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Title: A System of Practical Medicine By American Authors, Vol. IV
       Diseases of the Genito-Urinary and Cutaneous
              Systems.--Medical Ophthalmology, and Otology

Author: Various

Editor: Pepper William
        Starr Louis

Release Date: July 8, 2020 [EBook #62587]

Language: English

Character set encoding: ISO-8859-1

*** START OF THIS PROJECT GUTENBERG EBOOK PRACTICAL MEDICINE ***




Produced by Ron Swanson

A

SYSTEM

OF

PRACTICAL MEDICINE.

BY

AMERICAN AUTHORS.

EDITED BY

WILLIAM PEPPER, M.D., LL.D.,

ASSISTED BY

LOUIS STARR, M.D.,

VOLUME IV.

DISEASES OF THE GENITO-URINARY AND CUTANEOUS SYSTEMS.—MEDICAL OPHTHALMOLOGY, AND OTOLOGY.

PHILADELPHIA:
LEA BROTHERS & CO.
1886.

CONTENTS OF VOLUME IV.

DISEASES OF THE GENITO-URINARY SYSTEM.

DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS. By ROBERT T. EDES, M.D.

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS. By FRANCIS DELAFIELD, M.D.

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA. By JAMES TYSON, A.M., M.D.

CHYLURIA. By JAMES TYSON, A.M., M.D.

DISEASES OF THE MALE BLADDER. By EDWARD L. KEYES, A.M., M.D.

SEMINAL INCONTINENCE. By SAMUEL W. GROSS, A.M., M.D.

DISPLACEMENTS OF THE UTERUS. By EDWARD C. DUDLEY, A.B., M.D.

DISORDERS OF THE UTERINE FUNCTIONS, INCLUDING AMENORRHOEA, DYSMENORRHOEA, AND MENORRHAGIA. By J. C. REEVE, M.D.

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM. By B. F. BAER, M.D.

PELVIC HÆMATOCELE. By T. GAILLARD THOMAS, M.D.

FIBROUS TUMORS OF THE UTERUS. By WILLIAM H. BYFORD, M.D.

SARCOMA OF THE UTERUS. By WILLIAM H. BYFORD, M.D.

CARCINOMA OR CANCER OF THE UTERUS. By WILLIAM H. BYFORD, M.D.

DISEASES OF THE OVARIES AND OVIDUCTS. By WILLIAM GOODELL, M.D.

DISEASES OF THE URINARY ORGANS IN WOMEN. By ALEXANDER J. C. SKENE, M.D.

DISEASES OF THE VAGINA AND VULVA. By EDWARD W. JENKS, M.D., LL.D.

DISORDERS OF PREGNANCY. By W. W. JAGGARD, A.M., M.D.

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE. By W. W. JAGGARD, A.M., M.D.

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS, INCLUDING LEUCORRHOEA. By W. W. JAGGARD, A.M., M.D.

ABORTION. By GEORGE J. ENGELMANN, M.D. (Berlin)

DISEASES OF THE MUSCULAR SYSTEM.¹

¹ Though properly belonging in Vol. V., with Diseases of the Nervous System, this section has been placed here for convenience.

MYALGIA. By JAMES C. WILSON, A.M., M.D.

PROGRESSIVE MUSCULAR ATROPHY. By JAMES TYSON, A.M., M.D.

PSEUDO-HYPERTROPHIC PARALYSIS. By MARY PUTNAM JACOBI, M.D.

DISEASES OF THE SKIN.

DISEASES OF THE SKIN. By LOUIS A. DUHRING, M.D., and HENRY W. STELWAGON, M.D.

MEDICAL OPHTHALMOLOGY.

MEDICAL OPHTHALMOLOGY. By WILLIAM F. NORRIS, A.M., M.D.

MEDICAL OTOLOGY.

MEDICAL OTOLOGY. By GEORGE STRAWBRIDGE, M.D.

INDEX

CONTRIBUTORS TO VOLUME IV.

BAER, B. F., M.D.,

Professor of Obstetrics and Gynæcology in the Philadelphia Polyclinic and College for Graduates in Medicine, and Dean of the Faculty; Obstetrician to Maternity Hospital; President of the Obstetrical Society of Philadelphia, etc.

BYFORD, WILLIAM H., M.D.,

Professor of Gynæcology in the Rush Medical College, Chicago.

DELAFIELD, FRANCIS, M.D.,

Professor of Pathology and Practical Medicine in the College of Physicians and Surgeons, New York.

DUDLEY, EDWARD C., A.B., M.D.,

Professor of Gynæcology in the Chicago Medical College, Chicago.

DUHRING, LOUIS A., M.D.,

Professor of Skin Diseases in the University of Pennsylvania, Philadelphia.

EDES, ROBERT T., M.D.,

Jackson Professor of Clinical Medicine in Harvard University, Boston, Mass.

ENGELMANN, GEORGE J., M.D. (Berlin),

Professor of Obstetrics and Gynæcology in the St. Louis Polyclinic and Post-Graduate School of Medicine.

GOODELL, WILLIAM, M.D.,

Professor of Clinical Gynæcology in the University of Pennsylvania, Philadelphia.

GROSS, SAMUEL W., A.M., M.D.,

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Philadelphia.

JACOBI, MARY PUTNAM, M.D.,

Professor of Materia Medica and Therapeutics in the Women's Medical College, New York, and Professor of Diseases of Children at the New York Post-Graduate School.

JAGGARD, W. W., A.M., M.D.,

Professor of Obstetrics in the Chicago Medical College, Medical Department Northwestern University; Obstetrician to Mercy Hospital, Chicago.

JENKS, EDWARD W., M.D., LL.D., Detroit, Michigan,

Formerly Professor of Medical and Surgical Diseases of Women and Clinical Gynæcology in the Chicago Medical College, and in the Post-Graduate Medical School of New York.

KEYES, EDWARD L., A.M., M.D.,

Professor of Genito-Urinary Surgery and Syphilis in the Bellevue Hospital Medical College, New York; Surgeon to Bellevue Hospital; Consulting Surgeon to the Charity Hospital.

NORRIS, WILLIAM F., A.M., M.D.,

Clinical Professor of Ophthalmology in the University of Pennsylvania, Surgeon to Wills Ophthalmic Hospital, Philadelphia.

REEVE, J. C., M.D., Dayton, Ohio,

Formerly Professor of Materia Medica and Therapeutics in the Medical College of Ohio.

SKENE, ALEXANDER J. C., M.D.,

Professor of Gynæcology in the Long Island College Hospital, Brooklyn, and in the Post-Graduate Medical School of New York.

STELWAGON, HENRY W., M.D.,

Physician to the Philadelphia Dispensary for Skin Diseases; Chief of the Skin Dispensary of the Hospital of the University of Pennsylvania, Philadelphia.

STRAWBRIDGE, GEORGE, M.D.,

Clinical Professor of Otology in the University of Pennsylvania, Philadelphia.

THOMAS, T. GAILLARD, M.D.,

Clinical Professor of Diseases of Women in the College of Physicians and Surgeons, New York; Surgeon to the New York State Woman's Hospital.

TYSON, JAMES, A.M., M.D.,

Professor of General Pathology and Morbid Anatomy in the University of Pennsylvania; Physician to the Philadelphia Hospital, Philadelphia.

WILSON, JAMES C., A.M., M.D.,

Physician to the Philadelphia Hospital, and to the Hospital of the Jefferson College; President of the Pathological Society of Philadelphia.

ILLUSTRATIONS.

DISEASES OF THE GENITO-URINARY SYSTEM.

DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS.

The kidneys are two glandular organs, of a concavo-convex shape so characteristic as to be frequently used as a term of comparison, situated on each side of the vertebral column, with the longer diameters nearly parallel thereto, but slightly convergent toward the upper extremity, and extending from about the upper border of the eleventh rib on the left side and the middle of the corresponding rib on the right to the second or third lumbar vertebra. Hence they are somewhat less than half covered by the last two ribs.

The upper extremity is a little the wider and the thinner, and by this peculiarity and a recollection of the position of the vessels (from the front, vein, artery, ureter) the two kidneys may be assigned to their proper sides after removal from the body.

They are behind, and at their upper extremities nearly in contact with, the peritoneum, resting, with their more or less voluminous envelope of adipose tissue, upon the great muscles of the loins. The fat which in the normal condition surrounds the kidneys varies, as might be supposed, within wide limits, and is by no means devoid of importance, since its deficiency is undoubtedly a predisposing cause for some of the displacements hereafter to be described. In this fatty mass may also be situated perinephritic abscesses, and into it spread with considerable facility morbid growths originating in the kidney itself.

At the middle of the inner borders of the kidneys are situated the hiluses into which enter veins, arteries, ureters, nerves, and lymphatics, united by connective tissue and forming a sort of pedicle.

The normal weight of each kidney is to be expressed by a rough average as from four and a quarter avoirdupois ounces, or one hundred and twenty grammes, on the one hand, to seven ounces, or two hundred grammes, on the other; but since a deficiency in the size of one is not unfrequently compensated by an increase in the other, it would be safer to give the weight of the pair as from two hundred and forty to four hundred grammes, the lesser number representing those organs which are not only small but anæmic, and the larger those which are either distinctly hypertrophied or much congested: many diseased kidneys will also be found within these limits.

The size of the kidney is in a general way proportioned to the size of [p. 20] the body: the proportion is stated as 1 to about 240. A disproportionate change in the size of both kidneys without any change in structure is a true hypertrophy, and may be met with in persons whose habits as regards the ingestion of fluids (especially such as are freely secreted by the kidneys—for instance, beer or other forms of dilute alcohol) tend toward excess, or where a disease like diabetes throws a large amount of diuretic material into the circulation.

The deep position of the kidneys makes them usually inaccessible to physical exploration to any practical extent. In stout persons they are so entirely covered by their own immediate envelope of fat, by the adipose tissue of the mesentery, and by the thick abdominal walls as to be completely indistinguishable. In thinner persons deep palpation with both hands may enable us to say that there is a diminished resistance to pressure, as in the case of movable kidney, or that there is or is not any decided enlargement. Slighter changes in size cannot be accurately determined, although Bartels¹ states that he was once enabled to detect a considerable enlargement in a case of parenchymatous nephritis by double palpation. In moderately thin persons the lower end of the kidney can be more or less distinctly felt.

¹ Ziemssen, vol. xv.

A position upon the hands and knees (not the gynecological semi-prone position), allowing the whole abdomen to gravitate directly away from the backbone, is said to afford, by the varying concavity of the lumbar region on the two sides, information as to the absence of either kidney from its usual place. When the kidney, however, is displaced, and when it comes decidedly forward from increase in its own size or from the pressure of a tumor behind it, it may very often become extremely accessible.

Percussion gives even less information than palpation, since the dulness of the lumbar muscles extends laterally beyond that of the kidneys, and is of itself so complete as to offer no change from the addition or subtraction of the resistance of the underlying organ.²

² It is probable that Simon's method of thrusting the hand into the rectum and large intestine might be made available by a person with a small hand and arm for diagnosis in doubtful cases where the value of the information to be obtained would be sufficient to compensate for the risk of serious injury.

The removal of the kidneys may be accomplished through the rectum—and has been effected many times by myself and assistants—in cases where a complete autopsy is refused. The manoeuvre is not very difficult through a large and especially a female pelvis, but under other circumstances may be somewhat fatiguing. Considerable post-mortem information in regard to other organs may be obtained in the same way.

The most marked anomaly in the shape of the kidneys when both are present, and the only one which possesses a clinical interest, is that known as the horseshoe kidney, being a more or less complete fusion of the organs of each side in front of the vertebral column and the great vessels. This fusion is usually at the lower end, but may be in the middle or at the upper end. Sometimes there is a portion lying directly in front of the vertebral column so large and thick as to appear almost like a middle lobe or a third kidney. In a few rare instances this portion has formed a pulsating enlargement mistaken for an aortic aneurism or other abdominal tumor. In others compression of the great vessels has given rise to phlebitis, or the abnormal position of the ureters has obstructed the passage of the urine, with the results, as regards the secondary affection of the kidneys, to be described below. [p. 21] These instances are, however, among the curiosities of medicine, and no rule for their diagnosis can be laid down. A horseshoe kidney is usually discovered only after death, and with no special frequency in cases of renal disease.

Variations in the number of the kidneys possess this point of practical interest, that diseases affecting a single organ are more dangerous than if another exists which can take upon itself extra duty. Apparent absence of one kidney may be due to atrophy, attended with very small size of the renal vessels; in which case a small mass of connective tissue is found at the upper end of the ureter, which is usually illy developed. The other kidney is usually hypertrophied.

The kidney may fail to be developed. In this case there are no vessels corresponding to the renal artery and vein, and the ureter is stated to be invariably absent, but the writer has seen a specimen where the left ureter terminated superiorly in a rounded cul-de-sac, no kidney or suprarenal capsule being present. The other kidney was of rather large size in proportion to the size of the patient, but of the usual form. This defect is apt to be associated with some anomaly of the genital organs.

Another condition, apparently similar, but really due to a fusion of the two embryonic kidneys, is sometimes found. In this the single organ, situated upon one side, is irregular in form and in the number and origin of its vessels. There are usually two ureters, arising one above or beside the other, and directed to their proper positions in the floor of the bladder. A single ureter arising from a single kidney has been seen to empty upon the opposite side of the bladder.

Supernumerary kidneys have been noted. In one case an extra pair, situated below the others, were intensely inflamed, while the normal organs were not so.

A position of one kidney has been noticed considerably higher than normal, so as to push the spleen from its place. A more common anomaly, however, is the situation of one kidney at a point much below the usual, most commonly at the brim of the pelvis. When this happens the kidney itself is usually more or less distorted in form, and receives its blood-supply from several small arteries which enter it at irregular points, forming as it were several small hiluses. They may originate from the aorta or from one or both iliacs. The ureter is correspondingly short. This position is of some importance, since a pelvic tumor is formed which has in one instance proved an obstacle in childbirth, while in another the misplaced kidney itself underwent an acute nephritis from the pressure of the foetal head. The kidney tumor has in a few instances been felt in this position during life, but its nature has not been diagnosticated.

The most clinically important change in the position of the kidney is not a permanent one, but varies from time to time with the posture of the patient and the altered conditions of pressure—externally by dress or apparatus, or internally by the other abdominal organs. It is known as floating or wandering kidney. In this affection the kidney ceases to [p. 22] be firmly imbedded in the fat usually found in the lumbar region, constituting a support and packing for these organs as well as for the suprarenal capsules, and is allowed more or less liberty of movement, which is restrained by a pedicle consisting of the ureter, vessels, and nerves, with more or less connective tissue. As it passes downward and forward it comes into more intimate relations with the peritoneum, which usually covers only the anterior surface, often with an intervening layer of fat, so that it may even gain a sort of special investment or meso-nephron.

The extent of the excursions of which the tumor thus formed is capable must naturally vary considerably. Sometimes the organ can be pushed or make its own way forward so as to come into contact with the anterior abdominal wall on the same side, and not much lower than the normal position, or it may pass considerably downward, and thus be confounded with tumors arising from the pelvis.

This affection is much more frequent among women than in men, and the right kidney is more frequently movable than the left: both, however, are sometimes dislocated. It is observed in a much larger proportion of cases in the laboring classes than in those whose work is less severe and carried on in less constrained attitudes. Judging from the relative amount of the literature of the subject, it would appear to be much less frequently observed in this country than among the lower classes of Germany, where so large a proportion of the severest outdoor labor is carried on by women.

Various causes are assigned for this displacement. It is stated to be usually congenital, but is not described as found post-mortem in children with at all the frequency that it occurs in adults; and it is certainly possible in adults to fix in many cases the beginning of the disease with a reasonable degree of certainty. That a certain amount of predisposition, or peculiarly favorable position of the kidney, or an unusual laxity of connective tissue, exists in a certain number of cases is undoubtedly true.

The next most important factor is undoubtedly a laxity of the abdominal walls, affording a less firm and unyielding support to the contained viscera, and a deficiency, usually an acquired one, of the fat surrounding the kidney, which enables it in the normal condition to be supported by the layer of peritoneum passing across its front from the spinal column to the flank. This is seen in a certain set of cases where the trouble dates from an acute disease or a rapid emaciation. The well-known influence of repeated pregnancies is undoubtedly exerted in this way.

Another set, especially those exceptional cases which occur in strongly-built and not thin persons, are referable to severe shocks received in gymnastic exercises, hard riding, or falls from a horse.

One of the most frequent causes, and one which accounts for the fact of the affection being most prevalent among the working classes, is the use of a tight strap or cord to support the garments. Corsets, which exercise a more even pressure over a larger surface, do not have this effect. The right kidney, from the position of its superior extremity in front of the liver and its slightly higher place in the abdomen, appears to be more influenced by this pressure than the left. The movements of respiration, especially when reinforced by the forced inspiration and [p. 23] compression of the abdominal viscera accompanying violent exertion, appear to assist in the dislodgment already favored by the pressure of the girdle.

According to Müller Warnek,³ who has laid especial stress on this method of causation, a slighter degree of displacement is possible in this way without or preceding the full development of wandering kidney. A pressure is exercised upon the descending duodenum with which the right kidney is brought into intimate relations behind, and bound down by, the peritoneum; which leads, as Bartels supposes, to a hindrance in the passage of food from the stomach, and consequent dyspeptic phenomena. In these cases, when the kidney has become a more freely movable one and has dropped farther down in the abdominal cavity, the pressure on the duodenum ceases, the consequent symptoms disappear, and give place to the dragging sensations and severe colicky attacks which are apt to characterize an older case.

³ Berl. klin. Woch., 1877, 38.

SYMPTOMATOLOGY.—There is great variety in the kind and amount of effect which the movable kidney exercises on the general organism and the local effects it produces. Neither the local nor the general symptoms are necessarily proportionate in severity to the amount of the displacement.

It may be said in advance that, contrary to what might be expected, the symptoms are not usually connected with any disturbance in the urinary function, and, although exceptions are not unknown, the rule is for a displaced kidney to be an otherwise healthy one. Cystitis and uterine affections have been observed in this connection, but it is doubtful if any relation other than coincidence or a mutual dependence upon impaired general nutrition and overwork exists between them. The partial stoppages which might be supposed to arise from the twisting of the ureters are not frequently observed.

Hysteria and hypochondriasis have been frequently attributed to this lesion, and might undoubtedly find their exciting cause in anxiety about a tumor of unknown character and origin; but there seems no good reason to connect them in any other relation of causation. It is undoubtedly true that many pains and discomforts exist in these cases which are neither satisfactorily explained nor gotten rid of by being called hysterical. These abdominal pains, especially of a dragging character, and also the sensation as of something falling or moving about in the abdomen, particularly when the patient assumes the upright posture or makes unusual exertions, are very naturally connected with the existence of the actual condition which is likely to give rise to them. Müller Warnek has recorded the frequent coincidence of flatulent dyspepsia and dilatation of the stomach depending on retention, and its consequent fermentation, in connection with the movable kidney and its supposed pressure on the duodenum. It is not probable, however, that all the symptoms are to be explained so simply, but it is quite as likely that the dragging and tension of the pedicle may have a remoter effect through the renal and sympathetic nerves.

Severer attacks occasionally occur with violent colic and inflammatory symptoms, the tumor formed by the misplaced organ becoming exceedingly sensitive to pressure. These have been attributed to some [p. 24] incarceration, but there is no evidence that this accident occurs, and it has not been found after death. They are probably due to a localized peritonitis of the investment of the kidney, or perhaps to simple neuralgia. Icterus and hepatitis, consequent upon a circumscribed peritonitis set up by the pressure of the movable kidney upon the liver, have been observed.

Death is not one of the usual results of this affection, but a recent surgical writer (Keppler⁴) has called attention to cases where long-continued dyspeptic symptoms, with constant pain and the chagrin and melancholy due to inability to work, have been followed by death from exhaustion, and nothing except a movable kidney has been found at the autopsy.

⁴ Arch. für Klin. Chirurg., 1879.

There can be no doubt that in many cases the symptoms are more severe than might be supposed from the ordinary descriptions, and are very unfairly characterized as hysterical. On the other hand, many cases are attended with but the mildest form of the symptoms just described, and the patients, ignorant of any tumor either from its discomfort or from having felt it, live in health and comfort for many years.

DIAGNOSIS.—The diagnosis of this condition, if the physician keeps in mind the possibility of its occurrence, is usually not difficult. In many cases a tumor has been felt by the patient which when called to the attention of the physician is recognized by its shape. In some cases in thin persons the form of the kidney, even to its hilus with the strongly-beating artery, can be made out. It glides easily from between the fingers, and can be moved more or less remotely from its normal position, to which, however, it returns without difficulty, especially when the patient assumes the recumbent position. The excursions are of course limited to a certain length of radius, of which the origin of the renal vessels is the centre, and seldom go much beyond the median line toward the side opposite to that on which the movable organ belongs.

The usual statement of text-books, that a depression or lessened resistance is to be felt in the loins of the side from which the kidney is absent, and a diminution of the normal dulness, which returns again when the organ is replaced, rests, as regards the majority of cases, rather upon theoretical considerations than on actual observation. The thickness of the lumbar muscles, upon which the kidney rests, is such that the dulness on percussion is not capable of much change. In most persons the outer limit of dulness in this region is not that of the outer edge of the kidney, but of the extensor dorsi communis. Palpation and percussion therefore in the renal region are not likely to be of much value in diagnosis, although an occasional case appears to justify the ordinary statement. The hand-and-knee position described above would be more likely than any other to show an existing depression.

Palpation for the purpose of finding the tumor, if it be not at once evident, or for examining it after it is found, should be bimanual, one hand being placed in the space between the ribs and the crest of the ilium of the supine patient and pressed strongly upward, while the surface rather than the points of the fingers of the other hand should be carried and pressed with some firmness into the relaxed abdominal parietes. In this way the kidney may be caught between the two hands and examined more or less completely according to the thickness of the abdominal walls. Sometimes the kidney can be partly grasped between the [p. 25] finger and thumb of one hand. In this way the size, shape, and sensitiveness of the tumor can be determined, as well as its position and movability.

A movable kidney may of course present some difficulties of diagnosis from other abdominal tumors. The liver is sometimes, though very rarely, movable, and never to the same extent as a wandering kidney, and as it is pushed downward discloses its much greater bulk. The base of the gall-bladder may occasionally be quite movable, but its excursions are of a more limited radius, being of course executed only by the base and not the whole organ.

The spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. The splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. The left kidney, it should be remembered, is less frequently movable than the right.

A small ovarian tumor might be mistaken for a movable kidney low down in the abdomen, or vice versâ. The latter error has actually been committed, and has led to an attempted removal of the supposed cyst. The more easy movability of the kidney upward and of the ovary downward or laterally, as well as the shape, and in many cases the result of a vaginal examination, should be sufficient to make the distinction, which, if an exact diagnosis be absolutely necessary, may be confirmed by aspiratory puncture.

A malignant omental tumor might at the first examination present points of difficulty in diagnosis, but even if it were single and counterfeited with considerable accuracy the shape of the kidney, neither of these conditions would be likely to continue for any length of time.

TREATMENT.—The treatment usually suggested for this affection is based partly on the fact that many cases are hysterical, and also on that other more important one, that very little can be done to restrain the vagaries of the offending organ.

A correct diagnosis, it has been frequently remarked, is often sufficient to relieve the patient's mind, and secondarily her body, and may be all that is necessary in cases where the symptoms are all psychical and have arisen from the discovery of a tumor of unknown nature.

As a relief from the more serious annoyances the avoidance of certain disturbing causes may be of value, and such will consist in a proper regulation of the bowels and consequent avoidance of straining, and the choice of an occupation as little laborious and involving as little work in the upright posture as possible. No tight, narrow girdle should be worn about the upper part of the abdomen.

On the other hand, the use of a tight bandage over the whole abdomen is usually recommended, and seems to be useful in a small proportion of cases. It can of course act only by rendering the whole abdomen a little more tightly packed, and cannot exercise much restraint on any special portion of its contents. Pads of various shapes worn under the bandage may bring a little more local pressure to bear. One shaped like a carpenter's square, with an ascending branch to check the lateral movements, and a horizontal one to prevent the descent of the tumor, has been proposed. A truss with pads adapted to the loins and a front pad over the kidney has also been used.

It is impossible to read the history of many cases of this affection without becoming convinced that while the majority need but the mental assurance of the harmlessness of the tumor to restore their mental equilibrium, and others find their troubles bearable or capable of relief by mechanical appliances, no inconsiderable number are incapacitated from labor and the enjoyment of life by the necessity for great care in their movements, or suffer from severe symptoms, as pain and dyspepsia, which demand a more active treatment.

This has been afforded by operative surgery in two ways. Of these the most obvious is removal of the offending organ. It has now been clearly shown, by the number of nephrectomies that have been performed, that one healthy kidney is sufficient to support the function of urinary elimination; and if one kidney can be clearly shown to be healthy, the other can be safely removed. Such an operation undoubtedly adds to a patient's risks, since any subsequent renal affection is likely to prove fatal; but it has been now done a considerable number of times for the relief of the affection in question, and with good results. R. P. Harris⁵ has collected 16 cases with 10 recoveries, the organ removed in 3 out of the 6 fatal cases being diseased. Only 2 of these operations were by the lumbar incision, both being saved. They have since been reported.

⁵ Am. Journ. Med. Sci., July, 1882.

The operation has usually been done by the abdominal incision, which offers the advantages of greater accessibility of the pedicle for the purpose of ligating the arteries, and also greater ease in getting at the kidney itself, since it has often formed a partly separate pouch in the peritoneum, from which it would not be so easy to dislodge it by the lumbar incision. The latter operation is, as just stated, by no means impracticable nor specially dangerous. Of course it is desirable to avoid for some time after the operation anything which, like the use of diuretics or the excessive secretion of water, will throw any increased work upon the remaining kidney until it has had time to accommodate itself to them.

A singular case of attempted excision of a tumor supposed to be a wandering kidney, which could not be found after the incision was made, is recorded.⁶ In this case the symptoms, which, as well as the physical signs, had pointed distinctly to a movable kidney, disappeared after the operation. The author compares this case to another, in which great relief was experienced from a pretended operation for the removal of normal ovaries.

⁶ Hygeia, 11, 12, 1880, Svensson.

The other operation consists in the fixation of the movable organ. In one case a curved needle bearing a strong tape ligature was passed into the abdominal muscles, through the kidney, and out again. The ligature remained for some time, giving a certain amount of relief from the distressing symptoms, but maintaining a constant discharge until it came away without having accomplished any permanent benefit. The kidney was afterward removed by a lumbar incision, and a deep cicatrix found running longitudinally along the otherwise healthy organ.⁷

⁷ A. W. Smyth, New Orleans Med. and Surg. Journal, Aug., 1879.

In other cases⁸ a dissection has been made until the kidney was reached, which was then, with its adipose capsule, stitched firmly into [p. 27] the wound. In one of these cases the kidney became somewhat loosened again, but it is possible that the risk of this accident might be avoided by some modification in the operative procedure. If this operation can be made a successful one, and generally accepted, of which as yet the paucity of cases hardly permits us to judge, it is manifestly far preferable to removal, since it leaves in its place an organ usually perfectly capable of performing its functions.

⁸ Hahn, "Fixation of Movable Kidney," Am. Journ. of Med. Sci., April, 1882, from Cbl. für Chirurgie, 1881.

Polyuria is the name of a symptom the presence of which may be easily ascertained beyond a doubt, but which is notwithstanding occasionally overlooked. Its existence is to be determined by measuring the urine. In extreme cases this may be unnecessary, but slighter forms may easily escape notice if this is not done. The quantity of urine normally secreted varies considerably, owing to many causes, of which the principal are—the quantity of fluid ingested, not necessarily in the form of beverages, but of food more or less succulent; the activity of the other secretions, especially those of the skin and the intestines, and the presence of substances which increase the rapidity of its flow through the kidney or stimulate the glandular cells; and, to a certain extent also, individual peculiarities.

The quantity of water furnished by the kidneys depends largely upon the excess of pressure in the vessels, and especially in the Malpighian coils, over that in the interior of the tubes, and is consequently influenced by the general blood-tension.

The second factor of importance is the calibre of the renal vessels, especially the arterioles; and the third, the freedom of exit of the formed secretion from the uriniferous tubes. A certain amount of back pressure, so far from diminishing the amount of urine, seems to increase it, as shown in some of the cases of surgical polyuria, where the normal amount is considerably exceeded, while the renal parenchyma is being gradually destroyed.

The arterioles of the kidney being, like all other arterioles in the body, under the control of the nervous system through the vaso-motor nerves, it is easy to see how the various affections of this controlling element may act upon the secretion of urine; neither is it possible to deny (although by far the most important factor in the rapidity of the urinary secretion has been shown to be the blood-pressure) that the nervous system may have a direct effect upon the secreting renal parenchyma.

The normal quantity of urine for an adult of medium height and weight and ordinary habits as regards the ingestion of liquids may be stated as fifty fluidounces, or a liter and a half, which is of course to be considered as only a very rough approximation. One liter on the one hand, and two liters on the other, can hardly be considered pathological limits, unless the increase or decrease takes place under circumstances which ought to produce the opposite effect.

Frequency of micturition, especially if nocturnal, is often considered almost a proof of polyuria, but can at most only justify a presumption of it, which is to be confirmed or not by exact measurement. Any [p. 28] existing polyuria is likely to be greater during the night. Frequency of micturition may mean polyuria, or, on the contrary, may coexist with a considerably diminished total amount of urine; in which case it means only increased irritability of the bladder, and is then a purely nervous symptom; assuming, of course, the absence of inflammatory trouble. The rapidity with which the secretion accumulates in the bladder has a certain influence in determining the need for micturition; that is, a bladder containing five ounces of urine which has been gradually accumulating for some hours retains it with greater ease than if the same amount had been rapidly secreted, as, for instance, after a full meal with an abundant supply of fluids.

Polyuria is often, or always if persistent, an important symptom, and the suggestions made by it can easily be added to and confirmed by a more minute examination of the urine. Thus we may have the following combinations indicating important diseases:

Polyuria, moderate, with diminished specific gravity, albumen usually in small amount, and some casts; in chronic interstitial nephritis;

Polyuria, with pus and mucus and débris from the urinary passages, usually turbid and often alkaline and offensive; in irritation of the kidneys depending on lesions of the deeper urinary passages, prostate, or bladder (surgical polyuria);

Polyuria, with increase of urea (azoturia);

Polyuria, with increase of phosphates (phosphaturia);

Polyuria, with increased specific gravity and sugar; in diabetes mellitus;

Polyuria, with decreased specific gravity and diminished or normal solids; in diabetes insipidus.

These conditions have many points of mutual contact and resemblance, but the affection which is the subject of the present essay is diabetes insipidus—i.e. that form of polyuria which is accompanied by no abnormal constituents except occasionally inosite, a very little sugar, or a very small amount of albumen. In the cases where these constituents might lead to difficulties in the way of diagnosis the absence of other symptoms of the disease likely to be mistaken will suffice to mark off the affection as entirely distinct.

The normal elements may be decreased, normal, or increased. The disease thus defined includes not only diabetes insipidus, but many cases of so-called phosphaturia and azoturia, which, if not exactly coinciding, have many points in common.

In some cases which, from the character of the urine as well as from the other symptoms, should evidently be classed as diabetes insipidus, the quantity of urine, although somewhat increased, is not very excessive, reaching perhaps two liters, but in the great majority is discharged in much larger quantity. In a case which came under the observation of the writer by the kindness of H. E. Marion the amount of urine gradually rose from two or three gallons to five or six and seven, and on one occasion the patient, a girl of fifteen, after some unusual excitement is supposed to have passed eight gallons in the course of twenty-four hours. Of this eleven quarts was by actual measurement, and passed in the presence of her mother in the course of the afternoon.

The urine in these cases is, as would naturally be supposed, of a very [p. 29] pale color and of low specific gravity, which from 1005 to 1010, representing the usual range, may in extreme cases fall to or even below 1001 as measured by the ordinary urinometer. I have seen no case recorded where the specific gravity of such a urine has been determined by instruments of greater delicacy. Its odor is comparatively faint, but it is somewhat prone to decomposition. The solid constituents are often somewhat increased in the twenty-four hours, especially the urea, which may be present in double the usual amount. This is probably the result of an increased metamorphosis from the passage of so large an amount of water through the tissues.

It is not always true, however, that the solids are increased, and the difference in the amount of destructive metamorphosis taking place in different cases is probably closely connected with the clinical differences which may be observed in regard to the amount of wasting and affection of the general health. The phosphates are frequently increased, as found by Dickenson and Teissier; and such an increase has probably about the same meaning as the increase in urea. In other cases, however, they take part in the general diminution of solids, as in the case of Marion just alluded to, where they were reported as absent, which undoubtedly means simply present in so small amount as to escape the usual clinical tests.

Among the concomitant symptoms the most necessarily and closely connected with the increased discharge of fluid is its increased ingestion, so that the disease has been called polydipsia instead of polyuria, it being assumed that the thirst is the initial and important symptom upon which the diuresis naturally depends. It has been observed in many cases, however, that the quantity of water drunk is very much below that which is passed. In the case last spoken of the water ingested in the form of drink was but a small fraction of the quantity of the urine, so that the patient drank but two or three pints while passing many gallons. In cases where the beginning of the disease has been carefully observed patients have distinctly stated that the increased discharge began before they felt increased thirst. This of course takes no account of the quantity of water contained in solid or semi-solid food. Polyphagia is occasionally seen, as in the oft-quoted case of Trousseau, the terror of restaurant-keepers. So intense is the craving for water that in several instances where attempts have been made to limit its amount the unfortunate patient has drained the chamber-pot. Emaciation is probably connected with increased metamorphosis, as indicated by the increased secretion of urea and phosphates. Dryness of the skin has been frequently noted, and has been said to mark the distinction between polyuria and polydipsia, in the former the skin being dry, and in the latter moist. In one case, however, where copious perspirations were noted, the patient stated positively that the polyuria began a number of days before increased thirst was experienced. In another very extreme case, attended, however, with no wasting, night-sweats occurred. Pruritus has been mentioned as affording another point in the resemblance which undoubtedly exists between the severer cases of this disease and diabetes mellitus. Dyspeptic symptoms have been noted in some cases, and oedema may take place, as in many wasting diseases.

The nervous symptoms are perhaps the most important in the severer [p. 30] cases. In some which have been examined post-mortem distinct nervous lesions have been found, such as the remains of tubercular meningitis, tumors involving the cerebellum, and softening of the floor of the fourth ventricle; in others the patients are known to have been syphilitic.

Severe headache is a symptom of some importance, occurring in a considerable number, but not the majority, of cases. Atrophy of the optic nerve was present in two reported cases, to which the writer can add a third, where failing vision, headache, and emaciation were the principal and earliest phenomena, while at a later period the atrophy was demonstrable by the ophthalmoscope. The polyuria in this case, though marked, was not excessive, and the patient, a young man, after remaining for some years in a condition of chronic invalidism, died. Chronic interstitial nephritis had of course been suspected and sought for, but no evidence of it found beyond the symptoms already stated; neither were there any more definite cerebral symptoms.

Finally, it should be stated that a great many cases of this kind have no marked symptoms at all except the essential one, and so long as they are supplied with a sufficient amount of fluid live in comfort with their single inconvenience.

The diabète phosphatique of Teissier⁹ should be cited in this connection. In only a small proportion of his cases where an excess of phosphates was noted was the quantity of the urine also increased, and in these the symptoms seem as appropriate to the polyuria as to the phosphaturia. It is worthy of note, however, that one series of his cases is connected with disease of the nervous system; another alternates or coexists, as does also diabetes insipidus, with diabetes mellitus; and his fourth class closely resembles, with the exception of the increase of phosphates (if this can be looked upon, after what has been said above of the increase of solid urinary constituents, as an exception at all), the affection last named—i.e. diabetes mellitus. In fact, many of these cases of Teissier read like what would have evidently been called, without a quantitative analysis, simply polyuria or diabetes insipidus.

⁹ Du Diabète phosphatique, par L. S. Teissier, Paris, 1877.

According to Teissier, the presence of an excess of phosphates in the blood is sufficient to determine a polyuria. It is possible that in many cases where a polyuria accompanies phthisis, as noted in many of his cases, the symptom may be really due to actual organic (perhaps amyloid) disease of the kidney.

The COURSE AND TERMINATION naturally vary greatly with its etiology and the diseases with which it is associated. In some cases where nutrition is but little affected, and no attempt is made to check the natural appetite for water, the disease may go on for years with no essential change or impairment of the general health, as in the remarkable one quoted by Dickenson, where a French infant had at the age of three impoverished her family by her demand for water, which seems to have been an expensive luxury, and at a later period kept her husband—to whom, however, she bore eleven children—in a constant state of impecuniosity by the same depraved appetite. At the age of forty she drank in the presence of a scientific commission within ten hours fourteen quarts of water, of which she returned through her kidneys ten to their astonished gaze.

When polyuria is merely a symptom of cerebral inflammation, of central tumor, of syphilis, or of phthisis, the course and prognosis will of course be that of the primary disease. It occasionally comes on during pregnancy, and in one such case it is stated to have ceased two days after delivery, and in another the secretion, uninfluenced by parturition, resumed its normal quantity when lactation was fully established.

It is very rare, if indeed it ever happens, for life to be terminated by diabetes insipidus unaccompanied by any other disease, although from its association with many and severe affections, both of the nervous system and of the kidneys, it must of course not unfrequently happen that a patient dies in, though not on account of, the polyuric state. It is strange to observe, however, as has been often before remarked, how thin a shell of renal structure will suffice to carry on not only the usual, but an excessive, flow of water.

The ORIGIN of diabetes insipidus has been found in several conditions. Greater disposition toward it exists in early life, although it is by no means confined to youth. After middle life polyuria is likely to awaken the suspicion either of chronic interstitial nephritis or of prostatic disease, or other affection of the urinary passages setting up a sympathetic irritation of the kidney. It has been found to originate during convalescence from acute diseases, with perhaps preference for meningitis. Syphilis has its share of cases, as in most other organic nervous diseases. Shocks of various kinds, including fright, sudden or prolonged immersion in cold water, the rapid ingestion of large quantities either of water or of alcoholic fluids, are undoubted potent factors. In this respect, again, we may see the resemblance between diabetes without sugar and true or saccharine diabetes. It is favored by the hysterical diathesis. A very interesting case of severe hysteria with hemianæsthesia and hemiplegia and other marked symptoms varied for a time between almost complete anuria and the most profuse discharge of over two hundred ounces per diem.

A most interesting group of cases has been recorded by Weil,¹⁰ where out of a family of 91, 28 were polyuric. The head of the family, a polyuric, lived to the age of eighty-three, while his descendants were robust, many of them attaining a good old age. There were no anomalies of the circulation, and the persons affected were not alcoholics. Their only complaint was of a troublesome thirst, and they declined treatment.

¹⁰ Cbl. für die Med. Wiss., 1884, p. 263, from Virch. Arch., xcv.

The PATHOLOGY of diabetes insipidus, so far as is positively known, may be gathered from the previous account of its etiology and symptoms. It is evidently of nervous origin in the great majority if not all cases. It is often connected with distinct lesions of the nervous system, and attended with other nervous symptoms. In some cases it occurs in connection with a well-marked hysterical diathesis. The copious flow of pale urine as a sequel to the hysterical paroxysm is well known, and the same thing often attends a severe nervous headache in either sex. It is probable that the polyuria attending lesions of the urinary passages is a reflex nervous phenomenon, since it may be present when there is no suspicion of organic renal disease.

Guyon¹¹ states that surgical polyuria occurs under three [p. 32] conditions—painful excitation of the sensibility of the deeper portion of the urethra or the vesical mucous membrane; repeated attempts to urinate during the night; retention of urine more or less complete, but especially when there is distension of the bladder. Of the first cause he gives an instance in the case of a young man who had a polyuria whenever a bougie was passed beyond a urethral stricture.

¹¹ Leçons cliniques sur les Maladies des Voies urinaires, Paris, 1881.

Where, however, polyuria, especially chronic, is due to habitual over-distension, it is in the highest degree probable that it is at least partly due to structural alteration of the kidney. The well-known experiment of Bernard, by which an increased flow of urine was induced by a puncture of the floor of the fourth ventricle, and those of Eckhard on section of the splanchnic nerves, show how it is possible for nervous affections to influence the secretion of urine, though the path or paths of the influence are by no means completely made out.

One of the most noticeable points in the pathology of the more excessive cases of polyuria is the disproportion which often exists between the amount of fluid ingested and the amount discharged, the latter often exceeding the former several times. The source of the excess of water has not been satisfactorily determined, but it is evident from a careful experiment of Watson, repeated by Dickenson, that the body has under some circumstances the power of appropriating water from the atmosphere instead of discharging aqueous vapor through the lungs and skin as usual. In the experiments referred to persons affected with extreme polyuria were weighed immediately after passing water, and again after as long an interval as they were able to restrain their thirst, of course being also without food and under observation, when it was found that the weight had been increased by a number of ounces. In Dickenson's case, weighing thirty pounds more or less, where the amount of urine excreted daily was from seven to nine liters, the gain in weight at several observations was as follows: in three hours, 15½ oz.; in five hours twenty minutes, 19¾ oz.; in three and a half hours, 3¾ oz.

The DIAGNOSIS of this affection rests, in the first place, upon the determination of a permanent increase in the quantity of urine passed considerably above the normal, and, as has been already remarked, may require a measurement of the daily amount—a procedure which it is well to make a matter of routine in any cases where urinary trouble may be present. The increase being found, if it be very great it will only remain to determine whether sugar be present, which will be indicated by the specific gravity and the appropriate chemical tests. Traces of sugar are sometimes found in cases of polyuria which do not present the characteristics of saccharine diabetes, and can hardly be considered to materially affect the character of the disease.

A specific gravity decidedly above normal, with an excessive quantity of urine, is not likely to belong to anything but diabetes mellitus, though the chemical tests should never be neglected. If, however, the polyuria be only moderate, it becomes necessary to exclude surgical affections of the urinary passages, especially an enlarged prostate, often attended with retention and distended bladder. Pyelitis and hydro-nephrosis may also give rise to the same condition of over-activity of the kidneys. The appropriate surgical examinations with the sound may be necessary, but the presence of pus, bacteria, and the epithelium of the urinary passages [p. 33] in the surgical urine, as well as its frequent alkalinity, may direct a very strong suspicion before the sound is used. The age of the patient also will be of considerable weight in this connection.

A point of real difficulty of diagnosis, and great importance for treatment and prognosis, is the distinction between simple polyuria not excessive, but attended by constitutional symptoms, such as impaired nutrition, dyspepsia, and severe headache, from chronic interstitial nephritis, which often makes its appearance with similar symptoms. Mistakes between these two affections have undoubtedly occurred, and can in many cases hardly be avoided except by reserving the diagnosis for a time.

The similarity is rendered still more deceptive by the undoubted occurrence of a trace of albumen or a hyaline cast or two in cases of nervous disturbance, without justifying a diagnosis of progressive renal disease. High arterial tension also is likely to be found in both conditions. Nothing but repeated and careful examinations of the urine and of the circulation, especially at times when the nervous symptoms are less marked, and often a considerable amount of time, can fix the diagnosis.

Hypertrophy of the heart, and even slight dropsy, will undoubtedly be extremely decisive symptoms, but are not likely to occur until after a time when the doubt no longer exists. In other cases it may be highly important to carefully exclude organic cerebral disease before making a diagnosis of simple polyuria.

It is hardly appropriate to speak of a diagnosis from azoturia or phosphaturia, since these conditions are extremely likely to exist coincidently with typical polyuria and to make a part of the same disease. It is of much importance, however, to ascertain their presence with reference to the probable effect of the disease on the nutrition.

In regard to the TREATMENT, it may be remarked, to begin with, that restriction of water, although naturally diminishing somewhat the discharge of urine, does not cure the disease, but, on the contrary, in many cases augments not only the discomfort of the patient, but tends to the dryness of the skin, dyspeptic and nervous disturbances, and emaciation. Patients may recover flesh, strength, and spirits on being allowed to drink ad libitum, even although the inconvenience of excessive urination be thereby somewhat increased. Sufficient food and drink should therefore be allowed, although a patient may be ordered to observe such moderation as will not put his powers of endurance to too severe a test.

Of the drugs proposed, nearly all have offered some prospect of success, and have been accordingly reckoned almost specifics. Opium has in some cases been found as useful in these cases as in diabetes mellitus, and probably, as in that disease, by diminishing the sensitiveness of the nervous system. Valerian and valerianate of zinc, recommended by Trousseau and apparently successful in his hands, have reckoned both failures and successes in the hands of others. Nitric acid, in the dose of from 1 to 5 drachms per diem of the dilute in a large quantity of water, is said to have been highly efficacious in one series of cases.¹² It is given until aching of the jaws and teeth, with some gingivitis, denoting its constitutional action, is produced. It was more successful than any other drug in Marion's case, although the specific symptoms were not produced, the patient being now in good health or free from [p. 34] her trouble. Atropia from its general action in diminishing secretion has been tried, and with occasional alleged success, but with many more failures. Pilocarpine from its action on the skin might be of value in those cases where the skin is very dry, but has no very general applicability.

¹² Kennedy, Practitioner, vol. xx. p. 95.

The drug most frequently employed, and which can claim a larger proportion of successes than any other, is ergot in full doses, half a drachm or a drachm (2 to 4 cubic centimeters of the fluid extract) several times per diem. Its method of action is undoubtedly in the contracting effect which it exercises on the renal arterioles. In many cases it has decidedly diminished the amount of urine, and in some a permanent cure seems to have resulted.

In estimating the value of drugs in certain cases of this affection its not infrequent neurotic origin should be borne in mind, as well as the very capricious effect of supposed remedies in the hysterical diathesis. Unfortunately, many cases remain rebellious to all drugs, and can only be rendered as little uncomfortable as possible.

What has been said of treatment applies only to the well-marked cases of diabetes insipidus. Polyuria, as a symptom of other diseases or of surgical affections, is hardly likely to call for treatment other than that of the disease upon which it depends.

Albuminuria signifies a condition in which albumen appears in the urine, and has by some writers been made of equal significance with nephritis or Bright's disease. It is hardly necessary to say that this coincidence is far from being an exact one, and that the symptom may exist without Bright's disease, and also Bright's disease without the symptom. For our present purposes albuminuria will be taken to mean those conditions in which albumen may be found in the urine without the existence of decided diffuse nephritis. As a symptom, and a highly important one, of Bright's disease it will be considered elsewhere.

Albumen is secreted in the kidneys chiefly in the Malpighian capsules, where, if at all abundant, it may be easily demonstrated after death by hardening the kidneys by boiling. This coagulates the albumen in situ, where it may be shown by sections prepared in the usual method. It has been supposed that albumen is normally secreted in the capsules of the healthy kidney, and afterward absorbed by the epithelium lower down; but this view can easily be shown to be erroneous by subjecting a kidney which has not secreted albuminous urine to the process just described, which shows no coagulated albumen in the place where it ought to be most abundant.

The albumen found in the urine is chiefly that which forms the most important portion of the blood-serum, although other albuminoid bodies have from time to time made their appearance and have some diagnostic importance. Semmola¹³ states that the albumen appearing in the urine in true Bright's disease differs from that found with the cardiac or amyloid kidney. The distinction can, according to him, be shown in [p. 35] the appearance of the precipitate to a practised observer, and also by a more rapid diffusibility through animal membranes. He admits, however, that he has in vain sought for any distinct and clear chemical test by which the difference can be recognized.

¹³ Archives de Physiologie, 2d Serie, tome ix., and 3d Serie, tome iv.

Fibrin may occur in inflammatory conditions in the form of coagulated masses, and hence cannot affect the question of the presence of albumen. Casein has not been detected with certainty. Various albuminoid bodies, called albuminose, paralbumen, metalbumen, and serum-globulin, are occasionally met with in renal disease, and may give rise to some confusion during an analysis. They are at present, however, more suitable for chemical than for clinical study.

A variety of albumen is said to occur in osteomalacia which is not coagulated by heat alone nor by heat and nitric acid. This has been called Bence Jones's albumen, but has been seen by others. Peptone has been found in urine, but usually in such specimens as have been or which afterward become albuminous. Its exact signification when alone cannot be more exactly stated, as it has appeared in a variety of diseases, though not in perfect health.

Finally, a protein body, a ferment called nephrozymase, may be thrown down from every urine by an excess of alcohol.

Hæmoglobin gives a dark-red color to the urine, which on boiling forms a brown coagulum floating on the surface.

Hæmoglobinuria may be produced in animals by the intravenous injection of large quantities of water, causing a dissolution of the corpuscles, but the degree of hydræmia necessary to produce this condition is much in excess of any met with in diseases of the human being.

Human hæmoglobinuria may be the result of various pathological conditions, among which may be mentioned some infectious diseases, jaundice, burns, and the effects of many poisons, as well as the transfusion of sheep's blood.

Intermittent hæmoglobinuria, which is attended with fever, is usually the result of cold acting upon predisposed persons. The color of the urine and of the coagulum, together with the absence of red corpuscles under the microscope, will distinguish urine of this character from others which are also coagulable by heat.

Several methods are in use for the detection of albumen. Of these, boiling is perhaps the oldest and most generally employed, and if conducted with due care is a very delicate and useful test. The urine to be tested should be clear and slightly acid, when on boiling the albumen, if present, will be precipitated in whitish flocculi, more or less abundant according to the amount, or, if the quantity is very small, as a turbidity. The flocculi soon settle to the bottom of the tube when it cools, and the thickness of the deposit formed gives an approximation to a quantitative estimate. It is to the proportionate thickness of this deposit that the terms 30 or 50 per cent. of albumen are commonly but incorrectly applied. If the quantity is very small, it may not be distinctly perceptible until after cooling.

If alkaline or very slightly acid urine is boiled, a deposit of phosphates will be thrown down which closely resembles that from albumen, while, on the other hand, the albumen remains undissolved unless in large amount. These deposits of phosphates differ a little in appearance from [p. 36] an albuminous one, but in order to be accurate acetic or nitric acid should be added, drop by drop, to the hot urine, when the phosphates will be redissolved and the albumen, if present, precipitated. It is better, however, to add the acid cautiously to the point of slight acidity before boiling. A recent work¹⁴ gives the following directions for this reaction, which is then "absolutely conclusive and surpassed in delicacy by no other:" "The urine is first made distinctly acid with some drops of acetic acid, and then about one-sixth of its volume of a concentrated solution of chloride of sodium or sulphate of sodium or magnesium added. If the urine contains albumen, a precipitate of coarser or finer flakes appears on boiling." This reaction may be used as a quantitative test by diluting and acidifying, if necessary, a known quantity of urine, washing the precipitate on a weighed filter, drying, and weighing the whole.

¹⁴ Die Lehre vom Harn, Salkowski und Leube.

An exceedingly delicate and convenient test is that by nitric acid. The acid is placed in the bottom of a conical wine-glass, and the urine, filtered if necessary, allowed to flow on top of it from a pipette, so as to disturb the plane of junction of the two fluids as little as possible, and leave a distinct line of demarcation. At this plane of union, if albumen be present, will be formed an opaque white line varying in thickness according to the amount of albumen, so that after some practice and with care an approximate estimate of the percentage may be made. A deposit of urates may sometimes be formed a little above the plane of union, but it may be distinguished by its position, by its less distinct limitation on the upper surface, and also by its disappearance on warming. In a very concentrated urine and in cold weather this error may be conveniently avoided by previous warming of the urine and of the reagent. The same remark applies to the brine test.

A crystalline precipitate of nitrate of urea may give rise to error if the urine be very concentrated or the experiment conducted in the cold. This may be distinguished by its disappearance on warming or by the microscope. The action of the nitric acid on the coloring matter of the urine, forming a dark band at the point of junction, may obscure the reaction, but with care will not give rise to mistakes.

Another test recently introduced, which presents some advantages over the nitric acid, and is certainly quite as delicate, consists in a saturated solution of common salt in water acidulated with about 5 per cent. of the dilute hydrochloric acid of the Pharmacopoeia. This solution should be used exactly in the manner described for nitric acid. There is no change of color at the line of junction, and no precipitate takes place there except albumen or peptone, or resins when they have been administered. The opaque line of precipitate may, if the amount of albumen present be small, require a short time to form, so that in cases of doubt it is well to allow the test-glass to stand for a few minutes. It will, however, show very distinctly in any cases in which nitric acid shows any precipitate. The line does not, however, increase in thickness and density in proportion to the amount of albumen so exactly as that produced by nitric acid, so that the brine test is not so useful for approximately quantitative use as the nitric acid, although fully as delicate. If it be desired to distinguish peptone from albumen, it may be done by a comparison of this test [p. 37] with the nitric acid, which does not throw down peptone. If a deposit occur, which may consist of resin, the addition of more urine will dissolve it if resin, while albumen will not be affected.

Picric acid is a delicate and often a convenient test. The dry acid may be dissolved in the urine, or a saturated solution used into which the urine may be slowly dropped, each drop making a slight whitish cloud as it slowly falls through the yellow solution.

The iodo-hydrargyrate of potassium is perhaps the most delicate test of all: Potassii iodidi, 3.32 gm.; Hydrarg. bichlor., 1.35 gm.; Acidi acetici, 20 c.c.; Aq. destill. q. s. ut fiat 100 c.c.—Tauret's test. It may be used in the same way as the nitric acid or brine, or simply intermixed. Its only disadvantage is that it throws down alkaloids, but as this will not happen unless the alkaloid be taken in large quantity—as might happen, for instance, in the case of quinine—the chances of error from this source are not very great if this peculiarity be borne in mind.

Ferrocyanide of potassium in an acid solution has recently been proposed as a convenient test. It may be made up into pellets with citric acid or used in the same combination in the form of papers.

The phenic-acid test is prepared as follows:

This is said to be very delicate, but the writer has no experience with it.

Tungstate of sodium is another recent addition to the list, which it is evident is already long enough for practical purposes.

Several of the tests mentioned have recently been prepared in the form of papers saturated with known quantities of the reagent and dried. They may be carried in the pocket-book and applied at the bedside, if desired, in a test-tube small enough to be very conveniently carried in the vest pocket. The iodo-hydrargyrate is perhaps the most useful. It is the most delicate, and a plan has been proposed for making with it a quantitative estimate of considerable accuracy by means of a standard solution or piece of gray glass adjusted by such a solution, with which the precipitate produced can be compared as to its opacity.

Exact quantitative examinations for albumen may be made by several processes, but that by boiling, if carried out with the precautions described in works on chemistry, is as accurate as any, and probably the best adapted to the needs of the practitioner if he should wish for such results.

For clinical purposes, however, it will rarely if ever be found useful to determine the amount of albumen more accurately than can be done by the various approximations mentioned above.

When even the smallest trace of albumen is discoverable by any of these methods, the question of the integrity of the kidneys at once arises—a question which a few years ago would have been considered as settled in the unfavorable sense by the same occurrence.

It is necessary to distinguish, first of all, between an essential and an accidental albuminuria, the first referring to that condition where the albumen is secreted with the urine and forms an essential part of it, and [p. 38] the other to the accidental admixture from the presence of pus or blood, which may have made its appearance at any point below the secreting tubes. When hemorrhage takes place from the kidney, albumen is of course present in the urine, but its signification under these circumstances is entirely different from that which it bears when unaccompanied by the corpuscular elements of the blood.

No means at present exist for determining whether a small amount of albumen present in the urine is more than enough to be accounted for by the pus or blood known to exist by the presence of its corpuscular elements or of its coloring matter. An approximate estimate may be made by one familiar with such examinations, but no rule can yet be laid down. Such a rule might be approximately established by a succession of counts with the hæmocytometer of the corpuscles found in albuminous urine of known percentage, or estimates of hæmoglobin by color tests.

The exact conditions of the kidney or of the blood which may cause the appearance in the urine of albumen without blood or pus—that is, of true albuminuria—have been the subject of much experiment and argument, which it would be impossible to reproduce, even in outline, within the limits of this article; and this is the less to be regretted since they have as yet led to no practical or generally accepted conclusion. A few of the more important facts bearing on the question may, however, be stated here.

Albumen other than serum-albumen, when introduced into the circulation either by injection into the veins subcutaneously, or if in very large quantity by the mouth, is rapidly excreted by the kidneys. This albumen also, if collected from the urine of the first animal and injected into the vein of a second, again comes through the kidneys. The albumen, however, which is obtained from the urine of an ordinary case of albuminuria—that is, serum-albumen—does not behave in this way, but is not excreted through healthy kidneys. These facts seem to show that the appearance of albumen in the urine in ordinary cases of renal disease is not to be attributed to any change in its quality approximating it to egg-albumen, for instance, but is due to the condition of the kidneys.

Disturbances of the renal circulation, especially those giving rise to venous stasis, are very likely to cause albuminuria; a temporary ligature of the renal vein causes albumen to appear in the urine after its removal, and ligature of the ureter has the same effect.

The albuminuria succeeding the collapse of Asiatic cholera or yellow fever seems to have a somewhat similar origin, being the result of re-establishment of the circulation after extreme anæmia of the kidney. Clinical facts in general seem to point to simple disturbance of the circulation and to alterations in the kidneys themselves as the usual causes of albuminuria, though in many cases the lesion seems to be a slight and temporary one.

Some other conditions under which such disturbances and alterations may arise, exclusive of Bright's disease, are the following:

Munn¹⁵ found albumen in small quantities in 11 per cent. of cases presenting themselves for life insurance, supposing themselves healthy and having no lesions of heart or lungs. It is not stated whether casts were found in these cases or not, and their value as representing healthy [p. 39] persons cannot, it is obvious, be correctly estimated until some time has elapsed. It is well known that renal lesions may be exceedingly slow in their progress, and it is by no means improbable that a part of these cases may have been really in the early stages of a chronic form of Bright's disease. Albumen has been found in the urine of boys and adolescents, as well as in that of healthy soldiers, tested immediately after rising: in most of these cases the amount was extremely small. Certain conditions, moreover, may greatly increase the proportion of cases in these same classes in which albumen is present. Thus, fatiguing exercise will bring it on in some persons, and the urine of a body of soldiers if examined late in the day after severe drill shows a much larger proportion of albuminurics than if examined after rising. The urine of the pedestrian Weston is said to have contained not only albumen, but casts. It is certainly not true that fatiguing exercise will cause albuminuria in everybody, and it is not claimed, even by those who report these and similar cases, that they prove albumen to be a normal constituent. Some of the cases are distinctly described as delicate without being actually ill. Cases have been reported where cold bathing has been followed by temporary albuminuria. Here it is in the highest degree probable that a disturbance in the circulation is produced by contraction of the cutaneous arterioles; and it is possible that we may find in this increased sensitiveness of certain persons an explanation of the occurrence of acute dropsy as a sequel to scarlatina or as the result of exposure in only a small proportion of the cases where the exposure takes place. It is hardly necessary to admit, on the basis of these observations, that albumen is a constituent of healthy urine, although this may be shown at some future day by still more delicate tests, but simply that the renal circulation may in certain sensitive persons be sufficiently influenced by slight and transient causes to permit albumen to pass into the urine. It is the almost unanimous conclusion of practical writers, taking fully into the account these recently-ascertained facts of albuminuria in alleged health, that the presence of albumen in the urine in sufficient quantity to be detected by any of the ordinary tests is a decidedly serious symptom.

¹⁵ New York Medical Record, xv. 297.

The influence of many well-recognized pathological states in bringing about venous stasis, and that delay of the blood in the renal—and more especially the Malpighian—vessels which seems the most essential factor in the secretion of albumen, is well known, and its recognition is of much importance in diagnosis and prognosis, since the unfavorable signification of albuminuria in certain cases is liable to be overrated, and a diagnosis of chronic renal disease made to depend upon symptoms which really belong to some other affection. How far alteration in the capillaries and epithelium is in each case concerned in the production of albuminuria it is often impossible to say, since any alteration in these elements which can be observed after death is almost certain to be complicated with lesions which can disturb the local circulation.

Cardiac obstructive disease is very likely to be accompanied by albuminuria, and the state of the kidneys by which this condition is brought about is undoubtedly venous congestion. The urine in a case of this kind is usually scanty, of high specific gravity, high colored, often with a deposit of urates, while the albumen appears in small quantity. A few [p. 40] hyaline casts are not infrequently seen, and do not materially increase the gravity of the prognosis so far as renal disease is concerned. The kidney which furnishes this urine is usually a little harder and a little denser than normal, but with a nearly normal microscopic structure, exhibiting but little more than capillaries well filled with blood, and in the interior of some of the tubes casts similar to those found in the urine during life.

Doubt may occasionally arise as to the diagnosis between a congested kidney consequent upon valvular disease of the heart and an interstitial nephritis with hypertrophy of the heart. In the latter case, however, the urine, although containing albumen, is usually much more copious and of low specific gravity. Diminished power of the heart without valvular lesion may have as a consequence albuminuria which disappears if the heart recovers its vigor.

