tuation is communicated to the finger, and may continue for weeks without growing more perceptible, till at length the abscess begins to discharge itself through one or other of the channels which were described in the last Lecture. The question now naturally sug- gests itself, whether, when sup[»uration has once occurred, we cannot expedite the escape of the matter, and thereby hasten the recovery of the patient ? I believe that as a general rule it is safer to leave the emptying of the abscess entirely to nature, rather than to attempt the evacuation of its contents by puncture; those cases alwaj's excepted in which the inflammation has attacked the cellu- lar tissue external to the peritoneum, where the abscess conse- quentl}' points in the abdominal wall.^ In those cases the very tardy advaiTce of the matter towards the surface may sometimes be accelerated by the application of a blister; for even here it is not expedient to make an incision so long as any considerable thick- ness of parts intervenes. In the far more frequent instances in which the seat of the mischief is within the pelvic cavity, the pus tends to escape either per vaginam or per rectum, and the attempt to anticipate by puncture the exact course which it may take is very frequently unsuccessful, and not always safe ; while the danger of the rupture of the purulent collection into the peritoneal cavity is by no means so done away with by the existence of a counter-opening as might be supposed ; and my own observation of the occurrence of this accident, where a free communication existed with the vagina, is far from being a solitary case. The natural relation of parts is much changed by the eflfects of the in- flammation ; the swellins: and tension of the vaciinal walls extend far beyond the limits which circumscribe any actual collection of matter, and it is very likely that the trocar may be merely thrust through hardened textures, and though [)assing very near to the collection of matter, may entirely fail to enter it. The extent and relations of the tumor can be most accurately determined, and puncture can consequently be most safely performed, when the cellular tissue between the vagina and rectum has been tliC seat of the inflammation ; and a Pouteau's trocar introduced by the vagina will generally reach the matter, if the indications of its presence have been distinct. In one case, where inflammation of the cellu- 1 There are few points of practice concerning which there is so general an agreement as this of the inexpediency of earlj^ puncture of these collections of matter. Bernutz, op. cit., p. 434-6, accepts the jirinciple ; Aran, op. cii., p. 740, insists on it more strongly, and observes, " There is no evidence of the possihility of preventing, bj- the artificial opening of these purulent collections, the formation of spontaneous openings in other situations, and especially into the peritoneal cavity. There are, on the contrary, many observations on record of the occurrence of these perforations, sometimes on the very day, sometimes several days after the puncture of the abscess." Becquerel, Traiie des Maladies de V Vterua, 8vo., Paris, 1859, vol i, p. 464, expresses the same opinion still more decidedly, and lays down the rule that " the abscess is never to be opened, even though its apparent pointing in one situation should seem to invite interference." OF ABSCESS CONSIDERED. 359 lar tissue between the uterus and bladder had issued in suppura- tion, the escape of ten ounces of pus on puncture being made proved the expediency of the interference. In a few days, how- ever, the vaginal tumor had reacquired almost its former size ; the puncture was repeated, but no pus followed, for tlie trocar had at once entered the bladder through the firm and oedematous vaginal wall ; an accident which fortunately was not followed by any bad consequences. The previous introduction of a silver catheter into the bladder in the one case, and examination made simultaneously with one finger in the rectum and the other in the vagina in the other case, will suflUce to prevent a mistake which otherwise is more easily committed than might be supposed possible. The management of the patient after the discharge of the con- tents of the abscess calls for no special rules. The chief difi'ercnce indeed between those cases in which the discharge of pus takes place, and those in which it is either not secreted or is absorbed, consists in the greater degree of debility to which in the former circumstances the patient is reduced; a debility which is often extreme if the suppuration has been extensive, or if the discharge of pus is of long continuance. Even then, how^ever, and in spite of well-marked hectic fever, and of sweats alternating with colli- quative diarrhoea, by which, and by the exhaustion produced by continued suffering, life seems sometimes to be seriously threat- ened, the disease terminated fatally only in three out of the fifty- nine patients on whom these remarks are founded. With reference to the thickening left behind after the cessation of all active inflammation, I do not think that we can do much more than trust to time for its gradual, often indeed for its partial removal. Blisters, indeed, occasionally applied in the iliac region do something to relieve the pain and uncomfortable sensations which may long outlast the other symptoms ; and they may, per- haps, somewhat accelerate the removal of thickening in the sub- stance of the broad ligament. I have little faith, however, in the external application of iodine, or in its introduction as an ointment into the vagina; nor do I think that the subjecting a patient to a course of mercurial remedies, or of preparations of iodine, is likely to effect any local good at all equivalent to the impairment of the constitutional powers which such remedies can scarcely fail to produce. Within the past fifteen years attention has been called, chiefly by French writers,' to cases in which tumors have been formed by ' Cases of pelvic tumor, giving issue not to matter but to more or loss altered blood, are scattered here and there through our medical records, and some of them may be found referred toby M, Huguier, in a lecture on uterine hiematocele, which he gave before the Surgical Society of Paris, on May 28, I80I. As early as 1843, M. Velpeau, at p. 125 of his Rpclic.rdies siir les CavUes Ctosrs, gave an account of an instance in wliich he evacuated the sanguineous contents of one of these swell- ings, and afterwards injected a solution of iodine into its cavity. He seems, too, to have entertained a correct idea as to the nature of the affection ; but the mistake into which ]\[. Malgaigne fell in the year 18-")0, wlio, thinking to enucleate a iii)rous tumor of the posterior uterine wall, opened one of these collections of blood behind 360 SOURCE AND SEAT OF BLEEDING the effusion of blood in the immediate vicinity of the uterus. The name of uterine, retro-uterine, or peri-uterine hoematocele has been employed to designate these effusions which take place usually into the cul-de-sac between the uterus and rectum, and are gener- ally consequent on some disorder of the menstrual function, often on its temporary suppression. The source and seat of the hemorrhage in these cases have been a subject of much difference of opinion, and while some writers the womb (an operation which was followed bj' fatal hemorrhage), shows that the subject, even down to this time, had attracted very little attention. In the year 1851 M. Kelaton gave some lectures on the subject of uterine, or, as he termed it from its usual situation, retro-tiierine hematocele, which were published in the Gazette des JHopitaux, Dec. 11 and 13, 1851. In them he refers to 15 cases, — ^namely, 6 of his own, 2 reported by Bourdon as occurring in the practice of M. Kecamier, 1 reported by M. Laugier, in vol. v of the Dlctlonnaire en 30 voluynes, 2 cases 'which Nelaton saw in the practice of M. Beau, 1, IJalgaigne's unfortunate case, 1 of M. Dufraigne, 1 of M. Latis, 1 of M. Huguier. He has since recorded another case in the Monifeur des HCjniaux, August 23, 185G, and has made addi- tional remarks on the aflection in the Gazette des Ilopitaux, 1855, No. 23, in which he advocates an expectant mode of treatment. Other cases are recorded by M. Gallard, Union Medicale, 1855, and Gazette Hebdomadaire, Oct. 9, 1857 ; Laborderie, Gazette des HOpitaux, 1854, No. 149 ; Bernutz, Arcldves de Medecine, June, 1848, p. 188 ; Piogey, Bull, de la Societe Anatotnir/iie, 1850, p. 91 ; Kobert, Bull, de la Soc.iete de Cliiruryie, May 22, 1851, p. 136, and Gazette des Nopitaitx, ilay 5, 1855, p. 204; Follin, Gazette des JlCpitaux, 1855, June 5, p. 200; Laborderie, ibid., 1854, No. 149; Monod, Bull, de la Societe de CIm-itrgie, June 4, 1851, p 154; and Marotte, ibid., p. 152 ; and Engelhard, Archives de Medecine, June 1857. There is besides much valuable information to be gathered from the discussion on the subject which took •place in the Societe de Chirvrgie, May 14, 21, and June 4, 1851, and which is re- ported at pp. 132, 154 and 151 of the Bulletin, and in the inaugural thesis of M. Vigufes, Des Tumeurs Sanguines de V Excavation Pelvienne clitz la Feinme, 4to., Paris, 1850, with which, however, I am acquainted only through an abstract in Schmidt's JalkTbiichcr. Besides these communications, all of wliicii are of a directly practical character, one of a theoretical kind was addressed bj' M. Laugier to the Academic des Sciences, and is published at p. 455 of vol. xl of the Coniptes liendus. Its object is to connect the occurrence of these effusions with the escape of the ovule at or about the menstrual period. These historical details are rendered almost super- fluous since'the publication of the works of MM. Becquerel, Aran, and Nonat, in all of which full notice is taken of this ati'ection. M- Voisin, in an expansion of his inaugural thesis, has published, under the title i)e l^HemaiocUe Retro-Uterine, 8vo., Paris, 18G0, an essay which embodies to a great degree the opinions of M. N41aton ; and M. Bernutz, whose claims to priority in recognition of this affection I cannot, however, admit, has treated the subject with his usual elaborate detail in the first volume of his work on Diseases of Women. In Germany these effusions of blood have been less carefully studied than in France. Scanzoni's description is avowedly drawn from Fren'ch sources, and he expresses his opinion that the frequency' of the affection has been much overesti- mated. Some notice of it is taken by (Jr^d6, Mo7iatschriftf. Geburtskunde, vol. ix, p. 1 ; Breslau, ibid., p. 455; Hirtzfelder, ibid., vol. x, p. 812; and Hegar, vol. xvii, p. 418, as well as by Braun of Vienna, whose paper, however, I know only indi- rectly. Virchow,in his new work, Die Krankhaflen GeschwUlsie, 8vo., Berlin, 1863, has also studied its morbid anatomy. Dr. Tilt is the first English writer who noticed the affection, in the second edi- tion of his work on Diseases of Women, p. 261. Since then it has received due attention in this country; the lectures of Dr. Simpson, and the treatises of Dr. McClintock and Dr. Graily Hewitt, containing notices of it; while the interesting case published by Dr. Madge, in vol. iii of the Transactions of the Obstetrical So- ciety, and the very valuable paper of Dr. Matthews Duncan in the Edinburgh Medi- cal Journal, Nov., 1862, must not be passed unnoticed, any more than the able thesis of Dr. Tuckwcll, of Oxford, On Effusion of Blood in the Neighborhood of the Uterus, 8vo., Oxford, 1863. IN UTERINE HiEMATOCELE. 361 have believed that the bleeding may take place alike into the peri- toneal cavity, or into the cellular tissue around the uterus, or lining the pelvis, others are disposed to believe that the blood invariably occupies the cavity of the peritoneum. The weight of evidence is decidedly in favor of the latter view, which is that taken by Yirchow, as well as by Bernutz and Aran, and I do not know of any post-mortem examination made with due care in which the seat of the efiusion has been clearly proved to be extra-peritoneal. The blood seems to be poured out, in the great majority of in- stances, either from the rupture of the congested ovary itself, or else from the fimbriated extremity of the Fallopian tube of one or other side, whence it gravitates into the retro-uterine pouch, and forms there a distinct tumor, which pushes the uterus forwards and somewhat upwards. A few cases are on record where the blood has been thus poured out in such quantity as to destroy the patient almost at once ; and though some of these have been in- stances of extra-uterine foetation and of the rupture of the Fallo- pian tube, yet this explanation does not hold good of all ; and suddenly fatal bleeding from the uterine appendages into the peri- toneum must be admitted as a possible occurrence in the unim- pregnated condition. Any hemorrhage so profuse as at once to destroy life is indeed quite an exceptional occurrence, and usually the blood poured out speedily coagulates. It then excites inflam- mation around it, and becomes inclosed within a sac formed partly by the adhesion of the coils of intestine to the uterine appendages, and to each other, partly by false membrane. Within the sac thus formed the same changes now take place as occur in blood efiused elsewhere. In the most favorable cases it becomes by degrees absorbed, in others inflammation is set up (usually consequent on some increase of local congestion, and fresh outpouring of blood) in the cyst wall ; pus becomes intermingled with the blood, and instead of absorption of its contents taking place, the suppurating blood-cyst empties itself through the rectum, the vagina, or un- happily sometimes into the peritoneal cavity. The source of the bleeding in the uterine appendages themselves is sometimes verj^ obvious, as in one instance where both Fallo]»ian tubes were found distended with blood, and a partially decolorized clot hanging from the extremity of one of them. In other cases a distinct rupture of the ovary has been observed, and the congested or even apoplectic condition of its tissue has left no doubt as to the origin of the bleeding. In other instances again, where a longer interval had passed since the first occurrence of hemor- rhage, its source was not so clear; but the grave alterations whiidi the uterine appendages presented, or the absolute impossibility of discovering the ovary or Fallopian tube of one side, showed plainly that in them the evil had originated. Thus, in one case where I made the post-mortem examination of a patient in whom for a year symptoms of uterine hematocele had existed, one ovar}' could not be discovered even after the most careful search, while the other, in addition to a serous cyst of the size of a pullet's egg, 362 SYMPTOMS AXD COURSE presented an extravasation of blood into its substance as large as a sugared almond. The bleeding then takes place from the ovary itself or from the tube ; and now and then perhaps in this latter case from the reflux of blood to whose outflow from the uterus some impediment existed, though usually from the congested lining of the tubes themselves. Blood poured out from other sources may indeed collect in the neighborhood of the uterus, in obedience to the mere laws of gravity, but it would, I think, be an error to call such exceptional occurrences cases of uterine liDematocele. One theory of the source of these hemorrhages must, however, be noticed, if for no other reason, at least on account of the reputation of its author. It is that of Yirchow,^ whq says, — "In my opinion the blood in these cases is usually derived almost or altogether from the newly formed vessels of false membranes produced by previous pelvic perito- nitis." Even Virchow's theories ought to have some clear evidence to rest on. I know of none that would prove pelvic peritonitis to be an ordinary precursor of uterine hivjmatocelc. We learn, then, from these observations the existence of a pre- viously unknown hazard attendant on disorders of the sexual sys- tem in women ; that not merely may intense congestion lead to profuse and dangerous floodings, or functional disturbance issue in inflammation of parts in the vicinity of the uterus, but also that vessels may give waj-, and hemorrhage take place inwardly, in situations where it is hard to discover, and still harder to suppress. As might be expected, the accident is one which takes place only during the period of sexual vigor,^ it having occurred in 79 women at the following ages: Under 20 in 4 Between 20 and 30 " 51 " 30 " 35 " 17 " 85 " 40 " 6 At 40 " 1 79 Cases have not at present been recorded in suflicient number to prove the comparative influence of marriage and childbearing on the production of the affection. It seems, liowever, to stand but rarely in any direct relation to pregnancy or miscarriage; while the fact that it has sometimes been induced by sexual excesses is but another illustration of the connection subsisting" between con- gestion of the pelvic organs and the outpouring of blood in the neighborhood of the womb. The time of the occurrence of such special congestion at the return of a menstrual period is allowed by all writers to furnish the most frequent occasion for the effusion of blood; and though there is an absence of unanimity as to whether habitual menorrhagia or habitual dysmenorrhea most 1 Die Krankhaften Geschwiilsie, 8vo., Berlin, 1863, vol. i, p. 152. 2 See the tables ajipended to Dr. Tuckwell's thesis. OF UTERINE H ^> M A T C E L E. 363 frequently precedes it, yet menstrual irregularity of some kind or other will be found to characterize the history of the greater num- ber of patients. The liability to menstrual disturbance in the way either of excess or of defect indicates usually something wrong in tlie state of the general health; and just as occasional attacks of menorrliagia may occur in the chlorotic girl, so may the out- pouring of blood into the peritoneal cavity be in a measure due to constitutional causes. The profuse, and sometimes even latal hemorrhage, from the vulva or into the peritoneum, which has been known to occur in some cases of purpura and of the erup- tive fevers, is but an exaggerated illustration of this fact; and my own experience by no means leads me to the conclusion that the women most liable to these accidents are the health}'' and robust.^ Be the circumstances in which these hemorrhages occur what they may, there is usually a certain family likeness among tlie cases that will enable the attentive observer to recognize their nature, or, at any rate, will excite his suspicions with reference to it. After some disorder of the menstrual function — sometimes after its temporary suppression from cold, fatigue, or moral shock — severe abdominal pain comes on, referred usually to one or other iliac region. It is by no means constant for the menses to remain suppressed after the occurrence of this pain, which no doubt marks the outpouring of blood into the peritoneum; but usually they continue, though probably more scantily than in health; while now and then a profuse loss of blood takes place from the vagina, in spite of the evidence of internal hemorrhage. The pain, though severe, is seldom intense, nor is the shock which accompanies it at all comparable to that extreme depression which indicates the occurrence of intestinal perforation, or the rupture of the sac of an extra-uterine foetation. I cannot say how soon after the shock and pain a swelling is commonly perceptible in the abdomen, nor what proportion is borne to the other cases by those in w^hich the swelling is entirely absent, though without doubt the latter are quite the minority. I have detected the swell- ing within 48 hours after the first symptom, as a vaguely defined hard lump in the iliac region, apparently of the bigness of the fist, not quite even, not movable, tender on pressure, and feeling so similar to the swelling wliich is felt in cases of inflammation of the uterine appendages, that, apart from its history, one would be likely to make a mistake as to its real nature. Pain, exacei'bated at uncertain intervals, as is all pain associated with uterine ailment, tenderness limited to the neighborhood of the ])ainful part, and general febrile disturbance, though usually not very severe, continue to be experienced, accompanied with difficult micturition, with pain and difficulty in defecation, and generally with an increased pain on moving the leg of the affected side, or on attempting to assume the sitting posture. The febrile symptoms usually subside of their own accord, the pain also dimin- 1 See Bernutz, op. cit., vol. i, p. 441-4G0. 864 SYMPTOMS AND COURSE ishes, a sense of weight in the pelvis, bearing down, difEeult mic- turition and defecation remaining behind, with difficulty and dis- comfort in walking, and lead by the discomfort which they occasion to a vaginal examination, and to the discovery of the pelvic tumor. This pelvic tumor difiers much in its size, situation, and char- acter; and in some cases where the symptoms point unequivocally to the existence of hsematocele, no bulging of the vaginal wall has been present.' For this occasional absence of the pelvic tumor I do not know how to account, though I think it is most frequent when the effusion has been extensive. The fact at any rate is of much importance to be borne in mind, in order to avoid the errors in diagnosis which we should fall into if we regarded pelvic tumor as an invariable attendant on these hemorrhages. Usually, indeed, the pelvic tumor is present, and closely resembles that observed in cases of inflammation of the uterine appendages. It is equally firm, seems to be equally intimately connected with the uterus, and has the same globular form, differing perhaps chiefly in this, that it produces a greater degree of displacement of the Avomb than is observed in a tumor of equal size due to inflammation in the vicinity of the organ. This circumstance is, I think, readily explicable by the rapidity with which blood is effused, as com- pared with the greater slowness with which the changes take place that are due to inflammatory action, and by which, more- over, the womb becomes fixed in its position, and therefore less liable to displacement. The changes that take place in the tumor do not seem to be governed by any unvarying law. It often be- comes extremely firm, owing no doubt to the removal of the more fluid part of the blood, and it is in consequence of this change that a blood-swelling has occasionally been mistaken for a fibrous tumor. The supposed solid tumor, however, will be observed, if carefully watched, to diminish by degrees, and at length to dis- appear, leaving behind only a little thickening and resistance at the roof of the vagina ; and if, as is commonly the cnse, a swell- ing also existed in the iliac region, that, too, will diminish at the same rate with the one felt per vaginam, or will even be removed with still greater rapidity. In other instances, the tumor having shrunk from the dimensions which it presented at first, will once more suddenly increase, such increase coinciding with a more or less distinct menstrual efltbrt, often with actual menstruation ; and in a doubtful case there is nothing more characteristic of its true nature than the sudden increase of the swelling coinciding with a menstrual period. The gradual absorption of the blood, and the disappearance of the tumor as the patient becomes convalescent, is yet only one mode, and that by no means the most common, in which this 1 As in case 1, in Dr. Duncan's paper. I recollect two cases which came under my own observation, and which I now believe to have been cases of uterine ha^mato- cele, wliere the absence of any swelling in the vagina confused me, and prevented my forming a satisfactory diagnosis. I think that now, with larger experience, I should read them rightly. OF UTERINE HiEMATOCELE. 365 accident terminates. Of eight cases of which I have preserved a record, there was but one in which the tumor was removed by a process of simple absorption ; and in this instance the swelling was limited to the right iliac region, and produced no bulging of the vaginal wall. In two cases a discharge of blood, partly fluid, partly coagulated, took place from the rectum ; in a fourth, sup- puration preceded its discharge, and blood-stained pus escaped by the rectum ; and in a fifth, the sac burst into the peritoneum, and the patient died. In the three remaining cases the tumor was punctured by the vagina; and in the last of them the ailment was already chronic, and the blood-cyst had become an abscess long before the patient came under my care. It may be worth while to narrate briefly the particulars of these cases, since in the various circumstances in wdiich they supervened, and in the varying courses they ran, they may serve to illustrate more completely the history of this affection. In all the cases but one the patients were married women, of whom three were sterile; four had given birth to children. This exceptional case was that of a young unmarried woman, aged twenty-two, who, having long suflered from attacks of pain of a paroxysmal character in the left iliac region, was surprised at the age of nineteen by a profuse discharge of a dirty reddish-brown color from the vagina, which continued in varying quantity for many weeks, and was then suc- ceeded by a puriform discharge, occurring in gushes, which con- tinued down to the time of her coming under my care. A tumor in the iliac region, and another felt behind the uterus, fixing that organ in its place, were the evidences of some bygone inflamma- tion — of an old pelvic abscess, in short, the origin of wdiich in an effusion of blood was rather inferred from the patient's previous historj' than actuall}- demonstrated. Puncture of the abscess, and the injection of a solution of iodine into its cavity, were followed by its complete cure, and the patient afterwards married, though she never became pregnant. The second case was likewise one in ■svhieh the evil terminated in suppuration; but the symptoms ran a more acute course, and there was no re-collection of the matter after its spontaneous discharge by the bowel. The patient was a woman aged thirty-four, who, though married for fourteeu years, had never become pregnant. For two years she had habit- ually menstruated profusely, and for two months the discharge had been actually menorrhagic. On the return of the third period, however, the loss was extremely scanty; she experienced severe pain in the back and legs, with tenderness and some difficulty in micturition. Scanty menstruation had still been going on for some days when the patient came under my care. There was then a distinct swellina; in the left iliac res-ion, with much thick- ening in the recto-vaginal pouch. In the course of fourteen days this thickening and fulness assumed the characters of a definite tumor, which increased in size, until at the end of six weeks it burst, and discharged per rectum a discolored pus, and a fortnight after the patient left the hospital well. The patient's previous 366 CASES ILLUSTRATIVE OF COURSE history, the character of her symptoms, and the discolored pus which escaped from the howel, suffice, I think, to point to the origin of this pelvic abscess in a previous sanguineous effusion around the uterus. The third patient I saw but once, though I heard of her subsequent history; and I refer to it here because it illustrates the most favorable course which may be taken by these cases in their less severe forms. A lad}^ who was between twenty and thirty years old, and had given birth to several cliildren, caught cold during a menstrual period, and the discharge, though not suppressed, was immediately much lessened in quantity. Simultaneously with this diminution of the menstrual flow, she ex- perienced considerable abdominal pain, aggravated in paroxysms; and at the end of three days a distinct swelling was discovered in her right iliac region. This swelling, when I saw the patient about lour days from the commencement of her illness, was above, but in the direction of Poupart's ligament, of about the size of the fist, but of a more elongated form, not movable, tender, but not intensely so to the touch; and it was unassociated with uterine displacement, or with more than a vague sense of fulness at the roof of the vagina. Absolute rest, and an expectant plan of treat- ment, were followed b}' the complete disappearance of the swelling, and by the patient's restoration to perfect health. The fourth case is of special interest, on account of the development of the symptoms out of the sequelte of an abortion, not out of the dis- turbance of a menstrual period. The patient, aged thirty-three, having miscarried at the sixth week, followed her occupation as a washerwoman without paying any attention to her condition, and this exertion was followed by great increase of the sanguineous discharge, which continued for twelve weeks. At the end of this time a vaginal examination detected a tumor behind the uterus, of the size of an- apple. On being punctured it gave issue to a reddish-brown discharge, the continuance of which for three weeks was followed by the complete disappearance of the swelling. In the fifth patient, aged twenty-four, who for five years had lived in sterile marriage, the symptoms gradually developed themselves during the persistence for two months of a discharge su[)posed to be menstrual. Here, too, a tumor behind the womb gave issue when punctured to a black ofiensive discharge, which evidently consisted of decomposedblood ; and the patient, having surmounted 'an attack of peritonitis, perfectly recovered. The sixth case so well illustrates the symptoms and the dangers of the affection, that it seems to me deserving of relation somewhat in detail. A tall, stout, and tolerably healthy-looking woman, twenty-five years old, who had been married for seven years, had been preg- nant four times, and had given birth to three living children, of whom the youngest was twelve months old, was admitted into St. Bartholomew's Hospital on February 22d, 1851. Her general health had been good, her labors had been natural, and after all of them she had menstruated regularly during the whole period of lactation. After her third labor matters went on as usual until OF UTERINE II HEMATOCELE. 367 Christmas, when she menstruated naturally, but ever since that time a sanguineous discharge, neither verjprofusc nor intermingled with coagula, had been constantly present. For a month she liad pain of a bearing-down character, aggravated by exertion, but not notably relieved by rest, nor by any particular position; and she had also for the same time suiicred from occasional fainting fits. Micturition was frequent and })ainful, and her urine was reported to be both scantj' and high-colored. A medical man whom she had consulted told her that "her womb was down." The abdomen was large and somewhat tense, its enlargement being due to the presence of a tumor, the surface of which was slightly uneven, occupying the whole of the left side, extending three inches above the umbilicus, reaching about two inches across the mesial line, though gradually sloping downwards, so that on the right side its upper margin was an inch and a half below the umbilicus. The tumor was firm, non-fiuctuating, very tender to the touch, especially in the left iliac region. The finger on being introduced into the vagina came almost immediately on a somewhat firm, elastic tumor, of an oval shape, of about the thickness of the wrist, and which had pushed before it the posterior vaginal wall. This tumor seemed to pass over into the substance of the uterus about half an inch behind its orifice, the wdiole organ being so misplaced that the os uteri was felt lying horizontally immediately behind the symphysis pubis. The finger passed up in the front and right side of the pelvis without encountering any resistance ; but at the left side and posterior part of the pelvis a firm tumor was felt apparently con- tinuous with that immediately behind the uterus. The vessels of the tumor pulsated very forcibly. About three ounces of a bloody fluid were drawn off on the tumor being punctured with a grooved needle through tlie vagina. Tiie microscope discovered nothing but blood corpuscles in the fluid, and with the view of emptying the tumor if possible, and of thereby relieving the painful pressure on the rectum, which occasioned much distress, a Pouteau's trocar and canula were in- trodnced, but only about four ounces of fluid of the same character as before were let out. The tumor w^as not thereby much dimin- islied in size, nor was the patient's discomfort much alleviated. On February 27th no fresh interference having been resorted to, she was seized with peritonitis, during the course of which there was manifest increase of the tumor, which extended more towards the right side of her abdomen. By the 3d of ^Nlarch all active symptoms were sul)dued, and on that day the patient passed two copious evacuations, which were perfectly black, and appai-ently consisted entirely of altered blood. The same afternoon, too, she experienced a sensation as of something giving away internally, and this was immediately followed by an abundant gush Ironi the vagina of very fetid fluid, resembling coflee-grounds in appear- ance. This fluid flowed at first very abundantly, afterwards more scantily till morning, when it ceased, though another gush of it 368 CASES ILLUSTRATIVE OF COURSE took place on the following day. and afterwards recurred occasion- ally for several days, acquiring by degrees a lighter color, and be- ing at last a dirty sero-purulent matter. Very slowly the patient's general health improved, while at the same time her abdomen diminished in size, and having measured forty-six inches on her admission, had shrunk to forty inches on March 24th. The tumor in the left hypogastric region at the same time manifestly dimin- ished in size and became more mesial in its position ; and on April 5th the uterus had nearly regained its natural situation ; there was no longer any distinct tumor behind it, but a hard, scmicartilagi- nous thickening, ill-defined as to its extent and relations. On April 17th all discharge from the vagina finally ceased, and on May 5th all trace of abdominal tumor had completely disappeared, the position of the uterus was quite natural, the thickening behind it was much lessened. A year afterwards I again saw the woman ; she was in perfect health, menstruating regularly ; there was no trace of* abdominal tumor, the uterus was perfectly movable, and there was scarcely any thickening to be felt behind it, or to its left side. The seventh case is important, as well on other accounts as because the extreme firmness of the vaginal swelling raised the suspicion, more than once during the patient's illness, that it was due to a fibrous tumor connected with the posterior wall of the uterus. The patient was twenty six years old, and had given birth to three children during seven years of married life. Four months before she came under my notice she was attacked during a menstrual period by pain in the abdomen accompanied by expul- sive eftbrts of such severity that her medical attendant thought her about to miscarry. The pain by degrees subsided, and the menstrual flow was neither increased nor lessened ; and the two succeeding periods were punctual in their return, though accom- panied by an unusual amount of pain. Her third period was post- poned for nearly three weeks, and for tvro days before the dis- charge appeared the patient suftered pain similar to that which she had before experienced, but more severe. The menses were on this occasion unusually scanty. Their flow was accompanied by an increase of pain, by sickness, and by so much difliculty in micturition, that it was necessary on more than one occasion, to have the catheter passed ; and defecation also was attended by an increase of suffering. It was on the sixth day from the com- mencement of these symptoms that the patient came under my notice. The uterus was then carried forwards and to the right side by a swelling which occupied two-thirds of the posterior and left side of the pelvic cavity. The tumor was firm but elastic ; its surface was smooth, its vessels did not pulsate, and there was no increased heat of the vagina. It was not until a week later that an abdominal swelling was detected, though it had been previ- ousl}' sought for ; but possibly the intense abdominal tenderness interfered with that minute examination which was practicable so soon as it had subsided. This swelling was situated in the left OF UTERINE HJEMATOCELE. 369 iliac region ; it reached for about three fingers' breadth above Poupart's ligament, and from the pubis to the iliac spine; but its outline was indistinct. For the next fourteen days this abdomi- nal swelling increased to nearly double its former size, and at the same time its upper border became much more distinct, but no change took place in the pelvic tumor other than that the elas- ticity which at first it had so distinctly presented became much less marked. Without any discharge having taken place, the abdominal tumor now began to lessen ; the uterine lips and cer- vix, which, on the patient's admission into the hospital, were full and pufty, lost these characters completely, while the hardness of the tumor gave it a most deceptive resemblance to a fibrous tumor. A week afterwards, exactly thirty days from the patient's admis- sion into the hospital, and thirty-six from the commencement of the attack, a discharge of blood took place from the rectum, partly fluid, partly in clots ; and this recurred more than once. The ab- dominal tumor was found three days afterwards to have much diminished, and that in the pelvis to have altogether disappeared, the uterus having nearly resumed its natural position. Fourteen days later the patient left the hospital, a vague induration about Poupart's ligament indicating the former seat of the abdominal tumor, and a little thickening about the roof of the vagina and in the course of the broad ligament, interfering somewhat with the free mobility of the uterus. The eighth and last case was one which I saw at intervals only with Dr. Kirby, of Gordon Square, to whom I am indebted for many particulars of her history. The patient was a lady thirty- two years old, who had been married nine years, had given birth to one child between seven and eight years before I saw her, but had never afterwards been pregnant. Her labor was followed for some time by irregular and excessive menstruation, which was at lengtli suddenly checked by treatment. For several years after- wards menstruation became scanty, postponing, often absent alto- gether, and always associated with niucli pain and sickness. Kot infrequently, too, the constitutional disorder continued unaccom- panied by menstruation, and at last relieved by vomiting of blood. Gradually the more urgent symptoms subsided, but lor some two or three years before the commencement of her fatal illness, she had much dysmenorrhooa, ovarian tenderness, and uterine i)ain, though there was no change discoverable on a vagiiud examina-' tion. On October 19, 18t)2, a menstrual period came on which was very abundant and protracted, the discharge being intermin- gled with small coagula and matter like dysmenorrh;h not absolutelv solid, 3'et yielded nowhere any sense of fluctuation. It was at length determined, after the la})se of eight months, that an exploratory puncture should be made with a fine trocar, and that this should be enlarged if, as there seemed no reason for doubting, the collection of blood or matter were reached. This was accordingly done by Mr. Paget; but though to his own sen- sation as well as to the bystanders, the trocar seemed to have entered a cavity, nothing flowed but a drop of blood. A good deal of constitutional disturbance, much sickness, some abdominal tenderness, but no severe pain, succeeded this puncture, which was made on July 11th. The patient's pulse, too, became very frequent, and her condition altogether, though not such as to in- dicate immediate danger, excited much anxiety, as it seemed to point to the existence of cyst inflammation. In the morning of July 20th, the above-named symptoms having lasted without marked aggravation, the patient made an attempt to void urine, but finding herself unable to empty her bladder, sent for Dr. Kirl)y, who found her in a state ot collapse, and she died at four p.M on the same afternoon, haVing manifested all those symptoms which usually follow the perforation of any important viscus. The abdomen was found to contain a turbid, brownish fluid, a mixture of thin pus and blood, which had issued from the pelvic cavit}' and flowed among the intestines. There was a general fulness of vessels of both surfiices of the peritoneum, and of the surface of the intestines, and a little lymph thinly deposited here and there, evidently of comparatively recent formation. Besides this, below the umbilicus, and especially in the left iliac region, there was a good deal of roughening of the peritoneum as if from old peritonitis, and there were many small blackened spots, old ecehymoses, on the roughened surface. The pelvic contents were bounded above by a coil of intestines which was adherent to the upper surface of the pelvic viscera, and thus formed a kind of ej'st or sac, in the left side of which there was a small triangular rent about half an inch in length, through which its contents had escaped into the abdomen. This sac, which was bounded by the DIAGNOSIS OF THE AFFECTIOX. 371 left side of the uterns, still contained about eight ounces of brown pus, such as was found in the abdomen. The reason of its non- escape on the puncture being made ])er vagiuam was discovered in the presence of a layer of extremely firm black clot an eighth of an inch in thickness, wliich lined the lower half of the sac, and was almost as firm as a piece of leather, so that the point of the trocar had failed to penetrate it, but had detached it from the walls of the cavity, and thus failed to evacuate its contents. The right ovary contained a cyst the size of a pullet's egg, and also a large recent clot the size of a sugared almond. No com- munication could be made out between either tube and the sac; but the left ovary, after the most careful search, could not be made out among the folds of the thickened and altered broad ligament. The jielvic tumor had completely disapi)eared after death. This case calls for but little comment, though it illustrates ex- tremely well some of the more characteristic features of uterine luematocele. The disturbed menstruation, the pain in the per- formance of the function, the appearance of the pelvic tumor, the firmness which, but for the knowledge one had of the state of the womb before any such swelling existed, would have raised the question, whether by possibility it could be a fibrous growth, are all phenomena with which our previous study of the subject has made us acquainted. Next come the discovery of the swelling in the iliac region, always tender, often the seat of acute pain, aggravated in paroxysms, and increased specially at the menstrual periods, the cause of which pain is partly explained by the evi- dences of old pelvic peritonitis. Next may l)e added the variations in the size of both the internal and external swelling, coincident, no doubt, with the occurrence of fresh eflusion of blood, or with its partial absorption, and the diiferent sensations of firmness and elasticity wliich the internal swelling communicated at different times to the finger. Lastly, we have the occasional rigors, the ill- nuirked hectic, the fitful advances towards convalescence which seemed as if it were about to be arrived at, but was never actually reached; and then the surgical interference, which sufiiced, though so slight, to call the slumbering mischief into activity, and to dis- pose the frail wall of adventitious membrane to give wa}', which at length it did under the slight efibrt made in the attempt to empty the bladder. There are yevcral conditions with which this uterine ha'inatocele may be confuunchd, viz., extra-uterine pregnancy, retroversion of the [iregmint uterus, inllammation of the cellular tissue between the uterus and rectum, and fibrous or ovarian tumor; and the points of similarity between each of these are quite sufficient to lead very readily into error. The su[ipression of the menses, the abdominal or [telvic discomfort, and the sense of l)earing down backwards, are symptoms common to efiusion of blood behind the uterus, and to an extra-uterine fcetation between the second and fourth months; while the general contour of the tumor is very similar in the two cases, and there is often the same remark- 372 DIAGNOSIS OF able pulsation of the vessels distributed to it in both, though, I believe, this is by no means so constant in the case of uterine haematocele. The attacks of pain in extra-uterine foetation are, however, usually more intense and more paroxysmal, while the discomfort in the intervals is less ; the sanguineous discharge is absent, and the uterus, if examined with the sound, is ascertained to be increased in size ;^ and even without it the condition of the OS uteri and portio vaginalis of the cervix, with the pufty lips, the closed orifice, and the swollen tissue, differs widely from the com- pletely undeveloped state of those parts in cases of hemorrhage about the woml). The efl:usion, when considerable, mn}- cause, as it did in the case which I have related, complete retroversion of the womb, a con- dition which, when associated as it is sometimes with sup{)ression of the menses for two or three months, may raise the suspicion of pregnancy, and lead to the tumor being taken for the fundus of the enlarged and mis})laced uterus. I'rofessor Credd, of Berlin, relates an instance in which these very circumstances led him for a moment into error, and in which he endeavored vainly to re- place what he su[)posed to be the pregnant and retroverted womb. Further observation soon led him right, and the same considera- tions as rectified his diagnosis may keep us from error. The cervix and os uteri i)rosented none of the changes of pregnancy; the bladder was not affected; and the uterine sound, which entered readily in the natural direction, could not be turned round with its concavity backwards, nor be made to enter the tumor, inti- mately though it seemed connected with the womb. The characters of the tumor in cases of inflammation of the uterine cellular tissue very closely resemble those of uterine hfematocele, and the history and symptoms present a very near analogy in the two affections. There are, however, some points of difference between them which are generall}'' sufficiently marked to preserve the attentive observer from error. Pelvic abscess is very generall}' the consequence of delivery or of abor- tion, while it is scarcely ever associated with any other form of menstrual disorder than its sudden suppression ; the inflammatory symptoms developing themselves directly out of that accident. Uterine haematocele, on the contrary, is seldom the immediate con- sequence of a single suppression of menstruation ; it is not infre- quently preceded by nienorrhagia, and is often accompanied, at any rate for a time, by a copious sanguineous discharge, a symp- tom which never attends u^ton inflammation of the cellular tissue in the vicinity of the uterus. 1 am not sure that the consistence of the tumors furnishes any very trustwortliy clue to a correct diagnosis, since the degree of firmness of a uterine hsematocele is 1 With reference to the inference to be drawn from measurement of the uterine^ cavity, Dr. Matthews Duncan gives the important caution that "the uterus was found greatly elongated in every one of the instances he had recorded, when the hematocele was large, and in all it contracted with the contraction of the blood- sac." UTERINE n.^MATOCELE. 373 liable to very wide variations, but considerable value may be at- tached to the circumstance that at no period are there the same thickening and induration about it which are so remarkable in that part of the vaginal wall adjacent to any collection of matter. Ovarian cysts may occupy when small the same situation as uterine hsematocele; the}- are not, however, so sudden in their occurrence, nor so rapid in their increase; while, though their development is often associated with menstrual irregularity, they are not attended ]Dy any constant sanguineous discharge. The ovarian tumors, too, do not descend equally low into the recto- vaginal pouch, and consequently do not produce the same difficulty in "defecation, while, further, they are not so intimately connected with the uterine wall, and the womb can usually by means of the sound be completely isolated from the adjacent swelling. Though this be true, however, it must yet be borne in mind that the existence of an ovarian tumor is sometimes suddenly dis- covered, owing to some special inconvenience, pain, or unusual menstrual disturbance which it may have occasioned ; further, that the two conditions may coexist; and, lastly, that bulging of the recto-vaginal wall in cases of hematocele, although usually very marked, is sometimes altogether absent, and this even though the collection of blood may be very extensive, and the abdominal tumor may have attained a very considerable size. In the tirst case related by Dr. Duncan, though the tumor reached as high as the umbilicus, so that its contents were let out by puncture of the abdominal walls, yet the evidence of the collection of bloody fluid not having been contained within an ovarian cyst appears to me, as it does also to him, decidedly to preponderate. Many in- stances of the same kind, too, are on record, and one came under my own notice (though I have not included it among those on which my observations are founded), in which the very large size attained by the abdominal tumor, coupled with the absence of any bulging of it into the vagina, led me to regard the swelling as ovarian, though I have since entertained grave doubts as to the correctness of this opinion. In the great majority of instances the distinction between a fibrous tumor and an effusion of blood will be attended by little difficulty, though we know that very able men have sometimes mistaken the one for the other. It must not be forgotten that the liistory one receives of a patient's illness is too often imperfect, exaggerated, or even in many respects altogether incorrect. In the next place, the presence of a tumor in the iliac region by no means clears up the difficult/ as to the nature of that felt per vaginam, since both may be fibrous growths, or both may be due t<^ the effusion of l)lood, while pain and menstrual irregularity may attend on either affection, and the degree of firmness of the swelling is a most inadequate ground on which to rest a diagnfisis, and, when a mistake has been committed, has been the chief source of error. I believe that a fibrous tumor so situated as to be mistaken tor a haematocele, will displace the uterus more considerably than an 374 DIAGNOSIS, PROGNOSIS, AND effusion of the same dimensions, and further, that such disphice- ment will rarely be limited to the mere elevation of the womb, and the pushing it to one side, but that the organ will also be retroverted, or its position will be otherwise manifestly .changed. Time, however, will almost certainly remove the doubt, tlie imme- diate solution of which is seldom very urgent; and it must not be forgotten that three-fourths of our diagnostic errors arise from the needless haste of our decisions. Inclusive of my own eight cases, I have collected 103 instances of uterine heematocele, of which 20, or almost one-iifth, proved fatal. There can, I apprehend, be little doubt but that its usual fatality is considerably less than would appear from these imper- fect data; for, on the one hand, some of the cases have been reported as pathological rarities ; and on the other, many which have had a favorable issue have been unrecorded. Many, too, have certainly passed unrecognized, for the disposition to the spontaneous absorption of the efl'used blood, unless the quantity poured out has been enormous, seems to be very great, so that menstrual disorder and abdominal pain have probably often passed away without a suspicion having arisen of their connection with hemorrhage around the uterus, or into the cavity of the peritoneum. The subjoined tables will throw light on many points connected with the pathology as well as with the treatment of the affection. Of 55 cases of uterine hsenuitocele, treated on the expectant plan, 43 recovered, 12 died. Of the former — The blood was absorbed in, 30 " escaped by the rectum in, .... 7 " " " vagina, 4 " " " uterus, 1 " " into cavity of peritoneum, . 1 43 Of the 12 deaths— 1 took place from phthisis. 1 " " phthisis and albuminuria. 1 '< " supervention ot dysentery. 1 " " great debility and extensive ab- scess of the thigh, and are therefore only indirectly due to the sanguineous effusion. Of the remaining 8 — 1 took place from pya?mia after the tumor flad burst per rectum. 1 " " hemorrhage by the bowel. 2 " " hemorrhage into the cyst. 1 << " " " " and per vaginam. 1 " " rupture into al)domfn, and peritonitis. ( peritonitis without cyst rupture, the in- 2 " " "I flanimation being acute in the one case, ( and chronic in the other. 8 TREATMENT OF UTERINE H JE M A T C E L E. 375 Of 48 cases iu which surgical interference was had recourse to, 40 recovered, 8 died. In 38 of the 40 recoveries, the puncture was made h\ tlie vagina. In 2 of the 40 recoveries, the puncture was made in tlie ah(h>- men. Of the 8 deaths— 1 took place from poritonitis after puncture of the abdomon. In the other cases the puncture was made by the vagina. 1 " " cyst rupture after ineffectual puncture. 1 " " py^Miiia. symptoms of which had preceded the ])uncturf'. 1 " " pya'iuia, foUowini; the puncture. 2 " " hemorrhage through the wound. 1 " " " into the sac after closure of the * punctured wound. 1 " " peritonitis. 8 Lastly, we come to the important question of the appropriate treatment of this aflbctioii. It happens rarely, thouo'li uiiqucs- tionahly it does happen sometimes, that the hlood is ])()ured out in such great ahundance as to occasion immediate hazard to the patient's life, and in such circun)stances the local apitlication of cold, the employment of stimulants, and the use of opium, given as in cases of intestinal perforation for its stimulant rather than for its sedative properties, is clearly indicated.' I once saw a case which I imagine to have heen of this kind. It occurred in a woman hetvveen thirty and forty years of age, the mother of one child, who had for some few times menstruated irregularly. On the third day of an extremely abundant menstruation she suddenly sank into a state of great exhaustion, which the external liemor- rhage was quite inadequate to account for. She fainted, and lay long in a condition of syncope, her pulse was almost inn)erc('])til)Ie, her surface was as cold as tliat of a patient in the stage of collapse from cholera, and I thought her dying when I saw her al)out five hours after these symptoms had come on. A v^iginal examination threw no liglit upon the case, as no tumor was detected in the pelvis, hut one feared that the sac of an extra-uterine fcrtation had hurst, and that the shock depended on this cause. Ice was applied to the vulva and over the pubes, opium and stimulants wcvv ad- ministered, and attention was paid to kee[»ing the surface \v;irm. The next morning I saw the patient after an interval of eighteen hours. She had rallied slightly, and I heard, for I never saw her again, that she slowly recovered, without having presented at any time syni[>toms of peritoneal inflammation. Such occurrences as these are rare ; and usually the symptoms ' In a book far less known than it merits, Medicnl Prot>lrn>.i, by Messrs. Griflln, of Limerick, is a most suggestive chapter on the use of ojiiiim as a stimulant, which should be well studied by all especially who are engaged in obstetric practice 376 QUESTION OF PUNCTURE IN TREATMENT which one has to deal with are very similar to those of inflamma- tion of the uterine appendages, and are to be treated in the same way, by absolute rest, by poultices, by sedatives, and by the careful use of mercurial remedies. "With the return of each menstrual period, all precaution must be redoubled, since it is under the conditions of general excitement of the circulation and special congestion of the sexual organs which then exist, that fresh hemorrhages are apt to take place. I have occasionally applied a few leeches in the iliac region, when the tension seemed very considerable and the tenderness extreme, but have never resorted to large local depletion as a means of controlling the hemorrhage and hastening the absorption of the blood already effused. M. Aran,' however, has adopted a much more active plan, and, as he alleges, %vith very remarkable results. In a case where the effusion is recent, and the constitutional condition of the patient does not forbid it, he applies from twenty to thirty leeches over the abdominal swelling ; on the next day from fifteen to twenty in the same situation ; from twelve to fifteen on the third day, if the strength of the patient admits of it; and it is extremely seldom that a fourth application is needed. The patients are supported by nutritious diet while this local depletion is carried out, and this is succeeded as soon as possible by the use of blisters and frictions, or applications of iodine, to the abdomen. " By these means," says M. Aran — and he details cases in support of his assertion — "I have reduced to fifteen days in some cases, to from twenty to thirty in others of a less favorable kind, the course of an affection wliich has been estimated by all previous writers on the subject at a period of many months." The experience of one so cautious and so trustworthy as M. Aran demands consideration, and the practice based on it merits a trial. But wdiether an antiphlogistic plan be employed with more or less activity, the great question which presents itself in a large number of instances concerns the expediency or inexpediency of surgical interference. 0{)inion on this point differed formerly much more widely than it does at the present moment ; and there seems now to be a general approach to unanimity among French writers as to the inexpediency of meddling with these collections of blood. The cases which I have collected from all sources, and in doing which I have been very careful not to reckon the same twice over, are quite inadequate to decide the point. I think, however, they tend to show that the dangers of puncture are less considerable than some of its opponents have supposed them to be; and further, that tliey are of just the same kind as one has to encounter in cases which are left entirely to nature.^ 1 Op. c!t., pp. 817-822. 2 Dr. M. Duncan's cases are equally valuable as illustrative of the successful puncture of these collections of blood, whether one accepts or rejects his opinion as to their ordinary extra-peritoneal site. OF UTERINE HEMATOCELE. 377 The much-dreaded hemorrhage is evidently a very exceptional occurrence, and the supervention of fatal pyemic or peritonitic symptoms is by no means limited to cases where interference has been had recourse to. Still, these symptoms have unquestionably been lighted up by puncture of the cyst, even in numy cases which eventually recovered; while the hazard of rupture into the peritoneum is by no means certainly prevented, even though a free communication has been established with the vagina or rectum. In three out of four of my cases, where the cyst was punctured per vaginam, the operation was followed by peritoneal inflammation, which was once of great severity; and the existence of an o.pening in the vagina did not in that instance prevent the establishment of a communication with the bowel, and the dis- charge of a large quantity of blood per anum. Even an explora- tory puncture is not always free from risk, as my eighth case shows; while the cause of its failure has also been met with in other instances, where the coagulation of the blood has formed a thick layer of fibriiie within the sac, and has thus prevented the escape of its fluid contents. AVeighing the results of my own experience with what I can gather from that of others, I should be disposed Not to puncture the cyst — 1st. So long as the effusion is recent, and there is therefore reasonable prospect of its being absorbed. 2d. So long as the efliision, although of long standing, is in course of gradual, even tliough very slow diminution. 3d. For so long as the periodical increase of the effusion coin- ciding with the return of a menstrual epoch, shows the cause which originally produced it to be still in operation. I should puncture the cyst — 1st. When a long-standing effusion shows little or no disposi- tion to become absorbed. 2d. When the occurrence of rigors and the supervention of hectic symptoms prove suppuration to have taken place ; and in such circumstances I should puncture through the abdominal walls, providing the swelling were not readily accessible by the vasrina. 378 INFLAMMATION OF THE OVARIES. LECTURE XX lY. DISEASES OF PAETS CONNECTED WITH THE UTEEUS— INFLAM- MATION AND ITS RESULTS, AND KINDRED PROCESSES. Inflammation or Uterine Appendages; — of the Ovaries. InflaiDmatioii of the ovaries, iniperf(>ct state of our knovvli-du;*'. Morbid appear- ances, inflammation of their peritoneal surface fi'equent ; inflaniination of their substance rare Clianges produced by inflammation in the Graafian vesicles ; suppuration, and ovarian abscess. Symptoms of ovarian inflammation; of its acute form; of abscess of the ovary; cases in illustration. Chronic inflammatictn of the ovary, its frequency probably overrated; neuralijic character of syini)toms attributed to it. Occasional occurrence of subacute ovaritis; relation to it of the so-called displacement of the ovary. Note on Hernia of the Ovary ; and on Serous Cysts of Uterus. Frequently in the course of these Lectures I liave had occasion to lament the incompleteness of our knowledge, the imjterfection of the evidence on which we are comitelled to act; and have been fain to content myself with hints and suirge.stions ; with commu- nicating mere fragments of information where yet I felt that defi- nite statements and positive rules were most needed. Much of the subject of to-day's lecture can, I foar, be treated by me otily after tliis imperfect fashion, unless I widely overstep the limits of my own knowledge, and assume a positive air where yet my convictions are far from settled. Some facts, indeed, are well known and universally admitted, such as the frequency of acute ovarian injlammation as a complication of puerperal peri- tonitis, its rarity in other circumstances; but the frequency, the symptoms, and the importance of the more chronic forms of in- flammation of the ovaries, arc questions which have received very discordant replies, and for whose iinal decision data appear to me to be still wanting. The difficulties to which I have referred do not, indeed, arise from the rarity with which morbid appearanceH are discovered in the ovaries, but rather from the uncertainty whic^h |)revails as to their nature or as to their importance. In 21 out of G6 instances in which I examined the uterus and its appendages in the adult, the ovaries themselves, or parts immediately connected with them, presented changes more or less obviously due to inflammatory action. In 10 of the 21 cases the main evidence of inflammation consisted in traces of old peritonitis of the uterine appendages, and in 5 of the number there was no evidence of other or of more recent mischief. The amount of this peritonitis varied exceed- ingly. In some instances it was confined to one side, and its results were nothing more considerable than a thin and partial layer of fixlse membrane on the surface of one or other ovary, and long filamentous adhesions between the ovary and Fallopian tube. In other cases a complete web of false membrane enveloped the INFLAMMATION OF THE OVARIES. 379 ovaries, thickened the broad ligaments, and by its contraction shortened tlie ovarian lii^aments, thus drawing the ovaries much nearer than is natural to the sides of the uterus, while at the same time they and the Fallopian tubes were iirmly and inextricably matted together. Now and then, too, the ovaries were not merely drawn nearer to the uterus, but their position was in other respects changed, they being tied down behind it; as in the following notes of the examination of the body of a woman who died at the age of thirty-seven, of chronic bronchitis and emphysema, and all of whose four labors were alleged by her husband to have been perfectly natural. The uterine appendages on either side were doubled back behind the uterus, and matted together in that situation by firm old adhesions, in the cellular tissue of which a good deal of firm granular fat was intermingled. The Fallopian tubes of either side were convoluted, dilated to the size of the little finger, by the presence in them of a thick red secretion, like a mixture of blood and mucus. Each was firmly adherent to its coi-responding ovary, so that it was almost impossible to dissect them apart. Though twisted round as above described, they did not pass the mesial line, but wound al)out on either side of the uterus. On opening them they presented the appearance of a number of freely communicating sacculi, not unlike a section of the Fucus marinus ; and the right, which was the larger of the two, measured at its Avidest part, whi.*h was one inch from the uterus, just an inch and a line when laid open. This eidarge- ment continued, though diminishing, till about a quarter of an inch from the uterus, where it ceased ; the short remainder of the tubes, though pervious, not being wider than natural. The walls of the tubes were very dense, their muscular structure remarkably distinct, and their lining membrane stout, tough, easily detached from the subjacent tissue, and presenting somewhat of a polished surface. The left ovary was much atrophied, and was with difficulty dis- tinguishable in the midst of the thickened cellular tissue and the fat which abounded on either side of the uterus and within the folds of the l)road lii^-ament. The right ovary was much larger than natural, thougii very little of its proper tissue was distm- guishable. Its size, whieh was that of an unshelled walnut, was chiefly due to a cyst, lined by a smooth, polished membrane, and filled with thick, grumous blood, as well as containing some old coagulum, which required a little force for its detachment. In other cases I have met with a less degree of the same condi- tion of the uterine appendages, and have found the ovary wasted, api>arently as the result of its compression by the formation of false membrane around it, an occurrence to which must probably be attributed the sterility that frequently follows an attack of i>eri- tonitis, and the permanent 8upj>ression of the menses that occa- sionally, though less often, succeeds to the same cause. Moi-e important than the changes produced by infiamniatic^n on the exterior of the ovarv are those alterations which it causes in 380 CHANGES OF THE OVARIES their substance, and especially in the Graafian vesicles. The mere substance of the ovaries does not, indeed, except in the puerperal state, often present appearances indicative of inflammation or of its results. The softening of their tissue, the infiltration with pus — which is sometimes poured out so suddenly and in such al)un- dance as to produce rupture of the organs — or that sloughing of their substance occasionally observed in the bodies of w^omen who have died during epidemics of puerperal fever, are conditions which, to the best of my knowledge, are not met with in the un- impregnated state. Afl'ections of the ovarian tissue, apart from the puerperal condition, are, I believe, almost always secondary and subordinate to those of the Graafian vesicles themselves. Thus, when the functions of the ovaries are no longer exercised, and ovules are not in course of ]U'odncti()n and maturation, we find the substance of the organs shrunken, dense, and frorpiently intersected by white lines of firm cellular tissue; and just in a similar way do we find it swollen, congested, and infiltrated, in conjunction wnth a turgid state of the Graafian vesicles, and with the presence of evidences of ijiflamnnition about their coats. In these circumstances, indeed, we find the whole of the ovary con- siderably increased in size ; but m}- own experience corresponds with that of Kiwisch, who says that it is extremely unusual for the organ in the unimpregnated condition to be enlarged by any inflammatory atFection of its stroma to more than double its nat- ural size.' It is in the Graafian vesicles themselves that we find, as indeed might be anticipated, the most important results of inflammation ; and such inflammation is of great moment, from the circumstance that in some instances it is probably the first step in the produc- tion of ovarian dropsy. In the case of women who have died during or soon after menstruation, it is, as you know, very usual to find a state of general turgescence of one or other ovary, with great prominence of some of the Graafian vesicles, and minute injection of their external membrane, while a large clot occupies the cavity of that one of the vesicles from which the ovule has escaped. Such appearances of the ovary are physiological, and pass away with the subsidence of the periodical congestion that produced them, the clot itself being gradually removed, and the contracted vesicle disappearing by degrees. Appearances of a somewhat similar kind are met with, however, independent of menstruation, and in circumstances that point directly to inflam- mation as their cause. Thus, in the case of a prostitute, twenty years of age, who w^as suftering from severe gonorrhoea at the time of her death from pleuro-pneumonia, the whole interior of the cavity of the uterus was covered by a copious puriform secretion, the surface beneath being of a briglit red, just like red velvet. This condition ceased abruptly wdiere the plicated structure of the cervix uteri began, but was continued along the whole tract of the 1 Op. cit., vol. ii, second edition, p. 47. PRODUCED BY INFLAMMATION. 