In many of the cases in which albumen appears in the urine temporarily it is not easy to say whether an actual nephritis may not be present, though not sufficiently severe to give rise to other symptoms.

In almost any febrile disease of sufficient intensity albumen is often found, and when such a case terminates fatally without renal symptoms, the condition of the kidneys, consisting in more or less granular degeneration of the epithelium, is often spoken of as parenchymatous nephritis. If it is correctly called so, it is certainly very different from the idiopathic form, whether acute or chronic, since it is very rare for typhoid fever, for example, either to present the symptoms of acute nephritis during life or to terminate in chronic Bright's disease. In scarlatina, and rarely in other fevers, a distinct nephritis is present, but a degeneration of structure sufficient to produce albuminuria is in many instances a result merely of a high temperature.

Many applications to the skin produce albuminuria, but in almost all, if not all, of these an actual nephritis has been found to exist. The same is true of poisoning with strong acids, phosphorus, and arsenic.

A very important form of albuminuria is that found during pregnancy, more frequent with a first child or with twin pregnancy, and often associated with other symptoms of nephritis. It is probable, however, that in many instances it is a result of impeded abdominal circulation, although it is very rarely that the gravid uterus can press directly on the renal veins. In the severer cases a well-marked parenchymatous nephritis exists; but it should be distinctly borne in mind that if every instance of albuminuria in pregnancy is due to nephritis, it is certainly a form of the disease which may lead neither to severe symptoms nor to chronic disease. On the other hand, the appearance of albumen in the urine of a pregnant woman, though not necessarily calling for active interference of any kind, should always be a danger-signal, and put the physician on the lookout for other indications of actual renal disease.

In many nervous affections albumen may be found in the urine. It can be produced, as was shown long ago by Bernard, by a puncture in the floor of the fourth ventricle near to the point where a similar puncture gives rise to diabetes. Lesion of the cerebral peduncles, section, destruction, or irritation of the spinal cord, and irritation of the renal nerves are also causes of this symptom. It is by no means difficult to account for this phenomenon by the changes which take place in the [p. 41] renal circulation under influence of the vaso-motor nerves which originate or pass through the peduncles, pons, and spinal cord, although it is highly probable that similar results might follow irritation transmitted from a distance. These facts are not without practical importance, for they give rise to very considerable chances of error in diagnosis; as, for instance, where a patient suffering from severe headache, with possibly gastric symptoms, is found to have albumen and casts in his urine, which is also copious and of low specific gravity. It might not be easy to decide that such a case was not one of interstitial nephritis with symptoms far from unusual, and yet it might perfectly well be a cerebral tumor. The diagnosis would demand a thorough search for other symptoms, such as double optic neuritis on the one hand, as indicating cerebral disease and cardiac hypertrophy, with high arterial tension on the other, as connected with nephritis. A careful consideration of the order of their occurrence is also desirable.

After an epileptic attack albumen may appear in the urine for a short time, disappearing within a few hours. This occurrence might lead to an erroneous diagnosis of uræmic convulsions if the examination happened to be made shortly after a fit and not repeated at a later period. Transitory mania may perhaps be placed in the same category.

Chronic mental disease, like general paralysis of the insane, is frequently accompanied by albuminuria, and even temporary mental disturbance in a sensitive person has been known to excite the symptom.

In narcotic poisoning both by alcohol and by opium a similar state of things sometimes occurs. With alcohol, however, distinction is to be made between chronic cases, where a suspicion of parenchymatous nephritis may be fairly entertained, and acute alcoholism or delirium tremens, where the albumen appears and disappears within a few days. In a patient profoundly under the influence of opium the urine may contain not only albumen, but casts, and the diagnosis of uræmic coma is very likely to be made if nothing is known about the history—an error which might be of great consequence, as tending to discourage the efficient treatment necessary in opium-poisoning or causing the waste of time on inefficient measures.

It is obvious from what has been said that the diagnosis of albuminuria as a symptom is sufficiently simple with a little care in chemical manipulation, but that its significance is not so easy to determine in every case, since it is found in so many cases unconnected with chronic or progressive renal disease, and on the other hand may be absent while serious nephritis is going on.

Albuminuria, as defined at the beginning of this article—that is, occurring in the absence of chronic and serious renal disease—is only to be diagnosticated by the exclusion of such diseases, by careful consideration of all the symptoms present, such as changes in the quantity and specific gravity of the urine, in the force, rhythm, and size of the heart, and of the arterial tension, as well as the relation of the amount of albumen to the amount of urine and character of the sediment as indicating one or the other form of nephritis. Thus a very small amount of albumen with a highly concentrated urine is not likely to be met with in the usual forms of nephritis, but is often found in connection with valvular disease of the heart.

Treatment is but rarely directed to this symptom, since, when albumen is present in but small quantity, as usually happens, it is of little or no consequence except as an important element in diagnosis, while the few cases in which the amount is large enough to constitute a serious drain upon the system are almost exclusively cases of actual Bright's disease, and hence do not come under this head. The administration of astringents, especially tannic and gallic acids, has been found to diminish the quantity of albumen in the urine.

(A copious bibliography of this subject will be found in an article by Ellis in the Boston Medical and Surgical Journal, vol. i., 1880.)

Renal colic is the appellation of a group of symptoms caused, in by far the greater proportion of cases, by the passage of a renal calculus through the ureter, or sometimes merely its engagement in the upper extremity and impaction or subsequent falling back. Other foreign bodies large enough to cause distension and obstruction, such as clots of fibrin or portions of hydatid cysts, may give rise to the same phenomena. Most physicians, however, have seen cases where the same set of symptoms have not been followed either by the discharge of the stone per urethram or by evidence of its continued sojourn anywhere in the urinary organs. They may occur in persons of a neuralgic tendency in connection with the uric or oxalic diathesis. The conclusiveness of such cases, as proving the possibility of a purely neuralgic or spasmodic attack, must of course depend upon the carefulness and intelligence of the patient and the opportunities of the physician for observation extending over years. As it is admitted, however, that these symptoms may occur without the demonstrated presence of a calculus, it would be perhaps better nomenclature to apply the term renal colic to painful and spasmodic affections of the kidney and ureter, however caused, and to describe the passage of a calculus or other obstruction under its own name.

Calculi of various kinds, sizes, and shapes may be found in the pelvis of the kidney. They are most frequently composed of uric acid, which may exist alone or with layers of phosphates superimposed. They are usually in concentric layers, more or less irregular in shape, and of a reddish-brown color of various shades. Soft concretions of urates are occasionally noted. Oxalate of lime is the material of many small calculi, and may be the nucleus of a larger one or occur in alternate layers with uric acid. These stones are of a dark grayish-brown and are exceedingly rough and irritating. Among the most frequent constituents of renal calculi are to be found phosphates, either of lime or the triple salt of ammonia and magnesia. They may form layers with other material, or constitute alone the largest and most curiously shaped of all the renal calculi. Their surface may be smooth and almost polished, or roughened, eroded, and almost crystalline in texture.

Cystine rarely forms a renal calculus, and xanthic oxide still more rarely. Masses of fibrin resulting from renal hemorrhage are described. They are said to be of the consistency of wax, tough and elastic. Coagula of the ordinary form may also give rise to the same set of symptoms. [p. 43] On one occasion the writer saw the dilated pelvis of the kidney filled with hundreds of spherical brownish soft masses from the size of a mustard-seed to that of a pea, easily crushed in the fingers, burning with the smell of albumen, and leaving but a small amount of ash.

The size of renal calculi may vary from almost microscopic grains, which then usually take the collective name of sand or gravel, and are most commonly composed of uric acid, up to masses of some ounces in weight, completely filling a dilated pelvis.

It is doubtful in what way renal calculi originate, their constituents being always present in the urine, but rarely crystallizing out. The uric-acid infarction of new-born children can hardly be considered as accounting for any large number of cases, although it might be the basis of calculi in young children. The uric and phosphatic deposits sometimes found in the tubes of the more mature kidney may possibly, when dislodged, be a point upon which additional quantities of the same substances are deposited, but anything which delays in the pelvis or in some of its calices a concentrated urine, especially if much mucus be present, may be regarded as favoring the agglomeration of deposits. A previous pyelitis is perhaps the usual cause of phosphatic deposits. Small uric-acid calculi may sometimes be found in considerable numbers in the sulcus surrounding some of the papillæ, and of a size which could hardly afford any marked symptoms in passing down the ureter. These, if any inflammation were to arise, would form a mass with pus or mucus which might serve as a nucleus for a phosphatic calculus. These suppositions are, however, rather theoretical and fragmentary, and do not cover all the cases. Constitutional predisposition has been much discussed, though not a great deal is known about it. A gouty tendency, however, undoubtedly favors the production of uric-acid calculi.

A small renal calculus, when formed, may be the beginning of several quite different sets of phenomena. Of these, the simplest and most favorable event is its descent through the ureter into the bladder, with its subsequent expulsion with the jet of urine from the urethra. If the calculus be small and smooth, the passage through the ureter may be attended with little or no uneasiness, but if it is large enough to fill or distend the tube, and especially if the stone be irregular and rough, its descent gives rise to excessively severe symptoms. These are pain in the back at the level of the kidney, in the side and groin corresponding to the ureter affected, sometimes shooting down the thigh; with retraction of the testicle; usually no fever, but much general depression; feeble pulse, coldness and paleness of the surface, fainting, and vomiting. The beginning of the attack is usually sudden, corresponding to the entrance of the calculus into the ureter, and the pain continues without intermission, though with some remissions, until its discharge into the bladder. The pain is usually of the severest, and is described as cutting or tearing in character. It is probable that an attack may sometimes end by the calculus, which has become engaged in the ureter, falling back into the pelvis instead of advancing through the ureter. In this case the pain ceases for the time, to be perhaps subsequently renewed, or, if the stone grow larger, so that it cannot re-enter the ureter, giving place to the symptoms due to irritation of the pelvis.

The urine is usually diminished in amount until the arrival of the [p. 44] calculus at the bladder, when the fluid that has been retained is suddenly discharged with the stone. Constant attempts to pass water during the passage downward of the calculus are the consequence of sympathetic irritation of the bladder, and not of accumulation of urine therein. The urine is likely to be bloody, but is not necessarily so. The smoothness or roughness of the surface of the stone is of much importance as determining the presence of this symptom.

The DIAGNOSIS of renal colic is usually not difficult, but it may not always be readily distinguished from hepatic or intestinal colic. The suddenness of the attack and intensity of the pain, its location in the side and downward to the groin, will in most cases make the condition very characteristic.

From hepatic colic or the passage of a gall-stone the situation of the pain, which is in the latter affection naturally somewhat farther forward, the tenderness on pressure in the same region, and often the whitish color of the stools or the presence of jaundice, as well as the history of former attacks, will usually make the distinction a matter of a high degree of probability.

Intestinal colic is usually referred to the middle of the abdomen, is accompanied by constipation, while the movements of the intestines and of flatus are often distinctly perceived by the sensation of the patient or the ears of the bystanders, and on the whole the attack is less severe and the pain less intense.

As has already been stated, it is probable that symptoms closely resembling if not identical with those of the passage of a calculus may occur when the substantial cause of them does not make its appearance; and although many of these may perhaps be accounted for by the ill-success of the search or by the calculus having ceased to pursue its downward course and having become quiescent in the kidney, yet it is well for the practitioner to be prepared for an occasional disappointment in obtaining tangible proof of the nature of the attack. Time may be required to decide whether an attack is due to calculus, or is simply one of the spasmodic or neuralgic paroxysms mentioned above.

If after careful watching no stone makes its appearance, and on the other hand the pain does not continue and no pus gives evidence of pyelitis, it is highly probable that no stone is or has been present.

A true neuralgia of the kidney may undoubtedly exist. Lumbago and lumbar neuralgia may simulate renal colic, but are almost always much less severe, the pain less sharp and more dull and aching, aggravated by movement, while the sympathetic phenomena, especially those connected with the urinary apparatus, are wanting.

The diagnosis of the character of the calculus can sometimes be made with a reasonable degree of probability. If crystals of uric acid or of oxalate of lime have been or are present in considerable quantity, it is highly probable that a possible stone may consist of those substances. These crystals, however, are of little value in proving the presence of a stone.

The important diagnosis of the occlusion of a ureter by a calculus, and at the same time that of the soundness of the opposite kidney, may be made with great certainty if the urine, which has previously been purulent, bloody, or containing renal epithelium or casts, suddenly becomes [p. 45] clear coincidently with the occurrence of symptoms of the impaction of a stone.

It is not of course necessary that in every case of impaction the flow of urine from the affected side should be entirely stopped, since the calculus may be of such a shape as to permit the passage of urine past it.

The PROGNOSIS in this affection is extremely favorable, so far as the recovery from the individual attack is concerned, since if the stone is small enough to enter the ureter it will probably be successful in forcing its way through sooner or later. It is of course possible that this pain, like any other of excessive severity, might cause death, but such an occurrence must be extremely rare.

Perforation of the ureter may occur, with consequent peritonitis. A permanent plugging of the ureter from failure of the calculus to pass will give rise to changes in the kidney to be subsequently described.

In cases where only a single kidney exists, and this becomes obstructed, the symptoms of suppression of the urine may come on, including death by coma if the obstruction is not relieved. Ten days is the limit assigned by Ebstein beyond which recovery is not to be expected, but he mentions a case in which it took place after thirteen days of anuria. It must be remembered that a painful obstruction, or in fact any severe shock to one kidney, may produce a very great diminution in the amount of urine even when the other is sound. This is undoubtedly the result of nervous sympathy.

One attack of renal colic renders another very probable, either immediately or after months or years. Several hundred small calculi may follow each other in rapid succession, or, on the other hand, a single one may leave the patient in peace for a long time. Much depends on the character of the calculus, the diathesis and habits of the patient, and upon the treatment.

The subsequent history of the renal calculus belongs to surgery. After it has reached the bladder and failed to be discharged, it increases in size and is removed by lithotomy or lithotrity. The urethra, however, will usually permit to pass any stone which has come through the ureter. The patient who has just experienced relief from renal colic should be instructed to pass his water into a vessel which can be examined, and if the calculus do not soon make its appearance he should void the urine when stooping forward or even lying on his face, so as to bring the stone to the orifice of the urethra. It may catch in the urethra and demand surgical interference.

The TREATMENT of the paroxysm consists chiefly in relieving the pain, which may be partly done by the hot bath or hot applications. Opium, or preferably morphine subcutaneously, is likely to be called for in large doses. Attention has been called to the danger of morphine in sufficient dose to relieve severe pain in cases where, as in renal colic, the pain is likely to be suddenly terminated by the natural progress of the affection, thus destroying the physiological antagonism which exists between pain and morphine, and allowing the drug to exercise its full power to an extent which may be over-narcotic. The use of atropine with the morphine will mitigate to some extent its danger, without interfering with its analgesic effects.

In the milder cases ether and chloroform may be of value given by the mouth, while in excessively severe ones anæsthetics by inhalation may be called for, and their use continued for hours. This course also is not without its inconveniences. The writer has seen a case where a somewhat prolonged maniacal attack, with delusions lasting several days, came on after the long-continued use of chloroform to relieve the pain incident to the passage of a multitude of small uric-acid calculi.

The use of diluents has been suggested as hastening the passage, but there is no reason to doubt that the pressure upon the calculus is always sufficient to move it forward as rapidly as its shape and size will permit. The relaxation of the spasmodically contracted ureter is of much more importance than an excessive vis-a-tergo applied to the calculus.

The treatment of the incipient calculus in the kidney or of the condition which gives rise to it must naturally vary according to its chemical constitution, which can only be certainly determined after its discharge, but as to which an approximate opinion can be formed from a knowledge of the tendencies and diseases of the patient and from an examination of the urine.

The use of a largely-diluted solution of citrate of lithia or of acetate, citrate, or tartrate of potassium will probably prevent the deposition of uric-acid sand, and might even dissolve a small calculus, although the proofs of this having actually been done are not conclusive. If the urine be largely diluted the risk of the formation of a calculus of another kind—i.e. phosphatic—is not great. Simple water would be of great value in many cases, both as dissolving uric acid and as promoting the metamorphosis of tissue, upon some abnormality of which the accumulation of uric acid is supposed to depend. The benzoate of lithia, by the destructive action which Garrod has shown benzoic acid or its derivative hippuric acid to have upon uric acid and the solvent action of the lithia, may be of value. The phosphatic deposit, on the other hand, although beneficially influenced by a sufficient supply of water, is not so amenable to chemical influence as the other form, because it is much easier to render the urine alkaline than acid when any irritation of the urinary passages is present.

The vegetable acids, however, pass into the urine, and may render it acid if in sufficient quantity. Benzoic acid becomes hippuric acid, and can be used to make the urine more acid, as it causes very little gastric irritation even in considerable doses. Boric acid also passes into the urine, and acidifies as well as disinfects it, and might perhaps be used to promote the solution of a phosphatic stone, though the writer is unaware of any instance in which this has actually been done. It does much toward diminishing suppuration in the urinary passages, upon which phosphatic urine largely depends.

The conditions which lead to the deposit of oxalate of lime are not sufficiently well known to make the prophylaxis of this calculus easy by any chemical means, except by dilution of the urine and by a general tonic regimen with abundant exercise.

Although it is not usual for a calculus to be arrested in the ureter after having once fairly entered, this sometimes occurs, and the result is stoppage of the flow of urine upon that side, dilatation of the ureter, followed in turn by dilatation of the pelvis, and finally atrophy of the [p. 47] renal substance. This does not happen suddenly, however. The urinary passages do not rapidly dilate to any considerable extent, and their increase in calibre under pressure from within has been considered a growth rather than a distension. This condition will be treated under the head of Hydro-nephrosis.

When a calculus remains in the pelvis of the kidney without completely obstructing the flow of urine, it usually increases in size, while the resulting irritation may be the cause of fresh deposits either upon the surface of the original calculus or in the form of new concretions. In this way immense deposits of urinary salts may be formed. Thus, in a case given in detail in the second series of Boston City Hospital Reports there was found upon the one side a calculus which when perfectly clean and dry weighed 204 grammes, filling the whole dilated pelvis and sending prolongations into the calices, so that its shape was compared to that of a hippopotamus. The resemblance was made more complete by the wrinkling and roughness of the exterior. In the other kidney were several hundred calculi, from the size (and shape) of a large almond down to that of white mustard-seed. The latter were composed of two apparently distinct substances—one a reddish-brown, looking like uric acid, and the other of the color and polish of white marble; both, however, were phosphates.

The amount of local disturbance produced in the pelvis of the kidney by the presence of a foreign body seems to depend somewhat upon the character of its surface. Rough and uneven calculi, such as oxalate of lime, are apt to produce inflammation much more rapidly than smooth and polished ones, but it is seldom that any calculus remains without some pyelitis. At first only a loss of polish of the mucous membrane, with a little increase of mucus, may be observed, to which succeed roughening and suppuration with occasional fibrinous deposit. The pelvis, more or less dilated, may then contain a quantity of mucopurulent urine, with perhaps some blood, in which are concealed the stones which have given rise to this condition, and often phosphatic deposits not converted into calculi.

Pyelitis is divided by some foreign writers into catarrhal and diphtheritic—a distinction rather of degree than of kind. The mucous membrane of the pelvis may, like other mucous membranes rarely, and like serous membranes often, throw out a fibrinous exudation which takes the form of false membrane. This indicates intensity of inflammation, but has no necessary connection with diphtheria. A true diphtheritic pyelitis, that is, connected with the general disease known as diphtheria, is of course a conceivable lesion, but certainly not a common one.

The renal symptoms—especially true albuminuria, so common and of such grave import in this disease—are due to lesions of the secreting substance, and not of the pelvis. It is important, but not always easy, to decide whether there is more albumen present than is to be accounted for by the pus. The pyelitis may be acute or chronic, being [p. 48] characterized by the intensity of the attack and the rapidity with which the symptoms subside. The prospect of a given attack being acute is decided largely by the supposed cause: a small calculus passing into the ureter undoubtedly gives rise in most instances to a localized pyelitis, which subsides after the cause of irritation has disappeared. An inflammation from a larger one remaining is naturally of slower development, but may be more acute while the calculus remains rough and irritating, and partially subside when it becomes covered with a smoother coating of phosphates. The mucous membrane, however, is not likely to regain a completely healthy condition.

The mucous membrane in severe pyelitis may be deeply eroded, and even perforated, so that the contents of the pelvis escape and give rise to abscess in the perinephritic or prevertebral cellular tissue, which may be discharged through the loins with resulting cure, or the establishment of a fistula, from which issues pus and at times calculi. Among the rarer results of perforation may be mentioned gastro-nephric and duodeno-nephric fistulæ. These might be diagnosticated by the presence of food and other intestinal contents in the urine, provided that the ureter were still pervious. Vomiting of calculi and urine has been reported by the older writers.

The writer is indebted to J. R. Chadwick for references to two modern cases—one where such a fistula was diagnosticated during life;¹⁶ and another where a gastro-nephric fistula was found after death.¹⁷ In the latter case a diagnosis would have been impossible, as the kidney was disorganized and the ureter occluded. The extent to which the renal secreting substance suffers in calculous pyelitis varies considerably, and is very probably connected with the amount of pressure exercised either by the calculus itself when it attains a large size or by the urine in cases of obstruction. It is rare for either pyelitis or hydro-nephrosis to exist entirely independently.

¹⁶ Giornale di Anat. e Fis. path., iii. p. 370.

¹⁷ Marquezy, Thèse de Paris, 1856.

The changes which take place are those of atrophy. Interstitial suppurative nephritis seems to follow this form of pyelitis much less frequently than that which is due to extension upward of disease in the lower urinary passages.

Corresponding to the pressure of solid or fluid, the papillæ are eroded and the straight tubes shortened. In the cortical substance, which soon becomes diminished in thickness, the interstitial tissue is hypertrophied, dense, and hard, while the tubes become smaller or in time disappear. The Malpighian bodies are changed to dense masses of connective tissue, but are still plainly recognizable, irregularly crowded together instead of being arranged as usual in more or less symmetrical double rows. The cortex of the kidney may thus become but little more than a mere skin stretched over a large stone, with perhaps here and there a piece of renal structure recognizable and in a comparatively normal condition.

The extremer grades of hydro-nephrosis do not seem to be met with in this form of atrophy, but the pelvis is considerably dilated, while its internal capacity is also added to by the atrophy of the renal substance. The interior of the cyst thus formed usually retains distinct traces of its original division into infundibula, and may be, as already stated, almost filled by the calculus. Kidneys undergoing this process of degeneration [p. 49] often furnish up to a short time before death a normal, or even more than normal, amount of urine, and one is often astonished to find how little disturbance of elimination has been caused in cases where the true kidney-structure seems to the naked eye to have been almost entirely destroyed.

The DIAGNOSIS of a calculus remaining in the pelvis of the kidney depends chiefly on the determination of hæmaturia and pyelitis for which no other cause can be found, and upon the presence of pain in one loin. It is naturally greatly assisted by the presence or history of renal colic. An aching pain in the loins, more or less permanent, is a frequent but not invariable symptom. It may be such as to prevent the patient from standing upright, and cause him to assume an habitually stooping posture in standing or walking. A careful examination of the urine in conjunction with this symptom, especially if an unusually abnormal condition has been preceded by an exacerbation of the pain, may make the diagnosis almost certain. In the beginning of a case occasional not severe hæmaturia, with some increase of mucus or a little pus, may be all that can lead to the suspicion of calculus as the cause of pain. At a later period an increase of these symptoms, with a considerable quantity of the peculiar irregular epithelium lining the pelvis, may be observed. The latter constituent, however, can hardly be looked upon as entirely conclusive of pyelitis, since the lower urinary passages may give rise to cells of about the same form and size, and the irregularity is likely to be increased beyond recognition by the presence of inflammation. They may also undergo change of form in the urine. The presence of transparent or other casts denotes the irritation of the renal parenchyma.

The point of chief difficulty in the diagnosis of pyelitis is the determination of the origin of the pus, whether from the kidney or the bladder. Cystitis may be only partly excluded by the absence of dysuria. A point of considerable weight is the reaction of the urine, that from the kidneys being usually acid, while that from the bladder, when cystitis of much severity exists, is alkaline or rapidly becomes so. The pus coming from the kidneys is more intimately mixed with the often profuse urine than when formed in the bladder. The whole of it does not in the former case completely subside, but remains in sufficient quantity to form a turbid or opalescent mixture—the polyuric trouble of Felix Guyon, according to whom this condition in an acid urine is strongly indicative of renal as distinguished from vesical lesion. In cystitis the pus subsides in more or less distinct masses, but if the urine is alkaline, or when it becomes so, is altered to a ropy consistency usually spoken of as muco-purulent.

The procedure recommended by Thompson may be resorted to in order to determine whether the urine comes from the kidneys loaded with cellular detritus, or whether the addition is made in the bladder. This consists in washing out thoroughly the bladder with several successive quantities of water through a single catheter, until the water comes away clear and the bladder has contracted itself around the instrument, when the urine from the kidneys will for a time come through direct and comparatively uncontaminated.

In cases where the urine is alkaline in the kidney, which may happen, distinctions founded on the reaction cannot be of value, and the same [p. 50] may be said of cases where cystitis is known to exist, but where there is in addition a possibility of a renal calculus. In these some such mechanical procedure as that just described must be resorted to.

The presence of a calculus as a cause of pyelitis cannot always be demonstrated, but may be more or less strongly suspected according to the conclusiveness with which any other cause can be excluded, by the definiteness and character of the local pain, the history of renal colic, the presence of uric-acid crystals in the urine, and perhaps in some cases the results of palpation. The exploring-needle may be used, and may of course, if reaching the calculus and giving a characteristic grating feeling and sound, give absolutely positive results; but a failure to strike a stone could hardly be regarded as proof positive of its absence.

The diagnosis of renal calculus from lumbago or neuralgia should rest, in case the pain is severe enough or long-continued enough to really cause the question to arise, upon an examination of the urine.

A very important point in diagnosis, especially when the question of operative procedure arises, is that of the soundness of the other kidney. Accidental circumstances will sometimes permit this to be determined; as, for instance, when one ureter is suddenly blocked by a calculus, and at the same time the urine, which has previously been found purulent, bloody, and containing renal cells and casts, becomes clear and normal until the obstruction is removed and the abnormal ingredients reappear. Cases of exstrophied bladder, where of course it is possible easily to separate the urine of the two kidneys, may be, from their rarity, practically left out of the account. Various proposals for obtaining the separate urine of the two kidneys have been made. A small catheter has been passed into the female ureter through the dilated urethra. In the female also a finger in the vagina may succeed in temporarily blocking one ureter, while the secretion of the other alone is filling the bladder, a catheter with a bent portion at the end being used for making counter-pressure from the inside. It would probably remain doubtful in most cases how successful this manoeuvre had been in completely stopping the flow of urine, although experiments upon the dead body have been made by Polk,¹⁸ who proposes the method, with entire success. The male bladder offers greater difficulties, which are at present insurmountable. A point opposite the lower end of the ureter can, it is true, be reached with some difficulty in the rectum, and it is possible that a catheter might be so adjusted as to make counter-pressure to the finger in this position, but there could be no certainty that the occlusion was complete.

¹⁸ New York Med. Journ., Feb. 17, 1883.

The whole hand in the rectum, after Simon's method, would enable the object to be accomplished with more certainty, but this procedure has risks of its own. A staff with flattened extremity, as suggested by Weir,¹⁹ may more conveniently, though with somewhat less certainty, be used for pressing from within the rectum on the ureter where it passes over the brim of the pelvis. A compressorium consisting of an empty and folded bag, to be introduced into the bladder and there expanded by the introduction of metallic mercury, has been described and used, with the result of partly checking the flow of urine.²⁰ The proposition to pinch up the extremity of one ureter in the bladder by means of the lithotrite is still [p. 51] more open to the objection of great uncertainty, and would, to say the least, demand very special skill to obtain even a chance of success.

¹⁹ Ibid., Dec. 27, 1884.

²⁰ See Weir's article, just quoted.

None of these procedures have as yet been put to practical use, and it is doubtful whether any of them, unless we except perhaps the use of a staff in the rectum, would be justified for purely diagnostic purposes, considering the great risks involved. For the present, at least, the possibility of separating the secretion of one kidney from that of the other must be looked upon as depending chiefly upon accident, and in case of contemplated operation it is not possible to assure one's self of the integrity of the other kidney before the abdomen is opened. In many cases after opening the abdomen both kidneys may be examined before deciding upon further steps. Lawson Tait considers an exploratory incision distinctly indicated whenever abdominal disease not malignant threatens the life of the patient. The soundness of the other kidney, however, may be considered highly probable if in spite of demonstrated extensive disease of one kidney a sufficient quantity of urine with a normal amount of urea and salts continues to be formed.

The SYMPTOMS arising from a large calculus producing destruction of the renal substance, when both kidneys are affected or one is insufficient to supplement the partial or total loss of the other, may closely resemble those of diffuse nephritis, either interstitial or parenchymatous, or perhaps it would be more correct to say that these forms of nephritis are the symptoms of such a change. Thus we may have polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. The enormous calculus described above as resembling a hippopotamus had given rise to no marked symptoms until palpitation, dyspnoea, and oedema were complained of; the heart was hypertrophied.

The TREATMENT of calculi remaining in the kidney is, so far as medical means are concerned, that which has been already described, and, to say the least, is not a high degree of efficiency. Rest, diuretics, and solvents of the kind already spoken of, and narcotics, may afford relief, and in the case of quite small calculi, such as sometimes remain in the kidney even when not too large to pass through the ureter, solution is possible; but there is even less reason to suppose that large calculi can be dissolved in the kidney than that the tendency to their formation can be counteracted.

Surgery, however, offers in some cases complete relief. Two operations have been undertaken for this purpose, of which the surgical details are here inappropriate, but the indications for which may very properly be discussed from a medical point of view. These are nephrotomy or nephro-lithotomy, the removal of the stone through an incision in the pelvis or secreting substance of the kidney; and nephrectomy, or the removal of the whole gland with its contents. It is obvious that the indications for these two operations are quite different, although cases are likely to arise where it will be well to change the plan from the former to the latter during the operation.

When a sinus exists from the inflamed and perforated pelvis, or an abscess connected with the kidney has been recently opened, it may be dilated or enlarged by incision sufficiently to allow the passage of an exploring finger and forceps. The large arterial and venous branches which surround the pelvis make it safer to trust rather to dilatation or [p. 52] tearing to get through to its interior than to incision, which must, if necessary, be practised with great care. Experience has shown that an incision can be made through the renal substance without great danger, the hemorrhage being chiefly venous. This incision has been made in several cases, and where the secreting portion is much atrophied is obviously of still less consequence than in the healthy kidney. After the removal of the calculus, drainage may be established for a time until the pelvis has resumed its normal condition or the purulent discharge has diminished.

If no sinus exists, but a diagnosis has been clearly made, or even if symptoms of sufficient severity exist to justify a strong suspicion and decisive treatment, an incision may be made along the edge of the erector spinæ or the great mass of muscle attached to the spinal column and passing through the quadratus lumborum. An incision outside of the quadratus lumborum will come upon the kidney, but too far outside to make a direct access to the pelvis practicable. If it be known, however, that the cut must be made through the kidney itself, then the primary incision through the skin may be made in the exterior line, and will be less deep. Measuring along the last rib two inches from its extremity, and then at right angles an inch and a half downward and inward, will indicate a point at which a puncture will reach the renal pelvis. This may be made the central point of an incision, though it is often necessary to utilize the whole space from the last rib to the crest of the ilium. After reaching and exploring the kidney with the finger, the incision may be carried cautiously through the pelvis and enlarged by dilatation or tearing.

In order to feel the calculus it may be necessary to have counter-pressure made from the front of the abdomen in order to lift or fix the kidney, and a case has been mentioned where the finger, having failed to reach a calculus behind, was carried around and in front of the kidney with success. If the calculus is too large or too irregular to be removed whole, it may be broken and extracted piecemeal.

This lumbar method is undoubtedly to be preferred when it is known that a simple nephrotomy will be sufficient or when the more or less diseased kidney is to be treated as a cyst or abscess by drainage. It is open to the objection that if it be found desirable to change the operation into an nephrectomy, it is not quite so easy to remove a large mass in this way as by laparotomy, and the pedicle is much less accessible. The objection is not sufficient, however, to contraindicate it in many cases, for additional room can be obtained by resection of the last rib. So far as the writer is aware, laparotomy has never been performed for the simple removal of a calculus.

Nephrectomy, or removal of the kidney, may be required for various conditions, among which is to be reckoned a renal calculus with pyelitis of sufficient severity to threaten life or give rise to constant suffering; but as it is often indicated for other reasons, its consideration will be deferred.

Pyelitis may be excited by the presence of other foreign bodies, among which are coagula and parasites. An acute pyelitis may accompany an acute nephritis. Occasionally also an idiopathic pyelitis is said to be met with, but it must be difficult in such a case to exclude the presence of some irritant which has escaped observation.

Pyelitis is most frequently excited by the propagation of an inflammatory process upward from the bladder, and hence it is, with its resulting effects upon the renal structure, one of the most important complications of chronic cystitis and of surgical affections in the lower urinary passages. Anatomically, a pyelitis of this character differs but little from that of local origin described above, except that the contents of the inflamed cavity do not include deposits of urinary salts unless such have been formed secondarily. It is, however, more likely to be severe, and especially to affect the true renal substance more rapidly and more seriously, and consequently to be attended with constitutional symptoms in an acute form.

Two factors are of especial importance in determining the rate of development and severity of pyelitis supervening on affections of the urinary passages: First, the amount of obstruction which exists to the exit of the urine; and, secondly, the character of the cystitis as regards decomposition of the urine. It is obvious that whatever sends urine back into the ureters, or, what is the same thing, prevents its passage downward, will by keeping it longer in contact with the mucous membrane intensify whatever morbid action such an irritant would have, and of course a putrid or ammoniacal urine will induce inflammatory action, while a normal secretion might remain for a long time innocuous. Hence it is that we may have hydro-nephrosis and pyelitis entirely distinct from each other, but are very likely to have both combined in most cases.

It is especially in surgical affections of the urinary passages, involving, as many of them do, considerable obstruction with a more or less intense cystitis, that we meet with the combination of the two conditions. Such are enlarged prostate with its usual obstruction and frequent chronically-distended bladder, with ammoniacal, purulent, and decomposing urine, or stricture with frequent over-contraction of the bladder, forcing the urine backward as well as forward. In diseases of the female generative organs we are more likely to have the hydro-nephrosis and pyelitis as separate affections, since the compression which so frequently arises in cases of cancer or of pelvic inflammation is likely to be above the bladder, thus preventing the regurgitation of urine as well as its passage downward.

Two conditions of the renal substance seem to result from pyelitis of this kind: one, a chronic nephritis already described, with increased formation of connective tissue, atrophy of the tubes and the Malpighian bodies (the latter, however, remaining recognizable, although crowded together), and a general, and at times extreme, shrinking of the whole organ. The other is more acute, and consists in the formation of abscesses of small size, which in the medullary portion are somewhat elongated and arranged parallel to the tubes, and in the cortical portion preserve a less degree of regularity, though still having some reference to the columnar arrangement of the masses of convoluted tubes. The intervening structure is usually in a marked condition of parenchymatous degeneration. This is the so-called surgical kidney.

Whether the one or the other of these processes shall take place probably depends chiefly on the infectiousness of the cystitis or of the urine [p. 54] contained in the bladder and backing up into the kidneys, although it is not necessary that any degree of dilatation should be present for this condition to arise. Sometimes also the surgical kidney may be found when the original cystitis is not at all severe.

The DIAGNOSIS of a pyelitis supervening on a cystitis is not always easy, but may frequently be inferred, and it is possible that by careful treatment of the cystitis it may be reduced to a very low grade of severity, while the pyelitis still remains, which will permit the diagnosis to be somewhat more conclusive.

If the urine comes acid, but pus-laden, from the kidney, it will soon assume the contrary reaction in the bladder, and the pus will be changed by the ammonia into so-called muco-pus; the cells supposed to be characteristic of the pelvis of the kidney will, like the pus-cells, be so altered by the same causes, and so intermixed with similar cells from the bladder, that the distinction will be difficult or impossible. The presence of a few hyaline casts is very likely to be noticed, and indicates irritation, or perhaps a more decided implication, of the renal substance. Nothing, however, can be inferred from failure to find them. Hæmaturia is not so necessary an accompaniment of this form of pyelitis as of that arising from a mechanical irritant in the kidney. If, however, the urine does not become rapidly altered in the bladder, or if by any of the processes mentioned above the kidney urine can be obtained in a condition of comparative purity, the microscopic indications become more precise.

A dull pain and tenderness in the loins and along the course of the ureters is a symptom of value, though by no mean conclusive, and should lead to a suspicion of pyelitis. A polyuria of short duration may be a purely nervous symptom, but a persistent flow of pale urine, which fails to settle clear, and of which the turbidity is caused by pus, is due in great probability to renal disease, and if it could be shown to come in this condition from the kidney would almost certainly denote pyelitis.

The rational SYMPTOMS are of the greatest value as determining the extent and severity of the disease, although it may be impossible to distribute them with absolute exactness between the various organs involved—that is, bladder, pelvis, and renal substance.

The occurrence of a single chill, or even of several, with rapid subsidence of the fever, is not conclusive, since the ordinary urinary fever supervening on surgical operations, even so slight as passing the catheter, is not necessarily connected with renal disease.

A long-continued fever, not especially intense and of a more or less distinctly intermittent type, especially if becoming at some definite period decidedly more intense, is likely to mean the invasion of a new tract of mucous membrane, such as that of the renal pelves or even of the kidney-substance itself. Continued or remittent urinary fever is of very grave import. With this fever will appear the dry red tongue and the distressing anorexia, nausea, and vomiting, with either constipation or diarrhoea.

The TREATMENT of this form of pyelitis, so far as it differs from that of the calculous variety, depends largely upon that of the causative cystitis, though not entirely, since if it has once assumed the chronic condition it does not necessarily subside even if the cystitis be cured. The essentials of treatment may be said to be drainage from below and washing from below and from above. The measures for carrying the first of [p. 55] these indications are those which are also required for the causative cystitis, and, being chiefly surgical, a minute description of them does not come within the scope of this article. They may be simply catheterization, dilatation, divulsion or section of a stricture of the urethra, drainage of the bladder through the rectum or through the perineum.

It is not out of place, however, even in a strictly medical essay, to point out the extreme importance, not only in the way of treatment, but of prophylaxis, of securing a free exit for the urine. Even that small degree of obstruction or hindrance which leads a person to habitually put a little extra strain upon the bladder in order to expel its contents, especially if it be allowed occasionally to become dilated, may gradually lead to dilatation of the ureters, and thus make an easy passage upward for inflammatory and decomposed urine if such should afterward be formed as a consequence of cystitis by retention. The washing of the bladder from the urethra may be done with a great variety of antiseptics and acids: nitric acid in the proportion of 1 per mille may be used to change the reaction of the urine. Carbolic acid should be carefully used, from the danger of its absorption in poisonous amounts. Boric acid is a safe and quite efficient antiseptic.

Washing from above, which is evidently that which alone can directly affect the renal pelvis, must be done with such drugs as can be safely given internally, so that carbolic acid cannot be of much use in this way. Salicylic acid loses a part, but not all, of its antiseptic properties in its passage through the blood and kidneys. Boric acid passes readily into the urine, alters its reaction, and seems to have some antiseptic action. It is unirritating in the stomach, and may be given in doses of 30 centigrammes or 5 grains to the extent of 1 or 2 grammes per diem. Benzoic acid and the benzoate of sodium, ammonium, or lithium have been found to be of value in cystitis, and as they can only reach the bladder by previously passing over the pelvic mucous membrane, they should also have a good effect here. It is obvious that constitutional symptoms arising from cystitis and its consequent nephritis may demand the most attention, and should evidently be of a decidedly supporting character, the details of which have no special reference to the disease, but to the general condition. Quinine may be called for as an antipyretic.

The question of removal of a kidney for pyo-nephrosis is less likely to arise in this form than the other, since from its causation it is much more likely to be bilateral; but if under any peculiarity of anatomical arrangement, such as greater dilatation of the one ureter, it should be found that one kidney was nearly healthy while the other was in a state of pyelitis, and purulent inflammation was giving rise to serious constitutional disturbance, such an operation might be undertaken.

The operation of nephrectomy, or removal of the kidney, may be required for various lesions, most of which include more or less pyelitis, and it may be considered once for all in this place. It has now been practised more than one hundred times. A table including 100 cases is given by R. P. Harris in the American Journal of the Medical Sciences for July, 1882, and many have been recorded since.²¹ It can, of course, hardly be expected that the removal of one of a pair of vital organs, under circumstances where it is often the case that the other is not [p. 56] completely capable of carrying on the additional work, should present the same favorable array of statistics as ovariotomy; but it gives no small number of recoveries in cases which without it would undoubtedly have proved fatal, and it must be considered as having a legitimate and well-defined place among the major operations.

²¹ Weir, New York Med. Journ., Dec. 27, 1884.

There are two distinct methods, besides, of course, all the minor differences of detail called for in the individual case. The kidney may be reached from the loin by an incision along the outer edge of the erector spinæ, as already described for nephrotomy. It is to be enucleated from its capsule of fat by the fingers, and a ligature or ligatures passed around the pedicle consisting of the veins, arteries, and ureter. The kidney is then cut off, possibly leaving a little renal substance if the pedicle be short and accessible with difficulty. The wound is left partly open for drainage. This method has the advantage of avoiding the peritoneum and the handling of other abdominal organs. Its disadvantages are, in some cases, the want of room, and when undertaken for the relief of floating kidney the difficulty of finding the organ, which is likely to be at the end of a pouch formed of peritoneum. In cases of calculous pyelitis, where it may be at the beginning of the operation uncertain whether merely an incision for the removal of a stone or a total removal of a kidney of normal size may be necessary, this line of approach presents decided advantages.

The other method is by abdominal incision or laparotomy, which is usually made through the linea alba, though in a number of cases the outer edge of the rectus abdominis on the side corresponding to the organ to be removed has been taken as the guide. The steps of the operation are similar to those of ovariotomy where the pedicle is tied and returned to the abdominal cavity. This operation may be one of choice, from the greater ease with which the pedicle can be reached and the possibility of increasing the length of the incision in case of necessity for the removal of a very large tumor. In one case a crucial incision was made. When the kidney to be removed is a wandering one, and especially when a kidney has become fixed in an anomalous position, this is by far the easiest, and sometimes the only practicable, method.

Antiseptic precautions are of course to be used.

Obstruction to the discharge of urine from the body naturally produces special disorders in the secreting and discharging organs. If the obstruction exist below the neck of the bladder, as in stricture of the urethra or enlarged prostate, then the bladder is the organ primarily affected, and it may become distended, sacculated, its muscular coat hypertrophied, its mucous membrane affected with catarrhal inflammation, and its contents changed from the normal by the addition of mucus, of pus, of bacteria, or a deposit of earthy phosphates from the ammoniacal reaction produced by decomposition of the urea.

The effects of distension of the bladder will sooner or later make themselves felt in the upper urinary passages, and will then give rise to the same dilatation of the ureters and the renal pelvis as occurs when the [p. 57] obstruction is higher up. As regards the rapidity with which such changes progress, much depends upon the degree of obstruction as well as upon the amount of urine secreted. It probably, however, never takes place suddenly.

In a case which came under the observation of the writer a partial paralysis of the bladder, probably existing from infancy, had in the course of three or four years, during which large quantities of light urine were passed, given rise to dilatation of the ureters, slight dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and hypertrophy of the left ventricle.

Obstructions in the course of the ureters may exist at their opening into the bladder, which may be contracted by chronic cystitis; at a point immediately above this from compression by morbid growths, especially of the uterus, one of the most common causes of hydro-nephrosis, or even from retroflexion of the uterus when pregnant; at any point in its course by a twisting or sharp angle, as in movable kidney, although this is a much rarer accident than might be supposed; or at the brim of the pelvis, where it may be bound down by old peritoneal adhesions, and at its junction with the renal pelvis, which may be formed in such a manner as to constitute a valve, so that the urine escapes slowly or with great difficulty; or where it may be blocked by a calculus or other deposit in the cavity of the pelvis.

Obstructions by a twist or angle or by a valvular opening may, it is obvious, be temporary or intermittent in their action, and probably some arrangement of this kind was present in the cases which have been reported of relief of hydro-nephrosis by gentle massage of the abdomen.

Above the point of obstruction the ureter and pelvis are found dilated and the walls somewhat thinned. The kidney and its pelvis form a more or less irregular rounded pouch, with the tense cylindrical tube of the ureter attached to it below. The kidney itself becomes in various degrees atrophied. In some cases it retains nearly all its secreting structure, and is merely spread out upon the surface of the sac; in others, while the pelvis is but little dilated, the true kidney substance atrophies almost completely, and becomes a mere shell enclosing a cavity continuous with the pelvis and broken up by fibrous septa into subordinate cavities representing the original calices. A partial hydro-nephrosis is sometimes observed affecting only the calices.

Whether the one or the other of these conditions shall result depends, as has already been remarked, upon the completeness and suddenness of the obstruction. If the ureter of a rabbit is ligatured, the second condition—that is, atrophy of the kidney with but little dilatation—is observed. The pressure of urine soon puts a stop to further secretion, and there is no time for a slow and gradual dilatation of the pelvis and ureter. When, as is much more frequently the case in the human subject, the obstruction is more gradual or incomplete, the back pressure is for a long time insufficient to completely stop the passage of fluid through the renal capillaries, so that the pelvis and ureter, though allowing their contents to pass out only under a considerable vis-a-tergo, have time to accommodate themselves to the change, and dilate gradually, attaining sometimes enormous dimensions. The size of a hydro-nephrotic sac varies greatly: 60 liters of contents is certainly a very extreme case.

The sac is usually white and glistening, thinner at some places than at others, and lined with a smooth, pale, and atrophied mucous membrane. The muscular layer has degenerated, and perhaps partly disappeared. The liquid contained in the sac, supposing no inflammatory products to have been mingled therewith, is at first nearly identical with urine, and always contains urea. Afterward its character changes from the absorption of the urinary salts and the secretion of mucus. The contents may be dark-colored from hemorrhage or somewhat gelatinous. At a later period again they become serous and may contain cholesterin.

The description just given, as well as that of the symptoms, applies to simple hydro-nephrosis. When the sac has become inflamed we have the very common combination with pyelitis, and the affection is called pyo-nephrosis. The progress of a case of hydro-nephrosis may be in rare cases to recovery by spontaneous re-establishment of the permeability of the ureter. In others it persists a long time without giving rise to trouble. If inflammation supervene, it is obvious that fever, either simply irritative or of pyæmic character, may be a severe or even a fatal concomitant, or that in this condition a perforation may take place. When the tumor is large it may from its bulk alone produce disturbance of the circulation, dyspnoea, palpitation, and oedema of the lower limbs.

As regards the influence of this lesion on the secretion of urine, everything must depend on the amount of renal atrophy. A single kidney may undoubtedly be completely atrophied by this as by any other lesion without producing serious symptoms, since, as has been repeatedly demonstrated, the other is sufficient to carry on the work under ordinary circumstances; but if, as very frequently happens, both kidneys are involved, there must come a time when the renal substance no longer suffices, and the usual results of suppression of urine follow. It is possible, however, for extensive changes to take place in both kidneys before symptoms of insufficient secretion arise.

Hydro-nephrosis, in the entire absence of inflammatory symptoms and in the presence of conditions likely to cause it known to exist in the lower urinary passages, may be rather suspected than diagnosticated until the appearance of a tumor. Some dull pain in the loins without irradiations in any direction may exist, but so common a symptom can have but little weight in diagnosis. For an early recognition of swelling in suspected cases where nothing can be felt anteriorly, it has been recommended that the patient be placed upon the hands and knees, when the flank upon the affected side, instead of falling slightly forward and leaving a shallow depression outside of the erector spinæ, will remain full or protuberant. When an enlargement evidently connected with the kidney makes its appearance after obstruction to the passage of urine is known to exist, the diagnosis may often be very simple; but if the tumor be the first phenomenon observed, as may easily happen when the obstruction is situated high up or even at the commencement of the ureter, it may require to be distinguished from several other kinds of tumor occupying the lumbar region, or, since hydro-nephrosis of a movable or misplaced kidney sometimes takes place, from tumors of the abdomen in general. From solid malignant tumors of the kidney the feeling of comparative elasticity and fluctuation will in most cases distinguish it, though an encephaloid kidney may be so soft as to render the second of these points of [p. 59] comparatively little value. Absence of hæmaturia and of the cancerous cachexia, though not conclusive, would have much weight.

A hydatid cyst might counterfeit a hydro-nephrosis, but instances of this affection having its primary seat in the kidney are of extreme rarity. An ordinary cystic kidney is most likely to be connected with chronic diffuse interstitial nephritis, which will have made itself manifest by the usual symptoms, and is moreover unlikely to attain the dimensions of a large or even moderate hydro-nephrosis. In a thin person the ureter might, if felt dilated through the abdominal walls, clear up the diagnosis. Extreme cases of cystic kidney with comparatively little nephritis may, however, present great similarity and cause difficulty in diagnosis.

From most other tumors of the abdominal cavity those of the kidney present the important distinction that they are situated behind the peritoneum, and consequently behind the intestines, so that the surface of a renal tumor is likely to be crossed by a more or less extensive area of percussion resonance, representing usually the large intestine. This criterion is, however, not absolute, since a renal tumor may push the colon completely to one side, or, on the other hand, tumors not connected with the kidney may allow the intestine to come between themselves and the abdominal wall.

An ovarian cyst is more manifestly attached to the pelvis, and its history will disclose the fact of its having arisen from below. A gravid uterus should also, when small, be manifestly connected with the pelvis, and when larger be accompanied by the usual symptoms of pregnancy. The same may be said of extra-uterine pregnancy, which may be mentioned as among the conditions possibly giving rise to difficulties in diagnosis.

The most efficient aid to diagnosis, when it is of importance that such should be accurately made, is the aspirator-needle, which will procure a fluid more or less characteristic of the tumor into which it is thrust. In hydro-nephrosis the contents are a somewhat dilute urine, with perhaps mucus; in a solid tumor, blood, with pieces of tissue recognizable by the microscope; in a cystic tumor, fluid which is perhaps somewhat urinous, but much more changed than in simple hydro-nephrosis, and perhaps containing solid-looking bodies with concentric and radiating striation; in hydatid cysts, hooks and fragments of scolices; in ovarian cysts, the various contents, fluid and semi-fluid, but not urinous, generally found therein.

With all these means, however, cases will occasionally arise in which expert diagnosticians may be lead astray, and the difficulties become considerably greater when the dilated pelvis is that of a displaced or unusually-placed kidney. Such cases have been subjected to operation under the impression that an ovarian cyst was present.

The medical TREATMENT of hydro-nephrosis is nil. In many cases nothing is demanded by the immediate necessities of the case, and atrophy, if it be probable that only one kidney is involved, may be allowed to take place without interference. It is possible that in some instances manipulation of the tumor might relieve the obstruction and allow the tumor to subside when a slight twist or angle in the ureter is the cause. The fact of an occasional spontaneous subsidence of such a tumor shows that something of this kind has taken place.

The surgical treatment of affections of the lower urinary passages, as both a prophylactic and therapeutic measure, has already been spoken of under the head of Pyelitis. It would, however, be only in a minority of cases of pure hydro-nephrosis that the seat of obstruction could be efficiently reached by surgery.

Puncture and aspiration of the sac may very properly be resorted to, and may prove of value—in the first place, as a more or less temporary relief; and secondly, as a means of re-establishing the flow through the natural passages by the relief of pressure and consequent opening of the valvular fold, which has occasionally been observed at the junction of the ureter with the pelvis.

In a case where the obstruction is known to be irremediable, and where the hydro-nephrosis, if existing only on one side, is likely to increase, it is not desirable to make the puncture too early or to repeat it too frequently, since by allowing the pressure to increase the atrophy of the kidney will be more rapidly accomplished, and the need of frequently emptying the sac will not arise so often in the future. On the other hand, if there is a prospect of a restoration, if both kidneys are affected, or if the kidney not involved in the hydro-nephrosis is known to be seriously impaired in function, and it is desirable to preserve the secreting structure as long as possible, the punctures should be so arranged as to keep the pressure at its minimum. This must, however, be regarded as a temporary expedient. The puncture may be made either from the back or front, though in most cases the latter position, if the puncture be made with a small clean needle, would be the more convenient, and equally safe notwithstanding its traversing the peritoneum.

A hydro-nephrosis may be treated either by removal or by drainage. Both of these methods have been resorted to, and are to be employed according to the circumstances of the individual case. A pyo-nephrosis naturally demands interference more peremptorily and more promptly than a simple hydro-nephrosis, because it exposes the patient to the dangers not only of its pressure and of its tendency to destruction of the renal substance, but to those more urgent ones of purulent infection or of perforation and perinephritic abscess. Removal is to be undertaken by the ordinary rules of laparotomy. Drainage has been arranged in cases where removal was impossible or unadvisable by stitching the edges of an opened sac to the external wound. It is possible that the choice between the two operations can be made only after the primary incisions and explorations have advanced sufficiently to enable the extent of adhesions and the amount of healthy renal substance to be approximately determined.

Staples of Dubuque states, on the basis of 71 cases collected by him, that "63 per cent. of patients operated on are cured by lumbar nephrectomy, 68 per cent. by open methods in general, and up to date 100 per cent. by either lumbar incision and drainage or the creation of a fistula."

As pathological rarities only, and having but little clinical interest, may be mentioned, as occurring in the kidneys, fibroma, lipoma, [p. 61] myxoma, anginoma, and adenoma. Malignant growths originating in or involving the kidneys, sarcoma or carcinoma, are, however, more frequent and more important.

Sarcoma, primitive or secondary, of the kidney is a somewhat rare occurrence, but most frequent in children. The whole kidney may be transformed into a mass occupying its place and somewhat resembling it in form, but many times exceeding it in bulk and weight. Such a tumor may largely distend the abdominal cavity and compress its contents. Upon section we often find a substance varying greatly in consistence, from almost fibrous hardness to cavities filled with grumous material broken down by fatty degeneration and often colored by hemorrhage. In the interior may be found remains of the pyramids and cortical substance occupying their usual relative positions, but as it were distended, these portions being surrounded by a much thicker layer of purely abnormal neoplasm, probably connected with the capsule and its surrounding fat. In other cases all traces of normal form and structure may have disappeared. The microscopic structure of such a growth presents no peculiarity except so far as the arrangement of cells in the normal gland may be followed to a certain extent in the less-altered portions of the tumor. Besides this total destruction of the kidney, it is not uncommon to find nodules involving a part of one or both the organs, and more or less distinctly marked off from the healthy portion.

The origin of sarcomata involving the kidneys may be the subperitoneal cellular tissue or the neighboring organs. As a primary disease sarcoma of the kidneys is very rare.

True cancer or carcinoma of the kidney is not a common disease, and is said to have been found 12 times in 447 cases of cancer of various organs. It may be primary or secondary, and a description of the gross appearances would be essentially the same as that of the sarcoma. The tumor does not, however, usually attain so large a size, and the amount of degeneration of neighboring organs and of ulceration is greater. Calculi are often found in cancerous kidneys.

The SYMPTOMS produced by either sarcoma or carcinoma may be none at all for a time. Dull pains in the loins or referred to the hypochondrium—which, however, from their indefiniteness can have but little diagnostic importance—are among the early phenomena. Pains like nephritic colic may appear. The urine usually shows little of importance. There may be sympathetic disturbance of micturition, but unless hemorrhage occurs there is not likely to be anything in the urine discoverable by the microscope to fix the nature of the trouble. Fragments of cancer-structure in the very rare cases in which they are said to have been found would of course be conclusive, but evidence based on the alleged discovery of cancer-cells in the urine must be received with the utmost caution, recollecting the great variety of shapes and sizes assumed by the epithelium of the urinary passages. Hæmaturia is a symptom occurring in only a portion of the cases, its appearance in a given case evidently depending on the way in which the tumor invades the kidney and increases in size. If growing in such a way as to compress the ureter at an early stage before any erosion of the mucous membrane has taken place, blood, even if set free in the pelvis, cannot reach the bladder. If hæmaturia is present before any tumor can be felt, it has [p. 62] only a subordinate value, but if occurring after the discovery of such a tumor, the combination is of the highest significance. At a later period all the symptoms of compression of other abdominal viscera arise—anorexia, vomiting, jaundice, oedema, ascites, emaciation, and death.

When a tumor has become evident, it is to be diagnosticated from cystic disease and from hydro-nephrosis, with which it agrees in position and possibly in form. From the former of these its hardness and rapid growth, the invasion of other organs, and the cachexia will serve to distinguish it. Hæmaturia is not present in cystic disease. From hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated. On the right side it might not in every case be easy to distinguish a morbid growth of the kidney from one affecting the liver, and a similar difficulty might arise on the other side with the spleen. The diagnosis is to be made by a careful location of the tumor by palpation and percussion and the absence of symptoms likely to occur in connection with affections of the organs named. In children psoas abscess and degeneration of the lumbar lymphatic glands should also be considered.

A sarcoma of the kidney has been mistaken and punctured for an empyema. A sarcoma behind the kidney, pushing it forward, is very difficult to distinguish from a similar growth affecting the organ itself, especially as it is likely to give rise to signs of renal irritation discoverable by the microscope. A slight pyelitis, distinguished by pus and the absence of any cellular elements to indicate an origin at a lower point, has been observed in such a case.

The results of exploratory puncture have been before alluded to. If a piece can be brought away large enough to be examined microscopically, it may settle the diagnosis, not only as to a malignant growth, but also as to its kind.

The distinction between carcinoma and sarcoma cannot always be made during life, nor indeed, without a microscopical examination, after death. It is of importance chiefly with reference to prognosis after operation for removal of the organ. A more rapid growth, a greater tendency to invade other organs, and a more marked cachexia would speak in favor of carcinoma, while a tumor gradually attaining a very large size, and not spreading beyond the kidney and its immediate envelopes, is more likely to be a sarcoma.

There is no TREATMENT known to be of value in cancer or sarcoma of the kidney, except so far as it may diminish pain or regulate the secretions. Surgically, removal of the diseased organ is the only expedient to be thought of. Although nephrectomy has been shown to be a perfectly practicable operation, and one that is usually well borne when the other kidney is sound, it has not proved very successful with malignant growths, even as a temporary expedient. This is partly at least to be accounted for by the difficulties lying in the way of diagnosis in the earlier stages, and the reluctance with which so serious an operation would naturally be resorted to until hopes based either on the uncertainties of diagnosis or mistaken reliance on medical treatment have been given up. Cases, however, have been reported where patients have recovered from the operation, and the disease has not returned for some months. When an operation has been resorted to, the tumor has usually become too large to be extracted through the loin, and laparotomy has been the course [p. 63] pursued. According to Billroth,²² out of 33 operations for tumors of the kidney, 13 have been cured.

²² Mittheil. der Aerzte in Nieder Oesterreich, Bd. x. p. 161 et seq.

Three kinds of cysts are met with in the kidney besides those connected with the growth of parasites.

Kidneys congenitally affected with cystic degeneration contain a large number of sacs lined with a vascular membrane, among the partitions of which are found the remains of secreting structure. Both kidneys are equally affected, and are enlarged and more or less lobulated. They are occasionally so large as to constitute an obstacle to labor, and various operative procedures, even evisceration, have been required to accomplish the delivery of the foetus affected. The cysts are filled with fluid of various degrees of darkness of color from almost perfect limpidity to almost black. The fluid in the smaller cysts, at least, contains some of the urinary solids. The slighter degrees of this affection do not render a child necessarily non-viable, but with the larger some accident is likely to happen.

The formation of these cysts has been referred to an intra-uterine chronic nephritis, but another theory accounts for them by a vice of development. The fact that when the lesion is unilateral, as sometimes happens, there is apt to be a deficiency of some other part of the genito-urinary apparatus on the same side, and that several infants with cystic degeneration have been born of the same mother, speaks strongly in favor of the latter theory.

Serous cysts of later origin do not usually attain so large a size, or rather the kidney does not, on account of their smaller number. They are lined with a thinner membrane, and their contents are nearly clear, but coagulable, comprising uric acid, carbonate of lime, and cholesterin. Occasionally a single cyst attains considerable dimensions and produces by its pressure atrophy of part of the kidney. These cysts are supposed to arise in consequence of the blocking of a tube.