381 Fallopian tubes. They were pervious at their uterine ends, oblit- erated at their fimbriated extremities, filled with thick pus, which had distended the fimbriae into little pouches, while their lining membrane was of a finely flocculent appearance, and of the most vivid red. The ovaries were rather birge; they were somewhat congested, the Graafian vesicles were both numerous and turgid, and their membrane presented a most beautiful appearance, being traversed by very minute vessels, and looking as if the finest ver- milion injection had been thrown into them. I do not knov/ exactly what the subsequent stage of the disease would have been if the patient's life had not been cut short by the pneumonia. Probably, however, the contents of the vesicles would next have been ohyiously changed, and in all likelihood would have eventually become purulent. Such at least were the contents of many of the Graafian vesicles in the right ovary of a girl who died of very acute peritonitis; and in whom there was found a cyst distended with pus, of the size of an orange, connected with that organ, while many of the Graafian vesicles contained little drops of pus, though there was no suppuration of its general tissue, and the other ovary was quite healthy. The large cyst in this case had probably existed for a long time before the commencement of the patient's fatal illness, and the supervention of inflammation in it was very likely the point of departure of all the subsequent mischief As we shall have occa- sion hereafter to observe, the occurrence of inflammation and sup- puration in an ovarian cyst is an accident by no means unusual, and one which sometimes takes place without giving rise to symp- toms so severe as might have been anticipated. Such cases, how- ever, are perfectly distinct from those of primary ovarian abscess, which latter are also, I believe, of much greater rarity. For the most part the increase of such abscesses generally goes on rather slowly, and their development is usually attended with symptoms of for more serious constitutional disturbance than accompanies the growth of an ordinary ovarian cyst; though after a time they not seldom become stationary, and remain so even for years. Thus, in the case of a patient who died twelve years after her first attack of inflammation of the uterine appendages, and four years after her second and last seizure of a similar kind, the right ovary was beset with numerous yellow dots of a matter which looked like softened cheese, probably the result of some change in the contents of the Graafian vesicles, while the left ovary, to which the corresponding tube was firmly adherent, formed an abscess the size of an orange and lull of pus. The cavity of this abscess was sinuous, as if several collections of pus hid eventually been fused by the removal of their septa into one, and at its lower part there was a mass of cretaceous matter of the size ola chestnut. There are, besides, some appearances of no great rarity i»resonted by the Graafian vesicles, whicli have been sujtposed, aiid with con- siderable probability, to be the results of a chronic, or, at any rate, of a bygone inflammation. Such is the loss of transparency of 882 ACUTE OVARITIS. tlie coats of the vesicles, and especially their entire conversion into firm, whitish, or yellowish-white, shot like bodies, of the size of a small pea, and of a homogeneous, somewhat friable, texture. In some instances the stroma of the ovaries has appeared unaltered around tliese bodies, but at other times I have found it also the seat of a yellow matter like fibrine, either infiltrated into the centre of the organ or deposited in stride which intersected its tissue. This condition, too, has always been associated with considerable thickening of the ovarian capsule, and with a dead white color of its surface ; and the ovary generally has been small and shrunken, and contained lew Graafian vesicles, and sometimes none but those which had been the subject of this cliange. It is not, however, as might be supposed, a result of mere wasting from the advance of age and the cessation of the generative function, for I have met wnth this state in the body of a woman who died at the age of twenty-five, and in whose ovaries there were not merely other healthy Graafian vesicles, but also in one a large menstrual clot, and other evidences of i-eeent menstruation. Acute irifiummation of the substance of the unimpregnated ovary is of such rare occurrence that no case lias come under m>' own care, and but one has presented itself to my observation. To that case I have already referred, as afibrding an instance of suppura- tion in the Graafian follicles themselves, but the cause of death was the supervention of general [leritonitis. The patient's history a fiord ed no clue to the cause of her illness, for she was a young unmarried woman, eighteen years old, living in comfort as a domestic servant, and never having had any dis- order of her catamenia, or any uterine ailment. Her illness had come on spontaneously four or five daj's before her admission into the hospital, and not at a menstrual period, with }»ain in the back and abdomen, fever and languor, for which, however, no treatment W'as adopted before she entered the hospital, ller symptoms were just those of general peritonitis; a dry skin, a small pulse of 120, urgent thirst, and constant sickness, great headache, a full, tense, and tender abdomen, and much pain in the abdomen and back. Her condition did not seem to admit of active treatment, and the next day the pulse had risen to 160, the sickness was incessant, the matter vomited being of a dark greenish color; the abdomen was more tense, its tenderness undiminished, but the pain now recurred in paroxysms, between which were intervals of compara- tive ease. In eighteen hours more she died — about forty hours from her admission into the hospital. There was universal peritonitis; two pints of purulent fluid were present in the abdominal cavity ; and inflammation had ex- tended to the diaphragmatic pleura. The uterus and the left ovary were perfectly healthy. Connected with the right ovary was a cyst filled with pus, which reached as high as the brim of the pelvis, and pus coated the outer surface of the ovary as well as occupied the Graafian vesicles. So rapid a course of the disease, and so serious a termination ABSCESS OF THE OVARY. 383 of it, arc of great rarity. Inflammation commencing about tlie . uterine appendages on either side seldom extends beyond the peri- toneum in the immediate vicinity of the uterus; and even when the substance of the ovary is affected, and inflammation ends in sup[)uration, it is for the most part from a slow and wasting illness that the patient sutlers; the abacess attaining a very large size, and possildy even i)ersisting for years. Such at least is the expe- rience of Kiwisch,' and my own more limited observation leads me to the same opinion. lie notices the disposition of the symp- toms to come to a standstill, so that sometimes the patient suffers chiefly from the mechanical inconvenience of the tumor, while in other instances the arrest of the symptoms is of a more im]»erfect kind: the patient continues to lose flesh; occasional febrile at- tacks come on, till at length a condition of hectic manifests itself, indicative in many instances of decomposition of the contents of the abscess, and death takes place either before or soon after it has discharged itself All of these occurrences have come under my observation in cases of ovarian cysts in which inflammation has supervened, converting their contents into purulent matter; but I have only once met with an instance in which there was reason to believe that the tumor had been from the commence- ment an abscess, and had not originated in the inflammation of the cyst-wall of a dro[»sical ovarium. In this instance the patient's illness commenced with suppression of the menses five months after marriage, she being at that time twenty-six years old. The suppression of her menses was followed by pain in the right side of the abdomen, about the situation of the crista ilii, but extend- ing to the opposite side, aggravated by motion or exertion, and confining her by its severity, and by the general constitutional disorder which accom[ianied it, almost constantly to bed during the six months which preceded her admission into the hospital. Very soon after the commencement of her illness a tumor ap- peared in the right iliac region, which was said by her medical attendant to be an abscess. A month after the swelling was first perceived a discharge of pus took place from the urethra, which continued at intervals for some weeks, though without any marked change in the swelling. The discharge then ceased for a time, but at the end of three months it again recurred, and continued to take place occasionally until the patient came under my care, though in spite of this, the tumor had gone on slowly increasing in size. On her admission the patient looked very ill, her countenance Avas anxious, her i»ulse fre(pient, her tongue red at the tip and edges, and thiekly covered with ajihtha?. Her abdomen measured twenty-eight inches in circumferL'iice at the umbilicus, its cnlarge- ment being due to a pyriform tumor in the mesial line, which ' Kiwisch, op. cit , vol. ii, p. 07, mentions having seen nn abscess of the ovary wliicl) contained sixteen pints of pus. I have seen tiiirty-five |)ints of pure pus f'vacujiiesy, in which in- flammation of the cyst-wall had supervened, an accident to which further reference will lie made in another lecture. 384 ABSCESS OF THE OVARY. occupied the hypogastric, umbihcal, and lower part of the epigas- tric regions, and extended laterally to the lumbar and lower part of the hypochondriac regions. The tumor yielded a distinct sense of fluctuation, and was very tender on pressure, especially in the hypogastric region. The uterus was low down, and carried for- wards nearer than natural to the anterior pelvic walls. It did not seem to be altered or enlarged, neither was it fixed in the pelvis, nor was there any thickening of the vaginal walls. The move- ments of the organ were, however, im[)eded by some tumor, which, though not dipping down into the pelvic cavity, nor pre- senting any distinct outline, was yet to be felt as ottering a gen- eral resistance on pressure being made in any direction against the roof of the vagina. Three weeks after the patient's admission pus began to be dis- charged from the bowel, and in the course of a little more than a fortnight, under the continuance of these discharges the tumor almost entirely disappeared, though much pain continued to be felt in the right iliac region, and a little i)us occasionally re- collected in the sac of the abscess, and was from time to time discharged per rectum. The progress of her recovery was re- tarded by an attack of phlegmasia dolens of the left leg ; but about two months after her reception into the hospital she was discharged perfectly well, and no trace of the tumor was to be detected anywhere. In this case the suddenness of the attack, tlie acute character of the symptoms which attended its onset, and the rajiid formation of the tumor, are alike incompatible with the sujiposition that the case was one of dropsy of the ovary. On the other hand, the situa- tion of the swelling in the abdomen, the mobility of the uterus and the absence of thickening by the side of the womb, or at the roof of the vagina, clearly show that the case was not one of pelvic abscess, or of inflammation of the celiular tissue within the folds of the broad ligament. We thus arrive at the conclusion that the matter was secreted irom an abscess in tlie ovary due to inflam- mation excited in all probability by the sudden suppression of the menses which marked the commencement of the patient's illness. I do not know that practically there is very much to gather from the details of a case such as the j)receding beyond the knowl- edge of the fact that acute ovaritis, ending in sujjpuration, may come on without apparent cause, and that the tumor thus formed may acquire a great size, and may present all the characters of a dropsical ovary. As far as treatment is concerned, it would, I think, in the case last related, have been the wiser course to liave punctured the tumor and have evacuated its contents soon after the patient's admission. It is not from the observation of cases such as have hitherto been related, and which are confessedly as rare in their occurrence as they are formidable in their character, that has arisen the general impression of the importance and the frequency of ovarian inflam- mation. The ovaritis which is chiefly dwelt on by medical writers CHRONIC OVARITIS. 385 is paid, for the most part, to be eitlier subacute or chronic in its character. It is an affection supposed to be capable of lasting for many years without leading to any grave alteration of structure, though occasioning mucli functional disorder, and producing much local suffering. Disturbance of menstruation of various kinds, sterility, and pain in the abdomen, more especially pain referred to one or other iliac region, are the symptoms commonly assigned to this chronic ovaritis; and, indeed, a very large proportion of the ailments that have been referred by some observers to inflammation of the cervix uteri, and ulceration of its orifice, have been attrilmted by others equally confidently to chronic inflammation of the ovary. My own impression is, that a larger share has been assigned to chronic inflammation in the production of these symptoms than can be proved to be really due to it. In no class of ailments is pain so incorrect an index to the nature and importance of the morbific process which gives rise to it as in the disorders of the sexual system of women. On the one hand, diseases of the most formidable character sometimes run their course without the pro- duction of any suffering till they reach a stage utterly beyond remedy, while, on the other hand, pains of the severest kind recur in some instances for weeks or months, or even for years, and yet neither during life nor after death can any adequate explanation be discovered of their occurrence or their persistence. It seems, indeed, as if the sorrow which women are peculiarly heirs to were not confined to the time of parturition, but as if the sentence ex- tended in a measure to the performance of all the sexual functions. Pregnancy and menstruation, as well as childbearing, are very generally times of suti'ering, and sexual intercourse itself is not infrequently attended or followed by the same kind of pain as has been referred to ovarian inflammation. Pain in the ovarian region is a very general attendant on prolapse of the womb, and it suflices but to introduce the sound into the cavity of the uterus in order to produce, and often with great intensity, pain referred to the situation of the ovaries. But while such symptoms are of frequent occurrence, are some- times as causelessly persistent as in others they are causelessly evanescent, the researches of morbid anatomists do not make us acquainted with such changes in the ovaries as can be sup[)08ed to occasion them. We often, indeed, find the evidences of circum- scribed peritonitis about the ovaries, but we find them in cases where there have been no symptoms of an urgent character during life, often indeed where no symptom of any kind has existed. But with the exception of those evidences of inflammatory action on the serous surface of the ovaries, the signs of a morljid process, too, which must soon have run its course, there are but few changes in those organs which an examination after death re- veals, and those limited, or nearly so, to the Graafian vesicles, and usually to a few only of their number. In many of the in- stances, too, where such appearances are discovered, it has been matter of absolute certainty that during life all the sexual func- 25 386 OVARIAN PAIN OFTEN tions were performed with complete regularity, and without any suttcring. I could not acquiesce in the opinion that almost all the numerous ills of womanhood are due to inflammation of the neck of the womb. I can as little see in them the evidence of ovarian inflammation, and I believe that in "nineteen cases out of twenty in which the ovarian regions are the seat of deep, dull, aching pain, and appear tender and rather swollen, there is no actual ovarian disease whatever."* I cannot finish the sentence by saying with the author whose words I have quoted, that the symptoms are almost invariably the result of some uterine lesion, for 1 believe that in many cases the symptoms are purely neuralgic in their character, independent of any local lesion, and curable less by local treatment than by remedies addressed to the general state of the constitution. My opinions on this subject, indeed, correspond very closely with those expressed by Dr. Churchill,^ of Dublin, who has de- scribed this class of affections as the result of ovarian irritation. To this term, for my own part, I see no kind of objection, though, if preferred, the simpler designation of ovarian pain will answer every purpose, and serve equally well to impress upon your minds the fact that mere suffering does not of necessity imply either the presence or the previous existence of inflammation. Pain is in itself the patient's ailment, and this even varies greatly in diflerent persons, and causelessly and within very short intervals in the same person both in its character and intensity. It is ordinarily dull and aching, is accompanied by tenderness in the iliac region, in which situation a degree of fulness may often be detected, though careful percussion will discover that this fulness is due rather to the presence of flatus in the intestines than to the ex- istence of any solid tumor. Though this pain seldom subsides com|iletely, it is apt to be increased in paroxysms; walking, riding, exertion of any kind, and sometimes even the remaining for a short time in the erect posture, considerably aggravating it. Menstruation almost always adds greatly to its severity, and sexual intercourse nearl}^ invariably increases it, sometimes even induces a pnroxysm of great violence. The extent of the pain is very va- riable. Always severest in the situation of one or other ovary (and for^ome unexplained reason generally in the situation of the left), it is sometimes limited to that spot, but in other cases ex- tends more or less to all the pelvic viscera ; difficult, frequent and painful micturition are then always experienced, and defecation is likewise often attended or followed l)y severe suflering. While pressure in the iliac region is always painful, a vaginal examina- tion sometimes causes little inconvenience. In other cases, how- ever, it is productive of pain which lasts for several hours, and this even though no trace of disease may be detected. In some instances, indeed, in which the suffering produced by examination 1 Dr. H. Bennet, op. cit, p. 222. * Dublin Medical Journal, vol. xii, August, 1851, p. 82. INDEPENDENT OF INFLAMMATION. 387 was most severe, the uterus was smaller than natural, a condition which, when coupled with the sterility of the patient, seemed to indicate an imperfect development of the whole sexual system. In those instances where the patient's sufierings were severest, there were almost always unmistakahle signs of the hysterical temperament — often very ohvious symptoms of hysteria — while even when this was not the case, the sudden aggravation or sudden cessation of the pain was sufficiently characteristic of its neuralgic character. Though frequently independent of actual disease, pain such as has been described is also, in a very large number of cases, a con- comitant or sequela of various uterine ailments. Of course, when disease of any kind exists, its removal forms our first duty ; but even when this has been effected, the pain often outlasts the cause which first excited it ; or when it seems to have completely dis- appeared, may return during menstruation, or be rekindled by any imi»rudent exertion, or Iry sexual intercourse. Just like that backache which bears so large a part among the minor ills of women, so tliis ovarian pain, while easy to mitigate, is very hard to cure. Leeches do not relieve it, or if they give any ease, it is only for a few hours, and the pain then returns as severely as before. Blisters sometimes afford ease, though not often in those cases where the pain is most severe, while sometimes they seem rather to aggravate discomfort by the soreness of the surface which they occasion. In some instances I have found great comfort experienced from constantly wearing a wet compress on the painful side of the abdomen. Chloroform applied to the side generally gives temporary relief, even when the paroxysms of pain are most severe ; while a piece of lint soaked in a mixture of ((pial parts of chloroform and oil. and covered with a piece of oiled silk, is an application which, while in bed, the patient may employ constantly with much benefit. Tlie camphor liniment, with extract of belladonna, or the Linimentum Belladonufe of the new Pharniaco|)Oeia, is another external ajiplication which I have fourid advantageous; and when these means have been fruitless, I have emplo3'ed the tincture of aconite with advantage, a})[)lying the undiluted tincture by means of a brush, or laying a piece of lint soaked in it over the seat of pain. These symptoms sometimes wear themselves out, the pain by degrees subsiding as the patient's general health improves : but I have never been able to trace the permanent cessation of sulVering to the unaided use of any local measures. St)me caution, ttu), is necessary in their employment, for as with many neuralgic and almost all hysterical pains, so here any kind of local treatment which directs the patient's attention very much to the seat of her sufferings is apt to defeat its own object, and to perpetuate the evil instead of removing it. Attention to thegeneral health must always go hand in hand with the local treatnu-nt — must indeed, I think, hold the first place. It would be useless to endeavor to go into long detail here with reference to this subject. 1 will only 388 INFLAMMATION OF THE OVARIES. observe that there are two tonics which in cases of this kind generally do the most service. One of them is the sulphate of quinine, which, when tolerated by the patient, does the same kind of good as in other cases of neuralgic pain, though not so certainly, nor to the same extent. The other is the valerianate of zinc, to which I generally have recourse, wherever quinine is contraindicated or cannot be borne. I know of but one drawback from its employment, and that is the permanent taste which it is apt to leave in the mouth, and the unpleasant eructations with which patients are sometimes troubled hours after it has been taken, though when given in the form of a pill silvered this incon- venience is often avoided. There are indeed some cases, though I believe their number to be inconsiderable, in which the exist- ence of inflammation of the ovaries is less questionable. The attack in these cases is usually definite in its onset, and for the most part succeeds either to sudden suppression of the menses, or follows at least some considerable disturbance of the menstrual function, or occasionally comes on not very long after a miscar- riage, though once or twice I have met witli the affection with- out being able to assign any probable cause for its occurrence. General febrile disturbance, usually of no great intensity, and by no means invariably ushered in by shivering, is accompanied by pain referred to the hypogastrium, or to one or other iliac region, and by frequent desire to pass water, which is usually high- colored and deposits lithates. In the main, indeed, the symptoms are such as attend an attack of uterine inflammation, except per- haps that they are less severe. A vaginal examination suffices to show that the uterus is not the part affected, for though the heat of the vagina may be somewhat increased, the womb is neither enlarged nor tender, nor are its lips pufly ; while, at the same time, pressure against the roof of the vagina, at one or other side of the womb, not only produces considerable pain, but very often detects the indistinct outline of the enlarged ovary. Sometimes, indeed, the ovary may be very clearly felt, especially if, as is usually the case, it occupies the cul-de-sac between the uterus and rectum, and it may then be much more clearly distinguished by the finger, introduced into the bowel than by a mere vaginal ex- amination.^ The general symptoms, combined with the absence of affection of the uterus, and the pain on pressure at its side, suffice to point to the ovary as the seat of the patient's sufferings. When the tumor can be distinguished, it may be recognized as the ovary by its oval shape, its smooth surface, its elasticity, a certain degree of mobility, of which it is found susceptible, as well as by the peculiar sickening sensation which pressure upon it produces. ' These symptoms for the most part have a sufficiently active ' Dr. Lowcnhardt was the first person to draw special attention, in his Diagnos- tiseh-praktificJie AhhcnicUungen^ &c., 8vo., Prenzlau, 1835, p. 297, to these cases of ovarian inflammation, and to the value of examination per rectum as a means of diagnosis. DISPLACEMENT OF THE OVARY. 389 character to enforce the patient's attention, while tlie employment of local leeching, of the tepid hip-bath, the use of anochaie and mild antiphlogistic remedies, and the observance of absolute rest — the same remedies, in short, as would be applicable in cases of inflammation of the uterus itself — generally suflice for their re- moval in the course of a few days. Some exceptional cases are, however, occasionally met with, in which, in a somewhat mitigated form, the above-mentioned s^nup- toms continue for months or years, and are found to be associated with the presence of the enlarged and congested ovary in the cul- de-sac between the uterus and rectum. The late Dr. Rigby' was, I believe, the first person who drew attention to this condition under the name of displacement of the ovary, and the cases of it which have come under my notice bear out the accuracy of his description ; except that I have not observed the paroxysms of pain to have anything like that intensity which they assumed in some of his cases. The condition seems to be one of considerable rarity, for I have a record of but four instances of its occurrence, though I have seen a few other cases of which I have failed to preserve an account. The patients in all my cases were married women, of whom the eldest was thirty-two, the youngest twenty-three years of age ; but Dr. Rigby relates an instance in which he met with the condition in an unmarried girl only eighteen years old. Two of my patients were sterile ; the other two had given birth to cljildren, and both of these latter dated their symptoms from their last delivery. In all of them the severe pain attendant upon sexual intercourse had b}' degrees compelled its discontinuance, and had much to do with the application of tlie patients for medical aid. Besides this, how- ever, there were complaints of pain referred to the lower part of the abdomen, though severest on one side, aggravated by exer- tion, by mefistruation, often induced with great intensity by defe- cation, and generally being severer at night than in the daytime, thus preventing sleep, or causing the rest to be very disturbed. In one patient menstruation was natural, except that it was attended by unwonted suffering; but in the otlier three the discharge was both excessive in quantity, and anticipated the proper period of its return. Pressure in one iliac region always aggravated the pain f but the paroxj^sms of sufl'ering which were every now and then superadded to the abiding discomfort, and which were at- tended by a sense of darting and shooting referred to the womb, lasting sometimes for several hours, came on without any assign- able cause. These s^miptoms were present with considerable uniftu'mity in all the cases, and in all, on an examination per vaginam, there was found behind, and rather to one side of the uterus, or else quite in the cul-de-sac between the uterus and rectum, an oval body, slightly movable, elastic, intensely tender to the touch, and im- 1 Medical Times, July G, 1850. 890 OVARIAN DISPLACEMENT. mediately recognized by the patieut as the point whence all her suft'erings proceeded. In all of these cases, rest, abstinence from sexual intercourse, and the application per vaginam of leeches to the neighborhood of the painful part, were followed by the gradual cessation of sutlering, the diminution in size of the swollen ovary, and the almost complete removal of the tenderness. In no instance, how- ever, was there any such disappearance of the tumor felt through the roof of the vagina as to suggest the idea that the main element in the production of the patient's illness had been the displace- ment of the organ, or that the improvement in her condition was attributable to the ovary having regained its natural position. My own impression is, that cases of this kind are to be regai-ded as instances of a chronic congestion of the ovary and slow increase of its size, rather than as illustrations of any mere change in the position of the organ. The enlarged ovary almost always descends in i\\e pelvis, and in the early stage of ovarian dropsy the organ may often be felt per vaginam at a time when no tumor is per- ceptible in the abdomen. But though the organ may by growth thus apparently change its situation, and though besides its liga- ment elongates readily enough, as we see in cases where the ovarian cyst has already ascended into the abdominal cavity, we should yet, I think, be in error if we fancied the organ so loosely tethered in its place that without any other alteration it could fall down into the cul-de-sac between the vagina and rectum, and be made to resume its proper position merely by the patient ])lacing her- self in a prone posture. The persistent swelling, which in my cases remained perceptible, although its size was reduced by treat- ment, would seem to me to indicate that inflammation had affected the peritoneal surface of the ovary, and tied it down behind the womb just as in some of the cases which I referred to at the com- mencement of this Lecture. The subsidence of the inflammation was follow^ed by diminution of the enlarged ovary, by lessening of its exaggerated sensibility, but not by its return to its previous position. I imagine, too, that whatever relief a patient may ex- perience in these cases from assuming a prone position may iairly be referred to the removal from the congested and tender ovary of the weight of the superincumbent intestines, to which, either in the sitting or in the recumbent posture, it is subjected.^ 1 There are two conditions which I do not liiuld appear to be entirely mechanical, and to result from their pressure on adjacent organ*. In one instance the cyst was punctured per vaginiim; about ,^ij of trans])arent serum were evacuated, and the cyst-wall was lightly touched witli the nitrate of silver. The fluid did not re-collect, and no serious symptom followed the puncture. The chief importance of these cysts is, perhaps, from their introducing a new element of uncertainty into the diagnosis of ovarian tumor in an early stage. 392 SIMPLE OVARIAN CYSTS. They are formed sometimes by simple cysts containing serous fluid, at other times they are composed of solid matter, while in ver}" many instances their structure is identical with that of growths which morbid anatomists have unanimously designated malignant. Their rate of increase is sometimes quick, at other times slow, and the disease which liad seemed in course of rapid development becomes occasionally stationary, and so remains for months or years; while now and tlien nature herself interferes, and, excel- ling all that the most skilful physician could do, completely takes away the ill wdiich medicine is usually impotent to cure. Their diagnosis, in some cases most easy, is in others attended by extreme difficulty ; and yet there are scarcely any ailments in which so much is involved in a right decision. The determination that the sup- posed disease is in reality due to the existence of pregnancy, or that the suspected pregnancy is but the evidence of disease, often has moral consequences which touch more nearly the profoundest sources of human happiness or misery than any which would follow the mere assurance, though never so positive, of coming health, or the admission that the future has no other prospect than that of a lingering and painful death. The prognosis to be formed, and the treatment to be adopted,*bring with them, too, their own peculiar difficulties. Recovery, when there seemed small ground for hope ; death, when little had appeared to call for apprehension ; medical treatment rejected because it has been proved inefficacious; surgi- cal proceedings shrunk from because tliey are known to be hazard- ous; additional facts scarcely seeming to widen our experience, or serving only to detect the fallacy of some loudly vaunted plan of cure : such are the uncertainties, and such the difficulties that meet us when we propose to ourselves the inquiry — What shall we do ? In short, there are no diseases whose pathology is more imperfect, whose symptoms are more fluctuating, whose diagnosis is more obscure, or whose treatment is founded on more uncertain data than those very diseases of the ovaries which are yet so im- portant, and to whose study I must now call your most patient attention. In each of the different organs of the body we find a disposition more or less marked to diseased formation similar to its own proper healthy structure. This peculiarity is observable in tumors of bone, of muscle, of nerve, or of fibrous tissue, and even in the case of those formations which, from their non-identity with healthy structures, have received the name of heterologous, something of the same disposition is still jierceptible. Thus the cancerous tumor of bone, while interfering with and destroying the structure of the part in which it is formed, is yet itself built up upon a bony skeleton or fabric ; and I have already pointed out to you how, even in cancer of the w*omb, the bulk of the organ is increased, not merely by the morbid deposit in its substance, but also by the development of its natural structure. It is in accordance with this law that, in the ovary especially (as to a less degree in all glandular organs, such as the thyroid CYSTS OF THE AVOLFFIAN BODIES. 893 body, the testicle, and the mamma), there exists a peculiar liability to cyst-formation ; and that nineteen out of twenty of all ovarian tumors are cystic growths. Very various classifications of ovarian cysts have been proposed according as they have been regarded simply from a practical point of view, or as the minuter difierences in their anatomical structure have also been taken into consideration. It is, however, so desir- able to avoid multiplied divisions and subdivisions, that I propose to conform to the arrangement adopted by Mr. Paget,' and to speak first of Simple or Barren Cysts, and secondly, of Com- pound or Proliferous Cysts. This arrangement, too, will, I think, be found not simply anatomically correct, but also practically convenient. 1^\\Q first kind of Simple Cyst is one which, though in the im- mediate vicinity of the ovary, is, strictly speaking, not connected with it ; but which I mention here because until comparatively recently its nature was misapprehended, and erroneous conclu- sions, based on this misapprehension, have been applied to real ovarian cysts. In examining the bodies of female infants, and less often of female adults, w^e may sometimes notice hanging from the under surface of the Fallopian tube, nearer to its fimbriated than to its uterine extremity, small delicate cysts, varying in size from the bigness of a pea to that of a cherry, furnished with a slender pedicle from one to three inches in length, and containing a transparent, serous, or slightly gelatinous fluid. Now and then a similar cyst may be seen bearing the same relation to the Fallopian tube, with the exception of being sessile instead of pediculated. Sometimes, too, a cyst of larger size may be observed within the folds of the broad ligament situated between the ovary and the Fallopian tube, but obviously not originating in either; and the cysts of this latter kind, unlike the others, are observed in the grown subject. The diiference of their seat seems to be the only point of dissimilarity between them, for the wall of both is composed of a thin, structure- less membrane, incapable of division into layers, often, though by no means constantly, furnished with a lining of nucleated epithe- lium ; while their contents, though usually serous and colorless, are sometimes reddish and gelatinous. The delicacy of the cyst-wall, the absence of any support, and the slcnderness of its foot-stalk, are doubtless, as has been sug- gested by M. Verneuil,' the reasons why the pendent variety of cyst is seldom met with after early infancy, while tlie support which the peritoneum on either side furnishes to the sessile cyst 1 Surcjical Paihology, vol. ii, p. 26. 2 By far the best account of these cysts, which contains also a' notice of the ob- servations of previous writers, is tiiat of Dr. "\'erneuil, Rrclierchcs sur tes Kt/xfes de l'07\rjinir de Wolff, Mhyioires de In Sociele de C7iii"iir2) an account of these small cysts, demurs to the correctness of this hypothesis, and believes them to be usually, if nut invariably, new formations. * 394 CYSTS OF THE WOLFFIAN BODIES. which is situated between the folds of the broad ligament, allows of its readier enlargement and of its attainment of a greater size. An examination of the pedicle of those cysts which hang from the Fallopian tube furnishes the clue to the understanding of the real nature of these growths. This pedicle is often found to be hollow, though in the course of its gradual elongation and attenuation it becomes converted into a slender cord. The canal, however, some- times even communicating with the cj^st, points to its origin in the dihitation of one of the small ci^cal tubes which make up the "Wolffian bodies in the fcetus, and the slight remains of which, difficultly discernible in the adult, have received from their de- scriber the name of the Corpus Rosenmlilleri. The size of an egg, an apple, or an orange, is the greatest magni- tude to which these cysts have yet been proved to attain; and the pendent cysts very rarely indeed reach dimensions sufficient to make them recognizable during life. With the exception, too, of the giving way of the pedicle of the pendent cysts, and the prob- able rupture of the delicate walls of both kinds of these growths, there are no changes which have been observed to take place in them ; and in no instance has cyst formation occurred in their walls or into their cavity, though several distinct cysts, especially of the pediculated kind, are by no means infrequently seen in the same su Inject. Before proceeding to examine the other and more important cysts wliich really spring from the ovary itself, we must for a moment nf)tice a circumstance which has given to these cj'sts of the broad ligament, as they have generally been termed, a greater pathological value than really attaches to them. It has been very customary for medical men, whenever they met with a simple cyst tolerably movable, and of moderate size, to assume that such a cyst was not ovarian, and to console their patients with the assurance that it is a less serious disease, and one much less likely to in- crease. Now, while it is of great moment to give to our patients every legitimate comfort, and to encourage all reasonable ho[)e, it is yet no less important, in the interests alike of science and of humanity, that we should not make large promises or give posi- tive assurances w'ithout aderpiate grounds. A visit to any of the large museums of this metropolis will suffice to convince any one that cysts of the Wolffian bodies of size sufficient to be distin- guishable during life are of very great rarity, while the same evi- dence will also prove that for such cysts to exceed the dimensions of an apple is rarer still. Whenever then a tumor is discovered in the abdomen which has attained a greater size than that of the doubled fist, that circumstance may be taken as in itself affording almost conclusive proof that the cyst is not extra-ovarian, nor of that kind concerning which it can be foretold that its tendency will be to remain stationary, rather than to increase in size. But we may now pass to the study of those various kinds of cysts and cystoid growths which have their origin in the ovary itself. The simplest of these, the least dangerous — I fear, however, by SIMPLE CYSTS OF THE OVARY ITSELF. 395 no means the most frequent — are those which are produced by the dropsy, or over-disteusion with fluid, of one or more G-raafian vesicles. The structure of these simple ovarian cysts plainly indicates their orii^in. They are furnished with three coats: the first, the peritoneal investment of the ovary; the next, the capsule of the organ, on whose surface ramify the vessels that supply it; and the third, the wall of the Graafian vesicle itself, which is usually much thickened, generally divisible into several layers, and has a lining of tessellated epithelium. This laminated structure of the ovarian cyst is, as we shall hereafter see, not without its practical import- ance, inasmuch as it sometimes increases the ditficulties of the operator, who cannot, if adhesion exist, always distinguish read- ily whether his finger is breaking down the connections between the enlarged ovary and the peritoneum, or whether it is separating the layers of the cyst- wall. The surface of these cysts is generally white and glistening, and their interior smooth and polished; sometimes of" a dead white color, or even of a mother-of pearl lustre; unless the growth has been the seat of inflammation, when it will in many parts he dull, roughened on its interior by old deposits of lymph, and its walls will be found to present various degrees of firmnes^s, density, and thickness. Even independently of previous inflammation the thickness of the cyst-wall often varies at dift'erent parts, and is by no ineiins most considerable in all cases close to the pedicle of the growth. The vessels of these, as indeed of all ovarian cysts, are usually of considerable size ; while their distribution is uncertain beyond the fact that all converge towards the pedicle of the cyst. They almost all present a venous character, or, as Cruveilhier aptly says, in describing the structure of a large ovarian cyst,' '"They are venous sinuses analogous to those of the dura mater," and, ramifying immediately beneath the peritonetim, their delicate outer wall seems wholly formed by that membrane. The large size of these superficial veins is to be borne in mind as an occa- sional source of danger in tapping; while their convergence towards the pedicle of the tumor constitutes one of the principal objections to the operation of ta[)ping [tcr vaginam. The branches which pass from these trunks towards the interior of the cyst, and which ramify, sometimes very abundantly, on its inner wall, are small in size, but still retain their venous character, and this pre- ponderance of the venous over the arterial system is the groat peculiarity of the vascular supply of these growths. Be their size what it may (and this is liable to very wide varia- tions; for while sometimes no larger than a pea, they contain in other cases a gallon or a gallon and a halt of fluid) their contents are usually of the same description — namely, serum, often of a rather low specific gravity, and very seldom exceeding lOiiO, highly ' Anatomic PaUiologique Generale, 8vo., Paris, 185G, vol. iii, p. 408. 396 STRUCTURE OF albuminous, of a slightly greenish color, and though generally trans- parent, yet occasionally more or less stained with blood. Some- times, indeed, the fluid contains a large admixture of pus, and now and then presents characters but little distinguishable from those of healthy matter. This, too, may be the case even when few local symptoms of inflammation have been present, so that it is not possible to foretell with any certainty the nattire of the fluid which even a simple ovarian cyst may be found to contain ; or to infer the absence of inflammation from the absence of pain. The circumstance which imparts to this fact its practical importance is that inflammation of the interior of the cyst is in very many instances accompanied by inflammation of its peritoneal surface, of extent and intensity suflicient to produce very considerable ad- hesions with adjacent viscera, while even this peritonitis may give rise to no severe pain. The feasibility of various surgical proceed- ings for the cure of ovarian dropsy depends to a great degree on the absence of adhesions. The want of any certain means by which to determine their presence or absence is one of the most serious of the difliculties that beset all operations for the extirpa- tion of diseased ovaries. I have described this affection hitherto as it presents itself to our notice when confined to a single Graafian vesicle. It is, how- ever, seldom that the disease is so strictly limited, but usually other vesicles, sometimes in both ovaries, show a disposition to the same dropsical condition. Not infrequently, too, we meet with cases in which the affection of several vesicles has appeared to have commenced simultaneously, all being equally enlarged; and the ovary containing as many perhaps as ten or fifteen small cysts no bigger possibly than a large pea. As these cysts increase in size, they lose by their mutual pressure the regularly globular form which at first they present, becoming flattened, or somewhat wedge-shaped, with their broader end outwards. When, however, the ovary has attained to dimensions greater than those of an un- shelled walnut, or of an egg, the development of one or two of the cysts generally goes on at tlie expense of the others, and a multi- locular tumor is thus produced, made up of a number of simple cysts, of very various sizes, from that of the adult head to that of an apple or an orange. The contents of these cysts, too, may vary as much as their size, for while some are filled with transparent serum, others may contain fluid deeply tinged with blood, and others again a sero-purulent secretion, according as hemorrhage or inflammation has occurred in one and has not occurred in an- other, even though immediately adjacent. These varieties in the same tumor have sometimes given occasion to the opinion that a growth is a compound cyst, when in reality it is only an aggrega- tion of simple cysts in which morbid processes of various kinds have been going on. It is by no means an unusual occurrence, too, with tumors of this description, for their pressure on each other to produce absorption of the dividing septa, and for a multi- locular tumor to be thus in the course of time converted into a SIMPLE OVARIAN CYSTS. 397 single cyst. The openings of communication between the dif- ferent cysts are usually of a circular form, with smooth edges, as if a portion of the wall had been removed by some cutting instru- ment, and while small at first, the advance of the process of ab- sorption by degrees enlarges them ; till at length a slight irregu- larity in the external contour of the tumor remains as the only Bvidence of its original structure. The circumstances that regulate the process are, however, by no means clearly understood ; for tvliile the absorption of the septa sometimes takes place at a time ivhen none of the cysts are larger than a marble, it is far from unusual to find the partitions still entire when some of the cysts tiave reached the size of the adult head, or have even attained still larger dimensions. It is perhaps needless to say that dropsical enlargement of the Graafian vesicles is by no means the only source whence simple Dvarian cysts may be produced. There can indeed be no doubt ^ut that tlie development of cysts may go on in the ovary just as it iocs sometimes in the kidney, not by any enlargement of pre- existing cavities, but by a process which is one of new formation irom the very beginning. Still the whole tendency of pathological 'esearch is to increase the number of instances in which cysts are brmud by the enlargement of pre-existing cavities ; and besides, ;lie question has been set at rest as far as the occasional production )f ovarian dropsy from enlarged Graafian vesicles is concerned by [lokitansky's discovery of the ovule within the cyst in a case of ncipient cystic disease of the ovary.^ The precise mode in which the dropsical condition of the vesicles s produced, is indeed, and probably will always renuiin, to a great iegree unknown. It seems, however, to be very likely that in lome cases at least a state of congestion of the vesicle, and hemor- •hage into its cavity, are the first steps towards the production of he subsequent efiusion. In the museum of Guy's Hospital, to vhich I was most courteously admitted, are a series of prepara- ions which appear to illustrate this mode of origin of ovarian Iropsy. In some of them a clot alone is seen within the vesicle ; n others the clot occupies only a portion of the cyst, adhering to ts wall by a sort of pedicle, while the remainder of the cavity is )ccupied by a serous fluid; the relative proportions of the clot and he fluid varying much in difl'erent specimens. Now, just as lemorrhage into the sac of the arachnoid is followed in many iu- ^ ir/ewer WocJicnhlatt, 1855, No. 1, as quotod by Scanzoni, Lchrhuch der Krnnk- '^iteu dei- Weiblichen Sexual Organe, 8vo., Wicn, 1857, p. 354. See also Virchow, )ie Krankhaften Geschwiilste, vol. i, p. 259. The question is one of so much nomcnt with rctbrcnce to the prognosis of ovarian dropsy, and the ojiiniou of so ligh iin authority as Dr. Bright (see Guy's Hospital RcportH, vol. iii, 1838, pp. 181 nd 193) is so decidedly unfavorable, that one rejoices at obtaining any evidence phich enables us to soften the very dark hues of the picture wiiich he has drawn. 'Tliis ease," says he, loc. cii., p. 193, " adds to the doubt I have already expressed if having met witli any very distinct case of dropsical accumulation in the Graa- ian vesicles, as distinguished from the disease which runs into the malignant ivarian tumor." 398 COMPOUND OVARIAN CYSTS. stances by the subsequent effusion of serum so far exceeding in quantity that of the blood originally extravasated, as to produce one form of chronic hydrocephalus, so tliere can be no reason for doubting but that hemorrhage into the sac of a Graafian vesicle may in like manner be followed by a similar hypersecretion. A theory, indeed, has been propounded, the very opposite of this, by Professor Scanzoni,' who suggests that the dropsical con- dition of the Graafian vesicle may be due to the flow of blood to the ovary at a menstrual period having been insufficient to produce the rupture of the sac and the escape of an ovule, but sufficient only to occasion a certain degree of congestion, terminating in an increased effusion of fluid into its cavity. This theory is based chiefly on the alleged frequency of amenorrhoea, or of scanty men- struation, as a precursor of ovarian dropsy; an allegation which, as we shall see hereafter, is scarcely substantiated. I know of no other facts, nor of any other plausible theory bearing on the production of dropsy of the Graafian vesicles; and I fear that I must confess my inability to determine the proportion of instances in which simple cysts of the ovary are due to the enlargement of these cavities, and of those in which the cysts are tliemselves of new formation. That simple cysts may arise here, however, as in other parts, by the mere collection of fluid in the parenchyma of the organ, and the gradual formation of a cyst around it, I see no reason to doubt.^ Possibly some of the very delicate and thin-wallcd ovarian cysts which we occasionally meet with may have this origin ; but my conviction is, that this is not the general mode of production of simple cysts, but that most are formed l)y the distension of a pre-existent cavity. Another question of greater practical moment is w-hether single cysts always remain single, or whether they may not become pro- liferous or compound cysts in the course of their development. Here, too, it is to be regretted that our data do not suiflce for a satisfactory answer to this inquiry. The practical consequences involved in the decision of this point are very obvious; for it is apparent that if at any period a simple cyst is capable of passing into an active state, and of enlarging not by mere distension of its cavity, but by growth in its interior, or by cyst-formation in its walls, the ex[)ediency of having recourse to early and very decided therapeutical proceedings becomes far greater than it otherwise would be. My belief is, that such a change may take place, and that a cj'st originally barren may become pi'oliferous; that its con- tinuing simple is rather a happy accident than a condition on the permanence of which we can calculate with any certainty. A 3'oung woman who had been the subject of ovarian dropsy for two years and a half, and who had been* tapped a year before her death, sank under the effects of peritoneal inflammation induced by an 1 Op. cit, p. 353. ' A mode of cyst-procluction most fully illustrated by Professor Bruch, Ziir Ent- vneklmigs-geschichte der PathoLogischen Cystenbildungen, in Zeiischr.f. RationtUe Med- izi7i, vol. viii, 1849, p. 91. COMPOUND OVARIAN CYSTS. 399 attempt to inject the cjst with iodine. The cyst was found to be a tliiii walled simple cyst, but at one point, near to the pedicle of tlie growth, four little cysts, the largest of which was about the size of u bean, projected from its internal surface, and round this group the lining itself was more vascular and rather softer than elsewhere. Larger opportunities than I have ever possessed of making examinations alter death, would, I doubt not, have fur- nished me wnth other illustrations of a fact which is entirely in accordance with the result to wliich analogical reasoning wcnild lead us. Without the stimulus of impregnation, a Graafian vesicle does, we know, sometimes produce hair, fat, teeth, cartilage, and bone, and the proliferous power of which these are the highest instances, may also, without doubt, exert itself in lower fcJVms in the production of endogenous growths in its interior; and, though possibly less often, in exogenous cell-formation from its walls. In some of the cases of endogenous cell develojunent, the growths that occupy the interior of the cyst spring universally from its walls, and consist of an immense number of small ped- unculated cysts or vesicles, multiplied apparently by the same simple process of growth as has been so well studied in the hydatid disease of the chorion. Such growths may, too, be so numerous as to fill nearly the whole of the interior ol a very large cyst.^ In other cases the endogenous growth, though similar in its character, does not arise from the whole of the interior of the cyst, but is connected with it by a pedicle, from which a pyriform mass of cystic growths proceeds. Be-^ides these forms of endogenous growth, there is another in which the cavity of the parent cyst is more or less completely occupied by others of a smaller size, but springing from it by a broad base,^ and containing within thehiselves others of a third order, of smaller size, and with thinner walls. As these cysts grow, some probably empty themselves completely into the parent cyst, and, collapsing, become adherent to its walls, thus gi\ ing to them that thickness and resistance which in some cases, even of large ovaiian cysts, are very remarkable. At the same time the progressive increase of the smaller cysts, and the constant forma- tion of new cysts, help to make up that enormous mass to which ovarian tumors sometimes attain. I>ut while there is perhaps room for doubt as to the nature of the original growth whence these forms of complex cysts arise, there can be no question but that some cysts assume the complex character from their very commencement, and are not developed out of any transformation of the Graafian vesicles. In these cases we find the ovary converted into a tumor of irregular form ; its firm, fibrous capsule, some quarter or third of an inch in tliickness, inclosing a number of cysts or cells, one or two of whieh nuiy greatly exceed the dimensions of the others, and be capable of 1 As in a very remarkahlo preparation, No. 224j" in Guj-'s Hospital Museum. * As No. 2622 in the llunterian Museum. 400 COMPOUND OVARIAN CYSTS. containing many quarts of fluid, while the remainder vary in size from the bigness of a marble to that of a pigeon's egg, or an apple. While some of them may appear as separated cysts, adherent to the others, but apparently developed independently of them, others have obviously been formed in the thickness of the cyst- wall itself, and project, sometimes inwards, at other times towards its exterior. When the growths have attained to any considerable size, inflammation generally roughens their originally smooth in- ternal membrane, and deposits of lymph thicken it; or the col- lapse of some of the smaller cysts, and their incorporation with the dividing walls of the difl'erent cavities, thicken as well as otherwise alter the septa. At the same time, too, similar causes modity their contents, so that while one cyst is filled with a serous fluid, another contains a glairy, albuminous matter, or its contents are deeply tinged with blood, or are of a dark chocolate color; while others contain pus, or sero-purulent fluid, or a liquid in which scales of cholesterine sparkle like the brilliant particles in Dantzic eau de vie. It is usually towards the pedicle of these tumors, where the smaller cysts are mostly situated, that their structure can be best studied. They are then seen to be formed by a smooth, polished membrane, tough and resistant, though thin, scared}' semi-transparent, but of a white color, and su[>plied by long slender bloodvessels, which ramity on their outer surface. Their general form is oval, but as they increase in size this is much modified by their mutual pressure on each other; while besides, irregular spaces exist here and there, partly produced, perhaps, by the I'usion of two or more cysts together, partly by the inter- vals left between several adjacent cysts. The smaller size of the cysts near the pedicle of the tumor is apparently due to their being subjected to a grealfcr degree of compression than the others, for sometimes a large cyst will develop itself downwards into the pelvic cavity; while again, where the increase of the tumor has been very rapid, a number of small cysts may sometimes be Ibund towards its upper part, where apparently the resistance oftered by the transverse colon, the liver, stomach, and diaphragm, has also prevented their increase.^ The amount of solid matter which enters into the composition of these cystic tumors of the ovary varies exceedingly. In many cases, as in those just described, the whole mass is but a collection of cysts, whose walls, even when thickest, bear but a small propor- tion to the quantity of fluid which their cavities contain. In other instances, however, these proportions are reversed, and the bulk of the solid matter far exceeds that of the fluid. This is the kind of tumor to which the name of cystosarcovia has been applied by MiJller,'^ who describes it as principally composed of a more or less firm, fibrous, or vascular mass, but invariably containing solitary cysts in its substance. The fibrous masses consist of an albumin- ' A very good drawing of a compound ovarian cyst given by Dr. Bright, f>j^. cit., pi. V, p. 276. * On Cancer, &c., English translation, London, 8vo., 1840, p. 170. COLLOID TUMORS. 401 ous substance, and sometimes contain granules scattered between their fibrils, and the fibrous tissue forms the stroma in wliich the separate cysts are imbedded. 1 do not feel myself competent to decide how far these growths really require to be referred to a separate category. The structure of the cysts, and their various contents, are analogous to what one observes in other compound ovarian cysts. Perhaps, however, it should be added that fat-cysts, or cysts containing hair, teeth, or other products of cutaneous tissues, when not existing alone, are most frequently associated with cystosarcoma ; and, further, that these comparatively solid growths do not attain to the enormous dimensions of other compound ovarian cysts, and very seldom exceed the size of the adult head. Another form of compou^td ovarian cynt^ allied to the preceding kinds, but I believe essentially difi'erent from them, is that in which the organ is the seat of alveolar or colloid cancer, a disease* whose precise relations to other varieties of carcinoma are as yet undetermined. The grand characteristic of colloid degeneration of any part is, as you know, the development in its substance of innumerable cells, containing a tenacious, gummy secretion, which vary from a size too small to be discerned by the naked eye, to an inch or rather more than an inch in diameter. These cells in- crease, though by no means exclusively, by endogenous growth, and the presence of a countless number in the same stage of development shows that the formation of very many occurs si- multaneously. If their contents are washed out so as to leave be- hind only a skeleton of the growth, it is then perceived that very many of the cells or sacculi communicate with each other; the whole mass having a honeycombed appearance, or resembling, perhaps, more closely a section of the lung of a reptile. The septa between the cells are in general of a somewhat firm, though delicate fibrous tissue, of a whitish, sometimes of a dead-white color; though while the cells are very minute, their walls, or the septa between the areolae, are semi-transparent, and their jelly-like contents shining through, they look not unlike grains of boiled sago. In the ovaries this colloid disease assumes many diferent forms. Sometimes several rounded masses make up an irregular tumor, which is solid to the touch, and firm on section, presenting no trace of the proper tissue of the part, but a structureless substance in which are imbedded countless semi-transparent grayish cells, scarcely any of which are larger than the head of a large pin. Again, in other cases the cell-walls generally are very delicate, while large spaces are left between, of irregular form, and filled with the characteristic gelatinous secretion, whicli may be col- lected to the amount of several ounces or of a pint, or more. iSuch 1 A good representation of alveolar cancer of the ovary is given by Cruvoilhier, Atlas, &c., livr. v, pi. 3. 26 402 COLLOID TUMORS. spaces, however, do not appear to be cysts enlarged beyond the dimensions of those which surround them, but to be mere inter- spaces of irregular form produced by the absorption or liquefac- tion of the cell-walls, and the consequent escape of their contents into a common receptacle.^ Besides the instances in which colloid disease exists alone, cases are by no means unusual of its association either with compound cysts of the ovary, or with fungoid or medullary cancer of the organ. In the former case it is far from uncommon for one or two of the cysts to have attained to a very great magnitude ; and the colloid matter may be in part poured into them from some of the adjacent cells, so as to give to their contents almost the same de- gree of tenacity as is observed in the secretion within the small cells of alveolar cancer. Even though this should be the case, however, and though there should be very close juxtaposition of the two structures, the differences between them will, I think, be sufficiently obvious. In the case of the association of genuine fungoid cancer with the colloid disease, it is usually about the pedicle of the tumor, and near its base, that the great mass of cancer is situated. It is not, however, limited to tliis part, and sometimes a mass of soft brain-like substance is found in the midst of the tumor, surrounded by the delicate cysts and gelatinous substance of alveolar cancer ; while at other times the medullary matter seems altogether fluid, and on cutting through the tumor it issues forth from some of the irre<^ular cavities which have been already spoken of. The peculiarities of the nuitter contained in the cells of colloid cancer have been frequently referred to ; and even in growths of consideral)le magnitude these characters are sometimes still pres- ent in a marked degree. Often, however, they are more or less modified by the same causes as influence the contents of other forms of ovarian cysts, and the viscid secretion is often dark from the admixture of blood; sometimes even of a dark chocolate color, sometimes grumous; but I do not think that it becomes purulent, as is not infrequently the case with the secretion of the other ovarian cysts. One form of ovarian cyst still remains for notice, and it is one concerning which some problems still remain unsolved. Cysts are sometimes formed in the ovary, either alone, or associated with cystosareoma of the organ, containing fat, hair, teeth, or other pro- 1 Remains of the septa may in these cases be discovered by means of the mi- croscope, in the midst of the colloid material. It was the observation of this fact which led V^irchow, Verhandlunpen der Gesellschaflf. Gehurts/tii/fe, vol. iii, p. 197, to the assumption that all compound ovarian cysts ai'o in realit}' instances of colloid disease of the organ in which this liquefaction and disappearance of the septa has taken place. This theory, however, in the extension given to it by Virchow, is now generally regarded as untenable. Indeed, it is b\' no means unusual to meet withcompound ovarian cysts which present no similarity either in their structure or in the nature of their contents to alveolar cancer; and I believe that the micro- scope fully liears out the verdict which observation without its aid would induce us to return. FAT-CYSTS OF THE OVARY. 403 ducts of cutaneous tissue. The presence of scales of cliolesterine, or of small quantities of fat, is indeed often observed both in sim- ple and in compound ovarian cysts, and is due to the rapid for- mation and rapid desquamation of their epithelial lining, and to the alterations which the corpuscles undergo. In tliese cysts, however, fat is present in much larger quantities, so that it forms a layer on the surface of the fluid removed by tapping as firm as lard, or even firmer; or collects perhaps into large irregular flakes or masses, or else into a number of small l)alls like marbles, of a yellow color, and of the consistence of tallow, shaped into these symmet- rical forms by mutual attrition in the fluid which partly filled the cysts, of which there is a remarkable specimen in the museum of Guy's Hospital.' Sometimes the cyst contains no fluid, but a matter of the appearance and consistence of putty, possibly inter- mingled with hair. Hair, indeed, is often met with in these cysts, sometimes in shapeless, tangled masses, but more frequently rolled together into round balls; and teeth, bone, and bone cartilage are also all found in many instances. When it liad been clearly ascer- tained that these structures existed independently of impregnation, it was next assumed either that they were the relics of some im- perfectly developed germ included by accident within that ovule which had gone on to perfection, and that they were therefore congenital formations, or else that the ovule itself was capable of a certain imperfect attempt at growth, independent of its appro- priate vivifying power, and thus produced incompletely, and with no orderly arrangement, some of the materials of the foetus. In a measure, too, both of these theories are probably correct, though cutaneous cysts are found in circumstances which do not seem to admit of either of tliese solutions. In all such cysts there may be found any of the products of dermoid tissue regularly formed, as though growing in their natural situations ; the hairs im[)lanted in a perfectly normal manner into the cutaneous tissue, wdiich is found to be supplied with perspiratory and sebaceous follicles, while the teeth, in different stages of development, are imbedded in tooth-sacs. We owe the observations which have removed cases of this kind from the domain of the wonderful, and have shown how method and order reign, where a more imperfect knowledge could discover nothing but mere freaks of nature, to the acuteness of a German physician.* Another of his countrymen has done much to complete our information, and I will briefly state to you the results at which he has arrived. Dr. Steinlin,' on examination of the body of a young woman Irom whom seventy- eight pounds of pus were removed in four successive tapftings, found that while the left ovary contained several small cysts, none of which exceeded the size of a hazel-nut, the right ovary was the principal seat of disease. It was made up of many cysts, all of ' No. 2237-*. Rokitan>ky also relates a remarkable case of a sonio\vl)at similar kind, op. cit., vol. iii, ]i. ;')'.i7. 2 Dr. Kolilrau.«cli, in Muller's Archiv, 1843, p. 305. ' Zeitschrift f. Rationelle Medizin^\o\. ix, p. 14G. 404 STRUCTURE OF wMch, with the exception of one large sac containing several pounds of pus, were f'at-cjsts, varying from the size of a grain of linseed to three or four inches in diameter. The flit was in dif- ferent conditions in diiferent cysts, and in the other cysts was often intermixed with hairs intertwined into a mass. All the contents being removed, the greater part of the cyst-wall was seen to be smooth and shining, but there were one or more round islands, of a dull whitish color, with a wart-like prominence in their centre, overgrown with hair; and other similar spots without the wart- like prominence, and without the growth of hair, but with several teeth or portions of bone more or less buried under their surface. The cyst-wall admitted of division into several layers. Of these the outermost was composed of loose ceHular tissue, beneath which was a denser layer made up of fibres, which, though interlaced, had on the whole a parallel arrangement; under this was a layer of elastic tissue, and innermost of all a coating of epithelium. The epithelium was everywhere of the tessellated kind, and at the polished parts of the cell were round and regular, but at the dull parts the superficial layer was arranged irregularly, though round cells were regularly disposed beneath. On denuding the wart-like prominences of their epithelium, the subjacent surface exactly re- sembled that of the true skin, having well-developed papilla, and the whole of the cyst-wall beneath the unpolished islets had a similar structure. The hairs growing here sprouted from a regular bulb, and there were sebaceous glands and perspiratory follicles in varying number. The quantity of hairs is accounted for by their being deciduous, though formed in the natural manner, and the fat is not secreted by the whole interior of the cyst, but by the sebaceous glands, just as the vernix caseosa is in the ibetus. Th'e presence of teeth is explained by their being true products of der- moid tissue, so that wherever that tissue is found there always exists tiie possibility of teeth being developed; and their presence in the jaws is a sort of accident b}^ no means essential to tlieir formation. Dr. Steinlin concludes that the development of the cyst is but a secondary occurrence; that the first step in these cases is the formation of a tissue exactly identical with the external skin, the accumulation of its secretions by degrees distending the investing membrane. The earliest appearance of one of these tumors is as a small, fleshy-looking mass, of the size of a grain of hnseed, in the situation of a Graafian follicle, and surrounded by a small sac. In the course of time this small body becomes detached from the sac except at one point, where its stem remains, and where vessels having a looped arrangement enter it. Next, a thin layer of fat is found between the small lump and the sac, and on careful examination of the former the sebaceous follicles are now seen developed. With the increase of their numbers the fat increases, and the sac becomes distended, Avhile the perspiratory follicles modify by their secretion the contents of the sac. If to this description one adds that the intimate relation between pus and fat globules may be taken as explaining the general 8 98 28 215 14 41 19 92 FAT-CYSTS OF THE OVARY. 405 presence of pus in fat-cjsts of any considerable size, I tliink that the description of this, as of the other forms of cystic ovarian tumor, may be regarded as complete, in so far at least as the prac- tical object of these lectures is concerned. Two points, however, still remain which rerpiire a brief notice: namely, the comparative frequency of disease of one or other, or of both ovaries, and the comparative frequency of the ditiivrent varieties of ovarian disease. AVith reference to the first of these questions, the general evi- dence of statistics, as the subjoined table shows, goes to prove the preponderating frequency of affection of the right ovary. Right Ovary. Left Ovary. Both Ovaries. Total. Cases collected hj S. Lee,i 50 35 " " Chdreau,2 109 78 " observed by Scanzoni, 3 14 13 " " " the author, 35 38 208 164 69 441 This table, however, can be regarded only as a very rougli ap- proximation to the truth in this matter, since it is mainly deduced from observations made during the life of the patient, while it is often a matter of considerable difficulty to determine whetljcr a tumor is formed by the right or by the left ovary ; and harder still to decide that the disease is limited to one ovary, and that the organ on the opposite side is healthy. In two instances, indeed, in addition to those enumerated in the table, I found myself quite unable to determine which ovary occasioned the tumor, and very likely in some other cases the conclusion which I did come to was erroneous. This difiiculty, too, arises not simply from the mesial position of the tumor at the time when the case comes under observation, and from the inattention of the patient to her own early sym|)toms, though that is very frequent, but also from the circumstance that the ligamentum ovarii becomes twisted occa- sionally as the organ increases in size, so tliat a tumor of the left ovary sometimes produces enlargement of the right rather than of the left half of the abdomen. Observation after death, too, fails to bear out the alleged greater frequency of the disease on one side than on the other, while it shows that the affection tends far oftener than would ap}>ear from the former table to involve l)oth ovaries. Scanzoni's figures were deduced from post-mortem examinations, and if to them be added 24 of my own, and 15 of Dr. II. Lee's ca8es,^a total is obtained ot 80 cases, in 28 of which the disease occupied the right side, in 26 the left, and in 26 both ovaries. This result, too, tallies with that which we might reasonably anticipate beforehand, for to the best of my knowledge there is no ground for the sjiecial liability of one ovary, or for the special immunity from disease of the other. 1 On Tii7nors of the Uterus, etc., 8vo., London, 1847, p. 120. 2 As quoted by Scanzoni, op. cit., p. 418. * Ibid. * On Ovaihni and Uter'me Diseases. London, 1853. 406 OCCASIONAL ARREST Professor Scanzoni is, I believe, the only writer who has at- tempted any numerical estimate of the comparative frequency of the different varieties of cj'stic disease of the ovaries.