The third class of cysts closely resemble the first in appearance and in form, and contain more or less serous or gelatinous fluid, with albumen, blood-corpuscles, and pus, as well as the peculiar colloid bodies previously mentioned. They undoubtedly arise from the distension of tubes and of Malpighian bodies. These cysts are usually associated with chronic interstitial nephritis, and in fact they are rarely absent in cases of this kind, although the extreme degree—that is, where the cysts assume the most prominent position while the contracting nephritis falls into the background—are less common. In these latter cases the organ may be almost transformed into a mass of rounded bodies somewhat resembling a bunch of grapes.

The SYMPTOMS of the first two of these conditions—that is, of the cysts which are not connected with an active nephritis and attract attention simply as tumors—depend on the pressure they exert; and a diagnosis is to be made by a knowledge of their history and by the rules already given. The symptoms and diagnosis of the third variety are involved in those of chronic interstitial nephritis.

There is no reason to suppose that any drug has any therapeutic action on such kidneys, so far as the cysts are concerned. It should always be remembered that a kidney may contain a large number of cysts, and yet scattered portions of secreting substance enough be left to carry on the function indefinitely.

It might under some circumstances be justifiable to remove a cystic kidney on account of the pressure exercised on other organs, but as the cysts do not increase rapidly in size, punctures several times repeated, so as to empty a number of them, would in most cases prove as effectual an operation, and, what is of greater importance, would not involve the loss of any portion, even if small, of secreting structure which may be left.

The tubercles which are found in the kidney in cases of general miliary tuberculosis have usually no clinical interest, since the kidney is not, even in children, one of the points where tubercular localization is most intense, and renal tubercles are consequently but little advanced when death takes place from the extension of the disease in other organs. They present no symptoms which are perceptible among the much graver ones attending the progress of the disease elsewhere.

In the disease known as tubercle of the kidney, caseous nephritis, or nephro-phthisis, masses of caseous material are deposited in the renal parenchyma which may soften, break down, and communicate with each other and with the calices and pelvis. In some cases it is probable that the disease originates in or immediately underneath the mucous membrane of the urinary passages. This process of breaking down continues much in the same way as that of a phthisical lung, until the kidney becomes little more than a hardened, irregular, knobby shell enclosing a ragged, ulcerated cavity with thickened, pus-secreting walls and filled with pus, more or less blood, and débris of kidney-structure and tubercle. In such portions of renal substance as may remain it is not unusual to find miliary tubercle. If obstruction of the ureter exists, a pyo-nephrosis may exist in addition. Rupture into the peritoneal cavity or into the intestine has occurred.

It is probable that in this affection are included two processes, differing in pathology and etiology and to some extent in clinical history. It is probable that true tubercle may originate in the kidney as a result of either tubercle or cheesy inflammation elsewhere, as in the lungs, bodies of the vertebræ, or scrofulous glands. In this case there are no marked symptoms until the process of softening and breaking down has reached the mucous membrane of the pelvis. Besides this, renal phthisis sometimes succeeds, as a more local invasion, to tubercle or cheesy inflammation of the urinary passages, and in this case the symptoms appear simply as aggravations of those already present and depending upon ureteritis and pyelitis. Renal phthisis is seldom if ever an independent disease. It is often associated, besides the affections already named as standing in etiological relationship with it, with cheesy inflammation of the testicle, vesiculæ seminales, and much less frequently of the ovaries and Fallopian tubes.

The DIAGNOSIS of tubercle in the kidney before it has reached the pelvis is probably impossible. Pain in the back or slight albuminuria, as has been already stated, is of no diagnostic value except as pointing to some renal irritation, as to the cause of which it tells nothing. In the presence of tubercle elsewhere it might be regarded as suspicious.

After cavities have become connected with the pelvis or have extended from it, the symptoms become more marked. In the urine are to be found pus, some blood, epithelium of the urinary passages and often of the kidneys, in many cases in the form of casts; and it is claimed that masses of caseous matter as large perhaps as the head of a pin may be found, which will of course make the diagnosis almost a matter of certainty. If the urine containing such a deposit is acid, it is almost certain that the lesion is mainly in the kidney and that the bladder is but slightly if at all affected. It is also stated that the bacillus of tubercle has been found. The presence of this parasite will not only testify as to the presence of the clinical condition known as phthisis of the kidney, but will also make it sure that the affection depends upon tubercle in the strictest pathological sense, and will influence the prognosis accordingly. Inoculation of purulent sediment from the urine of a patient suffering from tuberculosis of the urinary passages has produced tubercle in the iris of the rabbit. This procedure has been suggested as a means of diagnosis as to the character of a chronic catarrh of these passages before the appearance of tubercle elsewhere.²³

²³ Ebstein, Centralblatt für die Med. Wiss., 1882, p. 918, from Deutsch. Arch. f. klin. Med., xxxi. S. 63.

If pyelitis have already been present, the change in the appearance of the urine will be less characteristic, but there may be a marked aggravation of symptoms when the contents of softened masses are added to the secretions of the mucous surface. There is likely to be much fluctuation in the quantity of débris present from day to day. Urinary fever of the hectic or subcontinued type, with anorexia, nausea, dry tongue, and diarrhoea, is present. In some cases the enlarged and irregular kidney may be felt.

The PROGNOSIS of this condition is in the highest degree unfavorable, although the finding of cicatrices in kidneys where symptoms of renal phthisis have been present suggests that it is possible for caseous masses in these organs, as well as in the lungs, to undergo absorption and healing.

The TREATMENT must be, in the first place, constitutional by tonics and reconstituents, and local by the use of such antiseptics as are eliminated through the kidney, as boric or benzoic acid or the benzoates. But little, however, is to be expected from it.

The most important parasite which is known to inhabit the kidney is the immature tapeworm of the dog, or Tænia echinococcus. It is decidedly rare in this country to meet with this affection in any part of the body, and as the kidney is not one of the organs most likely to be chosen as its habitat, the condition is not one which comes often under the observation of physicians.

It is hardly necessary to describe here the structure or contents of the hydatid cyst which forms the home of the parasite, nor its etiology, since these topics belong to general pathology, and the cyst is the same in whatever organ it may be seated. When it affects the kidney, it is usually the left—more frequently that of a man between thirty and forty years of age.

A hydatid cyst may be situated upon any part of the kidney. If small, it may never make its presence known. A larger one may give rise to those vague pains in the back found with so many diseases of the kidney and characteristic of none of them. A cyst may open in any direction, but is more likely to empty into the pelvis of the kidney. When this happens, the smaller cysts or pieces of the larger ones often enter the ureter and give rise to renal colic, and possibly, later, to a pyelitis. Other points of discharge are the intestines, the lungs, or the abdominal walls.

After a hydatid cyst has reached a certain size its presence may be recognized by palpation, but the diagnosis between it and other tumors of the kidney must be very difficult unless characteristic fragments make their appearance in the urine at the same time that the tumor diminishes in size, or unless they can be obtained by puncture. The hydatid thrill, if it can be obtained, will be an important factor in diagnosis.

The TREATMENT of this affection in the kidney presents no special points of difference from that of similar cysts in the liver; with this important exception, that besides punctures with large and small trocars, incisions, electrolysis, etc., the resource of complete extirpation still remains. Cures have been obtained by repeated punctures and subsequent suppuration, and by partial removal through the abdominal walls and subsequent drainage.

Among the parasites of the kidney it is customary to mention the Strongylus gigas, which is a worm somewhat resembling the ascaris and inhabiting the pelvis. It is not very infrequent among the Carnivora, but since only seven cases have been described in the human subject since the seventeenth century, and only a part of these are admitted as genuine by certain authors, its diagnosis, prognosis, and treatment must depend more upon theory than upon experience. The diagnosis is to be made, if at all, on the basis of a pyelitis and the discovery of the eggs of the parasite in the urine.

The Distoma hæmatobium is a parasite found chiefly in the blood-vessels, and especially those of the portal system. It is occasionally, however, met with in the veins of the kidney and also in the urinary passages. Its eggs pass into the pelvis and ureters, and there begin their development, which, however, is soon arrested, as they rapidly perish in the urine.

These parasites appear to produce either by a direct action or by the occlusion of vessels, ulceration, and hemorrhages from the urinary mucous membrane, including that of the bladder. These effects are supposed to be due to the blocking of the smaller vessels by the worms themselves. An adherent deposit consisting of masses of distoma eggs and grains of uric acid sometimes forms in grayish-yellow patches within the ureter, and gives rise to stricture, with dilatation and hydro-nephrosis above. This parasite has been considered the cause of the endemic hæmaturia of hot countries, but as cases of this affection have been carefully examined [p. 67] for the distoma with negative results, it must be considered as only one among several causes. Strongyli are said to have been found in some of the cases.

Nothing is known of an appropriate TREATMENT for the distoma. An abundant flow of urine might perhaps carry off more rapidly such individuals as have found their way into the urinary passages, and, considering the character of the deposit described above as causing stoppage of the ureter, treatment directed against the uric-acid diathesis might diminish the risk of this particular form of trouble.

Absence of the ureter may take place when one kidney is congenitally absent, though this is not an absolute rule, since the ureter may terminate above in a rounded sac. When a single kidney exists, consisting of the fusion of two, there are usually two ureters opening in the usual position. In one instance, in which only one kidney and one ureter were present, the ureter opened into the bladder on the side opposite to that upon which the kidney was situated.

Not very infrequently two ureters exist in connection with a normal kidney, remaining separate for the whole or a part of their course to the bladder. This condition is merely a sort of exaggeration of the separation between the two branches of the renal pelvis.

A few instances have been noted where a ureter or a fistula connected therewith has opened outside of the bladder at a point near the urethra. This malformation gave rise to symptoms of incontinence of urine, and in one case was remedied by operation.

Abnormal openings of the ureter into the uterus and vagina as the results of pelvic inflammations, and upon the external surface as the result of wounds, have occurred. They are more or less amenable to surgical treatment, and belong to the domain of surgery and gynecology rather than to medicine.

Occlusion of the ureter has already been spoken of in connection with the hydro-nephrosis and pyelitis to which it gives rise. This occlusion results from pressure exerted either at the vesical orifice from cystitis; a little higher up from malignant disease connected with the uterus or a fibroma surrounding the ureter; from contracting adhesions resulting from pelvic inflammation; or from sharp flexions of the tube itself, perhaps also from valvular folds of the mucous membrane. Sometimes its obliteration seems to be the result of old inflammation of the mucous membrane of the ureter itself in connection with that of the renal pelvis. In the latter case the occlusion may be complete at several points, while at others a collection of dry, cheesy, or putty-like material occupies the cavity of the ureter as well as the pelvis of the atrophied kidney.

Cancer is not known primarily to invade the ureter.

Tubercle is not infrequently found in the form of small granulations in cases of general tuberculosis, and it is possible that this deposit may be among the earlier ones; hence a chronic catarrh of the urinary passages without some known cause should be looked upon with suspicion, [p. 68] and the development of phthisis as far as possible guarded against. The presence of these small tubercles in the ureter, if none are present or no ulceration exists in the kidney, are of little or no local importance.

Inflammation of the ureter often exists in connection with cystitis and pyelitis, and in fact constitutes the means by which the higher urinary passages become gradually involved in the diseases below.

The DIAGNOSIS of this condition as a distinct disease is hardly possible, and is besides unnecessary, as the treatment to be directed thereto would be included in that called for by the more extensive and obvious inflammation of the kidney and bladder.

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS.

CHRONIC CONGESTION OF THE KIDNEY.

SYNONYMS.—Passive congestion; Cyanotic induration.

It is now generally recognized that we must separate from the other forms of kidney disease the condition of chronic congestion. Since Traube first called attention to the causation and characters of this lesion, all authors have recognized its special character, although there are still minor differences of opinion concerning it.

ETIOLOGY.—Chronic congestion of the kidney may be produced by any mechanical cause which interferes with the escape of the blood from the renal veins. Thrombi of the veins, tumors pressing on the veins, emphysema of the lungs, hydro-pneumothorax, pericarditis,—all may produce this lesion. As to how often it is produced by the pregnant uterus is still a question. But the most common cause of all is organic disease of the heart. Practically, the lesion comes under consideration as a complication of heart disease, of aneurism of the arch of the aorta, and of emphysema of the lungs.

LESIONS.—If the congestion has not existed for a long time, we find the kidneys increased in size and their weight great in proportion to their size. They are of an unnatural hardness—a hardness which can be imitated by injecting the blood-vessels of a normal kidney with water. The capsules are not adherent, the surfaces of the kidneys are smooth. Both the cortical and pyramidal portions are congested, and this congestion gives the entire organs a peculiar reddish, livid color. No lesions are found in the Malpighian bodies, tubes, stroma, or blood-vessels, except that the epithelium of the convoluted tubes may be a little swollen.

If the congestion has lasted for a longer time, the kidneys may continue to be large or they may be somewhat reduced in size; the weight remains out of proportion to the size. There are the same unnatural color and consistence. The capsules are now often slightly adherent and the surfaces of the kidneys finely nodular. In the cortex there may be patches of new connective tissue enclosing atrophied tubules, or there may be a more diffuse growth of connective tissue separating the tubes from each other. In the convoluted tubules the epithelial cells may be swollen and finely granular, or very much swollen and coarsely granular, so as to nearly fill the tubes, or flattened so that the cavities of the tubes are [p. 70] unnaturally large. The tubes may also contain cast-matter and detached and broken epithelial cells. The capsules of the Malpighian bodies may be a little thickened and the capsular endothelium swollen. In the pyramids the epithelium of the straight tubes may be granular and detached, and there is often cast-matter in the looped tubes. It is difficult to tell whether there is any real change in the veins of the kidney.

As a result of the same interference with the venous circulation, similar changes are found in other parts of the body—in the lungs, liver, spleen, stomach, small intestine, and pia mater. In all these organs there is, first, simply a venous congestion, then after a time structural changes are added. Formation of new connective tissue and of new functional cells of the particular organ, degeneration of these cells, dilatation and tortuousness of the small veins and capillaries, are regularly present. The kidney lesion, therefore, is only one of a number of lesions, all dependent on a common mechanical cause.

SYMPTOMS.—Of the persons who die with chronic congestion of the kidney, a large number present marked symptoms during life, but it is difficult to determine how largely these symptoms are due to the congestion of the kidney.

A congestion of the kidney of only a few days' duration does not seem usually to give rise to any symptoms. Even if such a congestion is prolonged to two or three weeks, as we see in some cases of hydro-pneumothorax from perforation of the lung, there may be no renal symptoms and no changes in the urine. On the other hand, it is extremely rare for organic heart disease or emphysema of the lungs to prove fatal without some disease of the kidneys.

The question is still further complicated by the fact that both in cardiac disease and emphysema there may be either chronic congestion of the kidney or chronic diffuse nephritis with the same symptoms.

After excluding the cases of cardiac hypertrophy secondary to kidney disease and the cardiac diseases with complications, I find in my casebooks 137 cases in which the patients died simply from heart disease, changes in the viscera due to the disturbance of the venous circulation, and kidney disease. Of these cases, 84 presented the lesions of chronic diffuse nephritis; 53 were in the state of chronic congestion. Of the cases of chronic diffuse nephritis, 27 were large white kidneys, 29 atrophied kidneys, 28 could not be classed as either large white or atrophied. In these cases there existed during life certain regular symptoms. There were changes in the urine, dropsy, headache, delirium, convulsions, coma, dyspnoea, vomiting, cough, hæmoptysis, loss of flesh and strength.

As regards the quantity of the urine, there was a very great variety until shortly before the patient's death; then the urine was usually diminished in amount, sometimes suppressed. A very marked decrease in the amount of urine was more constant in the cases of chronic diffuse nephritis than in those of chronic congestion. But in several cases both of chronic diffuse nephritis and of chronic congestion the patients passed from thirty to forty ounces of urine up to the time of their deaths.

Albumen and casts were often present—nearly always with the large white kidneys, not nearly as constantly with atrophied kidneys or with [p. 71] the cases of chronic congestion. In cases of chronic congestion the albumen was usually in small amount and often not accompanied with casts.

The specific gravity of the urine was apt to be low with chronic diffuse nephritis and high with chronic congestion, but there were many exceptions to this rule. With large white kidneys, atrophied kidneys, simple diffuse nephritis, and chronic congestion the specific gravity might be either normal, high, or low up to the time of death.

Transudation of the serum into the subcutaneous connective tissue and the serous cavities was a very constant symptom. It was a little more constant, and perhaps usually reached a greater degree, in the cases of chronic diffuse nephritis than in those of chronic congestion.

Headache, delirium, convulsions, and coma occurred in a moderate number of all the cases.

Dyspnoea was a very frequent symptom in all the cases.

Vomiting was also present in many cases.

Cough, with mucus or muco-purulent sputa, sometimes with hæmoptysis, was a very common symptom.

Many of the patients lost flesh and strength and became anæmic.

COURSE OF THE DISEASE.—There is a great deal of similarity in the histories of patients who suffer from the combination of cardiac and renal disease. There is first the history of the heart disease. A patient goes on for a number of years, sometimes apparently perfectly well and unconscious that his heart is diseased, sometimes more or less troubled with cough, cardiac dyspnoea, and palpitation. But after a longer or shorter time there is a marked change for the worse. Either gradually or rapidly the cough becomes worse, the dyspnoea greater, the functions of the stomach are disturbed, the patient loses flesh and strength, dropsy is developed, and finally cerebral symptoms. Some die suddenly, some with exhaustion, some with dropsy, some with dyspnoea, some comatose. It is always possible for the patient to recover from the first attack of this kind, sometimes even from a second, but eventually there comes an attack which proves fatal.

The most striking cases are those in which cardiac disease exists for many years without giving any symptoms, and then the symptoms are developed rapidly. Such persons, although they have organic disease of the heart, may seem to enjoy perfect health. They may even be able to take long walks, climb mountains, or perform laborious work. On some day they suddenly become sick. Sometimes the exciting cause of the attack is a pleurisy or a pericarditis, sometimes there is no apparent cause. The first symptom is usually dyspnoea, and this is not an ordinary cardiac dyspnoea. It is a very distressing and constant dyspnoea, which does not allow the patients to lie down. They pass days and nights sitting in a chair, fatigued, ready to sleep, but kept awake by the constant dyspnoea. Some of these patients will die at the end of a few days; others live longer and develop dropsy, anæmia, and cerebral symptoms.

When the chronic congestion of the kidneys is secondary to emphysema of the lungs, the course of affairs is much the same. The patient goes on for a number of years with the ordinary symptoms of emphysema, and then gradually or suddenly becomes worse. Dyspnoea, dropsy, [p. 72] anæmia, cerebral symptoms make their appearance, and the case terminates in the same way as the cardiac cases.

DURATION.—How long congestion of the kidneys may exist without producing symptoms it is hard to say. Certainly it may exist for a number of days without any apparent disturbance of the functions of the kidney. Whether it may exist for a time, give symptoms, and then disappear, is uncertain; the rule seems to be that the lesion, when once well established, persists up to the death of the patient.

TREATMENT.—It must be acknowledged that we can hardly hope for a cure of the lesion of the kidneys, and that even alleviation of the symptoms is not always possible. The mechanical cause of the obstruction to the venous circulation cannot be removed, and it is not only the functions of the kidneys that are disturbed, but those of the lungs, liver, spleen, stomach, and small intestine. Still, we can do something. The iodide of potassium, convallaria, caffeine, and digitalis may be of service in equalizing and strengthening the heart's action, and at the same time act as diuretics. Inhalations of the nitrite of amyl dilate the arteries and capillaries, and so unload the veins. Opium is the great remedy for the dyspnoea, although it must be given with caution. Inhalations of ether may render the patient's last days more comfortable.

BRIGHT'S DISEASE OF THE KIDNEYS.

After considering separately the condition of chronic congestion of the kidney, we find that there are a group of kidney diseases characterized by certain rational symptoms, changes in the urine, and alterations in the structure of the kidneys which are popularly known by the name of Bright's disease.

Various attempts have been made to classify these cases.

1. All the kidney lesions have been supposed to correspond to the stages of an inflammatory process—a stage of congestion, a second stage of exudation, and a third stage of contraction.

2. The disease has been divided, according to its clinical symptoms, simply into acute and chronic Bright's disease.

3. The gross appearances have been taken as a standard, and the cases are classed as examples of large white kidney, atrophied kidney, waxy kidney, etc.

4. The kidneys have been compared to mucous membranes, and authors speak of catarrhal and croupous nephritis.

5. The disease has been classified, according to the particular part of the kidney affected, into parenchymatous, tubular, glomerular, interstitial, and diffuse nephritis.

With our present knowledge of the subject it seems to me most convenient to speak of acute and chronic parenchymatous nephritis and acute and chronic diffuse nephritis. I include under the head of parenchymatous nephritis all those kidneys in which the lesions are strictly confined to the epithelial cells lining the tubules and the capsules of the [p. 73] glomeruli; under the head of diffuse nephritis, those kidneys in which the lesions involve the tubes, stroma, glomeruli, and arteries; under the head of interstitial nephritis, those kidneys in which the essential morbid changes are in the stroma.

This classification seems to me to be theoretically correct, but yet I must admit that from a clinical standpoint nearly all the cases may be conveniently arranged into the two classes of acute and chronic Bright's disease.

GENERAL SYMPTOMS OF BRIGHT'S DISEASE.—There are a certain number of symptoms common to all the varieties of Bright's disease, and it is convenient to consider them before going on to the special description of each of these varieties. These symptoms are—

Changes in the Urine.—Healthy adults usually secrete during the twenty-four hours from 40 to 50 ounces of urine of a light-yellow color, of acid reaction, of a specific gravity of 1015 to 1025, and holding in solution a number of excrementitious substances. Small amounts of albumen and of sugar seem to be, in some persons, physiological ingredients of the urine.

In most cases of Bright's disease the quantity of the urine at some time in the course of the disease deviates from the normal standard. Either the urine is increased in amount or diminished or suppressed, and in the course of the same case the urine may be at one time increased, at another diminished.

We find in healthy persons that the quantity of urine varies with the amount of fluids that are imbibed and with the condition of the skin and the bowels—that nervous influences and certain drugs will increase or diminish the amount of urine. Physiologists teach us that the amount of urine excreted varies with the degree of the blood-pressure in the renal arteries or with the rapidity with which the blood circulates through these arteries.

The urine may be very much increased or diminished in amount as the result of various morbid conditions. Scanty urine or suppression of urine is observed in the course of acute parenchymatous and acute diffuse nephritis and in the early stages of the development of the large white kidney. During the course of any case of chronic Bright's disease there are usually periods during which the urine is scanty or suppressed, especially toward the close of the disease. The kidney lesions which complicate scarlet fever, yellow fever, and cholera are often attended with suppression of urine. Any diseases accompanied by a well-marked rise of temperature are apt to be associated with a diminution in the amount of urine. Injuries to the urethra, even very slight ones, may be followed by complete suppression of urine, without any changes in the kidneys except congestion.

Marked diminution in the amount of urine occurring in the course of acute and chronic Bright's disease is usually associated with the development of cerebral symptoms—headache, restlessness, delirium, muscular twitchings, convulsions, stupor, and coma. Such a change in the amount of the urine usually lasts only a few days and may terminate fatally, or the quantity of urine will increase and the patient get better. There are, however, cases in which the suppression of urine lasts for several days without the development of uræmic symptoms. Whitelaw¹ relates a [p. 74] case of suppression of urine lasting for twenty-five days in a boy eight years old. The suppression began twelve weeks after an attack of scarlatina. There were no uræmic symptoms, and the child recovered completely.

¹ Lancet, September, 1877.

The suppression of urine due to injuries of the urethra gives rise to symptoms of great prostration—rigors, vomiting, and collapse—rather than to uræmic symptoms.

Suppression of urine is also produced by occlusion of the ureters by calculi, new growths, etc. It is a curious fact that in these cases the patients continue to live for a number of days (9 to 11, Roberts), and no uræmic symptoms are developed until a few hours before death.

The most marked examples of persistent increase in the quantity of urine are afforded by cases of diabetes mellitus and diabetes insipidus. But a daily excretion of from 70 to 100 ounces is common enough with atrophied kidneys, with large white kidneys, and with waxy kidneys.

It is exceedingly difficult to form any rational idea of the causes of the variations in the amount of urine in the course of the same case, and in different cases with similar kidney lesions. Various explanations have been attempted, ascribing these changes to the hypertrophy of the left ventricle of the heart, to changes in blood-pressure, to lesions of the arteries, to changes in the composition of the blood, to lesions in particular portions of the kidneys. But any one who tries to apply these explanations to any number of actual cases will find many difficulties.

The most evident causes of diminution in the amount of urine seem to be an abnormal condition of the circulation of the blood and either congestion or structural changes of the kidneys.

The specific gravity of the urine varies from day to day and from hour to hour in the same person, having a regular relation to the quantity of urine passed. But a long-continued deviation from the normal specific gravity is usually an evidence of disease. The highest specific gravities obtain with saccharine diabetes. Abnormally high specific gravities also often occur in the urine of patients with a high temperature, with chronic congestion of the kidneys, and in some cases of acute and chronic parenchymatous nephritis.

Low specific gravities are the rule in diabetes insipidus and with acute and chronic diffuse nephritis. In chronic diffuse nephritis the specific gravity remains low even if the quantity of urine passed is very small. When there is almost suppression of urine from occlusion of the ureters the urine that is passed is of low specific gravity.

These changes in specific gravity correspond of course to the amount of solid matter in solution in the urine, and may depend upon a change in the relative proportion of the fluid and solid constituents of the urine, or upon an absolute increase or decrease of the solid portions.

Any change in the absolute amount of solid matter excreted in the urine must depend upon changes in the composition of the blood, or in the circulation of the blood through the kidneys, or in the structure of the kidneys themselves. All these three conditions seem to exist in Bright's disease, and either together or separately may diminish the daily excretion of solid matter.

It is not necessary here to enumerate the different solid constituents of [p. 75] the urine. A change in the amount of many of them merely indicates disorders of the digestive process. Urea seems to be the most important of the excretory substances, and its quantity is regularly diminished both in acute and chronic Bright's disease.

Blood is found in the urine in a considerable number of cases of Bright's disease. If it is present in large quantities, the urine will be of a reddish color; if in smaller quantities, of a smoky color; and if in still smaller quantities, the color will not be changed. Blood is found regularly with acute diffuse nephritis, with the more severe cases of acute parenchymatous nephritis, with the exacerbations of chronic diffuse nephritis, and with suppurative nephritis. The blood seems to be derived from the tufts of vessels in the Malpighian bodies.

Albumen in the urine is a very common symptom of renal disease, but it is not confined to such cases. It is also found without any structural lesions of the kidneys.

1. There are some individuals whose urine, for many years, will contain small quantities of albumen, and yet their general health is good and they never develop any renal symptoms. In some of these cases the urine is always somewhat diminished in quantity, and in some there is also a little sugar in the urine.

2. In a large number of perfectly healthy persons small amounts of albumen will appear as a temporary condition after muscular exercise, sea-bathing, eating certain kinds of food, etc.

3. Albumen may be present in considerable amount for weeks or months in the urine of young persons, and then disappear altogether. The general health may continue good or be somewhat depreciated. After a time the albumen disappears and the patients have no further trouble.

4. General convulsions, concussion of the brain, and transfusion of blood often produce a temporary albuminuria.

Some observers believe that albumen is always present in the urine, but in such small amounts as to elude the ordinary tests.

Both physiological and pathological albuminuria is most constant and abundant after eating.

The albumen is not all of the same character. Most of it is serum-albumen, but with it is a smaller amount of globulin and sometimes of peptones. As yet the serum-albumen seems to be of the principal practical importance.

Pathological albuminuria is most constant and the albumen is most abundant with acute and chronic parenchymatous nephritis, with acute diffuse nephritis, and with the large white variety of chronic diffuse nephritis. It is least constant and least abundant with the atrophic variety of chronic diffuse nephritis, with some waxy kidneys, with interstitial nephritis, and with chronic congestion of the kidney. A variety of explanations have been given to account for the production of albumen by diseased kidneys, but none of them are very satisfactory.

The albuminuria has been ascribed to disease of the epithelium of the Malpighian bodies; to increase of the blood-pressure within the renal arteries, either with or without disease of the arterial walls; to slowing of the blood-current in the arteries; to diminution of the blood-pressure in the arteries; to congestion of the renal veins; to changes in the [p. 76] composition of the blood; to changes in the epithelium of the renal tubules.

For practical purposes it is to be remembered that large amounts of albumen regularly indicate structural changes in the kidneys; that small amounts of albumen are found without any kidney lesions, with chronic congestion of the kidney, and with chronic diffuse nephritis; that chronic diffuse nephritis may exist without albuminuria for a long time.

In many cases of kidney disease we find in the urine bodies of cylindrical shape called casts. The same bodies are also found within the tubules of diseased kidneys. Concerning the nature and origin of these bodies we are still ignorant. We only know that they are formed within the kidney tubules and are carried thence into the urine. With the exception of the blood-casts, which are composed simply of a number of blood-globules pressed together, all casts seem to be formed of a peculiar homogeneous hyaline substance to which other elements may be added. Hyaline casts are composed entirely of such material. Waxy casts are formed of the same substance, which becomes denser. Epithelial casts are made by the adhesion of epithelial cells to the surface of hyaline casts. Nucleated, granular, and fatty casts are hyaline casts with the fragments of degenerated epithelium incorporated in them.

Occasionally hyaline casts are found in the urine of healthy persons. They also occur as a temporary condition after severe muscular exertion, with typhlitis, with renal calculi, and with jaundice. Most frequently, however, they are associated with structural disease of the kidneys. Usually they are found in albuminous urine, and in proportion to the amount of albumen, but we may find casts without albumen and albumen without casts.

With chronic congestion of the kidney the casts are hyaline and few in number. With acute parenchymatous nephritis there are hyaline, granular, nucleated, and epithelial casts. With chronic parenchymatous nephritis there are hyaline, granular, and nucleated casts. With acute diffuse nephritis there are blood, epithelial, hyaline, granular, nucleated, and fatty casts. With chronic diffuse nephritis there are hyaline, waxy, granular, fatty, nucleated, and epithelial casts.

An accumulation of serum in the subcutaneous connective tissue, in the serous cavities, and in the lungs is one of the regular symptoms of Bright's disease. It usually appears first in the feet or in the face. Such dropsy is said to be due to a low specific gravity of the blood-serum; to the loss of albumen; to the scanty elimination of urine; to hydræmia plethora; or to changes in the walls of the blood-vessels.

The functions of the stomach are often disordered, either with or without the existence of chronic gastritis. Loss of appetite, nausea and vomiting, oppression after eating, etc. continue and grow worse throughout the disease. Vomiting is also a frequent concomitant of the so-called uræmic attacks.

Diarrhoea often occurs with dropsy and a scanty excretion of urine, and may then be of service to the patient, but it sometimes becomes very profuse, rebellious to treatment, and is of positive injury.

Dyspnoea associated with Bright's disease seems to occur in several different ways. It may be of mechanical origin from oedema of the lungs or from hydrothorax. It may be a purely nervous phenomenon, [p. 77] or it may depend upon a complicating heart lesion. The nervous dyspnoea seems to be allied to the uræmic vomiting and cerebral symptoms; it is often most distressing.

In the course of chronic Bright's disease disturbances of vision occur dependent on three different conditions: (1) There may be a loss of vision, usually temporary, without any discoverable lesion of the eye. (2) There may be simple neuro-retinitis. (3) There may be the characteristic nephritic retinitis with hemorrhages and fatty degeneration of the retina. These two forms of retinitis are often the first symptoms of renal disease.

Neuralgic pains, most frequently referred to some part of the head or face, but also to other parts of the body, are prominent symptoms in some cases.

The Blood.—Both in acute and chronic Bright's disease the patients often become markedly anæmic and pale. This change in the color of the patient corresponds to an alteration of the composition of the blood with the details of which we are not as yet fully acquainted. The blood seems to be thinner and more watery.

Cerebral Symptoms.—Headache, drowsiness, stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are of frequent occurrence. The headache and drowsiness may continue during the course of the disease for many months. The stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are apt to occur in attacks which last for several days, and then pass away or terminate in the death of the patient. With such cerebral symptoms are often associated dyspnoea, vomiting, increased temperature, and diminution in the excretion of urine. The entire group of symptoms is commonly known by the name of uræmia.

It is a matter of great practical importance to determine the cause of these cerebral symptoms, for otherwise there can be no rational treatment of them. It is evident that such cerebral symptoms must depend upon anatomical changes in the brain or its membranes, or upon a change in the composition of the blood which circulates through the brain, or upon the quantity of blood supplied to the brain.

It is to be remembered that such cerebral symptoms occur most frequently with the atrophic form of chronic diffuse nephritis; that they are often the first symptom of renal disease; that the same person may have several such attacks, with no cerebral symptoms during the interval; that the urine is usually, but not always, diminished during the attack, and becomes more abundant when the attack ceases; that such attacks also occur with the chronic congestion of the kidney due to cardiac disease, in pregnant women without kidney disease, and with diseased arteries and high arterial tension without kidney disease.

Anatomical changes in the brain or its membranes do exist in a considerable number of cases of chronic Bright's disease. Chronic meningitis with thickening of the pia mater and an increase of serum is quite common; anæmia and oedema of the brain-tissue are often seen. But there are a great many cases with cerebral symptoms without such lesions, and with such lesions without cerebral symptoms.

The composition of the blood is undoubtedly changed in most of the cases with cerebral symptoms. It is natural to look for such changes as [p. 78] are due to perversion of the excretory function of the kidneys, and to ascribe the cerebral symptoms to the poisoning of the blood by urea, by urea transformed into carbonate of ammonia, or by the other excretory matters which should be eliminated by the urine. Moreover, it has been demonstrated that there is a very marked increase in the amount of urea contained in the blood in such cases. On the other hand, we find that suppression of urine with accumulation of urea in the blood may exist for a long time without cerebral symptoms if the suppression is due to obstruction of the ureters; that with chronic congestion of the kidney, puerperal convulsions, and diseased arteries urea is excreted in fair amount, although cerebral symptoms exist; and that even in cases of cerebral symptoms with chronic diffuse nephritis there may be no increase of urea in the blood.

In most of the cases with cerebral symptoms, however, there are other changes in the composition of the blood, concerning the exact nature of which we are still ignorant. In most cases of chronic Bright's disease the patients become pale and the blood is thin and watery; and this is also often the case with chronic congestion of the kidney and with diseased arteries. In pregnancy the quantity of blood is said to be increased: in cholera a considerable part of the fluid portions of the blood is lost.

Changes in the amount of blood in the brain may be due to lesions of the cerebral arteries or to contraction of these arteries; to changes in the arteries in other parts of the body; to organic disease or functional disorder of the heart; or to a change in the whole amount of blood contained in the body.

It seems to me probable that the so-called uræmic symptoms are most frequently due to disturbances of the circulation of blood. Such disturbances of the circulation produce in the brain cerebral symptoms; in the lungs, dyspnoea; in the stomach, vomiting; in the kidneys, suppression of urine.

With the atrophic form of chronic diffuse nephritis we have all the conditions necessary for an irregular circulation—hypertrophy of the left ventricle, diseased arteries, and hydræmic plethora. In the other cases with cerebral symptoms there are also conditions present capable of interfering with the circulation.

PATHOLOGICAL ANATOMY.—The lesions of acute parenchymatous nephritis vary with the intensity of the inflammatory process.

(1) Mild Cases.—The kidneys are of normal size and weight. The capsules are not adherent, the surface of the kidney is smooth, the cortex is of normal color or rather pale. The epithelial cells lining the convoluted tubes are swollen and granular.

(2) More Severe Cases.—The kidneys are increased in size. The cortex is thick and whitish, with white striæ extending in to the bases of the pyramids. The epithelium of both the convoluted and straight tubes and of the Malpighian bodies is swollen and granular. There is cast matter in the tubes.

(3) The Most Severe Cases.—The increase in the size of the kidneys is still more marked. The epithelium of most of the tubes is not only swollen and granular, but is also in many tubes detached from their walls. A great deal of cast-matter, and sometimes blood, is found in the tubes. There are no changes in the stroma or in the blood-vessels of the kidneys.

ETIOLOGY.—Acute parenchymatous nephritis occurs both as a primary and secondary lesion. The idiopathic cases occur without assignable cause or after exposure to cold, and are not very common. The secondary cases are seen very frequently. They complicate a variety of other diseases. With pneumonia, typhus fever, and typhoid fever the nephritis is usually of mild type. With yellow fever and acute atrophy of the liver the nephritis is very severe. With scarlatina, diphtheria, pyæmia, peritonitis, phosphorus- and arsenic-poisoning the severity of the nephritis varies with the different cases.

SYMPTOMS.—(1) The Idiopathic Cases.—The urine is diminished in quantity and may be suppressed; its specific gravity continues nearly normal; it contains albumen, usually in large amounts, sometimes blood: in some cases very few casts are seen, in others there are large numbers of hyaline, granular, and nucleated casts.

As regards the other symptoms, it is convenient to divide the idiopathic cases into three classes. In the first class dropsy and anæmia are the most marked symptoms; with these there are loss of appetite and a depreciation in the general condition of the patient. In the second class cerebral symptoms are more prominent. There will be delirium, convulsions, stupor, coma, and with these persistent vomiting, dyspnoea, and great prostration, but no dropsy. The third class suffer from the symptoms of both the other classes. Dropsy, anæmia, loss of appetite, cerebral symptoms, vomiting, dyspnoea, and prostration are all present.

(2) The Secondary Cases.—The condition of the urine varies with the intensity of the nephritis. In the mild cases the urine is unchanged. In the more severe cases we find the urine diminished in quantity, containing albumen in varying amount, sometimes blood. Hyaline and granular casts are often present, but are not very numerous. Dropsy does not usually occur except with the parenchymatous nephritis of scarlatina. Nausea and vomiting are not infrequent, but it is often difficult to tell whether they are due to the primary disease or to the nephritis. Cerebral symptoms—convulsions, delirium, stupor, and coma—occur with the more severe cases.

DURATION.—(1) The Primary Cases.—The class of cases characterized by cerebral symptoms are of short duration. The bad cases die at the end of a few days, the milder cases recover within a few weeks. The class of cases characterized by dropsy last longer, often for several months.

(2) The Secondary Cases.—The renal symptoms continue during the course of the primary disease, and may disappear with the termination of this disease. But if the nephritis is severe the renal symptoms may continue for months after the primary disease has run its course. Albumen and casts are especially apt to persist for a long time. Such a persistence of the nephritis is especially apt to occur with scarlatina and diphtheria.

PROGNOSIS.—(1) The Primary Cases.—The cases characterized by both dropsy and cerebral symptoms usually end fatally. The cases characterized by cerebral symptoms alone are also very apt to die. The cases characterized by dropsy and anæmia often get well, but the albumen and casts may persist for a long time, and the patient may have several attacks of such a nephritis.

(2) The Secondary Cases.—Here the prognosis varies with the intensity of the nephritis. The more severe forms of the inflammation may add very much to the danger of the primary disease or may persist for a long time afterward.

TREATMENT.—(1) The Primary Cases.—In the cases characterized by dropsy the first indication is to get rid of the dropsy, and this is to be done by the methodical use of diuretics, cathartics, and diaphoretics. It will be found, however, that there is a great difference in the different cases as regards the precise time when these remedies will take effect and the dropsy decrease. Usually it is the best plan during the first few weeks of the disease to keep the patient confined to bed or to the house, and on a milk diet. From time to time efforts should be made to reduce the dropsy, but if these efforts produce no effect they should be discontinued and then tried again. In addition to the dropsy the condition of the stomach and the anæmia require treatment. For the stomach the milk diet is perhaps the most efficacious treatment. For the anæmia iron given by the mouth, combined with daily inhalations of oxygen gas, is of very great service. It is very important in these cases to guard against relapses. If possible, the patients should not return to their ordinary pursuits for a year after their apparent recovery, but should spend that time in travelling and improving their health in every possible way.

In the cases characterized by cerebral symptoms it must be confessed that treatment is not very efficacious. Diuretics have no effect, cathartics seem to do no good. Systematic sweating, the use of pilocarpine in small doses twice a day, inhalations of nitrite of amyl, the administration of chloral hydrate, caffeine, digitalis, and convallaria, and the use of fluid food in small doses, are indicated.

(2) The Secondary Cases.—While the primary disease, to which the nephritis is secondary, is running its course there is little to be done for renal symptoms. If, however, these symptoms persist after the termination of the primary disease, then the main indication is to improve the general health in every possible way.

A good deal of confusion is connected with this name, for the reason that many authors include in this one class all the large white kidneys except the waxy ones, and such kidneys present a variety of lesions. There are, however, a moderate number of cases in which the morbid changes are confined to the epithelium of the tubes and to the Malpighian bodies. All the kidneys, no matter what their gross appearance may be, which present changes in the stroma and blood-vessels, as well as in the tubes, belong properly to the class of chronic diffuse nephritis. I confine the name of chronic parenchymatous nephritis, therefore, to [p. 81] those kidneys in which the inflammatory process runs a chronic course and is confined to the epithelium of the tubes and the Malpighian bodies.

LESIONS.—The kidneys are regularly increased in size, often weighing sixteen or twenty ounces. The capsules are not adherent, the surface of the kidney is smooth. The cortex of the kidney is thick and white, with white striæ running into the bases of the pyramids; the pyramids are large and red. The epithelium of most of the tubes and of the Malpighian capsules is swollen, granular, and detached. Cast-matter is present in the tubes. There may be an increase in the number of the small cells which cover the tufts of vessels in the Malpighian bodies.

ETIOLOGY.—This form of nephritis is not very common. It may follow acute parenchymatous nephritis and chronic congestion of the kidney; it is one of the complications of chronic pulmonary phthisis, and it occurs as an idiopathic disease.

SYMPTOMS.—There is a good deal of variety in the different cases as to the quantity and specific gravity of the urine. Usually the quantity is somewhat diminished, and the specific gravity is between 1020 and 1030.

Albumen is regularly present in considerable quantity, but it may be scanty, and may even disappear altogether for a time. Hyaline and granular casts are usually present, but in small numbers.

Dropsy is a regular symptom, and often goes on to general anasarca, although the degree of the oedema varies from week to week. Occasionally a case will run its course without any dropsy.

The functions of the stomach are disturbed, and the patients suffer from loss of appetite, nausea, and vomiting.

Muscular twitchings, convulsions, stupor, and coma only occur in the very severe cases.

Dyspnoea is often produced by the dropsy, sometimes is simply a nervous phenomenon.

Bronchitis with cough and expectoration may be a complication.

DURATION.—The course of the disease is slow; it lasts for months and years. The cases vary a good deal in the number and severity of the symptoms. Some cases run their course with nothing but the changes in the urine, loss of appetite, and a moderate degree of anæmia. In other cases the dropsy is the most prominent symptom, and in still others the cerebral symptoms predominate. There may be intervals of weeks and months during which all the symptoms, except the changes in the urine, disappear and then come on again.

PROGNOSIS.—The prognosis of chronic parenchymatous nephritis is not good, but still it is not so bad as that of chronic diffuse nephritis: some of the cases recover and never have any further indications of kidney disease.

TREATMENT.—The main indications for treatment are to improve the digestion, remove the dropsy, and restore the blood to a natural condition. It is usually necessary for the patient to give up his ordinary business and if possible to pass the winter months in a warmer climate.

This form of nephritis has been described under a variety of names. It has been called acute Bright's disease, acute desquamative nephritis, acute tubular nephritis, croupous nephritis, acute albuminuria, the first stage of chronic Bright's disease, acute parenchymatous nephritis, glomerulo-nephritis, and acute interstitial nephritis.

MORBID ANATOMY.—The kidneys are increased in size, the capsules are not adherent, the surfaces are smooth. There may be an intense congestion of the entire kidney, including its pelvis, or the cortex is of an opaque white color mottled with red spots, and the pyramids are red. The tissue of the kidney is usually moist and succulent. In the tubes the epithelial cells are swollen, granular, and detached. Cast-matter and blood are found in many of the tubes. In the Malpighian bodies the cells which line the capsules are increased in size and number, sometimes to such an extent as to compress the tuft of vessels. The stroma of the kidney is infiltrated with serum, pus-cells, and blood.

ETIOLOGY.—Most of the cases of acute diffuse nephritis occur after exposure to cold or as a complication of scarlatina.

SYMPTOMS.—(1) The Idiopathic Cases.—Of these we may distinguish two sets of cases. In the first set of cases the invasion of the disease is acute. A person who has previously been usually in good health, after exposure to cold and wet will be suddenly attacked with rigors, a febrile movement, and pain in the back. There will be frequent and painful micturition, the urine being only passed a few drops at a time, or it is completely suppressed.

The urine is bloody or of a brownish smoky color. It is of low specific gravity. It contains a very large amount of albumen, numerous hyaline, granular, epithelial, and blood casts and renal epithelium, and sometimes pus-cells. Later in the disease fatty casts are also present.

The patient soon develops dropsy, the extent of which varies in the different cases. Sometimes it involves only the face, sometimes the hands and feet, or there may be general subcutaneous oedema, serum in the serous cavities, oedema of the lungs and of the glottis. The patients lose their appetite; often there are nausea and vomiting. As a rule, there are cerebral symptoms—headache, drowsiness, stupor, delirium, muscular twitchings, convulsions, and coma. In the milder cases there will be only headache and periods of drowsiness, alternating with periods of irritability. In the severe cases there will be dyspnoea, delirium, repeated convulsions, and coma.

These are the regular symptoms of the disease—symptoms varying in their number and development with the intensity of the nephritis. In the worst cases the cerebral symptoms are developed early and the patients die at the end of a few days. In other cases the symptoms continue for months, and at the end of that time terminate either in the death or recovery of the patient. Albumen and casts in the urine may persist long after all other symptoms have disappeared. In other cases the disease runs a very mild course; the patients are not at any time seriously ill, and they recover completely at the end of two or three weeks. In still other cases the acute inflammation is succeeded by [p. 83] chronic diffuse nephritis. Relapses and repeated attacks of the disease occur in some persons.

The course of the disease may be modified by complicating inflammations. Pericarditis, pleurisy, peritonitis, pneumonia, cystitis, and inflammations of the joints and muscles are not uncommon.

PROGNOSIS.—In the larger number of cases the prognosis is good. The milder cases recover after two or three weeks; more severe cases last for several months. The bad cases die at the end of a few days with cerebral symptoms, or all the symptoms continue and the patient dies at the end of several months, or they pass on to the lesions and symptoms of chronic diffuse nephritis, or they die from some complicating inflammation.

TREATMENT.—In the mild cases but little treatment is required. The patients should be kept in bed, should have a fluid diet, the bowels should be moved, and the restlessness should be quieted by the bromides, chloral hydrate, or opium. If the dropsy is a marked feature, more active purgatives are to be employed, hot-water or hot-air baths are to be used, and jaborandi may be of service. When the urine is very scanty, wet or dry cups over the region of the kidneys and hot fomentation over the same region are of much service. For the more marked cerebral symptoms treatment is not very satisfactory. As the patients get better iron and tonics are usually indicated. Great care must be used to prevent relapses. All exposure to cold must be avoided; the patient is to be kept in the house or sent to a warm climate for some time after he is apparently well. So long as albumen and casts persist in the urine the patients must not be considered well, although they may present no renal symptoms.

(2) In the second set of cases the invasion of the disease is not acute, and the symptoms may at first be so slight that the patient will hardly notice them. Usually the first symptoms are referable to the stomach. The patients lose their appetite, are troubled with nausea, and vomit occasionally. There may be a moderate amount of pain in the back, general languor, and indisposition for mental or physical work. Then they notice a change in the urine; they pass much less than before. The urine remains of its ordinary color or is a little smoky; its specific gravity is less; it contains a good deal of albumen, sometimes a little blood, and large numbers of hyaline, granular, and epithelial casts.

Dropsy makes its appearance at first in the face or feet; it may remain confined to these regions or extend to the rest of the body and become a general dropsy. The cerebral symptoms are slight—headache, irritability, drowsiness. The blood becomes thin and watery and the patients unnaturally pale. There may be dyspnoea either dropsical or nervous. The symptoms continue for weeks or months.

PROGNOSIS.—These cases, as a rule, do well, and recover at the end of a few weeks or months. But in some the symptoms continue and the patients go on to have chronic diffuse nephritis.

TREATMENT.—In the mild cases it is only necessary to keep the patients in the house, put them on a milk diet, keep the bowels open, and after a time give them iron. If the dropsy is more marked, we must try to get rid of it by cathartics, sweating, and diuretics. If the anæmia is marked, inhalations of oxygen must be combined with the [p. 84] administration of iron. In these cases also it is important to guard against relapses.

Most cases of scarlatina are complicated either by acute parenchymatous or diffuse nephritis. Some confusion has arisen from the attempt to describe scarlatinal nephritis as if it was one disease, while really there are two anatomical forms of nephritis which occur as complications of scarlatina. When we try to fix the time during the course of scarlatina when the kidney lesions are developed, we meet with the same difficulty—that statistics have been compiled on the supposition that there is only one form of scarlatinal nephritis. If we take all the cases together, we find that kidney symptoms may be developed from the very first day of scarlet fever to the end of the ninth week—that the largest number of cases develop symptoms on the fourteenth day, the next largest on the twenty-first day, and next to this on the seventh day (Tripe). It seems probable that parenchymatous nephritis belongs to the first weeks of the disease, diffuse nephritis to the later weeks.

SYMPTOMS.—The urine is diminished in amount, and may be suppressed. Its specific gravity is low, its color is bloody or smoky; it contains blood, large amounts of albumen, and numerous hyaline, granular, and epithelial casts.

The patients lose their appetites, and suffer from nausea and occasional vomiting. There is a febrile movement, usually not very severe, pain in the back and limbs. They become unnaturally peevish and irritable and complain of headache, the irritability alternating with drowsiness. In the more severe cases delirium, convulsions, and coma are developed. The color of the patients is changed, the skin and mucous membranes becoming pale. Dropsy is developed—sometimes only a little puffiness of the face, hands, or feet, sometimes general anasarca. Synovitis and muscular rheumatism are frequent complications, while pericarditis, pleurisy, and pneumonia occur less often.

The disease runs its course within a moderate length of time, although the changes in the urine often persist long after all the other symptoms have disappeared. The ordinary cases recover after from one to three weeks; the very bad cases die at the end of a few days. In a few cases the symptoms continue and the patient develops chronic diffuse nephritis.

PROGNOSIS.—The prognosis is quite good. The larger number of the cases recover completely. In the more severe cases, however, the patients may die with cerebral symptoms, or all the symptoms will continue and the patient die after several weeks.

TREATMENT.—The indications for treatment are the same as in the idiopathic form of acute diffuse nephritis.

This is the most common and the most important form of kidney disease. It has been described under a variety of names—chronic Bright's [p. 85] disease, croupous, catarrhal, interstitial, tubal, and parenchymatous nephritis; fatty, granular, atrophied, cirrhotic, and large white kidney.

Although all patients with chronic diffuse nephritis suffer from essentially the same symptoms, yet there is a good deal of difference as to the way in which these symptoms are developed and as to the predominance of some symptoms over others. Although the minute lesions of the kidneys are essentially the same in all cases, yet the gross appearance varies a good deal. There is, therefore, a practical convenience in distinguishing certain varieties of chronic diffuse nephritis. Of late years, however, the tendency to do this has been carried very far, especially as regards the atrophic form of chronic diffuse nephritis. Writers speak as if there were only two forms of chronic diffuse nephritis—the large white kidneys and the atrophied kidneys—and as if each of these had a distinct clinical history. More than this, the changes in the blood-vessels and in the circulation which so often complicate chronic Bright's disease have attracted so much attention that the arterial changes have been regarded as the most important part of the disease, so that we even hear of Bright's disease without any lesion of the kidneys. It is also customary to describe separately those kidneys of which the arteries have undergone waxy infiltrations.

I do not think that either the lesions or the symptoms are such as to justify such views. After separating the true cases of chronic parenchymatous nephritis—cases in which only the epithelium of the tubes and of the Malpighian capsules is changed—all the other kidneys of chronic Bright's disease present essentially the same lesions and give rise to the same symptoms.

We can indeed often tell during the life of the patient whether he has large white or atrophied or waxy kidneys, but in many cases such a diagnosis is impossible.

MORBID ANATOMY.—There is good deal of variety in the gross appearances and size of the kidneys. Most numerous are the so-called atrophied kidneys. These kidneys are usually diminished in weight, the kidneys weighing together three or four ounces, but often they weigh up to ten or twelve ounces. The capsules are adherent, and when they are stripped off portions of the kidney-tissue adhere to them. After stripping off the capsules the surface of the kidney is left finely or coarsely nodular. The cortex is thinned and of a red or grayish mottled color; the pyramids are small or of normal size, sometimes studded with small white concretions of urate of soda. There are often small cysts both in the cortex and pyramids.

Next in frequency come the so-called large white kidneys. Of these a certain number are not examples of chronic diffuse nephritis at all, but of acute or chronic parenchymatous nephritis. Of the large white kidneys which belong to chronic diffuse nephritis we can distinguish three varieties—the simple large white, the waxy large white, and the large white of cardiac disease.

The gross appearance of the kidneys is very much the same whether they are or are not the seat of waxy infiltrations. They are increased in size, weighing together from sixteen to twenty ounces. The capsules are not adherent; the surfaces of the kidneys are smooth and pale, often mottled by large stellate veins. The cortex is thickened, of white or [p. 86] white mottled with red, or yellow or grayish color. In the very waxy kidneys the gray or white color has a semi-translucent appearance. The pyramids are large and red, contrasting with the cortex. We find some kidneys of the same color and general appearance as large white kidneys, but with atrophied cortex and adherent capsules.

The large white kidneys due to cardiac disease are increased in size and weight. The capsules are not adherent, the surfaces are smooth. The cortex is thickened and of a peculiar pinkish-white color; the cortical striæ may still be visible. The pyramids are of a somewhat darker red than the cortex. The whole coloring is entirely different from that of chronic congestion of the kidneys, and the texture, although firm, is not of the stony hardness of that lesion.

Besides the atrophied and the large white kidneys, there are a large number of kidneys which are not diminished in weight and which do not resemble either the large white or the atrophied kidneys. These kidneys weigh together from nine to twenty ounces. The capsules are sometimes adherent, sometimes not. The surface of the cortex may look like that of a normal kidney or be finely or coarsely nodular. The cortex is of normal thickness or thickened; it is of a variety of colors. Sometimes it is not to be distinguished from a normal kidney, or it may be gray or gray mottled with yellow or red or white, or of a diffuse red color. The pyramids are of natural size or large, of red or pale color. I do not know a good name for these kidneys, but their appearance differs altogether from that of the large white or atrophied kidneys.

Still another class may be made of those kidneys which pass from the condition of chronic congestion into that of chronic diffuse nephritis. These kidneys retain the color and the hardness of chronic congestion, but the capsules are adherent, the surfaces finely nodular, and the cortex irregular.

Minute Lesions.—Nearly all the component parts of the kidneys undergo morbid changes. In the tubes the epithelial cells undergo marked changes, especially in the cortex. The epithelial cells are swollen, finely or coarsely granular, or fatty or completely disintegrated, or the seat of hyaline degeneration. They may be detached from the walls of the tubes, or sometimes they are in place, but flattened. The tubes may contain cast-matter, blood, pus-cells, small polygonal cells. The calibre of the tubes is often changed. The tubes may be dilated either in the form of cylindrical or sacculated dilatations; the latter often form cysts of considerable size. Such dilatations regularly affect groups of tubes, as if they were due to obstruction of the large tubes in the pyramids. In other cases the tubes are denuded of epithelium, become smaller, fall together, and look like connective tissue. The membranous wall of the tubules may be thickened or it may undergo waxy degeneration.

The Malpighian bodies are changed. Their capsules may be thickened, contracted, or dilated. The flat cells which line the capsules are increased in size, sometimes in number. The capillary tuft may be dilated or its walls may be thickened; it may be completely obliterated and changed into a ball of fibrous tissue, or it may be the seat of waxy infiltration. Often the Malpighian bodies are much closer together than they are in a normal kidney.

In the stroma, especially in the cortex, there is a new growth of connective tissue. This new connective tissue is in patches of varying size, surrounds Malpighian bodies and blood-vessels, and may be continuous with the capsule of the kidneys.

The arteries are frequently changed. There is a general thickening of all their coats, usually a simple sclerotic thickening.

All these changes, when they have once begun in the kidneys, have a natural tendency to go on and become more and more marked. There is much difference in different kidneys in the predominance of one or more of these changes over others. In one kidney the changes in the tubes will be most marked, in another those in the Malpighian bodies, in another those in the stroma. But there seems no good reason for believing that these changes are developed successively—that there is first a lesion of the stroma, then a lesion of the tubes, or first a lesion of the tubes, and then of the stroma. The earliest examples of chronic diffuse nephritis, obtained from persons dying accidentally of other diseases, show that the lesions are diffuse at the very outset.

In the atrophied kidneys the new connective tissue is in patches. In the earliest stages of the lesion these patches are confined to the region close to the capsule; later in the disease the whole thickness of the cortex is involved. The tubes embraced within these areas of new connective tissue are atrophied and collapsed. The rest of the cortex-tubes exhibit marked degenerative changes in the epithelium, and often cast-matter. Dilatation of the tubes is very common. The Malpighian bodies are usually much altered—the capsules thickened, the tufts atrophied. Occasionally there is waxy degeneration of the Malpighian tufts. There are some atrophied kidneys in which the changes in the stroma are very slight.

In the large white kidneys there is much variety. In some of them one is surprised to find how slight the minute lesions are. In others the principal changes are in the epithelium of the tubes, so that it may be difficult to tell whether they are examples of parenchymatous or of diffuse nephritis. In many others there is a very marked production of new connective tissue either in patches or diffuse. The large white kidneys which are waxy differ from the others only in the addition of the waxy degeneration of the Malpighian tufts and arteries to the other lesions. I have no knowledge of any kidneys in which waxy degeneration exists without the presence of the regular lesions of diffuse nephritis.

In the large white kidneys of cardiac disease the large thickened arteries are a prominent feature.

ETIOLOGY.—Chronic diffuse nephritis is more common in males than in females. It is said to occur at nearly all ages; the maximum liability is in persons between the ages of forty-five and fifty-five years. The disease prevails principally in temperate climates; in New York it is of very common occurrence. Persons who are habitually intemperate, who have constitutional syphilis, who suffer from privation, are very liable to the disease. There is a disposition in certain families to the development of the disease. Not that it is, strictly speaking, hereditary, but there will be a number of examples of it in the same family. A number of brothers and sisters or of more distant relatives in the same family will [p. 88] at different times suffer from the disease. There seems also to be some sort of relationship between chronic diffuse nephritis and pulmonary phthisis. Not only does nephritis complicate phthisis, but in the same family some members have phthisis, others nephritis.

Acute diffuse nephritis and chronic congestion of the kidney may be followed by chronic diffuse nephritis.

Heart disease, emphysema, phthisis, cirrhosis of the liver, chronic inflammation of the bones and joints, gout, rheumatism, and chronic arteritis, are often complicated by the disease.

SYMPTOMS.—It is sometimes impossible to tell which of the varieties of chronic nephritis exists in a given patient, but in other cases the diagnosis can be made. If, however, we correct our clinical diagnosis by post-mortem observations, we find that we may be mistaken about even the (apparently) most characteristic cases. There is more difference in the earlier stages of these cases than in the later ones. In hospitals, where the patients come to die, all the cases of chronic diffuse nephritis are a good deal alike.

The atrophied kidneys present us with a very great variety of clinical histories. It is impossible to describe all the different ways in which the disease may begin and run its course, but we may enumerate some of them:

1. Persons may have atrophied kidneys for a number of years without any renal symptoms; they die from accident or from some other disease, and at the autopsy the kidneys are found to be far advanced in disease.

2. The disease of the kidneys exists, but it gives no symptoms until the patient suffers from some severe accident or is attacked by some acute disease, and then the renal symptoms are suddenly developed.

3. The patient will very slowly lose flesh and strength, the appetite will be capricious, either mental or bodily exertion is an effort, but there are no positive symptoms, except that the urine is of rather low specific gravity, and in the evening urine there will be occasionally a trace of albumen. In this condition these patients may continue for years. They may improve very much under treatment, and finally die from some other disease without ever developing any renal symptoms. Other cases, however, do after a time develop all the characteristic symptoms.

4. For several months the patients do not feel well: the appetite is lost, there is nausea and occasional vomiting, they become pale and anæmic, do not sleep well at night, are irritable and easily worried, are troubled with headache. The urine continues normal or is of low specific gravity or contains a little albumen. Then they suddenly become worse and the regular symptoms are developed.

5. In other cases headache or sleeplessness or dyspnoea or loss of vision may precede all the other symptoms by several weeks.

6. Severe neuralgic pains in different parts of the body, coming on in attacks and very rebellious to treatment, may precede the other symptoms for months.

7. The very first symptoms may be an attack of convulsions. The patient may have been apparently in good health, and while sitting quietly in a room or lying in bed will be seized with a general convulsion. In some of these cases the convulsions are repeated; between them the patient remains partly or completely unconscious, and dies in [p. 89] a few days. In other cases one or two convulsions are followed by the development of the other symptoms of the disease.

8. With valvular disease of the heart and atrophied kidneys we may get the same combination of symptoms which I have described in the section on chronic congestion of the kidneys.

9. The patient may first notice that he is passing too much urine. This urine is of low specific gravity, and occasionally contains a little albumen and hyaline casts. Then the health begins to fail: there are dyspeptic symptoms, headache, occasional oedema of the legs. From time to time the patient becomes worse; the urine is diminished in quantity, the headache is more marked; he cannot sleep, he has dyspnoea, he vomits, the muscles of the face twitch, or there may be general convulsions or delirium or partial or complete coma. Such attacks may last for days or weeks, and then either terminate fatally, or the patient gets better and may be able to return to his ordinary business for a time. In this way the same patient may suffer from a number of such attacks.

10. In some cases dropsy is a prominent feature from the very first and goes on to general anasarca.

The following history would answer for many of the cases of atrophied kidneys: A woman, thirty-eight years old, was in good health, fat and robust, until January, 1873. Then she caught cold; her feet became oedematous; she had headache, pain in the back, vomiting; her eyesight was impaired; her urine was increased in amount and passed more frequently. She continued in this condition and losing flesh and strength until June, 1873, when she came into the hospital. At that time the urine was diminished to eighteen ounces in twenty-four hours; it contained a considerable amount of albumen and hyaline and granular casts. Her color was still good. There was moderate oedema of the feet. After this the urine increased in amount to eighty ounces daily—specific gravity 1002, albumen diminished. The dropsy disappeared, and the patient left the hospital feeling very well on September 29, 1873. In December, 1873, she returned to the hospital with nausea and vomiting, dyspnoea, cough, no dropsy; urine 80 to 100 ounces daily. She had become feeble and anæmic, and there was well-marked hypertrophy of the left ventricle of the heart. She again improved, and was discharged after two weeks. In March, 1874, she returned. The urine was now scanty, and she was troubled with vomiting, dyspnoea, cough, sleeplessness, slight convulsive movements of the voluntary muscles, no dropsy. By the end of April she was again feeling well, and left the hospital. In June, 1874, she returned with all the old symptoms and oedema of the legs. On July 20 she had two general convulsions. After this she again improved for a time, but in September all the symptoms returned, and she was delirious a good deal of the time. Urine 40 to 50 ounces daily, specific gravity 1005, moderate amount of albumen, no casts. By the end of September she again was sleepless, had several slight convulsions, and died October 2. The kidneys were a typical picture of the red atrophied kidneys with thickened arteries.

We may say in general that with the atrophied kidneys the so-called uræmic symptoms—headache, sleeplessness, delirium, convulsions, coma, dyspnoea—are very apt to occur, and that early in the disease. The urine is regularly increased in amount and of low specific gravity, except [p. 90] during the uræmic attacks, when it is diminished; but the uræmic attacks may come on while the patient is passing 30 to 40 ounces of urine of a specific gravity of 1020. Albumen is regularly present only in small amounts, and not constantly, but exceptionally there will be a good deal. Casts are hyaline, not constant, but exceptionally in considerable numbers. Dropsy may be absent throughout the disease, or a little oedema of the face and legs may come and go, or there may be marked general anasarca. Not unfrequently during the uræmic attacks the temperature runs up to 99° to 100°. Hypertrophy of the left ventricle of the heart is a frequent complication, but I have not found it in as large a proportion of cases in New York as it is described by English and German writers.

The duration of the disease is very uncertain. In fact, we seldom know what its real duration is, for the reason that there is no necessary relation between the development of the kidney lesions and the appearance of the symptoms. After the appearance of the kidney symptoms some of the patients die in a few days; others go on for months and years with either constant or intermittent symptoms.

The Large White Kidney.—These cases are more readily recognized than the cases of atrophied kidneys, for the reason that dropsy is more constant and occurs earlier in the disease, and that albumen is regularly present in the urine.

In many of the cases oedema of the face or feet is the first symptom. Often the patients will tell you that it is the only symptom, and that they would feel perfectly well if they could only get rid of the swelling. Closer questioning, however, will usually show that the functions of the stomach are disturbed, that there is occasional headache, that the eyesight is impaired, and that the patient has been passing less urine.

In some cases impairment of vision is the first symptom that attracts the attention of the patient. In some cases disturbances of digestion, or neuralgic pains, or gradual loss of health and strength, or a diminished amount of urine, will be the first symptoms, and may last for weeks before other symptoms are developed. Or the patient may be attacked suddenly as if with acute diffuse nephritis. The urine will contain blood and numerous casts; the dropsy and the other symptoms are rapidly developed. In some of the cases complicated with cardiac disease the history will be that of heart disease rather than that of kidney disease.

When the disease is fairly established the dropsy is always a prominent symptom, often very distressing to the patient. In some patients when once developed it continues to increase steadily up to the time of their death; in others the dropsy comes and goes, sometimes disappearing altogether for weeks and months.

The functions of the stomach are usually disturbed, the patients lose appetite, have nausea and vomiting, oppression after eating, etc. But some persons retain a good appetite for a long time, even though they vomit occasionally. Diarrhoea is often developed; sometimes only enough to carry off part of the dropsy, sometimes profuse, persistent, and uncontrollable. The blood becomes thin and watery, and the skin, the mucous membranes, and the sclerotic assume an unnatural white appearance. The patients lose both mental and bodily vigor, and become less and less fit to carry on their ordinary occupations.

Of the uræmic symptoms, headache and dyspnoea occur at any time in [p. 91] the course of the disease, but convulsions, delirium, and coma belong to its later stages.

The urine is regularly first diminished and afterward increased, but the quantity often varies very much from day to day. The specific gravity is regularly low, albumen is constant and in large amount; casts are usually present in considerable numbers, especially during the exacerbations of the disease, when hyaline, granular, and epithelial casts are found, but in other cases hardly any casts can be found. Blood is sometimes present in the urine during the exacerbations of the nephritis.

The disease varies much in its course and duration. Some cases progress steadily, getting worse from day to day, and die at the end of a few months from the time at which the first symptoms appeared. Other persons go on living for years, the symptoms improving or disappearing for weeks or months, and then coming again. Finally, the patients die—some in an exacerbation of the disease with bloody urine and acute symptoms; some with excessive dropsy; some with delirium, convulsions, and coma; some suddenly; some with complicating disease.

The following histories may serve to illustrate the course of the disease:

A male, thirty years old, of intemperate habits, for one year before his death noticed that his urine was sometimes scanty and high-colored, sometimes abundant and pale, and that his eyesight became impaired. For four months there was occasional nausea and vomiting. For six weeks there was occasional headache, dyspnoea, and oedema of the feet, the urine more scanty. For nine days before death he passed from one to four ounces of urine daily, specific gravity 1014, albumen 50 per cent., numerous hyaline, granular, and epithelial casts. The man was now feeble and anæmic, had headache, was drowsy, vomited occasionally, had twitching of muscles of face; continued drowsy, but with his mental faculties quite clear, so that he was able to transact some business an hour before he died. Death was sudden while lying quietly in bed. The kidneys weighed twenty ounces, surfaces smooth, cortex thick and white, pyramids large and red. The Malpighian bodies showed a marked increase in the size and number of the capsule cells; the cortex-tubes were dilated; in some the epithelium was flattened, in others swollen, granular, and detached; in the pyramid-tubes the epithelium was swollen and detached; there was cast-matter in some of the tubes, both in the cortex and pyramids; there was a very extensive new growth of new connective tissue in the cortex, partly diffuse, partly in patches.

A male, forty-one years old, six years before his death caught cold while bathing, and suffered with dropsy, a febrile movement, prostration, scanty urine which contained albumen, blood, and numerous casts. After a few weeks all the symptoms disappeared and he returned to his business. He continued to enjoy good health for about eighteen months; then in the winter the urine became scanty and contained blood, albumen, and numerous casts. General anasarca was rapidly developed. The dropsy lasted for six months, and then disappeared, but the urine from that time always contained varying amounts of albumen and casts. For nearly two years after this time the man continued to feel well, was actively engaged in business, had no dropsy, but the urine still contained [p. 92] casts and albumen. Then the dropsy returned again, and was very considerable. But the appetite and digestion continued good, there was no headache, the patient was intelligent and cheerful. The dropsy, a moderate diarrhoea, and the change in the urine were the only symptoms. In two months the dropsy had again disappeared and the patient returned to his work. After this time, however, the patient was never as well: a little oedema of the legs was present much of the time; he became gradually more and more anæmic and feeble, and finally died with marked dropsy and anæmia about six years from the time of the first appearance of kidney symptoms.

The Large White Kidneys with Waxy Infiltration.—It is well known that in certain persons a peculiar morbid change takes place in the viscera. The walls of the blood-vessels and some of the glandular cells become infiltrated with a peculiar translucent substance. This morbid change is commonly known by the name of waxy or amyloid infiltration. It is known that such an infiltration occurs regularly in persons who have chronic inflammations of the bones and joints, constitutional syphilis, and pulmonary phthisis. It is also known that this new substance is colored in a special way by iodine and some of the aniline colors. Beyond this we have no real knowledge of what the substance is or how it is produced.

In other parts of the body the waxy infiltration can hardly be said to produce any local symptoms. If one has a waxy liver or spleen, these organs may give the physical evidences of their enlargement, but that is all. We look upon such patients as suffering from some general changes concerning the nature of which we are ignorant, but not as suffering simply from disease of the liver or spleen.

It seems at first sight natural to think of waxy kidneys in the same way—not as examples of kidney disease, but as parts of a general morbid condition. This view has been adopted by most authors. They describe the waxy kidneys as something different from the other forms of nephritis. But really this is an error. In the vast majority of cases the waxy kidneys are simply a variety of chronic diffuse nephritis. It is possible (Cohnheim) to have waxy infiltration of the Malpighian bodies without other lesion of the kidney, but this is a rare exception. The rule is that we find the ordinary lesions of chronic diffuse nephritis; and, more than this, we often find the nephritic lesions very much farther advanced than the waxy infiltration. The association of the lesions is not at all such as to give the idea that the waxy infiltration is produced first and the other lesions afterward. It is also not uncommon to find waxy infiltration of the Malpighian tufts without similar changes in any other part of the body.

The type of the nephritis varies in different cases. Most of the kidneys resemble the large white kidneys, some the atrophied, some those which are neither large white nor atrophied. The clinical history varies in the same way, and is that of a large white or atrophied kidney, as the case may be. The only difference is that in some patients (not in the majority) there is a very large amount of urine passed of low specific gravity.

As a matter of fact, in most cases of waxy kidneys we simply make the diagnosis of chronic diffuse nephritis, and if we add to this that of [p. 93] waxy infiltration it is because the patients have had syphilis or bone or joint disease. Even in this way we are often enough deceived, as in the following case:

A woman, twenty-six years old, came into the hospital on January 25, 1876. She had contracted syphilis five years before. For two years she had suffered from dyspnoea and frontal headache. For seven months there was occasional oedema of the face and feet. At the time of her admission to the hospital she was very pale and anæmic; the urine was of a specific gravity of 1008, abundant, and contained no albumen or casts. The liver was very large and smooth. It was supposed that she had waxy liver and kidneys. She grew steadily weaker, continued to have a little oedema, vomited occasionally, developed the physical signs of bronchitis, with a temperature of 104° Fahr., and died on April 3, 1876. At the autopsy the aortic valves were found thin and insufficient. There was muco-pus in both the large and small bronchi, with irregular spots of red hepatization in the lung. The liver and spleen were large and waxy. The kidneys weighed together four ounces, and presented the ordinary lesions of atrophied kidneys, with only commencing waxy infiltrations of a few of the Malpighian tufts.

The Large White Kidney of Heart Disease.—This variety of chronic diffuse nephritis seems to be secondary to organic disease of the heart, and, less frequently, to emphysema of the lungs. The urine is diminished in amount, sometimes suppressed; it is dark-colored, the specific gravity varies between 1010 and 1030; albumen is absent altogether or present in small amount; hyaline and granular casts may be present, but are not constant. Dropsy may be absent or moderate or excessive. Cerebral symptoms—vomiting, cough, dyspnoea, anæmia—are usually present. Some of the patients die suddenly, some with dropsy, some with urgent dyspnoea.

The examples of chronic diffuse nephritis which are neither atrophied kidneys nor large white kidneys are numerous. Some of them give the clinical history of the large white kidneys, some that of the atrophied kidneys, some do not correspond to that of either; but they all exhibit some of the characteristic symptoms of chronic nephritis—changes in the urine, dyspnoea, vomiting, cerebral symptoms, dropsy, anæmia.

The following histories will show the course of the disease in some of these cases:

Case 1.—A male, forty years old, came into hospital on October 9, 1881. The patient was a beer-drinker, but denied rheumatism and syphilis. He said that he had been perfectly well until fourteen months before; then he had an attack of lobar pneumonia which confined him to the house for four weeks. Since that time he has never felt as well and has had occasional dyspnoea. Nine months ago the dyspnoea became so troublesome that he had to give up work, and he also began to suffer from severe headaches. Three weeks ago the urine became scanty and dropsy appeared in the legs and scrotum. When admitted to the hospital the patient was large and fat. There was dropsy of the legs and of the scrotum, marked dyspnoea, sibillant râles over both lungs; 10 ounces of urine in twenty-four hours, specific gravity 1023, albumen 10 per cent., hyaline and epithelial casts. The urine on Oct. 12 was 13 ounces; on Oct. 14, 42 ounces; on Oct. 18, 54 ounces. On this last day he had [p. 94] several convulsions, became comatose, and died October 19. At the autopsy the pia mater was thickened and there was an increase of serum beneath it. The heart weighed fourteen ounces, the aortic and mitral valves were a little thickened, the walls of the ventricles were unnaturally hard. In the lungs there were a few old hard miliary tubercles. The kidneys weighed sixteen ounces, surfaces smooth, capsules not adherent, cortex and pyramids of red color, urates in the pyramids. The cortex-tubes showed marked changes in their epithelium, but the Malpighian bodies, stroma, and arteries were nearly normal.

Case 2.—A female, forty-five years old, was admitted to the hospital December 5, 1881. Denied rheumatism, syphilis, and intemperance. She had considered herself strong and well until two months before. Then she had a sudden attack of dyspnoea, dizziness, faintness, and cardiac palpitation. After this she was never well, complained of pain about the heart, headache, attacks of dyspnoea, dropsy of the face, hands, and feet. The urine was scanty and dark-colored. She is now emaciated and anæmic, has moderate oedema of the legs, complains of dyspnoea, headache, and nausea. The heart's action is feeble and irregular, and there is a presystolic murmur. On December 19 she vomited blood. On January 2 she had a chill, followed by a temperature of 102°. On January 5 she became drowsy, then had twitchings of the muscles of the face; became semi-comatose, and died January 11. While she was in the hospital the urine varied in amount from 1 to 6 ounces daily; it contained a very large amount of albumen and a few hyaline casts. After death the pia mater looked sodden and finely granular. The walls of its arteries were a little thickened, and there were little clumps of endothelial cells on its outer surface. The mitral valve of the heart was thickened and stenosed. The kidneys were of medium size, their capsules slightly adherent, their surfaces finely nodular, the cortex of normal thickness, red mottled with yellow spots. There was an extensive growth of diffuse connective tissue separating the tubes both in the cortex and pyramids. The tubes were large and contained much cast-matter. Most of the Malpighian bodies were normal.

COMPLICATIONS.—The most frequent complication of chronic diffuse nephritis is disease of the heart. We find cardiac lesions and renal lesions associated in three different ways:

1. Valvular lesions or dilatation of the ventricles produce chronic congestion of the kidney, with its changes into parenchymatous or diffuse nephritis or the large white kidney of cardiac disease.

2. Chronic diffuse nephritis is followed by the development of hypertrophy of the left ventricle. This may occur with all the varieties of chronic diffuse nephritis, but is most common with the atrophied kidneys.

3. Valvular lesions and chronic nephritis occur in the same persons, but neither can be said to depend upon the other.

The arteries are often diseased, the aorta and the arteries throughout the body. There may be a simple sclerosis and thickening of the wall of an artery, or endarteritis deformans, or obliterating arteritis.

Cerebral apoplexy may occur with all the varieties of chronic diffuse nephritis, but much more frequently with atrophied kidneys.

Thickening of the pia mater, with increase of serum beneath it, is often seen.

Dilatation of the lateral ventricles of the brain sometimes occurs, and may give rise to cerebral symptoms.

Pericarditis is seen more frequently with the atrophied kidneys.

Pneumonia is especially apt to be fatal when it occurs in persons already suffering from chronic diffuse nephritis.

Emphysema and chronic bronchitis are often associated with the atrophied kidneys.

Phthisis is found with all the varieties of chronic nephritis.

Peritonitis occurs in a few cases as a complicating inflammation.

Cirrhosis of the liver is found quite frequently.

PROGNOSIS.—In every case of chronic diffuse nephritis the natural course of the morbid changes in the kidney tissue is to become more marked and involve more and more of the kidney. The effect upon the general health of the patient is not in any exact relation to the degree of the kidney lesion. These two facts render the prognosis of chronic diffuse nephritis very uncertain. The disease is always a very serious one, and terminates regularly in destroying life, but the length of time that will elapse before this fatal termination, and the precise way in which death will take place, are difficult to determine beforehand.

TREATMENT.—There seems no good reason for believing that we can directly influence the development of the lesions in the kidneys. It is possible that such a development may be indirectly delayed by improving the general health of the patient.

There is good reason to believe that some of the symptoms which occur regularly in patients who have chronic diffuse nephritis are dependent not upon the nephritis, but upon other causes. We may therefore look for indications for treatment in three different directions:

1. To delay the development of the disease by improving the general health of the patient.

2. To treat those symptoms which are not produced by the kidney disease.

3. To treat those symptoms which are produced by the kidney lesions.

To fulfil the first indication the most potent influences that we have are the giving up of business and of vicious habits and causing the patient to live year after year in the most suitable climates. Generally speaking, warm climates are to be preferred, but the individual disposition of each patient must always be consulted.

Of less efficacy, but still of importance, are the improvement of the digestion by means of drugs and the feeding of the patient.

In every patient suffering from chronic diffuse nephritis there are a number of symptoms which seem to depend directly upon other conditions, and not upon the kidney lesions; for if these conditions are removed the symptoms disappear, although the kidney lesions continue. To this category of symptoms seem to belong the headache, delirium, stupor, coma, and convulsions, the nervous dyspnoea, the vomiting in part, the dropsy in part, the diminution of urine in part. All these symptoms are due to disturbances of the circulation, and the disturbances of the circulation are produced by a number of causes which may act separately or together. Changes in the valves and walls of the heart, in the force and regularity of the heart's contraction, in the walls and size of the arteries and capillaries, and in the volume and composition of the [p. 96] blood, each, separately or associated, may interfere with the proper circulation of the blood, and this interference usually takes the form of too much blood in the veins and too little blood in the arteries.

Anatomical changes in the valves of the heart, in its walls, and in the walls of the arteries and capillaries cannot be influenced by any means at our command. The force and regularity of the contractions of the heart can, however, be very decidedly modified by drugs. Opium in moderate doses makes the heart's action slower and stronger; iodide of potassium makes the heart's action more regular; convallaria makes the heart's action slower and stronger; digitalis increases the force of the heart's action, but at the same time contracts the arterioles; aconite and veratrum viride make the heart's action slower and more feeble.

The size of the arteries and capillaries can also be altered by drugs. Nitrite of amyl and nitro-glycerin relax and dilate the whole arterial and capillary system; chloral hydrate dilates the arterioles (Fothergill).

The volume of the blood can be diminished by bloodletting and by eliminating the plasma of the blood indirectly by sweating, purging, or diuresis.

The symptoms which can be ascribed directly to the presence of the kidney disease are—(1) The changes in the composition of the blood. We have still very little exact knowledge of what these changes are, but we may say generally that there is an increase in the relative quantity of the watery constituents of the blood and of the excrementitious products which should be eliminated by the kidneys. (2) The changes in the quantity of urine probably depend partly on the changes in the circulation, partly on the composition of the blood, and partly upon the structural changes in the kidneys. The albumen and casts seem to be directly due to the kidney lesion. (3) The changes in the nutrition of the patient, the disturbances of digestion, and some of the headaches, all seem to belong directly to the kidney disease.

Now let us try to apply these principles to the practical treatment of the different symptoms.

The Urine.—As regards the presence of albumen and casts, it is doubtful whether we are able to do anything, although it is customary to give the tr. ferri chloridi and the bichloride of mercury in order to diminish the excretion of albumen. As regards the quantity of urine, we must distinguish whether the patient is in the ordinary course of the disease, whether he is having an uræmic attack, or whether he is having an acute exacerbation of the nephritis with congestion of the kidney and blood in the urine. Under the circumstances last mentioned the indications are to apply wet or dry cups over the lumbar region, to use hot fomentations to the back or hot-air baths, to open the bowels freely, to put the patient on a milk diet, and, if the heart's action is too strong, to give aconite in small doses.

If during the ordinary course of the disease the urine is constantly diminished, diuretics are often of good service, although the cases differ as to the particular drugs which answer best. The preparations of digitalis, the diuretic pill of digitalis, squills, and bichloride of mercury, the iodide and acetate of potash, and jaborandi in small doses, are the most reliable agents of this class. Sometimes the frequent use of milk or of water in small quantities (half an ounce or an ounce every half hour) will [p. 97] answer the purpose. There can never be any use in continuing the employment of diuretics in these cases if after a fair trial they do not increase the flow of urine.

During the progress of uræmic attacks diuretics do not act, and the same is often the case with cathartics and diaphoretics. The urine is only to be increased by the same means which are indicated for the relief of the whole uræmic condition, and of these we will speak later.

The dropsy in many cases will vary in amount, and even disappear at times without any treatment. It is regularly most marked with the large white kidneys and with those kidneys which are neither large white nor atrophied, especially when there is complicating heart disease and the patient is anæmic. Generally speaking, it is best to keep dropsical patients in bed most of the day. We attempt to get rid of the oedema by the skin, the bowels, and the kidneys, to regulate the heart's action, and to improve the condition of the blood. Hot-air baths or hot-water baths repeated every day, the milder hydragogue cathartics, and the different diuretics may all be used with advantage. If the dropsy is excessive, it may be necessary to tap the peritoneal or pleural cavities or to puncture the skin of the legs and scrotum. Sometimes bandaging the legs so as to exert moderate pressure seems to assist in getting rid of dropsy. To regulate the heart's action we find that digitalis, convallaria, and the iodide of potash are often of service. To improve the condition of the blood the systematic use of iron and oxygen is indicated. The most hopeless cases are those in which there is complicating heart disease and those in which the dropsy steadily increases, although the patient is passing from 60 to 100 ounces of urine daily.

Disturbances of the stomach are of different kinds and dependent upon different conditions. There may be simply loss of appetite or discomfort after eating, or nausea, flatulence, and vomiting; and these symptoms will be associated with chronic catarrhal gastritis or with a stomach that is anatomically normal. Sometimes, although there is occasional nausea and vomiting, the appetite continues good, or as part of an uræmic attack there will be constant vomiting.

The habitual dyspeptic disturbances are to be treated like other cases of gastric dyspepsia. A regulated diet, the vegetable bitters, the mineral acids, or the alkalies are sometimes of service. The repeated and persistent vomiting of uræmic attacks is a most distressing symptom and one often very difficult to control. The patients must be fed with small quantities of fluid food or of prepared meat. The most efficient remedies are those addressed to the condition of the circulation. Hypodermic injections of morphia, enemata of chloral hydrate, inhalations of nitrite of amyl, convallaria in small doses by the mouth, are all of service.

The anæmia from which the patients suffer is to be combated by the systematic use of iron and oxygen. Any efficient preparation of iron will answer, but it must often be given in considerable doses. Sometimes the bichloride of mercury in small doses answers better than iron. The oxygen should be inhaled for from five to thirty minutes twice a day.

The so-called uræmic attacks, although they have a general similarity, yet vary in their manifestations in different cases. In some cases the [p. 98] patient develops an unnatural restlessness and anxiety, an inability to sleep, now and then a sudden twitch of one of the facial muscles, and headache. Or a patient whose color is still good will only complain of pain in the epigastrium and moderate dyspnoea, and yet will be in bed and evidently seriously ill. Or a patient who has been troubled with dyspeptic symptoms and gradual loss of strength suddenly develops vomiting, intense headache, sleeplessness, a single convulsion followed by facial paralysis. A man with a previous history of chronic Bright's disease becomes persistently anæmic and dropsical; he has constant dyspnoea, cannot lie down, cannot sleep, and yet looks drowsy and stupid; is mildly delirious and has very little intelligence; then gradually becomes unconscious, then comatose, and so dies. Or there are first attacks of dyspnoea, either spasmodic or from exertion, but which are temporary and can be relieved. Then the dyspnoea becomes more constant and severe; the patient cannot lie down at all, all remedies become less and less efficacious, and the dyspnoea only ends with the life of the sufferer. In other cases a patient will suddenly become unconscious, although not comatose; he will lie flat in bed, the skin livid and bathed in perspiration, the respiration labored and rapid, with coarse râles all over the lungs, the heart's action rapid and feeble, the temperature perhaps a little elevated; or sudden and profound coma or noisy delirium or repeated convulsions may be the prominent features.

There is hardly a limit to the variety of the precise manner in which all these symptoms—restlessness, sleeplessness, headache, vomiting, delirium, convulsions, and coma—may present themselves. It is to be remembered that although all these symptoms are always dangerous, and often fatal, yet patients may pass through a number of such attacks before the fatal one arrives.

To relieve these attacks the most effectual remedies are opium, chloral hydrate, nitrite of amyl, convallaria, digitalis, caffeine, bloodletting, purging, sweating, and cathartics.

Opium is a very valuable remedy, but great judgment is required in selecting the preparation and the dose for each case. The old doctrine that opium is a dangerous drug for patients suffering from Bright's disease is perfectly true, but it is equally true that it is also a valuable remedy. Generally speaking, the more marked the uræmic attack the larger the dose of opium that will be borne. It is always well to try to obtain a free movement from the bowels, although this is not always possible.

In the milder cases the fluid extract of convallaria in ten-minim doses will often diminish the frequency of the heart's action, increase the production of urine, and improve the general condition of the patient.

In the earlier stages of dyspnoea five-grain doses of the iodide of potash with a little opium will sometimes keep the patient comfortable for months. For the severe attacks of dyspnoea dry cups over the chest and inhalations of oxygen are of service. In the worst and most uncontrollable dyspnoea it seems justifiable to keep the patient under the influence of ether or chloroform.

SUPPURATIVE NEPHRITIS AND PYELO-NEPHRITIS.

Suppurative inflammation of the tissue of the kidney and of its pelvis and calices occurs under several different conditions: It is the result of injuries; it is due to emboli; it occurs without discoverable causes; it is secondary to cystitis, the cystitis being due to strictures of the urethra, to stone in the bladder, to paraplegia, to operations on the urethra, bladder, and uterus, to gonorrhoea, to enlarged prostate.

Chronic suppurative pyelo-nephritis is often caused by the presence of calculi in the pelvis of the kidney.

1. Suppurative Nephritis from Injury.—Gunshot wounds, incised or punctured wounds, falls, blows, and kicks are the ordinary traumatic causes. If the injury is a very severe one, it causes the death of the patient in a short time; if it is less severe, suppurative inflammation may be developed.

The inflammatory process may be diffuse, so that the whole of one or both kidneys is converted into a soft mass composed of pus, blood, and broken-down tissue, or it is circumscribed, and one or more abscesses are found in the kidney which may communicate with the pelvis.

SYMPTOMS.—Rigors mark the beginning of the suppuration, and are often repeated through its course. A febrile movement is developed which is apt to assume the hectic character with sweatings. There is often vomiting. There may be very severe pain, referred to the region of the inflamed kidneys. The urine is diminished or suppressed; it contains blood alone or blood and pus.

In the bad cases the patients pass into the typhoid condition, become delirious, and die comatose or with a very rapid or febrile pulse. Or the disease is protracted, the patients become more and more emaciated, and finally die exhausted.

In other cases the symptoms abate, the urine returns to its natural condition, and the patients recover.

TREATMENT.—The management of these cases is rather surgical than medical. The external wound is to be treated antiseptically, and the general condition of the patient to be looked after in the ordinary way.

Such traumatic abscesses are of infrequent occurrence. I have no personal knowledge of them.

2. Abscesses produced by Emboli.—In ordinary endocarditis with vegetations on the valves it often happens that fragments of the vegetations become fixed in the branches of the renal arteries. When this is the case infarctions are produced, usually of the white variety.

With malignant endocarditis, with surgical pyæmia, and with the curious cases called idiopathic pyæmia, small emboli seem to find their way into the smallest branches of the renal artery. They do not produce infarctions, but small abscesses. In these cases the kidneys are increased in size and dotted with little white points surrounded by a red zone. These little white points are formed by an infiltration of pus-cells between the tubes, and in the larger foci by a breaking down of the kidney-tissue. Colonies of micrococci are sometimes, but not always, found in the Malpighian tufts, the veins, and the abscesses.

SYMPTOMS.—These embolic abscesses can hardly be said to have any clinical history. Whatever symptoms may belong to them are lost in those of the general disease from which the patient is suffering.

3. Idiopathic Abscesses.—Occasionally cases of abscesses of one of the kidneys are met with. They last a long time, and when the patient dies both the kidney tissue and the pelvis are involved to such an extent as to render the anatomical diagnosis difficult. The greater part of the kidney-tissue is destroyed and replaced by sacs full of pus; the pelvis is dilated and its walls thickened. The surrounding connective tissue is thickened; perforations and sinuses may extend into the surrounding connective tissue, into the large intestine, and through the diaphragm into the lung.

SYMPTOMS.—At first these cases are apt to be very obscure. An irregular febrile movement accompanied with rigors comes and goes, lasting for shorter or longer periods. The patients lose appetite, vomit occasionally, and become emaciated and anæmic. With this there may be pain over the region of one of the kidneys.

After a time a tumor may make its appearance in the position of one kidney—a tumor which can be felt through the anterior abdominal wall. If the abscess communicates with the pelvis of the kidney and the ureter remains pervious, pus and fragments of kidney-tissue are discharged with the urine. The pus is usually discharged at intervals, and at such times the size of the tumor diminishes. In other cases the pus burrows in other directions—into the retro-peritoneal connective tissue, the peritoneal cavity, the colon, or through the diaphragm into the lung. These cases are apt to run a protracted course and terminate fatally.

TREATMENT.—The only plan of treatment likely to cure the patient is a surgical one—either to extirpate the diseased kidney, or to cut down on the abscess and treat it on the antiseptic plan like any deep abscess.

4. Suppurative Pyelo-Nephritis with Cystitis.—LESIONS.—Usually both kidneys are affected. They are increased in size, and both the kidneys and their pelvis are congested. The mucous membrane of the pelvis is thickened and coated with pus or patches of fibrin. Scattered through the kidneys are abscesses and purulent foci of different sizes. The smallest foci are not visible to the naked eye, but with the microscope we find collections of pus-globules between the tubes, with swelling and degeneration of the epithelium within the tubes. The larger purulent foci look like white streaks or wedges running parallel to the tubes and surrounded by zones of congestion. The larger abscesses replace considerable portions of the kidney.

The ureters in some cases are inflamed, their walls thickened, their inner surface coated with pus or fibrin. The bladder presents regularly the lesions of acute or chronic cystitis.

ETIOLOGY.—For the production of this form of nephritis inflammation of the bladder seems to be necessary. How the inflammatory process is transmitted from the bladder to the kidneys is still uncertain, but it seems probable that it is effected by bacteria. The cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate.

SYMPTOMS.—When the nephritis occurs with cystitis due to stone in the bladder, strictures, or operations on the genito-urinary tract, the [p. 101] symptoms are much the same. The patient has first the symptoms belonging to the cystitis, then he is attacked with rigors, followed by a febrile movement. The rigors are often repeated; the febrile movement is very irregular and often accompanied by profuse sweating. There is a rapid change in the general condition of the patient. He becomes much prostrated and emaciated from day to day. The face is drawn and anxious, the tongue dry and brown, the pulse rapid and feeble, and delirium is developed, and the patient finally dies in a condition resembling that of typhoid fever or of pyæmia. The urine is diminished in amount; it may be suppressed. It contains blood, pus, and mucus. The pus and mucus belong to the cystitis; the blood seems to be derived both from the kidneys and the bladder.

Cases of suppurative nephritis complicating gonorrhoea are fortunately not common, but several of them have been observed. Murchison² describes two cases, in both of which the cerebral symptoms were very marked—delirium, convulsions, and coma. I have seen one such case. The patient was a prostitute who came into the hospital with a specific vaginitis. After a few days she developed symptoms of an acute cystitis; then after a few more days she was attacked with rigors and a febrile movement, passed rapidly into the typhoid condition, and died. At the autopsy there were found acute cystitis, pyelitis, and numerous small abscesses in both kidneys.

² Lancet, 1875, p. 80.

When suppurative nephritis complicates the cystitis due to enlarged prostate, the clinical symptoms are somewhat different. The patients are usually men over fifty. They have generally suffered from the symptoms of enlarged prostate—retention of urine, either constant or intermittent, and more or less cystitis, with pus and mucus in the urine in varying amount. Sometimes, however, no such history is obtained; the patients assert that they have had no previous bladder trouble. The first symptom is diminution in the amount of urine passed and the appearance of blood. The quantity of urine is only a few ounces or it is completely suppressed. The blood is present in considerable amount; often the patients seem to pass pure blood instead of urine. The patients rapidly become prostrated and very anxious. There are usually no rigors, and there may be no febrile movement. After this the prostration becomes more marked, the pulse is rapid and feeble, the skin cold and bathed in perspiration, and the patients die in collapse at the end of a few days.

PROGNOSIS.—Suppurative nephritis secondary to cystitis is a very fatal disease; so far as I know, all the cases die.

TREATMENT.—The treatment for these cases is altogether a preventive one directed to the cystitis. In the cases of paraplegia, stone in the bladder, stricture, and enlarged prostate constant care must be used to prevent the accumulation of urine in the bladder and the development of cystitis.

In all cases of operation on the genito-urinary tract the supervention of cystitis is to be guarded against.

PERINEPHRITIS.

The loose connective tissue which is situated around and beneath the kidney may become the seat of suppurative inflammation, and in this way abscesses of considerable size are formed.

LESIONS.—The connective tissue behind the kidney seems to be the usual point of origin of the inflammatory process, and it is here that the pus first collects. After the abscess has reached a certain size the suppuration seems to have a natural tendency to spread and the pus burrows in different directions—backward through the muscles; downward along the iliac fossa, even as far as the perineum and scrotum or vagina; forward into the peritoneal cavity, the colon, or the bladder; upward through the diaphragm. The kidney is either compressed by the abscess or its tissue also becomes involved in the suppurative process. The soft parts around the abscess become thickened.

ETIOLOGY.—Perinephritis is either secondary or primary. The secondary cases are due to extension of the inflammation from abscesses in the vicinity, such as are formed with caries of the spine, pelvic cellulitis, puerperal parametritis, perityphlitis, suppuration of the kidneys, and pyelo-nephritis. The primary cases occur after exposure to cold, after contusions over the lumbar region, great muscular exertion, and without discoverable cause. The lesion is said to complicate typhus and typhoid fever and smallpox. The disease occurs both in children and adults, most of the cases reported having been between the ages of twenty and forty years.

SYMPTOMS.—The disease begins regularly with pain and tenderness referred to the lumbar region on one side between the lower border of the ribs and the crest of the ilium, sometimes to a point above or below this. At about the same time are developed repeated rigors, a febrile movement with evening exacerbations, sweating, loss of appetite, vomiting, and prostration. These are all the symptoms for from one to two weeks. Then the skin over the lumbar region on one side becomes red and oedematous; the corresponding thigh is kept flexed and rigid, for any movement of it gives pain. Then the lumbar region becomes more and more swollen until fluctuation can be made out, and finally the abscess breaks through the skin. If such cases are left to run their course the abscess may reach a very large size. If the pus does not extend backward, but in some other direction, the symptoms are more obscure, for the local symptoms of an abscess in the back are absent.

If the abscess ruptures into the peritoneal cavity, the symptoms of acute general peritonitis are suddenly developed. If it perforates into the colon or bladder, the pus is discharged with the feces or the urine. If the perforation is through the diaphragm, there will be empyema, or the lung becomes adherent and pus is coughed up from the bronchi. As soon as the abscess is opened and the pus escapes the acute constitutional symptoms subside.

Trousseau believes that the inflammatory process sometimes stops short of the production of pus. In such cases of course there are no evidences of the formation of an abscess.

The disease may terminate in different ways:

1. The inflammation may terminate in resolution (Trousseau).

2. The abscess is opened by operation or spontaneously and the patient recovers.

3. Although the abscess is opened either by the surgeon or spontaneously, the suppurative process continues and the patient dies exhausted, usually with waxy viscera.

4. Perforation into the peritoneum, the pleura, or the lung causes death.

TREATMENT.—The main point in treatment is to discover the abscess and to open it. The longer the suppurative process goes on and the larger the abscess, so much the worse is the prognosis. It is proper to explore with the aspirator after the disease has lasted for a few days, even if no fluctuation can be made out. The abscess is to be opened and treated on antiseptic principles.

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA.

The above terms are applied, the first to a condition of urine in which, of the constituents of blood, red discs at least are present; the second to that in which, while no corpuscles are found, blood coloring matter is abundant. Each of these conditions has been repeatedly observed as a distinct state at the moment when urine is passed; but it is also to be remembered that a true hæmaturia may, in the course of a few hours, become a hæmatinuria or hæmoglobinuria, by solution or disintegration of the red blood-discs. So far as I know, this subsequent solution and conversion can take place only in an alkaline urine; but as any urine through decomposition may become alkaline, it is evident that any hæmaturia may, in the course of time, become a hæmoglobinuria—a fact sometimes overlooked. I have, for example, known urine to be sent from Southern parts of the United States which, when shipped, contained blood-corpuscles, but which, when received in Philadelphia, contained no blood-discs, only large amounts of blood coloring matter. Especially does this occur in warm weather, when urine decomposes quickly. Such a hæmoglobinuria might be characterized as secondary. Doubtless, too, a more rapid solution is contributed to in some instances by the state of the blood-discs themselves, which are at times disintegrated before or at the moment they leave the blood-vessels, at others are intact, and at others, still, may be just ready to fall to pieces. In the hæmoglobinuria, where the blood-corpuscles have been secondarily dissolved and disintegrated, their remnants may be found in the shape of dark-brown or red granules, which form a sediment of varying bulk.

The immediate cause of this dissolved state of the blood-discs, where not due to the solvent action of an alkaline urine, appears to be the difference in degree of the cachexia which is at the bottom of the renal hemorrhagic tendency.

The term hæmaturia is applied to blood in the urine from whatever part of the urinary passages it may come, whether the bladder, ureters, kidney, or even urethra; whereas the blood in primary hæmoglobinuria always comes directly from the kidney.

In this paper I shall confine myself to the consideration of renal hæmaturia and hæmoglobinuria in the strict sense of the term; nor will I include such renal hæmaturia as constantly occurs in the first stage of acute Bright's disease.

Emphasizing again that all primary hæmoglobinurias are renal, it is [p. 105] important to be able to say of a given hæmaturia whether it is renal or not. Even coarse methods are often sufficient to settle the question. Blood from the kidney, so far as my experience goes, is never discharged in the shape of clots, at least large enough to be recognized as such by the naked eye. More frequently coagula of blood are passed when hemorrhage takes place into the pelvis of the kidney. These coagula generally cause severe pain in their descent, and by this symptom are distinguished from coagula from the lower part of the ureter and bladder.

The smoky hue, which is characteristic of the presence of small quantities of blood in an acid urine, affords presumptive evidence that the blood is renal in its origin, because the conditions which are associated with blood from other parts of the genito-urinary tract are very apt to be associated with an alkaline urine, to which blood imparts a bright-red hue. This is, however, not invariable, as smoke-hued urine may be due to admixture of blood from the bladder and parts of the genito-urinary tract other than the kidney.

The microscope affords valuable assistance in determining the source of blood in the urine. In addition to blood-discs or their molecular débris, tube-casts made up of cemented blood-discs or their débris are very constantly, although not invariably, found in such urine. This evidence is conclusive, and, although sometimes wanting, the invariable absence of clots from blood descended from the kidney, together with the absence of irritation of the bladder, makes it usually quite easy to recognize a renal hæmaturia.

It is scarcely necessary to say that all urine containing blood or hæmoglobin contains albumen, the quantity varying with that of these substances present. Any further deviations from the normal composition of the urine are, in the main, due to admixture of other constituents of blood.

Hæmaturia is due to a variety of causes, which may be local or general. Local hæmaturia is caused by wounds, blows upon the kidney, or falls in which the kidney receives the force of the blow, as in striking the edge of a fence in falling; from cancer of the kidney, impacted calculus, parasites, embolism, acute Bright's disease; also poisoning from carbolic acid, cantharides, and mustard. General causes of hæmaturia are malaria, purpura, scurvy, blood-dyscrasias due to continued and eruptive fevers, especially typhus fever and smallpox, septicæmia and pyæmia, and cholera. Finally, it must be admitted that there is a hemorrhagic diathesis manifested by hæmaturia and hæmoglobinuria. Primary hæmoglobinuria may be produced by any of the general causes just named, or by the prolonged inhalation of arseniuretted hydrogen and carbonic acid, and the introduction of numerous substances into the blood, as iodine, arsenic, etc.

While a rupture of the blood-vessels of the kidney may be supposed to be at the bottom of a certain proportion of cases of hæmaturia, it is by no means a necessary condition of their occurrence, as it is well known that in inflammations there may be extravasations of blood without rupture of [p. 106] the blood-vessels. There is implied, however, in all these conditions an alteration of the vessel-walls which permits such transudation. Indeed, Ponfick¹ goes so far as to say that even transudations of hæmoglobin through the blood-vessels of the kidney are impossible without the presence of serious diffuse nephritis. There is every reason to believe, however, that simple alterations of the blood are of themselves sufficient to cause such transudations. Take, for instance, the extravasations in purpura, which are not confined to the vessels of the kidney. It is impossible to conceive inflammatory conditions so general as would have to be presupposed in this disease.

¹ "Ueber die Gemeingefährlichkeit der essbaren Morchel," Virchow's Archiv, Bd. lxxxviii. S. 47.

It is unnecessary to consider in detail the local causes of hæmaturia. It is evident how injuries and blows upon the kidney, and impacted calculus may produce hemorrhage. The history of nephritic colic or of gravel in urine, along with blood, would suggest the latter cause. Nor is it necessary to detail the phenomena of hemorrhagic infarction which succeeds embolism and is the direct cause of hemorrhage into the tubules of the kidney. Hæmaturia is by no means a constant symptom in sarcoma and cancer of the kidney. A small amount of blood in the urine is a constant symptom in acute nephritis, where it is due to a rupture of the blood-vessels of the Malpighian tuft. It is accompanied by blood-casts and other symptoms of acute Bright's disease. Carbolic acid, cantharides, oil of mustard, and similar substances produce hæmaturia by causing congestion and inflammation of the kidney.

The parasites which may cause hemorrhage in the substance of the kidney are the Bilharzia hæmatobia, the Filaria sanguinis hominis, the Strongylus gigas, and possibly common intestinal worms which may reach the kidney through fistulous openings. The first is a thread-like worm three or four lines in length, which was discovered by Bilharz, and infests the small vessels of the mucous and submucous tissue of the veins of the intestinal tract, the pelvis of the kidney, ureter, bladder, and more rarely of the kidney itself. It is very frequent in Egypt, where Griesinger found it 117 times in 363 autopsies; also in South Africa (Cape of Good Hope), where it gives rise to an endemic hæmaturia. It has been studied by Bilharz, John Harley, and William Roberts.

The Filaria sanguinis hominis is a long, narrow microscopic worm, not wider than a red blood-disc, and one seventy-fifth of an inch long, which infests the blood. Hemorrhages result from its accumulation in the vessels, causing rupture. The cases which have been studied occurred mostly in India, China, and Australia.

The Strongylus gigas is a large worm, resembling the ordinary lumbricoid, but larger, the male being from ten to twelve inches long and one-fourth of an inch wide, while the female is sometimes more than a yard in length. It infests the kidneys and urinary passages of certain lower animals (the dog, wolf, horse, ox, etc.), but rarely those of man.

SYNONYMS.—Intermittent hæmaturia; Paroxysmal hæmaturia; Malarial yellow fever; Swamp yellow fever; Paroxysmal congestive hepatic hæmaturia (Harley).

Perhaps the most important form of hæmaturia and hæmoglobinuria resulting from general causes is that due to malarial poisoning. I prefer the term malarial to intermittent or paroxysmal, not only because it more precisely indicates the cause of the condition, but also because the condition itself is by no means always intermittent, sometimes continuing without interruption until checked by appropriate treatment; and I have known it to continue uninterruptedly for a year, in spite of all treatment.

The first complete report of an undoubted instance of this affection appears to have been published by Dressler in 1854,² although incomplete and uncertain cases were reported prior to this date—one as early as 1832 by Elliotson.³ G. Troup Maxwell of Ocala, Florida, writes me, in 1883, that he first observed cases in Florida thirty years ago, and published an article on the disease in the Oglethorpe Medical Journal, Savannah, Ga., July, 1860. George Harley⁴ early contributed to our accurate knowledge of the subject in 1865, and since then numerous papers and reports of cases have appeared in English and American journals, the southern part of the United States being a fertile scene of the affection, while it is by no means rare in the Middle States.

² "Ein Fall von intermittirender Albuminurie und Chromaturie," Virchow's Archiv, Bd. vi. S. 264, 1854.

³ "Clinical Lecture on Diseases of the Heart, with Ague (and Hæmaturia)," London Lancet, 1832, p. 500.

⁴ "Intermittent Hæmaturia," Medico-Chirurg. Trans. London, 1865.

Two degrees of the disease are met with—a milder form, in which other symptoms as well as the hæmaturia are less pronounced, and of which instances occur in the Middle States as well as the South and West of the United States. Of this kind seem to be the cases studied by Harley and other English physicians. In addition to this, there is a second, more malignant, form, attended by great prostration, vomiting, and yellowness of the skin, along with copious discharges of bloody urine. Instances of the latter are numerous in the Southern States of this country, where they have recently been studied with much care; also in the East and West Indies and in tropical countries generally. In neither degree of the disease is it necessary that the red corpuscles of the blood should be present. They may be represented by their coloring matters alone, when the condition is called a hæmoglobinuria or a hæmaturia.

The Milder Form.—The subjects, in my experience of eight cases, have been, with one exception, men, and I believe the experience of others included more men than women. They are generally able to recall a history of exposure to malaria, and often of distinct attacks of malarial fever, intermittent or remittent. The hæmaturia appears suddenly, and when paroxysmal may occur daily or on alternate days or a couple of times a week, or even at longer intervals. When the attacks occur at longer intervals, say of ten days or two weeks, if the disease is left alone the interval is apt to gradually diminish until the passage of bloody urine becomes daily. The urine in the [p. 108] morning may be perfectly clear, and at two o'clock is evidently bloody. It continues so through one or two acts of micturition, and then becomes clear again; or it may be bloody on rising and clear up by noon. Sometimes the bloody urine is preceded or accompanied by a sense of weariness and chilly feeling, or sometimes simply by cold hands and feet or by cold knees, or by pallor and blueness of the face, or by accelerated pulse, or by no other symptoms whatever. There is sometimes a sense of fulness in the region of the kidney and sacrum. The attacks are often induced by exposure to cold.

Harley states that in one of the two cases which he reported there was a slight jaundice, and in the second a "sallowness which appeared to be due to a disturbance of the hepatic functions," but in none of the cases which I have met was this symptom present. In the more malignant form occurring in the tropics and the Southern States of America, jaundice is a constant symptom.

While a majority of cases of malarial hæmaturia are intermittent, many are continuous, and of my eight cases only three were distinctly intermittent. One of these cases I published in a clinical lecture in the Philadelphia Medical Times as far back as September 1, 1871.

Negroes are not exempt from this milder form of the disease, as they seem to be from the more malignant form of the South. While writing this paper I was consulted by a negro thirty-one years old who had a true malarial hæmoglobinuria, which yielded promptly to the treatment by quinine. But this was the only negro out of seven cases.

The duration of the disease is very various, and if neglected may be indefinite. Stephen Mackenzie⁵ reports a case which lasted twenty-three years.

⁵ "On Paroxysmal Hæmoglobinuria," London Lancet, vol. i., 1884, p. 156.

PHYSICAL AND CHEMICAL CHARACTERS OF THE URINE.—The urine is usually acid in reaction when passed, sometimes neutral, rarely alkaline, and ranges in specific gravity from 1010 to 1028. It is always albuminous, and always tinged by blood coloring matters, the depth of color varying from the trifling degree known as smoke-hued to a dark-red or claret color. Sometimes it is even darker, and is often compared to porter, though this degree of coloration is more characteristic of the malignant form. The urine deposits a dark, reddish-brown sediment, generally copious, but varies in quantity with the degree of coloration of the urine. This sediment is made up chiefly of red blood-discs or the granular débris resulting from their disintegration.

Casts of the uriniferous tubules are also often present. They are usually made up of aggregated red blood-discs or the granular matter referred to; but they may also be hyaline or hyaline with a moderate amount of granular matter attached. Granular urates also at times contribute to the sediment and also adhere to the casts. Renal and vesical epithelium may occur. Crystals of oxalate of lime and of uric acid are sometimes present, while blood-crystals have been found by Gull⁶ and Grainger Stewart, and a hæmatin crystal once by Strong.⁷

⁶ Guy's Hosp. Reports, 1866, p. 381.

⁷ British Med. Journ., 1878, vol. ii. p. 103.

That red blood-discs are at times exceedingly scarce, and even totally absent at the very moment when urine is passed, is a well-recognized fact; while that the coloring matter present is still that of the blood, [p. 109] even though no corpuscles are present, is easy of demonstration by the production of Teichmann's hæmin crystals,⁸ by spectrum analysis, or by the guaiacum test.

⁸ Place a drop of the sediment upon a glass slide and allow it to dry. Mix thoroughly with a few particles of common salt and cover with a thin glass cover, under which allow two or three drops of glacial acetic acid to pass. Carefully warm the slide for a few seconds over a spirit-lamp, and when most of the acetic acid is evaporated, examine by the microscope. Hæmin crystals will be seen to crystallize out as the mixture cools.

In the matter of the presence or absence of blood-discs, it is to be remembered that these may be present at the moment the urine is passed, but disappear by subsequent solution if the urine happens to be alkaline or becomes so secondarily. It is an interesting fact, too, that colorless blood-corpuscles are often present intact, even when red discs are absent. While I have frequently examined urine sent me from the South in which the coloring matter of the blood and no corpuscles were present, only one of the cases coming under my own observations furnished urine of this character. The proportion of urea varies, and bears no evident relation to the condition itself.

PATHOLOGY AND MORBID ANATOMY.—The pathology of malarial hæmaturia consists, as yet, chiefly of theoretical deductions. We can only conclude that the malarial poison acts upon the blood and blood-vessels, impairing the integrity of both. This goes so far occasionally as to produce an actual destruction of blood-discs, and always so alters the capillaries that they permit the transudation of blood-elements ordinarily retained.

The morbid anatomy is scarcely more precisely defined. Ponfick⁹ goes so far as to say that the exudation of hæmoglobulin is not possible without the concurrence of marked diffuse nephritis. Recently Lebedeff¹⁰ has sought to investigate the more minute alterations of the kidney in hæmoglobin exudation, but without very definite results. These, however, on the whole, seem to confirm Ponfick's view as to the presence of an inflammatory process, as also do those of Litten¹¹ and Lassar.¹²

⁹ "Ueber die Gemeingefährlichkeit der essbaren Morchel," Virchow's Archiv, Bd. lxxxviii. S. 476, 1882.

¹⁰ "Zur Kenntniss der feineren Veränderungen der Nieren bei der Hämoglobinausscheidung," Virchow's Archiv, Bd. xci. S. 267, Feb., 1883.

¹¹ "Verhandl. des Vereins für innere Medicin," Deut. Med. Wochenschr., No. 52, Dec. 29, 1883.

¹² Ibid., No. 1, Jan. 3, 1884.

DIAGNOSIS.—The diagnosis of this condition is not usually difficult. We have first to determine whether the hemorrhagic discharge is from the kidney rather than the bladder or ureters. The former is the case when tube-casts are found. But tube-casts are not always present even when the hemorrhage is from the kidneys. The absence of clots and of vesical irritation, and of pain in the course of the ureters, is characteristic of blood from the kidneys. Finally, all hæmoglobinurias are renal.

It being certain that the blood comes from the kidney, we have to distinguish it from that due to cancer, to calculus-irritation, and to cachexias, as purpura and scurvy; or to grave forms of infectious disease, septicæmia, pyæmia, etc.; or, finally, to poisonous substances introduced into the blood, such as arsenic, iodine, arseniuretted hydrogen, carbonic acid and carbonic oxide gas, and even certain species of edible fungi.

The diagnosis is greatly aided if it is found we have to do with a [p. 110] hæmoglobinuria rather than a hæmaturia. For although the former condition is produced by toxic and septic agencies of another kind, the attending symptoms, when it is thus produced, are so characteristic that it is not likely that error can be made.

To aid in distinguishing it from cancer we have the history of malarial exposure, and often that of other forms of malarial disease; and, notwithstanding the seeming drain upon the system, none of the cases I have ever seen present the profound anæmia of cancer. The bloody discharge in cancer of the kidney is always a true hæmaturia; there are always blood-discs in the urine. There is often pain in the region of the kidney in cancer, but never in malarial hæmaturia.

In calculous disease there is almost always pain before or during the hæmaturic attack, and characteristic crystalline sediments often appear in the urine.

The disease, being comparatively rare in this latitude, is sometimes overlooked on this account. Of the 8 cases which I have noted during sixteen years, 5 originated in Pennsylvania, 1 in New Jersey, 1 in Delaware, and 1 in North Carolina.

TREATMENT.—The treatment is distinctly that of malarial disease, and I have seldom seen more brilliant and satisfactory results than have followed the use of quinine in a case accurately determined, although such success is not invariable; and I have known the disease to resist for a long time the most thorough and judicious use of anti-malarial remedies. Usually, however, I take hold of a case of this kind with considerable confidence. When there are distinct remissions my practice has been to administer 16 to 20 grains of sulphate of quinia in the usual manner of anticipation of the paroxysm in intermittent fever—from 3 to 5 grains every hour until the required amount is taken; the whole amount may be taken in two doses, or even in one dose. Where there is no distinct remission I more usually direct 3 to 5 grains every three hours, until the hemorrhage ceases or decided cinchonism is produced.

The advantage well known to accrue in malarial disease from the combination of mercurials with quinine applies to hemorrhagic malaria as well, although I usually reserve the mercurial until I have ascertained whether the simple quinine treatment answers the purpose. If the usual method fails, I give 8 or 10 grains of calomel in the evening, followed by a saline in the morning, before reinstituting the quinine treatment. In the case of the colored man alluded to who had malarial hæmoglobinuria 36 grains of quinine failed to break the attack; but the same quantity, given after 10 grains of calomel had acted, succeeded.

Where these means failed I have not found the other methods of treatment commonly resorted to in obstinate malarial disease to be any more efficient. I allude to the treatment by arsenic or by iron and arsenic. Indeed, in the only two cases in which, after failure with the quinine treatment, iron and arsenic were used at my suggestion, they failed absolutely. In the one case, under the care of James L. Tyson, this treatment was carried out most faithfully. After four weeks' treatment with quinine without effect, Fowler's solution was given, at first in 5-drop doses three times daily, subsequently increased to 10 and 15, along with 20- and 30-drop doses of tincture of the chloride of iron, until oedema of the eyelids occurred, when the arsenic was discontinued, but [p. 111] the iron continued. In two or three days the arsenic was recommenced in 3- and 4-drop doses for three or four weeks longer without effect. Fluid extract of ergot in 20-drop doses was then substituted for the iron, alternating with the arsenic for two weeks longer, when some slight favorable change was apparent, but it was temporary. Repeatedly throughout the treatment the patient complained of weariness and backache, cold feet and knees, headache and acceleration of pulse, and a feeling of utter wretchedness; and then again he would feel quite comfortable for a day or two, but with little or no change in the urine, except occasionally in the morning, when it would sometimes be quite light-hued, but after breakfast would again assume its bloody character. A sojourn at the seaside for two weeks was without effect.

It will appear from the above that ergot, which has been found useful in some forms of hæmaturia, is of little service here, as is attested by two other cases in which I tried it faithfully. At the same time, it is a remedy which should be tried in case of failure with others.

The usual astringents, mineral and vegetable, of known efficacy in the treatment of hemorrhagic conditions, should be used alone or in conjunction with the specific anti-malarial treatment after the latter has been found of itself insufficient. To this class of remedies belong the mineral acids, persulphate of iron, acetate of lead, alum, gallic acid, catechu, kino, the astringent natural mineral waters, etc.

Rest is certainly an important adjuvant in the treatment of this form of malarial disease. I have known a recurrence to take place after a long drive.

It is claimed for many natural mineral waters that hemorrhage from the kidneys is one of the affections cured by their use. Chalybeate and alum springs might be expected to be of advantage by the local action of these astringents in their transit through the kidneys, and they frequently are. The following case illustrates their efficiency: The patient was a lawyer who consulted me in June, 1881, at the suggestion of W. W. Covington of North Carolina. He had frequently had chills, and a congestive chill in 1873. Three months before I saw him he began to pass bloody urine. He had no other symptoms, except a soreness and weakness in the neighborhood of the sacrum, extending into the outer part of the left thigh. The urine passed for me at the time of his visit was dark reddish-brown in color, acid in reaction, had a specific gravity of 1028, highly albuminous, and deposited a sediment of almost tarry consistence, which was made up almost entirely of blood-corpuscles. There were no tube-casts. He had been a dyspeptic since seventeen years of age, and medicines disagreed with him; but he was treated faithfully with quinine, iron, arsenic, ergot, benzoate of lime, all without the slightest effect. At the end of about a year from the time he consulted me he heard of the Jackson Spring, located in Moore county, North Carolina, fifteen miles distant from Manly Station on the Raleigh and Augusta Railroad. He went there, and remained one week. He stated that for the first two or three days the water acted decidedly on his kidneys, and he voided a number of clots of blood. On the third day all traces of blood disappeared, and it recurred but once since, on a very cold day in November last, but again disappeared after a day or two in the house. Unfortunately, no precise analysis of this water seems to have been made, but [p. 112] from what my friend writes it evidently contains iron and sulphur, and magnesia is also said to be present. It is promptly diuretic. Since this occurred I have used the water of alum springs in other instances with advantage.¹³

¹³ See the report of a case treated successfully by Rockbridge alum-water by Radcliffe, Med. News, Jan. 12, 1884.

The following are some of the chalybeate and alum springs the waters of which may be expected to be of service in hæmaturia: Orchard Acid Springs, New York; Rockbridge Alum Springs, Pulaski Alum Springs, Bath Alum Springs, Stribling Springs, and Bedford Alum Springs, all in Virginia. In all of these waters iron and alum are both present, accompanied, in many instances, by free sulphuric acid, by which their efficiency is increased. In one of my cases the hemorrhage disappeared temporarily under the use of the water from the Bedford Springs, Penna., but again returned. These waters contain a little iron, but no alum. Subsequently, the same patient was promptly relieved by quinine, which had not been previously tried.

But the cases most promptly relieved by the alum waters are the non-malarial cases depending, upon hemorrhagic diathesis without other local disease. A remarkable instance of this kind was related to me by letter by J. Macpherson Scott of Hagerstown, Md. After enormous doses of quinine had been used under the supposition that it was malarial, it was promptly and totally cured.

The second more serious form of this disease, as it occurs in the tropics and the southern part of the United States, is characterized by such increased intensity of all the symptoms that it may be well called malignant. Singularly, however, the disease has seemed to be much more prevalent during the last fifteen years. My attention was first called to it in September, 1868, when I received specimens of urine and the history of some cases from R. D. Webb of Livingston, Ala., who wrote also that it was not known in that part of his State prior to 1863 or 1864.