* His 41 cases and my 24 yield the following results : Simple cysts, in 16 cases. Fat-cysts, " 2 " Compound cysts, and cystosarcomata, . ... " 23 " Colloid, or alveolar tumors, " 21 " Cancer with cyst-formation, " 3 " Total, 65 It must be reserved for the next Lecture to consider what becomes of these tumors; to examine how nature endeavors, too often fruitlessly, to effect their cure, and how the disease tends too gen- erally and too inevitably to increase, and as it increases to bring added suffering, and to hasten the approach of death. LECTURE XXVI. OVARIAN TUMORS AND DROPSY. General cockse of the affection; exceptional character of the cysts of the Wolffian bodies — their disposition to remain stationary. Occasional arrest of growth of simple cysts usually temporary — their complete removal very rare. Cj-st sometimes discharges its contents through Fallopian tube, vagina, intestine, externally, or into peritoneum. Changes in cysts, their gradual softening. Inflammation of cysts. Disorder of health from pressure of cyst on viscera; cachexia attending the increase of cyst. Various modes of death. Causes predisposing to ovarian dropsy — influence of age, marriage, and child- bearing. Alleged exciting causes of the disease. The study of the anatomy of ovarian cysts and tumors which occupied us at the last Lecture, has enabled us now to advance a step further in our investigations, and to inquire what is tlieir course^ and what their tendency^ what efforts nature makes to effect their cure, and what are the different ways in which they frove fatal? It has been already stated that practitioners, though ignorant of their real nature, were long familiar with the occasional presence of thin-walled cysts between the folds of the broad ligament, which, unlike other cysts connected with the substance of the ovary, had no disposition to increase beyond comparatively small dimensions. I^ot unnaturally, however, they indulged the favor- able anticipations which were justified only in the case of a pe- culiar and infrequent affection, with reference also to a great number of simple ovarian cysts. Utterly unfounded expectations of the disease eventually becoming stationary have thus on several » Op.cit., p. 418. OF SIMPLE OVARIAN CYSTS. 407 occasions within my own knowledge deterred patients from justly estimating their own condition and prospects, and from consent- ing, while there was yet time, to the adoption of any curative measures. It is therefore of importance to bear in mind that the only cysts concerning which the disposition to remain stationary can he predicated as their general characteristic are the cysts of the Wolffian bodies; and, further, that these cysts have scarcely ever been met with exceeding the size of an orange, while even such dimensions are unusual, and in by far the greater number of instances they reveal themselves by no symptoms during life, and present themselves to the anatomist far oftener than to the physi- cian. One case, indeed, and but one, has come under my own notice, concerning which I could feel justified in assuming that the cyst was not ovarian, but was connected with the remains of the Wolfiian body. The i)atient, who, when she first came under my notice, was fifty years old, remained for eight 3'ears under my observation ; and the tumor which was connected with the right uterine appendages continued during the whole time of the same dimensions, being rather smaller than the foetal head until, with- out any symptom, it suddenly disap})eared, its thin walls having doubtless given way, and its contents having escaped into the peritoneal cavity. The tumor was extremely movable, floating loosely just above the pelvic brim, but occasionally sinking down into its cavity, and then producing discomfort of various kinds, by its pressure on the parts situated there, and es[)ecially by the obstruction it offered to emptying the l)ladder, symptoms which, with its disappearance, completely ceased. This, however, is in my experience a solitary instance of a cyst connected with the uterus remaining quite stationary at a small size ibr years ; so that I fear we must regard the chances as being against the more hopeful view of the nature of any of these tumors, and must furtlier look upon the mere fact of the cyst having attained a greater size than that of a large orange, or of the foetal head, as decidedly negativing it. The arrest of tlie disease may indeed still be hoped for as a lucky accident; it can no longer be counted on as a probable occurrence. I said that the arrest of the disease may in any case of simple ovarian cyst be looked for as a lucky accident; and, indeed, I do not know how more fitly to designate it, for the nice adjustment of the balance between exhalation and absor})tion depends on con- ditions which remedies cannot bring about, which diagnostic skill cannot even foretell. It is not in general while in the pelvic cavity that this arrest occurs ; for though the growth of the tumor may then be slow, it is while situated there liable to be pressed on, irritated, excited by the vaiying condition of the adjacent viscera. After it has risen al)ove the pelvic brim, this fortunate occurrence sometimes takes place, though it takes place but very rai-ely, for, though the cyst is no longer irritated as it was before, its increase is not now restrained by unyielding boundaries, and hence it fre- quently enlarges with greater ra[iidity. As a general rule, the 408 OCCASIONAL SPONTANEOUS enlargement goes on, not continuously, indeed, but by fits and starts, till at length the size of the abdomen causes distress, and necessitates interference. The exception is met with in instances where the cyst having attained a size somewhat less than that of the adult head, begins, to the patient's surprise and pleasure, to diminish, becomes notably smaller than it once had been, though it scarcely ever'entirely disappears, but remains for years, possibly even for the remainder of the patient's life, a source of apprehen- sion and an occasion of some discomfort, but not of much actual suftering, or of serious injury to the health. In March, 1853, 1 saw a single woman, aged thirty-one, in whom the development of an ovarian cyst had succeeded to a heavy fall on the nates three years before. Her abdomen on admission measured thirty-seven and a half inches at the umbilicus; and its increase was alleged to have been going on with rapidity; and the patient was anxious even to undergo some risks for the chance of being \3ured of an ailment now threatening to become the source of much suffering. She was ordered to keep her bed for a few days, in order that a careful examination of her abdomen and of the relations of the tumor might be made. In a week the abdo- men measured only tbirty-five inches; and in another fortnight only thirty-four. I need hardly say that in these circumstances the patient was advised neither to be tapped nor to have any other operation attempted. She returned to the country, and to her occupation as a village schoolmistress. In April, 1855, ber abdo- men measured little more than thirty-five inches; and tapping did not become necessary until between four and five years afterwards. To a slighter degree, and for a shorter time, the partial absorp- tion of the contents of an ovarian C3'st is by no means uncommon; and no one can have seen much of ovarian dropsy without having been struck by the different degrees of tension which the tumor at dilferent times presents. Sometimes it is so tense and firm as to seem almost solid, and, indeed, if the growth be but small, this extreme tension of its walls may so obscure the sense of fluctua- tion as to lead the observer, unless very carefully on the watch, into error. At other times not only is fluctuation most distinct, but the cyst-wall is so flaccid that if the tumor is large it may not be very easy to distinguish between an encysted dropsy and 'ascites.' It is not easy to determine the cause of such fluctuations in the condition of the cyst. A connection may now and then be ob- 1 Cruvcilhior, Anrttomie Pathol., vol. iii, p. 400, speaks of a variety of ovarian cysts as kysfes vniload aires flnsquen, and describes them as retaining a remarkable fiaccidity of their walls in spite even of having attained a very considerable size. He further gives the details of a case in which these characters led two very dis- tinguished physicians into the error of mistaking an ovarian drojtsy for ascites. These flaccid cysts seem to cause comparatively small discomfort, to interfere but little with the general health, and to give rise to no symptoms such as to justify tapping. One such case I saw quite recently, in which it was not till after I had carefully examined the abdomen several times that I came to the decision that the fluid was encysted. CURE OF OVARIAN DROPSY. 409 served between the approach of a menstrual period and an en- largement and increased tension of the cyst, while it once more grows smaller, and its walls become flaccid as menstruation passes otf. In the majority of cases, however, no approach to regular periodicity in these changes can be observed, though even when the disease goes on tolerably uninterruptedly from bad to worse, there are yet almost always seasons during which it remains stationary, followed by times of rapid increase. The increase of the tumor, too, sometimes takes place noticeably in the course of twelve or twenty-four hours; the suddenness of the enlargement showing it to be due to a rapid effusion into the cavity of the cyst, not to the comparatively slow process of growth. If the contents of an ovarian cyst may then vary from time to time, there certainly can be no reason why, in some instances, the process of absorption may not go on so as to effect the entire re- moval of the fluid and the complete cure of the patient. Such an occurrence, however, appears to be of extreme rarity, and some most competent authorities have even discredited it altogether.' In one case I believe that I witnessed it in the person of a young married woman, who had vague symptoms of discomfort about her uterus for nine months, and had been aware of the existence of a tumor for four months before her admission into the hospital. The tumor, which was connected with the left ovary, was tapped per vaginam, and sixteen ounces of highly albuminous fluid were withdrawn. It was determined tliat so soon as the cyst had re- gained its former dimensions, tapping should be repeated, and a solution of iodine be injected, in order to prevent the reaccuniu- lation of the fluid. On the forty-second day after the first tapping this operation Avas to have been done ; but it then struck some who were present that the tumor had seemed larger a day or two previously than it was then. The operation was postponed; and day by day the tumor shrank, not suddenly as if from rujjture oi its walls, nor with any discharge per vaginam suggestive of a com- munication existing between it and the Fallopian tube, but by degrees, as if its contents were gradually absorbed. Fourteen days afterwards, or on the fifty-sixth day from the first tapping, all traces of the tumor had disappeared. Another case lias come to my knowledge of the disappearance of an ovarian tumor in a lady from whom seven pints of deep amber-colored glutinous fiuid were removed by tapping five weeks before the birth of her fourth child. Her labor was quite natural, but nineteen da^-s afterwards, while seated on the sofa, she was attacked by sudden violent pain, with great fiiintness, and s^'mptoms of rupture of the cyst, f)l lowed by those of general peritonitis, for which she was treated very actively. Iler abdomen at this time became swollen to double the size which it had presented when she was tap[>ed. In tlie course of two months, however, this general enlargement sub- ' Kiwisch and Scanzoni, two of the most recent and of the highest authorities, most completely discredit its occurrence. 410 OVARIAN CYSTS MAY EMPTY THEMSELVES sided, disclosing a distinct elastic tumor occupying the hypo- gastric and right iliac regions. This next shrank gradually, so that at the end of nine months from the patient's confinement I could scarcely find any trace of it; and after a natural pregnancy she was confined of her fifth child, two years and a month after her former labor. On this occasion the medical man who attended her, and who had watched her through all her previous illness, searched in vain for any traces of the tumor. In this second case there can be little doubt but tliat some connection existed between the attack of peritoneal inflammation in which the cyst itself was involved and the subsequent complete disappearance of the tumor. In the former instance, however, no symptom whatever attended the removal of the fluid ; but though we do not understand the means by which it was efteeted, still the removal of the fluid is scarcely more inexplicable than the permanent cure which occa- sionally follows a single tapping, in cases where yet neither con- stitutional disturbance nor local suffering has Ibllowed the opera- tion.' The simple absorption of their contents is, indeed, the rarest of all the changes which take place in ovarian cysts. A much more common occurrence, and one by which their increase is for a time arrested, and their complete cure now and then effected, is their rupture, and the escape of their contents through various channels, the empty cyst ceasing, perhaps for a time, perhaps forever, to per- form its secretory function. An ovarian cyat may empty itself through the Fallopian tube, the most fortunate, but by no means the most frequent, outlet for its contents ; through the vagina, through the intestine, or even through the bladder; or it may burst into the cavity of the peri- toneum, or, forming adhesions with the abdominal walls, may pour out its contents at or near the umbilicus. Each of these outlets needs a moment's notice; and, first, of that which is formed by the dilated Fallopian tube. Cases are sometimes met with in which, on examination of the body after death, the fimbriated extremit}' of the Fallopian tube is found adherent to an ovarian cyst, and expanded over it, while the tube itself is distended at its abdominal extremity, and presents all the characters of dropsy. On pressure upon the cyst, however, it is found that the fluid can pass readily from it into the tube, while in most instances, and quite contrary to what might be expected, no mechanical obstacle is found closing the uterine end of the canal. The communication between the cyst and the tube is, however, free enough to admit the point of the index finger, a sliirht contraction marking its situation, and the longitudinal ar- ^ ... Ill rangement of the fibres indicating the commencement of the tube. The mere tonicity of the parts prevents the ready escape of the fluid at the uterine end of the tube. It collects in the canal, dis- 1 A case of gradual disappearance of a well-marked ovarian cyst is related by Dr. Huss in Monatschriftf. Gehui'tskunde, Feb. 1857, vol. ix, p. 143. THROUGH VARIOUS CHANNELS, 411 tending by degrees its abdominal extremity, and at length escap- ing throngb the womb only when it has dilated the whole length oftlie tube, and overcome the natural resistance of its walls. A gush of fluid then takes place by the vagina, and the cyst is partly or even completely emptied, though such discharges do not in general effect a permanent cure, but the cyst retills, the tube becomes redistended, and the same process may be several times repeated. Such at least appears to be the opinion of M. Adolphe Richard,* who has described these cases very minutely, and who suggests, and with much plausibility, that many of the instances of alleged communication of ovarian cysts with the vagina were in reality instances of tlioir opening into the Fallopian tube. No opportunity of studying this process has presented itself to me after death ; and, indeed, I am disposed to believe that it is a rare occurrence, since I have met with but one instance, out^f the ninety-four cases on which my remarks are founded, where the cyst appeared to empty itself in this manner. The patient in that case was a married woman, thirty-six years of age, whose aljdomen first began to enlarge six years before her admission into the hos- pital. After having acquired a considerable size, the swelling suddenly disappeared during a profuse watery discharge from the vagina; and the same occurrence took place afterwards eight or- ten times. The fluid thus discharged was colorless; it escaped with a gush, amounted sometimes to several quarts, and the sud- denness of its flow not infrequently produced faintness or actual syncope. Sometimes it escaped during the efibrt at defecation, but most commonly its flow was independent of any such exciting cause. I myself ascertained the presence of a distinctly fluctuating tumor, its sudden disappearance fourteen days afterwards, and then the slow return of abdominal enlargement during the ensuing three weeks, when I lost sight of the patient. The symptoms, however, were so characteristic, that I imagine one is perfectly justified in assuming the case to have been one of communication of the cyst with the Fallopian tube. The uterus itself was perfectly movable, rather high up in the pelvis, no aperture existed in the vagina, nor, indeed, was the tumor to be distinctly ielt through it; but it evidently floated in the abdominal cavity loosely tethered, as an unadherent ovarian tumor often is, by the elongated uterine appendages. IIow the communication is brought about between the ova'ry and the tube in these cases is uncertain; but it has been suggested, with considerable plausi- bility, that the process is one of a physiological rather than ot a pathological character. In the other instances, however, inflam- » Memoires de la Soci'etf de Chirurgie, vol. iii, 18")3, p. 121. The absence of any evidence of past inflanimatorv action about tlie communication between the ovary and tlic tube, leads M. Kicliard to suppose that the or'v^m of the condition dates back to a byc;one menstrual period ; that the Graafian vesicle haviiii: diseharijed its ovule, did not collapse and wither as it usually does, but still retaining its com- munication with the tube, enlarged, became dropsical, and thus formed what ho lirujioses to term a tubo-ovarian cyst. 412 RUPTURE OF CYST INTO INTESTINAL CANAL. mation, the formation of adhesions, and the absorption of the wall both of the cyst and of the adjacent viscus, are all implied in the escape of the fluid. Many instances are on record^ of a cyst emptying itself per voginam ; and this, too, even if we exclude those concerning which it is doubtful whether they do not more properly belong to the class described by M. Richard. Far more frequent, however, is the formation of a communication between the cyat and the intestinal canal. Generally, though not invariably, this communication takes place quite low down, and seems to be due to the pressure of that portion of the cyst which occupies the pelvic cavity upon the rectum, and the consequent absorption of the walls, both of the intestine and of the tumor. Not long since a communication took place in this manner, in the case of a patient of my own, between a large sac which formed part of a compound ovarian cyst and the rectum a little above the internal sphincter. Through the opening, which was of the size of a crown-piece, many quarts of a darkgrumous fluid escaped during the last few days of the ])atient's life, with much alleviation of her suflerings, and with conqdete removal of the obstinate constijiation that for a long time pre- viously had been maintained by the mechanical pressure of the tumor on the intestine. The observation of this and of similar cases suggests the expediency of attempting to tap the tumor per vaginam whenever serious inconvenience is produced by its pres- sure upon the intestine, and paracentesis through the abdominal walls has cither proved unsuccessful, or has aflbrded but yiartial re- lief. In the instance just referred to very little fluid was obtained by puncture of the abdomen, while, had a trocar been introduced into that part of the growth that projected into the pelvis, the principal cyst would have been enq»tied, and the patient's suffer- ings, which nature mitigated but too tardily, would long before have been assuaged. Sometimes, however, communications form between an ovarian cyst and the intestinal canal in other situations, and are not attrib- utable to the direct eftl'Cts of pressure, though their real cause is very obscure. Thus, in the nmseum of Guy's Hos[»ital there is a preparation of an ovarian cyst, at whose uj»per part an opening has formed into the bowel. A patient of mine, too, in whom an ovarian cyst had developed itself with rapidity in the course of two months, and who experienced much abdominal pain and ten- derness, suddenly felt a sensation as if something had given way within her, and was imn\ediately attacked by violent diarrhoea. In the course of ten hours the bowels were |)urged twenty times; the evacuations not being feculent, but consisting of a dark bloody fluid, which, under the microscope, was founcl to contain many blood globules, and also many pus corpuscles, as well as some crystals of cholesterine. The tumor had now completely disap- * Meissner's Frauenlrankheiten, vol. ii, p. 318, contains numerous references illustrative of this subject. KUPTURE OF CYST INTO PERITONEUM. 413 peared, and five weeks afterwards there was still no trace of it discoverable, though I am unable to say whether the cure was permanent. O^ienings in the abdominal parietes are another channel through which ovarian tumors sometimes empty themselves. In one in- stance which 1 saw the cyst had dilated the umbilical ring, and projected, like a hernia covered by the thinned integument, some inches beyond the surrounding abdominal walls. In this thin in- tegument an opening formed, through which on several occasions the cyst partially discharged itself. It is, however, more usual for the opening to take })lace below the navel, adhesions first forming between the cyst and the integuments. The opening sometimes continues long fistulous, though I have known it to close, and discliarges from it permanently to cease without any special change taking place in the condition cither of the tumor or of its contents. To the best of my knowledge, a permanent cure less often ibllows the discharge of the contents of the cj'st through the abdominal walls than their escape through some other channel. The rupture of an ovarian cyst into the peritoneal cavity is, how- ever an accident of far more frequent occurrence than the dis- charge of its contents through any other channel, and was met with in 6 out of 94 cases of which I have a record. In one of these cases, a fjill on the abdomen produced the bursting of the cyst, but in by far the greater number of instances on record its rupture has been independent of external violence. Sometimes the delicate cyst gives way from over extension, and this is prob- ably the explanation of its sudden disappearance in the case which I referred to some time ago, as being probably an instance of a tumor connected with the remains of the Wolffian body ; as also in another instance where a tumor half the size of the adult head suddenly disappeared, the same accident having occurred to the patient eighteen months before. In other cases inflammation and softening of the cj'st-wall have preceded its rupture ; and an exam- ination after deatli discovers it red and congested, and the edges of the rent soft, irregular, and jagged. Sometimes the sac, once ruptured, does not refill, and a permanent cure is obtained, though usuall}^ at the expense of an attack of peritonitis ; and I much fear that there is no direct or constant relation between the severity of the inflammation which follows the rupture of the cyst and the non-accumulation of the fluid afterwards. One of my cases was that of a young lady, aged twenty-six, in whom an ovarian cyst gave way twice, and whose life on each occasion was in the greatest jeopardy, but who did not gain thereby the slightest delay in the ra})i(lity with which the fluid re-collected. In two other cases of mine the rupture of the cyst proved fatal; the wall having in both instances given way at the posterior part of the tumor, where it was closely pressed against the pelvic brim, and extensive eccliy- mosis around the rent attested in one case the mechanical obstacle which had existed to the course of the blood in that situation. In 414 INFLAMMATION OF the other case decomposition was too far advanced to allow of any observation as to the state of the cjst-wall. The mortality of 2 cases out of 6 agrees very nearly with that which Dr. Tilt* deduces from a collection of 34 cases, in 10 of which death followed the rupture of the cyst. In 20 of the cases, however, the fluid did not re-collect, but I feel very doubtful whether a more numerous collection of facts would be found to bear out the conclusion that in 2 cases out of 3 the escape of the cyst contents into the abdomen is followed by the permanent cure of the patient.'-' For the very various results that have followed the escape of the fluid of ovarian dropsy into the abdomen an explanation has been suggested by Dr. Simpson,' and adopted by Scanzoni.^ It is supposed that the difl'erent characters of the fluid in the cyst determine the occurrence or non-occurrence of peritonitis; that the pure serum gives rise to no ill eflbcts, while dangerous peri- tonitis follows the escape of fluid mixed with blood or with the products of inflammation. Still, this is only an hypothesis, ])roba- ble, indeed, but not proven, and wholly insufficient to form the basis of any therapeutical proceedings. Otlier changes take place in ovarian cysts^ tending for the most part less to the cure than to the aggravation of the evil. Some of these changes seem incidental to the process of growth, as for instance the removal of the sc})ta between the cysts, the gradual liquefaction of the solid matter, and the consequent conversion of a firm into a distinctly fluctuating tumor. This alteration is in one sense of bad omen, since I believe its occurrence is generally contemporary with the more rapid increase of the growth ; on the other hand, however, it often jdaces within our reach the means of mitigating the patient's sutierings by tapping, wliich in the earlier stages of the aflection was impracticable. With the rapid growth of the tumor there is in all cases of compound ovarian cysts a corresponding increase in the vessels which supply it, and a consequently greater disposition to hemorrhage into its cavity. Sometimes, indeed, the admixture of blood with the fluid of the cyst is so considerable as no doubt to have had a large sliare in the production of that anaemia, and that extreme exhaustion of strength which are often observed in patients suffering from large ovarian tumors. Of all the morbid processes, however, of which these growths are the seat, inflammation is the most common and the most im- portant. Few cysts attain any considerable size without having been attacked by it, and this inflammation is of all the greater moment, since it is seldom limited to the interior of the cyst, but J Lancet, Aug. 5, 1848, vol. ii, p. 146. 2 In vol. V, p. 226, of Transactions of Pathological Society, a case is related by Dr. Bristowc of rupture of an ovarian c^-st into the abdomen, the aperture remaining permanent, the cyst still continuing to secrete, and ascites resulting from the accu- mulation of the secretion within the peritoneal cavity. 3 Op. cit., vol. i, p. 247. * Op. cit., p. 448. OVARIAN CYSTS. 415 generally affects its outer surface likewise, producing adlicsions between it and adjacent organs, and thus forming great, often insuperable obstacles to the success of various operations wliich have been proposed for the cure of ovarian dropsy. In a practical point of view, too, this inflammation is the more important from being often unattended by local suffering, sometimes, indeed, accompanied by a comparatively small amount of constitutional disturbance, so that it is almost impossible to determine anything with certainty concerning its occurrence or non-occurrence from the patient's history. Of this no better proof can be given than is afforded by the observation of cases where on tap[)ing a cyst, instead of the transparent serum which it was supposed to con- tain, a turbid fluid largely mingled with pus has been let out, or of other cases in which, the extirpation of the tumor having been resolved on, universal adhesions have been found connecting it with the viscera, and with the abdominal walls. In many in- ' stances the inflammation issues in the exudation of lymph as well as in the outpouring of pus, and the lining membrane ot the cyst is found roughened and thickened by its deposit, which is some- times so abundant that it may be stripped ofl'just as may the false membrane deposited on an inflamed pleura. Multilocular cysts are, I think, more liable than simple cysts to this occurrence ; and often, even where the diflerent cavities intercommunicate, inflam- mation and tlie outpouring of lymph may be found in one cyst, and no trace of any such occurrence be observable in another immediately adjacent. With the increase of the tumor, and the failure of the patient's powers, the liability to inflammation of the cyst appears to in- crease also, and its occurrence contributes to hasten the fatal event. It is but seldom, however, except after tapping, or some other operation, that cyst inflammation of itself proves fatal ; but many causes in general combine by slow degrees to destroy the patient. First among these causes may be mentioned the disorder of the functions of other viscera, as the tumor by its increasing size presses upon and disturbs them. The pregnant uterus, as you know, even when it has attained its largest size, interferes but little with the functions of other organs. The intestines find room on either side of it, while the direction of its fundus forwards in the axis of the pelvic brim obviates all interference with the descent of the diaphragm, and usually prevents all disturbance of the stomach or liver. The ovarian tumor, on the other hand, as it increases in size, so completely fills the lateral regions as to leave no room for the intestines except behind and above it, where they are often compressed into a very scanty space. No such law governing the direction taken by the tumor as regulates the enlargement of the pregnant womb, the descent of the (liai>hi:igm becomes earlier impeded, and respiration is thereby rendei-ed labored. The liver is at the same time pressed on and disturbed in the performance of its functions, and this just at a time when the active discharge 416 MODES IN WHICH of its duties is rendered all the more necessary by the congestion of the abdominal vessels which the pressure of the tumor occa- sions, and the scanty urinary secretion that is its attendant and its consequence.^ In a large proportion of cases this abdominal congestion relieves itself by the effusion of fluid into the peritoneum, and in some in- stances the amount of this effusion is very considerable; enlarge- ment of the superficial veins attests the obstruction to the circu- lation, and the ascites becomes the occasion of more distress than the original disease to which it is superadded. Oedema of the lower extremities is less frequent than in pregnancy, probably because the peculiar state of the blood which fixvors its occurrence in the latter condition is absent. AVliere it exists it is often con- fined to one limb, being the direct result of mechanical pressure. This is not invariably the case, however, for ovarian dropsy is sometimes associated with albuminous urine, whether as the re- sult of its accidental complication with granular disease of the kidneys, or of congestion of those organs produced by the pres- sure ol"the tumor, I do not feel myself able to determine. While the enlarging tumor thus tends to trouble all the func- tions -of the body, the patient's strength is further exhausted by the determination to the growth of a large quantity of that blood which ought to minister to the general nutrition of the body. Nor is this all ; but a state of cachexia, the consequence and the evi- dence of the deteriorated condition of the blood, occurs frequently in the course of this, as of other forms of malignant disease, with which, if not actually identical, many tumors of the ovary are at any rate closely allied. In the simple ovarian cysts it is true that this latter source of suffering and of peril does not exist, and the prospects of the patient are accordingly far less dark than in other varieties of the disease. These simple cysts, too, as has already been mentioned, now and then remain stationary for many years, life being not at all shortened, scarcely even embittered, by their presence. Such, however, are exceptional cases, and exceptions of but rare occurrence ; for generally the accumulation of fluid even in a simple cyst, sooner or later necessitates the perform- ance of tapping, while when once done its repetition is speedily required, and the patient is thus worn out by the frequent collec- tion and frequent evacuation of the contents of the cyst. A certain risk, too, of cyst-inflammation accompanies every tapping, and is, when it occurs, a hazard of a very serious kind. The liability to its occurrence appears to be greatest either after the first per- formance of the operation, or else in the case of patients who have been exhausted by the long continuance of the disease, and the frequent repetition of the tapping. In much debilitated pa- tients, especially in those who are sufiering from malignant or 1 Two drawings given by Dr. Bright, loc. cit., pi. vii, ix, are extremely instruc- tive illustratiuns ui' the manner in which tumors of the ovary press on and displace the viscera. OVARIAN DISEASE PROVES FATAL. 417 quasi-malignant forms of ovarian disease, the spontaneous super- vention of cyst-inflammation, or of a low form of peritonitis, is of no very rare occurrence, and not infrequently puts out the lite whose flame had burnt but flickeringly for weeks or months before. We have now completed our examination of the structure of cystic tumors of the ovary, and have also studied tlie dilfcrent modes whereby, in some rare instances, nature effects their cure, as well as those far more numerous ways by which the patient is usually conducted from bad to worse, and the fatal issue is but too surely brought about. Before we proceed to the investigation of the symptoms of these diseases, and to the inquiry as to what either medicine or surgery can do for the^ alleviation or their cure, there are still some questions concerning their causes, and the circumstances that favor their occurrence, to which we must endeavor to furnish a reply. It may be asked, when do these aifections commonly occur; what is the influence of the exercise of the sexual functions upon their development ; whether does sterility or fecundity predis})Ose to them; and does a disordered state of the uterine health com-' monly precede them ; or are they as likely to befall the person whose health has been previously good as her who for years has been a valetudinarian ? To these inquiries as to the aaum's of ovarian dropsy, it would seem that very definite and conclusive answers might be given, and yet, strangely enough, the replies are most contradictory. The young and the aged, the single and the married, the sterile and the mother of many children, the robust and she whose uterine functions have been performed with pain and difliculty, have all in turn been asserted to be specially liable to the occurrence of ovarian disease. With reference to the age of patients in whom the disease occurs, there seems to be no period of life that enjoys an absolute immunity from it; though it is of extreme rarity before puberty, and its commencement after the cessation of the menstrual func- tion, though far less uncommon, is certainly unusual. Professor Kiwisch mentions^ a preparation of cystic disease of the ovary in a child only a year old in the museum of Prague, and refers to a similar one at Wiirzburg, in which the affection involved both ovaries in the foetus. lie states, however, that fourteen years is the earliest age at which he himself had observed it; and a girl died in St. Bartholomew's Hospital, under the care of Dr. lUir- rows, from malignant disease of the ovaries, with cyst-formation in their substance, who had not attained her fitteenth year. One of my patients died of rupture of the cyst when in her sixteenth year, and the enlargement of her abdomen, which was very con- siderable at her death, was alleged to have been first observed when she was thirteen years old — menstruation not having occur- red till the age of fourteen years and six months. In another of my patients the disease began in her seventeenth year, menstrua- • Oj). cif., vol. ii, p. 70, ? 36. 27 418 CAUSES PREDISPOSING tion having occurred once at the age of fifteen and a half; "but it did not reappear till after she was tapped at the age of eighteen. These, however, are exceptional occurrences, and in nearly half of all cases of ovarian dropsy the commencement of the disease dates from hetween the asres of thirty and forty. This result, at least, is what I arrive at from a comparison of 94 cases of my own with 97 of Scanzoni's,^ which are thrown into the following table. I employ Scanzoni's figures in preference to those of any other writer, because he alone has taken as its basis the ages at which the first symptoms of the disease appeared, while many writers have constructed their tables according to the age at which the pati|^its fii'st came under their observation. Tables showing the Age at which, in 191 Women, the symptoms of Ovarian Dropsy ivere fir^t "perceived. Author's Scanzoni's Tot^l ^^'^ ** ^'"^ Proportion per cent, cases. Cases. ' ' symptoms. at different ages. 17 5 22 from 13' to 25 years, 11.5 15 12 27 " 25 " 30 " 14.1 15 21 36 " 30 " 35 " 18.8 23 82 55 " 35 " 40 " 28.7 11 14 25 •' 40 " 45 " 13.0 8 6 14 «' 45 " 50 " 7.3 3 2 5 ." 50 " 55 " 2.0 2 5 7 " 55 " 60 " 3.6 94 97 191 The next question concerns the influence of the exercise of the sexual functions in predisposing to the disease — an influence which you may remember was ver}^ decided in the case of uterine cancer, since only 3 out of 168 patients aft'ected by it were single women, and only 13 out of the 165 who had been married were sterile. Of 94 cases of ovarian disease, however, 24 occurred in single women, 13 in widows, and 57 in the married — a statement which refers to their condition at the time when the disease commenced. This proportion is not very materially altered by the employment of higher numbers, since, adding to my own cases those collected by ]\Ir. Lee and those observed by Scanzoui,^ we obtain the follow- ing results : Single women, 94, or 28.7 per cent. Widows, 31, " 9.4 " Married women, 202, " 61.7 " 327 or, in other words, considerably more than a third of all cases of ovarian disease began at a time when the sexual functions were not in active exercise ; and more than a fourth occurred in women in whom those functions had never been exerted at all. 1 Op. cit, p. 365. * Op. cit., p. 365. I have included in this list of married women, seven, who, though single, had given birth to one or more children. TO OVARIAN DROPSY. 419 That tlie exercise of the sexual functions does not predispose to ovarian disease, but that, on the contrary, some connection sub- sists between their imperfect performance and the development of this aftection, is evident from the low rate of fecundity among married women in whom ovarian dropsy occurs. Of 70 of my patients, either married or widows, there were 26 sterile ; and of Scanzoni's 52 cases, 18 who had likewise never been pregnant; or in other words, in 44 of 122 women who became the subjects of ovarian dropsy, or in 36 per cent., marriage had never been followed by conception, while among my patients generally at St. Bartholomew's IIosj)ital the proportion of sterile marriages was only 11.7 per cent. Even those marriages, too, that were followed by conception showed less than the average fecundity; for of my 70 cases, the 44 in which the women were not sterile yielded otdy 172 pregnancies; of these 129 terminated at the full time, 43 ended in miscarriage. These numbers yield an average of 3.9 pregnancies to each fruitful marriage, or little more than half the number which occurred in persons in whom cancer of tlie womb took place. It may perhaps as well be added, that in 14 of the total 33 cases pregnancy occurred but once, and terminated in 3 instances prematurely, in the other 11 at the full period of gestation. One question still requires an answer — namely, what connection, if any, subsists between the ordinary state of a 2:>afient's ntrrine health, and the subsequent development of ovarian disease? Now nothing can seem more probable than that she who has men- struated irregularly, painfully, or scantily, shall be more liable to suffer afterwards from diseases of the ovaries than the person whose menstruation has always gone on quite regularly. This, too, appears from Scanzoni's statement really to be the case ; though my own observations do not corroborate his assertion, and probably neither his facts nor mine are sufficiently numerous to decide the question. Of my own 94 cases, there were 72 in which the ordinary uterine health was quite good; 3 had had puerperal inflammation, but had quite recovered from its eftects; 1 was still weak from hemorrhage after delivery; in 8 menstruation was always painful; in 5 men- struation was always scanty; in 3 habituall}' irregular; 1 was chlorotic, and had bad uterine health in all respects; i had suffered for years from great hypertrophy of the neck of the womb, and much consequent discomfort. On the other hand, Scanzoni says that there were but 20 of his 57 cases in which menstruation was always healthy; while 19 patients had suffered more or less from chlorosis, 12 from dys- menorrhoca, 5 had always menstruated very profusely, and 1 })a- tient, in whom ovarian disease came on in her forty-first year, had never menstruated at all. Be the truth concerning this matter what it may, I cannot but think that Scanzoni's figures overstate the frequency of menstrual disorder, as a precursor of ovarian disease, as much as mine perhaps err on the opposite side. We find that in the case of most diseases, our patients like to 420 EXCITING CAUSES OF OVARIAN DKOPSY. assign some cause for the commencement of tlieir ailment, a cause often indeed quite fanciful, sometimes absurd. It is so in the case of ovarian diseases, while if all mere phantasies are rejected, the instances will turn out to be comparatively few and excei^tional in which any plausible ground can be assigned for the beginning of the affection.' In 21 of Scanzoni's 97 cases, and in 18 of my 94, or in 39 out of 191 instances, the following were with some prob- ability alleged as the exciting causes of ovarian dropsy : Bogan within a year after marriage, ... in 6 Came on during pregnancy, " 2 Followed not long after delivery, .... "15 Succeeded to abortion, " 4 " metritis from cold, " 3 " suppressed menses from cold, . " 2 " violent blow on the hypogastrium, " 1 " violent blows on the pelvis, . " 2 " strains, or over-exertion, . . " 3 Occurred simultaneously with ascites and ana- sarca from exposure to cold, " 1 39 From all these facts, then, we may conclude that the immedi- ately exciting cause of ovarian dropsy, when any cause can be assigned for it, is usually connected with some disorder of the uterine functions, or with the recent excitement of their highest forms of activity. Nevertheless, too wide an inference must not be drawn Irom this fact, since in the great majority of instances the disease comes on independently of any cause to which it can be reasonably attributed; while further, it occurs in the unmar- ried ortener than most other organic diseases of the sexual organs; and the married who suffer from it are remarkable for their low rate of fecundity, and for the frequency among them of absolute sterility. In the next Lecture we shall leave these incomplete and incon- clusive details for the more important practical inquiry into the symptoms and diagnosis of tumors of the ovary. ' Of 36 instances collected by Mr. Lee, op. cit., p. 118, there wore 28 in which the alleged causes had reference to the uterine functions, being in -3 marriage, in 9 labor, in 2 abortion, in 7 sudden suppression of the menses, in 2 cessation of men- struation, and in 3 irregularity of its performance. EARLY SYMPTOMS OF OVARIAN DROPSY. 421 LECTURE XXVII. OVARIAN TUMORS AND DROPSY. Symptoms of the disease occasionally absent in early stage: generally referable to five heads — of functional disorder of ovaries, pain, the etlects of pressure, cachectic symptoms, and the symptoms consequent on interference. Diagnosis, its difficulties; diagnosis from inflammation of broad ligament and its efl'ects, from fibrous tumors of uterus, misplacement of uterus, ascites, disten- sion of bladder, pregnancy, tumors of spleen or liver, &c. Note on floating tumors of tue abdomen. Many uterine ailments in their early stage present a puzzling resemblance to each other. Pain and menstrual disorder are common to most, and accompany as well the slight as the more serious affections, while it is often not until after some time that the distinctive features of the disease show themselves, and enable us to determine its nature, and to estimate its importance. This is especially true with reference to ovarian disease, which at its onset commonly attracts but little notice, owing to the vagueness of its early si/mptoms : while not infrequently, just as is the case with fibrous tumors of the uterus, its existence is not sus- pected till accident all at once reveals the presence of a growth of considerable size. On a comparison of the 94 cases on which these observations are chiefly founded, it appears that the first symptom of ovarian disease was — Suppression of the menses, 11 cases Irregular menstruation, 5 " Scanty and painful menstruation, 1 " Profuse menstruation, 2 " Sudden faintness, accompanied by symptoms resembling those of pregnancy, 1 " Pain in the abdomen, more or less distinctly referred to the side where the disease began, 31 " Retention of urine, or difficult micturition, .... 10 " The unexpected discovery of a tumor, 33 " 94 " The want of attention to their own condition innilied in the very considerable size to which abdominal tumors sometimes at- tain before they attract the notice of patients is so remarkable as to be scarcely credible if it were not of every-day occurrence. Not very long since I saw a young lady in whom an ovarian cyst of the size of the adult head was only accidentally discovered incon- sequence of her suflering from a severe attack of abdomintd pain while staying in the house of a medical man. If tumors so large can escape notice, it is less to be wondered at that those of smaller size should frequently be found out only when they become the 422 SYMPTOMS OF OVARIAN DROPSY seat of pain, or when they cause inconvenience by pressure on surrounding viscera. It is not easy to say on what the frequent absence of symptoms in the earlier stage of ovarian dropsy depends. The immunity from suffering then is also far from constant, and in many instances much more pain and discomfort are experienced while the enlarged ovary still remains within the pelvit in both lumbar regions, where there was semi-resonance on the right 432 ASCITES MISTAKEN FOR side and a clear sound more marked and more extended on the left. Her history was, that having begun to menstruate at fifteen, the catamenia continued regular for twelve months, when they ceased in consequence of a fright at a menstrual period. Her health, however, still remained pretty good, but about five months before she came under my notice the abdomen began to enlarge, and for a month this enlargement had been going on with great rapidity, and her respiration had become impeded, while some swelling of the legs had taken place within a week. There was no enla'i-gement of the superficial abdominal veins ; the generally dull sound on percussion, with the resonance in the lumbar re- gions, the patient's age, her history, all tallied so exactly with the opinion said to have been expressed by her previous medical attendant, that no doubt was for a moment entertained as to her disease being ovarian dropsy. Twenty pints of clear, yellowish serum were let out with great relief, a bandage was applied to the abdomen, and no bad symptoms followed. In eleven days, the fluid having re-collected, seventeen pints were once more let out, and oX. of a solution of iodine were thrown in through the eanula, and so com[)letely was the nature of the case taken for granted, that this was not preceded, as it ouglit to have been, by a repetition of careful examination of the abdomen. The injec- tion caused some pain and alarming faintness, and until the pa- tient's death in sixteen and a half hours great faintness was the prevailing symptom. There was but little pain, no anxiety of countenance, no restlessness, or jactitation ; and though the pulse was very feeble, yet for eight hours the heart's action was good and regular, the patient dozed occasionally, and awoke sensible. After that time, however, more marked collapse came on, the sur- face became cold, vomiting occurred frequently, and sinking thus, she died with very little sufiering, and retaining her intellect un- clouded almost to the last. Examination of the body discovered intense congestion of the peritoneum, a few adhesions between the coils of intestine in the upper part of the abdomen, and more numerous adhesions lower down, but no effusion into the abdominal cavity, nor any general deposit of lymph on either surface of the peritoneum. The uterus and its appendages were liealth}-, there was no tumor anywhere, but the liver was shrunken to half its natural size, and in a state of very far advanced cirrhosis. Both of these cases are instructive, but the latter is especially so. It teaches the sleepless watchfulness which alone can guard from error, the importance of not taking anything upon trust, nor of allowing our judgment to be swayed by any previously expressed opinion as to the nature of the disease, when once a patient comes under our care, and we assume the responsibility of her management. It shows the need, too, of not taking the previous history upon any other person's authority, but of cross- examining botli the patient and her friends ourselves. In this instance it was ascertained after the patient's death that her sister OVARIAN DROPSY. 433 had died of disease of the liver, and that the fright which was followed by suppression of the catainenia, was succeeded also by severe [)ain in the riglit hypochondriuni, and by great sallowncss of the complexion, which subsequently passed away. These facts would doubtless have awakened attention to the possibility ol" the fluid in tlie abdomen being dependent on some visceral disease, though the existence of advanced cirrhosis of the liver in so youno- a person is undoubtedly an exceptional occurrence. The case shows, moreover, that enlargement of the superficial abdominal veins is not a constant attendant on obstruction of the portal cir- culation, while it further proves that resonance in the lumbar region is not so trustworthy an evidence of encysted dropsy as is commonly supposed. The presence of a considerable amount of flatus in the large intestine may cause percussion to yield a clear sound, and this is especially the case on the right side, where the varying relations of the csecum greatly modi ty the result which we obtain. Lastly, we may deduce the rule, that the distinct per- ception of the outline of the tumor is a condition indis})enHable to any attempt at operation, and further, I may add, that this must have been perceived, not simply on a previous occasion, but also at the very time at which the operation, be it what it may, is attempted. lii the cases which I have related, no solid tumor existed, or at least none whose situation at all corresponded with that which would be occupied by the enlarged ovary. Ascites and ovarian tumor may, however, coincide, but the tendency of any error in diaijnosis in such a case will be rather to overlooking the existence of the tumor, than to misinterpreting the ascites. Sometimes, indeed, the solid tumor is not perceptible until after the removal of the fluid by tapping, while in other instances it is found, on careful examination of the abdomen, that the hand, displacing the superjacent fluid, comes down here and there upon a solid bod}-, whose exact dimensions and form it may yet not be possible to determine. It is chiefly as influencing our prognosis that the de- tection of the solid tumor is of importance. Tlie presence of a small quantity of fluid in the abdominal cavity adds little or nothing to the gravity of the prognosis of ovarian dropsy. On the other hand, the })resence of a largo amount of fluid in tlie peritoneum associated with a small solid tumor is always a matter of great moment. Such a tumor is seldom ovarian, for ovarian tumors, though when large they disorder the circulation through the abdominal vessels, seldom so far interrupt it as to jtroduce any considerable efl'usion. Solid tumors so situated as to have this effect are often malignant in character, are very likely to increase, and are scarcely at all within reach of any kind of inter- ference. The distended bladder has been taken for a dropsy of the ovary, but this is an error wliich ought not to be committed. The exactly oval ibrm of the tumor, its mesial situation, its tension as ascer- tained by external examination, the unchanged position of the 28 434 DIAGNOSIS OF OVARIAN DROPSY. uterus, the absence of any tumor felt per vaginam, or if any be discovered, its situation in front of the uterus instead of behind it, are characteristic, even if no history of the case were obtain- able. It is almost needless to remind you that in every instance where the nature of a tumor admits of doubt, the catheter should be introduced in order to obviate the possibility of this cause of error. The mistake of dropsy of the ovary iov pregnancy is impossible so soon as the case is submitted to a thorough examination, though it is far from rare for idle whispers to be raised prejudicial to a patient's character before she has come under medical observation. Examination per vaginam, and the discovery of the unaltered state of the OS and cervix and lower segment of the uterus, as contrasted with the closure of the os, the soitening of the cervix, and the ex- pansion of the lower segment of the womb which accompany pregnancy, cannot but remove all doubt. In those cases, how- ever, in which a mistake would be most serious in its conse- quences, namely, in unmarried women, we are often precluded from giving to any one the slightest hint of our doubts or suspi- cions, and are consequently unable to suggest the expediency of making a vaginal examination. So long, too, as an ovarian cyst docs not exceed the size of the womb at the fifth month of preg- nancy, it is by no means unusual for it to be elastic rather than distinctly fluctuating, while tlie position of the tumor is often so neurly mesial that its situation does not ailord any means of dis- criminating between it and the gi-avid uterus. The alisence of the mammary sympathies, and also of any sound like the uterine souille, can both in general be ascertained, and deserve great reliance, as strong negative evidence against the existence of pregnancy. There are still some rare conclitio11s\^voi\\\(i\\vQ. of enlargement of the abdomen which may be mistaken for ovarian tumors. Such, for instance, are those large accumulations of fluid which have been found in the substance of fibrous growths of the uterus,' and such the almost equally uncommon cases of encysted drojisy of the abdcmien, where the fluid collects in the sub-peritoneal cellular tissue, or between the layers of the omentum.'* One instance of this latter occui-rence has come under my own observation, in which between four and five quarts of a dark fluid were found collected between the folds of the omentum, and during the pa- tient's lifetime frequent discharges of a similar fluid had taken place from the umbilicus. The dropsy had during the life of the patient been supposed to be ovarian ; but though malignant disease 1 See a reference to these cases in a note at p. 220. "^ On the subject of cj'sts of the abdominal cavity see Abeille, T)-aiU des Hydrop- sies et des Kysies, 8vo., Paris, 1852, pp. 519-587; Copland's i)(c/;onari/, article Dropsy, and the references at p. 660; S. Lee on Tumors of the Uterus, p. 123; the cases of Sir B. Brodie, Med. Gazette, vol. i, p. 334 ; Dr. Thomson, ibid., p. 468 ; Cruvcilhier, Traite d'Anatomie Pathol., vol. iii, p. 518; and the papers of Mr. C. Hawkins, Med. Chir. Trans., vol. xviii, p. 175; and M. Chantourclle, Archives de Med.., 1831, vol. xxvii, p. 218. FLOATING ABDOMINAL TUMORS. 435 of Loth ovaries was discovered, yet neither of them contained fluid at all similar in character to that which was found in the omentum ; nor, indeed, could either be detected till after the fluid in the omental cyst had been let out. I am aware of no means by wliich such cases are to be discriminated from ovarian dropsy; as far as I know, their nature has scarcely ever been suspected during the lifetime of the patient. The only conditions in which large tumors of the spleen or liver are likelj' to be taken for growtlis of the ovary, are when they are of very long standing, have acqnired a very large size, and have occurred in persons who are either incapacitated by illness Irom telling their own history, or wlio have been so unoljservant as not to notice the beginning, and scarcely to attend to the progress of their disease. Still, even in these circumstances the prominence of the tumor at the ui)per part of the al)domen,the dulness in the h3'pochondriac region, and the fact that at some jxirt, if not at all, the lower Qi\g:Q of the growth can be detected, will keep the mod- erately careful observer fnmi error. And here, I think, we may take leave of the diagnosis of ova- rian tumor.^ That fasces in the large intestine have been taken 1 I know no place more fitting than the present for a brief reference to those foaling nhdom'mal iumorfi which all practitioners have occasionally met with, though much difference of opinion has prevailed with reference to their real nature. All of these tumors bear a very close resemhlance to each other, both in size, shape, and situation. Thcj' are oval in form, usually about the size of a turkey's egg, and are generally situated in the hy))ochondriac or lateral region, their lower margin seldom descending below the level of the iliac crest. In most instances one tumor only is present, but sometimes there are two in opposite sides, and for the most part symmetrical in all respects. They generally admit of displacement inwards towards the mesial line much more readily than outwards, and upwards to a far greater extent than downwards, so that they can sometimes be pushed up out of reach under the floating ribs, but seldom downwards into the iliac region, and never into the pelvic cavity. They are firm, though not without a certain degree of elasticity ; their surface is smooth and regular; no sound can be detected in them by means of the stethoscope, and they yield a dull sound on percussion, modified only by the presence of a coil of intestine distended with air behind them, when they may yield a sort of semi-resonance. Pressure on them is painful, but the pain, which is of a peculiar, sickening character, usually passes oti" when they are no longer handled. Sometimes, however, they arc the seat of a constant ■wearing pain, which comes on causelessly, and continuing for hours, days, or weeks, subsides equally without occasion, though it may be said, as a general rule, to be aggravated by exertion and mitigated by rest. They have either been acci- dentally found out on examination of the abdomen for some other purpose, or the pain experienced in them has led to the discovery of their jiresence by the [latient. Their rate of increase must be slow, for though jiatients atfected with them have for years been under my occasional observation, 1 have never ascertained that their size has und(^rgone any modification. I know of one instance, too, in which a tumor of this descrij)tion had existed for more than twenty years in a lady of sixty, unchanged in shape, size, or situation. This lady had been seen by th<> late Dr. Warren, by Sir Astley Cooper, and Sir Benjamin IJrodie, and it may illustrate the obscurity which jirevails with reference to their nature if I mention that each of these eminent men gave a ditlerent opinion with reference to it, one of them regarding it as connected with the mesentery, another as a floating kidney, and a third believed it to be ovarian. I have a record of thirteen cases, of which the chief particulars are rejiresented below in a tabular form : 436 FLOATIXG ABDOMINAL TUMORS, for them ; that fat and flatus have raised a suspicion of their pres- that the abdomen even has been opened to remove a tumor enee Age. Tears married. Seat of Tumor. Period it had existed. Symptoms. r Accidentally dis- "J 26 2 Right Hypochondrium. J covered when under I j treatment for [ (. another ailment. J None. 27 4 . « " One year. Pain and dyspepsia. 29 H Left Hypochondrium. " J I'ain. which came ) ( on after e.xertion. J 30 6, sterile. Right Hypochondrium. Eighteen months. Pain and dyspepsia. 35 Married. Both hypochondria. f Left, nine montlia. > I Right, three weeks. J Pain. 38 14 Right Hypochondrium. One year. " 47 Married. Left Iliac. Seven years. Pain, occasional. 60 /Twice married,) 1 now a widow, j' Right Iliac. Twenty years. Slight occasional pain. 38 17 Right Hypochondrium. Six months. Occasional pain. 30 5 " Three years: and a half. r Two years follow- "| Dull pain. 45 2, widow. » « J ing violent ( Slight pain in right j concussion on f ( raiUay. J leg. 40 20 11 « ■ Thirteen years after ) birth of a child. i Dull pain. 35 9 » « Accidentally dis- \ \ covered. J None. In 10 cases, then, the tumor was seated on the right side, in 2 on the left, and in 1 on both sides, its position having in 11 out of the 13 been distinctly in the hypochondrium, twice only in the upper part of the iliac region, and in those two instances allowing of displacement upwards, but not at all in a downward direc- tion. The connection of dy?pi'ptic sytnptoms with the tuniur in the right hypo- chondrium on two occasions may suggest the probability of its being sometimes formed by the scirrhous pylorus, an hypothesis which, in the case of a patient under the care of Dr. Burrows, was confirmed by post-mortem examination. Some movable tumors ma}- pos.-ibly be connected with the mesentery, and some may admit of the explanatit)n which 1 have been informed that the late Dr. Aber- crombie, of Edinburgh, proposed. He thought that a sort of spasmodic constriction of some of the fibres of the colon inclosed a small collection of flatus, suflicient to form a swelling distinctly perceptible by the hand of the physician, but di.T 1859, vol. il, pp. 158 and 301, M. Fritz has collected from various sources 35 cases of floating kidney. Of these 5 only occurred in the male, 30 in the female. In 19 cases the right kidney was movable, in 4 the left; and while in 7 both organs were somewhat misplaced, the mobility of the right kidney was in 5 of these in- stances much greater than that of the left. ' Ariatomie Pathologique Generale, vol. ii, p. 723. OVARIAN TUMORS AND DROPSY. 437 which was found to have no existence, proves only how large is the possibility of error, how vigilant must be our care if we will avoid a danger which the wisest have not always been so fortu- nate as to escape. LECTURE XXVIII. OVAKIAN TUMORS AND DROPSY. Treatment; difficulty of estimating its results. Duration of life in ovarian dropsy. Cases divisible into three classes: some must be let alone, some may be, some require interference. Prophylactic measures, and medicinal agents. Operative proceedings. Tapping, when absolutely necessary. Opinions as to danger of its performance, statistics of the subject, bad re.sults possibly over- estimated, circumstances in which early tapping may be admissible. Mode of performing the operation ; danger of exhaustion and of cyst inflammation ; their symptoms and treatment. • There is some fallacy as well as much truth in almost all pop- ular sayings. Even the adage that a "doubtful remedy is better than none," is not of universal application, for doubtful remedies are often dangerous, and if they fail to cure they frequently aggra- vate the disease. The danger of the disease itself is an element never to be lost sight of in our estimate of the expediency of interfering with its progress ; and if the present suffering it occasions is but small, if its advance is likely to be slow, if it may- be interrupted by occasional pauses, we should hesitate to advise any proceeding by which, though perfect cure may possibly be wrought, yet, on the other hand, life may be cut short suddenly. The chances of complete recovery will b}- few persons be felt to overbalance the risk of immediate death, and I do not think it becomes us to throw the weight of our influence into the scale. Considerations of this kind are nowhere more in place than in an inquiry into the treatment of ovarian tumors and dropsy — a class of diseases which indeed tend progressively from bad to worse, which often bring with them much suffering, Init in which, never- theless, the sufi:ering is not invariable, nor the downward tendency constantly progressive, so that we cannot limit their jiossible duration, or, from the date of their commencement, calculate with any approach to certainty the time which will elapse before they reach their close. The reasons for this uncertainty are so obvious as scarcely to need that I should insist upon them here. I may, however, re- mind you that in many instances we are unable to fix the time at which ovarian disease began ; so imperceptible are often its ad- vances, so few the symptoms that accom[)any its earlier stages, that not infrequently the growth has attained a considerable size before the attention of the patient, or of her medical attendant, is 438 UNCERTAINTIES OF PROGNOSIS drawn to its presence. Even after it has been discovered, it is often as difficult to foretell tlie future progress of the disease as to determine its past duration. The cyst may long remain stationary, its flaccid walls announcing that absorption goes on more rapidly than secretion, or it may possibly disappear altogether. On the other hand, just the opposite course may be run ; the barren cyst may become proliferous, or the compound cyst may suddenly, and apparently causelessly, pass into a state of active development, or evidences of malignancy may manifest themselves in a growtli i)re- sumed for a long time previously to be innocent; while to all these contingencies must be added those inseparable from the various kinds of interference which the mere palliation of the evil in most instances requires. Advocates of the most opposite views with reference to the dangers attendant on ovarian disease are not without ample support for their opinions: cases are to be found of life continuing for years in very tolerable comfort, and even of the sexual functions being duly performed, and pregnancy and labor occurring in spite of it, the patient dying at length of some other perfectly different ailment. Illustrations of just an opposite kind are still more numerous, telling of the rapid development of the growth, of speedy impairment of the general health, of death occurring in one, two, or tliree years from the commencement of the evil, or of life being cut short even sooner in consequence of some attempt at giving temporary relief, which it was not possible any longer to delay. The endeavor has been made, indeed, to arrive at more definite results, and the late Mr. Safford Lee' collected with characteristic diligence the particulars of 123 cases: In 38 of which the disease lasted 1 year. " 25 " " 2 " II jy (( u 3 u « 2Q <( <( 4 (< u 3 u (I 5 u " 14 " " 5 to 10 years. <( g II (( 10 .< 12 " K 5 u a 12 " 16 " (( 4 (I u 20 " 25 " (I 1 (i u 50 »« 123 ISTow from this table it appears that 90 out of 123 cases, or 3 out of 4, or 73.9 per cent., terminated fatally within five years, and more than a third of this number within one year from the observed commencement of the disease. But, on the other hand, between the observed and the real commencement of the disease, there is, as has already been stated, a wide difi^'erence, and while the numbers doubtless understate the duration of the evil in many cases where the disease appeared to be most rapid, they prob- ably by no means truly represent the degree to which life was often prolonged in spite of it. Even as they stand, however, the 1 On Tuviors of the Uterus, p. 177. IN OVARIAN DROPSY. 439 numbers show that in 16 out of 123 cases, or nearly 1 in 7, life continued for a period of from ten to fifty years; and it must not be forgotten, that when a disease has been long quiescent, the patient learns to think but little of it; she speaks of it stdl less; even her medical attendant is perhaps scarcely aware of its ]»res- euce; and when she dies either of that or of some other aftectiou, it is doubtful whether he who sees the end had also seen the be- ginning of the malady. One other point there is, concerning which there can be no doubt, and which invalidates all the statis- tics on the subject wherewith hitherto we have been furnished; and that is, the wide disparity between the results that diri'erent cases yield. One year and fifty years cannot both truly represent the time occupied by the same disease in running its course. We can fix the duration of uterine cancer with tolerable accuracy, and find the disease, when seated in the womb, to obey the same laws as govern it in other parts. We know, too, that the slow-growing fibrous tumors of the uterus have in themselves no tendency to destroy life, though in their course some accident may occur to compromise it, and many others to render it painful. The dis- crepancy between the results of diflerent cases of ovarian dropsy, on the other hand, plaiuly shows, what indeed the study of its morbid anatomy has taught us, that under this name several dif- ferent diseases have been included, having different tendencies, warranting a different prognosis, and calling for different modes of treatment. In any inquiry into the treatment of the disease these facts must not be lost sight of, but we must consider it with reference to the special form of the affection with which in each separate case we have to do. The question cannot be propounded as to whether this or that plan of treatment is suitable for ovarian dropsy ; but, given a certain form of ovarian disease, is this or that proceeding expedient or allowable; or is it wiser to do nothing, or to palliate; or is the attempt to do more, justifiable ; and wlicn at length the necessity for interference of some kind becomes abso- lutely unquestionable, are the risks even of palliative proceedings 80 considerable as to warrant a greater hazard being run for the chances of a perfect cure ? All cases' of ovarian dropsy and tumor may for the purposes of therapeutics be considered as belonging to one or other of three classes, according as they are, either 1st. Cases which mai/ be let alone. 2d. Cases which must be let alone. 3<1. Cases justifying, or ahsolutehj rerjuinng inferferennp.. All cases of ovarian dropsy, or of tumor undistinguishable from it, maj/ be let alone in which the growth does not exceed the size of two fists, in which its position does not seriously disturb the functions of the pelvic viscera, in which it is unaccompanied by severe suffering, and, as far as can be ascertained, is not in course of rapid increase. Furtlier, in proportion to tlie small size of the tumor, to the smoothness of its surface, to its elasticity when 4^0 TREATMENT OF OVARIAN DROPSY. pressed upon, and to its mobility, will be the amount of encourage- ment which we shall be able to afford to the patient, since tliere will be the more reason for hoping either that the tumor is one of those cysts of the Wolffian bodies, which never exceed certain com- paratively small dimensions, or that it may possibly be a mere dropsy of the Fallopian tube, which, though not equally limited in the size to which it attains, has in it nothing of the serious character that belongs to ovarian dropsy. Even in cases, too, in which neither of these hypotheses is correct, it may still bo re- membered, that an ovarian cyst, while small, is far more likely to remain stationary than when it has attained a considerable size. The mere size of the tumor, however, provided it does not by its bulk disturb the general health, cannot be taken as an indication for interference. The old maxim, " Quieta non movere," is at least as applicable in medicine as in politics, and you will remem- ber the instance which I mentioned to you,' where a tumor con- siderably larger than the adult head, remained for many years stationary; and when it did increase, was yet long before the operation of tapping became necessary. Still, when it is said that such tumors are to be let alone, I do not wish to imply that no precautions should be observed, or that nothing can be done to retard their growth. These precautions, however, are comparatively few, and abundantly simple. They may be summed up as consisting in the endeavor to maintain the general health, and to prevent congestion of the pelvic viscera. The first indication, I conceive, implies the avoidance of all such proceedings as courses of mercury, of iodine, of iodide of potass, or of liquor potassse, agents of whose power in retarding the de- velopment of ovarian cysts there is scarcely any evidence, while of their injurious influence on the constitution, when long con- tinued, there is the most abundant proof. To carrj' out the second object, we should certainly dissuade a person affected with this disease from contracting hny matrimonial engagement; though between that and the non-fulfilment of an engagement already formed, or the separation of a married woman from her husband's bed, there is a wide difference, and moral considerations enter into the question which more than counterbalance mere medical rules. Besides this, too, it is, I think, very doubtful whether in the m^'sterious influence of the mind over the body, disappointed aftection, or the removal of a wife from her husband's bed, would not act more injuriously even on the sexual system itself, than the physical causes wdiich alone our restrictions can control. 