In this, as in the milder form, there is a distinct but more invariable history of malarial exposure, and the attack often begins as an ordinary case of chills and fever, there being often one or two paroxysms before the hæmaturia appears. At other times the hemorrhage ushers in the disease suddenly. The urine is often black and almost tarry in consistence, and passed in unusually large quantities—it is said as much as a pint every fifteen or twenty minutes until a couple of quarts have been passed, or one or two gallons in the course of twelve hours. But after twenty-four hours the quantity diminishes. Epistaxis sometimes occurs, but is not often profuse. Distressing nausea, and vomiting of bilious and even black matter, like that of black vomit, also occur. Intense jaundice rapidly supervenes—said to come on sometimes in the course of an hour, often in from two to six hours. The tongue is brown and dry. The bowels are at times constipated, and at others loose. Although the patient may be feverish at first, with a temperature of 104° to 106°, and the skin dry, the pulse rapidly becomes small and feeble until it is [p. 113] scarcely perceptible. Drowsiness and coma sometimes intervene, and at others the mind is clear until the moment of death, which frequently supervenes within twenty-four or sixty hours; or the symptoms may subside, to be repeated again the next day if not prevented by treatment. If recovery takes place, which it sometimes does, and lately more frequently, convalescence is slow and tedious, the patient remaining for weeks in an enfeebled and anæmic state.

In this form, especially, of the disease it often happens that the coloring matter and the débris of blood-discs only are found in the urine, very few and often no entire ones being discernible: in other words, we have a true hæmoglobinuria or hæmatinuria. The urine is of course albuminous. A specimen recently received from North Carolina and analyzed by Wormley contained no corpuscles, but revealed the spectroscopic band characteristic of hæmoglobin. It contained 2½ per cent. of urea. The specific gravity of the urine ranges between 1010 and 1020, being lower when it is copious.

As to the jaundice, it is evidently a hæmatogenetic, and not a hepatogenetic, form with which we have to deal. It is due, not to the retention of bile, but to the disintegration of blood-corpuscles and the solution of their coloring matter, which diffuses through the tissues and stains them yellow or yellowish-green. This form too, apparently, is more frequent in males, and negroes appear to be exempt. This is not the case with the milder form, for it will be remembered that one of my patients was a negro.

Autopsies reveal the same intense yellow coloration of internal organs—lungs, liver, spleen, stomach, kidneys—anæmia rather than congestion, while the blood is dark-hued and is indisposed to coagulate. The spleen is often enlarged.

The TREATMENT for the breaking of the paroxysm is pre-eminently quinine or quinine with mercurials, and although this does not always succeed, there seems to be no other remedy. The quinine may be given hypodermically. The nausea has been controlled by morphia and lime-water, by carbolic acid, and by creasote. In addition, restorative measures are necessary, including the free use of stimulants. Turpentine has been used in large doses (fluidrachm j), it is said with advantage, in Alabama.

CHYLURIA.

The term chyluria is applied to a condition of urine in which the secretion is admixed with fat in a minute state of subdivision, whence the urine acquires a milky or chylous appearance. The proportion of fat varies greatly between such as gives a mere opalescence to the secretion and that which makes it absolutely indistinguishable, in appearance, from milk, while even the characteristic odor and taste of urine are often wanting. The further resemblance of such urines to milk is found in the fact that, on standing, a cream-like substance rises to the surface. On the other hand, a spontaneous coagulation into a jelly-like substance containing fibrin proves an unmistakable relation to blood.

The chemical composition of such a urine, having a specific gravity of 1013 and neutral in reaction, is given by Beale,¹ as follows:

¹ Urinary and Renal Derangements and Calculous Disorders, Philada., 1885, p. 73.

Such urines are of course albuminous, as will have been seen from the table. They therefore coagulate when boiled or on the addition of an acid. They also exhibit a tendency to spontaneous coagulation more or less complete, which is apt to be followed by later disintegration of the clot. The proportion of solids is larger than in ordinary urines.

Microscopically, the urine is found to contain, in addition to its usual elements, immense numbers of molecular particles easily soluble in ether, and therefore fatty in their composition. It may be rendered perfectly clear by the addition of ether, and again approximately milky after evaporating the ether and shaking the residue; but now the microscope shows the oil in the shape of oil-drops and not molecules. Oil-drops are also sometimes sparsely present in the fresh fluid, but the fatty particle is commonly molecular. Indeed, the molecules are commonly so small that an [p. 115] aggregated mass of them appears like a delicate cloud under the microscope, rather than a collection of individual particles. Blood-corpuscles may also be present, sometimes in sufficient quantity to produce a distinct pink coloration, but no unusual proportion of leucocytes is common. The pink tinge, and even an almost bloody appearance, is very apt to precede the chyluria. This bloody character sometimes gradually increases until the chyluria has become a hæmaturia, so that we have sometimes a chyluria spoken of as a first stage of hæmaturia. Tube-casts do not occur. Chyluria is seldom constant, and a specimen of urine passed a couple of hours after one white as milk may be, again, perfectly clear and in all respects natural. Thus, a second specimen, passed by the same patient as that of which the analysis is given above, was almost clear. It had a specific gravity of 1010 and a slightly acid reaction, and contained a mere trace of deposit, consisting of a little epithelium, a few cells larger than lymph-corpuscles, and a few small cells, probably minute fungi. Not the slightest precipitate was produced by the application of heat or addition of nitric acid. The following is Beale's analysis:

DISTRIBUTION OF THE DISEASE.—By far the largest majority of instances of the disease originate in tropical and subtropical climates. Thus, India, China, and South America—and in South America, Brazil, and Guiana—are countries in which it is common. It is said to be rarer on the coast of South America than in the interior; yet it is especially partial to insular countries, and most of the cases observed in this country originate in the West Indies—in Barbadoes and Cuba, in Bermuda and the island of Trinidad. Many cases occur in Bahia, Guadeloupe, Madagascar, the Isle of Bourbon, and Mauritius. Indeed, the first important study of the subject was based on cases observed in the latter island by Chapotin.² In Africa both Egypt and the Cape of Good Hope are favorite localities, and in Australia, Brisbane has furnished many cases.

² Thèse, Topographie médicale de l'Ile de France, 1812.

At the same time, cases do originate in temperate climates, and although the disease is rare in Europe and North America, Dickinson has collected five cases from his own practice or that of others, which undoubtedly originated in England. I know of but one case of certain North American origin, that of a woman reported by McConnell to the Medico-Chirurgical Society of Montreal, April 27, 1883. She was thirty-three years old, a native of the province of Ontario, and had had the disease eleven years. At the time of her death, which appears to have been from tubercular phthisis, there were cavities in the apices of both lungs.

SUBJECT'S ATTACKED.—There seems no election as to nativity, natives and foreigners being indiscriminately attacked in the countries in which it occurs. There is some difference of opinion as to whether the disease is more frequent in males or females; which is a reason for believing that it occurs with nearly equal frequency in both.

It is more common in middle life, but Prout reports an instance in a child eighteen months old, and Rayer one in a woman at seventy-eight years. She had had it, however, since she was twenty-five, or about fifty-three years. Dickinson was consulted with regard to a boy of five, and mentions a case fatal at twelve. Roberts says: "Chylous urine prevails mostly in youth and middle age."³ Of 30 cases collected by him, 3 were under twenty; 7 between twenty and thirty; 11 between thirty and forty; 6 between forty and fifty; and 3 over fifty.

³ Urinary and Renal Diseases, 4th ed., Philada., 1885, p. 344.

The subjects of the disease are apt to be pale and relaxed as to their tissues, but while this may be a possible result of the disease, it can hardly be regarded as a predisposing cause.

PATHOLOGY AND ETIOLOGY.—The precise mode in which chyluria is brought about is unknown. It is to be inferred, in view of our existing knowledge, that there has been produced, in some way, in each instance a communication between the urinary and chyliferous systems, although exactly where such communication is has as yet only been guessed at. It may be in the kidney itself, or its pelvis, or the ureter, or in the bladder. Cases originating in the tropics have been found associated with elephantiasis, but this is not very frequent. Dilatation of cutaneous lymphatics, producing cutaneous papules and vesicles and a discharge of lymph from them, has also been noted coincident with chyluria.

Prout,⁴ among the earlier writers on this subject, and more recently Bence Jones,⁵ Waters, Bouchardat, Robin, Bernard, and Egel, did not consider a positive lesion necessary, but ascribed the condition to a vice of nutrition and blood-making, accompanied by a slight consequent textural alteration in the blood-vessels of the kidney, through which the elements of the chyle transuded. Waters⁶ says that "the main pathological feature of the complaint is a relaxed condition of the capillaries of the kidney," which permits the transudation.

⁴ Stomach and Renal Diseases, 4th ed., London, 1843.

⁵ Lectures on Pathology and Therapeutics, 1868, p. 256.

⁶ Med.-Chir. Trans., vol. xiv. p. 221, 1862.

The results of examination of the blood, in cases of chylous urine, by Bence Jones, Rayer, and Crevaux, who found in certain instances an excess of fat, have been quoted in support of these views, but these examinations seem to have been microscopical and not chemical, and the results have not been confirmed by recent observers. Such views were also upheld on theoretical grounds by Bouchardat,⁷ based on the greater commonness of the disease in warm climates. He reasoned that when the heat-producing elements, whether absorbed from food or produced by metamorphoses of other proximate principles, are in excess, and an elevated external temperature does not favor their consumption, their elimination is attempted by certain organs, notably the liver and kidneys. The effort by the kidneys seems, however, to be attended by a structural change in the blood-vessels, as the result of which blood is [p. 117] eliminated with fat, especially at the beginning of the disease. Later the blood disappears, but the albumen remains some time longer, disappearing finally with the fat.

⁷ Ann. de Thérapeutique, 1862.

Bernard and Robin also compared the blood of such cases to that of geese artificially fattened, being that condition of blood which is normal after digestion but transient. Egel also held similar views, ascribing the imperfect elaboration to the effect of hot climates.

Gubler⁸ first suggested that chylous urine was due to a passage of chyle directly into the urinary passages, and that this was immediately preceded by a dilatation of the renal lymphatics similar to that known to occur on the surface of the body and attended by the local flow alluded to.

⁸ Gazette médicale de Paris, 1858, p. 646.

Vandyke Carter,⁹ of Bombay, suggested that the communication was between the lacteals and lymphatics of the lumbar region and those of the kidney. Those who have seen the semi-diagrammatic drawing of a dissection of the lymphatics as seen from behind, in the remarkable case of Stephen Mackenzie,¹⁰ cannot fail to be impressed with the probability of such communication.

⁹ Med.-Chir. Trans., vol. xlv., 1862.

¹⁰ Trans. Path. Soc. of London, vol. xxxiii. p. 394, 1882.

That a chylous urine is the direct result of a discharge of chyle into the urinary passages at some point between the kidney and the neck of the bladder, is further rendered likely by the experience of W. H. Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W., a native of Alabama, aged twenty-two, presented himself with a hydrocele. Mastin tapped the sac and drew off a white milk-like fluid, which was sent to me for examination. It was perfectly white and undistinguishable by the eye from milk. Upon microscopical and chemical examination, I found it presented all the physical and chemical characters of chyle. Six months later, the sac having refilled, Mastin evacuated eight ounces more of the same fluid—some of which was again sent to me—and then laid open the sac freely. Examining the cavity carefully, he found it smooth, polished, and pearly white, but at its upper portion, just where it began to be reflected over the testis, was a small, round, granular-looking mass about the size of an ordinary English pea. This he sliced off with a pair of scissors, and at once recognized the patulous mouths of three or four small vessels which did not bleed. These he dissected back for a short distance, and found that they passed into the connective tissue around the upper border of the testis. He then passed a ligature around the mass and brought the ends of the ligature to the outside, excised all the front wall of the tunica, and closed the sac. The patient recovered, and there was no return of the hydrocele. Although it is to be regretted that the patulous vessels were not watched for a few minutes, I do not think there can be any reasonable doubt that there was here a lymphatic varix, and that the chylous fluid in the tunica was the result of leakage through its walls. Since the patient had had gonorrhoea, Busey,¹¹ in his remarks on this case, suggests that the obstruction to the onward movement of the lymph, and the cause, therefore, of the dilatation and rupture, was inflammation attacking a single gland or an area of lymphatics.

¹¹ Occlusion and Dilatation of Lymph-Channels, by Samuel C. Busey: A series of papers reprinted for private distribution from the New Orleans Medical and Surgical Journal, from Nov., 1876, to March 1878.

If it be acknowledged, then, that in chyluria some direct communication must exist between the lymphatic and urinary systems, how is this communication brought about? Various causes have been supposed at different times to be responsible for this condition, among them traumatism in its various modes of occurrence, such as being thrown from a horse. Mental shock has also been held responsible. So, also, syphilis and hereditary tendency. But most cases still remained unaccounted for when, on August 4, 1866, Wücherer first detected in the chylous urine of a woman in the Misericordia Hospital at Bahia an unknown worm. In 1872 it was announced that Timothy R. Lewis had found in the blood, and also in the urine, of a person suffering with chyluria in Calcutta, a delicate thread-like worm about ¹/70 of an inch long and ¹/3500 of an inch wide. This observation was confirmed by Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since then the filaria has been found in the blood and urine of many cases. Lewis found six in a single drop of blood from the ear, and estimated 700,000 as approximately correct for the whole body. But Mackenzie calculated that there were in the blood of his patient from 36,000,000 to 40,000,000 embryo filariæ. These minute nematodes, discovered by Wücherer and Lewis, proved to be, as was indeed early suspected, the larvæ of a larger filaria which was discovered by Bancroft of Brisbane, Queensland, Australia, in December, 1876, first in a lymphatic abscess in the arm, and afterward in the fluid of hydrocele of persons infested with the smaller worm. The parent worm is about the thickness of a human hair and three or four inches long. It was named, by Cobbold, Filaria Bancrofti. Lewis himself found, in August following, a male and female of the parent worm, in a scrotum infiltrated with chylous fluid, in a case of elephantiasis. The female contained ova with embryos precisely like those found in the blood and urine. The worms are viviparous, but abortions seem frequent, ova being frequently discharged unhatched.

It has been rendered highly probable, by the researches, first, of Manson in China, and later of Lewis in India and Sonsino in Egypt, that the filaria in its fully-developed form is introduced into the stomach and intestines of man with water. Thence it makes its way into the blood and lacteal system, where it reproduces the embryo filariæ. These embryonic or larval filariæ are taken from the human blood by a mosquito, in the body of which it undergoes further development, after which the perfect Filaria Bancrofti is deposited in water, through which it again reaches the stomach of man, and thus the disease is perpetuated.

One of the most singular features in the history of the filaria is its nocturnal habit. It is found in the blood only at night, unless, as Mackenzie has shown, night be converted into day—that is, if the hours of sleeping and waking be reversed. In Mackenzie's case the worms appeared about seven o'clock in the evening, increased up to midnight, and disappeared by eight or nine o'clock in the morning. What becomes of them at the time when they are undiscoverable in the blood is as yet unknown.

Acknowledging filariæ to be the essential cause of chyluria, the precise method in which they operate to cause the obstruction, dilatation, and rupture of the lymphatics is a matter of speculation. The embryo filariæ are so lithe and small that they move among the corpuscles [p. 119] apparently without harming them, but the ova in which the embryos lie coiled up, and which are often discharged unhatched, are large enough to cause obstruction in the smaller lymphatics and lymph-passages of the lymphatic glands, and thus cause the phenomena of chyluria, as well as of the other diseases of the lymphatic system with which it is often associated, or which may occur independently of it, such as elephantiasis, cutaneous lymph-vesicles with their chylous and lymphous discharges, lymph scrotum, chylous hydrocele, and other diseases of the lymphatics. Indeed, the total number of affections other than chyluria which are found associated with filariæ exceed those of chyluria. Among the diseases with which it is said to be associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the discovery of the Filaria sanguinis hominis has shed a flood of light upon the subject of chyluria, the fact must not be overlooked that not a few cases of the disease have occurred in which the most careful search has failed to find this parasite in the blood. Careful examinations, during waking and sleeping hours, have been made without result, so that we cannot deny altogether the possibility of the disease occurring independent of filariæ as the cause. It is common, therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of persons apparently in perfect health. Manson tells us that out of every ten Chinamen taken at random, at Amoy, the blood of one will contain filariæ.

MORBID ANATOMY.—There can hardly be said to be any morbid anatomy of chyluria, unless we regard the lymphatic lesions which sometimes accompany it as a part of the disease. Again and again do we read the reports of autopsies at which the kidneys were found normal, and where lesions have been noted they were such as are found due to other causes, and the coincidence was accidental.

SYMPTOMATOLOGY.—Apart from the characteristic urine of the condition, there are no symptoms which can be regarded as in any way peculiar to the disease. The mode of onset is usually sudden, and yet many patients experience no symptoms whatever, and would be quite unaware that they were afflicted in any way, were they not aware of the fact that they are passing lactescent urine. Since the discharge is, however, a drain of very valuable nutrient and force-producing material, most patients sooner or later gradually grow weaker; and this symptom of weakness becomes sometimes very marked, so that they fall into a condition of extreme debility, even to fainting on exertion.

Another symptom sufficiently frequent to deserve mention is pain in lumbar region, sometimes very severe, sometimes on one side, at others on both.

Painful micturition, due to obstruction, is also a symptom traceable directly to the condition of the urine. The disposition of chylous urine to coagulate has already been alluded to. The coagulation taking place in the bladder, it is the clot which sometimes obstructs the urethra and makes urination difficult or impossible. Plugs of coagulum are ejected, sometimes with considerable force, after prolonged straining, and with this comes relief to the symptoms, which may be reproduced through the operation of the same cause.

Other symptoms which are occasionally present may have an accidental relation to the affection, while they may be due to it. Such are headache, nausea, and other gastric symptoms.

Mention has been made, too, of the concurrence of superficial lymphatic leakage, especially on the lower part of the abdomen, the thighs, and the legs. Such leakage is often from little vesicular elevations which are evidently dilated lymphatic vessels. The presence of such leakage should suggest the examination of urine for lesser degrees of chyluria. In like manner, the urine should be examined in case of elephantiasis, lymph-scrotum, and chylous hydrocele, with which also chyluria is sometimes associated.

The effect of intercurrent febrile states, whether symptomatic of local inflammation, as of the lungs, or whether the result of the idiopathic fevers, has often a singular effect on chyluria in causing its disappearance for a time. It would seem that states of high vascular tension, however induced, tend to make it cease.

While chyluria has made its appearance, for the first time, in a number of cases during pregnancy, this condition in other instances has caused it to disappear, especially toward the later months; whence it would seem that the pressure of the rising womb has a favorable effect.

The DIAGNOSIS of chyluria consists in the recognition of the chylous state of the urine. This, ordinarily very easily recognized, might be taken in its slight degrees for phosphatic or uratic or purulent conditions of the urine, and vice versâ. The disappearance of the first on the addition of acids, of the second on the application of heat or alkalies, will resolve any doubt, while the microscope will detect the pus-corpuscles in the last. None of the reagents named will dissolve the fatty molecules of a chyluria, while ether will cause the fluid to clear up completely.

The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and when such is the case it is from exhaustion—from the drain to which the system is subject. Tubercular phthisis is therefore a not infrequent immediate cause of death.

TREATMENT.—On the supposition that filariæ are the essential cause of the disease, the rational indication would be first to destroy them by the introduction into the blood of some parasiticide; and, second, to repair the lesion of communication between the lymphatic system and the urinary passages. As yet no agent is known which would not be as fatal to the host as to the filaria, if used in sufficient quantity to destroy the latter; nor has it ever been possible to find the point of communication between the two systems, although treatment has been directed to producing closure of such communication, and with some show of success. Thus, in a case under his care Dickinson of London injected into the empty bladder twelve ounces of a solution of perchloride of iron, containing at first two drachms of the tincture to the whole quantity, gradually increased to four drachms. The solution was retained in the bladder for from eight to twelve minutes with little or no inconvenience. The operation was repeated almost daily for twelve days. The effect was always to check the milky flow and to substitute a clear urine. But after the operation had been repeated a certain number of times there was a decided rise of temperature, with headache, nausea, lumbar pain, hæmaturia, and albuminuria which continued a short [p. 121] time after the hæmaturia ceased. Singularly, too, with the subsidence of these symptoms, the chyluria remained absent for some time. The injections were resumed on its return, and each time were followed by relief. In the course of their use, however, the strength of the solution was increased to an ounce of the perchloride to twelve ounces of water, and the strongest solutions were retained in the bladder for as much as an hour, the weaker longer. Ultimately, however, the use of the injections became so painful that they had to be discontinued.

Another measure, employed by Bence Jones, was abdominal pressure by means of a belt. This also, in his experience, relieved the lumbar pain. In his case, which was about eight years under observation, Dickinson applied the pressure by a sort of tourniquet about an inch below the umbilicus. This lessened, though it did not stop, the pulsation in the femoral arteries. It also was successful at first, the chylosity lessening, and finally ceasing, but on the removal of the belt the chylous character gradually returned, and in sixteen hours was as bad as before. Repeated trials were followed by the same transient effect, but no cure. Under this treatment, however, combined with a liberal diet and rest, the patient gained many pounds in weight, and was able to leave the hospital and resume her occupation as dressmaker, the pursuit of which, and the absence of the favorable conditions of hospital-life, as invariably caused a return of the symptom and its resulting debility, which again caused her to seek admission.

Rest, therefore, and an abundance of good nourishing food, tend at least to counteract the exhausting effects of the disease, and even to cause the discharge to cease. Tonics, and especially chalybeates, are indicated for the former purpose.

As the relaxing effects of warm climates and warm weather seem to predispose to the condition and to aggravate it, removal to cooler latitudes and places is indicated.

Astringents, internally administered, naturally suggested themselves at an early date, and were used by Prout, Priestley, and Bence Jones. The latter especially thought gallic acid useful. He reports a case in which the disease did not return after its long-continued use. Goodwin of Norwich, England, also reports a case in which the chyluria was controlled by the gallic acid, but returned in four or five days after the remedy was discontinued. It again disappeared on resuming the drug, and the patient could at any time render the urine nearly normal in appearance by taking it. The case was lost sight of before it could be regarded as cured. Waters also reports a case which apparently recovered completely after nine weeks' treatment by gallic acid. He gave at first 30 grains a day, which were gradually increased to 135 a day, and then gradually reduced.

Other astringents which have been used are tannic acid, matico, or acetate of lead, nitrate of silver, the mineral acids.

Mangrove was successfully used in a case related by Bunyan of British Guiana. It was used in the shape of a decoction at the suggestion of a negress, an ounce being taken four times a day. In seven days the patient was so much relieved that the remedy was discontinued for two days, but the symptoms returned. They again disappeared when the drug was resumed, and two subsequent attacks were immediately cut short by the remedy. Roberts suggests that it may act as a parasiticide, [p. 122] and suggests larger and sustained doses of the iodide of potassium for the same purpose.

Retention of urine, when present, should be treated like the same symptoms under other circumstances, by catheterization, washing out the bladder with tepid water, warm fomentations, and similar measures. It has even been suggested to wash out the bladder with ether under these circumstances.

As it seems impossible for the embryo filariæ to develop in the human body into the fully-developed Filaria Bancrofti, it is evident that with the death of the latter, which must occur sooner or later, the production of embryos must cease, while those previously produced must sooner or later also die, and in this way a spontaneous cure take place—just as a person infested with trichinous disease will ultimately recover if the introduction of the trichinæ cease and he is able to survive the irritation caused by the presence of the parasite in his muscles. In this manner we may account for the spontaneous disappearance of the disease in so many instances where all treatment has proved unavailing.

DISEASES OF THE BLADDER.

The bladder is a patient organ, and rather slow to resent injuries from within or without. It never inflames on account of such general causes as the influence of cold, anæmia, cachexia, or a depressed state of the general system. Any of these causes may act as adjuvants, but alone they are not effective. Thus a chilling of the legs, inoperative upon an individual with a healthy bladder, is a prime factor in exciting inflammation in the bladder of an old man with an enlarged prostate; while the simple passage of a sound upon an individual suffering from anæmia might provoke a cystitis which the same traumatic cause would not have produced upon a patient in a thoroughly healthy condition.

Yet inflammation of the bladder is very common. It is sometimes a malady, more often a symptom produced by some other malady (stricture, prostatic enlargement, stone), and only to be overcome by detecting and removing its cause. The causes of inflammation of the bladder therefore include nearly all the maladies to which the bladder is liable.

The varieties of cystitis take name from that tissue of the viscus which is involved, and from the modality of the inflammation.

We have—

This short section upon a surgical subject, only being granted a few pages in a medical work, cannot include a description of all these conditions, or more than a general outline of acute and chronic catarrhal cystitis. Suffice it to say for the other varieties that interstitial cystitis depends upon mucous cystitis or peri-cystitis, and is an inflammation of the muscular coat of the bladder, sometimes culminating in abscess, sometimes in concentric hypertrophy—i.e. contracture of the bladder. Peri-cystitis and para-cystitis occur in connection with peritonitis and pelvic cellulitis, and the peripheral inflammation may extend inward and involve the muscular and later the mucous coat.

All these conditions are grave only in proportion to the intensity of the malady causing them and to which they are subordinate.

Gangrenous cystitis occurs after injury, and occasionally in profound septicæmic conditions (puerperal) or after intense cantharidal poisoning. It is fatal.

True diphtheria of the bladder occasionally, but very rarely, accompanies general diphtheritic conditions, and is a very grave malady. Membranous cystitis is less grave, may be partial or complete. I have a fibrinous cast of a female bladder which was extruded through the meatus. This malady occurs sometimes as a late complication of advanced chronic cystitis mucosa in the male. Recovery is quite possible.

Cystitis mucosa is a common disorder, constantly encountered by the physician as well as the surgeon. The irritable bladder, sometimes called cystitis, demands description here, as it may go on to become subacute or even acute cystitis of the vesical neck.

Irritability of the bladder is a neurotic and not an inflammatory condition, although it may lead to the latter state and terminate in it. The bladder is said to be irritable when the calls to urinate are too frequent, generally with little or no pain. As a rule, the urine is clear, containing no pus or a quantity entirely disproportionate to the frequency of the call to urinate.

In true irritability of the bladder the patient sleeps all night, although he may have to empty his bladder every hour or two by day. There is sometimes a sense of weight, heat, or throbbing, more or less intense, in the perineum; the desire to urinate is normal but imperious; the satisfaction after the act is complete, and no pain accompanies its performance.

This condition of things is generally either neurotic directly, or indirectly (reflex). In children it may be caused by a tight prepuce, especially if irritated by retained smegma, by teething, by the existence of intestinal worms; and it may accompany chorea. It gets well by lapse of time or is cured by removal of the cause. In the adult it is most common in young men and recent widowers, and is often an expression of sexual distress due to sexual stimulation without relief, to sexual excess, or to improper sexual hygiene. The irritation of acrid urine will also cause it, as well as such peripheral troubles as a narrow meatus urinarius, a tight prepuce, urethral stricture, moderately enlarged prostate, kidney irritation (stone in the kidney, etc.). It appears in old men, sometimes, apparently, as a forerunner of organic prostatic changes.

Such stimulation as a glass of wine or beer, pleasant company, absorbing occupation, may cause it to disappear temporarily. It is habitually better in dry, clear weather, and worse in damp seasons when the wind is east. Worry, anxiety, fatigue, depression of spirits, and similar causes aggravate the condition. It is better for the first twenty-four hours after sexual intercourse, and worse than it was before during the next following twenty-four hours.

The SYMPTOMS of pure irritability are simply a frequent desire to urinate during the waking hours, the act not being attended by pain and the urine being reasonably clear.

The PATHOLOGY of this affection is not definitely known. It seems [p. 125] to be an essential neurosis involving the sensitive nerves of the deep urethra and neck of the bladder, attended, if long continued, by surface congestion of the deep urethra and neck of the bladder, and ultimately the phenomena of inflammation; for the very mechanical act of allowing the bladder incessantly to empty itself too often, and to squeeze its own neck, will, in many cases, after a time, lead to traumatic inflammation of mild type.

TREATMENT.—Marriage is a very effective treatment of pure vesical irritability when there is a sexual element in the case.

If any peripheral or local cause exists (stricture, contracted meatus, dense acid urine), its removal will effect a cure. Alkaline diluents, notably the citrate of potassium in gr. v-xxx doses, administered midway between meals, copaiba, or cubebs in moderate doses, often gives relief. Tonics, the tincture of the chloride of iron, and arsenical preparations are often of great value. The tincture of hyoscyamus in minim x-lx doses may be combined advantageously with any of these remedies.

One of the most efficient of all methods of treatment is the use of the conical steel sound, as large as the urethra will admit without violence. The sound should be warmed, lubricated, and gently carried into the bladder at intervals of two to four days. The daily passage of the sound is objectionable, even if it gives relief at first, for it is liable to kindle a slow inflammation in a urethra unaccustomed to its use. When a sound is inserted it should not be left an instant in the bladder, but should be gently withdrawn as soon as it has been fully inserted. If left in the urethra, it does no good, and may act upon the cut-off group of muscles in the membranous urethra, causing them to contract spasmodically, as in the physiological performance of the coup-de-piston after urination. Such contraction bruises the sensitive mucous membrane of the urethra against the hard sound, and does mechanical damage.

The sound acts in three ways: It (1) mechanically distends the irritable contracted cut-off muscle and seems to quiet its contractile tendency. It (2) squeezes all the blood from the passively congested vessels of the irritated mucous membrane, thus ensuring a new supply of blood to the part and an improved circulation in the reaction which follows the irritation. It (3) mechanically, by contact, blunts the sensibility of the terminal sensitive nerves in the mucous membrane of the deep urethra. In this way the sound acts, and its effects generally last several days, often a week. Its good effect is also instantaneous. The slight feeling of weight and discomfort in the perineum which the patient has before its use is gone instantly, and replaced by a feeling of comfort. When this immediate sense of relief is not experienced, it is doubtful whether such a case will yield to the simple treatment by sounding.

It is a mistake to suppose that any ointments smeared upon a sound do good in this condition. Mercurial, belladonna, and other ointments are used, but they are all and entirely rubbed off the sound before it reaches the deep urethra, and their good effect probably resides solely in the imagination of the physician and the credulity of the patient. Ointments are undoubtedly of service in some obstinate cases, notably strong tannic-acid mixtures, and sometimes iodoform, but these cannot be carried to the deep urethra by being rubbed upon a sound. The cupped sound may be used to effect this very neatly, the little cups on the sides of the [p. 126] curve of the sound being filled with the ointment which it is proposed to carry down and apply to the affected spot. A few drops of a mild nitrate-of-silver injection also give decided good results in some cases. The solution should vary between two and ten grains in the ounce of water, and may be accurately applied by means of a Bigelow or an Ultzmann syringe, a few drops being thrown into the membranous urethra. After the application, which should be made only when the patient has a full bladder, urination will wash out the canal and good effects may be looked for—not immediately, as after sounding, but after the irritation produced by the stimulating application has subsided.

Acute cystitis sometimes involves only the neck of the bladder; in other cases the whole mucous lining of the bladder is included in the morbid process.

The causes of acute cystitis may be grouped under six heads:

1. Traumatic.—Under this head may be ranged all injuries from without, with or without fracture of the pelvic bones—wounds, rupture of the bladder, the pressure of the child's head during labor; injuries from within, as during the use of instruments, by stone, or pedunculated tumor. The list may be increased by such chemical traumatisms as those produced by ammoniacal urine in cases of atony or paralysis, by excessively acid urine in neurotic conditions of the neck of the bladder. Such chemical causes, it will be observed, commonly act in conjunction with another cause. Irritating injections without any co-operative cause are capable of lighting up acute cystitis.

2. Extension of neighboring inflammation—gonorrhoeal cystitis and that attending prostatic inflammation, pelvic abscess, pelvic cellulitis, peritonitis from neoplasms growing at the vesical neck, tubercle, cancer, etc.

3. Medicinal—from cantharides, sometimes cubebs or turpentine.

4. Specific—in diphtheritic, puerperal, septicæmic conditions.

5. The influence of cold when chronic inflammation already exists.

6. Neurotic—actual, from extreme and long-continued neuralgia of the vesical neck; reflex, from irritation at a distance, tight meatus, stricture, inflammation of the seminal vesicles, kidney irritations.

SYMPTOMS.—The symptoms of acute cystitis are (1) frequent painful urination by night as well as by day, the pain being greatest at the close of, and immediately after, the act, and the pain persisting more or less between the acts, radiating from the perineum; (2) moderate fever, sometimes announced by chill; (3) commonly great despondency and a depression of spirits totally disproportionate to the degree and significance of the local inflammation; (4) the urine invariably is milky, with pus: it may at first be acid and of normal odor; it is often tinged with blood, especially toward the end of the act of urination. In extreme cases the urine may contain membranous or sloughy shreds or gangrenous gases. The urine eventually becomes alkaline, and finally deposits lumps of pus and abundant triple phosphate crystals.

Complications occurring with the cystitis yield appropriate symptoms. [p. 127] Such possible complications are congestion and engorgement of the prostate, possibly going on to abscess; epididymitis, orchitis, inflammation of the seminal vesicles, inflammation running up the ureters, pyelitis, surgical kidney; abscess in the walls of the bladder or in the connective tissue about the same; very rarely peritonitis or suppurative phlebitis in the veins about the neck of the bladder.

The pathological changes produced by acute cystitis are similar to analogous changes upon the other mucous membranes: patches of more or less brilliant uniform or punctate redness, perhaps surrounding small ecchymotic areas; a softened, swollen mucous membrane; enlarged follicles near the neck of the bladder, perhaps ulcerated spots; possibly false or true diphtheritic exudations (such exudations have been especially noted in cantharidal cystitis); possibly interstitial abscess of the bladder-wall, or even suppurative phlebitis in the veins about the prostate and neck of the bladder, as observed by Walsham¹ in a case of cystitis due to over-distension. This last complication is happily exceptionally rare.

¹ London Lancet, May 10, 1879, p. 665.

The PROGNOSIS varies with the cause of the cystitis, and as the latter often cannot be entirely removed, the acute cystitis may only be moderated so as to be made to assume the chronic form. When the cause can be entirely removed, acute cystitis gets well and leaves the bladder absolutely sound.

TREATMENT.—Acute cystitis from whatever cause requires a uniform general line of treatment. Anodynes are essential both for the patient's comfort and to prevent the constant straining to empty the bladder to which the unremitting, painful desire to urinate impels him. Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j doses, or any of the opiates by the mouth, or in suppository preferably combined with extract of belladonna in small dose. Sometimes quarter- or half-grain suppositories of extract of belladonna alone at intervals of six to eight hours keep the tenesmus more in check than anything else, but belladonna used too freely may bring on retention by causing spasm of the cut-off muscles. Camphor is useful, especially in strangury from cantharides. Rest in bed is essential in most cases, preferably with the hips raised. Heat in some form, as a hot poultice, fomentation, spongio-piline, hot-water rubber bottle, etc. over the hypogastrium preceded by a mustard plaster, gives great comfort. Hot-water hip-baths of short duration and frequently repeated are of service in most cases.

Alkalies are valuable, especially in the beginning of an attack—liq. potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with an anodyne or some demulcent drink.

Infusions and extracts of corn-silk, dog-grass root, buchu, pareira brava, uva ursi, etc. are of some assistance, but generally not so comforting as some of the bland diuretic waters—Bethesda, Mountain Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled water or rain-water, especially if taken warm, is a good diluent diuretic. On the advent of acute cystitis all instrumentation upon the bladder should, if practicable, be postponed, all stimulating drugs (cantharides, turpentine, cubebs, alcohol) stopped, and stimulating foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a highly nitrogenized diet are not allowable. The rectum should be kept empty and complications treated as they arise.

Catarrh of the bladder is chronic inflammation of the mucous membrane of the urinary reservoir, with more or less thickening of the walls of the bladder. This malady, so apt to persist for years, is probably more commonly encountered by the physician than acute cystitis. Acute cystitis, however, frequently complicates the chronic malady by occasional outbursts of acute symptoms. Thus an attack of the stone is acute calculous cystitis interrupting the course of chronic vesical inflammation due to stone. Catarrh of the bladder may follow acute cystitis, or it may commence insidiously as a subacute disorder, and be catarrh, in the popular sense, from the first.

The causes of catarrh of the bladder are never single. It always takes two causes to produce true catarrh of the bladder—one mechanical, and one chemical. After a traumatism inflicted on a healthy bladder, with proper care the patient recovers entirely. If, however, he insists upon keeping up and about, continues to drink liquor, and does not avoid straining at urination, the membrane about the neck of the bladder, irritated by the ammonia from the decomposing urine, secretes an excess of viscid mucus, the pus becomes gelatinized by the ammonia, the constant straining leads to hypertrophy of the muscular coat, the nerves lose their acute sensitiveness, and the milder persistent malady, chronic catarrh, is set up, to continue perhaps for an indefinite period.

Infiltrations of the bladder-walls with tubercle or cancer, urinary calculus, and, notably, enlarged prostate, stricture of the urethra, tumors of the bladder, hernia of the bladder, exstrophy, over-distension of the bladder from stricture, spasm of the urethra, coma, paralysis, or other cause, may be the traumatic element, while the liberated ammonia from the alkaline decomposing urine furnishes the chemical element; and the two causes, if continued, occasion and maintain the condition known as chronic catarrh of the bladder. In coma or the delirium of typhoid fever or paraplegia or hemiplegia (sometimes) the bladder becomes over-distended and atonied, perhaps paralyzed. Here the use of the catheter appropriately, with great gentleness, may relieve the patient without even the intervention of acute cystitis; while, on the other hand, acute cystitis may come on and be cured, or, if ammoniacal urine be allowed to accumulate and the bladder be not washed out so long as it is unable to entirely expel its contents, chronic cystitis, catarrh, results. I have known several cases of partial paraplegia and other disorders in which the patient could void no drop of urine except through a catheter, where there never had been any chronic catarrh, no stringy mucus, hardly a pus-corpuscle, through long years of the disability, owing to intelligence in the attention to emptying and washing out the bladder instituted by the physician having first charge of the case.

As prominent among the causes of chronic catarrh in a purely medical aspect it may be well to insist upon the ease with which this condition is sometimes brought about by the physician himself. A man with a weakened bladder may carry a pint or much more clear urine in his bladder constantly during many years as a residual deposit which his weakened bladder cannot throw off. Excess over the fixed residuum produces a desire to urinate, and the patient, mainly by voluntary contraction of the [p. 129] abdominal walls, voids that excess. If now the physician finds this globular accumulation in the patient's belly, and in his zeal to do all that is possible forgets his caution, he may throw the patient first into an acute cystitis (if haply he escapes collapse), and then into chronic vesical catarrh—an affair perhaps of a lifetime. Surgeons have noticed, and especially Sir Henry Thompson has pointed out, that a dirty catheter may poison the urine and bring about a cystitis which otherwise might have been avoided; and observers from all time have noticed that the sudden entire evacuation of the contents of a bladder long accustomed to over-distension is in itself a grave cause of serious inflammatory disturbance to the mucous membrane of the bladder. Recently much attention has been called to this condition and its possible fatal termination by Sir Andrew Clarke, under the name of catheter fever.

The deductions from a knowledge of these facts are obvious: they are—(1) always to thoroughly cleanse, and then to disinfect, a catheter on each occasion before its use; and (2) never to empty entirely at a first sitting a bladder which has been long habituated to over-distension; and when, finally, the bladder is emptied, always irrigate it with a disinfecting solution (borax) after each emptying.

SYMPTOMS.—Chronic cystitis varies in grade, and its symptoms vary with the grade of the inflammatory process. There is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. The sight is pitiable and never to be forgotten. On the other hand, a man may continue about and at his work with a patient flabby bladder containing constantly more or less stringy mucus and ammoniacal urine, suffering little or no pain or tenesmus, and perhaps having no subjective symptoms except a slight sense of weight in his lower belly and a rather frequent desire to urinate.

Between these limits the symptoms range, but in a general way it may be said that the symptoms of chronic vesical catarrh are these: frequent calls to urinate, attended by more or less pain, especially toward and after the termination of the act. The sense of satisfaction normally felt after urination is generally absent. Motion, particularly jolting as in rough riding, causes pain. This pain is referred to the lower part of the belly, to the perineum, to the end of the penis, the urethra, the anus. The straining after urination may be absent or of the most intense character, leading to prolapse of the rectum and causing excruciating torture. The urine always contains pus scattered through it, and generally also more or less pus in that semi-solid condition known as stringy mucus. Stringy mucus is pus gelatinized by the ammonia of the decomposing urine. These clots of muco-pus contain gritty crystals of the ammonio-magnesian phosphate. More or less blood is to be found in the urine, especially during acute paroxysms. Pure blood sometimes follows the urine after each act of urination. Bacteria abound in the fluid, which varies in odor greatly in different cases, not always strictly in accordance with the severity of the actual inflammatory process. Thus, the urine may be simply sweetish in its odor, ammoniacal, flat, and stale, or be possessed of a putrid, sickening sweetness of indescribably nauseating power. Again, it may be rankly rotten. The bottom of the chamber in some cases becomes [p. 130] covered with a thick coating of the viscid muco-pus, which strings out and reluctantly follows the fluid when the vessel is inverted. Sometimes the urine contains shreds of false membrane or putrid masses of sloughy tissue.

PATHOLOGY.—In chronic cystitis the mucous membrane of the bladder undergoes gradual thickening, loses its pink salmon tint, and becomes gray in color. The thickening extends to the submucous layer, and more or less to the muscular walls as well. In cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. In other conditions (concentric hypertrophy), where there has been a serious obstacle to the free outflow of urine without any atony of the muscular coat (stricture of the urethra, some cases of stone and of enlarged prostate), the walls of the bladder may be enormously thickened to the extent of an inch or more, the inside surface rough, perhaps ulcerated.

The thickening of the muscular bands within the bladder often causes them to stand out in bold relief, like the muscular bundles in the heart-cavity. These prominent bundles enclose spaces of various sizes and shapes, and from the bottoms of these spaces sometimes the mucous membrane protrudes between the muscular bands and forms pouches of varying size (sacculated bladder). These pouches consist of mucous membrane alone covered with peritoneum, and may become the seat of encysted stone.

If there has been a subacute grade of the surface inflammation before death, there may be livid spots on the mucous surface of the bladder, punctate or larger ecchymoses, reddened areas from which the epithelium is more or less detached, ulcers with or without sloughs or diphtheritic covering, perhaps perforations of the bladder and infiltration of urine, enlarged mucous follicles, granulations, fungosities, etc. Heterologous deposits, tumor, cancerous and tubercular ulcers, cysts, stone, complete the possibilities of what may be encountered in the bladder at an autopsy upon a patient with chronic cystitis.

The chronic like the acute varieties of cystitis may involve the whole of the inside of the bladder or only a portion of it.

The PROGNOSIS, like that of acute cystitis, varies mainly with the cause. If the latter can be entirely removed (stone), the bladder gets perfectly well. Not so, however, unless all the causes are removed. Thus, a phosphatic stone may grow in a bladder as a result of enlarged prostate and chronic cystitis. The presence of the stone excites the chronic cystitis, and subjects the patient to a crisis of acute cystitis from time to time. The removal of such a stone will by no means cure the chronic cystitis; its removal is only one step in the treatment of the cystitis.

As far as life is concerned, the prognosis of chronic cystitis is good. A patient may live many years with chronic cystitis, particularly if he treats his bladder properly. Although, as generally encountered, chronic cystitis is not curable, few maladies yield results to treatment more gratifying to the physician and the patient than the one under consideration.

The legitimate ultimate termination of chronic cystitis is by chronic [p. 131] inflammation of the ureter and pelvis of the kidney on both sides, interstitial kidney changes, and finally death by suppression. Generally, this end may be almost indefinitely postponed by well-directed efforts of palliative treatment.

TREATMENT.—The acute outbursts of inflammatory disturbance occurring during the course of chronic cystitis require the same means for their relief as those already indicated when considering the treatment of acute cystitis—all the prohibition of stimulants, the use of bland mineral waters, demulcent decoctions, infusions, and alkaline draughts. The anodynes, the rest, the heat, the hip-bath, are all indicated here for the acuter symptoms, just as they are in the acute malady, but very much more can be done both in a prophylactic and in a curative way. A milk diet, even an exclusive milk diet, is an element of great value in cases of chronic cystitis. I have two patients, both old men, now under observation, one of whom recovered entirely from cystitis with complete atony, necessitating the constant use of the catheter, by means of an exclusive milk diet. He takes one gallon of milk a day, and nothing else, and lives among his fellow-men at his work and amusements in entire contentment. He has remained absolutely well on this diet during many years. The other patient could not take milk after fair trial, but gradually emerged from the very jaws of death, due to prolonged chronic cystitis and double pyelitis, by the free use of koumiss, which his wife daily prepared for him. Vichy and milk in equal parts, taken cold, is another form of using the milk diet, and the more modern peptonized milk another.

Light white and red wines, or even a little gin or old brandy, are of decided advantage in the majority of enfeebled old men with chronic cystitis. The patient should be clothed with the utmost care. The feet and legs should be clad in wool unless in the very hottest season, and flannel should constantly encase the belly and loins. Nothing is more detrimental to chronic cystitis than chilling the legs.

Another word is necessary in favor of the internal use of alkaline remedies. Even where the urine is alkaline, ammoniacal, putrid, if the stomach will take an alkaline medicine kindly the effect is generally beneficial, for the urine, especially in old men who are prone to these maladies, is quite certain to be acid at the fountain-head. And even if the urine is immediately altered by chronic pyelitis through ammoniacal decomposition before it enters the ureter, yet it will generally irritate the pelvis of the kidney and the ureter and the bladder less if it be secreted in a bland alkaline state than if it be discharged into the irritated area full of uric acid.

Turpentine, copaiba, cubebs, and the muriate of iron are of service in selected cases, but ordinary astringents seem to possess little or no value. Benzoic acid, in ten-grain doses in capsules, sometimes improves the ammoniacal condition of the urine, but the stomach often rejects it. Boracic acid, which has of late been much talked about, in five- to ten-grain doses in water, three or four times a day, is of value occasionally. Quinine is serviceable where the nerve-force is failing. I have been unable to procure any very decided advantage from the use of salicylic acid or the salicylate of sodium by the mouth.

The most important general surgical principle in connection with [p. 132] chronic vesical catarrh is that which concerns emptying the bladder thoroughly and ensuring its cleanliness. In many, perhaps most, conditions of chronic inflammation of the bladder from atony, paralysis, obstruction, or other cause the bladder fails to empty itself entirely. There remains, therefore, a fixed residuum always in the bladder; and although this is diluted and partly evacuated at each act of urination, yet some of the pus, the bacteria, the ammoniacal ferment, remains constantly in the bladder ready to contaminate each new portion of urine as it descends from the kidneys. This must be disposed of, and the bladder washed out, if a permanently satisfactory treatment is to be instituted.

The soft-rubber catheter is to be preferred where it will pass, otherwise the woven silk or the French Mercier instrument, and the bladder should receive attention at least once in the twenty-four hours, and oftener if required. The last drops of urine should be drawn off and the bladder washed with water at about 100° F., in which is dissolved some borax—a heaping teaspoonful to the pint—or other substance capable of disinfecting the contents or mildly stimulating the circulation of the bladder.

Carbolic acid has not yielded good results in my hands. A host of remedies have been employed, but it is doubtful whether anything can do more good than the water mechanically, borax as a disinfectant, dilute nitric acid, minim i-x to the pint, as a stimulant, or, in some cases, nitrate of silver, gr. ½-x to the ounce, used with caution. The injections should be practised through the catheter which withdraws the urine, and repeated according to their effect. For cleansing purposes an injection of simple warm water may be used at each introduction of the catheter. A fountain syringe with two-way stopcock is the most convenient instrument to use for the purpose of simply washing the bladder, because the wash may be repeated indefinitely until it returns clear, without readjusting the nozzle in the catheter.

Very extreme, long-protracted cases of chronic vesical catarrh justify the performance of lateral cystotomy for their relief, or the modification quite recently proposed by Thompson²—a median perineal incision involving only the membranous urethra, through which a large soft-rubber catheter is passed and tied in for a few days or longer.

² Brit. Med. Journ., Dec. 9, 1882, p. 1131.

The most common vesical neurosis is neuralgia of the neck of the bladder, with or without the accompaniment of irritability of the bladder, spasmodic stricture, or vesical spasm. Irritability of the bladder has been already considered at the beginning of the section on Cystitis. The other neurotic conditions are always more or less interwoven with each other, and they may each and all of them complicate inflammatory states of the deep urethra, prostate, and vesical neck.

The CAUSES of this set of affections are most varied, and range from irregular sexual hygiene (the most common of all) through inflammatory local conditions, peripheral irritations (the most obstinate of which is [p. 133] chronic inflammation of the seminal vesicles, with or without true spermatorrhoea), up to organic changes in the spinal cord and brain.

The PROGNOSIS in neurotic states varies with the cause. Some cases are easily controlled; others absolutely defy all and every treatment of which I have any knowledge.

The TREATMENT involves a removal, if possible, of the cause. Local measures which have been found most effective in subduing the deep urethral irritation are—(1) the gentle passage of a soft bougie or conical steel sound into the bladder at intervals of one to seven days. The instrument should be removed at once. Sometimes it is necessary to cut a narrow meatus or a stricture in the pendulous urethra in order that a sound of large-enough size may be employed to put the sensitive deep urethra sufficiently on the stretch. (2) The application to the deep urethra and prostatic sinus of pastes of tannin or iodoform with the cupped sound or other apparatus, or the injection of the deep urethra with strong solutions of tannin or mild solutions (gr. i-x to ounce j) of nitrate of silver. (3) In the most extreme cases, those furnishing all the symptoms of stone, even cystotomy is justifiable. It nearly always furnishes a temporary, sometimes permanent, relief.

Medical measures include all the bland diluent mineral waters, alkaline and tonic remedies, already considered in discussing Irritability of the Bladder.

Atony of the bladder is more or less lack of expulsive force, due to failure in power of the muscles of the bladder, the nerves remaining sound. Paralysis is the same condition perhaps more pronounced, but due to central origin. A patient may be unable to pass water in more than a dribbling stream, but if he has true organic stricture or spasm of the deep urethra, the muscular coat of his bladder may perhaps not be to blame for his imperfect urination. The question of atony may be decided in such a case by introducing a catheter of any size that will pass. If there is atony, the stream flows sluggishly from the mouth of the catheter, and toward the end is influenced by the breathing of the patient. If there is no atony, the stream rushes through the catheter, and maintains its force until the last drop flows away. In paralysis and extreme atony the influence of the descent of the diaphragm during inspiration is noticed during the whole course of the flow of the sluggish stream through the catheter.

The CAUSES of atony are over-distension of the bladder, voluntary (by persistently neglecting the call to urinate), involuntary retention (from fever, coma, stricture, large prostate), and a certain intrinsic, sometimes inherited, tendency to weakness on the part of the bladder, noticed by some people during their entire lives.

Atony is most common, often a part of their malady, in old men with enlarged prostate. Paralysis of the bladder accompanies certain organic changes due to injury or disease in the spinal cord or brain. Both in atony and in paralysis the bladder may be constantly distended to a certain extent, perhaps to its utmost limit, as a passive sac, and the excess of urine over this uniform residuum may dribble away involuntarily [p. 134] (false incontinence), or may be expelled in small portions by repeated acts of urination performed in the ordinary way or by the aid of great straining and assistance from the voluntary contractions of the muscular walls of the abdomen. No condition of incontinence of urine can be considered proved until demonstrated by the passage of a catheter. Both atony and paralysis may get well under proper treatment in favorable cases. Many cases are incurable, but the discomfort they tend to cause may be almost entirely counteracted.

TREATMENT.—Under all circumstances where the bladder cannot empty itself, the catheter should be used, and the bladder should be washed out, kept clean, and disinfected. All the suggestions laid down for catheterization and vesical injection in the section on Chronic Cystitis are applicable here and need not be repeated. It is particularly necessary to disinfect the catheter on each occasion before it is introduced. This is best effected by washing the catheter outside and inside with a 5 per cent. solution of carbolic acid in water, and finally washing it outside with clean water, before its introduction. If the bladder is over-distended, it should not, as a rule, be entirely emptied at the first introduction of the catheter, for fear of possible collapse, or, what is more to be dreaded, setting up acute cystitis by suddenly taking off all the internal pressure from the vessels in the walls of the weakened bladder, to which pressure the circulation has become accustomed. If, therefore, the bladder is emptied inadvertently, it is better to inject a few ounces of warm water containing borax in solution (a teaspoonful to the pint), and leave it in until the next catheterization. The quantity left in may be reduced at each sitting. By careful attention to these means most cases of over-distension due to atony or paralysis may be relieved without the intervention of cystitis, or with so little that it does not become a serious factor in the case.

The medical treatment of these cases is less important than the mechanical. Under the latter alone and improvement in general health curable cases often get well. Milk diet is of service, and iron and tonics of considerable value in proper cases. Electricity has not yielded satisfactory results in my hands, and I have not derived the advantage from ergot which is often claimed for it. In cases of atony I think I have seen good results sometimes follow the use of strychnine internally in pretty full doses. The same remedy under the skin acts more promptly and more effectively if it is to do any good at all. In true paralysis of central origin the cure of the bladder depends upon relief of the original disease and local treatment to the bladder.

Hysterical women sometimes feign paralysis in order apparently to secure the sympathy and personal attention of the physician. The application of the actual cautery above the pubes, and entrusting a female nurse with the function of catheterization, is generally effective treatment in these cases.

After all sorts of wounds and injuries to the bladder, and in cases of rupture of the viscus, blood is found in the urine. In certain medical [p. 135] conditions, in scurvy, hemorrhagic eruptive diseases, cases of vicarious menstruation, it has been noticed. In strangury due to cantharides, or in any condition of acute or chronic cystitis with considerable spasm of the bladder, the urine contains more or less blood. Especially is this true if ulceration exist at or near the neck of the bladder, as in tubercular or cancerous cystitis.

In cases of stone in the bladder one of the cardinal symptoms is vesical hæmaturia, while in villous growth often the only symptom of the malady is repeated attacks of more or less profuse bleeding from the bladder coming on unexpectedly, without obvious exciting cause, and showing no regularity in the length of the intervals between the hemorrhages or the intensity or duration of the latter. Outbursts of unexpected hemorrhage are not uncommon in connection with some cases of enlarged prostate and chronic cystitis, while these outbursts are the rule, sooner or later, in most cases of true cancer of the bladder.

The DIAGNOSIS is often very important—that is, in a given case to decide whether the blood comes from the bladder or from the kidney. This may usually be ascertained by a very simple manoeuvre, especially when the flow of blood is not excessive: a silver catheter of short curve is introduced and the urine drawn off, the bladder gently washed several times without moving the catheter, and the shade of red in the wash noted. Now, the bladder being slightly distended with warm water, the point of the catheter is moved somewhat roughly in all directions and made to touch different portions of the wall of the bladder. The water is now allowed to escape, and its deepened color will decide that the hemorrhage has a vesical origin, for manipulations of a silver catheter in a healthy bladder will not occasion a flow of blood. In doubtful cases on two occasions I succeeded in locating the point whence the blood escaped as follows: In one I passed a soft catheter, and washed the bladder until the wash escaped nearly clean; I then withdrew the catheter until the point reached the membranous urethra (the bladder having been left full of clean water), and immediately passed the instrument again and withdrew the contents of the bladder, which were now brilliantly colored, thus locating the bleeding point in the prostatic sinus. In the other case, that of a young man with moderate stricture, whose urine was nearly solid with blood, I noticed that no blood escaped by the meatus between the acts of urination; therefore the bleeding point was posterior to the membranous urethra. Was it in the prostate, the bladder, or the kidney? To decide this I passed a soft catheter and washed the bladder until the wash flowed clear. I then injected some warm water, withdrew the catheter, and caused the patient to empty the bladder. The flow was brilliant with blood. In both these cases I effected a cure by one application of solid nitrate of silver through the urethra to the prostatic sinus.

The TREATMENT of vesical hæmaturia is the treatment of the cause, which, if possible, must be ascertained. For the symptom itself the internal use of iron, turpentine, opium, gallic and tannic acids, are of service. I have not derived any advantage from ergot. Locally, rest in bed, ice over the region of the bladder, and avoidance of straining at urination are generally all that is necessary. I have had good results from injecting the bladder with a solution of alum, gr. i-ij to ounce j of warm [p. 136] water, and cures have been effected by injecting nitrate of silver in solution. It is not well to inject iron in solution, since this substance makes a hard clot, and a soft clot is preferable. When the bladder fills up with a solid clot of blood, the best treatment, according to my experience, is to administer opium freely and diluent drinks. The urine slowly dissolves the clot, which has already arrested the hemorrhage, in most cases by its pressure, and the blood flows away as a dark coffee-ground material, sometimes nearly black. If the catheter is used, the clot broken up or dissolved with pepsin or other substance, and washed or pumped out, a new clot is apt to form at once; and although this treatment is based on high authority, and is often practised successfully, it is a question whether the patient would not in many cases do as well, or better, by being let alone, soothed by opium, until the urine dissolves the clot and nature relieves him.

These belong strictly to the province of surgery, but they fall also under the notice of the physician. Tubercular disease may involve the whole mucous surface or only the neck of the bladder; cancer may infiltrate its walls or grow out as a solid tumor in the vesical cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and cysts, simple and hydatid, have been encountered; villous growths, both benign and cancerous, may occur. These morbid deposits give rise either to recurrent hemorrhage or to varying grades of chronic cystitis. The diagnosis is often difficult, the treatment generally palliative. Much has been done of late in an operative way for the relief of tumors of the bladder, and some brilliant results have been secured by operations through the perineum as well as above the pubes. A tumor of moderate size may be detected by the searcher within the bladder, and often may be grasped in a lithotrite and measured. Such a tumor can generally be plainly felt by conjoined palpation in a thin subject, one hand pressed firmly down behind the pubes and two fingers of the other hand passed into the rectum. Recently, Sir Henry Thompson has advocated vesical exploration for purposes of diagnosis through a median incision in the perineum, as for median lithotomy, and has practised it a number of times with a large measure of success. I have made the same exploration several times, and have encountered and successfully removed one tumor. The expedient is worth bearing in mind for use in any obscure cases. It is probably less objectionable and more likely to yield valuable information than the exploration by introducing the whole hand into the rectum (Simon's method).

SEMINAL INCONTINENCE.

DEFINITION.—By the term seminal incontinence, which is synonymous with involuntary or abnormal seminal emissions, pollutions, and spermatorrhoea, is meant the involuntary discharge of semen beyond the limits of health. Although usually described as a distinct disease, it is symptomatic of, and, as a rule, primarily dependent upon, weakness or exhaustion, along with exaggerated irritability, excitability, impressibility, or mobility of the centres which preside over erection and ejaculation. Hence it should be regarded as a motor neurosis, and not as a functional disorder of the testes.

CLASSIFICATION.—Involuntary seminal losses embrace three conditions, which constitute as many varieties of the affection, and which may exist separately, or pass into one another, or be combined. These varieties are, first, nocturnal losses or pollutions, which occur during sleep, and are generally attended with an erection, erotic dream, and pleasurable sensation; secondly, diurnal pollutions, which take place when the patient is awake, are excited by trivial mechanical or psychical causes, and are associated with imperfect erection and diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea, in the strict acceptation of that term, which is characterized by a constant escape of a slight amount of seminal fluid, without the orgasm, pleasurable sensation, or impure thoughts, or during micturition and defecation.

1. Nocturnal Pollutions.—By far the most common of the varieties of seminal incontinence is the first, or that in which the emissions occur during sleep under the influence of an erotic dream, and which may, therefore, be regarded as an exaggeration of the normal or physiological condition. In health, provided the subject leads a continent life, the number of emissions varies greatly, and as they are merely reflex signs of distension of the seminal passages, they are not pathological nor are they attended with ill effects. The knowledge of this fact is of great practical importance, as it frequently enables the physician to assure his patient that the emissions are not abnormal, thereby relieving his mind of a great weight. It is, of course, to be remembered that the frequency of nocturnal pollutions depends upon age, climate, habits, temperament, constitution, diet, and predisposition, and that young men who suffered during childhood from nocturnal incontinence of urine are particularly obnoxious to them. Their frequency also varies greatly in the same person, and it is scarcely possible to determine what constitutes the standard [p. 138] of health merely by the intervals of their repetition, since a number which would be normal in one person would be abnormal in another. In men, however, who possess sound nervous systems and who do not trouble themselves with sexual matters an emission every fortnight is a sign of excellent health; and even if they should occur at intervals of several days, they are not inconsistent with temporary good health. The latter statement is well exemplified by a case which came under my observation in 1882. A druggist, twenty-seven years of age, had had for six years from three to live emissions a week, and occasionally two during a single night, attended with erections and voluptuous dreams, without the slightest evidence of impairment of his health. In all such cases, however, as well as in those in which the emissions have occurred at longer intervals for a number of years, it only requires a little longer time for general symptoms to manifest themselves.