8exual intercourse, however, should be moderate, and inasmuch as the influence of pregnancy and labor is often, though by no means always unfavorable, giving rise in many cases to irritation of the cj'st, to a more rapid increase of its growth, to inflammation of its peritoneal surface, and the formation of adhesions; or of its interior, and to consequent outpouring of pus, it is desirable that 1 Lecture xxxvi, p. 408. CASES TO LET ALONE. 441 intercourse slionld not take place at those seasons, just before or just after a menstrual period, when conception is most likely to occur. The condition of the bowels must always be most carefully watched, and every attention must be paid to insure the perfectly ref!;ular performance of the menstrual function. If the meustrual period is attended by any febrile disturbance, or by any increase of pain in the tumor, the patient must be kept strictly in bed, and four or six leeches must be applied over the painful spot, and repeated every second or third day so long as the pain continues; a warm poultice, or fomentations with spongiopiline being con- stantly employed in the intervals. As soon as the tumor has risen completely into the abdomen, a well-adapted bandage should be worn, partly for the comfort which it seldom fails to afford to the patient, partly because a cyst fills far less rapidly when mod- erate compression is made upon it than when no counter-pressure is employed to resist the accumulation of the fluid. It has, I know, been alleged that the power of medicine over this disease is much more considerable than I have represented. So great, too, is the influence of a name in determining the con- duct of most of us, that almost all the remedies of known efticacy in ascites have been assumed to be beneficial in ovarian dropsy. There can be no doubt, too, but that under the influence of such remedies very appreciable diminution in the size of the abdomen has taken place — a diminution, however, which I believe to be due to the absorption of the fluid, which in many cases of abdom- inal tumor is poured out into the peritoneal cavity, and not to any modification of the contents of the cyst. Some ovarian tumors, it was said, might, others must, be let alone. The latter are all those cases, for the most part of rather ra[iid growth, whose irregular nodulated surface, and whose solid non-fluctuating mass suggests the idea that they are not mere compound cysts, but productions of a malignant character. In most of such cases, too, we find in the patient's history other grounds still more cogent than the anatomical peculiarities of the tumor for avoiding all interference. Such are the facts that the general health has failed simultaneously with the develoi»ment of the tumor, and that loss of flesh and loss of strength have been early attendants on its progress, and have not first appeared when the diflerent functions of the body had been disordered by ita bulk, or when nutrition might be supposed to be impaired by the tax levied on the system 'iov the supply of the mass. Unhapi>ily, the cases which seem most to call for help are those in which it is least possible to aftbrd it, while it is in precisely those which may most safely be let alone that interference has the best chance of success. Between these two classes, however, there is a third in which present relief is called for, and in which it is in our power to aflbrd it. It is just in these cases that we encounter the inquiry as to the comi)arative risks and comparative merits of diflerent proceedings, 442 TREATMENT OF OVARIAN DROPSY. whether it is much more hazardous to attempt to remove the evil than to palliate it for a time with the almost absolute certainty tliat again and again it will return, and that on each occasion our power to palliate it will diminish? '^or is the question altogether confined to these eases. The uncertain tenure of health and life, even in instances where the evil seems quiescent, suggests the importance of discovering some proceeding which entails no greater hazard than we can conscientiously advise our patient to encounter for a reasonable prospect of ol)taining so great a good, and of freeing herself from danger ever impending, like the fabled sword which hung over the guest at the banquet. Very numerous, indeed, are the solutions which have been pro- posed to these inquiries. It is our duty carefully to examine their merit, and carefully to scrutinize the different surgical proceedings that have been recommended for the relief or the cure of ovarian dropsy. The first of these proceedings which we must notice, the simplest, the least hazardous, and at the same time the most generally ajtpli- cable, is the operation of tapping. Simple as it is, however, opinion is nmch divided 'with reference to the circumstances that warrant its performance; for while some practitioners look upon it as too dangerous to be justified by anything short of most absolute necessity, others consider it to be attended by little risk, and to be a palliative all the more valuable since it is sometimes followed by a perfect cure. Two questions then come before us. The first of these concerns the circumstances which by unanimous consent justify the per- formance of tapping as a palliative in cases of ovarian dropsy. The second refers to the amount of hazard attendant on the opera- tion, and the consequent expediency or inexpediency of having recourse to it when not actually compelled by the urgency of the patient's symptoms. The operation is absolutely indicated in all cases where the bulk of the tumor is so considerable as seriously to interfere with the patient's health, or to occasion her very severe suftering; and this, be the supposed nature of the tumor what it may. In proportion as the contents of the tumor are fluid will the relief gained by the operation be considerable ; but even though its great bulk should be solid, still the diminution obtained by letting out even some ounces may aftbrd considerable temporary relief to the pa- tient, and will fully justify the experiment. The state of things which calls thus imperatively for interference varies considerably in difterent patients, and is far from being ab- solutely connected either Avith a certain duration of the disease, or with a certain size of the abdomen. A slowly-increasing growth will often attain to a very large size indeed before it causes serious disorder, and a tumor whose contents are entirely fluid com- monly produces less distress than one even of smaller size, into the composition of which solid matter enters in large proportion. One reason of this probably is, that solid tumors more frequently press INDICATIONS FOR TAPPING. 443 upon the abdominal vessels, interfering with the circulation thro'ngh them, producing effusion into the peritoneal cavity, and distuibiug the ki(hieys in the ])erformance of their function. Ortliopiicea, habitual shortness of breath, even when .no exertion is made, com- plete loss of appetite, or sickness, owing in part to the stomach being mechanically prevented from retaining food, pain referred to the liver, and obstinate constipation, with frequent colicky pains independent of the action of the bowels, a very scanty secretion of urine, and a very feeble and thready pulse, with, jieihaps, irregularity of the lieart's action, — such are tlie symptoms which, when they begin to occur, indicate the immediate necessity for tapping. Mere unwioldiness in moving about, or discomfort from the tension of the abdominal integuments, though perhaps very painful to bear, cannot be regarded as absolute indications for the operation; and time not infrequently habituates a person to a state of things which at first seemed almost intolerai)le. Even the circumstance that a tumor is steadily on the increase cannot be taken as necessarily calling for the operation, since ovarian cysts, though large, sometimes come to a stand-still, and to decide in favor of interference when it is possible for a short time longer to dela}^ it, implies that we have answered to our own satisfaction the second question as to the amount of risk attendant upon simple tapping. In the cases hitherto referred to, the dangers of the operation scarcely enter as an element into our consideration, but tapping takes its place in the same Category wnth various other operations of necessity, such as amputation performed in consequence of in- juries, which, liow serious soever might be the risk attendant on them, would still be most legitimate, because the only resources at our command. It would, however, be unreasonable to expect that an operation performed in these circumstances shonld be free from danger, and this danger arises chiefly from two sources. Great as the relief often is to the patient, a certain amount of shock follows the evacuation of a large quantity of fluid, and patients previously much exhausted sometimes sink in two or three days after tap- ping. In spite of the warning given to the patient tluit tapping will in this way probably shorten her days, the choice is not in- frequently made to submit to a proceeding which brings at least present ease; nor have I thought myself failing in ni}' duty if, when our art was almost powerless, I tried to secure the last boon our patients ask of us, — a euthanasia. The other danger is one of inflammation of the cyst-walls, issuing in the eftusion of lymph and ])ns into its interior, and not infrequently associated with ]>eri- tonitis which often proves fatal in the course of two or three days. This latter occurrence, too, seems to be of greater fro piency alter first tappings than in those cases where the operation has been fre- quently performed, while death from mere collapse is, as might be supposed, more likely to occur where recourse has often been had to tapping. Besides these two risks, which not unnaturally have 444 RISKS ATTENDANT led practitioners to shrink from this operation, another objection has been nrged to it on the ground of the increased rapidity with which, after each time of its performance, the fluid reacciinmhites within the cyst. Expressed in various ways, the opinion is ahiiost unanimous that tapping is but the beginning of the end, and pa- tients are commonly advised, even at the expense of great incon- venience and discomfort, to put up \\\ih the present ill, and not to purchase prematurely a brief respite from suffering at so high a price. The result of the general impression as to the danger of tapping has been not only to postpone its performance in all cases to as late a period as possible, but also to lead to the endeavor to devise some other proceedings, which, if not in themselves less hazardous, should at least afford the chances of a greater good, and otter, by the high prize which they hold out to the fortunate few, some amends for the hazards that all must run, and in the encounter with wdiich many, perhaps most, must fail. Such endeavors are but the expression of a feeling deeply rooted in the breasts of all, and I see nothing to reprobate either in the surgeon who advises, or in the patient who encounters some great present risk, when in the one scale is placed the expectation of perfect health, — death, indeed, in the other; but still a death which does but an- ticipate, by a few months, the certain issue of her present sufter- ing existence. To judge at all fairly, however, on such a question we must not overcharge either side of the |>icture ; and that which it now con- cerns us to determine is wliether the colors in wliich the results of ta[)ping have been drawn are faithful, or whether they are not somewhat darker than the facts of the case altogether warrant. The chief, indeed almost the only numerical data of which we are possessed bearing on this subject, are derived from a table of 20 cases compiled by Mr. ^outham,' of 46 collected by the late Mr. S. Lee,^and of 64, the results of which are given by Professor Kiwisch.'* Of these 130 cases, 22 terminated fatally within a few hours or days after tapping, and 25 more in the following six months, or, in other words, 34.7 per cent, of the cases ended in the patient's death in the course of half a year after the performance of tap- ping. In 114 of the 130, death is stated to have taken place In 22 within a few hours, or in less than ten days after tapping. " 25 " six months. "22 " one year. "21 " two years. " 11 " three " " 13 after a period exceeding three, and sometimes amounting to several years. 114 » Med. Gazette, vol. xxxiii, p. 237, Nov. 24, 1843. ^ Op. cit., p. 176. ^ Oj). cit., vol. ii, p. 115. ON TAPPING. 445 III 109 of these cases we are further informed how often tlie patients had been tapped. It appears that 46 died after the first tapping. " 10 " second " " 25 " from three to six tappings. " 15 " seven to twelve " '* 13 " more than twelve " 109 The greater absolute mortality attendant upon first tappings of course does not represent an equal amount of greater relative danger. Still, when it appears that only 49 of the total 180 cases were instances of the first performance of tapping, and lurther, that all the 22 patients who died within a period often days from the operation bad undergone it for tlie first time, we are, I think, compelled to admit that the lirst paracentesis is accom})anicd by perils which are greatly lessened on its repetition. Ot 38 patients of mine who underwent the operation of paracentesis abdominis on account of ovarian drops}^ two died of inflammation of the cyst within a few days after its first performance, one sank exhausted thirty-six hours after tlie second tapping, and a fourth died of exhaustion on the sixth day alter the tenth tapping. The others all survived the operation, which in one instance was not repeated on account of the large amount of solid matter that entered into the composition of the tumor, and the serious symptoms which had followed its first performance. In one patient tlie fluid has never re-collected, and when I last saw her, after tbe hqise of three years, during which time slie had given birth to her fifth child, all traces of the tumor had disappeared, and recovery miglit be looked on as complete. In a second the cyst, having refilled, spontaneously subsided, and to the best of my knowledge the patient continues free from disease. • Three died subsequently after attempts at the extirpation of the cyst, four sank under the progress of the disease, in the course of which tapping was liad recourse to more than once, one died of apoplexy, and the remain- ing patients were still living when I last lieard of them, tapping in many having been subsequently repeated on several occasions, and the injection of a solution of iodine having in eight instances been resorted to with results concerning which I shall have more to say hereafter. Unfavorable, however, as are the conclusions to which we are irresistibly led by facts such as those which have just been men- tioned with reference to the ultimate issue of tapping, it is yet very questionable whether they represent the whole of the truth con- cerning this matter. Some of the data from which the tables were constructed were not collected originally with the view of illustra- ting the operation of taj»ping, while the majority of the others are deduced from observations in hospitals, and must therefore, for reasons obvious to all, yield a very high average of unsuccessful results. The cases that seek admission to those institutions are 446 RULES ATTENDANT ON TAPPING. almost always the least hopeful, geneililly the most far advanced, not infrequently those of persons who have sought out a place where death may come to them with less suHeritig than if they awaited it in their own homes. If relieved, such patients quit the hospital, and are often lost sight of; so that while the failures are known, the instances are frequently undiscovered in which life has been prolonged or rendered comparatively comfortable. i\lmost in proportion as experience concerning this operation is derived from hospital practice, or from observation in private, does the estimate of its danger appear to be increased or lessened, a cir- cumstance which seems to show that the hazards of the operation depend at least as much on the conditions that surround the pa- tient, as on anything inherent in the proceeding itself.^ It is, moreover, a question quite open to debate, whether the period at which the operation is generally performed has not con- tributed largely to its fatal issue? The delay, commonly con- tinued until the different functions are seriously disordered, and the patient's sufferings from mere mechanical causes have become urgent, may on the whole be expedient; but it can scarcely be doubted that it must lessen the prospects of recovery when at length the operation is resorted to. Besides, the favorable results which are said to have followed the early performance of tapping in some of those instances where tight bandaging was associated with it, renders it probable (due allowance being made for the ex- aggeration by which nuuiy of the published reports of cases where this proceeding was resorted to are vitiated) that the mere act of tapping in certain selected cases of ovarian dropsy is unattended by any considerable hazard. The whole of this subject needs a much more searching inves- tigation than it hitherto has received; but in default of this, I will venture to give my own impressions, and I do so as mere im- pressions, which further experience may modify or completely change. My present belief, however, is that the dangers of the operation of tapping have on the whole been over-estimated; and further, that while in cases where the amount of solid matter in the growth is considerable, the rule which prescribes the postpone- ment of the operation to the latest possible period is a sound one, it will probably be more expedient in the case of simple ovarian cysts to tap early, before the growth has acquired a large size, and ' In the Amei-ican Journal of Medical Sciences, vol. xix, New Series, April, 1850, p. 334, are some observations on the mortality attendant on tapping by Dr. W. Atlee, showing that, even tried by such evidence as that adduced by Mr. S Lee, the tendency of the operation is, on the whole, to prolong life, not to shorten it. M. Velpeau, too, in a discussion at the Academic de Medecine (Journal Heb. 406. * Op. cit., 3d ed., p. 402. 456 TAPPING PER VAGINAM, was inflicted on the cyst by the operation as practised by Kiwisch. He tapped the cyst per vaginani once in order to ascertain that the cyst was a simple one, a proceeding which, thongh it involves a dehay of some weeks, is certainly expedient in every case of ovarian dropsy, since now and then the fluid does not re-collect, and it is always desirable to give the patient that chance, even though it be but slender. So soon as the fluid had re-collected sufficiently to allow of the repetition of the puncture, the patient being placed in a semi-recumbent posture, her feet resting on two stools, and her knees separated by assistants, a small canula, curved so as to correspond with the axis of the pelvis, was carried along the fingers and introduced through the roof of the vagina into the cyst. "When but a small quantity of fluid had escaped, a grooved director, curved so as to correspond with tlie canula, was intro- duced through it, and the canula then Avithdrawn. A narrow probe pointed bistoury was then carried along the director, and the wound enlarged so as to admit the index finger to examine the interior of the cyst, and to allow of the ready escape of its contents. A metal tube of the thickness of the thumb, terminat- ing in a rounded, slightly bulbous extremity, was next introduced into the cyst, and retained there by a T bandage. Professor Scan- zoni adopts a similar plan, though he employs a straight trocar instead of one curved like that of Kiwisch, and leaves the silver , canula in the wound, which he does not enlarge, unless the con- tents of the cyst are too thick to flow out readily, in which case he enlarges the opening by a long handled knife with a blade an inch and a half long, which he introduces through the canula for this purpose. In the three cases in which I performed this operation, and which were carefully selected as suitable for it, I employed a trocar and canula having a curve like that of Kiwisch's instru- ment, and nearly as big round as the little finger. Through the canula a long elastic tube of the size of a Xo. 12 catheter was introduced, and the canula was withdrawn over it, while the tube was easily retained in the cyst by carrying it through a little silver collar in which it was fixed by a screw, the collar itself being at- tached to a framework such as used to be employed for retaining the uterine supporter in its place, and secured in a similar manner by tapes passing round the pelvis and thighs t>f the patient. My belief is, that the operation thus modified in its details is attended by less discomfort, and also by a smaller amount of risk, than -when an incision is made into the cyst and a heavy metallic tube afterwards fixed in the opening. Be this as it may, however, the proceeding has appeared to me to be attended by much more hazard than would be inferred from the language of Kiwisch or Scanzoni. The death of one of my patients Avas, indeed, not due to causes necessarily connected with the operation ; but in the other two, who eventually recovered, the symptoms of inflamma- tion beginning in the cyst and extending to the peritoneum were so formidable that their life was for some thirty-six hours in most AND WOUND KEPT OPEN. 457 imminent clanger, and most active local depletion was needed to subdue the mischief. Scanzoni, indeed, says that in some of his cases no symptoms of reaction followed the operation, nor any signs^of local inflammation, but the tumor gradually diminished in size, and in the course of a few days all discharge had ceased, so that the canula was sometimes withdrawn as early as the eighth or tenth day, or even sooner. Both he and Kiwisch, however, speak of the general occurrence of severe cyst-inflammation, during the continuance of which a thin or sanious discharge is poured out, and the local tenderness is extreme. Kiwisch speaks of the grad- ual subsidence of these symptoms in from ten to twenty days, and of the discharge then gradually assuming a puriform character, but not Anally ceasing until from Ave to seven weeks, previous to which it is not prudent permanently to withdraw the tube. During this time the cyst should be often syringed out gently with tepid water, and I believe the direction that this should be done twice a day is very judicious. I may also add that if an elastic tube be employed, that will require to be changed every five or six days, and I have been compelled by the contraction of the opening to dilate it by means of a sponge tent introduced for a few hours, before it would readmit a tube as large as that which had previ- ously been placed there. The one great peril of this operation seems to be the cyst-in- flammation, and this surmounted, the risk of the hectic symptoms occurring, of pyiemia and its consequences, does certainly seem to be much smaller than when the puncture is made in the ab- dominal walls. The most energetic antiphlogistic and depletory treatment afibrd the only chance of subduing the cyst-inflamma- tion ; and if very formidable, and not yielding at once to treat- ment, it would of course be our duty to withdraw the tube and to postpone the attempt at curing the disease to the more pressing necessity of preserving the patient's life. I ought to add that the results of the operation were, on the whole, satisfactory in the two patients who survived its perform- ance. I lost sight of one, however, within two months after her discharge from the hospital, though uj) to that time the fluid had not re-collected. The other patient continues now, after the lapse of twelve years, in very tolerable health, and stands all day to serve in a confectioner's shop. Iler case was one of flxt cyst of the ovary, consequently not one in which its complete obliteration was likely to occur. Nor, indeed, did this happen, but an open- ing into the C3'st remained fistulous, and from .^iij to .^vi of puru- lent matter escaped thus almost every day for several years, while if the discharge for a day or two became very scanty, headache occurred, and the patient felt various discomforts, which again ceased on the reappearance of the wonted secretion. About four years since, however, all discharge ceased, and an ill-defined solid mass, the size of an orange, behind the uterus, is now the only evidence of her previous disease. Whatever may be thought of tlie advantages of this operation, 458 DANGER OF CYST-INFLAMMATION it is not possible to adopt it in a very large number of cases, since the ovarian ejst often rises at a comparatively early period out of the pelvic cavity. In many others, also, it is clearly inexpedient, since in none but simple cysts is cure by this method possible. In the case of a small simple cyst, however, it appears to me more than doubtful whether we are justified in exposing a patient to a danger so very formidable as that of the cyst-inflammation which this operation almost invariably provokes. At any rate, we can- not, I think, rest satisfied with a proceeding, the indications for which must be furnished b}^ some purely exceptional conditions, but must carry our inquiries further after some measures more certain, or more safe. The dano-ers which attend on the incision of ovarian cvsts, or on any attempt to keep the puncture made in tapping perma- nently fistulous, accompany in a still greater degree the excision of a portion of the cynt-wall. No instance of the performance of this operation has come under my own notice, but several cases are reported in the medical journals both of its successful and its non- successful employment. In some instances it was had recourse to in consequence of unexpected adhesions preventing the com- plete removal of the tumor, as in the patients operated on by Martini,' Biihring,^ Poland,^ Prince,'' and Atlce,* of whom 4 died and 3 recovered. But it has also been selected in cases of thin- walled cysts, uncomplicated with adhesions, and existing in pa- tients whose health was but little inq>aired, on the sui)p()sition that partial excision might be found to be a less hazardous oi)era- tion than total extirpation of a cyst. In such or such-like condi- tions, the operation has been performed by Mr. Wilson, of Bris- tol," Mr. Brown, of London,^ and Mr. Crouch;^ and of these 6 cases, 2 terminated fatally, 4 had a favorable issue. One of the patients died from hemorrhage, the other from exhaustion and the effusion of purulent matter from the cyst into the peritoneal cavity; while so alarming were the sj'mptoms of inflammation iu one of Mr. Brown's cases, that it was considered necessary to bleed the patient from the arm four times in the first forty-eight hours after the operation. The existence of adhesions such as prevent the complete extir- pation of an ovarian cyst may possibly justify the incision into it, and the allowing the escape of its contents, though it is douljfful whether the risks of this proceeding do not outweigh the proba- bilities of success. The excision of a portion of the cyst, and the return of the remainder into the abdominal cavity, rest for their ' Bust's Magazin, vol. xv, p. 436. ' Op. cit., cases vii and viii, pp. 37 and 43. 8 Gki/'s Hospital Reports, 3d series, vol. i, p. 63. * Awericaji Journal, July 1850, vol. xlv, p. 207. 6 Ibid., April 1855, p. 387. Nos. 9, 12, and 13, in his table. 6 Provincial Medical Journal, 1851, p. 33. "> Op. cit., p. 235. ® Association Medical Journal, p 60. In this, unlike the others, the cyst-wall was of very considerable thickness. It is worth notice, too, that no fewer than seventeen small arteries required ligature. FROM THESE PROCEEDINGS. 459 justification on the assumption that the fluid, unchano;ecl by the grave injury inflicted on the cyst, will be absorbed by itlie perito- neum,— that tlie cyst itself will continue for but a short time to secrete, and will then become altered in character, and probably calcified. We need, hoAvever, some guarantee of the prolial)ility of this occurrence usually taking place, some evidence that the excision of a large portion of the cyst is not likely to be followed by very acute inflammation of that which is left behind, that the secretion from it will not become sanious or purulent, and conse- quently will not be likely to excite violent peritonitis. At }iresent we have no grounds for such expectations, and consequently no encouragement to imitate this jiroceeding,' which seems, indeed, now to have fallen into well-merited disuse. Y. The employment of iodine injections into the cavity of the cyst with the view of preventing the reaccumulation of the fluid. In many of the cases to which reference has hitherto been made, injections into tlie cyst were employed either for the pur|iose of more completely evacuating its contents, or with the view of excit- ing such a measure of active inflammation of its walls as should lead more quickly or more surely to the obliteration of its cavity. In all these instances the injections were but subsidiary measures, neither much relied on by the operators, nor to which any great sliarc in producing the patient's recovery (where recovery did take place) could be attributed. Of late years, however, the attempt has been made to destroy the secreting power of the cyst by the injection into it of a solution of iodine, a practice suggested by the success of a similar mode of treating hydrocele first adopted by Sir Kanald Martin and M. Velpeau. The first reported cases of tlie employment of iodine injections in ovarian cysts were pub- lished by M. Thomas in 1851;^ though M. Boinet,^ Avho is so strong an advocate of the measure, first put it in practice in the year 1848. Since that time it has been repeatedly had recourse to both in this country and on the continent, and the results hitherto obtained lead to the hope that in a very large proportion of cases it will be found to check the reaccumulation of the fluid, and in many instances to prevent it com[)letel3% while it appears to be attended by less serious danger than any other operation for the radical cure of ovarian dropsy. Some of the advocates of its em- ployment, indeed, represent the injection of iodine as being less hazardous than tapping unaccompanied by it; but we may hesitate to accept this conclusion till the statements concerning it are more definite than the alleged results of " twenty or thirty " cases.'' The 1 A judgment still more unfiivoralilt! to tliis procct'diiii; has hccii jmsscd byFock, in his able critique, pp. 362-807 ; and in even more unqualilied terms by Scunzoni, op. cif., |). 470. * J{f'i;ie Med. Chir., Feb , ]8r,l ; and Schmidt's Jnhrh., 1851, No. vi, p. 327. » ludoilternpie, &c., 8vo., Paris, lHr,.5, p. 4'J'.I. * Dr. Simpson, in Lnncci, March 'Jl, 1857, says tl)at only one death occurred in twenty or thirty cases in whicii he had used the injections of iodine. Sinijuiarly enoutjh, this statement apjiears in a paper devoted Id a defence of statistics. His Lecture in the Medirnl Times for Jan. '28, 18G0, is eortant elements to be taken into account in estimating the risks of iodine injec- tions. M. Boinet was accustomed to employ a mixture of equal parts of distilled water, and the tincture of iodine of the Paris Pharmacopoeia, which contains more than twice as much iodine as the compound tincture of the London Pliarniacopceia; the ])ro- portion being 1 part to 12^ in the former, 1 to 29 in the latter. From .^iv to i^viii or fyx of this mixture, to which some iodide of potass has been added to insure the complete solution of the iodine, are thrown into the cyst, and after being allowed to remain there tor from seven to ten minutes, are withdrawn through the caimla. Although, in many instances, a considerable f[uantity of the tincture of iodine has remained behind in the cyst without any l)ad symptoms i-esulting, M. Boinet always ]»refers allowing of its escape after the lapse of some minutes. No one can read ' Lehre der Bhdigen Operationen, folio, 38 Lieferung, Leipzig, 1859, p. 186. 462 CURE OF OVARIAN DROPSY the particulars of M. Teale's cases,^ of wliicli one proved fatal, while the other two patients remained nnconseious for fifteen and fourteen hours respectively, without feeling that the hazard is greatly increased by allowing the fluid to remain. The same symptoms of most formidable depression are also noticed in the report of a case under the care of Mr. Brown in St. Mary's Hos- pital.^ That gentleman appears usually to allow the solution of iodine to ren of iodide of pofassa, oO of spirit, and 100 of water. The quantity of iodine which this mixlurc contains does not differ materially from that which would be present in a mixture of equal parts of com- pound tincture of itidine of the London Pharmacopo'ia, and distilled water. ^ As rejiorted in Canstatt's Jahresbcric/ii, vol. iv, AViirzburg, 18G1, j). 401. 464 IODINE INJECTIONS IN OVARIAN DROPSY. ■I < c'^ ■a a so 5> u c — — ■- ■C S .S ~ •- ^ ^ 8 £i iJ'C a, (-. ci i; ^ t; 5 "^ ._ <-« a — 3? 5r ■= - - 5 - J3 ■!= "S i 1= =° » IT • £ ^ .S T3 2 "S -a C s ;= c ■« ^ ct |i; =

. -£ S o 5.' 2 '^ -i „ C=^ ; " i O D Cl >> £ S— =-~ S a"" a c V. . 3 o S '^ •- r =: ■*^ o* £ "■ •" M Sr: SS- -"^ :n ■- '■■° mont ; iod 5th mont ra-3 X ..^ O ^ 3, ^ i-^u P-2 C „ 1^ s 9 a fa 3 ■&-S a. P C8 X :j5'^-S - =i S if fc., s >:= g-a •3? =s S 1 =5 •° a K _ H >i 4.^s!a,p>^=.S. £ ■5 S = = i s 5 £ i a a t tcS c « '^ ■£•5 " >■•■- - a 2 2 t u 3 -S := o S = ^ ■' " — c ? ^ ^— to ? E ^ *^ "" 3 " o i '" c 0!!=^ . — t»-»>'C;r o i; w C -3 i o O. 1 c — Q) fS' 0! iii^ C K =s^ "1 -1 S g«a a ■5 a I' £a 1= S" ^ .£ T3 a c s) s. .E !r CO lllll c c », = £ • 4S i 3 2 c c f ■s ■.si * a o a fe ■" ® .£ = §-! a. c S o g -"■£ 5 s S a to ■p-TJ 2; * o i c^.2 5--? "5 2 MM <^3 IJ^a jj ■ - - a *=.9 a 9,s g * .- t-l (H CO EESULTS OF IODINE INJECTIONS ESTIMATED, 465 after tlie injection of the cyst, and suggest a peril even more imminent than in all prohahility really attends them. Coupled with this condition, which usually loses its more formidahle features in the course of twenty-four hours, there is a very scanty secretion of dark claret-colored urine, loaded with iodine; and a diminu- tion of the amount of iodine, an increase in the quantity of urine, and an abatement of the symptoms take place simultaneously. In the case where the symptoms of iodism were most alarming, an aqueous solution of iodine was employed, and one of the benefits of the admixture of a certain quantity of spirit with the fluid appears to be that it retards the absorption of the iodine. I found traces of iodine, however, in the urine fourteen days after the in- jection of the solution that I usually employed, and wliicli con- tained a third part of spirit, and this although the fluid was allowed to remain in the cyst only for ten minutes. The observation of these facts rendered me very decidedly op- posed to the practice either of employing very strong solutions of iodine, or of allowing the injection to remain permanently in the cyst, — a practice to which the formidable symptoms and the fatal results which have occui-red in some English cases appear to me in great measure attributable. The uncertainty as to the cases which will bear the iodine injection well, as distinguished from those in which cyst inflammation or profound iodism will be ex- cited by it, is a drawback irom its value which this operation shares with every other proceeding for the cure, or even tor the temporar}^ relief, of ovarian dropsy. It is hard to say how long a lapse of time is necessary to estab- lish the permanence of a supposed cure of this disease. At the end of two years after the injection of a cyst with the solution of iodine no re-collection of fluid had taken place in one case, and it is perhaps fair to regard that as an instance of its cure. In two other cases, however, the obliteration of the first cyst was followed at the end of eighteen months in the one, and of two 3'ears in the other, by the development of others, which showed that the tumor was not of that simple kind which it had at first been supposed to be. Such occurrences illustrate, indeed, the incompleteness of the success obtained b}^ this proceeding as com})ared with the really radical cure cflected by the extirpation of the ovary. But, on the other hand, even they are not without an encouraging feature, since they show that the presence of solid matter in the tumor does not contraindicate the injection, nor the compound character of the cyst always render the operation dangerous, but that from it we may expect retardation of the disease in cases where yet we must abandon tlie hope of effecting a permanent cure. The real value of this proceeding still remains to be definitely determined by larger trials than have yet been made, and it seems almost idle to bring forward an array of names to settle a question which as yet is not ripe for a decision. In this country, Dr. Simp- son is the only person who has often had recourse to iodine injec- 30 466 VALUE OF IODINE INJECTIONS tions in ovarian dropsy, and I Lave already mentioned the ex- tremely favorable conclusions at which he has arrived. The cessation of my connection with an hospital has deprived me of the opportunity of carrying my personal investigations any further; and it is, I think, to be regretted that attention has during the past few years been so exclusively turned in this country to the question of ovariotomy that no attempts have been made to determine more accurately the indication for the use of these in- jections, and the means by which their danger may be lessened. In France and Germany, too, though still resorted to, their value has not been subjected to that searcliing examination which could alone test their real Worth, and disappointment at finding the early estimates of success exaggerated seems likely to lead to a measure of undeserved neglect. Professor Scanzoni, however, while still keenly alive to the risks which he dwelt on in the former edition of his book,* published eight j^ears ago, has given the operation a renewed trial ; and all the three cases in which he has employed it have had a good result. He has taken the following precautions, to which some of the success is doubtless due. The cyst was first emptied as completely as pos- sible, and then, before the injection was employed, a most careful examination was made to determine whether the cyst was a simple one, and if it appeared not to be, the injection was not employed. If it were proceeded with, an elastic catheter, exactly fitting the canula, was carried down to the bottom of the cyst, and from one ounce to three of pure tincture of iodine were injected through it. In the course of a few n)inutes the whole of the fluid was care- fully withdrawn by means of a syringe, and after the closure of the wound the abdomen was kept covered with cloths wrung out of iced water so long as the pain produced by the injection, and which usually was severe, continued. In the first of his three patients the cyst refilled in six weeks after the first injection. Its repetition at the end of that time was followed by extensive peri- tonitis, from which the patient recovered, and continued quite well at the end of a year. In the second case a single puncture and in- jection were followed by a cure which was substantiated at the end of ten months. In the tliird case two tumors existed, pos- sibly aflecting both ovaries. In the one which was injected, no re-collection of fluid had taken place at the end of four months ; but the other tumor, which had at first seemed solid, was becom- ing softer, and it appeared probable that it would before long be in a state to admit of tapping and injection. We need, for the just estimate of the value of iodine injections, an answer to the following questions. I commend them especially to those gentlemen who seem to consider that a clamorous denun- ciation of ovariotomy, unaccompanied by any effort to increase our knowledge of the pathology of ovarian diseases, or to add to our 1 Op. cit, 3d ed., 1864, p. 468. ESTIMATED. 467 therapeutical resources, befits the solemn engagements under which we stand to our own profession and to our fellow-creatures. It needs to be ascertained — 1st. How far these injections may be safely employed in cases of compound cysts, and what etfect they have in retarding the deveh:)pnient of the principal cyst? and whether the cliaracter of the fluid, as, for instance, its being pellucid, and but slightly viscid, indicates the use of the injection even in cases of multi- locular cysts? 2d. How far the caution suggested by Professor Simpson, of never employing the injection after a first tapping, diminishes its risk ? 3d. "Whether a watery solution of iodine, or one containing spirit, is the safer, and whether the employment of a large quan- tity of a weak solution, or of a small quantity of a strong solution, is attended by the greater hazard ? 4th. What means afford the best guarantee against the escape of the injection into the abdominal cavity? 5tli. How long it is expedient to allovv^ the injection to remain in the cyst, and whether its complete removal by an exhausting syringe on the principle of Bowditch's furnishes an important safeguard against the occurrence of iodism, cyst-inflammation, or peritonitis? 6th. What relation subsists between the amount of pain at the time of the injection and the occurrence of dangerous peritonitis or cyst-inflammation afterwards ; and consequently how far is pain to be taken as an indication for desisting from the injection ? 7th. What are the best means of preventing or controlling dan- gerous symptoms after the injection ? 8th. In the event of the failure of a first injection, what is to be expected from its repetition ; and if repeated, is it desirable that the next tapping should be hastened, or that interference should be postponed until the patient's general condition indicates its necessity ? The grand objection to most proceedings hitherto devised for cure of ovarian dropsy is not only that they often fail to accom- plish that object, but still more that they frequently destroy the patient who submits to them. A comparatively low average of successes may be more than counterbalanced by an equally low rate of mortality; but a very high probability of perfect cure is needed to outweigh a great risk of life. It will, I apprehend, be found that the comparative safety of the iodine injection will be its great recommendation. For my own part, I c, and was coiiicd, without quite adequate aeknowledijjment, by Mr. S. Lee, in his very useful work on uterine tumors. Had he lived, the omission would have been reetilied, but justice to Dr. Atlee compels me to refer to it iiere. Dr. Robert Lee lias eoileeted in his Clinical lieporis, &e., the particulars of 102 cases in which ovariotomy was either attempted or actually ]ierformed in this country; while Kiwi-ch's taiile, in vol. ii, of h\^ Klini.ic/ie Fo/"i!/'a<7^, supplies some additional cases, chiefly contributed by continental ])ractitioners. In the American Journal for April, IS'iO, Dr. Atlee gives the general results of 179 cases, though not with the same detailed refiT- ences as in his former table; and in the same journal for April. 18')'), he contrib- utes a synopsis of 30 cases of ovariotomy occurring in his own jirai'tice. Mr. Clay, of Manchester, who has performed the ojieratinn miir(> fri'cpiently tlian any nther person, ])ublished in tiie BrUish Record af Qhs/rlric Mrdirinr the particulars of 40 cases that came under his own care, and his papers on this subject were collected and published by liim at Manchester in 1818. In Marib, 18')t> he .sent ii letter to Dr. Simpson, which appeared in Ed. Med. Journal for that month, in which ho briefly states the results of 29 additiomil cases. From all these sources, as well as from others either overlooked by former writers, or which have occurred subse- (piently to their investigations. Dr. Fock has collected a total of l21»'J ca.ses, on which he bases his conclusions, and I have availed myself of his labors. 470 PERFORMANCE OF OVARIOTOMY of failure, it is yet so convenient to deal with round numbers that I prefer adopting his figures as they stand. Now these 200 cases of actual extirpation of the ovary yield 111 recoveries to 89 deaths; or, in other words, the mortality is 44i per cent., or not very far short of half the number of persons in whom the operation is completed die from its eflects. But, besides these, there are 92 cases in which the operation could not be completed on account of the presence of adhesions, or of the tumor having some other situation or other attachments than was supposed beforehand, or in which some even greater diagnostic error was committed, and the very existence of the tumor was found to be a mistake. Of these 92 patients, 31 died, or 33.6 per cent., or 1 in every 3; but 9 of those who survived after passing through great perils, are re- ported to have been more or less completely cured of the disease. Putting all the cases together, it seems that of 292 recorded in- stances of the operation being attempted, 120 ended in death, and 92 in failure; or, in other words, the chances are two to one that the operation will be accomplished ; but, if it succeeds, they are nearly equal that the patient will die, and, if it fails, the prospect of her surviving the fruitless interference is only double that of her sinking in consequence of it. The belief was expressed by the advocates of the operation that the mortality attendant on its pertbi'mance was in course of dimi- nution, and that with the perfecting of our diagnostic skill the proportion of unfinished operations was also lessening. " The rate of mortality," says Dr. Atlee, in the year 1850, "has very much diminished since the publication of my table in 1845. Then there was 1 death in every 2*| cases of gastrotomy, or 37.62 deaths in every 100 cases. Since the publication of that table 78 cases have occuired, in which there was 1 death in every 3| cases, or 26.92 deaths in every 100 cases. There has also been a diminution in the proportion of unfinished operations .... hence diagnosishas also improved."' Unfortunately, as we have seen, it needs but to increase the number of observations in order to do away with the correctness of this very natural, though too sanguine expectation. One death in every 2|| of those cases in which the operation was completed, or 1 in Sj\ of all cases, those included in which the operation was abandoned, such are the results of the most recent data; while the number of instances in which the ovary could not be extirpated has risen from 1 in 5/4, at which Dr. Atlee estimated it in 1850, to 1 in S^^ six years atterwards, according to the cal- culation of Dr. Fock. This last category of cases, too, would, 1 doubt not, be swelled far beyond its present dimensions, if every instance in which an exploratory incision sufficed but to discover the impossibility of any further proceeding, were placed upon record. Besides the cases 88, 101, and 103, in Dr. Lee's list, the first of which occurred during my connection with the Middlesex 1 American Journal, April, 1850. OFTEN IMPRACTICABLE. 471 ITospital, while the other two were patients of my own, T have had two other cases at St. Bartholomew's Hospital, in wliich the attempt was made, with m_y full concurrence, to remove the ovary, but was made unsuccessfully. One of the patients, a cirl of twenty-two, survived the operation four months, hut after having struggled through an attack of cyst-inflammation, that followed within thirty-six hours after it was attempted, she sank into a state of hectic, which, after death, seemed to be accounted for by the extension of the inflammation to another cyst that was found distended by more than a quart of pus. The other case was that of a married woman, forty-seven years old, in whom the disease had been of very rapid development, but the cyst was ap])arcntly single, while the absence of any history of peritonitis, and tlic extreme mobility of the tumor, seemed to warrant the tolerably confident expectation that no important adhesions existed to inter- fere with its removal. This hope was found, however, to be illu- sory, and death took place from cyst-inflammation with all the symptoms of pyoemia seventeen days after the operation. The examination after death illustrated a source of difliculty which no wisdom could have foreseen. There were, indeed, adhesions to the abdominal peritoneum, and these it may be conceded (though I am by no means convinced of the fact) that the well-skilled tact of some one else might have detected. But the upper and pos- terior wall of the cyst adhered to the intestines, while from its upper part tliere passed off a pyriform prolongation, which reached up as high as the eighth rib, and, dividing into three separate branches or diverticula, adhered to the intestines, to tlie pancreas, and to the capsule of the left kidney. It happens, then, that my personal experience of ovariotomy is made up of the observation of five cases, in everyone of which the operation was undertaken, after much consideration, with the approval and under the direc- tion of surgeons of large experience and undoubted skill, but who, in every instance, were baffled in their attempt. Two of these cases are now published for the first time, and go to swell the list of unsuccessful operations. They were not withheld before excej)t as the mention of many an unsuccessful operation is withheld, because it teaches no new lact, and serves only to illustrate some well-known danger. I have no doubt, however, but that very many other cases of the same kind must have occurred, which are still unpublished just as mine were; but which, could they be collected, would bring out the dark side of the operation, not so much perhaps in proving the mortality from completed ovariotomy to be so much greater \han the present estimates, as in shov^'ing foilures to accomplish it to be much more common, and those failures to be much oftener attended by danger and followi'd by death. Some details as to the circumstances in which death takes place from this operation, and the conditions which favor its occurrence, may help us to a more correct estimate of its value. 472 CAUSES OF MORTALITY In 68 cases tlie date at wliicli death occurred is mentioned. It was immediate, or within six hours, in 4 " soon, "1 " on the 1st daj-, "6 " " 2d " " 14 << " 3d " " 12 " " 4th " "4 " «' 5th " "6 " " 6th " "6 " " 7th " "1 " " 10th " "2 " " 11th " "1 " «' 12th " "2 " " 17th " "1 " " 21st " "2 II <( 22d " "1 « " 26th " "1 " " 30th " "1 " " 34th " "1 " " 70th " "1 and 4 months in 1. In 37 of the fatal cases, then, or in more than half the number of instances in which death takes place, it occurs within seventy- two hours after the operation. In death from the Ci^sarean section 61.2 per cent, of the fatal cases occur within the first seventy-two hours. ^ That, however, is a desperate remedy for an urgent danger, and if life is cut short suddenly by its failure, nature un- ■aided would not have prolonged it further. But in ovariotomy while death comes, too, in 53.6 per cent, of the fatal cases within sevent3'-two hours from the performance of the operation, there is commonly the painful reflection that, but for it, life would have lasted for weeks or months ; and the risk of such a result will always be one of the great objections to the operation, and one which even a far larger proportion of successes than have hitherto been obtained will not remove, will even scarcely lessen. In. 59 cases the cause of death is clearly stated : In 29 cases death took place from peritonitis. " 13 " " hemorrhage. "8 " " exhaustion. " 2 " " shock. " 8 " " suppuration, or abscess. " 2 " " ulceration of the intestines. " 1 " " tetanus. " 1 " " phlebitis. 59 The great danger here seems to be the same as we encounter in the performance of the Csesarcan section, and we meet with it near]}' as often. Inflammation carries off 51 per cent, of those who die from the Csesareau section, 49 per cent, of those to whom the operation of ovariotomy proves fatal. The risk of fatal hemor- 1 See a paper by the author on the Csesarean section, in vol. xxxiv of Med. Chi?'. Tra7isactions, p. 61. OF OVARIOTOMY. 473 rLage appears to be miicli greater in the latter than in the former case, 13 out of 59 having died from it after extirpation of the ovary; only 14 out of 147 from hemorrhage alone after the C?esa- rean section. Shock, however, which forms a very injportant element among the various dangers which attend the latter op- eration, has scarcely any share in the production of death from ovariotomy, though the somewhat vague term exhaustion prob- ably includes some instances in which death took place from tlie direct result of shock to the nervous system. It is likely that care and improvements in surgery may somewhat lessen the dan- gers of hemorrhage, but the great frequency of inHammation, both after this operation as well as after the Cresarean section, certainly makes it questionable whether the laying open the abdominal cavity can be looked on as so innocent a proceeding as some writers believe when they speak of exploratory incisions as all but devoid of hazard. The presence or absence of adhesions, the size of the incision, the state of the patient, and the character of tlie tumor, have all been referred to as modilying the dangers of the operation, and consequently as deserving of consideration in the selection of cases for which it is suitable.* In 91 cases adhesions more or less considerable existed ; in 54 there were none. Of the former, 44, or 48.3 per cent, died; 17, or 31.2 per cent, of the latter. 1 cannot state the exact number of instances in which out of these 91 cases the operation was left unfinished on account of adhesions. Anotherseries of facts, how- ever, will serve to illustrate this point. The tables of Dr. R. Lee, and of M. Fock, contain mention of 92 uncompleted operations; in 71 of these 92 cases the adhesions of the tumor were the only reasons for the tliscontinuance of the attempts at its extir[iation. In many of these cases the wound was at once closed alter the evacuation of the contents of the cyst, and with the infliction of the least possible amount of violence upon it; but nevertheless, more than a third of these patients, or 35.2 per cent. died. The diagnostic difhculty does not seem as yet to have been diminished by all the attention which has been bestowed upon it, and the well-skilled tact of those who have oftenest performed ovariotomy appears in this respect to give to its possessor but little sui>eriority over the novice. AH the measures which have been proi>osed for ascertaining the freedom of an ovarian tumor from adhesions afi:brd little if any information, exce})t as far as the relation of the cyst to the abdominal parietes is concerned. The adhesions to the abdominal peritoneum, however, are by no means the most important, and their division is often attended with but little difficulty or danger, while connections between the cyst and the various viscera are frequently altogether undiscoverable before- hand, and attempts at dividing them are always hazardous, very 1 Somo oftho.ee niimbors nro taken from Dr. Atloo'.^ pnpor, in Amrrirnn Jniirrwl, April, 1850, with the addition of all cases that have been recorded subsequently. 474 CAUSES OF MORTALITY often impracticable. To the best of my knowledge there is no other operation in surgery concerning which the chances are nearly one in three that some unforeseen difficulty will prevent ita completion, or that a third of the abortive attempts at its per- formance will end in the patient's death. It has been suggested that the results of ovariotomy are partly governed by the age of the patient, and the activity of the sexual powers, its dangers lessening with advancing years. In the Bul- letin de la Societe de Chirurgie^ is a table constructed from data furnished by Dr. Lee's paper on ovarian disease, and which seems to support this opinion. It is as follows : From 18 to 30 vears, 40 operations, 19 deaths. " 30 " 40' " 41 13 " " 40 " 50 " 17 " 4 " " 50 " 60 " 13 " 2 " 111 38 A few facts more, however, refute these conclusions and suggest others, which in their turn further observation may prove errone- ous. I have obtained from other sources 91 more cases, with a total of 41 more deaths, and these added to the other numbers yield — From 18 to 30 years, 69 operations, 31 deaths, mortality 44.9 per cent. " 30 " 40 " 69 " 22 " " Si. 8 " " 40 " 50 " 37 " 10 " " 43.2 " " 50 <' 60 " 23 " 9 " " 39.1 " " 60 " 68 '< 4 (< 1 .( K 25.0 " 202 79 One fact, indeed, which the other table indicates this also cor- roborates, namely, the special risk attendant upQn the operation in very young women. Time will show the value of iodine injec- tions; should they prove to be as safe and as successful as their advocates believe, it is very satisfactory to know that precisely in these very patients are simple cysts most frequent, and conse- quently iodine injections are most applicable. It has been alleged that the success or fiiilure of the operation has depended to a considerable extent on the size of the incision made into the peritoneum, and that while to open the abdomen from the ensiform cartilage to the pubis is a very dangerous pro- ceeding, the withdrawal of the punctured cyst through a small incision is attended by so much less hazard as to render it unfair to place the two operations in the same category. This difference between the two operations appears, indeed, to be very clearly marked in the statements of tliose who first directed attention to this subject. The late Mr. S. Lee, states'^ "that in 85 cases where the major operation was performed, 50 were cured, 35 died, making the mortality 1 to 2| ; in 23, where the minor operation was per- formed, 19 were cured and 4 died, making the mortality 1 in 6." 1 Bulletin de la Societe de Chirurgie, vol. iii, p. 42. ^ Qp^ cii., p. 211. OF OVARIOTOMY. 475 The result of further observation has been to reduce the dis- crepancy between the two operations within narrower and nar- rower limits; not by proving the major operation to be less hazardous than was su})posed, but by showing that the dangers of the minor operation had been underrated. Some tliree years and a half later Dr. Atlee' having collected 133 cases of the major and 28 of the minor operation, found the mortality from the former to be 46, or 1 in 2^^ ; from the latter 8, or 1 in 3 J. I have since col- lected 18 cases of the major, 23 of the minor operation, referring to the latter all cases in which the incision did not exceed six inches in length, making the total 151 of the former, and 51 of the latter, from which the respective deaths have been 59 and 20, or one in 2|§, and 1 in 2^ J. The explanation of this difference between the earlier and the more recent statistics on this sulyect is doubtless furnished by the fact that the first operations were performed in cases of very thin- walled cysts, free from solid matter and uncomplicated with adlie- sions, which, therefore, admitted of being drawn throngh a very small opening. An incision of two inches in length, liowever, was found to be adequate only in a small minority of cases ; but 80 soon as the incision was made somewhat larger, though the principle of tapping the cyst and removing it through as small an opening as possible was adhered to, yet a much greater amount of interference than before became practicable, adhesions were sought for and divided, the hand, where it seemed necessary, was introduced into the abdomen, and the two operations have now come to be almost on a level in point of danger. It is not tlie division of the peritoneum three or four inches more or less that determines the fate of the patient, but the greater or less degree of meddling which has been necessary to the completion of the operation. This last fact, too, receives a further illustration from the influences which the character of the tumor exercises upon the fate of the patient. Operations on the thin-walled simple cysts, which are most easily removed, are attended by the smallest danger, while the hazards attendant on the extirpation of multi- locular cysts and solid tumors are far greater. This fact is very well illustrated by a tal)le drawn up by Mr. Humphry, of Cam- bridge,^ in which he divides the different tumors of the ovary into three classes, and shows the results of operations for their removal to have been as follows : RecoverfJ. Difd. Simple cysts, 16 6 Cysts with aftor-growtlis — multilocular cj-sts, some described as cysts with solid matter, and two con- taining hair and teeth, 13 I) Solid tumors, called lil)roiis, scirrhous, or solid with fluid, or solid with cysts, 7 10 30 2) 1 American Journal, April, 1850, p. 337. 2 In a pamphlet entitled, A Report nf some Cases of Operation: reprinted from the Association Medical Journal. Cambridge, 1856, p. 40. 476 REASONS FOR REJECTING I find also that on dividing ovarian tumors into two grand classes, the simple c^'sts on the one hand, and the compound cysts, and those containing more or less solid matter on the other, the following results are obtained : Recoveries. Deaths. Simple cysts, 31 12 Compound cysts, cysts with solid matter, and solid tumors, 62 56 93 68 E'either this table nor the preceding is referred to as showing the actual mortality from ovariotonw, which possibly may not be so considerable as the above figures represent, but merely as illus- trative of the comparative risks of the operation according as the tumor does or does not contain any considerable amount of solid matter. From this wearisome collection of details, imperfect, sometimes conflicting, what inference may we draw with reference to the operation of ovariotomy ; or is, perhaps, no conclusion at present possible, and must the decision of the whole question be adjourned to a future time, and to our possession of better information? Some points, indeed, must be left unsettled, but still there appears to me to be ground sufhcient for some conclusion, and that I fear must be unfavorable to the performance of ovariotomy. The chief grounds for this unfavorable opinion may be summed up under the three following heads : 1st. The rate of mortality from the operation docs not appear to be in course of diminution, as the result of the accumulated expe- rience and increased dexterity gained by its frequent repetition. 2d. Unlike most operations in which anything like the same rate of mortality occurs, it is scarcely admissible in the doul)tful or desperate cases to wjiich the Hippocratic axiom "ad summos morbos, summre curationes," applies. The cases in which it may be hoped that the disease, if left alone, will advance tardily or become stationary, those in which something may be anticipated from other less hazardous forms ol' interference, are the very cases that yield the successes on which it has been sought to establish the merits of ovariotomy. It is ])roved to be very hazardous indeed in the young; it is believed by some very competent surgeons to be attended by so much danger in those past the middle period of life, that they have proposed to regard the operation as contraindi- cated in all women who have exceeded the age of forty-five years. The compound cysts, the cysts with solid matter, the malignant, and quasi-malignant growths, those, in short, whose rate of prog- ress is commonly most rapid, which are the most burdensome to the patient, are attended l3y the greatest sufiering, and admit of the least palliation by other means, are precisely the cases in which the surgeon shrinks most from ovariotomy. In the table drawn up by Mr. Humphry, who himself is an advocate of the operation, cases of this description yielded, when operated on, 19 deaths to THE OPERATIOX. 477 20 recoveries; in my own table, deduced from a rather larger col- lection of facts, 56 deaths to 62 recoveries. 3d. Not only is the ojjeration so hazardous in those very cases where it is really most called for, that many surgeons shrink then from its performance; but even in instances that may be selected as the most favorable, we have no sure grounds on which to rest our prognosis as to its issue. "It is, in short, a venture at hap- hazard, since the medical practitioner is never able, in spite of the large experience already accumulated, to foretell the issue of the operation with the same certainty as guides him in undertaking other serious surgical proceedings. It has, indeed, been seen in numerous instances, that extirpation of the ovary, though per- formed under the most favorable conditions, and by the most Bkilful hand, and without the occurrence of any untoward acci- dent, has yet ended in a few days, sometimes even in a few hours, in the patient's death." These three reasons, the high mortality which experience and dexterity have failed to lessen, the special hazard attendant on those cases where yet the operation is s])ecially indicated, and the utter uncertainty in which we find ourselves, even in the most favorable cases, as to its probable result, have chiefly influenced me in the formation of my opinion as to the general inexpediency of performing ovariotomy. I have purposely abstained from entering on one argument much relied on by the defenders of ovariotomy, and which is based on the allegation that many other operations constantly taught and frequently practised are attended by at least as high a rate of mortality. I exceedingly doubt the correctness of some of the very low estimates of the danger of ovariotomy which have l)een sometimes put forth ; they are not only contradicted by the figures which I adduced in a former part of this lecture, but I may fur- ther add that Kiwisch, who himself had performed the operation, and whose weakness it certainly was not to underrate successes, or to overrate failures,' expressed his belief that the pro|»()rtion of deaths to recoveries is really as 5 to 4. But letting that pass, and also the important facts that otlier operations can almost always be completed, while ovariotomy is frecpiently left unfin- ished, and that the dangers of other operations can be estimated with considerable accuracy beforeliand, while there are no sure data from which to frame the prognosis of any case of ovariotomy ; I would object to the sort of comparison which it has been pro- posed to institute, on the gtound that there is no such resembhmco between ovariotomy and those other operations as to render them fair subjects for comparison. The propriety of the performance of tracheotomy in cases of croup has been much canvassed, and many persons of great reputation are still much ojiposed to it. Its defenders, however, have not sought to establish their point by a comparison of its mortality with that which follows ligature ' Op. cii., vol. ii, p. 109. 478 REASONS FOR REJECTING THE OPERATION of the subclavian artery, or amputation of the thigh. Comparison can be instituted only between things which bear to each other some resemblance, and the only operation which resembles ovario- tomy is the Csesarean section. We have found, however, that the danger of hemorrhage is greater, that of peritonitis almost as great, in the former, and that the smaller rate of the mortality that follows ovariotomy is to be attributed almost entirely to the absence of that shock which in the C?esarean section is inseparable from the violent interference with the process of labor and the infliction of injury upon the uterus.^ But I do not wish to carry out a comparison between ovario- tomy and another operation, which, though not without some points of resemblance, is yetpertbrmed in different circumstances, and in accordance with wholly different indications. It is to be compared with other measures for the cure of ovarian dropsy and ovarian tumor, just as the value of tracheotomy has always been measured with the value of other means for the cure of croup, and the efforts of surgeons and physicians have been directed to find out trustworthy indications for its performance, to ascertain the degree of additional danger which it brings with it, as well as the fresh elenicnts of hope which it brings with it too. Ovariotomy is to be tested by its results as compared not with those of amputation at the liip joint, or of lithotomy, or of the ligature of arteries, but with those of tapping, or of iodine injec- tions, or of any other means that have been used for the cure of the same disease, and Avith those, too, which may be expected if the malady is left untreated. On all of these points we need fur- ther and more exact information than we are as yet possessed of; and till we obtain this the question of ovariotomy cannot be looked on as wholly settled. At present, however, we are not in a position to lay down the indications justifying ovariotomy, or if we can succeed in sketch- ing them in our study we cannot aver that they exist in any case which we meet with in practice; nor can we venture on any re- liable grounds to express a prognosis as to the issue of our inter- ' I myself was not a little surprised at the very high rate of mortality which a dispassionate examination of the subject showed to be attendant on ovariotomy, and I can well imagine that to some persons who have been accustomed to form an en- tirely different estimate of its dangers, the comparison with the Caesarean section may seem absolutely untenable. While these sheets, however, were passing through the press, I received vol. iii, of Scanzoni's Beitrnr/e zur Geburtskunde, &e., at p. 99 of which is an account by Dr. Gustav Simon of all the operations, 64 in number, in which ovariotomy has been attempted or actually performed in Germany. The numerous universities, and the great activity of literary commerce in that country, render it probable that all cases, unfavorable as well as successful, will be reported in juster proportif>n there than elsewhere. These 64 cases, however, yield " 12 radical cures, 4() o))erations with fatal issue, and 6, the benefits of which were either questionable, temporary, or which turned out utter failures " The fatal cases, then, form 72 per cent, of the total number, a mortality which, as Dr. Simon observes, p. 108, is "even greater than that of the Cfesarean section, under which, according to Kayser's es- timate, 63 per cent., according to other authorities two-thirds, of the patients are lost." RECONSIDERED. 479 ference even when the operation has heen performed with the greatest success and the fewest difficulties. Till we can do this, however, the operation seems to me to take its place by the side of those exceptional proceedings, the expediency of which must he determined by each one for himself after a careful considera- tion of the peculiarities of the case and the idiosyncrasies of the patient. It is between six and seven years ago since I expressed these opinions. I have thought it right to reproduce them now, word for word, and to repeat the grounds on which they rested. I have done so because these opinions are still in the main those of the highest authorities in France and Germany, and it is only in this country and m America, that any important additional experience has been attained concerning the operation and its results. Even in England, most of the former opponents of ovariotomy retain the unfavorable opinion which they had already expressed, but I am not aware that anvthino; whatever has been done, or even attempted by them to devise other and less hazardous proceedings for the cure of ovarian disease, or even for retardins: its progress; and iodine injections, which seemed to promise so much, have been allowed to fall into disuse, almost without an attempt to ascertain their real value. Ovarian disease, then, remains, as far as curative measures are concerned, just where it was seven years ago ; a deeper conviction of the utter fruitlessness alike of internal remedies, and of outward ap})lications being all that the exjierience of these seven years has taught us. It becomes, then, of the more importance to inquire whether this gloomy picture admits of no alleviation, whether the hazard- ous operation of ovariotomy has lost none of its dangers, whether its attempt is attended by the same uncertaint}' as l)efore, and whether recoveries from it are still limited to cases where its ne- cessity was the least urgent? I am bound to admit that to all of these questions the reply must be much more favorable than it was seven years ago ; that the persevering etibrts of tlie advocates of the operation have led to a greater accuracy of diagnosis; to a more careful selection of cases ; to a removal of some of the dangers of the operation ; to the discovery of the comparative safety of some proceedings, such as the return of the pedicle with the ligature around it into the abdomen, from which surgeons would have shrunk as nothing less than fatal, and to a more judicious after-treatment; and, con- sequently, that ovariotomy has increased in certainty, and gained in safety. This improvement in the results of ovariotoni}-, however, is less apparent than might be expected if we confine our attention to those cases where the operation has been actually completed. The mortality in cases of completed ovariotomy, according to Dr. Atlee, down to the year 1850, may be stated at 32. 'JT per cent.; the mortality of the operations of Sir. B. Brown, Mr. irutchinson, Dr. T. Smith, and Mr. iSpcncer Wells, all of which have been per- 480 REASONS FOR REJECTING IHE OPERATION formed subsequent to that time, amount to 30.3.* The results of Mr. Spencer Wells's cases, subsequent to the publication of his paper in the Medico- Chirurgical Transactions^ show no progressive diminution of the dangers of ovariotomy. Of his first 50 cases, 17 died ; of his last^ 43, 15 died ; and the fractional difference between the mortality of the two series of cases shows a slight accidental increase of the death-rate of the latter. A division, too, of such of the cases tabulated in the appendix to Mr. Clay's translation of Kiwisch on Diseases of the Ovaries, as have any date assigned to them, into two classes, according as ovariotomy was performed before 1855, or afterwards, would even show that the fatality of completed operations had increased from 43 to 46 per cent. I do not for a moment believe this to be the case ; but I refer to this apparent result as a proof that the fatality of the op- eration has not greath/ diminished, if we regard those cases only in which it was actually completed. The nature of the risk, too, remains the same. Life does not seem in fatal cases to be prolonged much beyond the period which it attained to before. Of 68 fatal cases which I had found mention of seven years ago, 37 or 54.4 per cent, terminated in less than 72 hours. In 86 of 150 fatal cases, or in 50.6 per cent., the duration of life, as stated in Dr. Clay's table, was likewise less than 72 hours. In 59 of the fatal cases I found the cause of death stated. ' In '29, or 49 per cent., death took place from peritonitis. " 1.3, " 22 " " " hemorrhage. '« 2, " ... " " " shock. In 139 of Dr. Clay's cases the cause of death is given, and is stated to have been : Peritonitis, in 64, or 46 per cent. Hemorrhage^ and shock, " 49, " 35.2 " It is needless to say that these figures are dealt with not as representing absolute facts, but merely as showing the direction to which in([uiry on the whole is tending. They guide us aright, not as the compass does, which now enables the mariner to steer with absolute certainty, but rather as in old times the stars did, when they taught him, not without doubt and misgiving, yet in the main correctly, whither to shape his course. It seems, then, that completed ovariotomy is nearly as fatal as before ; that life is prolonged but little longer than it was formerly in fatal cases; and the causes of death are much the same as they Avere, though I have no doubt that, owing to improvement in the details of the operations, there has been a reduction in the risk of mere hemorrhage. 1 Deduced from numbers given by Dr. Graily Hewitt, oji. cii., p. 588. 2 The result of which Mr. Wells kindly communicated to me by letter in April of the present j^car, 1864. * The mortality from hemorrhage alone is said to have been 24 ; from shock alone 25. I RECONSIDERED. 481 The great advance wliich has been made, however, appears in the certainty of diagnosis that has now been attained, as seen by the far fewer instances where tlie operation has been commenced and abandoned, either from adhesions, or from some other cause interfering with its completion. Ileferriug again to Dr. Clay's tables, I find unfinished operations: Before 1855. Sin(-e 1855. Cases. Died. Cases. Died. Partial excision, tumor.s being ovarian, 23 13 1 1 " " e.xlra-ovarian, 12 9 Abandoned on account of adhesion, tumors being ovarian, 58 12 .5 3 " " extra-ovarian, 14 5 107 39 r, 4 This table, again, is to be taken with the cautions already given, for I myself know of one non reported case of death after partial extirpation of a fibrous tumor of the uterus; and Mr. Spencer "Wells' mentions six cases of exploratory incision, or of attempted operation, of which one had a fatal termination. The stigma of uncertainty, then, which formerly rested on the operation, may be regarded as now almost or altogether done away with; and the experienced surgeon may begin its performance without more uncertainty as to his ability to complete it than accompanies other of the capital operations of surgery. Some of the oi)jections against ovariotomy appear to have been the result of an over-hasty generalization. It does not appear that any age furnishes a positive contraindication of its performance ; and as we deal witli altered figures we arrive at difterent results, which prove, if nothing else, at least the absence of any law by which the age of the patient governs the result of tlie operation. In Dr. Clay's table the age of the patient is given in 274 cases, which may be thus distributed: Between 18 and 30 years, 120 operations, 58 deaths. " 30 " 40 " 81 " 3(i " " 40 " 50 " 4(5 " 23 " " 50 " 60 " 23 " 11 " Above 60 " ... u 4 u j u It is curious, too, with reference to the alleged extreme' fatalit}' of ovariotomy in the young, that 8 of Mr. Spencer Wells's So pub- lished successes, occurred in young women between the ages of 17 and 25 years, while no death took place under the age of '26. Another objection has been based on the assumption that the only cases wliich lurnish results sufficiently encoui'aging to Justity the operation, are cases of sim])le cysts, which usually increase the least rapidly, exercise the least injurious inlluence on the consti- tution, and are also most amenable to other modes of treatment. Such cases, too, are probably the most i'avorable for operation, though here, again, a little change in the data yields a dilferent result; but in fact by far the greater majority of the instances in 1 Med. Chir. Transncfions, vol. xlvi, 18G0, p. 49. 31 482 REASONS FOR REJECTING THE OPERATION which ovariotomy is performed are the more common cases where the c^ysts are compound, with a more or less considerable quantity of solid matter. In only 2 of Mr. Wells's 33 cases of successful ovariotomy was the tumor a simple cyst; in the remaining 31 cases the growths were multilocular, with a varying amount of solid matter. I^either the patient's age then, nor the nature of the tumor, can be regarded as of itself prohibiting the operation ; and we are clearly advancing into the region of certainty, when, instead of arbitrary laws deduced from the results of a limited number of figures, we become able to lay down indications for doing or ab- staining from the operation founded on the general principles of medicine and surgery. I think, then, that we are now bound to admit ovariotomy as one of the legitimate operations of surgery; as holding out a prospect and a daily brightening i)rospect of escape from a painful and inevitable death, which at last indeed becomes welcome, only because the road that leads to it conducts the patient through such utter misery. , Perhaps we may sum up the indications and contraindications for the operation somewhat thus: 1st. It is not to be performed in an}^ case of single cyst which is not increasing, or is increasing but slowly, while it has not as yet interfered with the patient's general health. In other words, life is not to be jeopardized for a mere discomfort. 2(1. It is not as a general rule to be performed until after the cyst has been tapped once. The reasons for this caution are three- fold. In some rare cases the fluid does not re-collect ; the amount of constitutional disturbance which follows tapping would be some index to the amount that might be apprehended from the more serious operation of extirpating the tumor; and lastly, when the cyst is emptied, and during the process of its refilling, its relations, and the presence or absence of adhesions, especially to parts within the ])elvis, can be more readily ascertained. I doubt whether, in the case of simple cysts, ovariotomy ought not to be further limited to cases in wliich trial has been made of iodine injections suflicient to ascertain them to be inefiicacious, or to prove them to be unsafe. 3d. It is 7iot to be performed in any case in which a tumor is felt in the pelvis, retaining the same situation but little changed after tapping, and from which, by means of the sound, the uterus cannot be distinctly isolated. 4th. It is further contraindicated by the presence of albumen in the urine, or at any rate by the persistence of any trace of it after tapping, and also by the early occurrence of swelling of the legs, and by the presence of any considerable quantity of ascitic fluid in the abdominal cavity. 5th. And lastly, its success is rendered extremely doubtfid by the previous occurrence of cyst-inflammation, and general perito- nitis, as evidenced by attacks of sickness, shivering, fever, and RECONSIDERED. 483 abdominal pain, and by the presence of pus in the fluid evacuated by puncture. The fact of a })atient having had occasional attacks of abdominal pain, of short duration, unattended by fever, or by abiding tenderness, does not contraindicate the operation, since such attacks occur independently of inflammation. On the other hand it is not contraindicated. — 1st. By the patient's youth or age, nor by the fact of her having previously undergone several tappings, nor by the irregularity or suppression of the menses, since complete menstrual suppression does not prove both ovaries to be implicated. 2d. It is justifiable and to be recommended in all cases of ovarian tumor, wliatever be its structure, and whether its existence be of long or short duration, and whether tapping has or has not been frequently resorted to, where the disease is steadily and pro- gressively increasing, and when the [)atient's health is beginning to sutler from this increase, but as far as can be ascertained from no other cause independent of the local mischief. Something, indeed, I think much of our conduct must be gov- erned by the state of the patient's own mind and wishes; by the calmness with which she can regard the possible failure of the operation, and the sudden entering on the "unknown land;" by the strength of the ties which bind her to the world, and make her desirous to continue in it, and by the spirit of hopefulness that may enable her to look beyond the risk of the few days, to the perfect health in future years which will be the reward of a successful venture. Dread of the issue is a bad state of mind in which to undergo an opei-ation of this magnitude ; I am not sure but tluit inditterence is even worse: I am quite certain that moral considerations must be weighed as carefully as those furnished by the character of the tumor, or the history of its growth. I cannot expect that the reasons which have seemed to me conclusive in favor of ovariotomy should appear to others equally cogent; though I quite expect that tlie next seven years will, as the past have'clone, lessen the objections to its performance, and increase the evidence in its iavor. So long, however, as there continues to be room for diflerence of opinion on the subject, the caution is not superfluous which I ventured to suggest seven years ago with reference to the grievous injury that is done, both to the advance of medical knowledge and to the standing of our pro- fession with the public, by tlie practice of treating some of these questions as though they were questions of moral right or wrong. It would seem, from -what has sometimes been said on the subject, almost as if ovariotomy could not be defended save from some sinister end, nor its ex[)ediency be doubted except from a moral obliquity rendered excusable only by hopeless dulncss. Ik'licl in each other's integrity of i)urposc seems to me essential to our eliciting truth by discussion ; and I see no reason why I am to suspect another of being less mindful of our common duty to humanity because he tries to relieve suflering or to prolong life by some means in which I have not the same conficlcncc. The 484 INFLAMMATION OF THE BLADDER. odium theologicum has at least age and respectability in its favor ; I fear the inimortal quarrel between Dr. Slop and Susannah has gone far to render the odium obstetricantium simply ridiculous. LECTURE XXXI. AFFECTIONS OF THE FEMALE BLADDEE. Inflammation of the bladder, its acute and subacute form ; the latter the more frequent — sometimes connected with tubercular disease of the kidney, or with chronic nephritis. Chronic cystitis. Treatment of the ditterent forms of the disease. Vesico-vaginal Fistula. Remarks on its prevention, and on the treatment preliminary to an operation for its cure. iNTESTINO-VKfSlCAL FiSTULA, Malignant Disease of the bladder. It may at first sight appear that the affections of the urinary organs do not deserve a phace in a course of lectures on the diseases of women. To a certain extent, too, the objection is well- founded ; and I will therefore state at once that it is not n)y in- tention to enter on the consideration of the whole of so extensive a subject, or to occupy your time with the minute study of diseases which are common to both sexes, which run in both a similar course, and manifest themselves ])y the same symptoms. There are, however, some disorders of the urinary apparatus almost peculiar to the female sex, and others whose causes and whose course are different in women and in men, and it is to these, and these only, that I propose to call your attention. Reference has been frequently made to the manner in which the bladder participates in the disorder even of the functions of the womb, and instances have been adduced of the advance of serious organic disease of the uterus, unannounced by other symp- toms than those which an irritable state of the bladder, or a some- what altered character of the urinary secretion presented. Nor is this all, but not infrequently the subsidence of uterine disease leaves behind some impairment of the functions of the bladder; and constant irritability of the organ, pain in micturition, or occa- sional difficulty in voiding the urine, remain as the after-effects of some not very severe attack of inflammation of the womb, or of its appendages. Inflammation^ indeed, beginning in adjacent parts, and by its ex- tension involving the bladder, plays a very important part among the causes of disorder of the urinary organs in woman. It is thus that irritability of the bladder is not infrequently left behind after an attack of vaginitis, or follows on a miscarriage or a tedious labor. The recovery in such cases seems at first almost complete; but the slightest cause, such as the natural congestion of the pelvic SYMPTOMS AND COURSE OF CHRONIC CYSTITIS. 485 viscera which accorapanies menstruation, accidental exposure to cold, or the occurrence of pregnancy, suffices to reproduce the frequent, and difficult, and painful micturition, and to render tlie urine once more turbid, charged with the phosphates, and aljoniid- ing in deposits of pus or mucus. Such symptoms, too, continue for months or years varying in degree, now worse now better, a life-long source of discomfort, tending rather to increase than to diminish. Acute Cystitis has never come under my notice except after de- livery, when its symptoms have been almost lost in those of the graver inflammation of the uterus, or of the peritoneum, -with which it was associated. These complications, when severe, often terminate in death, and then the interior of tlie bladder is not in- frequently found denuded to a great extent of its mucous mem- brane, which hangs in dark, sloughy shreds and patches from an intensely congested surface ; its state closely resembling that pre- sented by the interior of the womb itself. For the most part, however, the injury inflicted on the bladder, is less grave, or at least more circumscribed, and, not being at- tended by serious aftection of the womb itself, does not prove dangerous to life. At some one point where during labor the pressure of the foetal head was most considerable the tissue dies, and the patient's distress and dysuria find a melancholy allevia- tion in the unconscious outflow of the urine. The inflammation has ended in destruction of tissue and in the formation of a vesi CO- vaginal fistula, but it has ended; and suftering of a new kind now takes the place of that which the patient had before en- dured. But this accident is happily not the most usual result of inflammation of the bladder, the long-continued pressure on the organ, or the neglect to employ the catheter, or the inflammation of the uterus leading to a sort of .s-wSacu^e cijxtitis, very painful and very difficult of cure, but neither destroying life nor condemning the patient to permanent incontinence of urine Tlie history of such cases is generally something of this sort. Labor, or perhaps abortion, was followed by an attack of pain in the lower part of the aV)domen, with much tenderness on pressure, and with difficulty and pain in voiding the urine, or sometimes with actual inability to pass it. Leeches and other appropriate treatment had probably removed the other symptoms and miti- gated those referred to the bladder; but still the patient finds herself distressed by a constant desire to pass water, which she is unable to retain above twenty minutes or half an hour, the wish to void it being uncontrollable, though the pain in the act itself is liable to considerable variations. The urine is alkaline, often intensely so, loaded with the phosphates, and containing also a large quantity of pus or mucus, the amount of which, however, frequently seems to the naked eye more considerable than it really is from the abundant deposit of phosphates with which it is mingled. The constant direction of the mind to the urinary function no 48G CYSTITIS CONSEQUENT ON doubt increases the frequency of the desire to empty the bladder, and the incessant calls to pass water by night as well as by day break down the patient's health and grievously embitter her exist- ence. Every circumstance, too, which adds to the congestion of the pelvic viscera exaggerates the irritability of the bhxdder. Hence the menstrual period is always a time of increased discom- fort; hence, too, the symptoms are sure to be aggravated by the patient's return to her husband's bed, and the occurrence of preg- nancy is invariably accompanied by an exacerbation of all her sufferings, and by a real advance of her disease. Exaniination of the patient seldom fails to confirm the diagnosis to which a mere detail of the symi»toms would lead us, though it must be borne in mind that, according to their own preconceived notions, patients will sometimes give greater prominence to the indications of disease either of the womb or of the bladder, and will, till closely questioned, say little concerning those other symp- toms which, though perhaps not less distressing, had yet impressed them less, because they were supposed to be subordinate in im- portance or secondary in the order of their occurrence. Tender- ness on pressure over the pubes is a common attendant on inflam- mation of the bladder, though, owing to the contracted state of the organ this symptom is not always appreciable unless the pres- sure is made directly downwards into the pelvic cavity. The finger in the vagina generally ascertains all the parts to be unduly sensitive, though often there is no perceptible alteration in their condition. The mere increase of sensibility, too, is not always manifest unless pressure is made forwards against the anterior vaginal wall ; but then the suffering which is at once experienced points to the real seat of mischief, wliile the introduction of the catheter excites pain almost intolerable from its severity, and which often abides for many hours. In the higher classes of society the ailment scarcely reaches such a degree of severity as is here described. Appropriate treatment in the first instance, and prolonged care afterwards, if they do not completely remove the disease, in general so greatly mitigate it as to reduce it to, at the worst, a painful infirmity. Among the poor, however, the case is very different ; for the disease at first neglected, is often but little heeded afterwards, and when the pa- tient has recovered from the more urgent consequences of the delivery or the miscarriage in which her sufferings originated, she is compelled to return at once to her ordinary duties. Causes, in themselves trifling, a slight exposure to cold, inability to rest during a menstrual period, the ordinary incidents of married life, sexual intercourse, pregnancy, abortion, or delivery, add to the congestion of the bladde-r, and increase its irritability. At length the patient seeks admission into a hospital, but stays there only long enough to gain some slight relief, not long enough to make any real advance tO"wards cure. The mucous membrane of the bladder becomes ulcerated, and blood in small quantities appears in the urine, in addition to the deposits of pus and of the phos- DISEASE OF THE KIDNEYS. 487 phates which it before contained. The bladder is so contracted that it can no longer hold half an ounce of urine ; and sometimes the ureters themselves become dilated, as if tbe urine sojourned there with less distress to the patient, nor do the kidneys remain exempt from a participation in the mischief. Their substance wastes, while the distinction between tlie cortical and medullary portion becomes less obvious than natural; they become saccu- lated, and turbid urine is generally found within them, while their lining membrane is highly vascular, and the urine is sometimes actually purulent, or in otlier words, y.yelitis follows the disease of the bladdder, and with it atroi>liy of the })roper tissue of the kid- ney's. The mode of death in these cases is very various. Some- times the patient sinks exhausted, and, having long been feeble, passes away quietly and unexpectedly ; at other times the irrita- bility of the stomach becomes so extreme that all food and all medicine are alike rejected. Sometimes much suffering precedes death, and I remember one poor woman who all day and all night long sat crouched on a chamber utensil, so incessant was the call to empty her bladder, while she com]*lained ol' the urine as it passed scalding her like molten lead. She remained tlius, sway- ing herself to and fro in her agony, unrelieved by even the laigest doses of opium, till as life waned her pains lessened too, and at length she lay down for the first time for many weeks, worn out and weary, to die. In other cases the kidneys cease by degrees to perform their functions, and at last no urine at all is secreted, and typhoid symptoms come on, under which the patient sinks rapidl3\ There can b^no doubt but that some of these cases are con- nected with tubercular disease of the kidney,' the affection of the bladder being secondary' and subordinate, and this even tlnMigh the symptoms during life have pointed almost exclusively to the bladder as the seat of mischief. It is probable, too, that in other instances the irritation of the bladder consequent on the miscarriage or the labor from which the patient dates the commencement of her illness, may have been the exciting cause of the subsecpient mischief, and that the tubercular deposit in the kidney has really been occasioned by the previous cystitis. I have no means of 1 Sir 15. C. Brodic's work on Disensef; of ihe Uvinnn/ On/ons, contiiins, nt p. 133, a short but valuable chapter on symptoms aftVctint; the bladder in consequence of disease in the kidney, and some of the cases which he relates appear to be instances of tuberculous disease of that origan. Kokitansky, op. cU., vol. ii, p. 443, does but just refer to tubercular deposit in the kidney as a secondary occurrence, and one more common in the male than in the female ; whih* Louis. lirrhn-clirx utir la P/ifJiisic, p. 129, refers to the existence of considerable tuberculous disease of the kidney as a rare occurrence. Kayer, Maladies drs lirins, vol. iii, p. filH, treats very fully of the affection, but lie also speaks of it as bcint,' secondary to tuberculous disease elsewhere, and for the most part also to such disease in a ratln'r advanced form. Dr. Prout, On Stomach and Urinan/ Disrasrs, 3d editiun. pp. 393-400, no- tices another class of cases not connected with tubercle, concerninjj wbidi lie con- fesses his own knowledge to be but incomplete. Such cases are not very rnre in women ; they will deserve a careful investigation. In my hands, I must confess that they have been the opprobria of the ward. 488 TREATMENT OF judging of the comparative frequency of tubercular disease of the kidne}^ in the two sexes ; it certainly is not common in the female; or, perhaps, it may be that one comparatively seldom sees the ter- mination of a disease so chronic as this would appear often to be, causeless irritability of bladder sometimes occasioning distress and proving rebellious to treatment for years before the more serious symptoms set in. Possibly the more acute symptoms co- incide with the extension of mischief to the bladder, though its amount varies greatly; for while I have sometimes found nothing more than intense congestion of its lining membrane, I have also in other instances seen it ulcerated, with patches of Ij-mph on its surface, or have even found it completely destroyed, the muscular coat being everywhere exposed, and the broad bands of muscular fibre of a vivid red crossing the interior of the organ in all direc- tions. Once, too, the mischief had passed even this point ; the bladder was perforated at one spot near its upper and posterior part, where the adhesion of a portion of omentum to it had alone prevented the escape of its contents, and in other parts the peri- toneum alone remained entire. In this case, too, the disease had extended even to the urethra, the walls of which were exceedingly thickened, while its lining membrane was destroyed by ulcera- tion, and numerous warty growths or granulations beset its surface. In this, and in other cases, it is no doubt not to the tubercular deposit alone, but rather to the consequent pyelitis and cystitis that the patient's intense sufferings are due. "What it concerns us most to bear in mind is, that inflammation of the kidneys and of the bladder, may occur as secondai-y to tubercular deposit, when yet no other symptom of tuberculosis i% present, and further, that such a disease may run its course to a fatal issue without phthisis supervening, even without any deposit of tu- bercle in the lungs or elsewhere than in the diseased organs and the absorbent glands in their immediate vicinity. One other class of cases there is, characterized like the preced- ing by great irritability of the bladder, but more chronic in their course, and tending less certainly to a fatal issue, though as little amenable to treatment. Their symptoms come on in early adult age, and occur independently of pregnancy, marriage, or of any disorder of the uterine functions, while the changes which the urine itself presents are not very remarkable. It is neither laden with pus, nor does it abound in phosphatic dei30sits; its quantity usuall}^ falls a little below the average, but its specific gravity seldom much exceeds 1020°, occasionally falls below it; it is usually nearly neutral, slightly turbid, containing a little excess of phosphates; sometimes also crystals of the oxalate of lime may be discovered in it, and now and then a little albumen, though its presence is by no means constant. The history of these cases is usually very obscure, and often presents nothing more definite than the causeless occurrence of frequent desire to pass water, attended hy dull pain in the loins, extending to the hypogastrium. These symptoms come on so INFLAMMATION OF THE BLADDER. 489 gradually, that the patient can scarcely tell the date of their com- mencement, but knows only that for some two or three years or more, a source of discomfort from which she used to be free, has been by degrees growing ui)on her. The general health often continues comparatively undisturbed, even after the irritability of the bladder has become very troublesome, while the symptoms of constitutional disorder which do at length appear, are commoidy of a very vague and ill-defined character, such as loss of apjietite, loss of strength, and general gastro-intestinal disorder, with a tongue thinly coated with yellow fur, and not cleaning under any modification of treatment. My impression is, that these are cases of a chronic form of nephritis, and that when tliey endanger life, it is by the extension of the mischief to the lining membrane of the kidneys, and by the supervention of pyelitis, with that chronic inflammation of tlie bladder itself with which it is usually asso- ciated. So long as tliis complication is absent, the disease shows little disposition to increase, wdiile there are long pauses in its course, though never a complete subsidence of all the symptoms, the backache disappearing sooner than the irritable bladder, while even when things are at the best, a trivial cause, and especially a slight exposure to cold, will suflice to reproduce all the ailments with undiminished intensity. Of all these affections, that in which the bladder is the primary seat of the mischief is, as might be expected, the most amenable to treatment, though, even then the course of the diseasse is always slow, and recovery often but imperfect. Many of the instances of cystitis after delivery are traceable to neglect of the very obvious precaution of introducing the catheter when labor is at all pro- tracted, or whenever the ])ressure on the neck of the bladder has been so considerable as to render micturition for a day or two painful or difficult. Another error which often lays the founda- tion of this very troublesome complaint, is the omitting to treat those slighter forms of cystitis which frequently succeed to a tedi- ous labor, and which, though they in many instances subside s]>ontaneously, yet rarely disappear so speedily or so eomidetely if let alone as if a few leeches are applied over the hypogastrium, and the uva ursi, combined with some sedative, is administered, while the catheter is employed regularly to prevent any retention of urine. These precautions, too, are perhaps still more frequently overlooked, though scarcely less necessary in cases where periton- itis has occurred, or where inflammation of the uterine ajipcn- dages has taken place after delivery or abortion, or even in the unimpregnated state, since subacute cystitis is fiir from bring a rare sequela of any of the more active forms of abdominal inflam- mation in women of all ages and in all circumstances. If the disease, on whatever cause it depends, has not been checked at its ver}- outset, recovery will at best be tedious. Our prognosis as to this point ma}' in general be deduced with tolerable accuracy from the condition of the urine, the presence in it of a large deposit of the phosphates being a more unfavorable sign 490 trea'dment of than an abundance of pns or of mucus. "Witli reference to this, too, it may not be out of place to observe that in drawing our con- clusions from the gelatinization of the urine with liquor potasses, or from the abundance of mucus in the fluid, we ought to make sure that there is no considerable leucorrfioeal or purulent dis- charge from the vagina, since its unsuspected admixture with the urine has sometimes led to the expression of a far more un- favorable opinion as to the state of the patient than was really called for. So long as the disease retains anything of an acute character local depletion will still be useful, and the application of six or eiglit leeches to the hypogastrium, two or three times repeated, will be of more service than the employment once of a larger num- ber. So soon, too, as the tenderness of the vagina admits of the introduction of the speculum or of a leech tube, the relief afforded by drawing blood, from the anterior vaginal wall will generally be found to be very remarkable. The patient should be kept in bed ; her diet should consist of beef-tea, larinaceous substances, and milk, with barley-water and the Vichy water as her common drinks. In this stage, too, I know of no better medicine than the extract and decoction of uva ursi.' On the subsidence of the more acute symjitoms, the diet may be improved, and the hydrochloric acid with pareira,^ or half-drachm doses of the diluted phosphoric acid, may be substituted for the previous prescription, wliile any- thing which amends the patient's general health will probably be of service in lessening the irritability of her bladder. Wine and tonics are often of service when the acute stage of the ailment is passed, and the urine, thongh unhcaltliy in cliaracter, is secreted in suflicient quantity; and sometimes quinine, at other times chalybeate preparations, will be i'ound to be most useful. The irritability of the bladder not infrequently continues as the result of mere habit after the disease to which it was originally due has subsided. Large doses of the tincture of the sesquichloride of iron, as fifteen or twenty minims throe or four times a day, frequently relieve this infirmity; while it is also desirable to give a sixth or a fourth of a grain of morphia every night in order to lessen the incessant desire to pass water, which otherwise would deprive the patient of sleep. Something, however, will still always remain to be accomplished by the voluntary efibrts of the patient to over- come a habit which, if unchecked, will so much interfere with the comfort of her future life. During convalescence, the patient can- not too sedulously" guard against catching cold, or against any disorder of her menstrual function, each return of which will long 1 (No. 12.) R. Extract! Uva? Ursi, . . ^j Tiiict. Hyoscyami, . . . ^iij Tinct. Aurantii, . . . ."ij Decoct. Uva? Ursi, ad . . 5VJ M. ft. mist., cujussumatcochl. 2 ampla 4ta quaque hora. 2 (No. 13.) R. Extracti Pareirae, . . gr. xlviij Acid. Hydrochlor. dil., tijj xl Morphia^ Hydrochlor., gr. ss. Decoc. Pareirae, . . ,^vj M. ft. mist., cujus sumat 4tam partem 6ta quaque hora. CHRONIC CYSTITIS. 491 bring with it some revival of her former discomfort, and a threat- ening, at least, of the rekindling of former disease. Lastly, I may add, it is inexpedient that a married woman should return to her husband's bed, to the local excitement of sexual intercourse, and to the risks of pregnancy, until her recovery is well established. Cystitis is unfortunately less often met with, at least among the poorer class of patients, in the subacute form than in one de- cidedly chronic, in wliich, in addition to pus and the phosphates, the urine contains a large quantity of extremely tenacious mucus, is intensely alkaline, and of a higlily ammoniacal odor. In this condition, in spite of a very intense degree of local tenderness, and of very frequent desire to pass water, the abstraction of blood must not be resorted to ; for it weakens the patient's general powers without alleviating her ailment. A first step towards re- lieving her sufferings is to place her in bed ; the uniform temjiera- ture of the surface being thus maintained, prevents any sudden demand being made on the function of the kidneys, while the disposition to congestion of the pelvic viscera is much lessened by the maintenance of the horizontal posture. Throughout the wdiole course of one of these cases, opium in some form or other is the remedy on which our greatest dependence must be placed, and its value far exceeds that of any medicine supposed to exert a sp<'cific influence on the bladder. Of these medicines, two of the most useful, the uva ursi and the pareira, liave already heen alluded to. "When these remedies fail in the foiVns which 1 have already suggested, I have seen benefit result from the combina- tion .of the pareira either with small doses of copaiba or with the benzoic acid. Sometimes, too, especially where the secretion of urine is scanty, the benzoin alone has proved serviceahle, though a not infrequent drawback from au}^ of these medicines is that they nauseate the stomach ; and the alleviation of local suffering is then too dearly purchased at the expense of the patient's general health. I have on several occasions made trial of injections into the bladder in cases where tlie condition of the urine was vavy un- healthy, and where it contained a large quantity of ropy mucus. For this purpose I have, in accordance Avith Sir ]>. Brodie's sugges- tion, emi)loyed the decoction of popjdes, to which I have but very rarely added a few drops of dilute nitric acid. The instances, how- ever, in which this proceeding was at all tolerated were quite exceptional, and almost always such severe and such abiding j)ain was excited as to comi»el me to desist from a repetition of the ex- periment. Even when borne for two or three times, and giving an earnest of effecting some lasting good by the improvement W'hich it wrought in the state of the urine, pain has seldom failed to come on, and to preclude the continued employment of the measure. One reason of this failure (for I am not aware of any want of care either in the selection of the cases or in tlie ai>p]ica- tion of the remedy) may perhaps have been that the persistence of chronic cystitis iu the feniale subject for any considerable time, 492 VESICO-VAGINAL FISTULA. generally, if not invariably, occasions irritation of the kidneys, and a sort of subacute pyelitis. There seems also to be a great tendency for the mischief in these cases to terminate in ulcera- tion of the mucous membrane of the bladder, and not to stop short with the induction of that thickening which is so common in the male subject. One other proceeding which I have now and then resorted to in cases of chronic cystitis with much irritability of the bladder, has been the introduction of a seton just above the symphysis pubis. I have observed decided benefit from it, especially in those cases where the irritaljility of the bladder was out of proportion to the amount of obvious disease; tliough from its nature this remedy is one to which we cannot very often have recourse. It would perhaps scarcely be right to take leave of the subject of inflammation of the bladder Avithout a word or two concerning those sad cases in which vaginitis following delivery terminates in the death of the tissues, and in the formation of a fixtu/ous communication betiveen the bladder and vagina. There can be no doubt but that in the great majority of instances this accident is due to the delay of instrumental interference in tedious labor, coupled with the omission to use the catheter. It is extra- ordinary how often this latter simple precaution is neglected, how often the statement of the patient or of her nurse is accepted as conclusive other having emptied her bladder; while the practi- tioner, conscious perhaps of his own inexpertness in performing this little operation, is only too ready to frame an excuse to his own mind for not attempting to do that which he knows he should do but awkwardly, and fears that he might possibly fail to do at all. To this neglect of the catheter, and to the omission to inter- fere instrumentally as early as is necessary, is the occurrence of vesico-vaginal fistula to be attributed far oftener than to any direct injury inflicted by the instruments themselves. After labor is over, too, the same neglect to keep the bladder empty not only adds to the patient's distress, but greatly aggravates the perhaps inevitable cystitis, and renders the ease to a great degree unfit for any attempt at cure by means of a plastic operation. Wherever from the protraction of labor, and from the long stay of the head in the pelvic cavity, there is any reason to fear the occurrence of inflammation of the vagina, its possible issue in sloughing and in the formation of a fistula must always be borne in mind, and attention must be closely directed to the local con- dition of the patient as well as to her general symptoms. The bladder must be regularly emptied by the elastic catheter every six hours, a warm poultice must be constantly applied to the hypo- gastrium, and poppy fomentations to the vulva; while the vagina must be carefully syringed twice a day with lukewarm water, and local leeching must be at once employed on the first onset of symptoms of cystitis. The state of the parts must not be judged of from hearsay, but must be inspected every day ; a precaution which, though especially necessary when any laceration of the pe- MEANS OF PREVENTING IT. 493 rinenm has taken place, is yet in these cases always worth taking, since the appearance of the vulva furnishes no bad index to the general state of the vagina. If the secretion from the vagina as- sumes an unhealthy character, and if shreds of mucous membrane appear in it, we may be sure that sloughing has taken ])lace, and though the sloughing may be superficial, yet of this we cannot be certain, while contraction of the canal, and the formation of cica- trices are its almost inevitable results. The soothing injection previously used must now be changed for otliers of a more stimu- lating kind, while, when the parts begin to heal, it will be expedient to introduce a large gum-elastic bougie into the vagina, and to allow it to remain for some hours every day, in order to pi-event adhesions forming between the op})Osite surfaces of the vtiginaby which the orifice of the uterus is sometimes almost com[)letely closed, or the vaginal canal itself is divided into two chambers, into the upper of which the uterus opens. Nor indeed are these the only possible consequences of sloughing of the vagina, but in proportion to the extent of the mischief the vagina is shortened; the edges of any fistula are permanently kept asunder, the space between the opening and the neck of the womb is diminished, while the cicatrix tissue on wdiich the operator has to depend for the closure of the apertui'C is endowed with far feebler vitality than the unaltered structures of which, if the mischief has been cir- cumscribed, he may hope to avail liimself. Su[)posing all these points to have received due attention, the next question that suggests itself concerns the period after labor at which any operation for the cure of the fistula should be at- tempted. Now, I believe that nothing should be done within the first three montlis after delivery at the soonest, for the suscepti- bility to inflammation is greater in the woman who has recently miscan-ied or given birth to a child than in another, while not only are all plastic operations about the sexual organs attended by some hazard, but a degree of local inflammation quite iiuidequate to cause danger to the patient, may yet more than suffice to destroy the promise of the most dexterous operation. Another reason, too, for some delay is that wnthin certain limits a fistulous opening is likely to contract; and it is well to obtain the full amount of im- provement which nature can efi'ect before having recoui;se to any surgical proceeding. Besides this, too, it is of the greatest im- portance that a person should be in the best possible health before the operation is undertaken, and no delay can be regretted which attbrds the opportunity for the amendment of her general condi- tion, and the improvement of the state of her urine. The two generally keep pace with each other, and my own impression is, that to operate at a time when the health is feeble, and the urine abounds in phosphatic deposits, is completely to throw away all chance of benefiting our patient. If the aperture in the bladder is comparatively small, so that urine can be retained for an hour or so, in certain positions of the body, delay may be allowed a month or two longer, provided that the bladder tolerate the fre- 494 INTESTINO-VESICAL FISTULA. queiit introduction of the catheter ; an operation which the patient will soon learn to perform for herself. I am not, however, disposed to recommend that a catheter be kept constantly in the bladder; for a few days are generally the utmost limit during which the patient can bear it; the bladder then becoming irritated by its presence, so as to compel the removal of the instrument. Still less would T advocate the use of the plug, or of any mechanical device for restraining the outflow of the urine. All such contri- vances irritate, and are likely to interfere with that healthy con- dition of the parts which it is so essential to maintain. In all instances, therefore, where the aperture is large, and where no urine is retained, delay continued after the etiects of the puerperal processes have subsided, answers nouseful end ; while when wait- ing for this we must content ourselves with the daily use of the tepid hip-bath, with the injection of warm water into the vagina, and with the most sedulous al)lution and scrupulous cleanliness, as means of preventing the irritation of the parts by the perpetual escape of the urine. It would be out of my province to go into detail concerning the operation for the closure of vesico-vaginal fistula. Two jjointa only I may just refer to. One concerns the utility of the galvanic cautery, especially in the more chronic fistuhe, in those of small size, or whose dimensions have been reduced by other operative proceedings. By its frequent application in one case, my col- league, Mr. Paget, effected a complete cure. The other point has reference to the great merit both of the mode of operating adopted by Dr. Sims, of Alabama,' and also of his curved catheter, which often remains in the bladder without any trouble or atiy adapta- tion of her posture on the part of the patient, and answei-s the purpose of preventing all escape of urine by the wound far more effectually than a catheter of the ordinary form. Even this, how- ever, irritates in a few days, and requiies withdrawal earlier than is quite satisfactory; an evil which perhaps its construction of some very light material might in some measure obviate. It is not necessary to say much about that rare accident mtesfino- vesical fstula ; for the circumstances in which it occurs have no necessary connection with the sexual ailments of women. I have met with it but thrice. In the first case, it was associated with malignant disease of the uterus; and dysuria and painful defeca- tion had existed for between two and three years, their occurrence being coincident with the appearance of an indurated tumor in the left iliac and inguinal regions; and the escape of faecal matter with the urine had taken place for four months previous to the patient's admission into the hospital. In the second case, the mis- chief succeeded to ulceration of the intestines during fever nine 1 American Journal of Med. Sciences, Jan., 1852, and a pamphlet with the title, Silver Sidures in Sui-gery, New York, 1858. His earliest and his latest suy;<:;csti()ns present, indeed, many points of difference, but all seem tending to simplify the means of relieving this most grievous infirmity, and to increase the chances of its cure. FUNGOUS TUMORS OF BLADDER. 495 weeks before, which had issued in the formation of a pouch com- municating above witli the sigmoid flexure of the colon, and below with both rectum and bladder. This patient died in the course of a few weeks, but less in consequence of the local disease than of the progressive increase of the exhaustion which the fever had occasioned. The third case was that of a young lady in whom 8U[tpression of the menses from cold was succeeded b}- inflamma- tion, which involved among other parts the uterine appendages on the right side, where a distinct tumor formed. This tumor, at first quite solid, afterwards grew softer, and then diminished in size. Its diminution was not attended by any very marked dis- charge of pus, but about the same time purulent and fecal matter began to appear in the urine," and continued to be intermixed with it for three weeks when she first came under my notice. In this case, as in the other two, the sensitiveness of the bladder was so great that all attempts at syringing it with tepid water were of necessity discontinued ; but great relief followed the use of very simple means, such as the employment of the uva ursi, of hydro- chloric acid and the pareira, and the administration of opium or morphia, to mitigate sufl'ering and to relieve tlie irritability of the bladder. In the case of the young lady, too, concerning whom alone was there much room for hopefulness, the fistulous com- nmnication became closed in the course of two months, and after the lapse of a year I saw her in perfect health ; slightly diminished mobility of the uterus being the only remaining evidence of the serious bygone mischief I am not aware of having ever met with those soft fungous tumors, or polypoid excrescences from the bladder, whose true relation to malignant disease seems to be still undetermined. It is, indeed, possible that in some of the cases of dysuria which have come under my notice the symptoms may have arisen from this cause; but there is no sign actually pathognomonic of their existence, and though in all obscure cases I am accustomed to have recourse to the microscope for help, I have never yet succeeded by its means in the diagnosis of any outgrowth from the bladder.' In one respect, indeed, these growths conform to the same rule as decided malignant disease of the bladder, for while not very conmion in either sex, they are yet infinitely rarer in the female than in the male. Often cases of fungoid disease of the bladder recorded in the Transactions of the Pathological Socictg,^ there were but three in which the subject was a female, and in like manner of the seven cases of carcinomatous disease of the bladder 1 Tlio general opinion, and that adopted hy Kokitanskj-, op. cit., vol. iii, p. 4(50, is tliat these outgrowths all belong to the class of malignant diseases. An opposite view is, however, maintained by .Mr. Sibley, in Traxsdction.i of Path. Sucirii/, vol. vii, pp. 2.j() and 214, based on very careful microscopic observations. "Gross, On the Vriiutry Ortjanfi, 2d ed., l*hiladcl|)liia, 1H.')0, p. 324, in his notice of these out- growtlis. assumes their non-mulignant character. 2 Tile three eases in the female subject are reported in vol. v, p. 200, vol. vii, p. 2i')(), and vol. xi, p. l.')3; the otiiers in vol ii, pp. 8o and 237, vol. iii, pp. 126 and 127, vol. v, p. 201, vol. vi, p. 258, and vol. viii, p. 2(j2. 496 MALIGNANT DISEASE on which M. Lebert^ founds his observations, six occurred in the male subject. In the only case of primary malignant disease of the bladder that has ever come under my notice, the patient was a widow woman, sixty-two years of age, who had suffered for a year pre- viously from pain in the region of the bladder, aggravated after passing water, the calls to which became more frequent than natu- ral, while at the same time her urine grew turbid, and deposited a thick sediment. Blood now frequently appeared in her urine, sometimes in small quantities, sometimes in clots, and about three months before I saw her she lost a large quantity at once. She had of late suffered from pain in the back, and for two months the urine had been always thick with a ropy sediment. Ko treat- ment had been adopted till three weeks before her admission into the hospital, when the patient applied to a surgeon, who intro- duced a catheter, an operation followed by considerable hemor- rhage, which lasted for several days, though it was eventually sujjpressed by gallic acid. On being received into the hospital the patient's appearance was healthy, her pulse was 80, and soft, her tongue slightly coated, her bowels were regular. Xo tumor was percei)tible in the abdomen, but iirm pressure immediately over the pubcs caused some pain. The uterus was high up, small, its tissue soft and perfectly healthy. In front of the uterus, pushing it into the posterior half of the pel- vis, was a firm, somewhat irregular growth, reaching from the anterior half of the pelvis in the situation of the bladder, appar- entl}^ extending round that organ on either side, but much more on the right. This growth was perfectly immovable; it seemed to be connected with the pelvic walls; was somewhat tender on pressure. It was of such size as to occupy the whole anterior half of the pelvic brim, though not dipping down considerably into the pelvic cavity. The urine was pale, alkaline, depositing ropy mucus, and under the microscope crystals of the triple phosphate and cells of nucleated epithelium were perceptible. The patient derived considerable comfort from treatment dur- ing ten days' stay in the hos[)ital; Ijut, returning home at the end of that time, and indulging in the intemperate habits to which she was addicted, she fell and injured her face — an accident that was followed by fatal erysipelas on the twelfth day after she left the hospital. The uterus and vagina were found on examination after death to be perfectly healtliy ; but the whole posterior half of the bladder was occupied by a medullary growth, with an ir- I'egular surfiice, which projected into the cavity of the organ, its substance being in part firm, in part almost semifluid. The an- terior half of the bladder was quite healthy, as also was the sub- stance of both kidneys, except that the right ureter being involved in the diseased mass was dilated to three or four times its natural 1 Oj). cit, p. 876. OF THE BLADDER. 497 size, and the infunclibulum of the right kicluey was enormously enlarged. As far as it went, this patient's history was exactly tliat of malignant disease of the hhidder, and had not her life been pre- maturely cut short, the affection would no doubt have run its usual course. Hemorrhage would have returned again and again, and would have weakened the patient more and more ; the in- creased growth would have produced increased difficulty in mic- turition, while the advance of the malignant disease would have been associated with the further development of the cancerous cachexia; till, under these combined causes, death would at length have taken place in circumstances far more painful than those by which it was actually attended. As in this case, so I believe in most instances of primary malig- nant disease of the bladder, there is but little tendency to the per- foration of its walls and the extension of the disease into the vagina. The constant dribbling away of the urine which some- times attends the more advanced stages of this disease by no means necessarily indicates the existence of any communication between the bladder and vagina; but is due in many instances partly to the encroachment of the evil on the cavity of the blad- der, partly to its walls having been rendered unyielding by dis- ease, and especially to the infiltration of the tissue of the neck of the bladder with carcinomatous deposit. The observation of Kiwisch' is also worth repeating here, "that the occurrence of incontinence of urine in the course of cancer of the uterus is not to be regarded as a certain evidence of the occurrence of perfora- tion of the bladder, for this symptom is frequently only the con- sequence of carcinomatous infiltration of the neck of the bladder, and especially of that part corresponding to the spliincter, by which it is hindered in the performance of its functions, and thus, no longer closing the ostium vesicae, admits of the constant escape of the urine." Though the diagnosis of fungoid outgrowths from the bladder may be ol)scure, yet the ordinary form of malignant disease of the organ appears to be too well marked to leave much room ibr un- certaint3\ The ceaseless pain and difficulty in micturition, coupled with the frequent desire to pass water, the occasional appearance of blood in the urine, sometimes in considerable quantity, and in the form of clots, while the secretion is habitually alkaline, un- healthy, and deposits a sediment, are of tliemselves strong evi- dences of the nature of the case, though scarcely conclusive unless associated with a firm, immovable tumor in front of the uterus. In the absence of the evidence obtained by vaginal examination, the extreme rarity of primary cancerous disease of the bladder always renders it the more probable supposition that the kidneys are the seat of the mischief. There is no treatment specially applicable to malignant disease 1 Oji. cit., vol. iii, p. 308. 32 498 CONGESTION OF THE URETHRA, of the bladder. The indications to be followed are very obvions, and within certain limits and for a certain time their fulfihnent would not appear to be difficult. To relieve pain by opiates, to render the urine less irritating by the mineral acids, the pareira, and those other remedies to which reference has been made in the earlier part of this lecture, to keep the patient in bed, and thus to equalize as far as possible through the whole twenty-four hours the demands upon the functions of the kidneys, and to maintain the general health by good diet, and by the moderate use of stim- ulants, are the objects to aim at. When once the nature of the disease has been ascertained, the introduction of instruments into the bladder must be carefully avoided; while, if it should become necessary to draw off the urine, an elastic catheter without its stilet must be employed with all possiljle gentleness. It is, however, I believe, but seldom in the female subject that this disease pro- duces actual retention of urine, though I remember a patient many years ago in the Middlesex IIo8[)ital, in whom tlic urethra became im[)li('ated in the extension of the growth, so that it be- came eventually necessary to tap the bladder above the pubes, an operation which she survived only a very few days. LECTURE XXXII. DISEASES OF THE URETHRA AND VAGINA. Diseases of the Urethra. Congestion of the urethra, most troublesome as a chronic ailment; its symptoms and treatment. Vascular tumors of urethral orifice, their .seat, nature, symptoms, and treatment. Ulceration of urethra ; doubts as to its syphilitic nature. Diseases of the Vagina. Acute vaginitis; character of the discharge which attends it as distinguished from uterine leucorriuiia: its treatment. Chronic vaginitis. Granular vaginitis, its real nature. Cysts of vagina. Fibrous and libro-cellular tumors of vagina. Cancer of vagina. From tbe study of the affections of the bladder, we pass next by a natural transition to the examination of those incidental to the female urethra^ a class of ailments which, though compara- tively trivial, are often attended by very serious discomfort, and are by no means easy of cure. Of these ailments, one of by no means unusual occurrence is a state of undue congestion of the urethra, which sometimes presents itself in an acute form, at other times has a chronic character. In the former case, it very generally accompanies a similar condi- tion of the pelvic viscera, and hence is chiefly observed either in newly-married women, or at the commencement of a menstrual period, or is experienced during the first few weeks of pregnancy. It is then attended by a sense of itching and irritation about the AND THICKENING OF ITS WALLS. 499 urethral orifice, wliicli is redder than natural, slightly swollen, and tender to the touch, while micturition is accompanied by a scald- ing or cutting sensation, the discomfort of which induces the pa- tient to retain her urine longer than usual. This, however, is a temporary discomfort, lasting for the most part no longer than the cause which produced it, though its fre- quent recurrence may no doubt issue in the chronic form of the ailment, which constitutes an abiding source of annoyance difficult to remove and very apt to recur. Tljis chronic congestion of the urethra comes on with no apparent exciting cause in women who have given birth to many children, the interruption to the free circulation in the pelvic vessels having no doubt produced it, for which reason.it also sometimes follows on attacks of uterine in- flammation, or of pelvic abscess, or comes on during the growth of a uterine or ovarian tumor. It adds also in other instances to the distress produced by affections of the bladder, or is asso- ciated with disease of the kidney, and with morbid states of the urinary secretion. In this form of the disease there is very cou- sidorabic thickening of the whole canal, which may be traced as a firm cord as thick as the finger, or even thicker, running under the symphysis pubis, somewhat tender upon pressure ; while if the nymphae are separated, it may be seen as a large swelling at the upper part of the entrance of the vulva, looking almost like a distinct tumor growing from the anterior vaginal wall.* The long-standing congestion has here been followed, as it is else- where, by overgrowth of the part, by hypertrophy of the cellular tissue of the urethra, and hence, though the swelling may vary in size, and the symptoms which it produces may admit of very great alleviation, yet tlioy never entirely disappear, and very slight causes suffice to reproduce them. These symptoms consist in a sense of fulness and aching, ac- companied by frequent desire to pass water, which is scarcely at all relieved by the act of micturition. The erect posture aggra- vates these discomforts, as do sexual intercourse and the approach of the menstrual period, while relief is obtained by rest and the recumbent posture. The natural tendency of the affection is, as can be readily understood, to grow more and more troublesome under the influence of those causes which first produced it ; at- tacks of an acute kind coming on every now and then, during which the urethra becomes more swollen and more tender, and the pain in micturition extremely severe. In one instance I saw an attack of this kind issue in the occurrence of suppuration in the cellular tissue around the urethra, and on puncturing the ab- scess quite an ounce of pus escaped; but on all other occasions these attacks have subsided almost spontaneously, and without leading to any such result. There is no other condition with which, as far as I know, this 1 This condition was first described by Sir C. Clarke, Diseases of Women. yo\. i, p. 309. 500 VASCULAR EXCRESCENCES state of the urethra can be confounded. The only caution, there- fore, which seems to me necessary as to this point concerns the occasional dependence of this thickened state of the urethra upon the presence of one of those small vascular excrescences of its mucous membrane, which though usually seated at its orifice, are yet sometimes so far within the lips of the canal as to escape a superficial examination. The acute form of urethral congestion is generally so brief in its duration as scarcely to call for treatment. A tepid hip-bath, the temporar}' discontinuance of sexual intercourse, if the symp- toms have succeeded to marriage, the avoidance of all stimulants, mild diluent drinks, and slightly alkaline waters, such as the potass, or the Vichy water, generally answer every. purpose. In the chronic form of the evil, attended by more or less hypertro- phy of the tissue of the urethra, complete rest is an essential, and the avoidance of any cause, such as sexual intercourse, by which congestion about the pelvic viscera can be excited or maintained. Generally, indeed, if the urethral hypertropiiy is at all considera- ble, the act of intercourse is attended b}- so much discomfort as to lead to its discontinuance. One or two leeches applied by means of a small glass leech-tube to the urethra itself, and re- peated weekly, or twice a week for a short time, generally afford very great relief. Frequent cold sponging, and the use of cold astringent lotions, or of cold hip-baths, confirms the improvement which depletion and careful dietetic measures had obtained. I have found, however, that any attempt at the employment of pressure, as suggested by Sir C. Clarke, was attended by more annoyance than advantage, and therefore content myself, as the removal of the hypertrophied tissue cannot be expected, with ex- plaining to the patient the nature of her ailment, and the simple means by which, though she cannot expect a cure, she may always obtain for herself great alleviation. Under the name of vascular tumors of the orifice of the meatus urinarius. Sir C. Clarke described a very painful aft'cction, which though it had not altogether escaped the observation of previous writers, had yet received comparatively little notice. These tumors are hypertrophied papillae made up of elementary fibro-cellular tis- sue, covered by a layer of tessellated epithelium, the thickness of which varies much in difierent instances, and very richly supplied with vessels.' They grow from the lower, and often also from the lateral margin of the orifice of the urethra, but they scarcely ever involve the whole of its circumference, or spring from its upper border. Sometimes they are turnished with a pedicle, the bulk of the growth in that case projecting beyond the urethral orifice, but often they are sessile, and then distend its aperture, leaving a narrow passage at the upper part of the urethra, through 1 Sir C. Clarke, Diseases of Women, Part I, p. 803. Paget, oj). cit., vol. ii, p. 282, note ; Burford, I^orman, London and Ed. Monthly Journal, June, 1849, Avhieh con- tains an account of their microscopic structure by Mr. Quckett; and again in London Journal of Medicine, Feb. 1852, p. 146. FROM THE URETHRA. 501 wliich the urine flows, though not readily; the obstacle to its out- flow occasioning considerable dilatation of the canal behind the excrescence. These growths vary much both in size, in vascu- larity, and in sensitiveness ; but they do not in general exceed the bigness of a currant, are frcquentlj" smaller ; and I have never seen one larger than a hazel nut, thongh instances are alleged of their attaining the size of a pigeon's eo^g, or even a still greater magni- tude. Their vascularity and their sensitiveness are generally i»ro- portionate to each other ; those whose color is most vivid, bleeding the most easily, having apparently the most delicate epithelial covering, and the most exquisite tenderness. The most vascular of these growths are of a bright cherry-red, while those which are least so are of the same color with the sur- rounding mucous membrane. Though frequently solitary, yet, in many instances, two or three separate growths are situated at the edge of the urethra, or just within its orifice ; and it is by no means unusual to observe several small excrescences of a similar charac- ter, but generally of a much smaller size, springing from diiierent points of the vestibulum. Sometimes, indeed, they are scarcely larger than the head of a blanket pin, but of a vivid red color, and most exquisitely tender. Those growths which occupy the urethra seldom extend above a sixth, or a fourth of an inch along its canal, but now and then they reach further, and cases are re- lated in which almost the whole length of the urethra has been the seat of these excrescences, a condition the more unfortunate sin6e it is almost impossible of cure. The symptoms to wliich these outgrowths give rise are, pain in micturition, sometimes of extreme severity, though in other cases in which the sensibility of the tumor is lowest, the sensation^ is one of discomfort rather than of severe suffering. Coupled with this, there is in many instances pain on any attempt at sexual intercourse, and this pain is often aggravated by the presence of the small outgrowths to which reference has been made about the vestibulum. The presence of these growths does not produce a frequent desire to pass water, but, on the contrary, it not infre- quently happens that, on account of the pain which attciuls the effort at micturition, patients acquire the habit of retaining their urine for a longer time than natural. When, however, the long continuance of the irritation has produced that thickening of the urethra which was spoken of a short time ago, its characteristic symptoms manifest themselves in a constant sense of weight and aching, and frequent desire to pass water. It is not possible to say on what these outgrowths depend, though they have, in my experience, been much less conmion in the single than in the married, and in the young than in the middle aged. Thus of 21 cases of Avhich I preserved a record, 18 occurred in married women, only 3 in those who were single. Five of the patients were U|>wards of 50 years old, 4 betwi'en 40 and 50, G between 30 and 40, 5 between 20 and 30, and oidy one was under 20 years of age. All but three of the married women 602 VASCULAR TUMORS OF URETHRA. had given birth to children, and in the case of some of the patients there was a history of previous vaginitis or gonorrlioea; a circum- stance which favors the suggestion of Scanzoni/ that in some instances these outgrowths depend on previous chronic urethritis. There is a condition in some respects allied to this, and produc- tive of some of the same symptoms, in wdiich a tumor occn})ies and obstructs the orifice of the urethra, formed apparently only by a hypertrophied condition of the otherwise unaltered mucous mem])rane, a fold of Avhich nearly blocks up the canal, causing it to dilate behind the point of obstruction, and thus renders the act of micturition difficult and painful, though unattended by the acute sensibility which accompanies the genuine vascular tumor. In many instances this hypertrophy of the urethral mucous mem- brane is associated witli the presence of a number of small out- growths ot mucous membrane, fringing the orifice of the vulva, or growing from the outer edge of the lips of the urethra, and productive of some degree of irritation, and even of inconveni- ence in sexual intercourse. The treatment of these excrescences, of wlultever kind, is abun- dantly simple, and consists in their complete removal, and in the apppli cation to the surface whence they sprang of some strong caustic, or of the actual cautery, in order to prevent their repro- duction, which is otherwise very apt to occur, I am accustomed always to ap]d\' the actual cautery for this purpose, both because it most etfectually arrests that flow of blood, which I have known in one or two instances where it was not emjdoyed to be so con- siderable as to excite alarm, and also because it has seemed to me to be more efficient tlian any form of caustic in preventing the reproduction of the growth.^ The operation, though of very short duration, is so painful, that very few patients can dispense with the use of cliloroform, and its administration is the more needed since it is essential that the patient should remain absolutely quiet lest the urethra should be injured. Care to avoid this acci- dent is, indeed, the only [trecaution specially called for during the excision of these growths; this, however, is all the more neces- sary, since injury to the orifice of the urethra has sometimes been followed by incontinence of urine, or by difficulty in its retention. If after the excision of these growths there should remain any one spot where their removal has not been quite complete, or if, though no excrescence be present, a state of morbid vascularity of the urethra should continue, such as sometimes precedes or ac- companies the formation of these little excrescences, either condi- tion is generally capable of removal by the application twice a day, for two or three weeks, of the undiluted liquor plumbi. 1 Kiwisch, op. cit., vol. iii, p. 298. 2 Dr. 3Icdoro, of Padua, recommended some years ago in an Italian journal, ■whence it was extracted in Schmidt's Jahrbiic/ier, vol. xxxvii, p. 186, the u.«e of the actual cautery, without previous excision, for the removal of these growths. I have not tried it in this manner, but as an adjunct to excision I believe it to be most desirable. CHRONIC ULCERATION OF URETHRA. 