Nocturnal pollutions are to be regarded as pathological when they occur in married or single men who indulge in regular intercourse; when they are followed by backache, headache, enfeeblement of the functional powers of the brain, mental depression, and bodily or mental lassitude; when they take place without erections or dreams; when they accompany or follow acute or chronic diseases; when they coexist with diurnal pollutions or spermorrhagia; and, finally, when they are complicated by one of the varieties of impotence, which may be the only indication that the emissions are abnormal or one of the effects of impairment of the functions of the genital nervous centres. The associated symptoms of myelasthenia and cerebrasthenia vary very much in degree in men of apparently the same amount of vigor and tolerance, and in whom the pollutions occur with equal frequency, or they may even be absent altogether.

2. Diurnal Pollutions.—Ejaculation of semen during the day is fortunately of comparatively infrequent occurrence, since it indicates a more serious condition than do losses of seminal fluid occurring when the patient is asleep, the genital organs and the centres which preside over them being highly impressible or in a state of irritable weakness. In what may be regarded as the lesser form of the affection the ejaculation is due to slight peripheral irritation, induced, for example, by friction of the clothing, crossing of the legs repeated several times, horseback exercise, driving over rough streets, riding in railway-cars, or even shaving, combing the hair, or shampooing the head; while in the more aggravated variety an emission is induced by psychical irritation, such as reading libidinous books, the sight of indecent pictures, dwelling upon sexual ideas, or the mere sight of a female. In the former of these varieties there is a fair erection, but the sensibility is blunted; in the latter the erection is flabby or the penis is flaccid and there is little if any pleasure.

3. Spermorrhagia.—In the third phase of the affection, which is still more uncommon than the second variety, there is a continuous passive loss of semen, without erection or sensation—a condition which depends upon paralysis and dilatation of the orifices of the ejaculatory ducts, and which is most conspicuous during the acts of micturition and defecation. The existence of spermatorrhoea, in the restricted sense of the term, is denied by some authors, but I have myself met with it in five instances, and typical cases have been recorded by other modern writers.

CLINICAL HISTORY.—Seminal incontinence usually supervenes upon [p. 139] the interruption of sexual intercourse, especially when the subject has been accustomed to excessive venereal indulgence, or, as more frequently happens, upon the abandonment of the habit of masturbation. Any one of these varieties may exist separately, but they gradually pass into each other, and are variously intermixed in the advanced grade of the affection. In the mild type there is increased frequency in the occurrence of nocturnal pollutions, ejaculation taking place at intervals of several days or for two or three nights in succession, when there is a respite for a week or ten days. The emissions are associated with disturbances of the nervous system, referable to the brain or spinal cord or to the cerebro-spinal axis, of which mental lassitude and muscular debility are the most common signs. When, as the result of the increase in the irritability of the ejaculatory centre and of the progressive weakness or exhaustion of the entire nervous system, the case goes on from bad to worse, it usually pursues the following course: Abnormal frequency of the nocturnal pollutions is associated with pain in the back, headache, muscular fatigue, and incapacity for sustained mental effort. With the increase in the number of the emissions erection becomes imperfect, ejaculation on coition is frequently precipitate, and the patient complains of dulness of perception, impairment of memory, mental dejection, a dull pain in the occipital region, weakness of vision, vertigo, palpitation of the heart, trembling and numbness of the limbs, shortness of the breath, flatulence, constipation, and other signs of gastric derangement. Diurnal pollutions are now superadded, and intercourse is impracticable, either from failure of erection or from premature ejaculation. The general symptoms, too, are more serious. The patient constantly broods over his condition, assumes that he has permanently lost his virility, and the mental anxiety and dejection verge upon or merge into a condition of sexual hypochondrism. The gait is unsteady; the hands and feet are habitually cold; he is subject to wandering neuralgic and rheumatoid pains; passes restless nights; loses flesh and color; shuns society; imagines that every one recognizes his condition, and fears to look one in the face; and is utterly incapacitated for mental or physical exertion. With the still further increase of the irritable weakness of the genitalia and nervous centres the semen flows continuously out of the urethra, and its discharge is augmented during defecation and micturition. Finally, the man becomes a confirmed hypochondriac, and should he have inherited a tendency to insanity, epilepsy, ataxia, or other nervous disorders, he may lapse into one of these conditions.

In the early stage of seminal incontinence, when the nocturnal pollutions overstep the natural limits, the ejaculated fluid is unchanged. When, however, the pollutions are more frequent and diurnal discharges coexist, the semen is watery and scanty; the spermatozoids are smaller, comparatively few in number, and their movements are liable to be abolished in less than an hour, while spermatic crystals form more rapidly and more abundantly than in health. In the worst cases, or those characterized by diurnal and nocturnal pollutions and by the presence of semen in the urine, the spermatozoids are either entirely absent, or, if they are present, they are motionless, stunted, or variously deformed. In these advanced cases the ejaculated fluid, which consists principally of the secretions of the seminal vesicles and the prostate, frequently undergoes fatty [p. 140] degeneration, as indicated by granular epithelium, by molecular detritus, and even by oil-globules in the protoplasm of the altered zoosperms. The entire absence of spermatozoids, constituting the condition known as azoospermatorrhoea, is of infrequent occurrence.

An examination of the genital organs discloses elongation of the prepuce in nearly one-fourth of all cases; a rigid and pointed penis in one-tenth; relaxation of the scrotum in about one-eighth; irritable testes in 1 example out of every 25; varicocele in 1 case out of every 50; coldness of the genitalia in 1 case out of every 17; a feeling of heat in 1 case out of every 33; and irritability of the bladder in 1 case out of every 25. It will, moreover, be found that seminal incontinence is complicated by feebleness of erection, with precipitate ejaculation on coition, in 22 per cent. of all cases; by the occurrence of ejaculation on attempting intercourse, before penetration, simultaneously with erection, or even before erection, in 16 per cent.; and with total impotence in 5 per cent. of all cases. Prostatorrhoea is also a not infrequent complication, while urethral strictures and hyperæsthesia are nearly always present.

ETIOLOGY AND PATHOGENY.—Seminal incontinence is not a separate entity, but one of many symptoms of general or local disorders, or of both combined. In the majority of instances it must be looked upon as a neurosis, diurnal and nocturnal pollutions representing a motor neurosis with spasm of the seminal vesicles, and spermorrhagia indicating a motor neurosis with dilatation and paresis of the orifices of the ejaculatory ducts. In all of the varieties there is increased susceptibility of the cerebral and spinal genital centres to factors which in healthy persons are not productive of ill effects.

Like other nervous disorders, involuntary seminal emissions sometimes manifest themselves in several members of the same family through several generations, being the result of inherited predisposition. In this class of cases the subjects are of a nervous, excitable, or irritable temperament, somewhat anæmic, and possibly suffered during infancy from nocturnal enuresis. Among the predisposing causes the most common is indulgence in erotic fancies, which terminates in increased reflex impressibility of the centres which preside over the genital organs.

The affection is, however, usually acquired, being met with particularly in single subjects toward the termination of the second decade and between the second and third decades. Of these cases, at least nine-tenths can be traced to masturbation, while the remainder will be found to have had gonorrhoea or to have masturbated, suffered from gonorrhoea, or indulged their sexual propensities in various ways. Seminal incontinence is not common as the result of sexual coition, and it is highly probable that when married men are affected the sexual excess is engrafted upon a previously vicious habit. From a practical point of view, it is of the first importance to be aware of the fact that one or more strictures of the urethra will be found in 80 per cent. of all cases, and that decided hyperæsthesia of the prostatic portion of the urethra is present in 94 per cent. of all instances.

The rational explanation of morbid seminal emissions seems to be as follows: Under the influence of erotic ideas, masturbation, sexual excesses, or unsatisfied sexual excitement produced by dallying with women, exaggerated irritability of the genital organs is induced, and is [p. 141] followed by subacute or chronic inflammation and abnormal sensibility of the urethra, particularly of its prostatic division, which terminate, in cases characterized by diurnal pollutions and spermorrhagia, in relaxation and dilatation of the orifices of the ejaculatory ducts. As the natural result of the constant excitability of the terminal filaments of the nerves distributed to the prostatic urethra, these nerves are alive to the slightest impressions, act as peripheral sources of irritation, and induce permanent increased mobility or irritability of the cerebral and spinal genital centres, through which the motor nerves of the ejaculatory apparatus are thrown into action, and an emission ensues.

Seminal incontinence is an occasional accompaniment of injuries of the spine, and it is also met with during the progress of or convalescence from acute and chronic diseases which are marked by disturbances or exhaustion of the central nervous system. Thus, it may be symptomatic of phthisis, variola, typhus, progressive muscular atrophy, and incipient bulbar paralysis, ataxia, and paraplegia; while the habitual use of opium and chronic alcoholism predispose to its occurrence.

Of the local causes referable to the genitalia, by far the most important and most frequent are hyperæsthesia and inflammation of the prostatic portion of the urethra, which are generally induced by masturbation. These lesions constitute the primary source of the trouble in the large majority of cases, and tend not only to excite reflex pollutions, but to maintain the disorder by keeping the mind occupied with sexual matters. Other common local causes are found in congenital narrowing of the meatus, organic stricture of the urethra, a redundant prepuce, balanitis, and the accumulation of smegma. Among the more infrequent etiological factors may be mentioned herpes of the prepuce, congenital shortness of the frenum, spasmodic stricture, polypus of the deep urethra, spermato-cystitis, and epididymitis.

Among the remaining exciting causes of pollutions are diseases of the anus and rectum, as hemorrhoids, morbid growths, ascarides, fissures, ulcers, pruritus, and painful eruptions. The nerves of the rectum and anus being derived from the same region as those of the genitalia, it is not surprising that the ejaculatory centre should respond to an impulse transmitted from them. In habitual constipation straining at stool may also excite an emission through the consentaneous action of the muscles of the abdomen, rectum, and seminal vesicles; but this is only observed when the orifices of the ejaculatory ducts are paralyzed and patulous.

ANATOMICAL CHARACTERS.—There are no records of the morbid appearances which appertain to seminal incontinence in its early stage, but that the hyperæsthesia of the prostatic urethra depends upon chronic or subacute inflammation is rendered certain by the concomitant symptoms, by exploration with the sound, aided by the finger in the rectum, and by the results of treatment. In the advanced stage, post-mortem inspection has disclosed stricture of the urethra, injection of the mucous membrane of the deep portion of the urethra, dilatation and excoriation of the orifices of the ejaculatory ducts, and suppuration of the prostate and the seminal vesicles. The changes which occur in the nervous centres are unknown.

DIAGNOSIS.—The microscope affords the only positive mode of determining whether the fluid which is discharged from the urethra during [p. 142] pollutions, or constantly moistens that canal in spermorrhagia, or is expelled at stool or with the urine, or is brought away by the bulb of the explorer, is seminal in its character. Should spermatozoids be detected, there can be no doubt as to its true nature, but their absence is not an evidence that the case is not one of spermatic incontinence, since in the condition known as azoospermatorrhoea the exhausted sexual apparatus furnishes a thin, transparent, watery fluid which may be entirely devoid of fertilizing elements, and contains cylinder epithelial cells, epithelium which has undergone fatty or colloid degeneration, a few lymph-corpuscles, an abundance of fatty detritus, and a few small shining bodies which are the remains of the badly-evolved spermatozoids. Under these circumstances, the history of the case, the fact that the subject is or was a masturbator, and the associated nervous symptoms are aids in forming a diagnosis; and this is especially true of cases in which a fluid is expressed at stool, and which in the majority of instances is the altered secretion of the prostate. Under the microscope the thin, more or less milky prostatic fluid will be found to contain cylinder epithelium, numberless colorless and refracting granules of lecithin, and minute yellowish concentric amyloid concretions; and, after it has slowly dried upon the slide, crystals of phosphate of magnesium or of ammonio-magnesian phosphate will make their appearance.

Should a microscopical examination be impracticable, we may assume that the discharge which occurs during defecation in the subjects of too frequent nocturnal pollutions is an evidence of coexisting prostatorrhoea; while we may frame the rule that the flocculent sediment contained in the urine and the discharge at stool of persons suffering from both nocturnal and diurnal pollutions, and a slight continued discharge from the urethra represents semen. In the last event we may moreover assume, especially if the patient be impotent, that the orifices of the ejaculatory ducts are relaxed.

PROGNOSIS.—Nocturnal emissions are very amenable to treatment, particularly when they are kept up by appreciable local lesions, the only cases which are, as a rule, rebellious being those in which the pollutions are associated with chronic inflammation of the seminal vesicles. In expressing an opinion in a given case the physician should, however, be influenced by the severity of the signs of nervous exhaustion. If the general symptoms point to involvement of the cord alone, the prognosis is far better than when signs of cerebrasthenia are present; but the outlook is bad if, in addition to cerebral and spinal exhaustion, the patient is a sexual hypochondriac. Nocturnal pollutions occurring during the progress of acute or chronic general disorders are also, as a rule, readily checked. The prognosis in the same class of cases is, moreover, far better when the usual local lesion—namely, morbid sensibility of the prostatic urethra—has been induced by gonorrhoea rather than by masturbation; and it is also more favorable when the pollutions occur in mature years from sexual excesses than when they are due early in life to masturbation.

Even when the emissions occur during the day from trivial psychical or mechanical causes, ample experience has convinced me that the prognosis is far better than many writers would lead one to believe. These cases are, however, less tractable than those of nocturnal pollutions, but [p. 143] they finally recover with the exercise of a little patience. The worst outlook is when the emissions are passive, or occur without the orgasm, or during urination and defecation. In this class of cases not only are the ordinary remedies applicable to the other varieties demanded, but measures will have to be resorted to to overcome the paralyzed and dilated orifices of the ejaculatory ducts. Although the prognosis is not as favorable, I have never seen an example of spermorrhagia that did not finally yield to treatment.

TREATMENT.—Certain hygienic and moral rules must be observed in the management of all the varieties of seminal incontinence. The diet should be plain, nutritious, and digestible; the evening meal should be light and dry; and spirits and malt liquors, as well as stimulating articles of food, should be eschewed. As the morning fulness of the bladder is very liable to produce an erection, that organ should be thoroughly emptied on retiring; and as pollutions usually occur toward morning, the patient should set an alarm-clock one hour before the time at which he has generally observed that the emissions take place, in order that he may be awakened to relieve the bladder of its contents. He should also sleep upon a hair mattress without much covering. Everything calculated to induce a flow of blood to the genitalia, such as horseback exercise, driving over rough roads, and railway travelling, should be interdicted. Masturbation and sexual intercourse must be abandoned, and the subject should be informed that the enforced rest of the organs will possibly result in temporary increased frequency of the pollutions. Chaste associations should be cultivated, and erotic thoughts and desires be banished. To attain this end the mind and body should be kept pleasantly occupied by gymnastic exercises and the study of any subject which the patient may fancy. If, however, he be not in full health, or if there are commencing or marked signs of spinal or cerebral exhaustion, mental and physical exercise should be taken in moderation.

In the treatment of involuntary seminal emissions a thorough examination should be made of the genital and associated organs, with the view of detecting and getting rid of any reflex or eccentric lesions or causes which predispose to, or even excite and maintain, them in impressible subjects. If the patient has a redundant prepuce, it should be removed; if the meatus be contracted, it should be enlarged; while balanitis, herpes, hemorrhoids, rectal fissure or ulcer, or pruritus should be treated in the usual way. In not a few mild cases, particularly those dependent upon phimosis, a contracted meatus, or a stricture just behind the orifice, it will be found that operative interference is quite sufficient to bring about relief. Habitual constipation, which is met with in about one-third of all instances, demands particular attention, either by enemata of temperate water or a pill composed of one-tenth of a grain each of aloin and extract of belladonna, administered every eight hours.

In the section on the etiology and pathogeny of seminal incontinence attention is called to the fact that hyperæsthesia of the prostatic urethra is nearly always present. While it is undoubtedly true that the genital nervous centres may be highly impressible without the intervention of hyperæmia, inflammation, and abnormal sensibility of the prostatic urethra, it is none the less true that those lesions are the most constant and most important of all the causes which excite and maintain the [p. 144] disorder, especially in masturbators, in whom, moreover, strictures may be looked for in about eight-tenths of all cases. As a rule, the coarctations will be formed just behind the meatus, but others may be present posteriorly. Be this as it may, a knowledge of their existence is of the first importance, as they aggravate the morbid condition of the prostatic urethra and serve to keep up a peripheral source of spinal neurasthenia.

For the detection of a stricture the exploratory or acorn-headed soft bougie should be resorted to, as it is the only instrument with which coarctations of large calibre and granular patches can be accurately defined, and with which abnormal discharges can be withdrawn for minute examination. One being selected which fills the meatus, it is warmed and well oiled, and inserted as far as the bladder. Should its introduction be arrested, smaller sizes are successively employed until one will pass without difficulty. On its withdrawal the abrupt shoulder of the bulb coming in contact with the posterior face of the stricture imparts to the touch a sensation as if it had jumped over a band, while a granular patch conveys the impression of a limited roughness of the canal. Hyperæsthesia of the urethra is readily determined by the nickel-plated steel bougie, and its existence should never be based upon the passage of the soft explorer alone, as the latter is productive of far more pain than the former. In conducting these examinations a contracted meatus or a stricture just behind the orifice should first be divided, in order that the instruments for exploration may correspond to the normal calibre of the urethra. Unless this point receives attention the examination will be likely to prove valueless. Should one or more strictures be present, the case must be referred to a surgeon.

From the preceding considerations it follows that the treatment, whether it be local or general, must at the outset be of a calming and sedative nature, the end in view in the great majority of instances being to overcome the exaggerated irritability of the genital nervous centres and the abnormal sensibility of the deep urethra. By the indiscriminate employment of strychnia, cantharides, phosphorus, and cold ablutions great harm is done, and the management of involuntary seminal emissions is brought into disrepute.

Of the local remedies to overcome the hyperæsthesia of the prostatic urethra, there is not one entitled to so much confidence as the nickel-plated conical steel bougie, passed at intervals of four days, and at once withdrawn for the first few insertions, after which, with the decrease of the sensibility, the intervals should be shortened, and it should be retained longer, until it is inserted every forty-eight hours and permitted to remain in the canal for a few minutes. The size of the first instrument is to be gauged by that of the meatus if it be normal, and if it be found necessary during the course of the treatment the orifice should be enlarged, in order that bougies of progressively increasing sizes may be introduced until they correspond to the full calibre or distensibility of the urethra, as indicated by the urethrameter. Unless these precautions be observed the measure will not bring about the desired result.

As a rule, the bougie will meet the indication, but in exceptional instances a small, circumscribed area of tenderness remains, which comprises the sinus pocularis, and which proves rebellious to instrumentation. Under these circumstances it becomes necessary to apply a drop or two of [p. 145] a solution of nitrate of silver to the spot, which is best done with a small syringe attached to a perforated bulbous explorer. The ordinary forms of porte-caustique charged with the fused nitrate are objectionable, as the remedy does not come in contact with the orifices of the ejaculatory ducts contained within the sinus pocularis, and its application cannot be properly controlled. From an ample experience I can confidently recommend the use of a thirty-grain solution, repeated every four days. Provided the patient be kept in bed for a few hours, the pain and desire to urinate will not last more than thirty minutes. When the affection proves to be more than ordinarily obstinate, flying blisters, made by pencilling cantharidial collodion first on the one side of the perineal raphé, and, after the surface has healed, on the opposite side, will prove serviceable.

In addition to these measures great assistance will be derived on retiring from the hot sitz-bath, or from a sponge or cloth dipped in water at a temperature of at least 105° F. and applied to the perineum and lower part of the spine. Cold applications are to be studiously avoided.

Of the general remedies, not a single one is comparable to bromide of potassium, which not only diminishes the reflex excitability of the cord and suspends sexual desires and the power of erection, but corrects the acidity of the urine and exerts an anæsthetic effect upon the mucous membrane of the urethra. I am in the habit of administering from three to four scruples of the salt at bedtime, and if I find that it sets up signs of bromism I diminish it for a time, and afterward promote its excretion by the kidneys by combining with it about fifteen grains of bitartrate of potassium. Should the patient be anæmic, the dose should be reduced to one drachm, and three grains of quinine along with twenty-five drops of the tincture of the chloride of iron should be ordered every eight hours. When, on the other hand, the patient is robust and plethoric or in full health, I frequently add to the bromide ten drops of veratrum viride or tincture of gelsemium, or administer the bromide in half an ounce of the infusion of digitalis.

Another remedy which diminishes the reflex mobility of the genito-spinal centre, at the same time that it reduces the secretion of the seminal fluid, is the sulphate of atropia. Given in the average dose of the one-sixtieth of a grain on retiring, so that the patient may sleep through its disagreeable action, it will be found to be an invaluable addition to the treatment.

When the bromide of potassium and atropia do not agree with the patient, I substitute the monobromide of camphor and extract of belladonna in the proportion of ten grains of the former to one-third of a grain of the latter. In the remaining anaphrodisiacs, such as lupulin, camphor, and conium, I have not the slightest confidence.

Under the plan of treatment thus outlined the majority of cases of nocturnal and diurnal pollutions recover; but if the spinal genital centre still remains too impressible, galvanization with the anode to the lumbar region and the cathode to the perineum will prove highly serviceable. When the condition is one of spermorrhagia, after the hyperæsthetic symptoms have subsided the relaxed and paralyzed orifices of the ejaculatory ducts may be restored to their normal condition by the continuous current, the negative reophore being placed in the rectum and the positive on the perineum or the lumbar vertebræ. Should galvanization fail, [p. 146] the induced current may be passed through a negative catheter electrode in the prostatic urethra to the anode resting on the perineum or spine; but this mode of application requires great caution, and a feeble power should be employed at the commencement. For this reason the rectal is preferable to the urethral reophore. In the absence of electrical apparatus the tonicity of the muscles of the ejaculatory ducts may be greatly improved, and even restored, by the use of the cooling sound, by the application of a thirty-grain solution of nitrate of silver, and by cold sitz-baths. In these cases half a drachm of the fluid extract of ergot after each meal, or fifteen drops of a mixture composed of six drachms of the tincture of the chloride of iron and two drachms of the tincture of cantharides, will also prove valuable. The operations of castration and excision of portions of the vas deferens need only be mentioned to be condemned.

To sum up the results of my experience in the management of seminal incontinence, I may add that the steel bougie, bromide of potassium, and atropia are especially adapted to cases of nocturnal and diurnal pollutions, and that after the hyperæsthesia has been relieved electricity, ergot, and strychnia are the most reliable agents in spermorrhagia. The end having been accomplished, moderation in sexual intercourse should be enjoined if the patient is married; continence in thought and action should be observed if he remains single; and matrimony should be advised if his circumstances and inclination warrant it. Marriage should not, however, be encouraged if the emissions are not arrested, as I have met with several cases in which the patient was rendered miserable by this act, from the fact that he deemed his case beyond all hope, as the emissions still continued.

DISPLACEMENTS OF THE UTERUS.

The title of this article is not to be taken in a restricted sense, inasmuch as the uterus is anatomically so connected with adjacent organs that the displacements of the uterus cannot be intelligently considered or satisfactorily presented without at the same time incidentally taking into account the displacements, causative, resultant, or concurrent, of the ovaries, Fallopian tubes, rectum, vagina, and bladder.

¹ The importance of a distinction between location and position will become apparent hereafter: by the former is meant the situation of the organ regardless of its attitude, by the latter is meant the attitude alone. To change an object from one place to another is to change its location; to turn it over or bend it upon itself is to change its position.

In the works on anatomy and gynecology which we are accustomed to consult the uterus is represented as having a straight or nearly straight canal—as lying about midway between the symphysis pubis and the hollow of the sacrum, its axis corresponding to that of the pelvic inlet. They generally agree that its position is one of slight, and only slight, anteversion; some admit that slight anteflexion may not be injurious, but most would pronounce the organ anteverted or anteflexed to a degree that would endanger health if by conjoined manipulations its anterior wall could be felt through the anterior wall of the vagina. The classical idea of the normal position of the uterus presupposes a distended bladder and rectum occupying the anterior and the posterior thirds of the pelvic cavity. Such an arrangement would leave for the uterus only the intermediate space, and would constitute a condition seldom or never realized in health.

Suppose a straight line coincident with the vesico-vaginal wall (Fig. 1) to be continued through the cervix to the sacrum. This line represents approximately the antero-posterior diameter of the pelvis. The length of the vesico-vaginal wall is two and a half inches, and, supposing the cervix to be just midway between the symphysis and the sacrum, the distance from its posterior wall to the sacrum must also be two and a half inches. Add to the sum of these two parts of this antero-posterior diameter one inch for the cervix, and the antero-posterior diameter of the pelvis becomes six inches instead of the normal four and one-third; which proves that the cervix must normally be much nearer to the hollow of [p. 148] the sacrum than to the symphysis. Since the length of the vesico-vaginal wall plus the diameter of the cervix measures three and one-half inches, it follows that the distance from the posterior wall of the cervix to the hollow of the sacrum must be the difference between four and one-third and three and one-half inches, or five-sixths of an inch.

FIG. 1.

The Classical Representation of the Pelvic Organs.

Again, suppose the uterus (Fig. 1) to be carried bodily upward and backward, its axis remaining the same, until the cervix reach its normal position near the hollow of the sacrum; then would the body of the uterus impinge upon the bony sacrum. It is therefore clear that the anteversion must be the normal position, because the uterus and sacrum would otherwise occupy the same space.

Fig. 2 represents, according to Schultze,² the location and position of the virgin uterus and its surroundings, the bladder, rectum, and vagina being empty and collapsed. The angle of about 90° which the cervix forms with the vagina measures the forward inclination of the cervix, but is subject to slight variations in consequence of the physiological [p. 149] movements of the uterus. The body is furthermore bent forward upon the cervix, so that its anterior surface rests upon the empty bladder. The angle of the normal anteflexion, according to careful measurements by Schultze, is about 48°; Fritsch says that 90° is the physiological limit. This question will be further considered under the subject of pathological anteflexions.

² Archiv für Gynäkologie, 1875, Band viii. p. 134, and Lageveranderungen der Gebarmutter, Berlin, 1881.

Ely Van de Warker makes a full and critical study of the normal movements of the unimpregnated uterus in the N. Y. Medical Journal, xxi. p. 337, and of the normal position and movements of the unimpregnated uterus in the American Journal of Obstetrics, xi. p. 314. His conclusions substantially agree with those of Schultze.

Frank P. Foster (American Journal of Obstetrics, xiii. p. 30) presents a valuable paper giving a résumé of the literature, with original observations, in which he takes exceptions in part to the views of Schultze.

FIG. 2.

The Correct Representation of the Pelvic Organs.

Strictly, the uterus can have no absolutely normal position or location, because it has a certain normal range of movements which depend to some extent upon respiration, intra-abdominal forces, and locomotion, but more especially upon the varying quantity of material in the rectum and bladder. Its normal position, then, varies within the limits of its normal movements. If the body of the uterus rest upon the bladder, it must rise as the bladder becomes distended, and, conversely, if the urine be drawn through a catheter while the woman is lying on her back, the uterus, notwithstanding the opposing influence of its own weight, immediately follows the receding wall of the bladder and returns through an angle of 45°, or possibly even 90°, to its accustomed position. The dotted lines in Fig. 2 indicate the degree of version and flexion consequent upon the varying quantity of fluid in the bladder.

The full rectum forces the uterus in the opposite direction, toward the symphysis, and thereby counteracts the influence of the bladder. This anterior movement is, however, somewhat limited, and is confined to the cervical portion, except when the body has been forced back into close proximity with the rectum by the over-distended bladder.

The uterus is maintained in its normal position and location by the following agents:

a. The uterine ligaments;

b. The pelvic floor.³

³ For a description of the female pelvic floor see Hart's Atlas.

a. Physiologically, these ligaments are relaxed; the state of tension would be pathological; they do not fix the uterus; they only tend to limit its movements to their normal range. Backward displacement of the body is resisted by the round ligaments, backward displacement of the cervix by the utero-vesical ligaments and by the vesico-vaginal wall. Forward and downward displacements are resisted by the utero-sacral ligaments, and excessive lateral motion by the broad ligaments. This restraining power is doubtless greater in the utero-sacral than in any of the other ligaments.

b. The pelvic floor, which is the chief support of the uterus, is divided into two segments, the pubic and the sacral. The pubic segment⁴ is composed of bladder, urethra, anterior vaginal wall, and bladder peritoneum. It is attached in front to the symphysis pubis and laterally to the anterior bony walls of the pelvis. The sacral segment⁵ is composed of rectum, perineum, posterior vaginal wall, and strong tendinous and muscular tissue. It is attached to the coccyx, to the sacrum, and to the posterior wall of the bony pelvis.

⁴ Hart and Barbour's Manual of Gynecology.

⁵ Ibid.

Permeating the pelvic floor in all directions, entering into the composition of its single parts, binding them together, and sending its processes to the bony pelvis, is the pelvic connective tissue, upon the integrity of which depends the integrity of the pelvic floor as a uterine support. Its pernicious influence as a pathological factor will be considered hereafter. The old idea that the uterus is supported by the vaginal walls or by the perineum or by the uterine ligaments is obsolete; they are important parts of the pubic and sacral segments, and as such contribute their share, but the pelvic floor as a whole supports the uterus. The various uterine supports are to a great extent the seat of motor influence. They consequently not only resist excessive movement, but also serve to return the organ from its physiological migrations.

DEFINITION AND NOMENCLATURE OF DISPLACEMENTS.—In the foregoing pages the normal location, position, movements, and supports of the uterus have been defined. Those conditions are pathological which induce changes to positions or locations beyond the defined limits, or which so fix the organ that its normal movements are prevented. The displacements are divided into mal-locations and malpositions.

The mal-locations in which the entire uterus occupies a place outside [p. 151] its normal limits are as follows: ascent, retro-location, ante-location, lateral location, descent.

The malpositions are determined by excessive change in the inclination of the uterine axis. They are further divided into flexions, in which the organ is bent upon itself in an abnormal degree, manner, or direction; and versions, in which the axis of the unflexed uterus inclines in an abnormal degree or direction. The malpositions are retroversion, retroflexion, lateral version, lateral flexion, anteversion, anteflexion.

SYMPTOMS AND DIAGNOSIS IN GENERAL.—Each variety of displacement may be indicated by its own group of symptoms and physical signs. These will be presented in the study of the special lesions. To avoid repetition, those symptoms and signs which pertain to no special displacement, but which belong to all alike, will be mentioned at once. They may arise either from the displacement itself or from its possible complications, of which the following are examples: Metritis, ovaritis, salpingitis, atresia and stenosis, cystitis, vesical catarrh, rectitis, rectal catarrh, peri-uterine cellulitis and peritonitis, uterine catarrh, tumors, cicatrices, etc.

Uterine displacement may be a cause or an effect of associated complications, or together with them it may be a concurrent result of some common cause, or it may have had primarily no pathological connection with them. The symptoms of displacement refer to the pelvic organs or to the nervous system. Among the symptoms which refer to the pelvic organs are—difficulty in walking and standing; pelvic pain, more or less constant; dysmenorrhoea, menorrhagia, sterility, frequent abortion, constipation, painful or difficult defecation, dysuria, polyuria, tenesmus, etc. Among the symptoms which refer to the nervous system are—neuralgia in various parts, paralysis, hysteria, nervous dyspepsia, anæmia, chlorosis, spinal irritation, etc.

The final diagnosis must always depend upon direct examination of the uterus itself. The first division of the above group of symptoms is not likely to escape notice as indicative of displacement, but the nervous symptoms are constantly disregarded or treated without reference to their possible pelvic origin. The frequent dependence of these nervous phenomena upon displacement is proved by their persistence in many cases after ordinary treatment, by their prompt disappearance upon permanent replacement and retention of the uterus by mechanical means, and by their equally prompt recurrence upon removal of the support. The presence, therefore, of the second division of the group or any part thereof, even though the first be absent, will justify, may even necessitate, a careful investigation into the state of the pelvic organs.

That examination which results only in giving the name to a special variety of displacement, and does not include the complicating lesions, would not furnish a sufficient guide to the therapeutic indications, and is therefore inadequate. The successful treatment, for instance, of an anteflexion dependent upon inflammation of the utero-sacral ligaments must include the removal of the inflammation.

An important prerequisite to examination is the absence of material in the rectum and bladder. The full rectum distorts the vaginal walls, deprives the examiner of the space necessary for the introduction of the speculum, and throws the uterus out of its accustomed position. Much more troublesome is the presence of even a small quantity of urine in [p. 152] the bladder, because it causes the patient to render the abdominal muscles tense when the hand is placed over the lower portion of the abdomen for bimanual palpation, and makes it impossible to engage the uterus between the hand and the examining finger. The distended bladder by pushing the uterus upward and backward makes bimanual palpation almost useless. It is not surprising that conflicting opinions are common, when one day the patient is examined with rectum and bladder full, another day empty; one day in the dorsal, another in Sims's or the knee-chest position; one day with the cylindrical or bivalve speculum, another day with Sims's or Simon's.

For digital examination the dorsal position is preferred: the patient should be drawn close to the edge of a bed, or preferably a table, the thighs being flexed, the feet about fifteen inches apart, and the knees widely separated. The examiner should stand facing the patient, never at the side. The index finger of the left⁶ hand, lubricated with vaseline or oil, then slowly advances over the perineum into the vagina, noting the condition of the perineum, the presence or absence of cicatrices or of sub-involution of the vagina or perineum, the capacity of the vagina, the condition, size, and direction of the cervix, its distance from the sacrum and vulva, its mobility or fixation. Now, for the first time, the right hand is pressed well down behind the pubes, and the uterus is engaged between it and the examining finger. (See Figs. 16 and 17.) In this way the examiner may determine more accurately the position, location, and size of the entire organ; may detect the possible presence of complicating tumors, both inflammatory and non-inflammatory; may also note, if possible, the location and condition of the ovaries, which, especially in the posterior displacements, are liable to be prolapsed and excessively sensitive, and to constitute, therefore, a most intractable complication. The index finger sweeps around the cervix in search of tender places which may be the result of former cellulitis or the expression of some neurosis. Above all, the digital examination requires a light, gentle, delicate touch.

⁶ The left-hand method of examination is incomparably superior to the right. The palmar surface of the index finger is more easily directed toward the left side of the pelvis, which is especially subject to disease. Its tactile sense is more acute and more easily educated. The stronger right hand should be free to palpate the surface of the abdomen in conjoined manipulation.

In exploring the uterine cavity to learn its position the fine silver-wire probe of Emmet—not the sound—should be used. The uterus, if freely movable, is liable to be thrown out of its accustomed position by the heavier, unyielding sound. The sound also causes much more pain and exposes the patient to great danger of cellulitis. The frequent lighting and relighting of pelvic inflammation by injudicious slight manipulations of the uterus doubtless led Emmet to the utterance of a prophecy which ought to become classical: "A great advance in the treatment of the diseases of women will be made whenever practitioners become so impressed with the significance of cellulitis as to apprehend its existence in every case. The successful operator in this branch of surgery will always be on the lookout for the existence of cellulitis, and take measures to guard against its occurrence."

When the probe or the sound is used without the speculum, the patient [p. 153] should be on the back and the index finger of the left hand should be used as a guide. The bivalve and cylindrical specula are almost useless in explorations of the interior of the uterus. The exploration is most effectually and gently made with Sims's speculum, the patient being in the left latero-prone position. In some cases the probe cannot be passed by any other method.

This mal-location may result from traction above or from pressure below. The organ may be drawn upward and backward by shortening of the utero-sacral ligaments, which results from inflammation and which usually induces a troublesome form of anteflexion. The enlarged pregnant uterus sometimes becomes attached by adhesive inflammation to a portion of the peritoneum in one of the higher zones of the pelvis or in the abdomen, and the organ may consequently remain fixed in its elevated position after involution. A tumor connected with the uterus or its appendages which has grown too large to be retained in the pelvis may, upon rising into the abdomen, drag the uterus with it. Pressure below may come from excessive distension of the rectum or bladder, or from a large accumulation of menstrual fluid in the vagina, or from a tumor originating in any portion of the pelvis below the level of the uterus. In diagnosis, prognosis, and treatment this displacement is wholly subordinate to the more significant lesions of which it is only the incidental result.

The uterus may be forced back into a post-normal location by the presence of a tumor in front or by the distended bladder, or it may be drawn back and fixed by peritoneal adhesions. Retro-location is liable to induce vesical irritation by putting the vesico-vaginal wall on the stretch and thereby dragging on the neck of the bladder. This intractable symptom is sometimes relieved by Emmet's buttonhole operation of urethrotomy, for an account of which see section on Anteflexion. This operation would obviously be applicable also for the relief of the same symptom when caused by ascent of the uterus.

The causes of this displacement are similar to those which produce retro-location; they are—distension of the rectum, post-uterine hæmatocele, post-uterine tumors, and peritoneal adhesions. Ante-location often causes vesical irritation, consequent upon the invasion by the uterus of that space which belongs to the bladder.

The entire uterus is often displaced to the right or the left by a tumor or by an inflammatory exudate. The latter occurs as a product of [p. 154] cellulitis, usually in the left broad ligament, and crowds the organ toward the opposite side of the pelvis. After resolution the ligament, shortened by inflammatory contraction, draws the uterus to the affected side and fixes it there. Lateral displacement from this cause often accompanies laceration of the cervix, the cellulitis having occurred on the side corresponding to the laceration.

The nature of this displacement is clearly indicated by its name. It is convenient to distinguish three degrees of descent: In the first the organ is displaced downward and forward until sufficient space has been gained between the cervix and the sacrum to permit the body to turn back into extreme retroversion; in the second the cervix descends to the vulva; in the third the uterus protrudes partially or wholly through the vulva, constituting a condition sometimes called procidentia.

ETIOLOGY AND CLINICAL HISTORY.—Descent may be the result of any or all of the following causes: I. Pressure from above; II. Weakening of the supports; III. Increased weight of the uterus; IV. Traction from below. Either of the above conditions being the primary cause, the others singly or combined may result.

I. Pressure from above may depend upon the presence of a pelvic or abdominal tumor, ascites, fecal accumulations, tight or heavy clothing, etc.

II. The uterine supports may be weakened and relaxed in consequence of subinvolution, senile atrophy, abnormally large pelvis, increased weight of the uterus, pressure from above, traction from below, etc.

III. Increased weight of the uterus may be caused by congestion, subinvolution, hypertrophy, hyperplasia, pregnancy, fluid in the endometrium, uterine tumors, etc.

IV. Traction from below may be due to vaginal cicatrices, abnormally short vagina, falling of the pelvic floor, etc.

Obviously, descent of the vesico- and recto-vaginal walls, or, more comprehensively, the sacral and pubic segments of the pelvic floor, involves also concurrent descent of the uterus. Descent of the vagina, therefore, must be studied in connection with the descent of the uterus. Excessive descent of the vaginal walls usually originates with parturition.

In labor the anterior wall of the vagina is so depressed, stretched, and shortened by the advancing head that during and after the second stage the anterior lip of the cervix may be seen behind the urethra. If the puerperium progress favorably, with prompt involution of the uterus, vagina, perineum, and peritoneum, the relaxation of the vesico-vaginal wall and of the utero-sacral supports disappears and the uterus resumes its normal multiparous location and position.⁷ But if the enlarged uterus remain in the long axis of the vagina, with its fundus incarcerated in the hollow of the sacrum between the utero-sacral ligaments, and with its sacral supports so stretched that they cannot recover their contractile power, and with involution of all the pelvic organs arrested, the descent [p. 155] may not only persist, but may even progress with constantly increasing cystocele to the third degree of prolapse. The downward influence of the above conditions may be materially increased by rupture of the perineum, and consequent prolapse of the recto-vaginal wall into a pouch called rectocele.

⁷ The anteflexion of the multiparous uterus is less than that of the virgin.

In the great majority of cases of complete prolapse the posterior vaginal wall in its descent is peeled off from the rectum, leaving the latter in its normal position. In rare instances the lower portion of the rectum is also found to have extruded in extreme rectocele, making a pouch below and in front of the anus, where fecal matter may accumulate and remain in hard scybalæ.

Obviously, complete prolapse of the uterus is only an incident to the prolapse of the pelvic floor. The whole mechanism is in all respects analogous to that of hernia. The extruded mass drags after it a peritoneal sac, which, hernia-like, contains small intestine. This sac forces its way to the pelvic outlet and extrudes through the vulva, having the inverted vagina for its covering.

FIG. 3.

First Degree of Prolapse of the Post-partum Uterus. The posterior vaginal wall has been changed from its normal forward direction to a vertical direction by perineal rupture and anterior displacement of the cervix; the vesico-vaginal wall descends in cystocele, becomes hypertrophied, and drags the heavy uterus after it. The descending uterus carries with it a reduplication of the vaginal walls.

In descent of the first degree the location of the uterus is either changed to a lower level, the position remaining normal, or, as is more common, the cervix having moved nearer to the symphysis and the organ turns back into retroversion. In a given case suppose the vaginal walls from some cause to have become relaxed and to have settled [p. 156] to a lower level in the pelvis. As an associated fact the uterus to which these walls are attached must then also occupy a place correspondingly nearer to the vulva—i.e. the location of the uterus has changed, so that space enough intervenes between it and the hollow of the sacrum for the former to turn back into the position of retroversion or retroflexion. If, on the contrary, the descending uterus still maintains its normal anteversion and anteflexion, it must occupy space which belongs to the bladder. The vesical irritation consequent upon this mal-location has generally been ascribed to the anteversion and anteflexion, which are therefore oftentimes wrongly pronounced pathological. The prompt relief which follows permanent replacement of the organ in the normal location, even though in so doing its anteposition be exaggerated, proves that the symptoms depend upon the mal-location, not upon the anteposition. The importance of a clear distinction, therefore, between location and position becomes apparent. Vesical irritation, moreover, is sometimes caused by the dragging of the uterus upon the neck of the bladder. This traction occurs not only in ascent, but also when the organ descends below a certain level.

FIG. 4.

Showing Extreme Descent of the Uterus and of the Pelvic Floor, and the Hernial Character of the Lesion.

In the foregoing paragraphs traction due to the falling pelvic floor has been discussed as a cause of descent. The impairment of the uterine supports may, however, be such that instead of falling and dragging the uterus after them, they simply permit it to descend along the vaginal canal by the force of its own weight, and to carry with it the reduplicated vaginal walls. This influence is generally enforced by the increased weight of the diseased organ. The vagina more readily becomes a track for the descending uterus when from any cause the normal forward direction of the vaginal canal changes toward the vertical: this change may occur either as the result of a forward displacement of its upper extremity, involving anteposition of the cervix, or of a retro-displacement of its [p. 157] lower extremity in consequence of rupture or subinvolution of the perineum. (See Fig. 3.) Descent in the track of the vagina is obviously combined with some degree of retroversion, because the axes of the uterus and vagina then correspond.

The PATHOLOGICAL ANATOMY may involve all the displaced organs. The circulation throughout the pelvis is impeded by traction upon the vessels, and the entire pelvic contents therefore become the subject of venous congestion, with consequences disastrous to local innervation and nutrition.

The ovaries may suffer concurrent displacement, with resulting inflammatory and cystic enlargement. The peritoneum which enters into the formation of the uterine ligaments and of the pelvic floor is dragged along with the uterus.

The vagina is hypertrophied and swollen. Its mucous membrane becomes the seat of acute vaginitis and chronic catarrh. In the third degree of descent the exposed vagina, no longer lubricated by the normal secretions of the uterus, becomes dry, parchment-like, oedematous, eroded, and ulcerated. Sometimes the cul-de-sac of Douglas is distended by downward pressure of the intestines, by a small tumor, or by ascitic fluid, and a consequent hernial sac may protrude into the vagina through some portion of the posterior vaginal fornix. The anterior fornix is subject to a similar accident. These conditions are designated enterocele vaginalis, anterior and posterior.

The rectum and bladder are subject to inflammation and chronic catarrh, and the bladder especially to concurrent descent. The uterus may be enlarged from any one or all of a variety of causes—congestion, subinvolution, hypertrophy, and hyperplasia. Its cervix is often the seat of extreme erosion or so-called ulceration. The endometrium, in order to relieve the organ of its surplus blood, gives forth an excessive secretion of mucus, which upon being increased in quantity becomes vitiated in quality. This is termed uterine catarrh. The enlargement of the uterus often pertains more to the cervix than to the body, especially in prolapse of the second and third degrees. An explanation of this may be found in Figs. 5 and 6.

FIG. 5.	FIG. 6.
Descent of the Virgin Uterus into the Vaginal Canal, showing the Reduplicated Vaginal Walls. The utero-vaginal attachment, points X and Z, appears to be at X' and Z'. The apparent increase of length in the vaginal portion of the cervix due to the reduplication is measured by the distance from X and Z to X' and Z'.	Descent of the Uterus, showing Excessive Circular Enlargement of the Lacerated Cervix, consequent upon Reduplication of the Vaginal Walls and Out-rolling of Intracervical Tissues. The divided fragments of the os externum are at a and b. The curved lines forming the angles 1, 2, 3, 4, and 5 indicate the gradual process of the eversion. The angle of the laceration at point 1 has been forced by the swelling and out-rolling of the mucous and submucous tissues of the cervix to point 5. The apparent os externum is at point 5. The utero-vaginal attachment X and Z seems to be at X' and Z'. The vaginal portion of the cervix therefore appears much larger and longer than it actually is.

Apparent elongation and disproportionate circular enlargement of the cervix are conditions which almost every standard author wrongly calls hypertrophic elongation and circular hypertrophy. The question of elongation is easily settled by placing the patient in the knee-chest position. Then the uterus by its own weight falls toward the diaphragm, the vagina unfolds, and the apparent utero-vaginal attachment X' Z' (Figs. 5 and 6) disappears, disclosing the actual attachment, X Z. Further, the point of the sound, passed into the bladder while the [p. 158] cervix is exposed by Sims's speculum, may be placed against the anterior wall of the cervix at Z, which would be impossible if the attachment were at Z'.

The comparatively small amount of hypertrophy in disproportionate circular enlargement is proved by the operation of trachelorraphy or by bringing the points a and b (Fig. 6) together with uterine tenacula, the organ being exposed by Sims's speculum. Then the out-rolled intracervical mucous tissues are rolled back, the proper diameter of the cervix is restored, and a laceration on one or both sides, extending past the vaginal attachment, becomes apparent.

Hypertrophy or hyperplasia usually causes a nearly symmetrical enlargement of the entire organ. At any rate, those cases in which the reduplication of the vaginal walls does not almost entirely explain the great elongation so called, or in which great disproportionate circular enlargement has not been caused by laceration of the cervix, are the rare exceptions. The great merit of having secured general assent to the foregoing proposition, and of having given to the subject a new and right direction, must be accorded to Emmet. The cervix now is seldom amputated except for malignant disease.

Congestion of the uterus consequent upon obstruction in the stretched and displaced veins is often so extreme as to induce a state analogous to erection. Measurements by the probe just before and a few minutes after replacement generally show an appreciable decrease in the length of the uterine canal. If the prolapse has been of the third degree, the difference may amount to one or even two inches. It is important not to confound the enlargement of congestion with increase in the solid constituents of the organ.

SYMPTOMS AND COURSE.—A dragging sensation and pelvic and abdominal pain are generally present. Rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. In descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. The course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. The peritonitis sometimes effects a spontaneous cure by peritoneal adhesions which fasten the uterus in an elevated position and hold it permanently. The symptoms of descent may be so severe as to necessitate absolute rest in bed. In other cases they are often attended with very little discomfort.

DIAGNOSIS is by inspection, palpation, and exploration. The prolapsed uterus may be distinguished from cystocele, rectocele, inverted uterus, and fibroid tumor by the presence of the os externum. The sound may be passed through the urethra into the cystocele, and the finger through the anus into the rectocele. The length of the uterus may be determined by the sound, the size, shape, position, extent of descent, and difficulty of replacement by conjoined manipulation.

PROPHYLAXIS.—This requires such measures during labor as may be necessary to prevent long and powerful pressure upon the pelvic floor. After labor any injury to the perineum should be promptly repaired. The vagina should be kept clean by irrigations. The urine, if necessary, should be regularly drawn and the bowels moved daily without straining. If conditions be present likely to induce subinvolution—such, for example, as pelvic inflammation or laceration of the cervix—they should receive treatment at the proper time. Undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position.

TREATMENT.—The first indication is replacement, which in the first and second degree of descent is not difficult unless the uterus be held down by cicatrices or by a tumor. Complicating pelvic cellulitis and peritonitis may render replacement dangerous or impossible, and may for a time contraindicate all direct treatment. Replacement of the organs from the third degree of prolapse is accomplished in the inverse order of their descent: first, the posterior vaginal wall, then the uterus, and last the anterior vaginal wall. Not infrequently the completely prolapsed uterus and pelvic floor, hernia-like, become strangulated. Then taxis will usually suffice if supplemented by hot applications, elastic pressure, anodynes, and the knee-chest position. Should these fail anæsthesia may be required.

Undue pressure from above should if possible be removed. The clothing should be loose, and the weight of the skirts supported from the shoulders either by straps or preferably by buttoning them upon a waist made for the purpose. This waist is a good substitute for the corset, which under all circumstances and in all its forms is injurious. Increased uterine weight from subinvolution or congestion is to be overcome by appropriate means. Enlargement of the uterus when due to hypertrophy or hyperplasia is generally incurable. Amputation of the cervix for what was formerly considered circular hypertrophy and hypertrophic elongation is now seldom or never required for the purpose of decreasing uterine weight. Amputation except for malignant disease has given place to the operation of trachelorraphy. Tumors exerting pressure above or traction below should if possible be removed. Regulation of the bowels and general tonics are usually necessary. The knee-chest position assumed several times a day causes the uterus to gravitate toward the diaphragm, and thereby gives temporary rest to the overburdened supports. While in this position the patient should separate the labia, so that the air may rush in and the vagina become expanded. The measures enumerated above, together with rigid care of the diet and of such other hygienic requirements as the individual case may demand, are essential as adjuvants to the more special treatment which almost every case requires.

In exceptional cases of sudden descent, even to the third degree, replacement alone is sometimes followed by permanent relief; but if the descent has been gradual it always recurs immediately after replacement. Measures are therefore required for the maintenance of the uterus in its normal location and position. This indication is fulfilled by pessaries and by operations.

Pessaries.—The function of the pessary is not only to maintain the uterus on the health level in its normal location, but also, if possible, in its normal position, which requires the cervix to be about one inch from the sacrum. The cervix being thus placed, the organ cannot turn back into retroversion, because in so doing the fundus would encounter the sacrum. The direction of least resistance would then be forward into the normal anterior position. The application of the pessary is then based upon the general proposition that if the cervix be normally placed the body of the uterus will in the absence of complications take care of itself. Since the vagina at its upper extremity is attached to the cervix, displacement of the latter is clearly impossible if the upper extremity of the vagina be sustained in its normal location. The pessary restores and maintains the relations of the relaxed vaginal walls by crowding the posterior vaginal cul-de-sac backward into the hollow of the sacrum. It thereby also holds the attached cervix within a proper distance of the sacrum. The Hodge pessary or some modifications thereof fulfils this purpose in ordinary cases more satisfactorily than any other.

FIG. 7.

The Emmet Curves.

FIG. 8.

The Albert Smith Curves.

The curves of the pessary demand careful attention in its application. When the uterus is below the normal level, the broad ligaments are necessarily rendered more tense than natural, and the blood-vessels, more especially the veins, which are looped one upon the other, and which traverse these ligaments to and from the uterus, are made to collapse. This causes venous congestion and consequent increase in weight of the uterus—a condition favorable to malposition, uterine catarrh, and pathological changes in structure. A pessary which will raise the uterus to the health level clearly fulfils an indication. A pessary which raises it above the health level renders the broad ligaments tense and reproduces a condition which it was designed to relieve. Maintenance of the uterus upon the health level depends largely upon the curves of the pessary. The accompanying cuts illustrate the shape and curve of the Hodge pessary as modified by Emmet and Albert Smith. Fig. 7 represents the curve of Emmet, and Fig. 8 that of Albert Smith. For convenience let us characterize that curve which rests in the posterior vaginal cul-de-sac as the uterine curve, and that which occupies that part of the vagina [p. 161] adjacent to the pubis the pubic curve. The acuteness and length of the uterine curve determine the height to which the pessary will lift the uterus. The longer and more acute the curve, the higher the uterus will be lifted, and vice versâ. The smaller curve of the Emmet modification will answer the average indication more nearly than the sharper curve of the Albert Smith modification, which may lift the uterus too high. The pubic should generally be proportioned to the uterine curve; that is, the greater the uterine, the greater the pubic curve. A pessary properly adjusted in all other respects may, by pressure upon the urethra and neck of the bladder, create vesical tenesmus and urethral irritation. This calls for increase in the pubic curve. The pubic curve may, however, be so great that the lower part of the pessary occupies the centre of the vulva, where it may create irritation. For this condition lessening of the pubic curve is the remedy. The pessary should not be so wide as to distend the vagina. Its length should be measured by the distance from the lower extremity of the symphysis pubis to the posterior vaginal cul-de-sac, less the thickness of the finger. If properly adjusted it should sustain the pelvic floor in its normal relations and the uterus in stable equilibrium.

The uterus in the first and second degrees of descent is usually either retroverted or retroflexed. The reader is therefore referred to the remarks on the application of pessaries in the treatment of these displacements.

In advance prolapse dependent upon extensive injuries to the perineum and other parts of the pelvic floor, and usually associated with extreme subinvolution of all the pelvic organs, the axis of the vagina is often changed from its forward oblique to the vertical direction. (See Fig. 3.) The downward traction of the prolapsing cystocele and rectocele upon the fornix of the vagina may then be so great that the pessary is inadequate to maintain in place the upper extremity of the vagina. The cervix then moves forward, the corpus turns back, and the whole uterus easily descends in a vertical direction along the prolapsing walls of the vagina to the second or third degree of prolapse. In this condition pessaries which disappear within the vagina are liable to be forced out with the prolapsing pelvic floor, or if retained seldom maintain the uterus in position. In such cases the various cup pessaries which are supplied with external attachments and abdominal belts are often used, but they are inadequate, because they either so fix the uterus as to prevent its normal movements, or they hold it in such unstable equilibrium that it may assume any one of the various malpositions, anterior, posterior, or lateral; and they are open to the further serious objection of constantly reminding the patient of their presence. As an expedient the uterus may sometimes be held within the pelvis by means of a large Albert Smith pessary with extreme uterine and pubic curves. The rational treatment, however, requires first an operation on the anterior vaginal wall to restore the fornix of the vagina to its normal place in the hollow of the sacrum, and with it the attached cervix; and second, an operation at the vaginal outlet to bring the posterior wall in contact with the anterior, and thereby to restore the lower extremity of the vagina to its normal place under the pubis.

ANTERIOR ELYTRORRHAPHY.—Numerous operations on the vaginal [p. 162] walls have been devised for the purpose of narrowing the vagina, and thus preventing descent along the vaginal canal, but they are temporary in their results, because, as long as the direction of the vagina remains vertical, its walls again become dilated by the prolapsing uterus and the former condition is re-established. The operation to be effective is performed as follows: A Sims's speculum of long blade, perforated at its extreme end, to which the cervix has been attached by a piece of silver wire, passing through the perforation and the posterior lip, is introduced, the patient being in Sims's position. The cervix is thereby drawn by the point of the speculum far back into the hollow of the sacrum. The author finds this preferable to the method described by Emmet, who has the cervix held back by a sponge probang in the hand of an assistant. The space in the anterior part of the pelvis is now so increased that the uterus readily falls forward into decided anteversion. While the uterus is thus held in position by its attachment to the blade of the speculum, the operator with two uterine tenacula finds in the loose vaginal tissue on either side of the cervix two points which can be brought together in front of the cervix. Then at each of the two lateral points a surface is denuded with the curved scissors about one-half inch square, and in front of the cervix a surface an inch long by half an inch wide across the anterior vaginal wall close to the uterine attachment. A No. 26 silver-wire suture is then passed, as shown in Fig. 9, and twisted as shown in Fig. 10, so as to secure the lateral denuded surfaces in contact with the larger surface in front of the cervix.

FIG. 9.

The First Suture before Twisting in Emmet's Operation for Procidentia (Emmet).

FIG. 10.

Folds on the Anterior Vaginal Wall formed after Twisting the First Suture (Emmet).

Inasmuch as the operation often fails at the point of the first suture, the author has usually introduced two or three of this kind instead of one. Two longitudinal folds are now formed on the anterior vaginal wall, which serve as guides for denuding and turning in the remaining redundant tissue by a line of sutures, which should extend forward along the centre of the vesico-vaginal wall until the folds are lost in the vaginal surface near the neck of the bladder. Sometimes the redundant tissue about the urethra cannot be disposed of by turning it in from side to side. Then it is desirable to make a crescentic denudation across the lower portion of the vagina, its concavity being on the uterine side, and [p. 163] to unite the margins below to those above by means of a curved line of sutures. The completed operation is shown in Fig. 11.

FIG. 11.

Emmet's Operation for Procidentia and Urethrocele completed. Sims's Speculum, Left Latero-prone Position (Emmet).

The after-treatment requires the self-retaining Sims's sigmoid catheter in the urethra for a week or frequent catheterization, absolute rest in bed, hot-water vaginal douches, regulation of the bowels, and the removal of the sutures on the twelfth day. After the completion of the operation the cervix is maintained near the hollow of the sacrum, and the organ remains normally anteverted and anteflexed, making an acute angle with the vesico-vaginal wall, which has now been restored to its normal direction and length. Unfortunately, it is not unusual to abandon the patient after this operation, in the vain hope that the uterus and anterior vaginal wall will maintain their normal relations without the support of the perineum and posterior vaginal wall. This is a great mistake, because the cystocele and procidentia almost always completely reappear within a few months. Anterior elytrorrhaphy, therefore, is simply one of the steps in the treatment.

PERINEORRHAPHY.—This is the name usually applied to the repair of the ruptured perineum, but the scope of the operation has been extended to include also the surgical treatment of rectocele and relaxation of the posterior vaginal wall. The most scientific operation yet devised is the one proposed by Emmet,⁸ which is performed as follows: The patient being etherized and in the lithotomy position, the operator seizes with a tenaculum the crest of the rectocele or posterior vaginal wall at a point which can be drawn forward without undue traction—point a. With another tenaculum the lowest caruncle or vestige of the hymen (point b), [p. 164] and with another the posterior commissure of the vulva (point c), are hooked up. The triangle included between these points defines one-half of the surface to be denuded. The three tenacula are now placed in the hands of assistants, the sides of the triangle are made tense by traction, and the included surface denuded. The tenaculum at c is then removed, and the middle point of the line a b is caught and drawn toward the interior of the vagina in the direction of the vaginal sulcus on that side, and the sutures are introduced, as in Fig. 13. The same thing is then repeated on the other side, and the sutures are all tightened, forming a line of union running back into each sulcus, as shown in Fig. 14.

⁸ Trans. Am. Gynæcological Society, 1883; Principles and Practice of Gynecology, 3d ed.

FIG. 12.

a is at the crest of the rectocele; b at the caruncle just within the labium; and c at the posterior commissure. The cut represents that half of the surface to be denuded which is on the operator's right. The dotted lines represent the other half, on the left.

FIG. 13.

The Sutures in Place. When secured they will unite a d with b d, and lift the perineum up in contact with the anterior vaginal wall.

FIG. 14.

All the Vaginal Sutures Twisted. One suture, including the crest of the rectocele and the labium majus on either side, and three superficial external sutures, are yet to be secured. The lines a d and d b, Fig. 13, have been brought into coincidence by means of the sutures, and now form the line of union d b. The tissues between the lines a c and c b, Fig. 13, have been so lifted up and are so held under the line of union d b that the line c b, Fig. 13, has been reduced to c b, Fig. 14, which makes the external portion of the wound insignificant in extent.

The essential part of the operation inside the vagina almost always succeeds, but the external part of the rupture at the posterior commissure often fails to unite; furthermore, the operation as described by Emmet does not overcome the patulous condition of the introitus vaginæ in case of great relaxation of the vagina. The author has sought to obviate the first of these difficulties by the use of deep silver sutures instead of the superficial ones described by Emmet. They should be introduced before tightening the vaginal sutures, and should be passed far around in the posterior vaginal wall, their points of entrance and exit being the same as for the three lower unsecured superficial external sutures in Fig. 14. The second difficulty may be overcome by further denuding a triangular surface in the vaginal sulcus on each side, the base of the triangle corresponding [p. 165] to the line a b, Fig. 12, and its apex being in the vaginal sulcus at a distance corresponding to the degree of relaxation. This increases the length of the lines of union running into the sulci represented by d b and e f, Fig. 14. In the vaginal portion of the wound silk or catgut is preferable to silver, the latter being difficult to remove.

Emmet is entitled to great credit for having given to the profession an operation which brings the posterior vaginal walls up against the anterior more perfectly than any other, and which, being mostly inside of the vagina, is therefore followed by very little of the pain during convalescence which formerly rendered perineorrhaphy one of the most trying operations in gynecology. The operation furthermore has demonstrated the former teachings relative to the direction of perineal rupture⁹ and the tissues involved to be incorrect, or at least inadequate.

⁹ At the meeting of the American Medical Association in June, 1883, the author presented a paper describing the transverse laceration of the perineum and its operative treatment, which was published with illustrations in the transactions by the journal of the Association, Dec. 22, 1883. This communication referred only to the recent rupture and the immediate operation.

Retroversion is that position of the uterus in which the fundus is posterior to the axis of the pelvic inlet. If the cervix be in its normal place near the sacrum, retroversion is scarcely possible, because it is prevented by the proximity of the over-arching sacrum. (See Fig. 2.) The first degree of prolapse must therefore precede any considerable backward turning of the uterus. When the cervix has been displaced downward [p. 166] and forward so far that its distance from the sacrum is equal to or greater than the length of the uterus, retroversion to any extent becomes possible. (See Figs. 3 and 16.)

ETIOLOGY AND HISTORY.—From the above it follows that the causes of commencing retroversion must be identical with the causes of the first degree of prolapse. After the puerperium the relaxation of the supports and the weight of the organ may persist, and spontaneous replacement may be prevented by the pressure and weight of the intestines upon the anterior surface. Every act of defecation forces the cervix forward and downward, and the uterus, being in the axis of the vagina, and having therefore little support below, must depend upon the subinvoluted peritoneal suspensory ligaments and pelvic fascia, which are inadequate. This condition is very often induced by abortions, with resulting increased weight and relaxation of the vaginal walls. Local peritonitis and cellulitis may permanently fix the corpus in its retroverted position by cicatricial bands and adhesions.

SYMPTOMS AND COURSE.—The displacement and its complications usually cause bearing-down sensations, a feeling of heaviness in the pelvis, exhaustion upon walking and standing, especially the latter, and constipation. After the puerperium the extreme engorgement of the pelvic organs often produces uterine hemorrhage, which should not be confounded with the returning menstruation. Especially after abortion the hemorrhage often persists for a long time unless cured by treatment. Gradual or sudden replacement may occur spontaneously, or the causes may continue active, and even be enforced by cystocele and rectocele. The displacement may also be complicated by disease and displacement of the ovaries. Organic disease of the uterine walls may induce a superadded retroflexion. The heavy organ may descend along the relaxed subinvoluted vaginal walls even to complete procidentia.

DIAGNOSIS AND PROGNOSIS.—The symptoms outlined in the preceding paragraph indicate the probability of displacement, but the diagnosis depends upon direct examination of the uterus. Conjoined manipulation and the probe will usually show the retroverted organ with the cervix displaced toward the pubes and with the corpus in the hollow of the sacrum. The introduction of the probe is contraindicated by cellulitis and peritonitis. In certain cases of anteflexion, as represented in Fig. 23, the cervix is bent forward in the vaginal axis as in retroversion. The condition is in reality one of retroversion of the cervix with high anteflexion of the corpus, which may usually be detected by careful conjoined examination. The prognosis with treatment is generally favorable both for speedy relief and ultimate recovery.

TREATMENT.—As in descent, the treatment consists in removing cellulitis, peritonitis, and other complications, in the use of pessaries, and in operations on the anterior and posterior vaginal walls if needed. Inasmuch as the treatment corresponds to that of retroflexion, it will be presented under that subject.

ETIOLOGY AND PATHOLOGY.—Retroflexion is that displacement in which the organ is bent backward upon itself. It usually results from, [p. 167] and is associated with, retroversion, but for convenience the double displacement will be termed retroflexion. It may be caused by the great weight of the corpus, the soft flexible state of the uterine walls during and after involution, intra-abdominal forces, downward pressure during defecation, tight clothing, and not commonly by the obstetric bandage.

The ovaries, unless fixed elsewhere by adhesions, are displaced with, and held down on either side of, the corpus, sometimes enlarged from inflammation, often adherent, and always extremely sensitive. Chronic metritis, cellulitis, and peritonitis, with adhesions more or less firm, are usually present, and not infrequently as the result of gonorrhoea, abortion, or injudicious treatment. Peritoneal adhesions between the corpus and the cul-de-sac of Douglas sometimes make replacement impossible. In rare cases the displacement is congenital.

FIG. 15.

Extreme Retroflexion, with Hypertrophy of the Corpus, which impinges upon the rectum and compresses the recto-vaginal wall.

SYMPTOMS AND COURSE.—Among the most pronounced symptoms are profuse uterine catarrh, menstrual disorders, sterility, abortion, weakness, pain in the back, painful defecation, rectal tenesmus, the symptoms of pelvic inflammation, neurasthenia, and other nervous symptoms. The uterine catarrh is due to an effort on the part of the engorged pelvic organs to relieve themselves by an exaggerated secretion of mucus from the uterus, which upon being increased in quantity becomes vitiated in quality, and therefore pathological. Menorrhagia and abortion may also result from congestion. Dysmenorrhoea and sterility result from the [p. 168] general anæmic condition and from the inflammatory complications, and from the obstruction in the uterine canal or in the blood-vessels at the angle of flexure. (See Pathology of Anteflexion.) The rectal symptoms are caused by the pressure of the corpus uteri upon the rectum, which gives the sensation to the patient of an overloaded bowel.

Should pregnancy occur, the rapid growth of the uterus may induce spontaneous reposition at about the fourth month, when the fundus rises out of the pelvis, but if the corpus be incarcerated under the sacral promontory from adhesions or from any other cause, the uterus will, unless manually replaced, relieve itself by abortion.

Abdominal pains, nervous dyspepsia, and neuralgia in distant parts of the body are often present; indeed, the nervous symptoms may be of the most exaggerated character, and may comprise all that is implied by the word hysteria in its most comprehensive signification.

DIAGNOSIS.—Digital touch discloses the cervix low in the pelvis, and the fundus uteri is felt through the posterior vaginal wall in the cul-de-sac of Douglas. Conjoined manipulation with the index finger of the left hand, first in the vagina and then in the rectum, and the right hand over the hypogastric region, will show the size, form, consistency, and location of the uterus, the degree of the flexure, and the difficulty of replacement. An inflammatory exudate or hæmatocele, posterior to the uterus, or a fibroid in the posterior uterine wall, may be mistaken for the retroflexed corpus. The probe will always verify the diagnosis, but if there be great tenderness with fixation in the cul-de-sac of Douglas, treatment should be directed against the inflamed condition, and the final diagnosis made by repeated examinations or after the disappearance of the inflammation. Great and lasting injury is often done in the attempt to complete the diagnosis at the first examination. The presence of a fibroid in the posterior uterine wall with post-uterine inflammation is a serious complication both in diagnosis and treatment. If the rectum be overloaded with fecal matter, the diagnosis should be deferred. The displacement is distinguished from the presence of an ovary or small ovarian tumor in the pouch of Douglas by careful bimanual examination and by the probe.

TREATMENT OF RETROVERSION AND RETROFLEXION.—The objects of treatment are replacement and retention of the uterus. The obstacles to replacement are cellulitis, peritonitis, and fixation of the uterus, and these complications often require weeks, and in severe cases months, of treatment preparatory to replacement. Some of the general therapeutic suggestions under the subject of descent are also applicable to the retro-positions. Rest, massage, careful regulation of the bowels, feeding, and general tonics are essential. For the inflammation small blisters over the inguinal regions frequently repeated, and the daily application of the cotton and glycerin plug to the cervix, and dry cupping over the sacrum, are most efficacious. The glycerin may be combined with alum, tannin, chloral hydrate, or iodoform. Thymoline in small quantities partially destroys the disagreeable iodoform odor. The most useful and essential topical application is the hot-water vaginal douche, but its use will be followed by failure and disappointment if it be applied in the ordinary way. The following is quoted from a paper by the author which was published in the Chicago Medical Gazette, Jan. 1, 1880:

"A satisfactory substitute for the bed-pan may be made as follows: Place two chairs at the side of an ordinary bed with space enough between them to admit a bucket; place a large pillow at the extreme side of the bed nearest the chairs; spread an ordinary rubber sheet over the pillow, so that one end of the sheet may fall into the bucket below in the form of a trough. The douche may then be given with the patient's hips drawn well out over the edge of the bed and resting on the pillow, and with one foot on each chair; the water will then find its way along the rubber trough into the bucket below." The Davidson syringe, which has an interrupted current, is preferable to any of the fountain syringes.

As the tenderness disappears the cotton plugs may be increased in quantity, and thereby made to serve as temporary support for the uterus until a more permanent pessary can be substituted. The sluggish circulation in the pelvis and torpid condition of the bowels may be much relieved by the daily application of the wet pack. A small flannel sheet folded lengthwise to the width of two feet, dipped in very hot water, and dried by passing it through a wringer, is wound about the hips and covered by another dry one. At the end of a half hour, during which time the patient maintains the recumbent position, the sheets are removed. When the tenderness has been sufficiently reduced, gentle attempts at replacement may be made every day or two by conjoined manipulation. The patient's tolerance of manipulation may thus be observed and the way prepared for complete replacement and permanent retention after the subsidence of the inflammation.

In retroversion and retroflexion always replace the uterus before adjusting the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur: (1) The pessary may not be tolerated on account of pain; (2) the pessary may be forced down by pressure from above so near to the vulva that it will fail to do the least good; (3) the uterus, finding it impossible to hold its position against the pessary, instead of taking its proper position will often be bent over it in exaggerated retroflexion, with the cervix between [p. 170] the pessary and the pubes and the body between the pessary and the sacrum, or the whole organ may slip off to one side of the instrument into a malposition more serious than the one for which relief is sought. The safest and most effective method of replacement is by conjoined manipulation, as represented in Figs. 16 and 17. The dotted lines in the former indicate the gradual elevation of the corpus out of the hollow of the sacrum to the pelvic brim, where it may be anteverted by the fingers of the right hand pressed well down behind its posterior wall. During the process of anteversion the index finger of the left hand in the anterior fornix of the vagina presses the cervix back to its place in the hollow of the sacrum, as in Fig. 17. Efficient reposition of the uterus is very often impossible without anæsthesia.

FIG. 16.

Commencing Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).

FIG. 17.

Completed Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).

The replacement is not usually accomplished by drawing the fundus forward and pushing the cervix back directly in the median line. In most cases the fundus sweeps around the arc of a circle on the left side of the pelvis, and the cervix on the right. This is owing to the greater frequency of cellulitis on the left side, and consequent shortening of the left broad ligament. After replacement the organ is to be held in position by a suitable pessary.

Bimanual replacement has two great advantages over the more familiar methods of the sound or repositor: first, it is more effective and more [p. 171] permanent; second, the lever action of the sound or repositor, by which the operator may unwittingly use an undue and dangerous amount of force, is avoided in the use of the hands, through which the operation is not only constantly under his control, but also within his appreciation.

Inasmuch as the pessary fulfils its indications by sustaining the pelvic floor, and thereby holding the cervix in the hollow of the sacrum, the same general principles, and in fact the same pessaries, which are applicable to prolapse apply also to retroversion and retroflexion. Indeed, the first step in the genesis of the retro-positions has been shown to be prolapse. The student is therefore referred to the general remarks on the adjustment of pessaries for prolapse.

The operations of elytrorraphy and perineorraphy, especially the latter, already described in the treatment of descent, are often of the utmost importance in the treatment of the posterior displacements, and should therefore be carefully studied in this connection.

In the adjustment of the pessary it is desirable, if possible, to avoid direct pressure upon any part of the uterus. Pessaries designed to prop up the body of the uterus by pressure upon the posterior wall to correct the posterior malpositions, and upon the anterior wall to correct the anterior malpositions, are very liable to induce metritis and perimetritis, and are therefore generally unsafe. In certain cases, however, the vaginal walls, [p. 172] especially the posterior, may be so relaxed from subinvolution and other causes that the instrument, though very long, fails to maintain the cervix in its normal place. Under such conditions a pessary may be required to act directly upon the uterus. The Schultze's sleigh pessary represented in Fig. 19 fulfils this indication. Schultze's figure-of-eight pessary, or a long Albert Smith pessary with its uterine curve made so extreme as to bring the upper part of the instrument in front of the cervix instead of behind, answers the same purpose.

FIG. 18.

Showing the Pelvic Organs sustained by the Emmet Pessary alter reposition of the prolapsed, retroverted or retroflexed uterus.

Thomas's retroflexion pessary, with its bulbous upper extremity, is a long narrow instrument of extreme uterine curve. It lifts the uterus very high, and is specially applicable in cases of great relaxation of the pelvic floor and of complicating prolapse of the ovaries (Fig. 21). The bulbous portion is sometimes made of soft rubber.

A properly-adjusted pessary gives to the patient no consciousness of its presence. If the instrument cause pain it should be removed and search made for the tender places; it should then, if possible, be remoulded into such shape that it will not exert pressure upon them. Often a slight indentation at some point will enable the patient to wear it with comfort.

Sometimes when the corpus has been firmly bound back by peritoneal adhesions they may be broken up by very forcible conjoined manipulation under ether, but the operation is dangerous, and should therefore be [p. 173] undertaken only by an expert operator. In place of this operation Lawson Tait has proposed to open the abdomen, break the adhesions, and stitch the fundus uteri to the abdominal wound. This operation in the hands of such an operator as Tait is probably not more dangerous than breaking up firm adhesions by forcible conjoined manipulation.

FIG. 19.

Schultze's Sleigh Pessary in place, as adjusted for prolapse, retroversion, or retroflexion with great relaxation of the vaginal walls (after Schultze).

In certain cases in which replacement is impracticable or impossible on account of inflammation or adhesions a soft rubber ring may be inserted, and will often give decided relief by lifting the uterus and pelvic floor nearer to the health level. In the treatment of all displacements coition should be forbidden or permitted only with great moderation, and the pessary should be kept clean by copious daily applications of the vaginal douche. Every three or four weeks the instrument should be removed and the pelvic organs carefully examined.

It should be urged that no man can safely apply the pessary until he has fully appreciated its indications and contraindications. Few practitioners possess naturally the mechanical skill necessary to its proper adjustment. Of this thousands of unfortunate women bear witness. Its dangers in inefficient hands are in striking contrast with its usefulness when judiciously employed.

Many cases of displacement, both anterior and posterior, are so complicated by prolapsed and adherent ovaries, by advanced disease of the ovaries and Fallopian tubes, and by peritoneal adhesions, that not only [p. 174] replacement, but even palliation, is impossible; then, as a final resort, the activity of the pelvic organs, both physiologically and pathologically, may be put at rest by the removal of the ovaries and Fallopian tubes.

FIG. 20.	FIG. 21.
Front View of Schultze's Figure-of-Eight Pessary. The upper opening is intended to hold the cervix. This pessary has the uterine and pubic curves, as in Figs. 7 and 8.	Thomas's Retroflexion Pessary.

William Alexander of Liverpool has devised an ingenious operation of shortening the round ligaments for the radical cure of descent and of the posterior displacements. He reports twenty-two cases of the operation in his own practice and several more in the practice of other surgeons, with almost uniform success in completely curing the displacements. The operation, although new, gives promise of a brilliant and successful future.

The lateral malpositions which often complicate retroversion and retroflexion are usually the result of inflammation in a broad ligament or in the uterus itself, or in both. Their treatment is that of the causative inflammation, and follows the general principles which have been laid down for the treatment of other versions and flexions.

Sometimes the physiological angle of flexure becomes obliterated in consequence of chronic metritis, resulting in permanent straightening of the uterus, and the cervix becomes elevated and fixed above, or the corpus depressed and fixed below, the normal level. This constitutes pathological anteversion (Fig. 22).

FIG. 22.

Pathological Anteversion.

ETIOLOGY.—The exaggerated anteversion of early pregnancy is physiological, the exaggerated anteversion of the uterus in chronic metritis is pathological. Elevation of the cervix and depression of the corpus may be induced by peritoneal adhesions. Increased weight from a mural fibroid may also depress the corpus.

The SYMPTOMS are due to the pelvic inflammations already mentioned and other complications. The increased weight of the uterus, which is usually hypertrophied from metritis, generally causes a dragging sensation, especially if the organ be also prolapsed. The enlarged corpus occupying the territory of the bladder often induces persistent vesical irritation or even cystitis. Menorrhagia, when present, is the result of the metritis or a fibroid rather than of the displacement per se.

DIAGNOSIS AND PROGNOSIS.—The displacement is recognized by digital touch, which discloses the anterior wall of the uterus parallel to the anterior wall of the vagina, with the fundus close to the symphysis and the cervix elevated. Conjoined examination will show the size, shape, hardness, and degree of fixation. Exaggerated anteversion of the healthy uterus is not necessarily pathological in its results. This is illustrated by the anteversion of early pregnancy. The prognosis is therefore good if the causes can be removed.

TREATMENT.—Inasmuch as exaggerated anteversion is the position taken by the uterus in chronic metritis, it follows that the treatment is often that of chronic metritis. For the treatment of metritis, perimetritis, fibroids, menorrhagia, etc. the reader is referred to the special literature of those subjects. Irritable bladder, which is often a mechanical result of the displacement and enlargement, may sometimes be relieved by means of an Albert Smith or Hodge pessary, which lifts the organ to a higher level away from the bladder. In thus elevating the uterus the [p. 176] anteversion may be rather increased than diminished, which proves that the symptoms were dependent not upon the anteposition, but rather upon descent and antelocation. Should the parts be too sensitive to tolerate the hard-rubber pessary or a flexible rubber ring, the daily application of medicated pledgets of cotton will give support to the uterus and decrease the tenderness until the more permanent instrument can be worn. The numerous anteversion pessaries designed to elevate the corpus by direct pressure on the anterior wall of the uterus generally irritate the organ, and thereby aggravate the inflammatory complications. They are therefore to be used with extreme caution.

DEFINITION.—The normal forward bending of the corpus upon the cervix uteri when the bladder is empty makes an angle of which the approximate physiological limits are between 45° and 90°: the flexure would generally be pathological if less than 45° or more than 90°. Furthermore, if the flexure, whether it be normal or abnormal in extent, does not disappear upon filling the bladder, but remains constant under all conditions, the rigidity makes the flexure pathological. Anteflexion is therefore pathological if the mobility at the angle of flexure is increased or diminished or absent.

ETIOLOGY AND PATHOLOGY.—Anteflexion may be congenital or acquired. By congenital is meant not defective foetal development, but failure of the immature child uterus to develop at puberty, a failure which usually pertains alike to the uterus, Fallopian tubes, ovaries, and vagina. In congenital anteflexion the uterus is bent upon itself almost double, the body and cervix both pointing in the direction of the pelvic outlet, with the cervix somewhat elongated and situated in the long axis of the vagina. (See Fig. 23.)

FIG. 23.

Congenital Anteflexion. Both cervix and body are flexed forward.

Acquired anteflexion may be simply an exaggeration of the normal flexure, due either to increased weight of the corpus from the presence of the uterine fibroid near the fundus or to unequal growth of the uterine walls or to unequal involution. A very frequent cause of anteflexion is thickening of the posterior wall of the uterus from the products of inflammation, and a corresponding atrophy of the anterior wall from prolonged pressure at the angle of flexure. Post-uterine cellulitis and peritonitis involving the utero-sacral ligaments is a frequent and discouraging complication. Sometimes the inflamed ligaments contract and drag the anteflexed uterus upward and backward, where it may be permanently fixed by peritoneal adhesions. (See Fig. 24.)

FIG. 24.

Anteflexion with Post-uterine Fixation.

A constriction of the uterine canal at the point of flexure may, by confining the secretions above, produce inflammation in the body of the uterus, Fallopian tubes, and ovaries analogous to the cystitis, ureteritis, pyelitis, and nephritis which follow stricture of the male urethra. The [p. 178] peri-uterine inflammations, having the relation either of cause or effect of the flexure, often bind the pelvic organs together in a mass of exudate, with resulting failure of nutrition, nerve-irritation, and constant pain, which sometimes render the patient's life miserable and useless.

SYMPTOMS AND COURSE.—The numerous symptoms due to the inflammatory and other complications should not be confounded with those of the displacement. The symptoms of anteflexion are polyuria and dysuria, dysmenorrhoea and sterility.

The vesical symptoms are produced either by the rigidity of the uterine tissue at the angle of flexure, which prevents the body from rising out of the way of the filling bladder, or by the inflammatory shortening of the utero-sacral ligaments, which, by drawing the uterus upward and backward, put the vesico-vaginal wall on the stretch, thereby causing traction upon the neck of the bladder.

The dysmenorrhoea may depend upon the presence of constriction of the uterine canal at the angle of flexure. This causes the blood to accumulate and to coagulate in the body of the uterus, from which it is expelled at intervals by uterine contractions simulating labor-pains. The pain when due to this cause is therefore always very severe just before the passage of a clot. Furthermore, the dysmenorrhoea may be caused by obstruction in the veins at the angle of flexure, which causes intense venous congestion of the entire body of the uterus; pain is then due to the pressure of the swollen vessels upon the nerve-filaments and to a consequent irritable condition of the muscular tissue of the uterus. Sometimes upon the establishment of the flow the uterine canal becomes temporarily straightened; this removes the cause of the vascular obstruction, and together with the flow gives relief.

Sterility is very commonly associated with anteflexion. The fact that dilatation and incision of the constricted canal have frequently been followed by conception has been accepted as proof that the sterility is due to the constrictive obstruction. This mechanical theory is questioned by many, who say that the dilatation cures sterility by straightening the uterus and thereby removing the venous obstruction and the consequent congestion.

DIAGNOSIS.—The educated touch which distinguishes the normal version, flexion, and movements of the uterus will appreciate the anatomical differences between pathological and normal anteflexion. The degree of flexure, the mobility or rigidity, and the size, shape, location, and consistency of the uterus may be ascertained by conjoined manipulation. The presence of post-uterine cellulitis is recognized by the pain caused in dragging the uterus slightly forward and by increased thickness and tenderness in the region of the utero-sacral ligaments, which may be felt by vaginal or rectal touch. Anteflexion is distinguished from a fibroid in the anterior wall of the uterus by the probe. When the diagnosis of anteflexion is obscured by the presence of cellulitis, it is usually better to wait for absorption of the exudate than to subject the patient to needless danger from the probe. Should it be necessary to pass the probe, the danger is decreased by gentle manipulation, which is facilitated by Sims's speculum and the latero-prone position. The common error of mistaking the normal version and flexion of a prolapsed uterus for pathological [p. 179] version and flexion has been exposed in a previous paragraph. (See Etiology and Clinical History of Descent.)

TREATMENT.—If complicating cellulitis or peritonitis exist, in the relation of either cause or effect to the flexure, its removal becomes the prime indication, because unless removed it is a positive contraindication to the more direct treatment of the malposition itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable tumors sometimes render cure impossible. Improvement of the general health, treatment of complications, and palliation then become the only resources.

The direct treatment of pathological anteflexion has for its object the straightening of the uterine canal, which is usually accomplished either by division of the cervix or by dilatation. But before considering the treatment more specifically, it should be remembered that surgical treatment of anteflexion in cases of dysmenorrhoea and sterility is only justifiable when the anteflexion is pathological. To say that most women who suffer from dysmenorrhoea and sterility have anteflexion is only saying that in the majority of such cases the uterus is in its normal position.

The Marion-Sims operation of dividing the cervix is open to two objections: first, its results are apt to be only temporary, in consequence of rapid contraction upon healing of the wound; second, it has frequently been followed by death. Dilatation by means of tents is also transient in its results, and dangerous to life. Both Sims's operation and dilatation by tents have given frequent and serious warnings in the shape of pelvic inflammations, which, if not destructive to life, have been almost as disastrous in their influence upon health.

The following, with some modifications, is an abstract of a valuable contribution¹⁰ by Goodell of Philadelphia, in which he gives positive endorsement to rapid dilatation as proposed by Ellinger and others. The instruments recommended are two Ellinger dilators, which are preferred on account of the parallel action of their blades. The dilatation is commenced with the smaller instrument and completed with the larger, which has powerful blades that do not spring or feather. The light instrument needs only a ratchet in the handle, but the stronger one has a screw which forces the handles together and the blades apart. To prevent injury to the fundus when the instrument is open, the length of the blades is limited to two inches. The larger instrument has a dilating power of one and a half inches, and has a graduated arc in the handles which indicates the divergence of the blades. Goodell's modification of Ellinger's dilators is provided with serrated blades, to prevent them from slipping out of the canal during the process of dilatation.

¹⁰ American Journal of Obstetrics, 1884, p. 1179.

For dysmenorrhoea or sterility due to flexion or stenosis the method of operation is as follows: A suppository containing a grain of the aqueous extract of opium is introduced into the rectum, the patient etherized, and the uterus exposed by Sims's speculum. The cervix is held by a tenaculum, and the smaller dilator is introduced as far as it will go. Upon gently stretching open that portion of the uterine canal which it occupies, the stricture above so yields that when the blades are closed they will pass higher. By repeating this manoeuvre a cervical canal is tunnelled out which before would not admit the finest probe. Should the os [p. 180] externum or cervical canal be too small to admit the instrument, a pair of pointed scissors may be substituted, and by the same opening and closing motions the canal may be prepared for the introduction of the smaller dilator. As soon as the cavity of the uterus has been entered the handles are brought together. This dilator is then withdrawn, the larger one introduced, and its handles slowly screwed together. If the flexure be very marked, the larger instrument after being withdrawn should be introduced with its curve in the opposite direction to that of the flexure, and the final dilatation made with the dilator in this position. But in reversing the curve the operator should take care not to rotate the organ upon its own axis, and not to mistake a twist thus made for a reversal of the flexure; the ether is then withheld, and the instrument allowed to remain in place until the patient begins to flinch, when it is removed. The best time for the dilatation is midway between the monthly periods. In the majority of cases the dilatation should be carried to about one and a quarter inches. The infantile uterus which has failed to develop at puberty has thin, unyielding walls, and should therefore not be dilated more than three-fourths of an inch or an inch. In using the larger instrument it is usually necessary to have the assistant make decided counter-traction with the vulsella forceps to prevent the blades of the dilator from slipping out. The cervix is sometimes lacerated, but not sufficiently to produce unpleasant results.

Goodell's statistics include one hundred and fifty operations of full dilatation under ether, with no fatal result and without serious inflammatory disturbance. As precautions against cellulitis, peritonitis, and metritis the patient should be fortified for the operation with moderate doses of opium and full doses of quinine, and for two or three days after the dilatation this should be continued and supplemented by the application of an ice-bladder over the abdomen.

After forcible dilatation under ether the cervical canal rarely returns to its previously angular or contracted condition. The cervix shortens and widens, and the plasma thrown out thickens and stiffens the uterine walls. In a small minority of cases the operation must be repeated. Dysmenorrhoea or sterility, if dependent solely upon the flexure, is cured by the dilatation. The comparative safety of forcible dilatation in the hands of a skilful and experienced gynecologist may be contrasted with its great danger when undertaken by an operator unacquainted with the special requirements of uterine surgery. Peri-uterine inflammation is a positive contraindication to the operation.

Post-uterine inflammation, which has drawn the anteflexed or anteverted uterus upward and backward by the contraction of the utero-sacral ligaments, often produces traction upon the vesico-vaginal wall and neck of the bladder, with a constant desire to micturate. For the relief of this intractable symptom, which sometimes goes on to cystitis, Emmet has proposed a most satisfactory remedy known as his buttonhole operation of urethrotomy.¹¹ He makes a longitudinal opening about five-eighths of an inch long through the urethro-vaginal wall, between the meatus and the neck of the bladder, without cutting through either. To prevent the opening from healing together, the margins of the mucous membrane of the urethra are united with fine catgut sutures to the [p. 181] margins of the mucous membrane of the vagina. According to Emmet, the operation relieves irritation due to traction on the neck of the bladder by freeing the pelvic fascia at the fixed point where it converges to its pubic attachment. The operation is equally applicable for the relief of this symptom when due to inflammation in any other part of the pelvis. The same result may be secured, but less satisfactorily, by forcible dilatation of the urethra.

¹¹ Emmet's Principles and Practice of Gynecology, 3d ed., pp. 275 and 761.

From personal experience the author can testify to the gratifying effects of this operation. Vesical irritation caused by post-uterine inflammation and consequent contraction of the utero-sacral ligaments is often wrongly attributed to the mechanical pressure of the anteflexed fundus uteri upon the bladder, which is manifestly impossible, if the contracted utero-sacral supports hold the entire uterus back away from the bladder.

The various anteflexion and anteversion pessaries which have been devised for the purpose of propping up the corpus are almost useless. Their false reputation depends upon the relief which they frequently give to complicating prolapse, the symptoms of which have been wrongly attributed to anteflexion or anteversion. The same pessaries therefore may be applied as in descent. (See Etiology and Clinical History of Descent.) Intra-uterine stem pessaries designed to straighten the flexed uterus are sometimes effective, and always dangerous.

DISORDERS OF THE UTERINE FUNCTIONS.

Menstruation with its disorders is the only subject to be considered under this head. In its monthly recurrence it is most intimately connected with, and dependent upon, ovulation, each menstrual discharge being the sign and evidence of the maturation and expulsion of one ovum or more. This proposition is denied by some, but the evidence adduced against it, while sufficient to show that the two processes may be dissociated, and may sometimes occur independently, is not strong enough to invalidate the truth of the general statement.

Menstruation may be entirely absent, the flow may be excessive, or it may be accompanied by severe pain; and these derangements have been designated from time immemorial as amenorrhoea, menorrhagia, and dysmenorrhoea. The time is long past, however, when these affections could be treated as distinct diseases. Each of them may be caused by influences so various—and, above all, may depend upon pathological conditions so different, and even dissimilar—that the name applied to each is indefinite, and, like the term dropsy, only incites inquiry as to some abnormal condition of which the deranged flow is the symptom. A due appreciation of this fact is of prime importance, because treatment cannot be instituted with expectation of success until the particular form of each derangement has been distinguished.

The great majority of cases of uterine derangement depend upon changes of structure. Those considered purely functional are largely in the minority, and would be still less in number with a more intimate knowledge of pathology or with greater skill in examination. No argument is needed, therefore, to show that a direct and thorough examination of the organs concerned is essential to rational treatment of this class of affections. There are obvious difficulties in the way of such an investigation, different from and far greater than attend the investigation of the diseases of any other organ of the body. With tact and proper demeanor, however, these difficulties can be generally overcome, but in any other than trifling cases, and especially in those continuing for any considerable time, the practitioner will do injustice to himself as well as to his patient if he do not insist upon this indispensable investigation.

A due appreciation of the influence of uterine disorders and diseases upon other and remote parts of the body is necessary to a correct estimate of their importance, and often of great practical value in treatment. Through the sympathetic nervous system pathological conditions of the uterus modify the processes of organic life, and by direct or reflex action [p. 183] affect the cerebro-spinal system in its centre or at any point of its terminal ramifications. That the stomach responds readily to uterine excitations is shown in pregnancy, and uterine disease often causes disorders of the digestive organs the origin of which may not be suspected. Eructations, vomiting, and the various forms of indigestion are not uncommon. The bowels are irregular in action, constipation alternating with diarrhoea, and flatulent distension may occur even to a degree demanding special treatment. Failure of general nutrition and impoverished blood are the consequences of this disturbed digestion; without good blood there is no sound innervation, and the nervous system is soon in such a condition as to respond unduly to even insignificant impressions. Normal menstruation is marked by a nervous erethism which shows itself by irritability, fits of despondency, and exhibitions of temper. There are therefore abundant reasons why nervous diseases should be very frequently seen as a remote effect of uterine disorders.

A very large proportion of these reflex diseases first occur at the period of puberty, many present striking exacerbations at every menstrual period, and some are so closely associated with this function as to be cured only by remedies addressed to it. Headache, neuralgia, hysteria in its varied forms, chorea, catalepsy, epilepsy, and even mania, have been repeatedly shown to have their origin in the sexual organs. The reproach often directed at gynecologists, of a disposition to magnify their specialty, falls pointless before such important facts; and since it is not uncommon for diseases of organs in close proximity to the uterus, as those of the urethra, bladder, and rectum, to be mistaken for or confounded with diseases of the uterus itself, there is abundant warrant for urging the closest scrutiny as to a possible uterine origin of remote diseases, especially those of a nervous character.

The term amenorrhoea signifies the absence of menstruation. It occurs in two different forms: First, those cases in which menstruation has never occurred—emansio mensium; second, those in which it has disappeared after having been established—suppressio mensium.

The following pathological schedule may assist in the study of the subject. It need scarcely be said that it is not presented as correct in every particular, nor with the idea that the dividing-lines between physiological and pathological conditions can be always determined, but as a convenient guide to follow in the study of the subject:

Absence or want of due development of some of the sexual organs is not of very infrequent occurrence. The ovaries are very rarely found wanting; they are more often checked in development and present the characteristics of early life. This condition may be the cause of delayed, irregular, or scanty menstruation, making a more or less near approach to amenorrhoea. Absence of the uterus is often combined with absence or with an undeveloped condition of the vagina, but this canal may be perfect and no change of the external organs be present to indicate that the uterus is wanting. It may also exist in a rudimentary form, and may be found corresponding in size and shape to the uterus of any period of early life.

Absence of the ovaries not only causes amenorrhoea, but checks the progress of the bodily development and prevents the sexual changes of puberty. When the ovaries are wanting there is almost always absence of the Fallopian tubes, uterus, and vagina. The symptomatology of absence of the uterus is not generally striking, the lack of menstruation being the principal sign; exceptionally, however, it is otherwise. In some cases where the ovaries are present and the uterus wanting, the most aggravated affections of the nervous system show themselves.

Congenital atresia of the genital canal may occur in any part of its course. Imperforate hymen is the most frequent as it is the least dangerous form, being more than twice as common as atresia of the vagina and three times as frequent as that of the cervix uteri. The vagina may be extremely small in calibre, closed in part or the whole of its course, or only a fibrous cord indicate where it should be. The uterus may be closed at the internal or external os; the latter is the more frequent. An occlusion at one point does not preclude the existence of other closures higher up. The effect of a closed canal with a recurring secretion above is evident, and gives rise to a well-marked class of cases. The organs above become distended, and the distension increases until an opening is made by art or the retained fluid bursts a passage for escape. This may occur outwardly with immediate relief and cure, or into the peritoneal cavity, causing speedy death. The time at which the uterus may be expected to give way under such distension cannot be stated, as the power of resistance of the organ differs and the amount of secretion each month may vary widely. Scanzoni in one case evacuated eight pounds of blood, the result of seven months' accumulation, and found the uterine wall as thin as paper. Bernutz states that the average time before interference is necessary is three or four years, and gives a case first operated upon in the tenth year of its course.

Menstrual retention is not at first indicated by pronounced symptoms. Suspicion of the nature of the case may be first excited by the severity of those symptoms which at every period announce the approach of menstruation and known as the menstrual molimen. As distension increases these become extreme, with rectal and vesical tenesmus and severe uterine colic. The nervous system sympathizes, as with all menstrual derangements, and there may be rigor, fainting, or even convulsions.

Whenever a patient presents such symptoms an examination should be insisted upon. It will generally reveal a smooth, soft, and fluctuating tumor, projecting externally if the case be one of imperforate hymen, or higher up if the vagina be occluded. If the uterus has become distended, [p. 185] there will be a round, smooth, elastic tumor above the pubes. Diagnosis will be more or less difficult according to the seat of the obstruction. Cases of imperforate hymen may be readily diagnosed by sight, if touch and the history are not sufficient. When the occlusion is deeper, the patient should be placed under the influence of an anæsthetic. By one finger in the rectum and the thumb in the vagina, and a sound in the bladder, the seat and extent of the obstruction may be determined. Should it be necessary, the urethra may be dilated and a finger passed into the bladder in order to make a diagnosis. Rectal exploration is of great assistance in discovering the uterine enlargement and its character. Scanzoni calls attention to the difference in the cervix when the atresia is at the internal or external os. In the latter case the cervix will be obliterated; in the former, it will be unchanged. With a perfect vagina and a cervix of this character retention may be taken for an early pregnancy, especially as it is not uncommon for sympathetic mammary symptoms and gastric troubles to be present. Time will demonstrate the nature of the case if a diagnosis cannot be made at once.

The age at which the menstrual flow is established varies greatly. The average age of puberty in this country, as appears from Emmet's tables made up of 2330 cases, is 14.23 years, and these are believed to be the only American statistics. A close correspondence may be noted between this and the statistics of the four largest cities of France, which give 14.26 as the average. But that it is not unusual for the appearance of menstruation to be delayed is shown by the fact that of the above 2330 cases, 288 only menstruated at sixteen years and 254 more between that age and twenty-three. The circumstances which may influence, within physiological limits, the appearance of menstruation should be considered in connection with cases of this kind. Climate and social position are the principal ones. The epoch of puberty descends in the scale of age in proportion to the average height of the temperature of various countries, and vice versâ. Social position and city life show a marked effect in hastening puberty as compared with the simpler manners and plainer life of rural populations. It amounts to an average of something over a year, and is explained by the influence of enervating and luxurious habits, of light reading and the drama, the chief subject of both being the grand passion, but especially of a freer intercourse between, and the co-education of, the sexes, and the greater extent to which music is cultivated and enjoyed.

Among pathological conditions giving rise to amenorrhoea it would seem that disease of the ovaries should occupy the first rank in frequency and importance. The reverse is the truth. The ovaries are rarely inflamed, and when so amenorrhoea is not always the result. They are frequently the seat of cystic degeneration, producing tumors of large size, yet so long as but a small portion of one of the organs remains unaffected Graäfian vesicles may still be furnished and menstruation continue. It is by the influence of remote pathological conditions that the menstrual flow is most frequently restrained, and especially by those general affections known as cachexiæ, all of which exhibit marked depression and low grade of vital power and activity, if not more pronounced pathological processes. Chlorosis, the relations of which to menstruation are intimate, and which seems to be sometimes the offspring of [p. 186] amenorrhoea, exerts a marked retarding influence, amounting to an average of one year and a half. The scrofulous cachexia is still more potent: Scanzoni states that of 31 well-marked cases, in 19 menstruation did not occur until the twenty-first year.

Amenorrhoea which is the result of pulmonary tubercular disease comes frequently under observation. It may occur at a very early period of the disease, before there is any great amount of deposit in the lungs, when it is rather the expression of want of vital force than of the exhausting effect of the disease. Under these circumstances it is only to the laity a subject of serious consideration; to the physician it is but a symptom.

The suppression as well as the absence of menstruation may be caused by atresia of the passages, this form differing from the congenital only etiologically, and in the fact that the flow has been once established. The acquired atresiæ are mostly the result of violent inflammations or traumatic influences. The vulva and vagina, or either, may be closed from sloughing after difficult labors or gangrene following the septic fevers. Occlusion of the cervix uteri may follow labor or amputation of the part, but a far more frequent cause is the application of severe caustics, happily less frequent now than formerly. Lawson Tait says he has never met with atresia of this part from any other cause.

The mode of diagnosis has already been given, and in regard to symptomatology there is only to be noted the statement of Bernutz, that there is far greater intolerance of retention from acquired than from congenital atresia.

Atrophy of the uterus is a normal process after the menopause, but it sometimes occurs much earlier in life, and then causes scanty and irregular menstruation or amenorrhoea. Attention was first called to this condition by Simpson as a process sometimes following parturition under the name of super-involution. Several labors in rapid succession have been stated to be a cause, but Simpson and Courty both give a case after a single birth. Uterine atrophy may also result from the pressure of tumors, and it has been observed in paraplegias the result of defective innervation.

The deranged menstruation is the one prominent symptom of this condition, and a diagnosis is to be made by exploration. The cervix is found small and the body light when lifted on the finger. Bimanual examination and the introduction of the sound will reveal the true condition of the organ. The latter process should be cautiously conducted on account of a frequent change of texture in the uterine walls which allows the instrument to pass through them with the use of but very little force.

Amenorrhoea is physiological during nursing and pregnancy. The former needs no attention, the latter only in regard to diagnosis. A sudden cessation of menstruation, the patient presenting all the appearances of good health, should immediately excite suspicion as to the nature of the cause. It needs but little experience to distinguish and manage these cases in the lower social ranks. The case is different, however, in a family of good position, with an anxious mother urgent for active measures, where no suspicions will be tolerated and the imputation of possible pregnancy be warmly resented. Time is here the sure ally of the physician, and an examination should be deferred until such a period [p. 187] has been reached that pregnancy can be positively negatived or determined.

The influence of acute diseases in suppressing menstruation is not marked. During convalescence from them the flow frequently ceases from general debility. All chronic diseases depressing and exhausting in nature cause suppression, as albuminuria, cirrhosis, and cancer. Tuberculosis is as fruitful in interrupting the return as in preventing the appearance of the flow, and suppression from this cause is very frequent. Under impaired nutrition and depressed powers vital force is engaged wholly in maintaining existence; there is none for any function relating to the propagation of the species. In this class the disappearance is gradual; the flow becomes scanty and irregular in recurrence, and finally ceases. This form of amenorrhoea differs in no material point from the similar class already considered; it is but a symptom of disease of some vital organ or of some general abnormal condition.

Suppression from psychical influences is not at all uncommon. Fright, grief, bad news, sudden or prolonged anxiety, frequently cause this disturbance of function. The mental impression need not be very profound. Amenorrhoea is a common event with girls who go away from home to boarding-school. In these cases it is not probable that there is any pathological condition of the sexual organs; a change in their innervation is a phrase which will best serve to explain the origin of the derangement or to express our ignorance. The diagnosis of this form may be a matter of deep interest when it occurs directly after marriage, as it not infrequently does, and gives ground for the belief that pregnancy has occurred. Still more important is it when the suppression follows illicit intercourse, the fear of pregnancy then exerting a powerful emotional influence. Some cases are on record, and the writer has met with two: in both the function resumed its course after a time without remedies.

Exposure to storm, getting the feet wet, and the sudden application of cold to the genitals frequently cause suppression. All the conditions, however, are not well understood. The bathing- and fishing-women of Europe are said to ply their vocation without reference to menstruation, and to suffer no inconvenience. In these cases the increased flow of blood to the pelvic organs oversteps the narrow line which separates physiological from pathological congestion, and may even pass on to inflammation.

The SYMPTOMS are well marked—at first, local, as severe backache, increased heat and pressure in the pelvic region, discomfort passing on to pain, even uterine colic. If the impression be severe enough to affect the general system, there will be febrile action more or less intense, and various nervous symptoms, spasmodic or convulsive.

The therapeutics of amenorrhoea must be directed in accordance with the conditions which cause it. But the strictly scientific method cannot be followed at the outset. This method presupposes a direct examination of the organs as the first step. For obvious reasons this must be deferred until special symptoms show its necessity. For treatment the cases may be classified, in some instances according to the schedule, but more frequently according to the cause or leading features, and very generally without reference to whether there is absence merely or suppression of the function.

In amenorrhoea from atresia the measures of relief will be purely [p. 188] surgical; the treatment, therefore, does not fall within the scope of this article.

The physician is frequently consulted in cases where menstruation has occurred once or twice, perhaps at long intervals, and not appearing regularly the fears of friends are excited. This is the normal course of establishment in a large proportion of cases. Time and assurance and regimen are alone needed, provided there is no evidence of deteriorated health. Absence of the function alone does not demand treatment—a fact which should be kept steadily in mind.

In a still larger class of cases the amenorrhoea depends upon, and is the direct result of, some pronounced cachectic condition, as chlorosis, scrofula, or a more or less active tubercular disease of the lungs. The treatment of this class resolves itself into that of the disease causing the derangement, and the reader is referred to the articles on the corresponding subjects.

The cases requiring more direct consideration therapeutically are those closely allied to the preceding, in which delay in appearance depends upon want of development of the body or general feebleness of constitution, or those in which absence follows and continues unduly after some severe disease. In all these cases the treatment is to be indirect rather than direct. The absent function is to be restored by improving nutrition, by increasing bodily vigor, and by using every means to establish the general health on a firm basis. Measures for this purpose should be addressed to every particular of the habits, occupation, and surroundings of the patient. They do not differ from those of a general tonic course, but in some particulars a special influence may be exerted upon the function at fault. The clothing should be warm, especially about the pelvis and lower extremities, due care of the feet being impressed in proportion to the universal neglect shown by girls and women in regard to these important parts of the person. The diet should be of plain, wholesome, substantial food, and in many cases one of the lighter wines may be added to the principal meal of the day with decided advantage. Gymnastics may be prescribed, but outdoor life should be urged, with horseback riding as the very best mode of exercise for promoting the flow. A change of air and scene exerts a well-known and powerful influence in improving nutrition and modifying vital actions. It should be rather from the city to the country for these cases. Special advantages may be derived from a residence at the seaside on account of the beneficial effects of surf-bathing. A scientifically-conducted hydropathic establishment is very desirable for its regular hours, well-ordered diet, and treatment by baths and douches. Or a watering-place may be preferred where a chalybeate water may exert a special influence in addition to those of moderate indulgence in the gayety and amusement of such a place.

Inquiry as to school-life and educational work should never be omitted. The general mode of education of girls is faulty in the extreme. No attention is paid to the great change of puberty, which amounts to a revolution in the economy, and instead of aiding the vital forces drawn upon for effecting this change, they are still further depressed by sedentary life in close rooms or strongly urged in another direction. No two leading organs of the body can be pushed in development at the same time with impunity. There is no exception here: either the brain and nervous [p. 189] system or the sexual organs will suffer. In this direction is often found a potent cause of all the forms of uterine derangement—a fact which cannot have escaped the observation of every physician. The writer has always urged an entire break in the school-life of girls of at least one year's duration at the time when signs of puberty begin to manifest themselves; and this period is too short rather than too long.

Tonics should supplement these regiminal measures. They may be hæmatic, stomachic, and nervous—either or all. There is a chain of diseased actions, and it may be attacked at any of its links. Iron stands at the head of the list. It is not only an hæmatic tonic, and in proper conditions a promoter of digestion, but decidedly promotes pelvic congestion, and has therefore an emmenagogue action. The forms at command are so numerous as to meet the requirements of any case or to satisfy any fancy. The standard preparations, as a rule, deserve the preference over more modern ones, in which efficacy is often sacrificed to elegance. Among the best are those which contain the remedy in a nascent state, as the compound mixture or the compound pills of iron of the Pharmacopoeia. Dialyzed iron, the tincture of the chloride, and the pyrophosphate are reliable, while the addition of manganese, as in the syrup of the iodide of iron and manganese, is believed by some to increase the efficacy. With iron may be combined nux vomica or strychnia and quinia. In large sections of our country malaria is a constantly-acting depressant of vital force, and the latter medicine may be given for a time with a free hand, and may be followed by or combined with arsenic to great advantage.

Constipation is almost universally present in women. It deserves especial consideration in treating all disorders of the sexual organs. When attention to habits and appropriate laxative food, as fruits, oatmeal, Indian meal, cracked wheat, and salads, do not suffice, resort must be had to enemata or drugs. Aloes has always had a reputation of special virtue in amenorrhoea which is doubtless well founded. In pill form it may be combined with any or all the other medicines. Pills of aloin, one-fifth or one-third of a grain, have the advantage of very small bulk.

Before considering more direct measures for establishing menstruation it may be well to recall to mind the two elements of the function—ovulation and the uterine flow. The first, the prime factor, we can not influence by any medicines nor by any mode of treatment except, perhaps, by electricity. Observation of animals shows that mere proximity of the male influences it plainly, but this only indicates a line along which we cannot prescribe. An opinion may, however, be asked in regard to the propriety or advisability of marriage for a woman who has never menstruated. In such case no advice should be given until after a thorough local examination, and its tenor will then be in accord with the condition of the organs. With such atresia or absence of organs as not to permit sexual intercourse marriage should be positively negatived. In such cases as those of partially-developed or absent uterus the facts should be laid before the parties interested and the decision referred to them. In the former class of cases some hopes of improvement may be entertained.

The second factor of menstruation, the flow, we can influence by such measures as cause a more or less intense pelvic congestion. The ovaries sharing in this congestion, it is not impossible that ovulation is in some [p. 190] degree also promoted, but it can be only to a minor degree and when the ovaries are in a favorable condition. The uterus is the principal organ to be affected, and to it the most of these measures are addressed.

Direct treatment for the establishment of menstruation should be first of a character rather to solicit than to force the flow. These measures act best where, the general health having been restored, the flow does not appear, but the premonitory symptoms are present. Rest in bed, warmth to the pelvic region by poultices or other means, and hot drinks, are to be prescribed; among the latter infusions of pennyroyal, some of the mints, tansy, and cotton-root have a high domestic reputation and should be preferred. Hot pediluvia or hot sitz-baths, prolonged to twenty or thirty minutes, may be taken at bedtime. These may be rendered sufficiently stimulating to irritate the skin by the addition of mustard. More active measures are stimulating enemata and vaginal injections—for the former ten grains of aloes in mucilage, and for the latter liquor ammonia in milk, fluidrachm j-pint j, gradually increasing the strength to production of slight leucorrhoea. Both these have the endorsement of high authority.

Such measures should be used or plied more assiduously about the period, when that is known. During the interval a tonic course is almost always required, and a powerful local influence can be exerted by cold sitz-baths of brief duration, say one or two minutes, once daily, followed by vigorous rubbing with a coarse towel or a flesh-brush.

There are a few drugs known as emmenagogues from the reputation they have of promoting the menstrual flow. They all are powerful stimulants or irritants, and as they are also nearly all abortifacients, their reputation is probably well founded. Modern physiology, by exploding the doctrine of peccant humors to be carried off by menstruation, and by establishing the doctrine of ovulation, has greatly diminished their importance, while the varied conditions and causes of amenorrhoea already given show at a glance how restricted is the field for their administration. To give them when the anatomical conditions are unknown is blind work; to force a function relating to reproduction when the general system is struggling for existence is folly; and to goad diseased organs with special stimulants is certain to do injury. Now and then, however, special stimulants of this class and of the class next to be considered are required. There are some cases which fail to respond to the measures already detailed; there are others, generally recognized by writers, when menstruation is absent without any deterioration of health, known as cases of sexual atony or torpor; and others in which the flow fails or disappears earlier than the usual age. In these latter atrophy of the ovaries may be suspected, but cannot be verified during life, and treatment should be faithfully continued so long as there is reasonable probability of success. One case occurred in the experience of the writer in which the menses appeared occasionally during two years, each time apparently brought on by special stimulants, but ceased at thirty-two, the general health remaining excellent.

The principal emmenagogue drugs heretofore relied on, besides iron, are saffron, apiol, rue, and savin. The first, from impurity and costliness, is rarely prescribed, yet Trousseau says it is a fact of public notoriety that women engaged in picking saffron suffer from frequent attacks of uterine hemorrhage. Apiol may be given in capsules in doses of five or six [p. 191] drops twice daily for a week before the expected flow, or fifteen drops may be administered in the course of the few hours immediately preceding. The oils of savin and rue are generally prescribed in doses of minim ij-v, three times daily. Ergot and iodine figure sometimes as emmenagogues. The efficacy of the former is denied by very high authority. The latter was esteemed very highly by Trousseau. Its influence upon the scrofulous constitution may possibly explain its action in promoting menstruation.

The permanganate of potassium is a recent addition to emmenagogues, and the testimony in its favor is already sufficient to make it probable that it is the most efficient of the list. The indications for its use are want of action or atony of the organs. It should be administered during a few days or a week preceding the time for menstruation, in doses of from two to four grains three times daily; or two grains three times daily may be administered during the whole month. The union of its elements is but feeble, so that in pills as ordinarily made it would be very likely to undergo decomposition, while in solution it is unpleasant. Compressed tablets of the pure drug are now placed at command of the profession, and are an unexceptionable form for administration. The best time for taking the medicine is toward the close of the digestive process, and each dose should be followed by drinking at least a wineglassful of water. Pain in the stomach has been sometimes observed even when every precaution has been taken. The liability of the remedy to decomposition and its irritating powers are objections to it, but the testimony in favor of its power to bring on or promote the menstrual flow is at present very strong.

More decided measures of local stimulation than those already given may be resorted to, and are far more reliable than drugs. They are—tents, cupping the uterus, and electricity. A sea-tangle or tupelo tent may be kept in the uterus over night just previous to the time of the flow. In cases where stimulation rather than dilatation is needed a tent of slippery-elm bark may be used. Thomas recommends a rubber exhauster for cupping the cervix uteri. Simpson fashioned one for acting on the lining membrane of the body. These measures are most likely to be efficacious just before an expected period.

Electricity is the most reliable emmenagogue, and has such an amount of testimony in its favor as not to permit a doubt as to its value. It is the only direct uterine or menstrual stimulant except permanganate of potassium. Statical electricity is now but little used, although Golding-Bird published striking instances of its efficacy in amenorrhoea at an early day in its therapeutic history. Faradization is now most frequently resorted to. One pole is to be applied to the sacrum and the other above the pubes or over either ovary. The internal application of the current is much more powerful as well as less painful. It is administered by applying a cup-shaped electrode to the cervix, or by introducing an insulated sound into the uterus, the other electrode being external as before. The séances should be repeated every second or third day, and should be more frequent just before the periods when their time is known. Beard and Rockwell insist that general electrization should be administered at the same time, and Mann passes the constant current through the organs during the intervals and the faradic at the periods. Simpson originated [p. 192] a galvanic intra-uterine pessary, which Thomas has modified. It is doubtful whether the feeble current generated by these instruments produces any effect, or whether they act simply as mechanical irritants. When they are used, it should be borne in mind that there is eminent and high authority against the use of intra-uterine pessaries of any kind, and that all agree that a patient to whom one is applied should be kept under careful observation.

It must be stated that good results have been obtained with this class of local remedies in cases which would seem extremely unpromising—even in those in which amenorrhoea depends upon partially-developed organs. There is most positive testimony of the highest character as to good effects obtained in increasing development and promoting the flow.

Cases of acute suppression are to be treated by rest in bed, warmth locally by baths and applications, and hot drinks, as already detailed. Steaming the lower part of the body by placing the patient over the vapor arising from aromatic herbs upon which boiling water has been poured is a remedy which dates back to Hippocrates. Early in the case a drink of spirituous liquor, taken hot, is often efficacious. If, however, there is febrile action, diaphoretics should be administered, such as the liquor ammonii acetatis with spirits of nitrous ether, and aconite if required. Dry or wet cupping may be used if there is evidence of intense uterine congestion. Should internal metritis or inflammation of some pelvic organ result from acute suppression, the treatment will be that for the disease thus caused. If efforts to restore the suppressed flow do not prove speedily successful, special measures should be postponed until the next period, the general health meantime receiving due attention. At the return of the next period such of the remedies for amenorrhoea should be administered as may seem best adapted to the case, considered as to cause, condition of the organs, or constitution of the patient.

Vicarious menstruation is so closely allied to amenorrhoea as to demand some consideration here. The term is applied to a sanguineous flow, recurring at regular intervals, from some organ or part of the body other than the uterus. This flow has taken place from almost every organ or part of the body; most frequently, however, it has been from some mucous membrane, a wound, scar, or some part which by structure is favorable to the exit of blood. Amenorrhoea is frequently present, and is sometimes followed by acute suppression. Puech found 11 cases attended by vaginal atresia congenital, and in 42 others the uterus was absent or but partially developed. The treatment does not differ from that of amenorrhoea. While measures are used to restore normal menstruation, active repression of the abnormal flow should not be attempted, unless the organ from which it proceeds is one likely to be injured by its continuance.

Dysmenorrhoea, according to derivation, signifies a monthly flow with labor or difficulty; its modern synonym is painful menstruation.

In but a very small proportion of women is menstruation painless. Not only general and local distress attends it, but more or less pain. [p. 193] When the suffering reaches such a degree as to demand relief, the case is one of dysmenorrhoea. In such cases the period generally commences with a more pronounced molimen than ordinary; as it progresses pain makes its appearance and gradually increases in severity. Its seat is the pelvic region, the back and loins, and down the thighs. It may be paroxysmal or continuous; in some cases the flow is accompanied by expulsive efforts like those of labor. The pain may last during the whole period, or relax very much, or even cease as soon as the flow is freely established. In degree it may reach any height, often causing the severest agony, taxing the powers of endurance to the utmost, and requiring the most energetic measures for relief.

The organs in proximity to the uterus, partaking as they do of the menstrual congestion, are also markedly affected. There is rectal tenesmus, and on the part of the bladder frequent micturition and dysuria. Remote organs are influenced either directly or by sympathy. The breasts become tumefied and tender. There is flatulence, nausea, or even vomiting. The nervous system, during normal menstruation in a state of erethism, responds readily to the painful impressions, and presents symptoms of the most varied character and degree, amounting even to general convulsions.

Attacks of severe pain recurring at short intervals cannot but exert a powerful deleterious influence upon the general health. Digestion is interfered with, nutrition and sanguification are imperfectly performed, and there is a continuous chain of deranged function. The results to the nervous system, indirect and direct, and sometimes also from the measures of relief resorted to, are most deplorable. From every point of view this class of cases presents the strongest claims for relief.

The discharge in dysmenorrhoea varies very widely in amount and character. It may be so scanty as to border on amenorrhoea or so profuse as to be menorrhagic. It may be more or less fluid than usual. The expulsion of clots is a frequent feature, and the size and shape of these sometimes give indications of value. Like other uterine derangements, dysmenorrhoea is not a disease per se, but a symptom of some pathological condition the exact nature of which is to be ascertained whenever possible. Cases may be classified as follows: I., Obstructive or mechanical; II., congestive; III., neuralgic; IV., membranous. It cannot be too distinctly kept in view that this classification, like many others, cannot be rigidly followed. The dividing-lines are sometimes but faintly drawn by nature; some cases present the features of more than one class; some by natural progress pass from one class into another. Based upon leading clinical features, this classification will assist in the study of the subject, facilitate diagnosis, and aid in directing therapeutic measures.

Two classes given by some authorities are not included in the above classification. They are spasmodic and ovarian dysmenorrhoea. If by the former is implied painful contractions of the uterus during menstruation, the cases fall into the first class given above, the obstructive; and if irregular nervous action is implied, they belong to the third, the neuralgic. The term ovarian has been applied to those cases in which an abnormal condition of the ovaries exists, such as inflammation, enlargement, or dislocation. Such conditions are not easily ascertained during life; if ascertained, the fact throws light on the etiology of the case; but for [p. 194] treatment the case will range itself, according to the clinical features it presents, among those in which the vascular or the neurotic element predominates.

Obstructive or mechanical dysmenorrhoea is that form in which some impediment exists to the free escape of the menstrual discharge. The genital canal presents no exception to the general rule that when an excretory channel is obstructed violent and painful expulsive efforts are excited.

The causes which give rise to the obstruction are various. Among them are the following: fibroid tumors of the uterus distorting, and polypi obstructing, its cavity or neck; stenosis of the cervical canal, either congenital or acquired, the latter often the result of the injudicious use of strong caustics; a long and conical cervix; a contracted os, sometimes so small as to be justly termed the pinhole os; versions and flexions of the uterus.

The seat of obstruction is almost always uterine, but may be in the vagina or at its entrance. There is much difference of opinion as to the relative frequency of occurrence of obstruction at the internal or external orifice of the cervix.

The pain in this form of dysmenorrhoea generally does not precede the flow. In character it is sometimes like colic, but its leading feature is expulsive effort. It occasionally so nearly resembles abortion as to require care to distinguish between them. It is frequently intermittent, presenting intervals of complete relief. In severity it varies widely. In some cases the patient assumes and maintains a certain position which she has learned affords her some relief. This indicates with great probability uterine distortion from fibroid tumor. The writer has met with a marked instance of this kind.

The flow is more irregular in this than in other forms. It is sometimes extruded drop by drop; more often it appears in gushes, the fluid accumulating and distending the uterus until expulsive efforts are excited. Clots are often thrown off under these circumstances in shape and size corresponding to the cavity of the uterus.

Absence of prodromata, presence of the fluid being necessary to excite the pain, the intermittent and especially the expulsive character of the pain, and the kind of clots, indicate the nature of the case. A certain diagnosis, however, rests alone on physical examination. This should be by the touch, bimanual and rectal, and the sound. Sometimes additional aid will be derived from the speculum. By touch the form, size, shape, and direction of the cervix are ascertained, and its relations to the body of the uterus. The sound will give evidence as to the patency and direction of the cervical canal and uterine cavity.