503 There is a condition of cJironic ulceration of the urethra of wliicli I have met with a few instances, and which it may ])e wortli wliile to refer to here, since, thongli I believe it to be of sy})liilitic origin, and therefore to lie, strictly speaking, beyond my province, I yet have found no mention of it in treatises on the venereal disease. The afltection has come six times under my observation : twice in married women, who acknowledged to having suffered from venereal disease ; and four times in women of unchaste life, one of whom was at the same time sufiering from a secondary syphi- litic eruption. In every instance the })atients alleged either that they had been aw^are of the ulceration of the urethra, or that they had experienced difficult and painful micturition for periods vary- ing from nine months to five years. Twice the disease was asso- ciated witli an excrescence from the mucous membrane of the urethra, having the characters of the less vascular form of those outgrowths which have just been described. The ulceration ap- pears to commence at the orifice of the urethra, and to extend thence inwards towards the bladder, producing as it extends a great widening of the canal, and a patulous state of its orifice, so that the finger-tip can enter it with ease, while the surface is the seat of large, firm, indolent granulations, which secrete a small quantity of a muco-purulent fluid, are not in general very tender to the touch, but highly sensitive to the passage of urine. I have met with this ulceration of the urethra independent of any other disease of the sexual organs, but have also observed it in cases where previous ulceration had destroyed the clitoris and the nym- pha.% and have seen it associated with uidiealthy ulceration about the posterior conmiissure of the labia and the entrance of the vulva ; as also with those small condylomatous growths about the vulva in cases of vascular tumor of the urethra, and these latter, indeed, are more commonly present than absent. When the disease has advanced far, or has been of long standing, the cellular tissue be- neath the urethra usually becomes considerably thickened, and I have seen the lower wall of the urethra represented by a dense, cartilaginous substance, not unlike one of the lips of a hypertro- pliied and partially procident cervix uteri ; while on two occasions I have been able to carry my finger along the whole length of the canal into the bladder. Even when not very far advanced this disease causes difficulty in the retention, or actual incontinence of urine, while, when it has extended along the whole canal, and left its aperture })erniancntly patulous, the patient becomes almost completely unable to retain her urine at all. One such case I saw in a young woman, aged 22, in whom there was not the least power to hold the urine: an in- firniity that she said had existed man}' months. I gave her an elastic pessary to wear, which, by pressing against and mechani- cally closing the urethra, rendered her more comfortable. Once, also, I saw a prostitute whose ulcerated urethra was so widely open that two fingers could be passed into the bladder with ease. She was constantly soaked with urine ; but in spite of her loath- 504 CHRONIC ULCERATION OF URETHRA. some condition still plied her trade, and no argument could induce her to abandon it. "Whether these cases are truly syphilitic, or whether they de- serve more properly to be classed with the rodent ulcer, or lupus exedens, I am at present unprepared to say. On the one hand their directly syphilitic origin may appear to be rendered doubt- ful by the circumstance that in only one instance was there any evidence of then existing venereal taint; while on the other hand the affection of the urethra differs from the other forms of rodent ulcer, lupus, or esthiomene, in being unattended by the same dis- position to great thickening of the adjacent tissues, which, in the case of lupus of the vulva, approximates the affection at a first glance very closely to elephantiasis. In its less severe forms I have seen this condition greatly im- prove, the pain in passing water diminish, and the ulcerations cicatrize under the use, twice a day, of a lotion composed of .5j of oxide of zinc suspended by means of half an ounce of mucilage in an ounce of water, and injected into the urethra, while the surface was shielded from the irritation of the urine by the abundant ap- plication to it of the zinc ointment. At the same time the con- tinued employment of the iodide of potass and syrup of iodide of iron have seemed to exercise a beneficial influence on the patient's general health, which in every instance has appeared to be indif- ferent. For the most part, however, these measures seldom prove more than palliatives ; but in one case of very long standing, when other means had completely failed, the repetition three or four times of the actual cautery was of the most signal benefit. It was of course applied but light!}', so as not to destroy the tissues to any depth ; and under its use the large granulations by degrees disappeared, leaving a healthy surface beliind ; the pain in mic- turition subsided; the wide urethra contracted its dimensions; and the patient regained the power of holding her urine. I am not prepared, however, to say how for in this instance the amend- ment was lasting, or how far the most extreme cases would be amenable to the same treatment. As we approach the end of these lectures, the interest which I would fain persuade myself attached in some degree to the subjects that were brought before your notice diminishes, I fear, at almost every step. We have come now to the study of ailments purely local in their character, often, indeed, painful, always annoying, sometimes dangerous, but which yet afibrd small matter fur inves- tigation, and seem to yield little scope for the exercise of the higher qualities of the practitioner of medicine. But an observa- tion which I made some years ago, when addressing the seniors of our profession, may perhaps be repeated without apology to those who are but beginning the exercise of medicine, and on whom it cannot be too deeply impressed that " the thousand smaller ills to which mankind is subject, bring, in their frequent repetition, as much suftering, cause as much sorrow, and therefore are as worthy of our heartiest labor to understand, and of our best efforts ACUTE INFLAMMATION OF THE VAGINA. 505 to relieve, as those perilous visitants — inflammations, fevers, apo- plexies, wbicli threaten lite only at long intervals, or on rare occa- sions."^ With this preface let us now pass to the study of the diseases of the vagina, and of the external organs of generation. And first among the ailments of the vagina we may notice, as we have done in the case of other organs, those affections which are the result of inflammation either in an. acute or in a chronic Form. The acute form of inflammation of the vagina, apart from those cases in which it occurs in the puerperal state, is probably oftenest due to impure sexual intercourse. Between gonorrhoea, however, and acute vaginitis dependent on any other cause, there does not seem to be any certain distinction furnished either by the character of the symptoms or by their severity, while a similar treatment is applicable to both. When dependent on the contagion of gonor- rhoea, the symptoms generally commence within three days after the suspected intercourse ; but vaginitis may be equally excited by exposure to cold or wet, and especially by getting wet-footed; by local irritation of the sexual organs, by intemperate or unac- customed sexual intercourse, and to this latter cause attacks of moderately severe vaginitis are not very rarely due in newly- married women. A disagreeable sense of fulness, heat and tenderness about the vulva, with frequent desire to pass water, and pain and scalding in the act of micturition, are the symptoms with which it sets in. Sometimes there is associated with these discomforts great swell- ing of the labia, which are so tender that the sitting posture can scarcely be borne, while a feeling of aching and weight extends along the perineum, and considerable tenderness of the hypogas- trium announces that the bladder has become involved by the advance of the inflammation. For the first twenty-four hours the customary secretion is suppressed; but a discharge then begins to be poured out in great abundance ; yellow, acrid, purulent, occasionally streaked with blood, always of an offensive smell. Tliis discharge is chiefly furnished from the lower extremity of the vagina, though the inner surface of the nymphte, and the parts about the vestibulum also contrilnite to it, and sometimes the in- flammation extends along the vaginal canal, the whole of which may then pour out the discharge. In a few instances the mischief extends even further; I have seen internal metritis supervene uj>on inflammation of the vagina, and two successive attacks of vaginitis, after an interval of eighteen months, were followed in the same patient l)y such severe peritonitis as to call on each occa- sion for the abstraction of blood. These, however, are purely exceptional occurrences ; and in most instances the affection re- mains limited to the vulva and the lower part of the vagina. If the parts are examined during the acute stage of the affection, they appear of a bright red color, shining, and swollen, while if • Croonian Lectures, 8vo., London, 1854, p. 94. 506 ACUTE VAGINITIS. tlie finger is introdnced into the vagina, the heat of the parts will be found to be greatly increased. The introduction of the finger even is almost always excessively painful, and the tenderness is so great as to render the employment of the speculum quite im- possible. During the severity of the onset of the disease, an abscess sometimes forms in one or other labium, usually, if not invariably, having its seat in Cowper's gland, but, supposing this not to be case, the swelling and tenderness generally abate in four or five days, the discharge loses its acrid character and oftensive odor, and except that its quantity is excessive, differs little from the muco-purulent secretion which constitutes ordinary leucor- rhoea. These changes in the character of the discharge appear to depend on the more or less abundant presence of pus globules, and of the tessellated epithelium of the vagina: desquamation of which takes place so very abundantly in vaginal leucorrhoea that it lurnishes us, as Dr. Tyler Smith' has shown, with a very valuable means of determining the source of the discharge from which a patient suffers. To a very great extent also similar information may be gathered from the discovciy in the discharge of a small infusorial animalcule first described by M. Donnd, and once sui)])()sed by him to be pathognomonic of gonorrlueal, as distinguished from simple vaginitis. He soon, however, found cause to renounce this opinion, though he still alleges that the Trichomonas is never ob- served in healthy vaginal mucus, but only in the secretion when containing a large admixture of pus globules. This latter state- ment, too, is confirmed by the researches of Kcilliker and Scanzoni,^ who further add the remark, that while never present in the cer- vical mucus, and by that circumstance plainly demonstrated to be sometliing more than a mere cell of ciliary epithelium, as has been sometimes imagined, the Trichomonas is on the one hand not constantly present in vaginal leucorrha>a, and on the other the existence of the disease in a grave form is by no means essential to its development, since it is found in some persons in ap[)arent health, and in whom the admixture of pus globules with the dis- charge though evident, is yet not very considerable. It may perhaps be added, that as the microscope fails to furnish us with a means of distinguishing between gonorrhoeal and sim[)le vaginitis, so no S3'mptom or combination of symptoms is absolutely conclusive on this point. Tlie amount of affection of the urethra certainly strengthens the suspicion of the gonorrhoeal origin of the disease ; but urethral inflammation and discharge are some- times present in cases where no suspicion of gonorrha^a can for a moment be entertained, and according to M. Ricord, are likewise absent in cases avowedly due to impure intercourse, about once in every three times. 1 On Leucor7-hcea,&c., chap, iv, pp. 51-79. 2 See with reference to these points, the very elaborate investigations of Kolliker and Scanzoni, on the secretion of the mucous membrane of the vagina and cervix uteri, in Scanzoni's Beiirage, &c., vol. ii, VViirtzburg, 1855, pp. 128-146. CHRONIC VAGINITIS. 607 It is comparatively seldom, at any rate in private practice, that vaginitis or vaginal leucorrhoea comes under our notice in its acute stage. If it does, the employment of tepid hip-baths, of tei)id vaginal injections, rest, and mild laxatives, usually suffice to afford relief, while as the inflanimatf)ry symptoms subside injections of cold water, of the diluted liquor [)lumbi, of solutions of sulphate of zinc, or of alum, will restrain, and in a week or two put a stop to the profuse discharge which for a season remains behind. Xow and then, however, if the pain is ver}- severe, the tenderness great, and the swelling of the labia considerable, it is expedient to apply eight or a dozen leeches to the vulva, to encourage the bleeding by a warm hipbath, and a warm bread-and- water poultice, and after- wards to keep warm fomentations of two parts of the decoction of poppy and one part of the diluted lead lotion constantly ap))licd to the vulva. These measures will, in most cases, within less than twenty-four hours, reduce a state of previously intense suft'ering to one of very bearal)le discomfort. Sometimes, however, the diffi- culty and pain in passing water continue very distressing, and in that case the extract and decoction of uva ursi with small doses of liquor potassa and of the tincture of henbane seldom fail to afl'ord very speedy and very marked relief. I am disposed to think, indeed, from my hospital experience, that the complication of vagi- nitis with some degree of inflanmiation of the bladder often fails to receive that degree of attention which it merits ; for it has hap- pened to me not infrequently to meet with patients in whom very distressing dysuria, the evident result of chronic cystitis, was referred back to some acute attack of leucorrhoea or gonorrhoea which had occurred months before. But it is, as I have stated, a more chronic form of ailment with which we oftener have to do, and tliis not only in cases where a leucorrhoeal discharge has been left behind after the subsidence of the acute attack, but in a large number of instances where the ailment has been chronic from the outset. Such are many of the cases of leucorrhoea that occur in women exhausted by frequent childbearing, or by prolonged lactation, or by menorrhagia. Such, too, are the instances in which leucorrhoea accompanies cldorosis, and of the same kind are those abundant discharges from the sexual organs which take place in strumous children, and which, sometimes assuming a subacute character, and being associated with much swelling of the external parts, have been erroneously supposed to be due to criminal attempts at intercourse. I may just add, however, that the discharge in the case of the child takes place almost entirely from the parts in front of the hymen, and is the result, therefore, rather of vulvitis than of vaginitis. Any condition which maintains or is dependent on habitual venous congestion of the abdominal viscera is apt to be associated with vaginal leucorrhoea. Hence the discharge is often observed not only in women who sutler from ovarian or other abdominal tu- mors, but also in })ationts liable to disorders of the liver, or to hemorrhoidal aftections, or who sutler from hal>itual constipation. 508 TREATMENT OF Uterine tumors, and uterine misplacements are, as it is almost needless to observe, apt to be associated with vaginal leucorrlioea; while even in those cases in wliich the greater proportion of the discharge is poured out from the interior of the uterus, there is almost invariably a large admixture of secretion furnished from the walls of the vagina. It is obvious that the chances of cure of this chronic vaginal leucorrlioea depend entirely on the uncomplicated character of the ailment, or on the diseases with which it is associated being of a kind to admit of removal. Thus, the leucorrlioea attendant on uterine tumors, while in itself it need not excite any solicitude, yet scarcely admits of cure, its restraint by astringent lotions being all that can be attempted. For the same reason, too, those vaginal discharges which are associated with abdominal tumors do not admit of cure; while in those instances in which they accompany hepatic disorder or abdominal congestion, as is not in- frequently the case in women after the middle period of life, and in whom menstruation has ceased, the cure of the local ailment depends on the removal of the constitutional disorder. The leucorrhoea of the feeble and chlorotic obviously needs a tonic plan of treatment, and the administration of chalybeates, in addi- tion to the employment of local remedies ; while, in the case of children, it is always necessaiy to ascertain that the discharge from the vulva is not produced by the irritation of ascarides in the rectum. But, not to dwell upon points which are almost self-evident, I must just notice some of the more useful astringent applications; for to these local means we must chiefly trust, since there are no internal remedies that exercise a direct influence on vaginal dis- charges in the same way as cubebs and copaiba restrain uterine leucorrhoea. First among these means stands the abundant use of cold water, either for ablution, for vaginal injection, or in the form of the hip-bath; for simple though it is, and therefore often too little had recourse to, it is not only very efiicacious, but in many instances suffices of itself to arrest the discharge, and, if continued, to prevent its return. The water may be rendered more astringent by the addition of about a quarter of an ounce of alum to each pint of water used for injection, or by mixing a quarter of a pound of alum with the water used for the hip-bath, and which should be employed either on rising from bed, or, at any rate, during the morning hours, not just before going to rest at night. The alum bath has the advantage of being one of the best astringents, and also of being one of those remedies with which a patient can always supply herself without the intervention of the chemist. If, however, it should fail, as all local applications, if long continued, are in turn apt to do, a more powerful injection may be obtained by the addition of a drachm of tannin to each two drachms of the alum, or by dissolving the alum in decoction of oak-bark instead of in water. Both of these lotions, however, have the disadvantage of staining the linen almost as indelibly as the nitrate of silver, VAGINAL LEUCOllRHCEA. 509 though not of so dark a color. The lead lotions of various strengths, and lotions of sulphate of zinc, either alone, or in comlnnation with alum, may also be employed, if other means fail ; hut iailures very often depend on the inefhcient use of the injection, rather than on any fault in the remedy itself; and it is therefore always of importance to ascertain that the patient employs a syringe of sufficient size, and that she uses the injection when in a recumbent and not in a sitting posture. 1{ is also always desirable that cold w^ater shoukl be injected into the vagina, so as to remove the dis- charge as much as possible before the medicated injection is employed. I have no personal experience of the use of nitrate of silver in solution or in substance in cases of chronic leucorrhoea. There can be no doubt, however, but that in instances of very obstinate dis- charge after acute gonorrheal vaginitis, the remedy has proved of great service.^ For veiy obstinate cases of vaginal leucorrhcjea a plan of iScanzoni's will probably be found successful.^ lie intro- duces into the vagina a plug of cotton-wool, the outer surface of which has been bestrewn with alum in .powder; or if there be much sensitiveness of the parts, with a mixture of one part of alum and one or two parts of loaf-sugar. This plug should not be allowed to remain longer than twelve hours at a time, nor should its intro- duction be repeated oftener than every second or third day, injec- tions of tepid water being employed in the intervals. The chief drawback from the adoption of this plan seems to be that unless carefully watched a very troublesome vaginitis may be induced by the remedy, which in that case may aggravate instead of arresting the discharge. M. Guerin,^ whose experience in the management of this class of ailments is so extensive, speaks also in the .highest terms of the result of introducing a plug of cotton-wool, of the size of a walnut, and containing about a teaspoonful of powdered alum, through the speculum, and quite up to the fundus of the vagina, where he allows it to remain live or six days. lie does not seem to have experienced any graver inconvenience from its use than a little irritation of the mucous membrane, near the fourchette, as the dissolved alum comes in contact with it, and which is readily removed by washing with tepid water. For the majority of cases even of very chronic leucorrhcea, however, a very efficacious and probal)ly a safer mode of keeping the astringent in constant con- tact with the vaginal walls is furnished by the use of the alum or tannin ])essaries of Dr. Simpson.* Attention was specially drawn some few years ago by M. I)eville, of Paris,* to what he believed to be a previously unnoticed form ' Acton, On the GeneraHve Organs, &c., p. 287. ' Op. cit., p. 287. * Miila'/ics des Orgnnes Qenitaiix ExteTUcs dc la Femmr, 8vo., Paris, 1804, p. .30,3. * Ed. Monlhhj Journal, .Juno, 18^8, and Ohniefric U'vrl.s, p. 'J8. Fornuihc are given tliero for various iiinds of possaries. Tlio nlum and tannin arc made as fol- lows: R. Tanniiiic ^ij, Cene all):i> ^v, Axuniciie ,:^vi, misce, ct divide in Pessos quatuor. R. Alum, .xulph. 3J, pulv. Catuciiu 3J, Cerje fluvaa 3J, Axungiae gvsa. Misce, et divide in Pessos quatuor. * Archives de Medecine, Quatrifeme S6rie, tome v, pp. 305, 417. 510 GRANULAR VAGINITIS. of inflammation of the vagina, and to which, from its anatomical peculiarities, he applied the name of granular vaginitis. These peculiarities consist in the presence of numerous round, shot-like bodies of a more vivid red color than the adjacent tissues, in the depressions between the rugte of the vagina, and especially abun- dant towards the upper part of the canal. These bodies were im- agined to be the hypertrophied follicles of the mucous meml)rane, and were supposed to bear a large share in secreting the abundant thick yellow discharge which was poured out from the vagina. The affection was further observed to be connected very closely with the pregnant state, while it scarcely ever occurred in women wlio had not at some comparatively recent period given birth to children. The researches of minute anatomists, and especiall}^ those of M. Mandt,' have shown, however, that the vagina is singularly desti- tute of mucous follicles, and that these bodies are nothing else than hypertrophied papilhe. This discovery, while it exjdains the association of granular vaginitis with the pregnant condition, at once deprives it of all claim to be regarded as a peculiar disease. It is nothing else than vaginitis, associated with hypertro[)liy of the vaginal papillae; a physiological condition in pregnancy ; one which, independent of that state, may follow or accompany long- continued inflammation, irritation, or discharge. On two occasions I have met with ci/sts projecting into the vagina. In one instance their presence gave rise to no inconve- nience, and the patient, who died of faecal abscess, was not aware of their existence, though they were so low down as partially to protrude through the vulva. Two, which were of the size of a chestnat, were connected with the posterior vaginal wall, and were so firm as to convey the impression of being solid fibrous growths. The anterior cyst was smaller, softer, and felt like a small vaginal cystocele. The surface of all three was of the same color with that of the adjacent vaginal wall. After death, these cysts were found to have firm, thick, fibrous walls, to be hned by a polished niend^rane, and to contain a perfectlv clear, glairy, yellowish, and rather viscid fluid, not unlike synovia; the anterior cyst ditlering from the others only in its walls being rather thinner. Similar in kind to this was a cyst described by Scanzoni,^ which had slowly developed itself till it had attaitied the size of a pigeon's egg. It had probably been many years in course of development, for the patient had long experienced pain in sexual intercourse, referred to the situation of the cyst, and this pain at last became so severe as to render the act impracticable. The tumor was seated at the right side and anterior part of the vagina ; it was very sensitive, tense, but yet yielded a sense of fluctuation. The mucous membrane covering it and in its immediate neighborhood was very red, and there was abundant secretion from the vagina. ' Zeiischrift f. Rationelle Medizin, 1849, vol. vii, p. 1. 2 Op.cit., p. 470. CYSTS OF THE VAGINA. 511 The cyst was opened, and an ounce of transparent serous fluid was let out from its interior, which was felt to be lined by a smooth membrane. Injections of a solution of nitrate of silver were made into the cyst for fourteen days, in order to prevent any re collection of the fluid, and apparently with good effect; for six months after- wards no trace of the tumor could be detected. Almost identical with this was the history of the patient in my second case. She was a married woman, as^cd thirty three, who for some seven years had been aware of the i)ro.sence of a swelling about the size of an egg, which, though not painful, was yet the cause of inconvenience in sexual intercourse, while besides she had more or less aching about the vulva, and for six months had suffered from frequent desire to pass water and from pain in micturition. The situation and appearance of the swelling were such as immediately to sug- gest the suspicion that it was a procident bladder, and it was only after the introduction of a catheter that this was ascertained not to be the case. It was of the size of an egg, projecting between the labia, and its surface, from exposure, had assumed much of the character of ordinary integument. It was elastic, evidently con- taining fluid, was situated at the upper part and ratlier to the right side of the vulva, springing from the under surface of the right nynipha, and sufficiently movable to allow of its being pushed back entirely within the vagina. On puncture, nearly an ounce of glairy fluid was evacuated, and the cavity was afterwards in- jected with equal parts of tincture of iodine and water. The pre- vious uncomfortable sensations were greatly relieved by the pro- ceeding, and for a time at least the tumor was got rid of; but I do not know whether the fluid recollected. The only point of special moment connected with these cysts regards the distinction between them and those cases in which the vaginal wall itself is prolapsed, constituting a rectocele or a cystocele; either of which conditions, when of long standing, is associated with thickening of the vaginal wall, and may on a superficial examination be mistaken for a cyst in these situations. The complete disappearance of the tumor formed by the j)rola})sed vagina under pressure, and its increase upon any effort at strain- ing, coupled with the results of the introduction of the catheter, are simple and conclusive means of distinguishing between a swelling produced by mere vaginal prolapse and one de[»endeut on the presence of a cyst in its walls. There is still much obscurity with reference to the mode of development of these cysts, though Virchow' is inclined to the opinion that they originate in obstructed mucous follicles. Such, no doubt, is the origin of those small superficial subnuu-ons cysts, seated quite low in the vagina, especially around the urethra, or at the lower part of the anterior vaginal wall, of which M. lluguier,- to whom we owe an elaborate essay ou the subject, also makes ' Die Krankliaftcn Geschwulsie, vol. i, 247. * Mimoires de la Societe de C/drurgie de Paris, vol. i, 4to., lS-17, pp. 326-:i9l. 512 CYSTS OF THE VAGINA. mention. These cysts, wliicli seldom exceed the size of a large pea, and are often smaller, appear to he merely obstructed mucous follicles, since their walls are always thin, and so transparent that their contents are visible through them. These cysts, with which I confess that I am not familiar, though Huguier speaks of them as being more frequent than the others, seem to produce no sj-mp- toms, but to burst spontaneously, or to give way during sexual inter- course, and are therefore of less importance even than the others. Aly knowledge of fibrous tumors of the vagina is ecpially frag- mentary, and indeed I believe them to be still rarer than cysts connected with its wall. In the only instance that I have met with, the tumor, which was spherical in form, did not exceed the size of a cob nut, gave rise to no symptoms, and remained quite stationary for more than two years, during which period the patient was under my observation. Sometimes, however, tumors having this origin acquire a very considerable size; and the late Professor Kiwisch^ quotes from a German journal the history of a case in which a tumor weighing more than ten pounds sprang by a pedicle of two fingers' bieadth from the posterior vaginal wall, two inches from the orifice of the canal. Tumors of this large size, however, are possibly fibro-ctllular, rather than strictly s})eaking fibrous growths, and spring originally not from the substance of the vaginal wall so much as from the cellular tissue around it, but naturally grow as they increase in size, in that direction where they encounter the least resistance, and thus come at last to as- sume the iip]»earance of pedunculated tumors of the vagina. Such is probably the nature, and will most likely be the progress, of a tumor in a patient who was under my care in June, 1857, in St. Bartholomew's Hospital. She was 33 years old, had been married eight years, and a year after marriage had given birth to her only child. She professed to have suffered habitually from some degree of dysuria, which had been aggravated after her marriage; but in August, 1856, had suddenly become so much worse, after sujipres- sion of the catamenia, from catching cold, that the use of the catheter became necessary, and liad at intei-vals been required since. Her urine, on admission, was turbid and mixed with blood, but her general health was good, and the dysuria almost disappeared under the influence of rest and very simple treat- ment in the hospital. The cause of her symptoms seemed to be a tumor, about three fingers broad, somewhat oval in form, but with its larger end towards the uterus, and which lay in the direc- tion of the urethra. This tumor was firm, but with some degree of elasticity; its surface was smooth, and it was not tender on pressure. Behind it, and driven quite into the posterior part of the pelvis, was the healthy uterus, which had no connection with it whatever. The introduction of the catheter was attended by some difiBculty, and the instrument, in entering the bladder, passed much to the left side. jS'ow, supposing this tumor to increase, as 1 Op. cit., Tol. ii, p. 560. FIBROUS TUMORS OF THE VAGINA. 513 it doubtless will, it is in the direction of the vagina that it will encounter the least resistance ; thither it will therefore grow, and there it will probably, in course of time, present itself as a poly- poid tumor. Such, doubtless, was the history of the growth of a tumor which Mr. Paget^ has described, and which I had the op- portunity of seeing with him. It sprang originally from the right side of the vagina, and the patient had been aware of its existence for between three and four years, though she had sought for medical advice on account of it only within the previous twelve- month. One physician whom slie consulted took it for an abscess, and punctured it; another recommended the employment of some support. It had not protruded beyond the external parts till some ten days before its removal by Mr. Paget, at which time it hung beyond the vulva as a mass five inches in diameter, of a somewhat pyriform shape, connected by a pedicle, an inch and a half long and of the same thickness, with the right wall of the vagina, and the tissues beneath, just behind the right nympha, which was as it were arched over the uj^per part and right side of the neck or pedicle of the tumor. Its removal was accomplished with very little loss of blood ; and the pedicle was found to pass by the outer wall of the vagina, in the loose tissue between it and the ra- mus of the pubes, and reached nearly two thirds of the way to the uterus. The characters of the tumor, as minutely described in Mr. Paget's own notes, with a copy of which he favored me, were just those of the fibro-cellular outgrowth, which is apt in all situ- ations to attain a size such as the firm fibrous tumor less often reaches, and is alwaj's much slower in acquiring. The subject oi malignant disease of the vagina has been already in a measure anticipated in the remarks made upon uterine cancer. I am, however, inclined to think that the rarity of primitive cancer of the vagina has been to some degree exaggerated; and although the main features of the disease are the same as when it takes its point of departure from the womb itself, there are yet some reasons on account of which it deserves a separate notice. Cancerous disease of the vagina, consequent on similar affection of the uterus, begins for obvious reasons at tlie upper part of the vaginal canal, and travels thence downwards, involving in general the anterior more than the posterior wall. Primitive cancer of the vagina does not show the same predilection for the anterior wall ; nor does it in general seem to begin at one spot, and thence extend; but, for the most part, cancerous infiltration takes place into the whole of one, or more often of both walls of the vagina simultaneously, and is at least as obvious near the vulva as in the neighbor- hood of the uterus. To this rule, which obtains in all instances of fungoid cancer of the vagina (and they are by far the more numerous, since to that class may be referred 15 out of 10 oases of which I have a record), the epithelial variety of the disease ' Oy>. clt.., vol. ii, p. 115, 33 514 MALIGNANT DISEASE forms an exception ; for in that the mischief seems to begin at one circumscribed spot, not in the vicinity of the uterus, and, as far as my experience goes, in the posterior wall; and to extend to the subjacent tissues and to pass into the state of ulceration, while as yet the womb is quite unatt'ected, and apparently healthy tissue is to be found both above and below the seat of mischief The following statements embody the chief results that are deducible from the cases to which 1 have referred: In 15 instances the disease was fungoid; in 4 epithelial. In 1 case only the disease, which was fungoid, was limited to the an- terior wall ; and in 1 of fungoid cancer, the right side of the vagina only was atiected when I saw the patient, though the disease, doubtless, extended afterwards. In 6 cases, of which 2 were fungoid and 4 were epithelial, the disease was limited to the posterior wall. In the fungoid cases the posterior uterine lip also was aftected ; in the epithelial, the uterus was free, though in one instance the os uteri began to be red, spongy, abraded, and bleeding, yet I think not cancerous. In 11 cases, all of which were instances of fungoid disease, both vaginal walls were involved. In 2, however, the anterior wall was chiefly atiected. In 2 of these cases the contraction of the vagina prevented the uterus from being reached. In 1 case there was an outgrowth from the interior of the uterus, and in 1 a granular state of the anterior lip, the nature of which was doubtful. Or, in other words, in 6 cases the uterus was perfectly healthy; in 2 it could not be reached; in 2 the afiection of the uterus was slight, and its nature not quite certain; in 9 it was the seat of decided cancerous disease. With reference to the circumstances which favor its occurrence, cancer of the vagina seems to conform to the same rules as in- fluence the development of uterine cancer; except, perhaps, that it appears to come on at a later period of life than cancer of the womb; for only 7 of the 19 cases were observed between the ages of 35 and 50; and the remaining 12 between the ages of 50 and 66. As with cancer of the womb, so also with that of the vagina, marriage and childbearing apparently favor its production ; for only 1 of the 19 patients w^as unmarried; wliile the remaining 18 had been pregnant 95 times, and had given birth to 86 children; or, in other words, there were 5.3 pregnancies and 4.7 labors at the full period to each marriage. Beyond the evidence furnished by these data of the general conformity of vaginal cancer to the same laws as govern the de- velopment of cancer of the uterus itself, I do not know^ that the conclusions are of much moment. The same similarity, however, between the two forms of disease, obtains also betw^een its symp- toms, whichever be the situation that it occupies, and the duration of the afiection appears to be about the same in both instances. OF THE VAGINA, 515 The early symptoms very closely resemble, as tliis table shows, those which attend the commencement of uterine cancer. The first symptom was pain, in 4 cases. " " iiemorrhuge without pain, . "6 " a ears in both instances to be analogous; the can- cerous cachexia is developed in the one case as in the other, the advance of the evil is equally rapid, and the disposition to secondary deposits at least as decided in fungoid disease of the vagina as in fungoid disease of the womb. Tlicre is but little to observe with reference to treatment, ex- cept that the topical palliatives which are of use in uterine cancer are obviously of more dithcult application when the disease is seated in the vagina. The only gleam of hope that brightens the case of a patient with malignant disease of the vagina is afforded in those instances where the affection is o\' the eitithelial kind. The similarity of structure between the vagina, vulva, and ex- 516 CANCER OF THE VAGINA. ternal parts shows itself, as lias beeu so well pointed out by M. Ilnguier/ in the similarity of the diseases by which they are at- tacked. There is, therefore, some hope that ulcerated growths of the epithelial kind about the vagina may be found to belong to the class of lupus, or rodent ulcer, rather than to the more utterly hopeless category of diseases which are intimately allied with cancer, and that local treatment may not be so thoroughly fruit- less as experience has too amply proved it to be in the case of malignant disease of the womb. But hope even derived from this source is, I fear, but too often doomed to be illusive ; for, on the one hand, the position of the disease not only renders surgical in- terference extremely dithcult, but in all the cases which have come under my notice, the mischief has extended too deep into the submucous tissue for it to be possible to dissect ofl' the diseased structure from the subjacent tissues. On the other hand, the pain attendant on the introduction of the speculum generally renders any attempt at the continuance of the local treatment abortive. Some time since a case was under my care that seemed favorable for local treatment. A long strip of raised, red, large granulations extended for nearly an inch in breath and two in length along the left and posterior wall of the vagina up to its roof, but leaving some quarter of an inch of healthy tissue between it and the neck of the womb. Mr. Paget, who was good enough to see the patient with me, was in hopes, from the absence of thickening about the parts, that the disease might be classed rather with rodent ulcer than with true carcinoma; and accordingly we determined to ap- ply the nitrate of mercury to the affected surface. The results of this proceeding were, for a time, most encouraging; and though the introduction of the speculum caused pain which lasted for many hours, yet the patient gladly submitted to a plan of treat- ment, the benefits of which she experienced in the diminution of the previously profuse, offensive, blood-stained discharge, in the mitigation of the backache, and the improvement of her general health. Three or four applications of the acid produced the com- plete cicatrization of all but just that part of the disease which affected the roof of the vagina. In that situation, however, the application of the caustic was extremely difficult, and there the mischi?if spread. De}tosits took place, thickening the vaginal wall, the granulations grew larger, bled more readily, and extended close up to the side of the cervix uteri, between which and the diseased stuctures an interval no longer existed ; and thus treat- ment was baffled, hope was lost, and we were driven once more to recognize the very narrow limits that circumscribe our power to heal. The patient left the hospital, and died painfully a few months afterwards; and I do not know that her life could be said to have been prolonged by the local treatment, though unques- tionably it was for a short time brightened by a hope which, though illusive, yet cheated her only of some suffering and some sorrow. 1 Memoires de I'Academie de Medecine, vol. xiv, 1849, p. 500. INFLAMMATION OF COWPER'S GLAND. 517 LECTURE XXXIII. DISEASES OF THE EXTEKNAL ORGANS OF GENERATION. Inflammatory AFFECTIONS. Inflammationof the labia, its oonnoction with ob- litfTution of duct of Cowpcr's gland ; description of the gland ; mode in which inflammation occurs in it. FuruncLilar inflammation. Eczema. Prurigo, its rarity. Pruritus generally independent of it ; causes and treatment of pruritus. Inflammation of Follicles of Vulva. HYPKRiESTHESiA OF EXTERNAL ORGAN.s. Vaginal Spasm, or Vaginismus. Coc- cygodynia, or pain about coccyx. Remarks on Masturbation, and excision of clitoris for its cure. Ulcerative affections. Tertiary Syphilis ; difficulties of its diagnosis. Lu- pus ; its characters, its relation to epithelial cancer. Case in illustration. Treatment. Malignant Disease, generally assumes form of Epithelial Cancer, its sj-mptoms and course. Importance of early removal. The arbitrary line of demarcation which in this country separates the province of the physician from that of the surgeon has limited my experience both in private and in hospital practice with refer- ence to the diseases of the external organs of generation. If, indeed, we leave out of consideration such as are the result of syphilitic infection, the remainder of these ailments are by no means of fre- quent occurrence, nor in general of very great importance. Of Inflammation of the labia, nymphce, and external organs, ex- cept as an accompaniment of vaginitis, I have seen almost nothing, and of the unhealthy erysipelatous infiammation of those parts, which, occurring in the ciiild, is apt to pass into a state o\' slough- ing, I have seen very little. Indeed, notwithstanding that for more than five-and-twenty years I have been coimected with large institutions for the diseases of children, I have met with but three or four instances of its occurrence, and only one of diphtlieritic in- flammation of the labia and nymphre. The circumstances in which either of these affections occurs do not seem to be as commonly met with in this country as in some parts of the continent; while they both appear to belong to the class of blood diseases rather than to be purely local ailments such as come more strictly within the scope of these lectures. The inflammation of the labia attendant on vaginitis, more particularly on that form of it which is dependent on gonorrha'a, sometimes extends to the cellular tissue on one or other side, and ends in the formation of abscess. For the most part, however, abscesses in the labia are not the result of diffuse inflammation, but o^ inflammation seated in one of those glands whicli are known by the name of Duverney's, Bartholin's, or Cowpcr's glands.' They 1 Like some old discoveries, so that of the existence of these glands, first found by Duvernoy in the cow, and aft"r\vards by Hartholin in the human female, became forgotten after Haller had sought for them in vain. Mr. Guthrie, in his work on 518 INFLAMMATION OF COWPER'S GLAND. are situated one on either side of the entrance of the vagina, in that triangular space bounded by the orifice of the vagina on the one side, the ascending ramus of the ischium on the other, and the transversalis perinagi muscle on the third, and are covered by the superficial perineal fascia, and by some fibres of the constrictor vagina. They are small conglomerate glands, of about the size of a bean, and open by a narrow duct some seven or eight lines in length just in front of the hymen, or of the carunculaj myrti- formes, and secrete that albuminous fluid which is poured out abundantly in sexual intercourse. It happens sometimes that the duct of this gland on one or the other side becomes obliterated, and tliat the secretion then accu- mulates within it, causing it to form a small swelling of the size of a marble, a cob-nut, or somewhat larger, which projects at the lower part, and towards the inner surface of the labium. It may remain for some time in this condition producing little inconve- nience, but in general it becomes irritated in walking, or painful in sexual intercourse, and thus the case first presents itself to our notice. If now it be opened before inflammation has attacked it, a couple of drachms of a fluid like the white of agg will be let out, the swelling w'ill disappear, and may perhaps never be reproduced, since in many instances the cyst, after a free incision has been made into it, becomes obliterated. Sometimes though no consid- erable annoyance has been produced by the swelling, inflamma- tion has taken place in its interior siifiicicnt to render its contents purulent, while in other cases the inflammation is not limited to the gland itself, but extends also to the adjacent tissue. The labium then becomes hot, swollen, and intensely tender and pain- ful at its lower part, so that the patient is unable to move about, or even to leave the recumbent position without great sufl'ering, while on its inner surface the gland forms an exquisitely painful prominence, and matter escapes on a puncture being made, with great and usually permanent relief to the patient. It does, how- ever, now and then happen that much sufl'ering is produced by the successive re-formation of these tumors of Cowper's gland at intervals of two or three months, an annoyance which can only be prevented by laying the cyst i'reely open, and j-emoving a portion of its wall, or probably by the injection of a solution of iodine into its cavity. The above condition has never come under my notice except in comparatively young women, and who either were married or at least were accustomed to sexual intercourse. There are some other Diseases of the Bladder^ refers to them, though without giving any exact descrip- tion of their form or relations; butit is to the venerable Tiedemann, of Heidelberg, that we owe our present accurate acquaintance with them. His essay, Von den Diivenieyschen Driisen, «&c., was published at Heidelberg in 1840, his investigations having been begun the year previouslj'. In 1850 M. Huguier published in the Memoires de V Academic de Medecine, a description of these glands, of which he be- lieved himself to have been the re-discoverer in 1841 ; for like so many of his countrj-men, he was unacquainted with what had been done, even in his own field of investigation, beyond the borders of France. BOILS AND ECZEMA OF THE VULVA. ' 519 afFections, however, which have no such relation, but wliicli are perhaps more frequent in the middle-aged than in the young, and are at least as apt to occur in the single as in the married. Yerj troublesome boils, slow in their advance to suppuration, attended by much discomfort, occurring two or three at a time, or in rapid succession after each other, fresh crops of them frecpienti}'' apjtear- ing at intervals of two or three weeks, sometimes show themselves on the outer surface of the labia. The patient's attention is usually first called to them by a disagreeable itching and smarting, and she then perceives a small pimple or two with a hardened base. The, pimple by degrees enlarges, and the hardness around it extends both superficially and into the substance of the labium till it forms a mass as big as a small hazel-nut. It is not attended by much general swelling of the labium, and does not form a distinct head like an ecthymatous pustule, but its surface continues flat even at the time when, suppuration having taken place in it, a small quantity of matter is discharged, after which the hardened spot gradual I3' disappears. The only local treatment which has seemed of much service in this troublesome ailment consists in the free application of the nitrate of silver while the boils are still in the papular state. If done efiectually, this often prevents the fui'ther progress of the pim})le, and spares the patient much of that sufi'ering which fo- mentntions, poultices, and all other surgical appliances at a later period do but very imperfectly mitigate. There is no general treatment which will prevent their formation any more than that of boils elsewhere; but as their occurrence seems sometimes con- nected with that irritation of tlie sexual system wliich oiten ac- companies the final cessation of the menses, we are in such cases furnished with an indication to guide us worth bearing in re- membrance. ^One of the most troublesome affections of the external organs is eczema of the vulva, which is apt to run a very chronic course, and to prove extremely intractable. For the most })art the ailment appears in the flexures between the thighs and the labia, whence it extends to the labia themselves, and afterwards, as it becomes chronic, to the nymph[c, while it is not infrequently associated with eczema about the margin of the anus, and extending along the perineum. In its acute stage it presents no difference from eczema in other parts of the body, but it seldom remains long in that condition, passing rapidly into a chronic state. In this state the labia are apt to lose the hair which naturally besets them, and they waste from removal of the fat which gives them their ro- tundity, while the}' and the nymphjTa become covered with a thick, hard, white epithelium, and the mucous membrane on their inner surface becomes dry, unlubricated, harsh, and unyielding. It is not usual for this disease to affect the vulva, generally, but in- stances in wliich it has done so have come under my notii-e, the mucous membrane entirely losing its natural appearance, the dry, harsh, and thickened condition of the orifice of the vagina being 520 * BOILS AND ECZEMA OF THE VULVA. associated with a marked narrowing of its calibre. In the worst cases, too. the disease involves the prteputium clitoridis to such a degree, that its thickened indurated tissue projects between the labia, while where the opposing surfaces are in contact they con- tinue red, abraded, and just in the condition of parts affected by acute eczema. It is noteworthy, also, that in two instances of severe chronic eczema, a vascular tumor of considerable size grew from within the orifice of the urethra, but I do not know which of the two was of the longer standing. Those slight attacks of eczema to wliich some women are liable at the return of a menstrual period, from over-walking, or from similar causes, are often much relieved by the frequent applica- tion of a glycerine lotion,^ while the parts where the eruption has been wont to appear may be afterwards rendered less irritable by the employment of pure glycerine or of zinc ointment. If the inflammation is severe, and the discharge from the surface abun- dant, the patient must remain in bed, and the continued api)lica- tion of an oxide of zinc lotion,'^ will both restrain the secretion and abate the soreness, while afterwards the ablution of the parts with thin starch, and the keeping them constantly covered with the benzoated zinc ointment (a compound which has the advan- tage of not readily becoming rancid), seldom fails to bring about very speedy relief It is, however, the chronic form of eczema, attended with the desquamation of dry scales of epidermis that is most troublesome to cure, or even to relieve. I have observed it in its severest forms only in hospital patients, and these it was almost impossi- ble to induce to remain long enough for more than some measure of alleviation of their ailment to be obtained. The distressing itching was in most instances relieved for a time by smearing the parts with cod-liver oil. The relief which this afforded, however, was but temporary, and other unctuous applications answered the same end, also, only for a time, and in general less effectually. Indeed nothing short of completely modifying the state of the skin by caustic applications seemed in these cases to hold out any prospect of cure. I have for this purpose employed the solid ni- trate of silver, substituting for it, as fresh and more delicate epi- dermis was produced, a solution of twenty grains of the salt to an ounce of distilled water. Professor Scanzoni'^ uses with the same object a solution of half a drachm of caustic potass in an ounce of distilled water, which is to be lightly applied b}' means of a camel's hair ])encil, and advises, besides, as the disease abates, very copious and frequent ablution with cold water. Mere external applications, however, though essential for the 1 (Formula, No. 14.) R. Gh'c. purificati, .... .^^ij Aqua3 Rosse, ^vj M. ft. Lotio. 2 (Formula, No. 15.) R. Zinci Oxydi, ,:^ij Mist. Aciicise, .^i Aquie Rosaj, ^v M. ft. Lotio. Op. cit., p. 562. PRURIGO, AND PRURITUS OF THE VULVA. 521 patient's relief, and condncino; much to her permanent recovery, seldom siithce in cases of much severity and long standino;. In them, as in chronic eczema seated elsewhere, a long continued course of arsenical preparations appears to furnish the only means of effecting a permanent cure. Prurigo is often spoken of in connection with that distressing itching of the sexual organs from which women frequently suffer. "While pruritus, however, is a common affection, prurigo is one of very considerable rarity; and I have never met with an instance in which the eruption was limited to those parts, though patients suffering from general prurigo are sometimes much distressed by the appearance of the erui)tion on the genitals, while others are driven by the irritation to scratch themselves to such a degree as to wound the skin, and thus produce little bloody points not un- like those wliich one sees on the top of the papillfe of prurigo. In spite of this absence of any necessary connection between the painful itching of the sexual organs and the appearance of any eruption on their surface, this will perhaps still be the most con- venient place for introducing what I have to say concerning it. Though commonly spoken oli as, j^ruritus of the pudenda or of tlie vulva, the sensation is by no means limited to one part, but is sometimes referred to the external organs, to the surface of the labia, or to the mons veneris ; at other times it is experienced about the nymph?e and the vestibulum, while sometimes it affects the vaginal canal, or even the os uteri. The circumstances in which it is met with vary as much as the situations to which the sensation is referred, and serve to show that in strict propriety the ailment deserves to be classed, as it is by some continental writers, among the nervous affections of the sexual organs. It is far from being an infrequent attendant on the earlier months of pregnancy, and likewise sometimes accompanies organic disease of the womb, especially carcinoma in its earlier stages. It some- times attends, and still oftener precedes, the menstrual period, esjteeially in w^omen who menstruate scantily, irregularlj', or painiully ; while again it frequently occurs at the approach of the climacteric period, when menstruation has either finally ceased, or is about to disappear. It accompanies hemorrhoids, and is sometimes one of the discomforts |)roduced by a varicose state of the veins of the labia, it attends the onset and decline of most cases oC inflammation of the vagina, and, in short, is seldom al- together absent when any cause whatever produces a state of un- natural congestion of the sexual organs. Now and then it is associated with a sort of herpetic eruption of the inner surface of the labia, the vesicles of which are apt to assume, on l)ursting, something of the character of small aphthous sores; but my own cxjjcrience does not lead me to regard this condition as at all of common occurrence. To describe a sensation is proverbially difficult; but it may be observed, that as this pruritus varies in degree, so it does also in kind. It is sometimes an unpleasant sense of creeping or formi- 522 PRURITUS AND OTHER cation, at other times a feeling of smarting, while in other cases the positive itching is so distressing as to be almost unbearable. "Warmth always aggravates it, and with some persons it suffices to come into a warm room in order to experience an attack of it, while in the case of most patients the nights are in great measure sleepless, because to lie down in bed is at once a signal for the commencement of the itching. Cold for a moment eases it, but this relief is but momentary, and patients are driven to scratch and rub themselves in order to obtain a sort of relief which con- sists in the substitution of a burning, smarting sensation for the less tolerable itching. This, however, not only does no real good but the very rubbing of the parts both aggravates the patient's condition, and also helps to produce and to keep up a state of morbid sexual excitement, which in some of these cases consti- tutes by no means the least other sufferings. The treatment obviously depends on the conditions with which this distressing symptom is associated. The empirical prescrip- tion of lotions, ointments, or other ap[»lications, without [)revious inquiry as to the state of the uterine functions, is worse than idle. One case I remember in wliich the application of the nitrate of silver to a long-standing abrasion of the os uteri was followed by the almost immediate cure of a previously very distressing pruri- tus. When consequent on vaginitis the cure of the inflammation and the cessation of the itching take place almost simultaneously, while in general nothing relieves the irritation which accompanies the decline of the vaginitis more than the Goulard water and liydrocyanic acid, in the proportion of two drachms of the latter to eight ounces of the former. Whenever there is much evidence of congestion about the external parts, as shown either by their heat, swelling, or redness, and tenderness, a few leeches to the vulva, or to the margin of the anus, will generally give much re- lief, and the same local leeching is, as might be expected, of much service when the pruritus is associated with hemorrhoids. The herpetic eruption on which Dr. Dewees, of Philadelphia, laid so much stress as a cause of this ailment, is relieved — as arc other cases where, without any disposition to the formation of vesicles or of little aphthous ulcers, much heat and redness of the parts exist — by a lotion of borax and morphia,^ which indeed has proved more generally serviceable in my hands than any single remedy besides. In those cases in which there is any local inflammation, or con- siderable congestion present, unctuous applications do not in general do much good. In others in which this condition does not exist, or has been completely removed, the employment of a liniment of half a drachm of chloroform to an ounce of olive oil, ' (Formula No. 16.) R. Soda Subboracis, ^iv. Morphise Hydrochlor, jjr. viij. Aquae Rosae, Jx. M. ft. Lotio. NEURALGIC AFFECTIONS OF VAGINA AND VULVA. 523 both externally and to the vaginal walls, which, I believe, Scan- zoni was the first to recommend/ is often of great service. The pure cod-liver oil, also, often relieves the external irritation, though I suspect chiefly in those cases in which there is an approach to a state of chronic eczema ; while Dr. Rigby, in his recent work, strongly advocates an ointment of equal parts of cod-liver oil and red precipitate ointment as successful in cases which have proved rehellious to other means. Two other remedies have sometimes done good service in cases of f)bstinate pruritus ; one of these is quinine, which, given in two- grain doses every six hours, has in some, I fear exceptional in- stances, appeared to me to relieve this as it does other neuralgic affections. The other remedy is belladonna, which both out- wardly employed and internally administered, has often proved extremely useful. I generally give the belladonna in the ibrm of pills and combined with camphor, beginning with half a grain of the extract to three grains of camphor, and increasing the bella- donna until dimness of vision, or sense of dryness in the throat is produced. At the same time, I direct an ointment of a scruple of the extract of belladonna to half an ounce of spermaceti oint- ment and half an ounce of glycerine, to be smeared twice a day over the surface, and the relief which these measures obtain has not seldom outlasted their employment and proved to be per- manent. There still remains the employment of the nitrate of silver, either externally or to the vaginal walls, according to the seat of irritation; but I have not myself had recourse to it; for either other remedies have relieved the ailment, or it has -ceased with the removal of its cause, as in cases where it occurred during preg- nancy ; or the patient has no longer heeded it, as in some instances of cancer, where other and worse sutfering has made the former annoyance seem less intolerable. This is perhaps the best place to notice two painful neuralgic affections, the one of the vagina, the other of the rectum, which under the names of vaginmnus and coccygodynia, have of late at- tracted considerable attention, though both conditions must have long been known practically to all wlio have had much to do with the treatment of the diseases of women. The former condition is one of pain and spasm at the entrance of the vagina, so severe as to be a complete bar to sexual inter- course. The pain, however, is often by no means limited to the act of sexual congress, but the patient experiences a sense of dis- comfort about the vulva, which is raised to positive pain on walk- ing, and sometimes even on at^suming the sitting jiosture, though the degree of suffering varies much in different women, and in the same woman at different times. If any attempt is made to introduce the ffnger, the pain at once becomes intt)lera1)le, and the completion of the examination is prevented not merely by the 1 0;;. ci7.,p. 545. 524 VAGINISMUS. patient's inability quietly to submit to it, but by the violent con- striction of the sphincter vagiuse which is at once produced. This state is by no means invariably limited, as in the cases related by Dr. Marion Sims,' who first proposed for it the name of vaghiismus, to newly married persons in whom intercourse has been imperfectly accomplished, and in whom the hymen has been but partially obliterated. I have seen it in its less extreme degrees, left behind after chronic uterine inflammation, and have observed that in some cases long after the introduction of the fine-er or even • of a speculum, could be borne without suffering, the act of coitus, no doubt owing to the peculiar excitement of the nervous system which attends it, was so painful as to be altogether impossible. I have never seen it as an isolated symptom in patients other- wise altogether healthy, but have always observed it to be asso- ciated with other nervous and hysterical symptoms, with dysmenor- rhcea, often with pain in defecation and micturition ; and like all ailments of this class, its severity is liable to great and apparently causeless variation. Allied to this condition, too, is the intense pain in micturition which I have occasionally observed in un- married women, and which I have seen baffle all kinds of treat- ment. Of this a most striking instance came under my notice in a young unmarried lad}' about 24 years old, in whom it had been gradually coming on almost from the very time of puberty. She was pale, delicate, and thin, but had no other positive ailment than the agony which attended every act of micturition, and which con- tinued for a quarter or half an hour after she had emptied the bladder of urine, which was found invariably to be healthy. She was seen by numbers of doctors; she was sounded for stone on more occasions than one, was treated by all imaginable remedies; her bladder was injected with sedatives, and with carbonic acid gas, tonics, large doses of chalybeates, sea-air and bathing, and visits to the German watering-]»laces, were all had recourse to. Her general health at the end of these experiments was no worse, and her local sufi'ering no better, than at their commencement, and she continued, after years of treatment, a feeble, nervous, hysterical invalid, with little power of body or of mind, and with this one distressing peculiarity only to distinguish her from a hundred others. ^ 1 do not think that a state of vaginitis is, as Dr. ChurchilP con- siders, usually the first step towards the production of this vaginal pain and spasm; and as I have known the state to supervene in women who had been married two or three years before the com- mencement of the symptoms (though never in any who had given birth to children) I believe the conditions in which it originates may be very various. The first essential in all cases towards the patient's improve- 1 Obstetrical Transactions, vol. iii, p. 356. 2 Diseases of Women, 4th ed., Dublin, 1864, p. 123, where will be found a very good account of this condition. VAGINISMUS. 525 ment is her separation from her husband's bed, and the complete cessation of all attempts at intercourse. Tepid hip baths, soothing local treatment, and the removal of any inflammation of the vagina or of its oriflce, should any such condition exist, come next. The application, for this purpose, of a solution of nitrate of silver by a speculum to the whole tract of vaginal mucous membrane, as recommended by Dr. Churchill, implies, however, that already considerable progress must have been made towards the patient's cure, since in some of the cases which I have seen the lino^er even coukl not be introduced without intense suflerini;. The removal of any obvious uterine ailment, and the improve- ment of the patient's general health, are of course to be attended to; but I may say that in no case have I found the much-vaunted bromide of potass either abate the sensitiveness of the sexual organs, or control any of those nervous ailments of an hj'sterical or epileptiform kind wliich are commonly supposed to be associated with disorder or excitement of the sexual system. The te[)id douche to the sacrum, and nates have in some in- stances proved of much service in my hands; and I should expect the mud and carbonic acid gas baths of Meinberg and some other places in Germany to be useful, though I have not had any oppor- tunity of trying them in these cases. The gradual dilatation of the orifice of the vagina by means of bougies is the last step in the treatment of these cases, and one which acts in two ways, both by mechanically widening the canal and also by accustoming the vagina to the presence of the foreign body. I have employed rectum bougies of difterent sizes, direct- ing the patient to introduce one for an hour daily, exchanging it as she was able for one of a larger and still larger size. Dr. Sims and Dr. Churchill employ glass dilators, which have the advantage of being more cleanly. I have seen one case in which I can conceive it possible that some surgical proceeding, such as is practised by Dr. Marion Sims, would be of advantage, though in this instance the intense vaginal tenderness was but one of a set of symptoms of most aggravated hysteria. Dr. Sims's operation consists in the excision of the re- mains of the hymen, the subsequent incision of the vaginal orifice, and the further enlargement of the canal by means of a dilator. This proceeding, indeed, is somewhat formidable, and is attended sometimes b}' a good deal of hemorrhage; but the condition of vaginal spasm and jtain is so grievous as to justify almost any means being adopted for its relief Backache is so common an attendant upon a large number of the diseases of women, that both we and our patients often pay but little heed to it, and except in instances where it is unusually severe, make but lew inquiries as to its exact situation, or as to the circumstances that aggravate or relieve it. To this it is })rob- ably due that, until quite recently, when Dr. Simpson' directed 1 Medical Times, July 2, 1859. 526 PAIN AT THE COCCYX, OR C OC C Y GO D YNI A. attention to pain in tlie coccyx, or coccygodr/nia, it had not been recognized as a distinct affection. Usually after childbirth, sometimes after a fall or blow on the lower part of the spine, occasionally after long-continued horse exercise, sometimes as one of a train of symptoms associated with misplacement or some other ailment of the uterus, and now and then, independent of any obvious exciting cause, women complain of pain which they refer to the coccyx and its point of junction with the sacrum. This pain is experienced in sitting, is often very severe during defecation, is usually constant and dull, though aggravated at intervals without any apparent cause. It is relieved by the recumbent posture, but, unlike the pain that accompanies prolapsus, is not aggravated by walking or by the erect posture. It is often worse at the menstrual period, is considerably aggra- vated by constipation, and is sometimes rendered very severe by sexual intercourse. There is no special tenderness of the lumbar region, or of the upper part of the sacrum ; but the lower part of the sacrum is often sensitive, and the patient directs attention to the coccyx it- self as the point whence this sensitiveness proceeds; and pressure on the bone is found to be acutely painful. The pressure of the bone upwards causes much more suttcring than its pressure back- ward by the finger in the vagina or rectum, and the sacro-coccy- geal joint is especially painful. Professor Scanzoni/ who has given by far the fullest and best account which we possess of this affection, states that 9 out of 24 patients, of whose cases he has a record, first complained of the pain during childbed; that 6 of these patients were primiparaj, and 5 of them had been delivered by the forceps after a tedious and difficult labor. Two other patients referred to frequent long rides on horseback as the occasion of their suffering. In 11, then, of the 24 cases, the ailment seemed due to causes calculated to produce local injury of the coccyx, and how frequent such injuries must be receives a good illustration in the fact, that 32 out of 180 coccyx bones which the anatomist Ilyrtl collected in two years presented evidence of dislocation and subsequent anchylosis. In many cases, however, the pain in the bone is not due to any traumatic cause, but is sympathetic with some uterine or ovarian disease, and that by no means of a kind to affect the bone by pressure, or in any mechanical manner. In these instances the removal of the coexistent disease is ob- viously the first duty of the practitioner, and how important tliis may be is further shown by a fact which Scanzoni mentions, that three women who had suffered much in their younger years from this coccygodynia, became completely free from it as soon as men- struation had completely ceased. I have not seen, or at least have not recognized this affection in 1 Op. cit, pp. 589-602. MASTURBATION, AND REMOVAL OF THE CLITORIS. 527 its severer and more intractable forms. One of the worst cases of it wliich I have observed occurred in a young unmarried lady, in connection with hemorrhoids and habitual constipation, and dis- appeared completely when these conditions were relieved. Perfect rest, mikl aperients, the complete emptying the rectum of all ffecal matter; leeches to the coccyx, tepid hip-baths, and warm fomen- tations: such are the means by which, in the majority of instances, much relief is atlbrded. If these means fail, or if the pain is ob- viously neuralgic, or if, though mitigated, it is not removed by this treatment, Scanzoni resorts to the subcutaneous injection of morphia over the painful s[)ot. He has found this a far more effi- cient remedy than any kind of liniment, ointment, or suppository, and, unlike Dr. Simpson, states that its results have but rarely disappointed him. The condition, though tedious, and apt in its severer forms to relapse, appears to be tolerably amenable to treatment. Of Scan- zoni's 24 cases, 10 recovered perfectly, 9 were much relieved, the result of 3 which he saw but once is unknown to him, and in 2 the evil continued unrelieved by any treatment. Even in these, however, the sutfering was not so severe as, in his judgment, to warrant the subcutaneous division of the muscles, ligaments, and fascige connected with the lowest part of the coccyx, which Dr. Simpson has recommended, and practised with perfect success. The object of the operation is to set the coccyx perfectly free and perfectly at rest, and, if other means fail, should und()ul)tedly be had recourse to, though not as a first measure and independent of previous treatment. A few words may be added here, better perhaps than anywhere else, with reference to the alleged frequency of masturbation in the female sex, and the removal of the clitoris for its cure. There can be no doubt but that self-abuse is not limited to the male sex, and that women sometimes become addicted to it; and it must have happened to all practitioners of medicine to receive occasional painful confessions from women who were unable to overcome a vice, indulgence in which polluted their thought, or who traced the absence of sexual feeling in married life to habits contracted in their girlhood. Such cases, however, are by no means fre([uent; and it seems doubtful whether the practice of masturbation pro- duces such injurious jdiysical effects in the female as in the male subject, though it is im[)0ssible to over-estimate its banetul influ- ence on the moral feelings and the sense of self-respect. If the habit could be overcome, if the mind could be restored to its purity by any mutilation of the person, one would feel that no penalty would be too great to pay for sucli a boon. The seat of sexual feeling is, however, by no means confined to the clitoris; habitual masturbation brings with it no change in the organ, and it is not by irritating it that some women who have sunk to the lowest depths earn ibr themselves a nauseous living by minister- ing to the passions of the most abandoned of their own sex; nor 528 FOLLICULAR INFLAMMATION by removing the clitoris would the habit be broken through, or the means of indulging it removed.^ There are some subjects which by common consent are little mentioned among honorable practitioners of medicine, and the professed curers of self-abuse and its consequences in men, whether they advertise themselves by notices at the corners of tlie streets, or by noisy self-assertion, occupy a position morally like that which his red cloak, his bell, and his cry, "Unclean, unclean," gave to the leper of old. They are seen and they are shunned. Like their prototypes, too, wanton outrage seems to have for them a peculiar attraction. It will, I imagine, scarcely be contended that proceedings which we should reprobate if practised on the one sex change their character when perpetrated on the otlier. I know a lady, aged fifty-three, whose ^^oungest child was more than twenty-years old, who had suffered from a painful fissure of the anus, for which she underwent the usual operation of dividing the mucous membrane of the ulcer. The surgeon who did this, without saying one word to the lady or to her liusband, or hinting in any way what he was about to do, cut oft' her clitoris. The stump of the amputated clitoris became the seat of pain, such as sometimes follows amputation of a limb, and for months the i)atient was in a state of almost ceaseless anguish, which, after the lapse of between two and three years, abated, but has not yet altogether ceased. In answer to her inquiries why some other operation had been performed in addition to that which she knew was requisite, after some evasion, she at length learned what had beefi done, and further, had the humiliation of discovering that the justification of the outrage was, that she was assumed by the surgeon to be ad- dicted to a vice with the very name and nature of which she was alike unacquainted. Our profession ought to be a noble one. The ring and the sword in some universities of the continent still symbolize the knightly vows taken by the candidate for the doctor's degree ; and it is in the spirit of chivalry alone that medicine can be safely practised. I have written this history in all sadness as a warning to my younger brethren, how if they are not watcliful, it is possi- ble, " as noblest things find basest using," that they may pervert their talents, and degrade their manhood, till they sink so low as to find opportunities for mischief in the practice of their art, in- stead of occasions for the exercise of that power of healing which is most God-like. M. Huguier has described, with extreme minuteness, in the 1 With reference to the absence of any change in the sexual organs in connec- tion with habitual masturbiition, the .statements of Parent Duchatelet are decisive : "Thus les jours on revolt dans la prison des prostituees quelques unes de ces filles d'une lascivet6 etfrenee, ou de ces fcmtnes, plus lascives encore, adonn^es au vice honteux dont j'ai parle ; on examine ces femmes comma les autres,et jamais eiles n'ont prdsenrees dans leur organisation, la moindre chose qui les distinguat du teste des prostituees, on du commun des femmes." La Prostitution dans la Viile de Paris, Paris, 1867, 3d ed., vol. i, p. 111. AND TERTIARY SYPHILIS OF THE VULVA. 529 Memoirs of the Aoademy of Medicine of Par is, ^ tlie diseases of tlie sebaceous and piliferous follicles of the vulva, lie s[)eaks of a condition of acne of the vulva, in which the contents of some of the sebaceous follicles accumulate without any obvious cause. The number of follicles so affected is not in general considerable, though like acne of the face, which in all respects it closely re- sembles, the affection is extremely chronic, and different follicles are apt to become diseased in succession. The accumulation of their contents, too, sometimes occasions inflammation of the folli- cles, and then that disease is produced which M. Huguier terms vulvar foUiculitis, and which has occasionally come under my ob- servation, though far less often than it and other ailments of the external organs present themselves to one who has so peculiar a field as is furnished by the Hopital de Lourcine. This affection, which he states to be most frequent during pregnancy, may occur also at other times, induced by local irritation of any kind, and especially by habitual want of cleanliness. It is characterized by the appearance in the fold of the thigh, on the outer surface and free edge of the labia, on the nymphre, and on the base of the prjie- putiuin clitoridis, of little red rounded papilke, which at first scarcely exceed the size of a pin's head ; some of them are distinct, while others are collected together into irregular patches. By degrees these follicles, at first merely congested and enlarged by the accumulation of their contents, become more inflamed, a little drop of pus may be seen at their apex; they then usuall}' burst and shrivel, though sometimes they wither without having pre- viously discharged their contents. The ailment, if left untreated, is chronic in its course, and the follicles take as long as twenty or thirty days, or even longer, to pass through the three stages of eruption, suppuration, and desic- cation, while successive crops will run the same course, and pro- tract the disease for weeks or months. It is, however, amenable to very simple treatment, such as rest, cleanliness, baths, the em- ployment of mild astringents, such as the lead lotion, or of weak solutions of nitrate of silver. From these eruptive diseases of the external organs we pass now to the study of some other aflections, not so superficial in their character, though still seated exclusively in the integument, and in the subjacent cellular tissue. The correct classification of these diseases is very difficult, for while some are undoubtedly of syphilitic character, others belong to the same class with lupus, and are rpiite independent of venereal taint, and of these some pass by gradations difficult to seize into the same class with un- doubted epithelial cancer. I do not pretend to say anything concerning the more usual varieties of syphilitic disease of the external organs. In truth, my familiarit3' with them is but small. I have, however, occa- sionally met with what would seem to have been forms oitertianj 1 Vol. XV, p. 527. 34 530 LUPUS OF THE VULVA. syphilis, but which had been of such long standing, and had proved so rebellious to treatment, that questions had been raised as to whether they were not really of a malignant character. Such a case was that of a patient aged forty-five, who was ad- mitted under my care with ulceration of the external parts, of a year's duration, which appeared to have caused no other consider- able inconvenience than occasional difficulty in retaining her urine. On the inner surface of her left labium, and extending on to the nympha, was a sore of a semicircular form, sliglitly irregular in its outline, its edges somewhat indolent, its surface covered by tolerably healthy granulations. The concavity of the sore was directed upwards, its convex edge downwards, beginning by a narrow edge about a quarter of an inch below the clitoris, and extending down to within about three-quarters of an inch of the lower part of the left wall of the vagina. The cicatrix of a similar sore occupied the inner surface of the right nympha, and the right side of the entrance of the vagina, and a small portion of its lower edge was still unhealed. The orifice of the urethra was red and ul- cerated, but it was not unnaturally open. The uterus was healthy, and there was no enlargement of the glands in the groins. In this patient there were no other venereal symptoms, though she confessed to having had sores accompanied by buboes, and by sore throat, fourteen years previousl3\ Recovery, and complete cicatrization of the sores took place in three months, under the continued employment of the iodide of potass, with the black wash externally, and the occasional application of nitrate of sil- ver. Other doubtful cases which have come under my notice have neither presented any evidence of syphilis, nor has it been possible to obtain from the patient's statenients any proof of its previous existence. The danger in such cases is scarcely of taking them for scirrhus, but rather of confoundinir them with some forms of epithelial car- cinoma. The stony hardness of a scirrhous labium or nympha has in it something very characteristic, and the sore which forms on the mucous surface at that early stage when alone mistake is possible, is a mere superficial abrasion of ephithelium, not a dis- tinct ulcer with raised edges. Genuine epithelial carcinoma, beginning on the external parts, is less apt to extend up the va- ginal canal, and does not show the same exclusive preference for the mucous surface of the labium; while, when ulcerated, its hardness usually extends deeper, and its surface presents a more coarsely granular appearance. From rodent ulcer, or lupus, the diagnosis is more difficult. In that, however, the base of the ulcer is usually more indurated, and an indurated state of the in- tegument extends beyond the limits of the ulcer, producing in vei'y many instances a marked contraction of the orifice of the vulva; while, further, this disease is seldom limited to the inner surface of the labia, but in general affects their posterior part, the posterior vaginal wall for a short distance, and also, in many in- stances, the vestibulum ; a greater extent of surface than syphilitic LUPUS OF THE VULVA. 531 disease commonly involves, while lastly, in a large number of cases, there is associated with the ulceration a very remarkable disposition to hypertrophy of the labia and nymphse. Tiie last peculiarity led M. Iluguier,' who was the first person to give a minute description of this disease, to propose for one of its varieties the name of hqnis Itypertrophicus^ designating its other forms lupus serpiginosus, and lupus perforans. In most instances, however, the characters are so blended as to render it doubtful whether there is any special advantage in these subdivisions. The affection may be briefl}- described as a form of ulceration, attended by little pain, which creeps all round the vulva, healing at one part while it advances at another, indolent in its progress towards healing, but also extending slowly; having irregular, usually rather overhanging edges, the tissue of which, and of the parts immediately around, is hard and cartilaginous. It is, moreover, attended by a disposition to hypertrophy of the parts not destroyed by ulceration, as for instance, of the labia and nymph{ie, and by the formation of condylomatous groAvths about the entrance of the vagina, and the orifice of the anus, which growths themselves also become ulcerated. It is a farther characteristic of this affec- tion, that the ulcerations in healing tend to produce great con- traction of the orifice of the vulva, by the formation of a firm cicatrix-like tissue, Avhich also usually occupies a greater extent of surface than the ulceration had done which it succeeds. M. Huguier's essay contains an account of nine cases of this disease, and five have come under my own observation, making a total of fourteen cases, all of which occurred in women who were either married, or were known to have indulged in sexual inter- course, with the exception of one of M. Huguier's patients, con- cerning whom no mention is made on this point. Onl}- two of M. Huguier's patients, and only one of mine, had had children ; a peculiarity which seems scarcely accounted for by the impediment which, when the disease has reached an advanced stage, it may present to sexual intercourse : The influence of age in the production of this disease is shown in the following table: Patients came under Disease said to Patients came under Difea2 points on which information needed, 466 Intra-uterine injections, in monorrhagia, 66 Inversion of uterus, 188 its causes, 188 symptoms at time of its occurrence, 189 results, 191 spontiineous replacement of, 192 diagnosis of, when recent, 193 chronic, 199 treatment— attempts at replacement, 194 extirpation of uterus, 196, 200 from polypus, 201 Involution of uterus ; results of its interrup- tion, 84 Irritable uterus, 72 Kidneys, atrophy of, from prolapse of blad- der, 137 in cancer of uterus, 302 disease of. producing symptoms of cysti- tis, 487 Kreuznnch, waters of, in cases of fibrous tu- mor, 247 Labia, inflammation of, 517 boils on, 519 Labor, share of, in production of uterine ail- ments, 113 cause of inflammation of uterine appen- dages?, 337 complicated with polypus, 267 fibrous tuuior, 244, 258 cancer, 31 1, 324 induction of, prematurely, in fibrous tu- mor, 258 Leeches to uterus, how applied, 78 caution with reference to their use, 93, 119 Leucorrhcea, cervix uteri its alleged source, 117 treatment of, 121 cervical, treatment of, 125 vaginal, microscopic character of, 506 treatment of, 508 Lupus of vulva, 531 Malformation of sexual organs, a cause of amenorrlxjea, 37 Masturbation, removal of clitoris for, 527 Menorrhiigia, its causes twofold, 52 con.^itiiutional causes of, 63 from local causes, 56 occiisional death from, 63 its treataient, 58 of cases requiring depletion, 60 use of astringents in, 61 digitalis in, 62 local measures in, 64 intra-uterine injections in, 66 Menorrhagia, .scraping uterine mucous mem- brane in, 67 Menstruation, various causes of its disorders, 21, 34 disorders of, referred to three classes, 34 first, average djite of, 35 tardy, usually difficult, 36 precocious (note), 63 Metritis, acute, 90 hemorrhagic, 60 Nabothian bodies ; their nature, 124 enlarged, 208 cyst-formations from, 209 Obliquity, congenital, of uterus, 169 Ovaries, special function of, 20 defective development of, 37 displacement of, 389 hernia of (note), 390 inflammation of, 378 in cases ol acute metritis. 93 rare in an acute form, 382 occasional occurrence of abscess, 383 most frequently chmnic, 385 symptoms of chronic ovaritis, 385, 388 treatment, 387, 390 simple cvsts of, connected with Wolffian body, 393 often stationary, 407 from enlarged Graafian vesicles, 395 from other causes, 398 sometimes stationary, 407 disappear, 409 compound cysts, 398 cysto-sarcomatous, 400 colloid cysts, 401 cancerous, 402 fat-cysts, 402 frequency of different cysts, 406 difi"erent "kinds of, 402 cysts of, discharge of, by various chan- nels. 410 danger of rupture into peritoneum, 413 inflammation of, 414 Ovarian dropsy, disorder of health from, 415 predisposing causes of, 417 exciting causes of. 420 early symjitoms of, 421 advanced symptoms of, 423 diagnosis of, 233, 373, 420 prognosis of. 437 treatment, 439 palliative, 440 tapping in, 442 radical, 450 tight bandage after tapping, 450 subcutaneous )iuncture, 452 puncture per vaginani, 452 maintenance of opening, 453 excision of jiortinn of wall, 453 iocline injections. 459 extirpation of ovary, 468 Ovariotomy, 4i'))S often impracticable, 470, 474 two operations, 46'J their results compared, 474 its mortality (note), 469, 478 542 INDEX. Ovariotomy, its mortality, causes of, 471 and of Caesarean section compared, 472, 478 reasons for formerly rejecting the opera- tion, 476 these reasons reconsidered, 478 indications for and against it, stated, 482 Pelvic cellulitis, 336 diagnosis from uterine haematocele, 351, 372 Peritoneum, rupture of ovarian cyst into, 413 Peritonitis, hysterical, 20 external, 349 Pessaries, their diiferent kinds, 146 rules for their introduction, 150 Plug, in cases of menorrhagia, 64 operations on uterus, 332 Polypus of uterus. Mucous polypus, 207 Glandular, 208 symptoms of, 209 sources <»f hemorrhage in, 210 diagnosis of, 211 removal of, 212 Fibrinous, 213 its nature, symptoms, and troatment, 214 Fibro-cystic ; its nature doubtful (note), 215 Fibrous ; structure of, 259 source of hemorrhage in, 210, 260 development of, 262 inversion of womb by, 201 symptoms of, 262 diagnosis, 263 and of inverted womb, 199 management of labor with it, 267 removal by ligature or excision, 263 Malignant, 288 Pregnancy, share of, in production of uterine ailments, 1 13 obscured by fibrous tumors, 240 diagnosis of, from fibrous tumor, 239 ovarian dropsy, 434 rendered dangerous by fibrous tumors, 243 cancer, 311 extra-uterine, diagnosis from uterine haematocele, 371 Procidentia of uterus, 132 its symptoms, 140 treatment of, 151 cautions in returning it, 152 operations for its cure, 153 failure of all operations, 155 danger of Huguier's operation, 157 extirpation of uterus for, 158 Prolapsus uteri, its different degrees, 127 anatomical arrangements which prevent its occurrence, 128 its causes, 129 mode of production in the aged, 130 alterations in the uterus itself from it, 131 complete prolapse, or procidentia, 132 secondary to prolapse of vagina, 133 symptoms of its earlier stages, 138 complete prolapse (see Procidentia), 140 associated with pregnancy, 142 its treatment, 143 Prolapsus uteri, mechanical support, when to be used (see Pessaries and Supports), 145 of vagina, 133 a cause of hypertrophy of cervix uteri, 134, 136 partial, of anterior or posterior wall (see Bladder, prolapse of), 135 symptoms of, 142 Pruritus of vulva, 621 attendant on diabetes, 19 Puberty, precocious (note), 53 tardy, from various causes, 36, 40 Puncture, subcutaneous, of ovarian cyst (see Tapping), 452 Rectum, prolapsus of, 137 its treatment, 143 Recurrent fibroid tumors of uterus, 268 Retroflexion of uterus, comparative frequency of it, and of anteflexion, 166 Retroversion of uterus, 160 mode of its production, 160 causes of, 161 diagnosis from uterine ha3matocele, 372 ovarian tumors, 428 Rodent ulcer of uterus, 292 Rupture, spontaneous, of ovarian cyst, 410 Scarification of uterus ; its uses, 79 Scirrhus of uterus, 278 Secretions, from sexual organs ; their various sources, 22 Sensibility, disorders of, in diseases of women, 22 Sound, uterine ; by whom suggested, 27 Dr. Simpson's described, 28 mode of introduction, 28 Speculum uteri, invention of, 29 varieties of, 30 mode of introduction, 31 its value estimated, 33 Support, mechanical, in prolapsus uteri, 145 internal, 146 external, 149 Supporter, the uterine, 182 objections to its use, 183 Sterility, influence of flexions of uterus in producing it, 177 polypi, 211 fibrous tumors, 228 Syphilis, tertiary, of vulva, 529 Tapping in ovarian dropsy, 442 attitude in, 447 its dangers estimated, 443 exhaustion after, 448 cyst-inflammation from, 448 followed by tight bandaging, 450 subcutaneous, 452 per vaginara, 452 and maintenance of opening, 453 injection of iodine, 459 Teeth in ovarian cysts, 402 Trichomonas, characteristic of vaginal len- corrhcea, 506 Tubercle of uterus, 274 ulcerations said to be tuberculous, 291 Tumors, floating, of abdomen (note), 436 INDEX. 543 Ulcer, rodent, of uterus, 292 Ulceration of os uteri ; its characters, 101 its alleged importance, 102 importance doubted, 103 success of local treatment explained, 108 local treatment sometimes mischiev- ous, 109 objections to frequent use of caustics, 111 local treatment, when necessary, 123 Urethra, congestion of, 498 vascular tumors of, 500 chronic ulceration of, 503 Urine, albumen in, from presence of leucor- rhoea, 19 Uterine sound (see Sound), 27 Uterus, absence of, 38 knowledge of its structure and diseases formerly defective, 95 assumed constitutional origin of its dis- eases, 97 its special liability to disease accounted for, 98 inflammation of its cavity and body, 90 cancerous, extirpation of, 326 appendages of, inflammation of, 336 its causes, 337 extent to which peritonitis attends it, 341 tendency to suppuration, 341, 345 post-mortem appearances, 342 process of cure of, 343 nature and analogies of, 344 its symptoms, 345 chronic course, 347, 351 Uterus, appendages of, inflammation of, di- agnosis, 348, 426 occasionally independent of puer- peral causes, 353 its treatment, 355 puncture, when indicated, 358 Vagina, acute inflammation of, 505 its treatment, 507 chronic inflammation of, 507 its treatment, 508 cysts of, 510 fibrous tumors of, 512 malignant disease of, 513 extension of cancerous disease of uterus to, 285 rupture of ovarian cyst into, 412 spasm of, or vaginismus, 523 Vaginitis, 505 granular, 510 Vesico-vaginal fistula, 492 treatment previous to operation for, 493 Vulva, eczema of, 519 puritus of, 521 follicular inflammation of, 529 gangrenous inflammation of, 517 tertiary syphilis of, 529 lupus of, 531 cancer of, 535 Wolffian bodies, cysts of, 393 often remain stationary, 407 Zwanck, his pessary described, 148 HEN^RY C. 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THE MEDICAL NEWS AND LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per' annum. Its "News Decaktmext" presents the current information of the day. with Clinical Lectures and Hospital Gleanings; while the " Library Department" is de- voted to publishing standard works on the various branches of medical science, paged * CommanicatioDS are invited from gentlemen in »11 parts of the country All elaborat-e 8rti«le» incerted by tlie Editor are paid for by the Publisber. Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 3 separately, so that they can be removed and bound on completion. In this manner subscribers have i-eceived, without expense, such works as "Watson's Practice," '"Todd and Bowman's Physioixx^y," " Wkst on Children," "Malgaignk's Surgery," &c. &c. The work now appearing in its pages is Dr. Hudson's valuable "Lectures ON THE Study of Fever," which was commenced in the number for July, 18G7. 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It pur- ports to be "A Di(jeM of Dritis.h and Continental Medicine, and of the progres.i of Medicine and the Collateral Sciences," and it presents an abstract of all that is impor- tant or interesting in European Medical Literature. Each article is carefully con- densed, so as to present its substance in the smallest possible compass, thus aft'ordiug space for the very large amount of information laid before its readers. The volumes of 1807, for instance, thus contained FIFTY-FIVE ARTICLES ON GENERAL QUESTIONS IN MEDICINE NINKTY-SliVEN AUTICLES ON Sl'ECIAL QUESTIONS IN MEDICINE. FIVE ARTICLES ON FORENSIC MEDICINE. THIRTY-TWO ARTICLES ON GENERAL QUESTIONS IN SURGERY. ONE HUNDRED AND SEVEN ARTICLES ON Sl'ECIAL QUESTIONS IN SURGERY. SEVENTV-TWO ARTICLES ON MIDWIFERY AND 1)ISEA.SES OF WOMEN AND CHILDREN. FOUTV-EIGHT ARTICLES ON MATERIA MEDICA AND THERAPEUTICS. SIXTY-THREE REVIEWS AND HIBLIOGRAPHICAL NOTICES. THREE ARTICLES IN API'E.NDIX. Making in all four hundred and eighty-two articles in a single year. Each volume, moreover, is systematically arranged, with an elaborate Table of Contents and a very full Index, thus facilitating the researche's of the reader in pursuit of particular sub- jects, and enabling him to refer without loss of time to the vast amount of infor- mation contained in its pages. The subscription price of the "Abstract," mailed free of postage, is Two Dollars and a Half per annum, payable in advance. Single volumes, §1 50 each. As stated above, however, it will be supplied in conjunction with the "American Journal of the Medical Sciences" and the " Medical Wews and Library,'' the whole/ree of postage, for Six Dollars per annum in advance. For this small sum the subscriber will therefore receive three periodicals, each of the highest reputation in its class, containing in all over two thousand pages of the choicest reading, and presenting a complete view of medical progress throughout the world. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers io the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, aud tiiat he will be sustained in the endeavor to permanently cstaljlish medical periodical literauire on u footing of cheapness never heretofore attempted. *^* Gentlemen desiriog to avail themselves of the advantages thus ofii'red will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 18GB. 1^ The safest mode of remittance is by postal money order, drawn to the order of the undersigned. Where money order post-offices are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in rbgisterkd letters. Address, HENRY C. LEA, Nos. 706 and 708 Saxsom St., Puiladklpiha, Pa. Henry C. Lea's Publications — {Dictionaries). T\UNGLISON {ROBLED, 31. D., "^ Prnfessor of Institutes of Medicine in Jeffetson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for OflBcinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology ot the Terms, and the French and other Synonyraes ; so as to constitute a French as well as English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented In one very large and handsome royal octavo volume of 1048 double-coluraned pages, in small type ; strongly done up in extra cloth, $6 00 ; leather, raised bands, $6 75. The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. The mechanical exe- cution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the emjiloyment of a small but clear type, on extra fine paper, the additions have been incorporated without materially increasing the bulk of the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. It wonld be a work of supererogation to bestow a It Is nndonbtedly the most complete and useful word of praise upon this Lexicon. We can only wonder at the labor expended, for whenever we refer to its pages for information we are seldom di.iap- polnted in finding all we desire, whether it be in ac- medical dictionary hitherto published in this country. — Qhicayo Med. Examiner, February, l.sg.O. What we take to be decidedly the betit medical dic- tionary in the English language. The present edition cuntuation, etymology, or definition of terms.— iV«M» , |„ brought fully up to the advanced state of science Turk MedicalJournal, November, 1S6j. p^^r many a long year "Duuglison" has been at our It would be mere waste of words in us to express I elbow, a constant companion and friend, and we eur admiration of a work which is so universally | greet him in his replenislied and improved form with and deservedly appreciated. The most admirable I especial satisfaction. — Pacific Med. and Unrg. Jour- work of its kiud in the English language. As a book of reference it is invataable to the medical practi- tioner, and in every instance that we have turned over its pages for information we have been charmed by the clearness of language and the accuracy of detail with which each abounds. We can most cor- dially and confidently commend it to oar readers. — Glasgow Medical Journal, January, 1866. A work to which there is no ^ual in the English language. — Edinburgh Medical Journal. It is something more than a dictionary, and some- tbing less than an eacyclopsedia. This edition of the well-known work is a great improvement on its pre- decessors. The book is one of the very few of wliich it may be said with truth that every medical man should possess it. — London Medical Times, Aug. 26, lSt>5. Few works of the class exhibit a grander monument «f patient research and of scientific lore. The extent of the sale of this lexicon is sulHcieul to testify to its c-efalness, and to the great service conferred by Dr. Eobley Dunglison on the prof9.<.>(ion, and indeed on others, by its issue. — London Lancet, May 13, 1865. The old edition, which is now superseded by the nal, June 27, 1S6.5. This is, perhaps, the book of all others which the physician or surgeon should have on his shelves. It is more needed at the present day than a few years back. — Canada Med. Journal, July, 1865. It deservedly stands at the head, and caiinot be surpassed in excellence. — Buffalo Med. ana Surg. Journal, April, 1865. We can sincerely commend Dr Dnnglison's work as most thorough, scientific, and accurate. We have tested it by searching its pages for new terms, which have abounded so much of late in medical nomen- clature, and our search has been successful in every instance. We have been particularly struck with the fulness of the synonymy and the accuracy of the de- rivation of words. It is as necessary a work to every enlightened physician as Worcester's English Dic- tionary is to every one who would keep up his know- ledge of the English tongue to the standard of the present day. It is, to our mind, the most complete work of the kind with which we are acquainted. — Boston Med. and Surg. Journal, June 22, 186.5. We are free to confess that we know of no medical dictionary more complete ; no one better, if so well B«w, has been universally looked upon by the medi- i adapted for the use of the student; no one that may ral profession as a work of immense research and ^e consulted with more satisfaction by the medical treat value. The new has increased usefulness; for medicine, in all Its branches, has been making such progress that many new terms and subjects have re- eeutly been introduced : all of which may be found fully defined in the pre.sent edition. We know of no other dictionary in the English language, that can bear a comparison .with it in point of completeness of subjects and accuracy of statement. — N. Y. Drug- gists' Circular, 1865. For many years Dnnglison's Dictionary has been the standard book of reference with most practition- ers in this country, and we can certainly commend this work to the renewed confidence and regard of , in the English language for accuracy and extent oar readers. — Cincinnati Lancet, April, 1S65. ! references. — London Medical Gazette. practitioner. — Am. Jour. Med. Sciences, April, 1865. The value of the present edition has been greatly enhanced by the introduction of new subjects and terms, and a more complete etymology and accentua- tion, which readers the work not only satisfactory and desirable, but Indispensable to the physician. — Chicago Med. Journal, April, 1865. Jfo intelligent member of the profession can or will be without it. — St. Louis Med. and Surg. Journal, April, 1865. It has the rare merit that it certainly has no rival TTOBLYN {RICHARD D.), M.D. A DICTIOXARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition, revised, with numerous a^lditions, by Isaac Hats, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 600 double-columned pages; extra eloth, *1 50 ; leather, S2 00. It is the best book of deflulti.'n.- we have, aad oright always to be npon the etadeat'e Xa.'iii^.— Southern Med and Surg Journal. Henry C. Lea's Publications — (Manuals). ■^EILL [JOHN), M.D., and OMITH [FRANCIS G.), M.D. Pro/, of the Institutes of Medicine in the Univ. of Penna. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal I2mo. volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4 ; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. Neill and Smith is incompara- bly the most valuable work of its class ever published Hn this country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetries, Materia Medica, and Chemistry into a single manual; but the opera- tion has sig^Uy failed in the hands of all up to the advent of" Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably di-awn and illustrated, and the authors are eminently entitled to the grateful consideration of the .student of every class. — N. 0. Med. and Surg. Journal. This popular favorite with the student Is so well known that it requires no more at the hands of a medical editor than the annunciation of a new and improved edition. There is no sort of comparison between this work and any other on a similar plan, and for a similar object. — Nash. Journ. of Medicine. There are but few students or practitioners of me- dicine unacquainted with the former editions of this anas^umiog though highly instructive work. The whole science of medicine appears to have been sifted, as th<3 goM-bearing sands of El Dorado, and the pre- cious facts treasured up in this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion. — West- ern Lancet. To compress the whole science of medicine in less than 1,000 pages is an impossibility, but we think that the book before us approaches as near to it as is pos- sible. Altogether, it is the best of its class, and has met with a deserved success. As an elementary text- book for students, it has been useful, and will con- tinue to be employed in the examination of private classes, whilst it will often be referred to by the eoaotry practitioner. — Va. Med. Juurnal. As a handbook for students It Is Invaluable, con- taining in the most condensed form the established facts and principles of meilicine and its collateral sciences. — N. H. Journal of Medicine. In the rapid course of lectures, where work for the students is heavy, and review necessary for an exa^ mination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and sound- est doctrines and the latest improvements and dis- coveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recom- mend it to all last course students, but there is a clans to whom we very sincerely commend this cheap boob as worth its weight in silver — that class is the gradn- I ates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not ex- actly now what it was when they left it oif. — The I Stethoscope. I Having made free use of this volume in our exami- I nations of pupils, we can speak from experience in j recommending it as an admirable compend for stu- 1 dents, and especially useful to preceptoi-s who exaio- 1 ine their pupils. It will save the teacher much lab who has h particle The work of Maclise on surgical anatomy Is of the "^ enthusiasm. The English medical press has quite highest value. In some respects it is the best puhli- exlmusteil the words of pmise, in recommending this CHtion of its kind we have seen, and is worlhr of a admirable treatise. Those who have any carioeiiy place in the libiary of any medical man, while the f," /'"'^"''y- '° reference t write an educational work, Mr. Marshall's treatise might be reviewed favorably withont even opening We may now congratulate him on having com- pleted the latest as well as the best summary of mod- ern physiological science, both human and compara- tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice to its author. To write such a book requires a varied and wide range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the ta.'k has been fulfilled, The book will prove not only invaluable t« the student of medicine and surgery, but service- able to all candidates in natural science examinations, to teachers in schools, and to the lover of nature gene- rally. In conclusion, we can only express the con- viction that the merits of the work will command for it that success which the ability and vast labor dis- played in its produciion so well deserve.— LoncioH Lancet, Feb. 22, ISbS. If the possession of knowledge, and peculiar apti- the covers. There are few, if any, roorenccomplished anatomists and physiologists than the distinguished professor of surgery at IFnirersity College ; and he has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. It is only re- markable that Mr. Marshall has allowed so long a time to elapse before producing a text-book after his own heart. The plan of this book differs in many respects from that of existing educational books ; the science of human physiology being treated in wider and more constant reference to chemistry, physics, and comparative anatomy and physiology. There can be no question, we think, that this is the most satisfactory, philosophic, and frnitfnl mode of teaching physiology. We have rarely the pleasure of being able to recommend a text-book so unreserv- edly as this. — British Med. Journal, Jan. 25, 1S68. c 'ARP ENTER [WILLIAM B.), M.D., F.R.S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illnstrationa. Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed ; extra cloth, $5 50 ; leather, raised bands, $6 60. We doabt not it is destined to retain a strong hold on public favor, and remain the favorite text-book lii our colleges. — Virginia MeAical Journal. The highest compliment that can be extended to this great work of I)r. Carpenter Is to call attention to this, another new edition, which the favorable regard of the profession has called for. Carpenter Is the standard authority on physiology, and no physi- cian or medical student will regard his library as complete without a copy of \\..— Cincinnati Med. Ob- si^rver. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of tlio physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology iu its reference to the institutes and practice of medicine. — Am. Jour. Med. Sciences. t We have so often spoken in terms of high com- mendation of Dr. Carpenter's elaborate work on hu- man physiology that, in announcing a new edition, it is unnecessary to add anything to what has hereto- fore been said, and especially is this the case since every intelligent physician is as well aware of the character and merits of the work as we ourselves are. — St. Louis Med. and Surg. Journal. The above is the title of what is emphatically th>> great work on physiology ; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any inllnence, that it is our aulhorUy. — Atlanta Moi. Journal. B r THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- can from the Fourth and Revised London Edition. In one large and haml.some octavo volume, with over three hundred beautiful illustrations Pp. 752. Extra cloth, $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. or THE SAME AUTHOR. THE MICROSCOPE AND ITS REVELATIONS. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very hand- some octavo volume, of 724 pages, extra cloth, $5 25. jriRKES { WILLIAM SENHOUSE), M. D., A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition . some royal 12mo. volume. ~ With two hundred illustrations. In one large and hand- Pp. 586. Extra cloth, $2 25 ; leather, $2 75. It is at once convenient in size, comprehensive in design, and concise in statement, and altogether well adapted for the purpose designed. — St. Louis Med. on/t Surg. Journal. The physiological reader will find it a Ho»»t excel- lent guide in the -study of physiology in its most ad- vanced and perfect form. The author has shows himself capable of giving details sufficiently ample in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not lengthened. — Edinburgh Med.'ttnd Surg. J'/urnoL Henry C. Lea's Publications — {Physiology). f)ALTON [J. C), M.D., -*--' Professor of PhysioUiyy in the College of Physicians and Surgeons, New York, &c. A TREATISE ON HUMAN PHYSIOLOGY, Designed for the use of Students and Practitioners of Medicine. Fourtli edition, revised, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of about 700 pages, extra cloth, $5 25 ; leather, $6 25. {Now Ready.) From, tlie Prefo.i'e to the Ni»o Edition. " The progress made by Physiology and the kindred Sciences during the last few years has re- quired, for the present edition of this work, a thorough and extensive revision. This progress has not consisted in any very striking single discoveries, nor in a decided revolution in any of the departments of Physiology ; but it has been marked by great activity of investigation in a multitude of different directions, the combined results of which have not failed to impress a new character on many of the features of physiological knowledge. ... In the revision and correction of the present edition, the author has endeavored to incorporate all such improve- ments in physiological knowledge with the mass of the text in such a manner as not essentially to alter the structure and plan of the work, so far as they have been found adapted to the wants and convenience of the reader. . . . Several new illustrations are introduced, some of them as additions, others as improvements or corrections of the old. Although all parts of the book have received more or less complete revision, the greatest number of additions and changes were required in the Second Section, on the Physiology of the Nervous System." The advent of the first editiou of Prof. Dalton's Physiology, about eight years ago, marked a new era in the sludy of physiology to the American student. Under Dalton'e skilful luanagement, physiological science threw off the long, loose, ungainly garments of probability and surmise, in which it had been ar- rayed by most artists, and came among us smiling and attractive, in the beautifully tinted and closely fitting druss of a demonstrated science. It was a stroke of genius, a& well as a result of erudition and talent, that led Prof. Dalton to present to the world a work on physiology at once brief, pointed, and com- prehensive, and which exhibited plainly in letter and drawings the basis upon which the conclusions ar- rived at rested. It is no disparagement of the many excellent works on physiology, published prior to that of Dalton, to say that none of them, either in plan of arrangement or clearness of execution, could be compared with his for the use of students or gene- ral practitioners of medicine. For this purpo.se his book has no equal in the English language. — Western Journal of Medicine, Nov. 18t)7. A capital text-book in every way. We are, there- fore, glad to see it in its fourth edition. It has already been examined at full length in these columns, so that we need not now further advert to it beyond remark- ing that both revision and enlargement have been most judicious. — Londun Med. Times and Gazette, Oct. 19, 1867.' No better proof of the value of this admirable work could be produced than the fact that it has al- ready reached a fourth edition in the short space of eight years. Possessing in an eminent degree the merits of clearness and condensation, and being fully brought up to the present level of Physiology, it is undoubtedly one of the most reliable text-books upon this science that could be placed in the hands of the medical student. — Ain. Journal Med. Sciences, Oct. 1867. Prof. Dalton's work has such a well-established reputation that it does not stand in need of any re- commendation. Ever since its first appearance it has become the highest authority in tlie English language ; and that it is able to maintain the enviable position which it has taken, the rapid exhaustion of the dif- ferent successive editions is sufficient evidence. The present edition, which is the fourth, has been tho- roughly revised, and enlarged by the iucMrporation of all the many important advances which have lately been made in this rapidly progressing science. —N. Y. Med. Record, Oct. l.j, 1867. As it stands, we esteem it the very best of the phy- siological text-books for the student, and the most concise reference and guide-book for the practitioner. —N. Y. Med. Journal, Oct. 1867. The present edition of this now standard work fully sustains the high reputation of its accotnplished au- thor. It is not merely a reprint, but has been faith- fully revised, and enriched by such additions as the progress of physiology has rendered desirable. Taken as a whole, it is unquestionably the most reliable and u.seful treatise on the subject that has been issued from the American press. — Chicago Med. Journal, Sept. 1867. TkUNGLISON {ROBLEY), M.D., -*--' Profe^s-sor of InslUtdes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition, Thoronghl^y revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes of about doOO pages, extra cloth. $7 00. EHMANN [C. G.) ' PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by George E. Dav, M. D., F. R. S., Ac, edited by R. E. Rogeus, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustratione pelected from Funke's Atlas of Physiological Chemistry, and an Appendi.K of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, extra cloth. $6 00. ■DY THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J CnKSTON Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuei, Jackson, M. D., of the University of Ponn,«yl- vania. With illustrations on wood. In on© very handsome octavo volume of 336 pages extra oloth. $2 25. JVDD {ROBERT B.), M.D. F.R.S., and JgOWMAN {W.), F.R.S. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume of 950 pages, extra cloth. Price $4 75. 10 Henry C. Lea's Publications — (Chemistry). -DRANDE ( WM. T.), B. G.L., and /TAYLOR {ALFRED S.), M.D., F.R.S. CHEMISTRY. Second American edition, thorouglily revised by Dr. Taylok. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 09. (Now Ready.) From Dr. Taylor's Preface. "The revision of the second edition, in consequence of the death of my lamented colleague, has devolved entirely upon myself. Every ch:ipter, and indeed every page, has been revised, and numerous additions made in all parts of the volume. These additions have been restricted chiefly to subjef^ts having some practical interest, and they have been made as concise as possible, in order to keep the book within those limits which may retain for it the character of a Student's Manual " — London, June 29, 1867. A book that has already so established a reputa- tion, as has Brande and Taylor's Ch(»mistry, can hardly need a notice, save to mention the additions and improvements of the edition. Doubtless tbe work will long remain a favorite text-book in the schools, as well as a conveaient book of reference for all.— A', r. Medical Gazette, Oct. 12, 1S67. For this reason we hail with delight the republica- tion, in a form which will meet with general approval and command public attention, of this really valua- ble standard work on chemistry — more particularly as it has been adapted with snch care to the wants of the general public. The well known scholarship of its aulhor.*, and their extensive researches for many ypars in experimental chemistry, have been long ap- preciated in the scientific world, but in this work they have been careful to give the largest possible amount of information with the most sparing use of technical terms and phraseology, so as to furnish the reader, "whether a Ktudeut of medicine, or a man of the world, with a plain introduction to the science and practice of chemistry." — Journal of Applitd Chem- istry, Oct. 1867. This second American edition of an excellent trea- tise on cliomioal science is not a mere repnblication from the Knglish press, but is a revision and en- largomenl ol the original, under the supervision of the Kurviving author. Dr. Taylor. The favorabla opinion expressed on the publication of the former edition of tliis work is fully sustained by the present revision, in which l>r. T. has increased the size of the volume, by an addition of sixty-eight pages. — Am. Journ. Med. Scie/icts, Oct. lSti7. The Handbook in Chemistry op the Student. — For clearness of language, accuracy of description, extent of information, and freedom from pedantry and mysticism, no other text-book comes into com- petition with it. — The Lancet. The authors set out with the definite purpose of writing a book which shall be intelligible to any educated man. Thus conceived, and worked out iu the most sturdy, common-sense method, this book gives in the clearest and most summary method possible all the facts and doctrines of chemistry. — Medical Times. nOWAIAN {JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fourth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. which have come to light since the previous edition was printed. The work is indispensable to every student o/ medicine or enlightened pi-actitioner. It Is printed in clear type, and the illustrations ar« numerous and iutelUgible. — Bontun Med. and Surg. Journal. The fourth edition of this invaluable text-book of Medical Chemistry was published in England in (Octo- ber of the last year. The Editor has brought down the Handbook to that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in tbe science B Y THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fourth American, from the fifth and reviseil London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. (Just Issued.) One of the most complete manual.s that has for a long time been given to the medical student. — Athenceum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. It is by far the best adapted for the Chemical student of any that has yet fallen in our way. — Britinh and Foreign Medico-Chimrgiral Review. The best introductory work on the .subject with which we are acquainted. — Edinburgh Monthly Jour. QRA HAM { THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by Hesky Watts and Robert Bridges, M. D. Complete in one larcje and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 50. Part II., completing the work from p. 431 to end, with Index, Title Matter, Ac, may be had separate, cloth backs and paper sides. Price $3 00. Prom Prof. E. N. Hor.ifi>rd, Harvard College. j afford to be without this edition of Prof. Graham's It has. in its earlier and less perfect editions, been Elements.— Si7/im«7i'* Journal, March, IS.iS. familiar to me, and the excellence of its plan and \ From Pmf. Wolcott GihhH, If. T. Free Acaiicmy, the clearness and completeness of its discussions.! The work is an admirable one in all respects, ana have long been my admiration. j ij^ republication here cannot fail to exert a positive No reader of English works on this science can 1 influence upon the progress of science in this country. Henry C. Lea's Publications — (ChemlHtry, Pharmacy ^&c.). 11 JpOWNES [GEORGE], Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY ; Theoretical and Practical. With one hundred and ninety- ----- - M. D. In one large royal I2mo. volume, We know of uo treatise iu the language »o well calculated to aid the student in becoming familiar with the numerous facts in tlie intrinsic science on which it treats, or one better calculated as a text- book for those attending Cheinica! lectures. * * * * The best text-book on Chemistry that has issued from our press. — American Medical Jonrnnl. We again most cheerfully recommend it as the best text-book for students in attendance uponriiem- ical lectures that we have yet examined. — III. and Ind. Med. and Surg. Journol. A first-rate work upon a first-rate subject. — 8t. Lonis Med. and Surg. Journal. No manual of Chemistry whicM we have met comes so near meeting the wants of the beginner. — Western Journal of Medicine and Surgery. seven illustrations. Edited by Robert Bridges, of 600 pages, extra cloth, §2 00; leather, S2 60. We know of none within the same limits which has higher claims to our confidence as a college class- book, both for accuracy of detail and scientific ar- rangement. — Augwita Medical Jmirnal. We know of no text-book on chemistry that we would sooner recommend to the student than this edition of Prof. Fownes' work. — Montreal Medictel Chraninle. A new and revised edition ofoneofthebest elemen- tary works on chemistry accessible to the Americaa and English student. — N. T. Journal of Medical and Collateral Science. We unhesitatingly recommend it to medical stu- dents. — N. W. Med. and Surg. Journal. This is a most excellent text-book for class Instruc- tion in chemistry, whether for schools or colleges. — Sillirnan's Journal. ABEL AND BLOXAM'S HANDBOOK OF CHEMIS- TRY, Theoretical, Practical, and Technical. In one vol. 8vo. of 662 pages, extra cloth, $t .W. GARDNER'S MEDICAL CHEMISTRY. 1vol. 12mo., with wood-cuts ; pp. 396, extra cloth, $1 00. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. With American additions, by Prof Waltkr R. Johnson. In two very handsome octavo volumes, with 500 wood engravings, extra elolh, $6 00. pARRISH {ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulse and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 860 pages, with several hundred illustrations, extra cloth. $6 00. The immense amonnt of practical information condensed in this volume may be estinjated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36 ; Extracts, 159 ; Lozenges, 25 ; Mixtures, 65 ; Pills, 66 ; Syrups, 131; Tinctures, 138; Unguentum, 67, &c. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats; a more complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay. — Caruida Med. Journal, Nov. 1S64. The medical student and the practising physician will find the volume of inestimable worth for study and reference. — San Francisco Med. Press, July, \mv. When we say that this book is in some respects the best jvhich has been published on the subject in the English language for a great many years, we do not wi.sh it to be understood as very extravagant praise. Iu truth, it is not so much the best as the only book. — The London Chemical New/i. An attempt to furnish anything like an analysis of Parrish's very valuable aud elaborate Treali.ie on Prortic'd Phrirmacy would require more space than we have at our disposal. This, however, is not ho much a matter of regret, inasmuch as it would be difficult to think of any point, however minute and apparently trivial, connected with the manipulation of phariuaueutlc substances or appliances which has | March, 1864. not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of its merits. — Duf/lin Quarterly Jour, of Medical Science, August, 1864. We have in this able and elaborate work a fair ex- position of pharmaceutical science as it exists in the United States ; aud it shows that our transatlantic friends have given the subject most elaborate con- sideration, and have brought their art to a degree of perfection which, we believe, is scarcely to be sur- passed anywhere. The book is, of course, of more direct value to the medicine maker than to the physi- cian ; yet Mr. Parkisu has not failed to introduc* matter in which the prescriber is quite as much interested as the compounder of remedies. In cua- clusion, we can only express our high opinion of tl.e value of this work as a guide lo the pharmaceutist, and in many respects to the phys-ician. not only in America, but in other part:* of the world. — British Med. Journal, Nov. 12th, 1861. The former editions have been suflUciently long before the medical public to render the merits of the work well known. It is certainly one of the mosl complete aud valuable works on practical pharmacy to which the student, thf practitioner, or the apothe- cary can have access. — Chicago Medical hxaminer. jyUNGLTSON [RODLEY], M.D., -^ Profexsor of InMitute.s of Medicine in Jeffenioyi Medical ColUge, Philadelphia, GENERAL THEUAPETTICS ANT) MATEIUA MEDICA; adapted for a Medical Text-Book. With Inde.xe.s of Reineilies and of Diseases and their Remedies. Sixth edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols, of about 1100 pages, extra cloth. $6 50. TtT THE SAME AUTHOR. NEW REMEDIES, WITH FORMUL.T: FOR THEIR PREPARA- TION AND ADMINISTRATION. Seventh ei. QRIFFITH {ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring and Administering OfBcinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-dolumns. Extra cloth, $4 00; leather, $5 00. In this volume, the Formulary proper occupies over 400 double-column pages, and contains about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable receipts for the preparation of essences, perfumes, inks, soaps, varnishes, Ac. our meridian. Without his emen- dations aud additions it would lose much of its valne to the American sludpnt. With them it is an Ameri- can book. — PaoiAc Medical and Surgical Journal December, 1866. ' TJLLIS [BENJAMIN], M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of mnny of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much extended by Albert H. Smith, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one volume 8to. (Nearly Ready.) frequently noticed in this Journal as the successive editions appeared, that it is sufHcient, on the present occasion, to state that the editor has introduced intu the eleventh edition a largo amount of new matter, derived from the current medical and pharmaceutical works, as well as a number of valuable prescrii)tions furnished from private sources. A very comprehen- sive and extremely u.seful index has also been sup- plied, which facilitates reference to the particular article the prescriber may wish to administer; aiiJ t)ie language of the Formulary has been made to coi- respond with the nomenclature of tho new nation,tl Pharmacopoeia.— >lm. Jour. Med. Sciences, Jan. lSu4. We endorse the favorable opinion which the book has so long established for itself, and take this occa- sion to commend it to onr readers as one of the con- venient handbooks of the office and library. — Cin- einnnti Lancet, Feb. 186t. The work has long been before the profession, and Its merits are well known. The present edition con- tains many valuable additions, and will be found to be an exceedingly convenient and useful volume for reference by the medical practitioner. — Chicago Medical 'Examiner, March, 1864. The work is now so well known, and has been so c ARSON (JOSEPH), M.D., Profe.inor of Materia Midira. and Pharmacy in the Univer-iity of PeuTUiylvania, An. SYNOPSIS OF THE COURSE OP LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the "University of Pennsylvania. With throe Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth $3 00. (Now Ready.) ROYLB'S MATERIA MEDICA AND THEHAPED- ticn; including the Preparations of the Pharma- copoeias of London, Ediubnrgh, Dublin, and of the United States. With many new medicines. Edited by .TosEPH Carson, M.D. With ninety-eight illus- trations. In one large octavo volume of about 700 pages, extra cloth. $! 00. CHRISTISON'S DISPENSATORY; or. Comhbntaut on the Pharmacopojias of Great Britain and the United States. With copious additions, and 21.3 large wood-engravings. By R. Eoi-K.-iPKi.DfiuiKFiTH, M.I). In one very handsome octavo volume of over 1000 pages, extra cloth, lilt 00. CARPENTER'S PUIZE E.S.«AY ON THE USE OF Ai.ronoi.in Liqimrs i.v IIkai.tii and Disease. Ni-w edition, with a Prefuce by I). "F. Conuib, JI.D.. mid explanations of scienllflc words. In one neat l'2ma. volume, pp. 178, extra cloth. 60 cents. De JONOH on the three kinds OF COD-LIVER Oil, with their Chemical and Therapeutic Pro- perties. 1 vol. 12mo., cloth. 7.^ cents. MAYNE'S DISPENSATORY AND THKRAPEtTTICAL RKMKMnKANCKR. With every I'ractical Formula contniued in the three British PharmacopmiaH. I Edited, with the addition of the Formula! of the U. S. Pharmacopojia, by R. E. Orifkitu, M. D. la I one 12mo. volume, 300 pp., extra cloth. TCi ceuli*. 14 Henry C. Lea's Publications — (Pathology). fyROSS {SAMUEL D.), M. D., ^^ Prnfesxor of Surgery in the Jefferson Medical College of Philadelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handjome octiivo volaino of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra, cloth. $4 00. The very beautiful execution of this valuable work, and the exceedingly low price at which it is offered, should command for it a place in the library of every practitioner. To the student of medicine we would say tliat we kmiw of no work which we can more heartily com- mand than Gross's Pathological A^naXoiay.— Southern yfed and Surg. Journal. The volume commends itself to the medical student ; it will repay a careful perasal, and should be upou thebook-shelf of every American physician. — Charles- tim Med. Journal. It contains mnch new matter, and brings down our knowledge of pathology to the latest period. — Londun Lancet. J ONES [G. HANDFIELD), F.R.S., and SIEVEKING [ED. K), M.D., Aissivtant Physicians and Lecturers in St. Mary's Hospital. A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 760 pages, extra cloth, $3 50. and the most recent invo.stigations presented in suift- cient detail for the student of pathology. We cannot at this time undertake a formal analysis of this trea- tise, as it would involve a separate snd lengthy considoralion of nejirly every subject discussed ; nor wonld such analysis be advantageons to (he medical reader. The work is of snch a character that every physician ought to obtain it, both for refereneo and study. — N. ¥. Joumnl of Medicine. Its importance to the physician cannot be too highly estimated, and we wonld recommend our readoi-s to add it to (heir library as soon a8 tf ey couveQiently Oar limited space alone restrains us from noticing more at length the various subjects treated of in this interesting work ; presenting, as it does, an excel- lent summary of the existing state of knowledge in relation to pathological anatomy, we cannot too sti'ougly urge upon the student the necessity of a tho- rough acquaintance with its contents. — Medical Ex- aminer. We have long had need of a hand-book of patholo- gical anatomy which should thoroughly reflect the present state of that science. In the troitise bef>ire ns this desideratum is bnpplied. Within the limits of a moderate octavo, we have the outlines of this great I can. — MimireM Med. Chronicle. department of medical Bcieuce accurately deQued, | T>OKITANSKY {CARL), M.J)., Curator of the Imperial Pathological MvJteum, and Profe.isor at the. ITntversity of Vienna. A MANUAL OF PATHOLOGICAL ANATOMY. W. E. SwAiNE, Edward Sievekivo, C. H. Mooke, and Q. E. Day. bound in two, of about 12U0 pages, extra cloth. $7 50. Translated by Four volnmeB octavo. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOOV. Translated, with Notes and Additions, by JasEPU Letdy, M I). lu one volnrae, very large imperial qnarto, with 320 copper-plate figures, plain and colored, extra cloth. $100. SIMON'S GENERAL P.\THOLOGY, as conducive to the Establishment of Katicmal Principles for the I'revtMition anil Cure of l)i-pase. In one octavo Tolumo of 212 pages, extra cloth. 91 25. TJ/'ILLIAMS {CHARLES J. B.), M.D., Profejisfir of Clinical Medicine in University College, London. PRINCIPLES OF MEDICINE. An Elementary View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume of about 500 pages, extra cloth. $3 50. The unequivocal favor with which this work has I A text-book to which no other in our language 1« been received by the profession, both in Europe and | comparable. — Charleston Med. Journal. America, is one among the many gratifying evidences i jhe lengthened analysis we have given of Dr Wil- which miijht be adduced as going to show that there | liams's Principles of Medicine will, we trust, clearly isasteadyprogrjesMakingpUce^in thejci^en^^^^^ ! prove to our readers his perfect competency for thfe ^^ ,.„„ t^jsk he has undertaken — that of in>part!ng to the as in the art of medicine. — St. Louis Med. and Surg Journfd. No work has ever achieved or maintained a more deserved reputation. — Virginia Med. and Stirg. Journal. student, as well as to tha more experieucnl practi- tioner, a knowledge of those general principles of pathology on which alone a orrect practice can b« founded. The absolute necessity of s8cli a w^irft One of the best works on the subject of which Jt I w"*' »>» evident to all who pretend to more than treats in our laugua-'e 1 """* empiricism. We must conclude by again ex- , , ,, V v 1. J I pressing our high sense of the immense benefit which It has already commended itself to the high regard i d^ Williams has conferrM on medicine by the pnb- of the profession; and we may well .say that we | Hcation of this work. We are certain that in tlra know of no single volume that will afford the source i present state of our knowledge his Principles of Medi- of so thorough a drilling in the principles of practice I cj„g pQ„|j ^^j possibly be .snrpas.sed. While we this. Students and practitioners should make themselves intimately familiar with its teachings — they will find their labor and study most amply repaid. — Cincinnati Med. Observer. There is no work in medical literature which can fill the place of thi.s one. It is the Primer of the young practitioner, the Koran of the scientific one. — Stethoscope. regret the loss which many of the rising generation of practitioners have sustained by his resignation of the Chair at University College, it is comforting to feel that his writings must long continue to exert a powerful influence on the practice of that profession for the improvement of which he has so assiduously and successfully labored, and in which he holds so distinguished a position. — London Jour, of Mbdicim Henry C. Lea's Publications — {Practice of Medicine). 15 PLINT {A USTIN), M. D., -*■ Professor of the Principles and Practice of Medicine in Bellevue Med. College, K. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Second eiHtion, revised and enlaru;e(l. In one large and closely printed octavo volume of nearly ]()(I0 pages; handsome extra cloth, $6 50; or strongly bound in leather, with laised baMJs, $7 50. {Just Issued.) From the Preface to the Second Edit-ion. Four months nfter the publication of this treatise, the author was notified that a cecond edition was called for. The speedy exhaustion of the fir.<:t edition, unexpected in view of its large size, naturally intensified the desire to make the work still more acceptable to practitioners and students of Medicine; and, notwithstanding the brief period allowed for a revision, additions have been made which, it is believed, will enhance the practical utility of the volume. Weai'e happy in heiug able once nuire to coininpiid this Work to thestudents and practitioners of medicine who seek fur accurate information convoyed in Ian guage at once clear, precise, and expressive. — Amer. Journ. Med. Sciences, April, 1S67. Dr. Flint, who has been known in this eonntry for many years, both as an author and teacher, who has discovered Irutb, and pointed it out clearly and dis- tinctly to others, investigated the symptoms and na- tural liistory of disease and recorded its language and facts, aud devoted a life of incessant study and tlionght to the doubtful or obscure in his profession, has at length, in his ripe scholarship, given this work t<) the profession as a crowning gift. If we have spoken highly of its value to the profession and world ; if we have said, all considered, it is the very best work upon medical practice in any language; if we have spoken of its excellences in detail, and given points of special value, we hive yet failed to express in any 4egr»e our present estimate of its value as a guide in the practice of medicine. It does not contain too much or too little ; it is not positive where doubt should he <}spressed, or hesitate where truth is known. It is philosophical and speculative whei-e philosophy and speculation are all that can at present be obtained, but nothing is admitted to the elevation of established truth, without the most thorough investigation. It Is truly remarkable witb what even hand this work has been written, and how it all shows the most care- ful thought and untiring study. We conclude that, though it may yet be susceptible of improvement, it still constitutes the very best which human knowledge can at present produce. "When knowledge is in- e surmounted in order ^Buffalo Med. and Surg. Journal, Feb. 1867. He may justly feel proud of the high honor con- fwred on him by the demand for a second edition of bis work in fonr months after the issue of the first. Jfo Amerit-an practitioner can alford to do withovit Flint's Practice. — Pacific Mexi. aud Surg. Journal, Feb. 1867. Dr. Flint's book is the only one on the practice of medicine that can benefit the young practitioner. — Nasfiville Med. Journal, Aug. 1S66. We consider the book, in all its es.sentials, as the enabled liim to arrive at in reference to the relative merits of different therapeutical agents, and diffeiiMit methods of treatment. This new work will add not a little to the well-earned reputation of Prof. Flint an a medical teacher. — N. Y. Med. Record, April 2, 1806. We take pleasure in recommending to the profession this valuable and practical work on the practice of medicine, more particularly as we have had oppor- tunities of appreciating from personal observatioa the author's preeminent merit as a clinical observer. best adapted to the student of any of our numerous j This work is undoubtedly one of great merit, iind we text-books on tins subject. —iV.r Jlf«i. ./ourn., Jan.'67. f,,el confident that it will have an extensive circula- Its terse couciseness fully redeems it from being WnA.— Tlut N. 0. Med. and Surg. Journal, Sept. IbtW. TiUNGLISON, FORBES, TWEED IE, AND COXOLLV. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatise*" on the Nature and Treatment of Diseases, Materia Medica and Therajwutici", Disea.ses of Women and Children, Meilical .lurisprmlcnce, Ac. .tc. In four large super-rnyal octavo volumes, o j;V254 double-columned pages, strongly and hiindsomely bound in Icaihur, $15^ extra cloth, $11. *jir* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. the day. As a work of reference It Is invalnahle. — Western journal of Medicine and Surgtry. It has beon to us, both as Iparuer and teacher, a work for ready aud frequent reffrence, one in which modern English medicine is exhibited In the most ad- vantageous light. — Medical E.raminer. The most complete work on practical medicine extant, or at least in our language. — Buffalo Medical atid Surgical Journal. For reference, it is above all price to every practi- tioner. — Western Lancet. One of the most valuable medical publications of BARLOW'S MANUAL OF THE PRACTICE OF MKDICI.VE. With Additions by U. F. CoKDlE, JI. I). 1 vol. Svo., pp. COO, cloth. *2 30. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. From the third aud enlarged English edi- tion. In one handsome octavo volume of about 600 pages, extra cluth. $3 iO. 16 Henry C. Lea's Publications — {Practice of Medicine). TTARTSHORNE {HENRY), M.D., mJL Professor of Hygiene in the Univerxity of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. In one handsome roynl ]2ino. volume of about 350 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. (Just Issued. ) The very cordial reception with which this work has met show? that the author has fully suc- ceeded in his attempt to condense within a convenient compass the essential points of scientific and practical medicine, so as to meet the wants not only of the student, but also of the practi- tioner who desires to acquaint himself with the results of recent advances in medical science. Dearly than any similar manual lately before us the .standard at which all such books should aim — of As a strikingly terse, full, and comprehensive em- bodiment in a condensed form of the essentials in medical science and art, we hazard nothing in saying that it is incomparably in advance of any work of the kind of the past, and will stand long in the future without a rival. A mere glance will, we think, im- press others with the correctness of our estimate. If or do we believe there will be found many who, after the most cursory examination, will fail to possess it. How one could be able to crowd so much that is valu- able, especially to the student and young practitioner, within the limits of so small a book, and yet embrace and present all that is important in a well-arranged, clear form, convenient, satisfactory for reference, with 80 full a table of contents, and extended general index, with nearly three hundred formulas and recipes, is a marvel. — WesteT^ Jonrnal of Medicine, Aug. 1867. The little book before us has this quality, and we ean therefore say that all students will find it an in- valuable guide in their pursuit of clinical medicine. Dr. Hartshorne speaks of it as "an unambitious effort to make useful the experience of twenty years of pri- vate and hospital medical practice, with its attendant study and reflection." That the effort will prove suc- cessful we have no doubt, and in hi.s study, and at teaching much, and suggesting more. To tlie student we can heartily recommend the work of onr transat- lantic colleague, and the busy practitioner, we are sure, will find in it the means of solving many a doubt, and will rise from the perusal of its pages, having gained clearer views to guide him in his daily struggle with disease. — Dub. Med. Preso, Oct. 2, 18(i7. Pocket handbooks of medicine are not desirable, even when they are as carefully and elaborately com- piled as this, the latest, most complete, and most ac- curate which we have seen. — British Med. Journal, Sept. 21, 1S67. This work of Dr. Hartshorne must not be confound- ed with the medical manuals so generally to be found in the hands of students, serving them at best but as blind guides, better adapted to lead them astray than to any useful and reliable knowledge. The work be- fore us presents a careful synopsi-s of the essential elements of the theory of diseased action, its causes, phenomena, and results, and of the art of healing, aa recognized by the most authoritative of our profes- sional writers and teachers. A very careful and can- did examination of the volume has conTinced us that the bedside, the student will find Dr Hartshorne a ] it will be generally recognized as one of the best mau- ■afe and accomplished companion. We speak thus ' uals for the use of the student that has yet appeared, highly of the volume, because it approaches more I — American Journal Med. Sciences, Oct. 1867. 'U/'ATSON [THOMAS), M. D., ^c. LECTURES ON THE PRINCIPLES AND PRACTICE OP PHYSIC. Delivered at Kings College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D. , author of "A Practical Treatise on the Diseases of Children," Ac. With one hundred and eighty- five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; extra cloth, $6 50; strongly bound in leather, with raised bands, $7 50. Believing this to be a work which should lie on the table of every physician, and be in the hands of every student, every effort has been made to condense the vast amount of matter which it con- tains within a convenient compass, and at a very reasonable price, to place it within reach of all. In its present enlarged form, the work contains the matter of at least three ordinary octavos, rendering it one of the cheapest works now offered to the American profession, while its mechani- cal execution makes it an exceedingly attractive volume. DICKSON'S ELEMENTS OF MEDICINE; a Compen- dious View of Pathology and Therapeutics, or the History and Treatment of Diseases. Second edi- tion, revised. 1 vol. 8vo. of 750 pages, extra cloth. $i 00. "WHAT TO OBSERVE ATTHE BEDSIDE AND AFTER De.\th in Medical C.\ses. Pnblishi'd under the authority of the London Society for Medical Obser- vation. From the second London edition. I vol. royal 12rao., extra cloth. $1 00. LAYCOCK'S LECTPRES ON THE PRINCIPLES ANn Methods op Medical Observation and Rd- SEARCH. For the use of advanced students and junior practitioners. In one very neat royal l2mo. volume, extra cloth. )ll 00. jyARCLAY [A. W.), M. D. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. A work of immense practical utility. — London Med. Times and Gazette. The book should be in the hands of every practical man. — DiMin Med. Press. JPULLER [HENRY WILLIAM), M. D., -^ Physician to St. Oeorge's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, 3rd Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. (JSow Ready.) Dr. Fuller's work on diseases of the chest was so | accordingly we have what might be with perfect jns- favorably received, that to many who did not know tice styled an entirely new work from his pen, the the extent of his engagements, It was a matter of won- | portion of the work treating of the heart and great der that it .should be allowed to remain three years I vessels being excluded. Nevertheless, this volume is ©at of print. Determined, however, to improve it, of almost equal .size with the first. — London Medical Dr. Fuller would not consent to a mere reprint, and j Times and Gazette, July 2C, 1867. Henry C. Lea's Publications — {Practice of Medicine). 17 JpLINT {A USTIN), M. D., J- Professor of the Principles and Practice of Medicine in BelJevue Hospital Med. College, X. Y. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 60. (Just Issued.) Premising this observation of the necessity of each student and practitioner making himself acquainted with auscultation and percussion, we may state our honest opinion that Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tendency to over-refinement and unne- sessary minuteness which characterizes many works on the same subject. — Dublin Medical Press, Feb. 6, 1867. In the Invaluable work before us, we have a book of facts of nearly 600 pages, admirably arranged, dear, thorough, and lucid on all points, without pro- lixity; exhausting every point and topic touched ; a monument of patient and long-coutiuued observation. American medicine. — Atlanta Med. and Surg. Jour- nal, Feb. 1867. The chapter on Phthisis Is replete with Interest ; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's style is clear and elegant, and the tone of freshness and originality which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system. — London Lancet, Jan. 19, 1867. This is an admirable book. Excellent in detail and execution, nothing better could be desired by the practitioner. Dr. Flint enriches his subject with which does credit to its author, and reflects honor on I much solid and not a little original observation. — I Banking's Abstract, Jan. 1867. B T THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume of nearly 500 pages, with a plate ; extra cloth, $3 50. We question the fact of auy receut American author in our profession being more extensively known, or more deservedly esteemed in this country than Dr. Flint. We willingly acknowledge his success, more particularly in the volume on diseases of the heart, in makingan extended personal clinical study available for purposes of illustratiou, in connection with cases which have been reported by other trustworthy ob- servers. — Brit, and For. Med.-Chir. Review. pHAMBERS {T. K.), M.D., ^ Consulting Physician to St. Mary's Hospital, London, &o. THE INDIGESTIONS ; or. Diseases of the Difjestive Orfrans Functionally Treated. Second American, from the second and revised English Edition. In one hand- some octavo volume of over 300 pages, extra cloth, $3 00. {Now Ready.) He is perhaps the most vivid and brilliant of living [ and practical skill — that his success as a teacher or medical writers; and here he supplies, in a graphic series of illu.strations, bright sketches from his well- Slored portfolio. His is an admirable clinical book, like all that he publishes, original, brilliant, and in- teresting. Everywhere he is graphic, and his work supplies numerous practical hints of much value. — Edinhurgh Med. and Surg. Journal, Nov. 1867. Associate with this the rare faculty which Dr. Chambers has of infusing an enthusiasm in his sub- ject, and we have in this little work all the elements which make it a model of its sort. We have perused literary expositor of the medical art consists ; and the volume before us is a belter illustration than its au- thor has yet produced of the rare degree in which those combined qualities are at his command. Next to the diseases of children, there is no subject oh which the young practitioner is oftener consulted, or on which the public are more apt to f>irra their opinions of his professional skill, than the various phenomena of indigestion. Dr. Chambers comes moat opportunely and effectively to his assistance. In fact, there are few situations in which the commencing practitioner can place himself iu which Dr. Cham- tt carefully; have studied every page; our interest , praciiiiouer can p.ace ui nseu .u w....,u x... v.,.au^ in the subject has been intensified as we proceeded, l>ers' conclusions on digestion will not be of service, and we are enabled to lay it down with unqualified -London Lancet, February 23, 1807. praise.— iV. Y. Med. Record, April l.-i, 1867. j ^his is one of the most valuable works which it It is in the combination of thesequalities — clearand j has ever been our good fortune to receive. — London vivid expression, with thorough scientific knowledge ■ Med. Mirror, Feb. 1867. -nillNTON ( WILLIAM), M. D., F. R. S. LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood. In one handsome octavo volume of about 300 pagea, extra cloth. $3 25. {Just issued.) Nowhere can be found a more full, accurate, plain, I The most complete work in our language upon th« and instructive history of these diseases, or more ra- 1 diagnosis and treatment of these puzzling and Impor- (jciiial views respecting their pathology and therapeu- taut dioeases. — Boston Med. and Surg. Journal, Hov. tics. — Am. Joum. of the Med. Sciences, April, 186.1. | 1865. JJABERSHON {S. 0.), M.D. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DIS EASES OF THE ALIMENTARY CANAL, (ESOPHAGUS INTESTINES. With illustrations on wood, pages, extra cloth. $2 50. STOMACH, CECUM, AND In one handsome octavo volume of 312 H UDSON- (A.), M.D., M. R.I. A., Physician to the Menlh No.ij)ilal. LECTURES ON THE STUDY OF FEVER. In one vol. 8vo. iishing in the "Mbdical News and Libkaby'' for 1867 and 1868.) (Pub- 1! Henry C. Lea's Publications — {Practice of Medicine). ROBERTS ( WILLIAHf), M. D.. -*■*' Lecturer on Medicine in the ManCJie/iter School of 3fedioine, &c. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. In one very handsome octavo volume of 516 pp., extra cloth. $4 50. {Just Issned.) In carrying out this design, he has not only made ] sive work on urinary and renal diseases, considered good use of his own practical knowledge, hut has i in their strictly practical aspect, that we possess ia brought together from various sources a vast amount j the English language. — British Medical Journai, of information, some of which is not generally pos- sessed by the profession in this country. We must now bring our notice of this book to a close, re- gretting only that we are obliged to resist the temp- tation of giving further extracts from it. Dr. Roberts has already on several occasions placed before the profession the results of researches jnade by him on various points connected with the urine, and had thus led us to expect from him something good — in which expectation we have been by no means disappointed. The book is, beyond question, the most comprehen- ,^*^ " Bird on Urinary Deposits," being for the present out of print, gentlemen will find in tb« above work a trustworthy substitute. Dec. 9, 1S6.3. We have read this book with much satisfaction. It will take its place beside the best treatises in our language upon urinary pathology and therapeutics. Not the least of its merits is that the author, unlike some other book-makers, is contented to withhold much that he is well qualified to discuss in order to impart to his volume such a strictly practical churao- ter as cannot fail to render it popular among British readers. — London Med. Times and Gazette, March 17, 1866. MORL.\ND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRE- TION. 1 vol. Svo., extra cloth. 75 cents. BLOOD AND URINE (MANUALS ON). By J. W. TONES [0. HANDFIELD), M. D., ^ Phyxician to St. Mary's Hosjiital, &c. CLINICAL OBSERVATIONS DISORDERS. Second American Edition. extra cloth, $-3 25. (Just Issued.) Taken as a whole, the work before us furnishes a Bbort but reliable account of the pathology and treat- ment of a class of very common but certainly highly absoure disorders. The advanced student will find it a rich mine of valuable facts, while the medical prac- titiocer will derive from it many a suggestive hint to I aiil him in the diagnosis of "nervous cases," and in detr rmiiiing the true indications for their ameliora- tion or cure. — Amer. Journ. Med. Set, Jan. 1867. | Griffth, G. 0. Ree.'?e, and A. Markwick. 1 vol. 12mo , extra cloth, with plates, pp. 460. $1 2i>. BUDD ON DISEASES OF THE LIVER. Third editiott. 1 vol. 8vo., extra cloth, with four beautifully colored plates, and numerous wood-cuts. pp. .500. $4 00. ON FUNCTIONAL NERVOUS In one handsome octavo volume of 348 pages, We must cordially recommend it to the profession of this country as supplying, in a great measure, a deficiency which exists in the medical literature of the English language. — Jfew York Med. Journ., ApsU, 1867. The volume is a most admirable one — full of hints and practical suggestions. — Canada Med. Journal, April, 1867. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OK THE NERVOUS SYSTEM. In one octavo volume of 2U2 pp. %\ ')0. SOLLY ON THE HUMAN BRAIN: its Structure, Phy- siology, and Dise.'tses. From the Second and much enlarged London edition. In one octavo volume of 500 pages, with 120 wood-cuts; extra cloth. $2 50. BUCKNILL AND TUKES MANUAL OF PSYCHO- LOGICAL MKDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Patho- logy, and Treatment of Insanity. With a Plate. In one handsome octavo volume, of .536 pages, extra cloth, ifcl 25. S LADE [D. D.), M.D. DIPHTHERIA; its Nature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised edition. In one nea* royal 12mo. volume, extra cloth. $1 25. {Just issued.) SMITH ON CONSUMPTION ; ITS EARLY AND RE- j JIEDIABLE STAGES. In one neat octavo volume I of 254 pages, extra cloth. *2 25. SALTER ON ASTHMA ; its Pathology, Causes, Con- sequences, and Treatment. In one volume octavo, extra cloth. $2 50. BUCKLER ON FIBRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. In one octavo vol., extra cloth, pp 150. $1 2.5. FISKE FUND PRIZE ESSAYS.— LEE ON THE EF- FECTS OF CLIMATE ON TUBERCULOUS DIS- EASE. AJS'D WARREN ON THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TH- BEUCLES. Together in one neat octavo volume extra cloth, *1 00. HUGHES' CLINICAL INTRODUCTION TO AUS- CULTATION AND OTHER MODES OF PHYSICAI. DIAGNOSIS. Second edition. One volume royal 12mo., extra cloth, pp. 304 *! 25. WALSHE'S PRACTICAL TREATISE ON THE DIS- EASES OF THE HEART AND GREAT VESSEL^ Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, extra cloth. $3 00. TYONS [ROBERT D.), K. C. C. A TREATISE ON FEVER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth. $2 25. CLYMER ON FEVERS; THEIR DIAGNOSIS, PA- TROLOOY AND TREATMENT. lu One octavo volume of riOO pages, leather. $1 75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pages, extra cloth. $2 50 LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeu- tical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in othejr parts of temperate as well as in tropical regiona^ In two large and handsome octavo volumes, of nearly 1500 pages, extra cloth, $7 00 LA ROCHE ON PNEUMONIA ; its Supposed Conneo- tion. Pathological, and Etiological, with .\utumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome o!»- tavo volume, exira cloth, of 500 pages. Price $3 00. Henry C. Lea's Publications — ( Venereal Diseases, etc.). 19 jyUMSTEAD {FREEMAN J.), M.D., J-^ PruftHHor of Venereal JJi.^eases at the Col. of Phys. and Surg., New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Includino; the results of recent investigations upon the subject. A new and re- Tised edition, with illustrations.' In one large and handsome octavo volume of 640 pages, extra cloth, $5 00. [Lately Issticd.) During the short time which has elapsed since the appearance of this work, it has assumed the position of a recognized authority on the subject wherever the language is spoken, and its tran.«la- tion into Italian shows that its reputation is not confined to our own tongue. The singular clear- ness with which the modern doctrines of venereal diseases are set forth renders it admirably adapted to the student, while the fulness of its practical details and directions as to treatment makes it of great value to the practitioner. The few notices subjoined will show the very high position universally accorded to it by the medical press of both hemispheres. Well known as one of the best authorities of the which has long been felt in English medical literature. present day on the subject. — British and For. Med.- Giiiriirg. Review, April, 1S66. A regular store-house of special information. — London Lancet, Feb. 24, 18()6. A remarlcably clear and fall systematic treatise on the whole subject. — Land. Med.' Times and. Gazette. The best, complelest, fullest monograph on this subject in our language. — Britiish American Journal. ladi-^pensable in a medical library. — Pacific Med. aaid Surg. Journal. We have no doubt that It will supersede in America every other treatise on Venereal. — San Francisco Med. Press, Oct. ISB-t. A perfect compilation of all that is worth knowing on venereal diseases in general. It fills up a gap ■Brit, and Foreign Med.-Chirnrg . Review, Jan., 'W>. We Tiave not met with any which so highly merits our approval and praise as the second edition of Dr. Bumstead's work. — Glasgow Med. Journal, Oct. ISB-k We know of no treatise in any language which is its equal in point of completeness and practical sim- plicity. — Boston Medical and Surgical Journal, Jan. 30, 1S6-1. The book Is one which every practitioner should have in his possession, and, we may further say, the o«/»/book upon the subject which he should acknow- ledge as competent authority. — Buffalo Medical and Surgical Journal, July, 1S64. The best work with which we are acquainted, and the most convenient handbook for the bu.sy practi- tioner. — Cincinnati Lancet, July, 1864. T>OMSTEAD [FREEMAN J.), -*-'' Professor of Venereal Diseases in the Co flULLERIER [A.), ond ^ Surgeon to the Hdpital du Midi. - -'■'' Professor of Venereal Diseases in the College of Physicia.ns and Surgeons, N. Y. AN ATLAS OF VENEREAL PTSE.\SES. Translated and Edited by Freem.\n J. BuMSTEAT). To be issued in five parts, at Three Dollars e.nch, making a large imperial 4to. volume of oven .300 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Parts I., II., and III. are now ready. Parts 'IV. and V. are in a state of forw.ard progress, and will be issued at short intervals. As the successor of Ricord in the great Venereal Hospital of Paris, M. Cullerier has enjoyed specitil advantages for the present undertaking, and his series of illustrations, though only recently finished, is already recognized as the most complete and comprehensive that has yet appeared on this subject. In reproducing these plates every care has been had to pre.«erve their artistic finish and accuracy, and they are confidently presented as equal to anything that has yet been produced in this country. The reputation of Dr. Bumstead as a writer and syphilographer is too well known to require other guarantee for the fidelity of the translation or the value of the additions introduced. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. *4* A specimen of the plates and text sent free by mail, on receipt of 25 cents. This is a very handsome edition in English of a well known and highly valued French publication. That Dr. Bumstead. the author of by far the best and most popular treatise on venereal diseases in the English language, should think it i)roper to translate Willi edit this ono, speaks more highly in its favor than atiything that can be said. It is a judgment e.x ca- OiedrH. The translation is an excellent one. The plates in the tirst Part represent blenuorrhagia and its complications, swelled testicle, and gonorrhieal ogththaluiia. They are admirably and anistically ex- ecuted. Indeed they are superior to any illustrations (rf the kind hitlierlo exccut»-d in this country The uoles added by Dr. Huiiistead enliauce the value of tiie work. The whole getting-up of this publication is of rare excellence, and most creditable to all cun- cej-ned. — Am. Journ. of Med. Sciences, April, 1S6S. A magniflcont work, in the best style of artistic Olustration. — Chicago Med. Journal, April, 186S. knowfrom personal examination. Theappearsnce of the work in parts places it within the reach of all, and when complotod it will be a mi>st valuable accession to our literature. — N. 1'. .Veil. Journal, April, 1.'^^1S. This is probably the handsomest work of its class ever published in this country. — Boston Med. and Surg, .lournal, .\pril l.'), IStiS. The two parts thus published are illustrated by plates, than which none superior have been issued from the press; in fact, in this country, no more magnificent work bus ever been published. Infinite credit is due the publisher and translator that they should have placed before the profession, in such a style, so valuablo a production. — St. Louis Med. Re- porter, May, lSt)8 This is one of the most elegantly published and valuable works that have been ipprintcd and edited in this country, relating to the loathsome, though im- I)ortant, class of venereal diseases. The author and We desire now oKpeclally to call the attention of , ^,,1,0^ .^^„ ^lj,50 „„.„ „,■ flxporionoo and emineLt ahi- tlie profession to the appearance of this niugnilicent , my. ^qj ^q fr<,piy commend the product of their w..rk. The plates in ehromo-lithography are most , i^f.^^s to the general patmuago of the profession.— admirably executed, and compare very favorably in Chicago Med. Ejximiner, May, IStiS. dijitinctness and brilliancy with the originals, as we | ALLEMAND AND WILSON. 'a P II a otto a L TREATISE AND tre.\t.mi:nt of edited by Hknrv J ON THE CAFSES, SYMPT0:\rS, SPRR.MATORRHOyv. By M. Lxi.t.KMANn. Tianslated and McDoi'OAl.L. Fifth Aineriean edition. To which is a,'pneral use in this coun- try as a text-book. The style is exceedingly clear and concise, and the views expressed eminently prac- tical and scientific — Quarterly Joum. of Paycluil. Medicine, April, 1868. The work is concise and practical, avoiding the dis- anssioii of unsettled questions, but giving a judicious resume of known facts. — Chicago Med. Journal, A^ril, 1S68. We are led to believe that it is the best work that has yet appeared on the diseases of women. There is about It a precision and accuracy, a fulness and completeness, a clearness and simplicity, to be found in no other book on the same subject wilhiu onr knowledge ; its views on uterine pathology are, to onr mind, more consonant with reason and common sense than any other we have seen. Enjoying fine opportunities in an extensive field of observation. Dr. Thomas, as an author, has fully sustained liis high reputation as a teacher. We have no hesitation in strongly recommending it to the profession as the best exposition yet published of the subjects (jf which it treats. — Atlatila Med. and Surg. Journal, April, '68. In no work with which we are acc|nainted. is theirs to be found so full nnd complete an exhibit of the iii»- proved means of diagnosis of the obscure subjects of gynecology, or of their more enlightened therapy. Did our space permit, we should be glad to go into au extended review of the work before us, giving nol merely au outline of the subjects treated of, but full extracts from the text itself. As it is, we can only recommend our readers to buy it, feeling convinced they will be amply repaid for the outlay. — Leam.»- worth Medical JJeialii, Jlay, 1SG8. Indeed, we do not know a better study in briefe* space^ not for medical students merely, but for prac- titioners, who may really wish to have light npou an obscure pathway, to be trained in the thorough in- vestigation of diseases peculiar to women, than ie herein to be found. — Western Journal of Medicin*, May, 1868. It is a masterly risumf of what is known, by an experienced and honest observer. The Profession is indebted to Prof. Thomas for thus tabulating th« much that has been accepted as valuable and reliable in gynecology, but this is not by any means all \.ha merit of the work ; we have his ample experience, given in his opinions on pathology and treatment, which carry conviction by the confidence we feel that they are the candid opinions of an honest and compe- tent observer. — Humboldt Med. Archives, April, L868. c B H cm CHILL {FLEETWOOD), M. D., M. R. L A. ON THE DISEASES OF WOMEN; including those of Pre,gnancy and Childbed. A new Atnerican edition, revised by the Author. With Notes and Additions, by D. Francis Co.ndie, M. 1)., author of " A Practical Treatise on the Diseases of Chil- dren." With numerous illustrations. In one large and handsome octavo volume of 768 pages, extra cloth, $4 00; leather, $5 00. Y THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DIS- E V.'^ES PECULI.AR TO W0MP:N. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 4&0 pages, extra cloth. $2 50. BROWN ON SOME DISEASES OF WOMEN AD- MITTING OF SLUUilCAL TREAT.MENT. With handsome illustratioug. Cue volume 8vo., extra cloth, pp. 276. *l 60. ASHWELL'S PK.VCTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised Lon- don edition. In one octavo volume, extra cloth, of .528 pages. ijsS oO. EIGBY ON THE CONSTITUTIONAL TREATMENT OF FEMALE DI.^EASE.-^. In one neat royal l'_'mo. volnme. extra cloth, of about 2.'>o paues. tl (X). DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correo- tions. In one octavo volume of 536 pages, with plates, extra cloth, *:i 00. COLOMB.\T DE L'ISERE ON THE DISEASES 0? FE.MALES. Translated by C. D. .Meios, M. D, Se- cond edition. In one vol. 8vo, extra cloth, with numerous wood-cuts. pp. 720. $;1 7.i. BENNETT'S PRACTICAL TREATISE ON INFLAM- MATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease Sixth American, from the fourth and re- vised English edition. 1 vol. 8vo., of about iOO pages, extra cloth. $3 75. Henry C. Lea's Publications — {Diseases of Women). 23 'W'EST [CHARLES], M.D. LECTURES ON THE DLSEASES OF WOMEN. Tliinl American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth. $3 75; leather, $4 75. (Now Ready.) The reputation which this volume has acquired as a standard book of reference in its depart ment, renders it only necessary to say th;it the present edition has received a careful revision at the hands of the author, resulting in a considerable increase of size. A few notices of previoiw editions are subjoined. The manner of tlie author is excellent, his descrip- tions graphic and perspicuous, and his treatment up to the level of the time— clear, precise, deliiiite, and marked by strong common sense. — Chiango 3Ied. Journal, Dec. 1861. We cannot too highly recommend this, the second edition of Dr. West s excellenflpctnres on the dis- eases of females. We know of no other book on this Mibject from which we have derived as much pleasure and instruction. Every page gives evidence of the honest, earnest, and diligent searcher after truth. He is not the mere compiler of other men's ideas, but his lectiues are the result often years' patient investiga- tion in one of the widest fields for women's diseases — St. Bartholomew's Hosjiital. As a teacher, Dr. West is simple and earnest in his language, clear and com- prehensive in his perceptions, and logical in his de- ductions. — Cincinnati Lancet, Jan. 1862. We have thus embodied, in this series of lectures, one of the most valuable treatises on the diseases of the female sexual system unconnected with gestation, in our language, and one which cannot fail, from the lucid manner in which the various subjects have been treated, and the careful discrimination used in dealing only with facts, to recommend the volume to the careful study of every practitioner, as affording kis safest guides to practice within our knowledge. We have seldom perused a work of a more thoroughly practical character than the one before us. Every page teems with the most truthful aud accurate infor- mation, and we certainly do not know of any other work from which the physician, in active practice, can more readily obtain advice of the soundest cha- racter upon the peculiar diseases which have been Blade the subject of elucidation. — British Am. Med. Jtiurnal. We return the author our grateful thanks for tl>« vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease &11 speak for themselves. — Mmlico-Chiriirg. Seview. Most justly esteemed a standard work It bears evidence of having been carefully revised, and is well worthy of the fame it has already obtained. — Dub. Med. Quar. Jour. As a writer. Dr. West stands, in onr opinion, se- cond only to Watson, the "Macaulay of Medicine;" he possesses that happy faculty of clothing instruo- tion in easy garments ; combining pleasure with profit, he leads his pupils, in spite of the ancient pro- vei-b, along a royal road to learning. His work is one which will not satisfy the extreme on either side, hat it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, saf«, and valuable guide. — ^V. A. Med.-Ghirurg Review. , We must now conclude this bastily written sketch with the confident assurance to onr readers that the work will well repay perusal. The cooscientioua, painstaking, practical physician is apparent on every page. — if. T. Journal of Medicine. We have to say of it, briefly and decidedly, that tt is the best work on the subject in any language, and that it stamps Dr. West as the facile princejjs of British obstetric authors. — Edinburgh. MeA. Jiturnal. We gladly recommend his lectures as in the highest degree instructive to all who are interested in ob- stetric practice. — London. Lancet. We know of no treatise of the kind so complete, and yet so compact. — Chicago Med. Journal. B Y THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OP ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. 31 EIGS {CHARLES D.), M. D., Late Professor of Ohstttrics, &c. in Jf.ffer. 00. Every topic discussed by the author is rendered so plain as to be readily understood by every .student : aud, for our owa part, we consider it not only one of the most readable of books, but one of priceless value to the practitioner. — H. Am. Med.-Ohir. Re^ncto. B H r THE SAME AUTHOR. ON THE nature; SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsom* octavo volume of 365 pages, extra cloth. $2 00. ODGE {HUGH L.), M.D. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised. In one beautifully printed octavo volume of about 500 pages. (Preparing.) the day — one which every acconchenr and physician should most carefully read: for we are persuaded that he will arise from its perusal with new ideas, which will induct him into a more raliotial pnictica in regard to many a suffering female who may h.iv« placed her health in his hands. — British AiufricoM Journal, Feb. IStil. Indeed, although no part of the volume is not emi- nently deserving of perusal and study, we think that tJie nine chapters devoted to this subject are espe- aially so, and we know of no more valuable mono- graph ui)on the symptoms, prognosis, and manage- ment of these annoying maladies than is constituted by this part of the work. We cannot but regard it as (Mie of the most original aud must practical works of s IMPSON {SIR JAMES Y.), M.D. CLINICAL LECTURES ON THE DISEASES OF WOMEN. With numerous illustrations. In one octavo volume of over 500 pnges. Second edition, preparing. 24 Henry C. Lea's Publications — {Midwifery). JJODGE {HUGH L.), M.D., Late Professor of Midwifery, &c, in the University of Pennsylvania, &c. THE PRIXCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 650 double-columned pages, strongly bound in extra cloth, $14. (Lately published.) We have examined Professor Hodge's work with great satisfaction; every topic is elaborated most fully. Tlie views of the author are coraprelieusive, and concisely .stated. The rules of piactice are judW cious, and will enable the practitioner to meet every emergency of obstetric complication with confidence. — Chicago Med. Journal, Aug. 1864. The work of Dr. Hodge is soraetbing more than a simple presentation of Ins particular views in the de- partment of Obstetrics ; it is something more than an wdinary treatise on midwifery; it is, in fact, a cyclo- psedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle 18 left unstated or uaezplained. — Am. Med. Times, Sept. .3, 1S64. We should like to analyze the remainder of this ftxcoUent work, but already has this review extended beyond our limited space. We cannut c6nclude this notice without referring to the excellent finish of the work. In typography it is not to be excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends Itself for its originality, and is in every way a most valn- Dihle addition to those on the subject of obstetrics. — (kunuda Med. Journal, Oct. 1S64. It is very large, profusely and elegantly illustrated, and is tilted to take its place near the works of great qbsietricians. Of the American works on the subject it is decidedly the best. — Kdinb. Med. Jour., Dec. 't>4. *** Specimens of the plates nnd letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by far the most original, complete, and carefully composed treatise on the principles and practice of t)bstetrics which has ever been issued from the American press. — Pacijit Med. and Surg. Journal, July, 1864. We have read Dr. Hodge's book with great plev sure, and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly instructive, and iu the main, we believe, correct. The great attention which the author has devoted to the mechanism of parturition, taken along with the coiv- clusion.s at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. — Glasgow Med. Journal, Oct. 1864. JIANNER {THOMAS H), M. D., ON THE SIGNS AND I)TSE.\SES OF PRKONANCY. Fir.«t Amoriean from the Second and Enlarged Englisl\En gathered from every source. — Boston Med. and Sung. Journal. There Is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich evury medicttl library. — Chicago Med. Jortrnal. 26 Henry C. Lea's Publications — (Surgery). QROSS {SAMUEL D.), M.D., Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, carefully revised, and improved. In two large and beautifully printed royal octavo volumes of 2200 pages, strongly bound in leather, with raised bands. $15 00. The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. Though but little over six years have elapsed since its first publication, it has already reached its fourth edition, while the care of the author in its revision and correction has kept it in a constantly im- proved shape. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long I'emain the most comprehensive work on this important part of medicine. — Boston Medical and Surgical Journal, March 23, 1S6.5. We have compared it with most of our standard Works, such as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, in justice to our ftuihor, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and erahracing every suhject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confldenlly recommend to our brethren, for its utility is becoming the more evident the longer it is upon the shelves of our library. — Canada Med. Journal, September, 186.5. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work. — Chicago Medical Journal, September, 1865. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance. — British and Foreign'MKdico-Chirurgical Ri-view, Oct. IStiu. The most complete work that has yet issued from the press on the science and practice of surgery. — London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and he the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in any language. — N. Y. Med. Journal. Not only by far the best text-book on the subject, SB a whole, within the reach of American students, but one which will he much more than ever likely to be resorted to and regarded as a high authority abroad. — Ara. Journal Med. Sciences, Jan.' 186.5. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of modera Burgery, where the student and practi- tioner shall not seek in vain for what they desire.— San Francisco Med. Press, Jan. 186.5. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of th« future of surgical science. — Edinhnrgh Med. Journal, Jan. 186,5. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most cuniplete "System of Surgery" ever pub- lished in any ciinntry. — St. Louis Med. and Surg. Journal, April, 186.5. The third opportunity Is now offered during our editorial life to review, or rather to indorse and re- commend this great American work on Surgery. Upon this last edition a great amount of labor has been expended, though to all others except the author the work was regarded in its previous editions as so full and complete as to be hardly capable of improve- ment. Every chapter has been revised; the text aug- mented by nearly two hundred pages, and a con- siderable number of wood-cuts have been introduced. Many portions have been entirely re-writteu, and the additions made to the text are principally of a prac tical character. This comprehensive treatise upon surgery has undergone revisions and enlargements, keeping pace with the progress of the art and science of surgery, so that whoever is in possession of this work may consult its pages upon any topic embraced within the scope of its department, and rest satisfied that its teaching is fully up to the present standard of surgical knowledge. It is also so comprehensive that it may truthfully be said to embrace all that is actually known, that is really of any value in the diagnosis and treatment of surgical diseases and acci- dents. Wherever illustration will add clearness to the subject, or make better or more lasting impression, it is not wanting; in this respect the work is eminently superior. — Buffalo Med. Journal, Dec. 1864. A system of surgery which we think unrivalled in our language, and which will indelibly associate his name with surgical science. And what, in«our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow. — Tim Brit. Am. Journ., Montreal. Ttr THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second edition, revised and much enlarged, with one hundred and eighty-four illustrations. In one large and very handsome octavo volume, of over nin« hundred pages, extra cloth. $4 00. Whoever will peruse the vast amount of valuable practical information it contains will, we think, agree with us, that there is no work in the English lan- nr THE SAME AUTHOR. — A PRACTICAL AIR-PASSAGES. pp. 4S8. $2 75. gnage which can make any just pretensions to be its equal. — A\ 1'. Journal of Medicine. TREATISE ON FOREIGN BODIES IN THE In one handsome octave volume, extra cloth, with illustrations. Henry C. Lea's Publications — (Surgery). 21 J^RICHSEN {JOHN), •'-* Professor of Surgery in Univursity College, London. THE SCIENCE AND ART OF SURGERY; beincr a Treatise on Sur- gical Injuries, Diseases, and Operations. New and improved American, from the Second enlarged and carefully revised London edition. Illustrated with over four hundred wood engravings. In one large and handsome octavo volume of 1000 closely printed pages ; extra cloth, $6; leather, raised bands, $7. We are hound to state, and we do so without wish- I as one of the very best, if not the best text-book of ing to draw iuvidious comparisons, that the work of! surgery with which we were acquainted, permits ns Mr. Ericlisen, in most respects, surpasses any that to give it but a passing notice totally unworthy of its has preceded it. Mr. Erichsen's is a practical work, \ merits. It may be confidently asserted, that no work combining a due proportion of the "Science and Art on the science and art of surgery has ever received of Surgery." Having derived no little instruction more universal commendation or occupied a higlier from it, in many important branches of surgery, we position as a general text-book on surgery, than this can have no hesitation in recommending it as a valu- treatise of Professor Erichsen. — Savannah Journal of able book alike to the practitioner and the student. [ Medicine. — Dublin Quarterly. j in fulness of practical detail and perspicuity of Oivfcs a very admirable practical view of the scl- style, convenience of arrangement and soundness of e«ce and art of surgery. — Edinburgh Med. and Surg, discrimination, as well as fairness and comi)letenes8 Journal. 1 of discussion, it is better .suited to tlie wants of both We recommend it as the best compendium of sur- fitudont and practitioner than any of its predecessors, gery in our language.-io7!,ioji Lancet. ; --■»"»• '^^>v^rnal of Med. Sciences. It is, we think, the most valuable practical work ' After careful and frequent perusals of Erichsen's on surgery in existence, both for voang and old prac- . f.^rger/.. ^e are at a lo.ss fully to express our a. inira- KXthm^TS.-Nashoille Med. and Surg. Journal. \ »>»" "f ''■ ^ho author s style is eminently didactic, I and characterized by a most admirable directness. The limited time we have to review this improved clearness, and compactness. — Ohio Med. and Surg. edition of a work, the first issue of which we prized Journal. r>T THE SAME AUTBOR. (Ready in June.) ON RAILWAY, AND OTHER INJURIES .OF THE NERVOUS SYSTEM. In small octavo volume. Extra cloth, $1 00. We welcome this as perhaps the most practically useful treatise written for many a day. — Medical Times. It will serve as a most useful and trustworthy guide to the profession in general, many of whom may l)e consulted in such cases; and it will, no doiilit, lake its place as a text-book on the subject of which it treats. — Medical Prexs. JlflLLER [JAMES), J-'-L Late Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. r THE SAME AUTHOR. B THE PRACTICE OF SURGERY. Fourth American, from the la.st Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. It ts seldom that two volumes have ever made so I acquired. The author is an eminently sensible, prao- profound an impression in so sliort a time as the tical, and wcll-infornied man, who knows exiiitly "Principles" and the " Practice" of Surgery by Mr. what he is talking about and exactly how to talk it. — Miller, or .so richly merited the reputation they have | Kentucky Medical Recorder. P IRRIE ( WILLIAM), F. R. S. E.. Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, Ac. In one very handsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. iJARGENT {F. W.), M. D. ON BANDAQING AND OTHER OPERATIONS OF MINOR SUR- GERY. New edition, with an additional chapter on Military Surgery. One handsome royaJ 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, $1 75. Exceeilingly convenient and valuable to all mora- We cordially commend this vuluuio as one wliloli b^Ts of the profession.— CTiicaj^o Mtdical Examiner, the ineilical student should most closely study; and May, ISii'J. to the surgeon in practice it must prove Itself iustrne*- The 'very best manual of Minor Surgery we have '/^ on many points which he may have forgolleu<— »eea.— Buffalo Medical Journal. ^rit. Am. Journal, May. ISiii MALGAIGNE'S OPERATIVE SDRQERT. With nn- I SKEY'S 0PER.4TIVE SHKOERT. In ome very hand> nierous illustrations on wood. In one handsome some octavo volume, extra cloth, of over e.'M) pagoa, o«tavo volume, extra cloth, of nearly 600 pp. l|2 60. | with about 100 wood-cau. $3 26. 28 Henry C. Lea's Publications — (Surgery). TiRUITT {ROBERT), M.R.C.S., Sfc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated veith four hundred and thirty -two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00 ; leather, $5 00. Besides the careful revision of the author, this work has had the advantage of very thorough editing on the part of a competent surgeon to adapt it more completely to the wants of the Ameri- can student and practitioner. Many illustrations have been introduced, and every care has been taken to render the mechanical execution unexceptionable. At the very low price afiBxed, it will tiierefore be found one of the most attractive and useful volumes accessible to the American practitioner. All that the surgical student or practitioner could i theoretical surgical opinions, no work that we are at desire. — Duhlin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure. — Boston, Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the present acquainted with can at all compare with it. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserves the estimate placed upon it. — Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among our best text-books on elementary su?- praclice of surgery are treated, and so clearly and ^exy.-Columhux Rev. of Med. and Surg. perspicuously, as to elucidate every important topic. | We must close this brief notice of an admirable Thefactthat'twelve editions have already been called i work by recommending it to the earnest attention of for, in these days of active competition, would of every medical student. — Charleston Medical Journal itself show it to possess marked superiority. We and Review. have examined the book most thoroughly, and can I ^ text-book which the general voice of the profes- say that this success is well merited. His book, ^j^j j^ both England and America has commended as moreover, possesses the inestimable advantages of ^^^ ^f ^^^ j„„st admirable "manuals," or, "wtcJ* having the subjects perfectly well arranged and clas- „j,,g„^>. ^^ ■^^^ English title runs, which can b« siHed, and of being written in a style at once clear pi„ced in the hands of the student. The merits of and succinct.— ^m. Journal of Med. Sciences. Druitt's Surgery arc too well known to every one to Whether we view Druitt's Surgery as a guide to need any further eulogium from us. — Nashville Med. operative procedures, or as representing the latest Journal. H AMILTON [FRANK H.), M.D., Professor of Fractures and I>islocations, &c. in Bellevue Hasp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume of 777 pages, with 294 illustrations, extra cloth, $5 75. (Just Issteed.) The demand which has so speedily exhausted two large editions of this work shows that the author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad as well as at home, has pronounced it the most complete work- to which the surgeon can refer for information respecting all details of the subject. In the preparation of this new edition, the author has sedulously endeavored to render it worthy a continuance of the favor which has been accorded to it, and the experience of the recent war has afforded a large amount of material which he has sought to turn to the best practical account. In fulness of detail, simplicity of arrangement, and ; American professor of surgery; and his book adds accuracy of description, this work stands unrivalled, jone more to the list of excellent practical works which So far as we know, no other work on the subject in ' have emanated from his country, notices of which the English language can be compared with it. While have appeared from time to time in our columns du- congratulating our trans-Atlantic brethren on the! ring the last few months.— iondon Zanee<, Dec. 15, European reputation which Dr. Hamilton, along with 1866. many other American surgeons, has attained, we also 1 Tiiese additions make the work much more valua- may be proud that, in the mother tongue, a classical i ble, and it must be accepted as the most complete work has been produced which need not fear compa- ' monograph on the subject, certainly in our own, if rison with the standard treatises of any other nation. — Edinburgh Med. Journal, Dec. 1860. The credit of giving to the profession the only com not even in any other \».a^\xa,gQ. — Am.erican Journal Med. Sciences, Jan. 1867. This is the most complete treatise on the subject in The credit ol giving to tne proiession me oniy com ., * " , . 'r, d i • r"^i, 7 , t "^ ic^i plete practical treatise on fractures and dislocations /^^e English \a.^^yia.g6.- Ranking s Abstract, Jan. im. in our language during the present century, belongs A mirror of all that is valuable in modern surgery, to the author of the work before us, a distinguished Richmond Med. Journal, Nov. 1866, BRODIE'S CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., 3oO pp.; cloth, %\ 25. BARWELLS TREATISE ON DISEASES OF THE JOINTS. With illustrations. 1 vol. 8vo., of about 600 pages ; extra cloth, $.3 00. COOPER'S LECTURES ON THE PRINCIPLES AND rRACTiCE OF Surgery. In one very large octavo volume, extra cloth, of 750 pages. $2 00. GIBSON'S INSTITUTES AND PRACTICE OF SUR- OERV. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- umes, about 1000 pages, leather, raised bands. $6 50 JOKES' PRINCIPLliS AND PRACTICE OF OPH- THALMIC MEDICINE AND SURGERY. With one hundred and seventeen illustrations. Third and revised Americam, with Additions from the second London edition. In one handsome octavo volumre of 45.T pages, extra cloth. $3 2.5. MACKENZIE'S PRACTICAL TREATISE ON DI8J EASES AND INJURIES OF THE EYE. Brom the fourth revised and enlarged London edition. With Notes and Additions by Addinell Hewson, M D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume of 1027 pages.^ extra cloth, with plates and numerous woodcnte. SSU 50. Henry C. Lea's Publications — (Surgery). 29 rpOYNBEE {JOSEPH), F. R. S., -*- Aural Surgeon to and Lecturer on Surgery at St. Mnrifs Hospital. THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treat- ment. With one hundred engravings on wood. Second American edition. In one very handsomely printed octavo volume of 440 pages; extra cloth, $4. ^ The appearance of a volume of Mr. Toynbee's, there- fore, ia which the subject of aural disease is treated In the most scientific manner, and our knowledge in respect to it placed fully on a par with that which we possess respecting most other organs of the body, is a matter for sincere congratulation. We may rea- sonably hope that henceforth the subject of this trea- tise will cease to be among the opprol/ria of medical science. — London Medical Review. The work, as was stated at the ontset o'our notice, is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Con- sidered all in all — as an original work, well written, philosophically elaborated, and happily illustrated with cases and drawings — it is by far the ablest mo- nograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable con- tributions to the art and science of .surgery in the nineteenth century. — N. Am. Med.-Vliirurg. Revieto. T A URENCE [JOHN Z.), F. R. C. S., and MOON [ROBERT C), -^ EdUor of the Ophthalmic Review, &e. -'■"■ -»■''««« S^irgeon to theSoulhwark Oph- thalmic Ho,spital, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. With numerous illustrations. In one very handsome octavo volume, extra cloth. $2 50. (Just Issued.) Not only, as its modest title suggests, a "Handy- Book" of Ophthalmic Surgery, but an excellent and well-digested rimiint of all that is of practical value in the specialty. — New York Medical Journal, No- vember, 1S66. No book on ophthalmic surgery was more needed. Designed, as it is, for the wants of the busy practi- tioner, it is the neplus ultra, of perfection. It epito- Bttizes all the diseases incidental to the eye in a clear and masterly manner, not only enabling the practi- tioner readily to diagnose each variety of disease, but affording him the more imporiant assistance of proper treatment. Altogether this is a work which ought certainly to be in the hands of every general practi- tioner. — Dublin Med. Press and Circular, Sept. 12, '66. We cordially recommend this book to the notice of our readers, as containing an excellent outline of modern ophthalmic surgery. — British Med. Journal, October 13, 1866. This object the authors have accomplished in a highly satisfactory manner, and we know no work we can more highly recommend to the "busy practi- tioner" who wishes to make himself acquainted with the recent improvements in ophthalmic science. Such, a work as this was much wanted at this time, and this want Messrs. Laurence and Moon have now well supplied. — Am. Journal Med. Sciences, Jan. 1S67. TA W80N [GEORGE), F. R. G. S., Engl -*-' Asstitant Surgeon to the Royal London Ophthalmic Hospital, Moorfw.ld.i, &c. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $3 50. (Now Ready.) This work will be found eminently fitted for the general practitioner. In cases of functional or structural diseases of the eye, the physician who has not made ophthalmic surgery a special study can, in most instances, refer a patient to some competent practitioner. Cases of injury, however, supervene suddenly and usually require prompt assistance, and a work devoted espe- cially to them cannot but prove essentially useful to those who may at any moment be called upon to treat such accidents. The present volume, as the work of a gentleman of large experience, may be considered as eminently worthy of confidence for reference in all such emergencies. It is an admirable practical book in the highest and fulness of practical knowledge. We predict for Mr. best sense of the phrase. Copiously illustrated by excellent woodcuts, and with well-selecled, well- described cases, it is written in plain, simple lan- guage, and in a style the transparent clearness and Frankness, so to speak, of which, add greatly to its value and usefulness. Only a master of his subject could so write; every topic is handled with an ease, decision, and straightforwardness, that show the skilful and highly educated surgeon writing from Lawson's work a great and well-merited success. We are confident that the profession, and especially, as we have said, our country brethren, will feel grateful to him for having given them in it a guide and counsellor fully up to the most advanced state of Ophthalmic Surgery, and of whom they can make a trusty and familiar friend. — London Mulical Timee and Oazette, May 18, 1867. irORLAND [W. W.), M.D. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume of about 600 pages, extra cloth. $3 50. Taken as a whole, we can recommend Dr. Morlnnd'n I of every medical or surgical praciilioBer. — Brit, and eompendinmasa very deslrableadditJouto thelibrary | Fiir. Med.-Chir. Revieto, April, 1869. riURUNG {T.B.), F.R.S., Surgeiin to the London Hospital, President of thf Hunterinn Society, *c. A PRACTICAL TREATLSR ON DISEASES OF THE TESTIS, SPERMATIC CORD, AND SCROTUM. Seoond American, from the second and enlarged Enelish edition. In one handaome octavo volume, extra cloth, with numerous illustra- tions, pp. 420. $2 00. 30 Henry C. Lea's Publications — (Surgery). rmLES {PHILIP S.), M. D., Surgeon U. S. N. MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and forty-two illustrations on wood. In one large and handsome octavo volume of about 700 pages: extra cloth, $5 75; leather, $6 75. {Now Ready.) A Naval Medical Board directed to examine and report upon the merits of this volume, oflScially states that " it should in our opinion become a standard work in the hands of every naval sur- geon ;" and its adoption for use in both the Army and Navy of the United Slates is sufficient guarantee of its adaptation to the needs of every-day practice. The title of this book will give a reasonably good idea of its .scope, but its merits can only be appreci- ated by a careful perusal of its text. No one who un- dertakes such a task will have any reason to com- plain that the author has not performed his duty, and lias not taken every pains to present every subject in A clear, common-sense, and practical light. It is a unique specimen of literature in its way, in that, treating upon such a variety of subjects, it is as a, whole so completely up to the wants of the studeiit and the general practitioner. We have never seen any work of its kind that can compete with it in real utility and extensive adaptability. Dr. Wales per- fectly understands what may naturally be required of him in the premi.ses, and !n the work before us has bridged over a very wide gap which has always here- tofore existed between the lirst rudiments of surgery and practical surgery proper. He has emphatically given US a comprehensive work fur the beginner ; and when wo say of his labors, that in their particular sphere th(>y leave nothing to be desired, we assert a great deal to recommend the book to the attHnlion of tiiose specially concerned. In conclusion, we woubl iitato, at the risk of reileratiim, that this is the most compreheusiveb.>okon the subj.^ct that we have seen ; in the best that can be placed in the hands of the stu- dent in need of a first book on snrgery, and the most useful that can be named for such general practition- ers who, without any special pretensions to surgery, a^ occasionally liable to treat surgical cases. — 2v. 1'. ited. Record, March 2, 1868. It is certainly the most complete and thorough work o^ its kind in the English language. Students and young practitioners of surgery will tind it invaluable. It will prove especially useful to inexperienced coun- try practitioners, who are continually required to t»ke charge of surgical cases, under circumstances precluding them from the aid of experienced surgeons. — Pacific Med. and Surg. Journal, Feb 186S. This is a most complete and elegant work of 67.3 ]>«ges, and is certainly woU deserving of the com- mendation of every Amorican suriieou. This work, besides its usefulness as a reference for practitioners, is most admirably adapted as a text-book for students. Its6^2illustratiou8in woi)d-ciits, represent every man- ner of surgical appliance, together with a minute de- scription of each, the name of its inventor, and its prac- tical utility in mechanical surgery. There is, perhaps, no work in the English language so complete in the description and detail of surgical apparatus and ap- pliances as this one. The entire work entitles the au- thor to great credit for his clear and distinct style as a writer, as well as for his accuracy of observation and great research in the field of surgery. We ear- nestly recommend every member of the profession to add a cipy of it to his library, with the assurance that he will find some useful suggestion in the treat- ment of almost every surgical case that may come under his observation. — Humboldt JItd. Archives, Fei>. 1858. It is the completestbook on these subjects we know of, and it cannot fail to be exceedingly useful to the busy practitioner, especially to the busy country phy- sician who has thrown upon his care something of surgery in its various details, with all manner of gene- ral practice, and, therefore, may often wish to refresh himself as to the most convenient and elegant modes of dressings and manipulations. — Cincinnati Lancet and Ohse.rmr, Jan. 18>i8. We have examined Dr. Wales' book with much care, and believe that his labor will greatly benefit the practitioner of surgery. It seems to us especially beneficial to the country medical practitioner who is surgeon, physician, and cibsteti'ician, as occasion re- quires. We commend the work to our readers as a most useful one. — Nashville Mtd. and Surg. Journal, Jan. 1868. The title of the above work is sufllciently indica- tive of its contents. We have not seen for a long time (in the English langnajfe) a treatise equal to tluN in extent, nor one which is better adapted to the wants of the general student and practitioner. It is not to the surgeon alone that this book belongs; the physician has frequent opportunities to fill an emer- gency by such knowledge as is here given. Every practitioner should make purchase of such a book — it will last him his lifetime. — St. Louis Med. S«- porttv, Feb. 1868. A useful book is always a necessary one, and that this book is eminently one of that character, needs but a glance at its pages to show. It certainly de- serves a place In the library of every physician. — Leavenworth Med. Herald, Feb. 186S. The book seems to be complete In every respect, and is a welcome addition to onr shelves. — Boston Mtd and Surg. Journal, Jan. 9, 1868. In onr opinion it is a good book, and one which every student and practitioner needs in his library. Especially would its value be appreciated by the sur- geon whose field of practice is anywise remote from the larger cities. — Chicago Med. Journal, Jan. 1868. This volume will be a useful acquisition to a large number of the working members of the medical pro- fession in thiscounlry. I'ractitiouers will find mate- rial aid and encouragement in its pages which they could nowhere else obtain, to the same extent, in sfl convenient a form. — Ant. Journal Med. Sciences, Jan. 1868. He must be a blockhead indeed who, after study- ing this portion of the book before us, fails to adapt himself to the emergency of any case, for we find here described pretty much every contrivance ever devised, and we can hardly conceive of Ihiit combi- nation of circumstances wliicli would deprive us of all these means of assistance, and the ab.seuce of on« or more of the usual aids would only stimulate the ingenuity to devise some other plan of relief. — Net* York Med. Journal, May, 1868. A SET ON [T. J.) OX THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume of about 300 pages, %'i 25. {Just Issued.) We can recommend this volume of Mr Ashton's in tbe strongest terms, as containing all the latest details at the pathology and treatment of diseases connected with the rectum. — Canada Med. Journ., March, 1866. One of the most valuable special treatises that the physician and surgeon can have in his library — Chicago Medical ExanUner, Jan. 1.S66. The short period which has elapsed since the ap- pearance of the former -American reprint, and th« numerous editions publir>hed in England, are the best arguments we can otfer of the merits, and of the nse- lessness of any commendation on oar part of a book already so favorably known to our readers. — Boston Med. and Surg. Journal, Jan. 26, 1866. Henry C. Lea's Publications — {Medical Jurisprudence^ &c.). 31 rPAYLOR {ALFRED S.), 31. D., -*- Lecturer on Sled. Jurisp. and Vhemiiilry in Guy's Hospital. MEDICAL JURISPRUDEXCE. Sixth American, from the eighth and revised London edition. With Notes and References to American Decisions, by Cle- ment B. Penrose, of the Philadelphia Bar. In one large octav^ volume of 776 pages, extra cloth, $4 50 ; leather, $5 60. {Just Issued.) Considerable additions have been made by the editor to this edition, comprising some important sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence," as well as references to American law and practice. The notes of the former editor, Dr. Harts- horne, have likewise been retained, and the whole is presented as fully worthy to maintain the distinguished position which the work has acquired as a leading text-book and authority on the subject. A Dew edition of a work acknowledged as a stand- ard authority everywhere within the range of the English language. Considering the new matter intro- duced, on trichiniasis and other subjects, and the plates representing the crystals of poisons, etc , it may fairly be regarded as the most compact, comprehen- sive, and practical work on medical jurisprudence which has issued from the press, and the one best fitted for students. — Pacific Med. and Surg. Journal, Feb. 1867. The sixth edition of this popular work comes to us In charge of a new editor, Mr. Penrose, of the Phila- delphia bar, who has done much to render it useful, not only to the medical practitioners of this country, but to those of his own profession. Wisely retaining the references of the former American editor. Dr. i . , . , , , . , . Hartshorne, he has added many valuable notes of his : ro"s references to cases which have occurred in this (jwn. The reputation of Dr. Taylor's work is so well i country. It makes thus by far the best guide-book established, that it needs no recommendation. He is i "i this departinent of medicine for stude^uts and the now the higliest living authority on all matters con- i general practitioner la our language.— i(«««y'/t Mtd. , nected with forensic medicine, and every successive i ^"* Surg. Journal, Dec. 27, Isbb. edition of his valuable work gives fresh assurance to Taylor's Medical Jurisprudence has been the text- his many admirers that he will continue to maintain book in our colleges for years, and the present edi- his well-earned position. No one should, in fact, be { tion, with the vi^luable additions made by the Ameri- without a text-book on the subject, as he does not l can editor, render it the most standard work of the know but that his next case may create for him au I day, on the peculiar province of medicine on which elaborate treatises. — New York Medical Record, Feb. 15, 1SG7. The present edition of this valuable manual is a great improvement on those which have preceded it. Some admirable instruction on the subject of evidence and the duties and responsibilities of medical wit- nesses has been added by the distinguished author, and some fifty cuts, illustrating chietly the crystalline forms and microscopic structure of substances used as poisons, inserted. The American editor has al.so introduced several chapters from Dr. Taylor's larger work, "The Principles and Practice of Medical Juris- prudence," relating to trichiniasis, sexual malforma- tion, insanity as affecting civil responsibility, suicidal mania, and life insurance, &c., which add considerably to its value. Besides this, he has introduced uume- emergency for its use. To those who are not the for- tunate possessors of a reliable, readable, interesting, and thoroughly practical work upon the subject, we would earnestly recommend this, as forming the best groundwork for all their future studies of the more it treats. The American editor, Dr. Hartshorne, has done his duty to the text, and, upon the whole, we caunot but consider this volume the best and richest treatise on medical jurisprudence in our language.— Brit. Am. Med. Journal. W: INSLOW {FORBES), M.D., D.C.L., Sfc. ON OBSCURE DISEASES OP THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised Engli.sh edition. In one handsome octavo volume of nearly §00 pages, extra cloth. $4 25. {Just Issued.) our conviction that it is long since so iipportant and beautifully written a volume has issued from the British medical press. The details of the manage- ment of confirmed cases of insanity more nearly in- terest those who have made mental diseases their special study; but Dr. Winslow's masterly exposi- tion of the early symptoms, and his graphic descrip tions of the insidious advances of incipient insanity, together with his judicious observations on the treat- ment of disorders of the mind, should, we repeat, be carefully studied by all who have undertaken tli* responsibilities of medical practice. — Dublin Medical Press. Of the merits of Dr. Winslow's treatise the profe.s- eiou has sufficiently judged. It has taken its place in the front rank of the works upon the special depart- ment of practical medicine to which it pertains. — Oin' i aw iii Journal of Medicine, March, IStiG. It is an interesting volume that will amply repay for a careful perusal by all intelligent readers. — Chicago Med. Examiner, Feb. 1866. A work whieh, like the present, will largely aid tlie practitioner in recognizing and arresting the first in.sidious advances of cerebral and mental disease, is one of immense practical value, and demands earnest attention and diligent study on the part of all who cave embraced the medical profession, and have Uiereby undertaken responsibilities in which the welfare and happiness of individuals and families are largely involved. We shall therefore clow this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work by expressing It is the most interesting as well as valuable book that we have seen for a long time. It is truly fasci- nating. — Am. Jour. Med. Sciences. Dr. Winslow's work will undoubtedly occupy an unique position in the medico-psychological litera- ture of this country. — London Med. Review. J EA {HENRY C.) SUI'EUSTITTON AND FORCE: ESS.WS ON THE WAGER OF LAW, THE AVAGER OF BATTLE, THE ORDEAL, AND TORTURE. In one hand- some volume royal 12ino., of 405 pages ; extra cloth, $2 60. The copious collection of facts by which Mr. I.ea has ( a humor so fine and good, that he makes us regret It tUnstratod his subject shows in the fullest manner ihe consiiint coiiHicl and varying success, the advances "tMid defeats, by which the progress of humane legisla- tion has been and is still marked. This work lilts up with the fullest exempliflcatiou and detail the wise remarks which we have quoted above. As a book of ready reference on the subject it is of the highest value. — Wesliiiinster Revieto, Oct. 1807. was not within his intent, as it wns certainly within his power, to render the whole of his thorough work more popular in manner. — Atlantic Monthly, Feb. '67. This is a book of extraordinary research. Mr. Lea h'hs entered into his subject con amore ; and a more striking record of the cruel superstitions of our un- happy Middle Ages could not possibly have been com- piled. ... As a work of curious inquiry on certain When — half in spite of himself, as it appears — he | outlying points of obsolete law, "Superstition and o^ketchesa sceneor character in tha history of legalized i Force" is one of the most remarkable books we have error and crualty, ko betrays 8oarti»tica feeling, niid I mui with. — London Atheiiaum, Nov. 3, 1866. 32 Henry C. Lea's Publications. INDEX TO CATALOGUE. Abel and Bloxam's Handbook of Chemistry Allen's Dissector and Practical Anatomist American Journal of the Medical Sciences Abstract, Half-Yearly, of the Med. Sciences Anatomical Atlas, by Smith and Horner Ashton on the Kectum and Anus Ashwell on Diseases of Females Brinton on the Stomach Barclay's Medical Diagnosis . Barlow's Practice of Medicine Barwell on the Joints . Bennet (Henry) on Diseases of the Tterns Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Brande & Taylor's Chemistry Brodie's Clinical Lectures on Surgery . Brown on the Surgical Diseases of Women Buckler on Bronchitis . ' . Bucknill and Tuke on Insanity . Budd on Diseases of the Liver Bumstead on Venereal .... Bumstead and Cnllerier's Atlas of Venereal Carpenter's Human Physiology . . ■ Carpenter's Comparative Physiology . Carpenter on the Microscope Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Chambers on the Indigestions Christison and Griffith's Dispensatory Churchill's System of Midwifery . _ . Churchill on Diseases of Females Churchill on Puerperal Fever Clymer on Fevers Colombat de I'lsere on Females, by Meigs Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery . CuUerier's Atlas of Venereal Diseases Curling on Diseases of the Testis . Cyclopedia of Practical Medicine . Daltoo's Human Physiology . De Jongh on Cod-Liver Oil Dewees's System of Midwifery Dewees on Diseases of Females Dewees on Diseases of Children . Dickson's Practice of Medicine Druitt's Modern Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Dunglison's Therapeutics and Materia Med Ellis's Medical Formulary, by Smith . Erichsen's System of Surgery Erichsen on Nervous Injuries Flint on Respiratory Organs . Flint on the Heart Flint's Practice of Medicine . Fownes's Elementary Chemistry . Fuller on the Lungs, &c. Garduer's Medical Chemistry Gibson's Surgery Gluge'8 Pathological Histology, by Leidy Graham's Elements of Chemistry . Grav's Anatomy Griffith's (R. E.) Universal Formulary . Griffith's (J. W.) Manual on the Blood, &c. Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy Hartshorne's Essentials of Medicine . Habershon on Alimentary Canal . Hamilton on Dislocations and 'ractures Harrison on the Nervous Systeri . Hoblyn's Medical Dictionary Hodge on Women Hodge's Obstetrics Hodge's Practical Dissections Holland's Medical Notes and Reflections Horner's Anatomy and Histology Hudson on Fevers, .... Hughes on Auscultation and Percnssion Hillier's Handbook of Skin Diseaies Jones's ;T. W.) Ophthalmic Medicine and Surg. PAGE 11 6 1 3 6 30 22 17 16 1.1 2S 22 10 10 10 2s 22 1,S 18 18 19 19 Jones and Sieveking's Pathological Anatomy Jones (C. Handfleld; on Nervous Disorders Kirkes' Physiology •. . . . Knapp's Chemical Technology Lea's Superstition and Force Lallemand and Wilson on Spermatorrhoja La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye .... Laycock on Medical Observation . Lelimann's Physiological Chemistry, 2 vols Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever Maclise's Surgical Anatomy . Malgaigne's Operative Surgery, by Brittan Marshall's Physiology .... Markwick's Examination of Urine Mayue's Dispensatory and Formulary Mackenzie on Diseases of the Eye Medical News and Library . Meigs's Obstetrics, the Science and the Art Meigs's Lectures on Diseases of Women Meigs on Puerperal Fever Miller's System of Obstetrics Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Modand on Urinary Organs . Morland on Uiiemia Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Neligan on Diseases of the Skin . Prize Essays on Consumption Parrish's Practical Pharmacy Peaslee's Human Histology . Pirrie's System of Surgery PABS 14 Pereira's Mat. Medica and Therapeutics, abridged 13 Quain and Sharpey's Anatomy, by Leidy Hanking's Abstract .... Roberts on Urinary Diseases . Ramsbotham on Parturition . Reese on Blood and Urine . . . Rigby on Female Diseases Rigby's Midwifery Rokilansky's Pathological Anatomy . Royle's Materia Medica and Therapeutics Salter on Asthma Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Simon's General Pathology . Simpson on Females .... Skey's Operative Surgery Slade on Diphtheria .... Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Solly on Anatomy and Diseases of the Braii Slill6's Therapeutics .... Tanner's Manual of Clinical Medicine . Tanner on Pregnancy .... Taylor's Medical Jurisprudence . Thomas on Diseases of Females . Toda and Bowman's Physiological Anatomy Todd on Acute Diseases .... Toynbee on the Ear .... Wales on Surgical Operations Walshe on the Heart .... Watson's Practice of Physic . West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . Wilson's Dissector Wilson on Diseases of the Skin . Wilson's Plates on Diseases •f the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Healthy Skin Wilson on Spermatorrlioja . • ' • Winslow on Brain and Mind UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. NOHED OCT 29 '63 BIOMED LIB. NOV 1 3 RECB Form L9-10m-5,'67(H2161s8)4939 isssiiiSiiiiiii