A diagnosis of obstructive dysmenorrhoea should not be rejected because the patient occasionally passes a period without pain. In the male an enlarged prostate may for a long time interfere but little with micturition, and then all at once completely obstruct the flow of urine. A diagnosis cannot be based alone upon the condition of the cervical canal as found during the intermenstrual period. Two elements are to be considered, each of which may, and doubtless often does, play a part: tumefaction from the congestion attendant on the process, and spasm. The latter, caused by reflex action excited by irritation in the body of the uterus, assumes a leading position with those who claim that obstruction is the [p. 195] sole cause of dysmenorrhoea. That it plays an active part in many cases cannot be doubted; that it is a necessary condition of even spasmodic dysmenorrhoea is disproved by the positive statement of Matthews Duncan, that in some cases he could pass a sound freely into the uterus during the paroxysms.

A due estimate of the part which a uterine flexion plays in producing the dysmenorrhoea is important, but very difficult. Theoretically, the narrowing of the canal at the point of flexion should account for the symptoms, but experience does not accord with theory. All cases of flexion are not accompanied by dysmenorrhoea, and when so accompanied removal of the deformity does not always cure. Siredey in 52 observations found only 22 cases of dysmenorrhoea. Emmet's carefully-prepared tables show that in nearly 50 per cent. of anteflexions menstruation is painless. The conditions necessary seem to be extreme flexion, producing an acute angle. In less-pronounced cases it is maintained by many that the flexion is an unimportant factor, and that the dysmenorrhoea depends upon secondary conditions produced by it, as endometritis and congestion. The problem is difficult, and each individual case requires careful study. The facts indicate that there is much in the pathology of this form of disease not yet fully understood.

Congestive dysmenorrhoea depends upon an advance of the menstrual congestion beyond the physiological limits. In these cases the patient generally suffers for a few days before the period from a sense of fulness, weight, and heat in the back and pelvic region. Pain follows, is more or less severe, and varies somewhat in character, although generally dull and heavy. The hypogastric region usually becomes distended, and is sometimes very tender to the touch over the ovaries, "especially on the left side, without any reason for the difference being known." After a longer or shorter duration of these symptoms the flow appears, and this is often, especially if free, followed by an amelioration of the pain. In many cases, however, there is no remission of the suffering upon the discharge occurring. Not infrequently the general circulation is affected, the face is flushed, the skin hot, and there is more or less fever.

The flow may vary widely as to quantity. It is often at first and for a time more profuse than normal. Leucorrhoea frequently precedes and follows it, persisting during the entire interval. During that time also the patient suffers much from backache and bearing down, with difficulty of walking or of remaining on her feet.

Upon examination the vagina is found hot and tumefied, and increased arterial action is evident to the touch. The uterus is tender, enlarged, and heavier than usual. In cases associated with or dependent upon chronic inflammation or areolar hyperplasia the increase of size of the uterus during menstruation is marked. The sound may be used to determine the amount of enlargement and also the amount of tenderness. In cases dependent on endometritis touching the interior of the organ causes severe pain. Dyspareunia is frequently a symptom in this class of cases.

The conditions upon which congestive dysmenorrhoea depends are various, and may be either general or local or both combined. Plethora is rare in females, and local congestions are much more frequently dependent upon anæmia, the abnormal condition of the blood favoring them [p. 196] directly and also indirectly by its effect on the nervous system. In past times gout and rheumatism were considered to act frequently as the cause of dysmenorrhoea. They have almost disappeared from view since the era of direct examination began. Malaria, however, as a possible cause or a powerful factor should never be overlooked in regions where it prevails. The sexual instinct plays an important rôle; enforced abstinence, especially when suddenly brought about, and excess, being alike effective etiological factors. Young widows and prostitutes are both subject to this form of disease.

The local causes are numerous. Pelvic inflammations, as cellulitis or pelvic peritonitis, give rise to the disease. Affections of the uterus are frequent causes; displacements, as retroversion or prolapsus; and inflammation, either parenchymatous or of the endometrium. Quite a moderate grade of inflammation, as found during the interval, may, under the increased congestion of menstruation, become extreme. Many cases doubtless depend upon an ovarian influence even when no affection of these organs can be made out. Scanzoni hazards the theory that the maturation of Graäfian vesicles lying deeper than usual in the stroma of the ovary is one cause of this form of dysmenorrhoea.

In neuralgic dysmenorrhoea the neurotic element preponderates. The nerves play a part corresponding to that of the vessels in the congestive form. In some cases of this class no organic lesions can be discovered, and they are then termed idiopathic.

This form of dysmenorrhoea depends upon either a peculiar condition of the general nervous system or upon hyperæsthesia of the sexual system, or both combined. Either or both may have been inherited or acquired. It is frequent in subjects of the hysterical temperament, and in those presenting that preponderance of the nervous system so often seen as the result of over-refinement, luxury, habits of idleness, and other violations of hygienic law. Those subject to it often suffer from severe headaches, neuralgia, and other nervous affections. It is often caused by anæmia or chlorosis. Sexual influences, psychical or physical, and especially those that excite without satisfying, are sometimes efficient causes. Ovarian influence is often an important factor; some authorities designate all those cases in which no anatomical change can be found, ovarian. The prodromata of this form are very apt to be some of those nervous attacks to which such patients are liable, as headache or neuralgia, and they may be psychical, as aberration of temper, undue irritability, or tendency to melancholy. In character the pain is generally stated to be more acute than in the other forms. It is subject to great and sudden alternations. In acuteness and irregularity it often justifies the term spasmodic. From these characters and from the absence of anatomical change a differential diagnosis may be made. As in this form the most marked nervous symptoms are witnessed, so are also the most pronounced complications on the part of the general nervous system. They are often hysterical in character, but may be of every kind and degree, even to general convulsions, and mental aberration is sometimes a complication or result.

Membranous dysmenorrhoea is characterized by the expulsion at the menstrual periods of organized membrane, either as a whole or in pieces. In the former case it is like a cast of the interior surface of the [p. 197] uterus. The expulsion of this membrane is accompanied by pain, often of the most severe character. The pain presents well-marked features; it is markedly expulsive, identical with that of the obstructive form, closely resembling an abortion, to which the membrane adds an additional element of similarity. This pain and these expulsive efforts may continue twelve, eighteen, or twenty-four hours, and then cease, to be renewed only at the next period.

This form of disease is rare—so rare that observers having a large field of observation may never meet with over half a dozen cases. In regard to many points very diverse views are held, and the limits of a practical work do not permit even a statement of all of them. The nature of the membrane is one of these points too important to pass over. When thrown off entire, its internal surface is smooth and marked by the openings of the utricular glands; its external or uterine face is rough and villous. It presents the exact shape of the interior of the uterus, with openings corresponding to the Fallopian tubes and the os. It is impossible to escape the conviction that this membrane is the lining membrane of the uterus, thrown off as a whole, instead of by gradual melting down of its superficial layers, as in normal menstruation. The microscope sustains this view, and this is the generally received opinion; yet that the membrane is not always such is testified by competent observers from observations with the same instrument. It seems probable that this disputed point will be settled, as have been so many others in medicine, in favor of both parties. Siredey suggests the possibility of different kinds of membrane in these cases, while Barnes boldly states this as a fact.

Various theories have been advanced to account for the formation of the membrane. An abnormal course of conception, a changed ovarian influence, a peculiar endometritis, have been from time to time favorite terms in which to express our ignorance. Only in regard to the first has unanimity been obtained. That the membrane is always a product of conception is not now maintained by any respectable authority. It is a well-established fact of the utmost importance that such membranes may be expelled when there has never been sexual intercourse.

The membrane of dysmenorrhoea is to be distinguished from fibrinous masses, the remains of blood-clots from which the corpuscles have been squeezed; from mucus coagulated into shreds by astringent injections; and from the products of membranous vaginitis. Neither of these will present much difficulty with the aid of the microscope. The case is very different, however, when the membrane is to be distinguished from the decidua of an early pregnancy. From a single specimen or a single attack a diagnosis cannot be made. Thomas gives an instance of disagreement as to the nature of the same membrane by two of the highest microscopical authorities. The recurrence of the attacks at the regular menstrual periods will establish the diagnosis.

The prognosis of dysmenorrhoea varies in the different classes. In the obstructive form it will depend upon the curability of the lesion upon which it depends, and the same may be said of the congestive. The neuralgic cases do not yield readily to treatment, especially when dependent upon a peculiar and perhaps inherited nervous constitution. Caution should be exercised, however, in expressing an unfavorable prognosis. [p. 198] Like all nervous diseases in the female, it is subject to great mutations without apparent adequate cause, and will sometimes suddenly disappear in an inexplicable manner.

The membranous form affords still less promise of cure: the unsatisfactory results of treatment are generally acknowledged.

During an attack of dysmenorrhoea the patient should remain in bed for the benefit of rest and warmth. In those cases where the flow is not too free, and especially when relief follows its appearance, active measures to promote this end may be instituted by hot drinks and hot fomentations. In married patients a hot sitz-bath, during which the vaginal syringe is used to douche the uterus, is an efficient measure. Pain being the prominent symptom, and remedies for its relief being at hand and reliable, the indication is clear and the treatment can be briefly stated. In execution, however, it is not a simple problem: immediate relief is not alone to be considered. If opiates be resorted to for frequently-recurring pain, a habit will soon be formed that is no less a calamity than the disease itself. While, therefore, opium and its preparations are reliable remedies, and in many cases indispensable, they should be administered as seldom and as sparingly as possible, and always with an appreciation of possible injurious consequences. Many cases can be successfully managed with chloral hydrate, or belladonna, or Indian hemp. When opiates are resorted to, they should be combined as much as possible with other medicines by which their effects are modified, and relief afforded with the smallest possible dose. Thus in cases attended with vascular excitement these ends may be attained by the union of opium with tartar emetic or aconite; when there is marked disturbance of the nervous system, it may be combined with an antispasmodic, as the compound spirit of ether. Administration by the rectum will produce a local as well as a general effect, and injections of starch and laudanum or suppositories of opium and belladonna may be administered. The speediest and most certain relief is afforded by the hypodermic syringe. Resort to it should, however, be rigidly controlled; it should be used as a miser uses his gold, and it need scarcely be added that only very exceptional, if any, circumstances will ever justify placing the syringe in the hands of friends or attendants, no matter with what restrictions. Unfortunately, this is sometimes done, but very rarely without great injury resulting.

During the intervals general treatment should be instituted according to the indications. All functions at fault are to be regulated. Anæmia is to be corrected, the debilitating effects of malaria counteracted, good digestion promoted, and a weakened nervous system strengthened. These indications are met by tonics in various forms, notably iron and zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by the judicious use of wine. There are other remedies quite as useful as drugs—cold sponging and shower-baths, followed by vigorous rubbing, general electrization, and, when the patient cannot or will not take outdoor exercise, massage. Change of scene and air is sometimes beneficial or even necessary. In many cases of pronounced neuralgic form, or in which the nervous system has been shattered by the severity or long duration of the attacks, there can be but little hope of amelioration without a thorough change of habits and mode of life in every respect.

The local treatment will be according to the conditions present. In the [p. 199] obstructive form, polypi are to be removed if present, and in stenosis the patency of the canal restored. Dilatation may be accomplished by tents. Should these fail, resort may be had to surgical measures, as the frequent passage of bougies gradually increasing in size, forcible dilatation with steel dilators under an anæsthetic, or by incision. Each of these measures has its advocates, and with all cures have been effected. Flexions should be corrected as far as possible by a vaginal pessary. Intra-uterine pessaries more certainly correct the deformity, but great care should be exercised in their use. If inflammation be present, uterine or pelvic, they will not be tolerated or will do positive injury; nor should a patient with any instrument of this kind ever be allowed to pass out of reach of the physician unless she can herself remove it.

The treatment of many cases of congestive dysmenorrhoea is very similar to that of suppressed menstruation from cold—warm drinks, hot foot- and sitz-baths, fomentations, and douches.

Particular attention should be paid to the bowels, not alone to correct constipation, but to give full relief to a clogged portal system by saline purgatives. If there be prolapsus, a pessary should be adapted so as to keep the uterus up in its place; by this means passive congestion is much relieved. Bromide of potassium is a reliable remedy as a corrector of pelvic congestion. In the congestive cases of anæmic subjects iron will act beneficially; in inflammatory congestion it does injury. Dysmenorrhoea dependent upon hyperplasia or endometritis should receive the treatment appropriate to those affections.

In neuralgic dysmenorrhoea the general treatment is far more important than the local. All those hygienic and therapeutic measures already detailed should be faithfully persevered with. For the relief of pain and control of the nervous symptoms enemata of asafoetida are useful. Chloral may also be administered in the same way or by the stomach, with camphor, valerian, and the æthers as required. In this form apiol has been successfully used; the evidence as to its value is clearer than the explanations of its mode of action. It may be given in capsules, each containing five grains, one, two, or three daily.

Some local measures often render good service: among them is the passage of bougies, which sometimes modify the sensitiveness of the cervical canal, as they do that of the male urethra. The galvanic current, both continuous and Faradic, has effected cures, but the cases to which it is best adapted or in which it is most likely to be good cannot be clearly indicated. A galvanic stem-pessary may be used, observing due caution. This instrument has been modified and much improved by Thomas: being made like a string of metallic beads, it is extremely flexible, and many of its former objectionable features are removed.

A successful treatment of membranous dysmenorrhoea has not yet been promulgated. The great difficulty of its cure is admitted by the highest authorities. Some cases associated with stenosis of the cervix have been cured by dilatation—a fact which but strengthens the general principle of correcting all anatomical changes whenever possible. Strong caustics have been applied to the interior of the uterus with a view of exerting an alterative influence upon the seat of the disease. The course seems correct in theory, but in practice it has not proved fruitful of good results, and treatment in the majority of cases is limited to palliation.

In regard to marriage in females afflicted with dysmenorrhoea, it may be stated to be advisable in many cases of the neuralgic form and in anæmic subjects where the flow is so scanty as to border on amenorrhoea. In cases of the congestive form, if dependent on inflammation or on organic lesions, as fibroids, there is very great probability that the symptoms will be aggravated by this radical change of mode of life.

The term menorrhagia signifies excessive menstrual flow. The excess may be by increased rate of discharge during the usual time, by lengthened duration, or by too frequent returns of the periods.

There are wide physiological limits to the amount of discharge and the duration of a menstrual period. While the average time is from three to five days, and the average amount from three to five fluidounces, both these terms may be doubled, or, on the other hand, they may be diminished to a single day and a single ounce, without detriment to the health. Menorrhagia may be said to exist when the flow is in excess as compared with what is usual with the individual, or when the loss is so great as to affect her general health.

The periodical return of the flow is of prime importance in establishing the existence of menorrhagia. Repetition at periods approximating the menstrual is the keynote of diagnosis. By this menorrhagia is distinguished from the hemorrhage of a miscarriage and from metrorrhagia. A profuse flow of blood after an absence of menstruation for one or two months is held by patients, in perfect good faith, to be the effect of taking cold: with almost absolute certainty such a train of events indicates an abortion. Metrorrhagia is uterine hemorrhage occurring independently of the menstrual periods. More surely indicative of organic disease than menorrhagia, it is often most closely allied to it; many cases which in the early stages present an increased menstrual flow as a symptom are at a more advanced period accompanied by metrorrhagia.

Thus far the diagnosis of menorrhagia is easy. Not so that differential diagnosis upon which alone can therapeutic measures be based.

This derangement depends upon as many and as widely diverse causes as the others. It is often one expression of affections of the general system, is sometimes caused by disease of organs neither pelvic nor generative, is a common symptom of a number of organic diseases of the uterus, or it may be simply functional. The necessity for a thorough physical examination is apparent. By touch, single and bimanual, by the speculum, and by the uterine sound the condition of all the pelvic organs should be investigated. These means failing to reveal the cause of the menorrhagia, the examination should be pushed farther. The cervix should be dilated by tents and the cavity of the uterus explored. Very frequently this measure, and this alone, will reveal the cause of the derangement. Such an examination is often as valuable for its negative as for its positive results. No practitioner fulfils his duty to his patient or is just to himself who treats a menorrhagia for any length of time without making a physical examination. It may seem unnecessary to emphasize so plain a duty, yet consultants very frequently find cases in [p. 201] which palpable causes of the disease exist and where a direct examination has not even been proposed.

The following schedule will indicate the widely diverse conditions which may give rise to menorrhagia, and will serve as a guide to the study of the subject:

I. Menorrhagia, the result of the first class of causes, but rarely occupies more than a subordinate position. The acute affections, as the exanthemata, do not afford time for more than a single flow, and this has been well termed uterine epistaxis. The condition of plethora is manifest. The cachexiæ are generally well marked and evident. An exception may be made in this regard as to the effect of prolonged residence in malarious locations. There can be no question that menorrhagia is frequently of malarial origin, and even when the patient does not present a cachectic appearance. The disease may be produced by hepatic and splenic derangement, by deteriorated sanguinification, or by depression of nervous force. Menorrhagia is not infrequently a result of Bright's disease; an examination of the urine would determine this point. That the opposite conditions of plethora and anæmia should both cause menorrhagia is not difficult of explanation; in the one there is excess of blood with increased vascular pressure; in the other, a changed condition of the blood favoring transudation, with loss of tone of the vessels.

II. That menorrhagia, as well as amenorrhoea, may have a purely [p. 202] emotional origin there can be no question, although this cause is not generally recognized. The following case is an illustration: A healthy young married woman, while menstruating, saw a neighbor's son thrown from his horse; his foot became entangled in the stirrup, and he was trampled to death before her eyes. She was immediately taken with flooding, and profuse menstruation occurred for several succeeding periods. Siredey expresses doubts as to cardiac and pulmonary diseases so frequently causing menorrhagia as they are generally believed to do. In a considerable experience during several years, and paying special attention to this point, he found but one case thus caused. The mechanical effect of disease of the abdominal organs in producing passive congestion in distal parts is more direct and the influence in producing menorrhagia more apparent. The same may be said of accumulations in the bowels and the pressure of abdominal tumors. Peri-uterine inflammations rank very high in the list of causes: their presence and results, direct and indirect, as abscesses, displacements of the uterus, etc., should never be overlooked. Ovarian influence is naturally a potent etiological factor; menorrhagia is a frequent result of sexual excesses, and is often seen in prostitutes and where there is great disparity of age between the husband and wife.

III. Affections of the uterus itself are by far the most frequent cause of menorrhagia. The necessity of investigating accurately the condition of the great central organ of menstruation, and of ascertaining to what particular disease the derangement of the flow is to be attributed, will bear repetition. That an anatomical or pathological diagnosis can always be made is not maintained, but when examination has failed to reveal a basis for such a diagnosis, the practitioner should distrust his position and consider his diagnosis provisional only, awaiting more information from renewed examination or from further progress of the case. The cases are few in which such a diagnosis cannot be made. They are recognized by the term congestion as a cause in the schedule given above. Congestion is of course the prominent factor in many cases of menorrhagia, as in those from polypi and fibroids, those produced by ovarian influences, and others which are evident. But the class here recognized consists of those cases in which no anatomical or other cause can be found, excess of the congestive element of menstruation alone affording a rational explanation. Such cases occur most frequently at the two extremes of life—at puberty and at the menopause. During both these periods menorrhagia often occurs unexpectedly and inexplicably.

The grosser forms of uterine growths, as malignant disease, polypi, and fibroid tumors, are generally discovered without difficulty. The touch reveals them, or the sound or bimanual examination indicates their possible presence, which is confirmed by dilatation of the cervix and exploration of the cavity of the uterus. This class of cases gives rise more frequently to metrorrhagia; only exceptionally is the hemorrhage confined to the menstrual periods.

A recent delivery in the history of the patient will indicate with some probability one of several conditions which may give rise to menorrhagia. Especially is this the case if the complete generative cycle has been broken in any part of its course. If there has been a miscarriage, there will be great probability of retained portions of the placenta or membranes; [p. 203] if from death of the child or other cause nursing has not been performed, the conditions will be favorable for subinvolution of the uterus; if labor has been instrumental or precipitate, laceration of the cervix may be suspected. The first two far exceed in frequency the last as causes of menorrhagia. Laceration of the cervix exists often without producing this functional disturbance, while subinvolution and retention of products of conception are very often active agents.

Displacements of the uterus, either prolapsus or versions and flexions, often have menorrhagia as a symptom.

The chronic inflammatory affections of the uterus are fruitful causes, and menorrhagia is often found associated with, and sometimes dependent on, the condition known as chronic corporeal metritis or areolar hyperplasia, with consecutive erosions or ulcerations. Inflammation of the lining membrane of the uterus accompanied by granulations or fungous growths is one of the most frequent causes of menorrhagia. Opinions differ as to the part inflammation plays in producing this condition. Its entire absence in some cases is not improbable, the fungosities springing from the seat of the placenta. By Winckel the affection is termed adenoma diffusum et polyposum corporis uteri; by Olshausen it is called endometritis fungosa. Under various names the condition is well known and recognized as one of the most frequent of all the uterine causes of menorrhagia; Siredey believes it to be the origin of nearly one-half the cases. Due consideration of this cause is especially important, because especial investigation is required for its detection. The cervix must be dilated and the blunt curette passed over the internal uterine surfaces. This will furnish ocular and tangible evidence by detaching and bringing away some of the fungous growths, and a diagnosis will thus be made impossible in any other way.

In considering the treatment of menorrhagia the management of the patient during the intermenstrual periods must first engage attention. The general health is to be promoted in every possible way and sound hygienic regimen enforced. Two points demand especial attention—the clothing and the bowels. All tight bandages around the abdomen should be loosened, and all skirts and underclothing which hang upon the hips be supported from the shoulders. The beneficial influence of free action of the bowels cannot be overrated. Regular daily movement is required in all cases, but much more is often of decided benefit. In menorrhagia of the menopause in patients who have accumulated considerable adipose tissue, especially about the abdomen, in those where there is evident hepatic derangement, and in some others free purgation with salines is one of the most efficient measures of treatment.

During the menstrual intervals cachexiæ are to be treated according to their nature. Chlorosis and anæmia will require iron, quinine, nux vomica, and other tonics—the malarial cachexia the same, with the addition of arsenic, which often renders especial service under these circumstances. Then, too, the various uterine lesions giving rise to menorrhagia must be corrected. Subinvolution is to be remedied, polypi removed, the evil effect of fibroids combated by hypodermic injections of ergot, displacements corrected by suitable pessaries, the tone of the vessels and tissues of the pelvis increased by cold bathing, and all indications fulfilled according to the nature of the case. For details of treatment the reader [p. 204] is referred to the articles upon the various general, local, and uterine diseases which have been shown to cause menorrhagia.

Especial attention should be given to girls whose menstrual life begins with menorrhagia, lest a vicious habit become fixed. The evils of school-life or those of sedentary indoor occupations should be corrected, and rest in the recumbent position during menstruation enforced. For the menorrhagia of puberty tonics, especially nux vomica and brief applications of cold to the pelvic region, are particularly indicated.

During an attack of menorrhagia the first remedy, and one without which all others are useless, is rest in the recumbent position. If the attack be severe recumbency should be absolute. Food should be light in quality and moderate in amount, while all drinks are to be taken cold, as ice-water, iced lemonade, or water acidulated with sulphuric acid and sweetened to the taste, the beneficial effect of acids in addition to cold being generally recognized. The bed should be hard and the clothing light, and the foot of the bedstead may be raised some inches. Many cases require no more active measures of repression. In subjects about the menopause, in some cases of malignant tumor, and in some others the hemorrhage seems to be a vent, and in moderate degree is rather beneficial. Such cases are to be watched, but need not necessarily be actively treated, certainly not with repressants and astringent applications, until regimen and mild measures have been tested.

In proceeding to medication the state of the general system first demands consideration. If there be increased vascular action and temperature, with evidences of active congestion of the pelvic region, manifested by pain, distension, and tenderness of the hypogastric region, with heat and throbbing of the passages, arterial sedatives and relaxants will be demanded. Aconite or veratrum viride may be given until an effect is produced on the pulse, and they may be combined to advantage with salines, as the liquor ammonii acetatis. It is in these conditions, of rare occurrence, that nauseants, such as ipecacuanha, are of service.

Medicines having a more direct action in checking uterine hemorrhage produce their effect by exciting contraction of the uterine walls and blood-vessels, moderating congestion, and modifying the condition of the nervous system. They are ergot, digitalis, bromide of potassium, quinine, cannabis indica, and cinnamon.

Ergot stands at the head of the list from its well-known effect in causing uterine contraction, and although reliable in proportion to the increased size of the uterus and the distension of its cavity, it is indicated in almost all cases for its hæmostatic action on the capillaries, as well as for its specific action on the uterus. Digitalis slows the action of the heart and excites the contractility of the arterioles, while experience has proved it to be an efficient remedy for menorrhagia. Bromide of potassium moderates vascular and nervous excitement of the pelvic organs, and is especially indicated in cases having an ovarian origin. Several of the French writers give very strong testimony in favor of the efficacy of cinnamon as a remedy, having tested it in a large number of cases without other medicines. It may always be used as an adjuvant.

All these medicines may be combined in various proportions, and they should be given in full doses. Infusion is the best form for the administration of digitalis. Sulphate of quinia in doses of gr. vj-x is often an [p. 205] efficient remedy, and especially in cases where there have been malarial influences. Cannabis indica is stated, by very high authority, to be one of the best remedies, although its mode of action is not clear. Iron should be administered as an hæmostatic tonic, and not merely because there is some uterine disease or derangement.

The action of medicines may be supplemented by local applications. Cloths wrung out of cold water or vinegar and water may be applied to the hypogastric region or to the vulva. A bladder or rubber bag filled with pounded ice may be laid on the abdomen above the pubes, or applied to the lumbar region for its effect upon the spinal cord. One of the most efficient means of applying cold is by an enema of cold water, or, this failing, of ice-water. The rectum and uterus being contiguous, the cold is applied almost directly. Siredey speaks highly of the cold douche to the soles of the feet, the water being projected in jets from a sprinkler. During the application uterine contractions are felt and the flow stops. This is more especially adapted to debilitated and anæmic patients with loss of vascular tone. Patients will often object to the application of cold to check a flow of blood from the uterus, knowing well the bad effects of suppression of menstruation which often results from exposure to this agent. It is believed that evil results never follow the application of cold when the flow is excessive; perhaps because the system and the organs concerned have been relieved.

The application of heat is also an efficient remedy—hot-water bags to the spine on Chapman's plan, or hot vaginal injections may be administered, as recommended by Trousseau and Emmet, the water being at a temperature as high as the patient can bear. To be properly administered the aid of a nurse is required, as the flow should be kept up for some time, at least a gallon of water being used.

There is only apparent contradiction in the use of both cold and heat to check uterine hemorrhage. Various explanations of the action of both have been given, and much argument presented why one should act better than, or be preferred to, the other. The truth is, that both are efficacious, and the value of both is based upon clinical experience.

The flow in menorrhagia is sometimes, if rarely, so excessive as to demand mechanical means of restraint. A well-applied tampon gives absolute control, and should never be omitted when the hemorrhage is severe and the practitioner is not within easy reach of the patient. Plugging the cervix with a sponge tent, supported by a vaginal tampon, is to be preferred as most reliable, and also because upon its removal the uterus can be explored for diagnosis or is prepared for direct applications. Should a vaginal tampon alone be trusted, it must be thoroughly applied to be reliable. This can only be done through a speculum, preferably with Sims's duckbill. Pledgets or discs of cotton, the first provided with strings to facilitate removal, squeezed out of a carbolized saturated solution of alum, should be packed carefully and firmly around and over the cervix, and the vagina filled. A folded napkin to the vulva, supported by the usual T bandage, sustains the whole. Such a tampon may remain, if necessary, thirty-six hours, the catheter being used to relieve the bladder.

Direct applications to the interior of the uterus are sometimes necessary both to check the flow and, in some cases, especially those dependent [p. 206] upon fungous growths of the endometrium, as a means of cure. They may be either fluid by application or injection, or solid. The former may be by swabbing the interior of the uterus by means of an applicator armed with cotton dipped in the liquid, or by injection. The drugs used for application are carbolic acid diluted with glycerin or pure tincture of iodine, or the stronger tincture known as Churchill's, Monsell's solution, or the liquor ferri perchloridi diluted or of full strength. The preparations of iron are objectionable from the hard, gritty, and disagreeable coagula formed, and the tincture of iodine is generally quite as efficient as a hæmostatic and more active as an alterative.

For efficient application the cervix should be dilated if not sufficiently patulous, and a cervical speculum should be used, or the solution will be squeezed out of the cotton before it reaches the seat of the disease. For injection the same articles are used, beginning with weaker solutions and gradually increasing the strength. They should never be resorted to without the utmost caution. The os should be patulous as a sine quâ non, and the injection carefully administered. In case the os is open the instrument may be the common extra long-pipe rubber syringe bent to a suitable curve by heating. This having been charged with a drachm or so of the liquid, the end is served with cotton like an applicator; over this several clove-hitch turns with a string are taken, so that the cotton may be withdrawn if pulled off in the uterus. The pipe is then carried to the fundus and the piston very slowly depressed. Buttle's syringe is a more elegant and a safer instrument in cases where the os is not thoroughly opened. The terminal pipe of this instrument is very slender and perforated with minute openings, and the piston is forced in by screw-action of the handle, so that the fluid is expelled drop by drop.

Nitrate of silver is sometimes applied in solid form to the interior of the uterus, both as a means of checking excessive hemorrhage and to effect a cure by modifying the condition of the endometrium. It may be done with a probe, the end of which has been coated with the substance, passed in detail over the inner surface of the organ. A piece of the solid caustic is also sometimes carried into the uterus and left there, the application à demeure of the French, some of whom claim that in their hands this measure has never failed to check the hemorrhage.

In those cases where positive evidence has been gained that the disease depends upon fungous growths of the endometrium there is yet another and a more reliable remedy. It is the curette. By this instrument the growths which are the origin of the menorrhagia can be certainly and safely removed, their return prevented by a thorough application of iodine to the surface from which they spring, and a cure often effected when all other means have failed.

Intra-uterine applications, injections, and surgical measures affecting the interior of the uterus have been detailed, as they are advised and used by authorities. It remains to give an opinion as to their merits, and to state the precautions which should be taken when they are resorted to.

First, it must be said that there is a very considerable difference of opinion as to the safety of these measures. While some do not hesitate to apply to the interior of the uterus fuming nitric acid, and introduce pieces of nitrate of silver to dissolve there, others are extremely careful [p. 207] about making any applications to this part, and reject intra-uterine injections altogether. Nor can it be denied that very severe symptoms have frequently, and death sometimes, followed the application of these remedies. In resorting to them, therefore, the practitioner cannot be too minute in observing every precaution, and they should never be resorted to if evidence of peri-uterine inflammation exists. No intra-uterine injection should be given unless the os be patulous, and the fluid should be thrown in with the utmost gentleness. The milder articles should be tried first, and the severer only as the temper of the uterus is tested. Always treat the patient afterward as the subject of an operation, keep her in bed strictly, and combat the first symptoms of trouble with opium.

While the writer would not be just to the reader if he did not state that some very high authorities are strongly opposed to intra-uterine injections and applications, he would not be just to himself did he not state that his own experience has been favorable to them. While he once saw severe and dangerous symptoms follow syringing the cervix with water to cleanse it of mucus, he never in a single instance saw any evil effects from intra-uterine injections properly administered, nor from nitrate of silver à demeure or the application of nitric acid. But while these measures have often ameliorated cases of menorrhagia where the endometrium was affected, they have seldom cured, as compared with the curette. Indeed, the general statement may be made that as of late years the value of the curette has become more and more recognized, resort to severe intra-uterine applications has proportionally diminished. From his experience he is fully prepared to believe with Courty, that "there are cases of uterine hemorrhage which cannot be mastered in any other way," and with Siredey, that "the operation cures in the great majority of cases." It should be noted, in this connection, that some of the warmest advocates of the instrument explain its beneficial effects otherwise than by the removal of fungosities. Thus, Thomas attributes them to "the fracture of tortuous and distended blood-vessels," and Siredey to "the irritation and excitation produced by its introduction and action during reflex contractions."

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.

The subject of inflammation of the tissues surrounding the uterus and its appendages would be very much simplified, especially for the general practitioner, by debarring it of all new and superfluous names and subdivisions, and by treating it on a broad clinical basis. It will be my aim in this paper to keep that idea constantly in view, rather than to follow the history and varying pathological views by which it has been surrounded and complicated.

The importance of this disease is probably greater in its influence on the health and future usefulness of the woman than any other; and its causes and prevention, as well as its early recognition and treatment, should be fully understood by the physicians who are most likely to be first consulted in the matter, those engaged in general practice. I feel safe in making the statement that were this so, many of the chronic cases of almost incurable displacement of the uterus, Fallopian tubes, and ovaries, resulting from thickened, indurated, and contracted ligaments, with their distressing symptoms, would never reach the gynecologist, because they would not then exist. In many cases the disease would have been prevented; in others it would have been arrested in its incipiency.

Whether we understand the primary pathological lesion to be inflammation of the cellular tissue, the peritoneum, the lymphatics, or the veins, matters very little, practically, if we recognize the immediate location of the process; for there can be no doubt that the disease, once started, soon involves to a greater or less degree all of the tissues and organs adjacent to it, and the therapeutic requirements will be much the same in either case.

That inflammation of the cellular tissue can exist without also involving the peritoneum in its neighborhood is scarcely to be conceived, and vice versâ; but the one has always a predominating influence over the other, and differs somewhat in its cause, course, and consequences. When the inflammatory process has its origin in the cellular tissue, it is more likely to run through a regular course and end in abscess than if it had started as a peritonitis, in which case the course of the disease is often more chronic, resulting in the formation of false membranes which bind the uterus and other pelvic organs in permanent displacement. For these reasons, and for the more systematic study of the subject, I think it best to follow the plan of those authors who describe the disease separately under the two general heads, Parametritis and Perimetritis.

¹ Virchow, Duncan.

DEFINITION AND SYNONYMS.—By parametritis is understood an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds—viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. I think it a better name than pelvic cellulitis or peri-uterine inflammation, because it more correctly expresses the primary location of the disease than any other. The disease has been described under many other appellations, among which have been pelvic abscess and peri-uterine phlegmon.

ETIOLOGY.—Parametritis does not occur before puberty, and rarely before the great predisposing causes, abortion and injury at parturition, have prepared the parts—opened up the channel—for the more ready advance of the inflammatory process. This is easily understood when we remember how compactly bound together are these ligamentous folds, and how small the cellular-tissue spaces are before impregnation when compared with the condition of the parts after the function of gestation has been performed. Even were no accident to occur to interfere with the perfect involution of the parts which enter into the process of the expulsion of the product of conception, the tissues would probably always remain more vulnerable than before the gestation had occurred. But when the retrograde change which is necessary to perfect involution is retarded, a condition of relaxation and looseness of the parts results which increases many fold the liability to the affection. The blood-vessels and lymphatics remain large, and the connective-tissue cells are not only larger in size, but a cell-proliferation is probably induced as a result of the increased amount of blood-supply. Then a certain low condition of the general nutrition, a diathesis or an inflammatory tendency, no doubt act as predisposing causes of this disease. Now, add to the predisposing causes the injury which probably always attends abortion, and that which so often results from parturition proper, and a condition results which I believe to be the cause of parametritis in the majority of the cases.

Abortion the result of accident or design is a most prolific cause of parametritis, because abortion is so often followed by endometritis, which is frequently the starting-point of the former. Abortion results in a wounding of almost the entire surface of the uterine cavity, from which the placenta is torn, and often also in direct injury to the tissues of the neck of the womb. This almost necessarily interferes with involution; and if nothing worse follows immediately, there is left a strong tendency to a low grade of inflammation or hyper-nutrition, which may practically result in the same condition of induration and thickening of ligaments. It is seldom that the subject of an abortion of this character escapes from a certain degree of parametritis. If it does not manifest itself at the time in violent symptoms, the results are found afterward, when the patient is forced to consult her physician for the relief of suffering the consequence of the thickening and induration mentioned above.

Parturition without injury or accident is a predisposing cause, as before mentioned, of parametritis, and renders the patient more susceptible to the disease from cold, fatigue, etc., and from septic influences; but when the labor has resulted in injury to the soft parts, as laceration of the cervix, endometritis, injury to the vessels outside of the uterus, in the broad ligaments from pressure, the disease is far more liable to follow.

Parametritis may result from the various operations on the perineum, vagina, and uterus; from the application of medicines to the uterine cavity; and it is even said that the disease has been excited by the introduction of the uterine sound. I cannot believe that the simple introduction of the sound, when properly done, can be the means of so much harm. If harm follows, it must result from carelessness or want of skill. Of course there are contraindications to the use of the sound, and if these are violated evil will often follow. The use of the instrument ought not to be thought of if a suspicion of pregnancy exists, or when there is marked tenderness of the uterus or of the parts around it, or just before, during, or immediately after menstruation, and certainly not when active inflammation is present. Then the awkward manipulation of the sound when the uterus is fixed as a result of a former inflammation is very apt to relight anew the process.

If the same restrictions are applied and care used in the medication of the uterine cavity, the cases in which parametritis will follow as a result will be almost nil. The same will apply to operations. The danger lies in proceeding with the treatment of cases as they present themselves, by a hurried method and without fully investigating the condition of the tissues and organs outside of the uterus itself.

There is probably no place where experience is of more value than in the manipulations and instrumental measures necessary for the diagnosis and treatment of the various diseases of the pelvic organs—where more depends upon the skill and care of the operator. I believe, with Duncan, that pelvic inflammation and abscess are always secondary, and that these tissues are not specially inclined to idiopathic inflammatory action. But, undoubtedly, certain low conditions of the system or certain individual peculiarities furnish such a strong predisposing influence that a mechanical cause otherwise inactive will be sufficient in some of these cases to produce the disease. We probably see this expressed most fully in the low types of puerperal inflammations which develop gradually and without apparent cause, so far as injury at labor is concerned, and which often persistently progress to a fatal termination. It will be said that these are cases of septic origin; and it may be true, but I believe the poison is developed autogenetically.

COMPLICATIONS.—Parametritis is usually associated with perimetritis, and it may be complicated by ovaritis, endometritis, and salpingitis. Uterine displacement also often complicates this disease; and I wish here to emphasize the statement that no attempt should be made at restoring the organ to its normal position until all evidence of active inflammation shall have subsided. I have seen great harm result from such attempt having been made on the supposition that the symptoms were due to the displacement rather than to the parametritis.

ANATOMY, PATHOLOGY, COURSE, AND TERMINATION.—Everywhere in the pelvis, below the peritoneum, connective tissue is found in sufficient [p. 211] abundance to serve the purposes for which it exists—viz. first, as a bond of union between the pelvic viscera and organs, bladder, uterus, rectum, ovaries, and Fallopian tubes; second, to surround, support, and protect the numerous blood-vessels, lymphatics, and nerves from injury during the mechanical disturbances to which the pelvic tissues are subjected in the performance of their various functions.

If it were not for the padding of the pelvic connective tissue, which allows a free range of movement to the pelvic contents, the ordinary sudden jars from walking, coughing, etc. could not be sustained without pain, nor could the functions of the rectum and bladder be fulfilled properly; much less could the functions of coition and gestation be performed. This cellular tissue most abounds where it is most needed—in the locality or spaces where the vessels and nerves are found in greatest number; viz. at the sides of the uterus and upper portion of the vagina, extending outward between the folds of the broad ligaments toward the pelvic wall and the under surface of the Fallopian tubes and ovaries; next, within the folds of the utero-sacral ligaments and the vesico-uterine space beneath the peritoneum. There is little between the peritoneum and posterior vaginal wall, between the bladder and its peritoneal investment, as well as between the rectum and peritoneum; and there is none between the latter membrane and the posterior, superior, and anterior surfaces of the body of the uterus.

This areolar tissue is the seat of the disease under consideration, and from a priori reasoning it would be inferred that the inflammatory process would be found most frequently and in greatest severity in the locality where this tissue and the vessels most abound; and this is true, for parametritis almost always has its starting-point immediately at the sides of the uterus, in the lower inner edge of the broad ligaments.

But there is another reason why the disease so often begins here. It is the point, which, with the cervix, must bear the brunt of the pressure and injury during parturition and abortion, as well as from many of the operations which are performed upon the uterus. That inflammation of these tissues is secondary to injury is proven by the fact that we so often find the results of it, induration and thickening of the broad ligaments, in the cases of laceration of the cervix which come under our care. I have constantly observed that the inflammatory indurations were greatest on the side on which the laceration was most extensive, and that were the laceration unilateral the evidences of inflammatory action would be unilateral also. I have so frequently met with this condition in connection with laceration of the cervix that I have come to regard its entire absence as quite exceptional. I refer now to the deeper lacerations. Of course these inflammatory products are met with when the cervix is entire and apparently healthy, but this does not disprove the statement that they are probably invariably secondary, and very often secondary to injury at labor; for while the cervix may have escaped laceration, the tissues and vessels may have been so contused from pressure and instrumental measures as to result in the disease. But, however originated, the inflammation and infiltration advance in the direction of least resistance—i.e. along the course of the connective-tissue spaces between the various ligaments. The product of the inflammation, the pus, would therefore most likely follow these channels in making its exit. If the primary inflammation arise at [p. 212] the base of the broad ligament, it may travel within the folds of the ligament outward to the lateral wall of the pelvis and upward to the iliac fossa. This is probably the course which is most commonly taken by the process in puerperal parametritis, and to which is due the induration and tumor which so often exist in that region during the course of the disease. Tumor in the iliac fossa, however, is not at all uncommonly met with in the course of a severe parametritis in the non-puerperal state, and it is doubtless of the same pathological character. Or the infiltration may propagate in the folds or under surfaces of the utero-sacral ligaments, resulting in the formation of a tumor which may eventually surround the rectum. In rare cases, and probably only in the puerperal, the process may develop higher up and more anteriorly, finally taking the direction and following the course of the round ligaments; but I have never met with an instance of it. And it would be impossible to tell correctly in a case opening in the groin—without a post-mortem demonstration, the opportunity for which, fortunately, does not often occur—whether the pus had not descended subperitoneally along the pelvic brim toward the inguinal region. Of course the inflammation and infiltration may be general, so that the uterus may be surrounded by exudation tumors, but this is the exception. Inferiorly, the parametritic process is limited by the pelvic fascia which covers the levator ani muscle.

Parametritis, as phlegmonous inflammations elsewhere, has three stages: 1st, that of active congestion; 2d, that of effusion of serum; 3d, that of suppuration. But the disease does not reach the third stage in all cases. It may be arrested in the first stage or end by resolution in the second. I believe, however, that resolution in the second stage is the exception and not the rule. First, because to end in suppuration is the natural course of the disease; and secondly, because in many of those cases which are carefully observed the ordinary symptoms of the formation of pus, as chill, etc., are usually manifested, and followed by its evacuation. The fact that pus is not discovered should not be accepted as proof that the disease has not advanced to the suppurative stage; for it may be so small in quantity as to escape observation, or it may be discharged into the bowel so high up as to mix with the fecal matter, so that its character is lost by the time it is expelled from the anus, or the point of exit may be so small as to allow it to escape guttatim, and thus elude detection.

Further, pus is sometimes formed and reabsorbed harmlessly, or it may remain deeply seated in a cavity—usually, under these circumstances, a number of small cavities—where it may undergo decomposition and result in the absorption of septic material and destruction of the patient before it finds exit. Then, again, it may become encysted and be retained indefinitely, when it is a source of constant and sometimes obscure suffering, as well as an abiding cause of a renewed attack of the disease.

It is probable also that the process is sometimes arrested in the second stage, neither resolution nor suppuration taking place, the serous portion of the liquor sanguinis being absorbed, the remainder undergoing a change to plastic lymph, so called, which proceeds to organization, resulting in persistent induration of the affected parts; or, instead of being absorbed, the serum may remain encysted within cavities formed for it by the lymph. This likewise subjects the patient to the constant menace of a renewal of the inflammation. The late D. Warren Brickell of New [p. 213] Orleans has called special attention to what he named the serous form of pelvic inflammation, and which he thought had been too much neglected.² I have met with at least one well-marked case which supports Brickell's views.

² "The Treatment of Pelvic Effusions," Amer. Journ. of the Med. Sciences, Philada., April, 1877.

The usual course, however, of an acute parametritis which has advanced to suppuration is evacuation of the pus by the most favorable channel—i.e. through the rectum or vagina. If through the latter organ, the point of perforation is either directly posterior to, or a little to the side of, the cervix. But if the inflammation be located in the vesico-uterine space—which is rare, however—the point of rupture may be anterior to the cervix. Less frequently the bladder is perforated and the pus discharged with the urine. More rarely the abscess is discharged through the abdominal wall, groin, or saphenous opening, and still more rarely through the sacro-ischiatic and obturator foramina. It may also find exit through the floor of the pelvis near the anus, and it may rupture into the peritoneal cavity, but the latter termination is fortunately the least common. This is probably due to the fact that the slightest irritation and pressure, under these circumstances especially, result in adhesive inflammation between the peritoneal surface of the abscess and that of the intestine with which it may be in contact, thus favoring rupture into the intestinal tract. Then, rupture into the intestine is conservative and protective, and the other is not, for should the pus be discharged into the peritoneal cavity the patient would most likely perish.

When the abscess opens at its most dependent portion, which is the rule, it is kept thoroughly drained of the pus, and if a single cavity exists it gradually contracts, and under favorable circumstances soon disappears, the trouble ending by absorption of the wall of the abscess. This is the most favorable termination of a parametritis, and belongs only to the acute form.

When the pus has not been evacuated from the bottom of the sac, or when there is more than a single cavity and only one is drained, or where the pus has taken one of the circuitous routes mentioned above, the disease merges into the chronic form, and may then be indefinitely prolonged by the formation and evacuation of abscess after abscess, until the pelvic cellular tissue becomes involved throughout and riddled by fistulous tracts connecting them.

SYMPTOMATOLOGY.—Pain is probably the first symptom to attract the attention of the patient, and if the attack is sudden or acute the pain is usually attended by a chill of more or less severity. The pain may be so sharp and lancinating as to cause the patient to cry out in agony, or it may be of a throbbing, aching character. If the former, it indicates either intense congestion of the vessels and tissues involved, or that the peritoneum is largely implicated, probably both. Where the pain is of this character the attack is usually of shorter duration, since it is soon followed by the second stage, exudation, when the symptom is at once modified, becoming less acute and resembling now the pain attending an attack of less severity. Of course the location of the pain corresponds to the seat of the inflammatory process. If it is in one or the other broad ligament, the pain is greater in the right or left iliac regions, most [p. 214] frequently in the left. Pain is often experienced in the hypogastric and sacral regions in the beginning of, or preceding, an attack of parametritis, and it is due to congestion of the endometrium and uterus, from which the disease is spreading to the looser cellular-tissue spaces in the ligaments. If, however, sacral pain persists throughout the course of the disease, or exists in that region chiefly, it indicates that the inflammation has become general or has invaded the utero-sacral ligaments. But it would not be correct to estimate the extent of the disease by the amount of pain complained of, for that symptom depends so largely upon the temperament of the patient and her station in life that it is not trustworthy. Some women suffer so much that they become inured to it or acquire the habit of suffering in silence; others, from temperament, do not actually experience pain; whilst others, again, from a love of hardihood, do not complain, although they may be enduring constant and severe pain. To one of these classes those cases must belong which are said to pass through an attack of parametritis without suffering. That cases do rarely present themselves, on account of mild but persistent symptoms, which are found on examination to contain a large pelvic exudation, I can attest; but I have so constantly found on careful questioning that the usual symptoms of pelvic inflammation were present at some time during the course of the existing illness that I cannot agree with the statement made by some authors that this disease may develop "without causing any particular disturbance" (Emmet).

As a rule, the bladder and rectum are reflexly affected, the former sometimes becoming very irritable, so that there often exists a constant desire to micturate. Constipation is the rule, though I have known a severe diarrhoea to accompany the disease, the result, I thought, of reflex irritation. The stomach also is often sympathetically affected, nausea, and sometimes vomiting of an aggravated form, being present.

With a subsidence of the chill the temperature begins to rise, and continues to increase, with evening exacerbations, until it reaches 102° to 103°, usually its highest point. It may, however, rise suddenly and reach as high as 104° or even 105°—rarely above the latter point. The pulse is usually full, and beats from 112 to 120 per minute, sometimes oftener.

In severe cases tympanites exists, with great tenderness in the hypogastric region; the thighs are also flexed upon the abdomen to protect the parts from pressure and to relieve the abdominal muscles from tension. But when these symptoms are marked it may be confidently concluded that the peritoneum is extensively involved.

Within a few days to a week from the initial symptoms the stage of effusion is probably completed or well advanced, when the symptoms are usually ameliorated. Pain is diminished and the temperature decreased, and if, happily, resolution begins, the patient may gradually recover during the succeeding two or three weeks. But, unfortunately, this very favorable course is not the usual one. Instead of it, the disease often advances to the third stage, that of suppuration. This stage is very commonly ushered in and manifested by rigors or chill, followed by a rise in temperature and an increase in the pulse-rate. There may now be daily afternoon exacerbations of temperature, followed by sweating, until the pus is disposed of, usually by evacuation.

PHYSICAL SIGNS.—If an opportunity is afforded for making a vaginal [p. 215] examination during the first stage, it will be found that the local temperature is markedly increased, that great tenderness exists, and that the parts involved are rigid from congestion. A little later this rigidity or erection subsides, and a bogginess may be discovered at the point or points where effusion is now taking place. Still later, a rather firm and, it may be, irregular swelling of variable size and location can be detected, usually in one of the broad ligaments, and from the size of a hen's to that of a goose's egg. If the inflammation has existed on both sides of the uterus, the pelvic roof, so called, may be found as hard and firm as a board. If pus has formed, fluctuation may be felt, and later a softening process may be detected, indicating the point where Nature is attempting to rid herself of the product of the inflammation.

The uterus is usually displaced by the exudation to an extent depending upon the size of the swelling, to which it is fixed more or less firmly. If the effusion has taken place in one of the broad ligaments, the organ will be displaced to the opposite side, but if the inflammatory process has extended to the cellular tissue in the posterior region of the cervix and in the utero-sacral ligaments, the organ may be displaced forward as well as laterally. If the cellular space between the bladder and cervix alone be involved in the inflammation, the resulting effusion may displace the uterus backward, but the disease is rarely met with in this location. Retroversion of the uterus frequently complicates parametritis, but in that case the abnormal position is not necessarily due to displacement by the exudation. It may have existed previous to the attack.

It must not be forgotten, however, that the symptoms and physical signs, as described above, apply only to the acute form of the disease, and that they do not exist in the same degree nor in the same regular order when the inflammatory process has been subacute, as it often is, from its commencement. When the disease is subacute from the start, the patient may be enabled to go about, and even to pursue a laborious occupation, but not without suffering. There will always be more or less pain experienced in the affected region, and the temperature and pulse will be slightly increased. In rare cases the manifestations of the disease may be so slight or so little complained of that the physician is surprised to find, on examination, a large exudation in one or both broad ligaments.

DIFFERENTIAL DIAGNOSIS.—It is of the greatest importance that this disease should be recognized early, so that prompt measures may be taken to arrest it if possible, or at least to modify the severity of its course. Fortunately, as a rule, the subjective symptoms of pelvic inflammation are so marked that the attention is at once directed toward seeking for their confirmation by eliciting the physical signs; and for diagnosis these local manifestations of the inflammatory process are to be relied upon entirely, as the subjective symptoms of inflammation of the other tissues and organs of the pelvis somewhat resemble those of parametritis.

The diseases the local signs of which approach more nearly those of parametritis are—pelvic hæmatocele, fibrous tumor, the early stage of extra-uterine pregnancy, the early stage of parovarian and ovarian cystic degeneration, and perityphlitis.

In pelvic hæmatocele the symptoms occur suddenly, and often with hemorrhage; there are also constitutional signs of loss of blood, as pallor and coldness of the surface of the body, and if the hemorrhage is great [p. 216] failure of the pulse and syncope. The tumor caused by the escape of blood into the pelvic cavity is generally post-uterine, distending Douglas's cul-de-sac and crowding the uterus forward toward the symphysis pubis, while that formed by parametritis is oftenest located at the side of the uterus. The hæmatocele at first is soft and compressible, becoming hard within a short time—a few days—as a result principally of the surrounding wall of lymph which nature throws out as a protection. The symptoms of parametritis, on the other hand, are more likely to come on gradually, and to present the pulse- and temperature-signs of inflammation, while the resulting swelling or tumor is rigid at first from congestion of the tissues, then hard, becoming soft later as the process advances to suppuration. Mere location of the tumor, however, cannot be depended upon; we must be guided by the history of the case and the special character of the tumor.

Fibroid tumor is not attended with the usual acute symptoms of parametritis, such as pain, increase of temperature, and accelerated pulse; the tumor is hard from the beginning, or at least never soft; it is circumscribed, usually smooth, and not sensitive to the touch. Its attachment to the uterus is also different from that of the tumor caused by parametritis. The former shows a tendency to pedunculation, while the latter has always a broad surface attachment.

The tumor resulting from the arrest and development of a fecundated ovum in the Fallopian tube or ovary resembles very much in its locality, and somewhat in its characteristics, a parametritic tumor; for usually more or less inflammatory exudation is present in connection with extra-uterine pregnancy, giving at times a fixity and hardness to the gestation-sac not unlike that sometimes observed in a tumor parametritic in origin; besides, there may also be constitutional signs of an inflammatory action. But the presence of some of the ordinary signs of pregnancy and a little time will clear up the difficulty; for as the case progresses the tumor will increase in size and change in character, while the mammary and other signs of gestation will develop. In addition, the pain attending tubal pregnancy is never like that of parametritis: it is more persistent, lancinating, and cramp-like in character, and is unattended by rise in temperature. Soon also the placental bruit may be detected, which of course never exists in parametritis.

The early stage of normal pregnancy is said to have been mistaken for this disease. I can hardly conceive how this mistake in diagnosis could be made, although I have met with several cases where the congestion consequent upon fecundation was so violent as to result in actual pelvic inflammatory symptoms with subsequent exudation.

The following case, which I saw with H. A. M. Smith of Gloucester, N. J., markedly illustrates and confirms this opinion: Mrs. B——, æt. 21, had been married five years, but had never conceived. Her catamenia had always been regular in time, but the flow had been slight in quantity. In the latter part of November, 1884, or about three months before I first saw her, she was attacked with severe pain in the pelvis, accompanied by rise in temperature and accelerated pulse. She was compelled to go to bed, where she had remained up to the time of coming under my care. During this time she suffered from great tenderness over the hypogastrium, some tympanites, and considerable nausea and vomiting. She [p. 217] did not menstruate in November—the period was due when she was first attacked with pain—but in December she had severe uterine tenesmus and a profuse metrorrhagia—symptoms of abortion. Pregnancy had not been suspected, however, as she had been so long sterile, and the inflammatory symptoms had been so violent that the signs of gestation had been masked by them. At the time of my first visit (March, 1885), there was great tenderness of the hypogastrium with slight tympanites; nausea and at times vomiting; great nervous prostration; loss of flesh; menses absent since November, except the uterine tenesmus and hemorrhage in December, as above stated; and at each menstrual cycle afterward she had the symptoms of uterine contraction with a profuse leucorrhoeal discharge, but no hemorrhage. The mammary glands showed the usual signs of gestation at about the fourth month; the vagina was purplish; the cervix uteri low down on the floor of the pelvis, and the mucous membrane around the os hypertrophied, soft, and abraded. The body of the uterus was anteverted and symmetrically enlarged to about the size of the organ at the third month of gestation. The uterus seemed to be fixed—incarcerated within the pelvic cavity—by an indurated exudation in the lower portion of the right broad ligament. I diagnosticated pregnancy, and accompanying parametritis as a result. The treatment consisted in painting the right side of the fundus of the vagina opposite the base of the broad ligament with iodine; the application of iodized glycerin on pledgets of cotton, together with the use of the hot-water douche; internally, opium enough to relieve pain and an alterative tonic in the form of the four chlorides, the formula for which will be given at another place. She began to improve at once, but as she was still threatened with abortion and the uterus was still incarcerated within the pelvis, ether was administered for the purpose of attempting to release it. With two fingers of the left hand in the vagina and the right hand upon the hypogastrium to exert counter-pressure, gentle manipulation was made with the view of stretching the adhesions. This resulted in a slight elevation of the womb, and from this time pregnancy went on to full term without further trouble.

This case is introduced chiefly to show the possibility of the existence of parametritis with normal gestation. It is true that the inflammation, which developed simultaneously with fecundation, may have had a latent existence before the occurrence of that event, and that the stimulus of pregnancy served simply to bring about an attack of an active character, but nothing in the previous history of the case indicated such a condition.

Perityphlitis may somewhat resemble in its subjective symptoms, as pain and rise of temperature, an attack of parametritis. A careful study of the physical signs, and also of the exact position of the tumor in each case, however, ought to be sufficient to differentiate between the two diseases. The tumor of perityphlitis is always on the right side, and situated high up in the false pelvis; that of parametritis may be on either side—it is oftenest on the left—and is usually located low down in the true pelvis. The latter is easily reached per vaginam, while the former is almost or quite out of reach from this direction.

Parovarian cystic disease in the early stage, before the tumor has developed sufficiently to rise above the pelvic brim, resembles in its location parametritic exudation; but the history of development and the physical [p. 218] characteristics of each are different. There is an absence of hardness and tenderness to the touch in the former, which always exist in the latter. Parovarian tumor develops without the constitutional phenomena of inflammation; parametritis, I believe, never.

It must not be forgotten, however, that either one or more of these various diseases may exist in connection with, and as complications of, parametritis, rendering the diagnosis at times exceedingly difficult, requiring time and patience to clear the way. A case in point may be stated in brief as follows: Mrs. H—— was sent to me some months ago. She complained of great pain in both iliac regions—more in the right—extending into the pelvis and sacrum and down the limbs. There were also menorrhagia, and profuse leucorrhoea during the intermenstrual periods. She dated the trouble from an abortion which had occurred nine years before, and which was followed by symptoms of acute parametritis, from which she never fully recovered. Physical examination showed the uterus to be considerably hypertrophied and fixed, as in a vise, by an indurated mass on either side of it, which seemed to occupy both broad ligaments or to be closely adherent to them. The cervix uteri was also badly lacerated; its mucous membrane presented a surface so hypertrophied, abraded, and jagged that I was at first strongly impressed with the fear that epitheliomatous degeneration had begun to develop. I pursued a plan of treatment designed to reduce the congestion and hypertrophy of the diseased neck, and at the same time to induce an absorption of the plastic and indurated lymph around the uterus, to render the organ mobile, so that an operation might be made safe. I only partially succeeded, for while the uterus became much more mobile, there still remained a swelling or tumor on either side of it. These tumors had ill-defined borders—were not circumscribed, but elongated and rather cylindrical in form, and fixed to the lateral pelvic walls as well as to the uterus, though not very firmly to either. I now suspected disease of the Fallopian tubes, and probably also of the ovaries. The patient entered my private hospital in February, 1885, when I operated upon the cervix, dissecting away a large quantity of tissue for the purpose of making proper adjustment of the labia and to get rid of the cicatricial tissue; it was not epitheliomatous. I had hoped by this operation to not only restore the cervix to health, but at the same time to induce, by a derivative action, a retrograde metamorphosis in the diseased tissues and organs appended to the uterus. I succeeded in the former, and also in modifying all of the symptoms except the pain in the ovarian regions. This seemed to be made worse, or at least to become more prominent, as the other symptoms were improved. The patient was sent to her home, and advised to rest in the recumbent position for at least a part of every day. Later, when she did not improve, a local treatment, consisting of an application of the tincture of iodine to the fundus of the vagina at intervals of a week, with boro-glyceride tampons almost daily, was renewed. At the same time, counter-irritation, applied to the hypogastrium by means of blistering, was faithfully pursued. But nothing proved of more than temporary avail. She began to lose flesh and to fail in strength. The old fulness at the sides of the uterus, instead of diminishing, had increased. She again entered my private hospital. Under the influence of ether I now determined that the [p. 219] Fallopian tubes were distended to the size of a small sausage, that the ovaries were also enlarged, and that the tubes, ovaries, and ligaments were all adherent to one another by plastic lymph. I now advised laparotomy for the removal of the diseased uterine appendages. The patient very readily assented; indeed, she urged the operation.

A week later I made an incision three inches in length through an abdominal wall fully two inches in thickness, and came upon the omentum, which was very fat. This was adherent by its lower border to the pelvic tissues and organs, so that I was compelled to dissect it off on the right side before I could reach the uterus with my fingers. All the parts—Fallopian tubes, ovaries, broad ligaments, uterus, omentum, and intestines—were so adherent and matted together that it was difficult to differentiate between them. The tubes were greatly distended and contained—the right pus, and the left serum. The fimbriated extremities were glued to the lateral pelvic walls. The ovaries were as large as a good-sized hen's egg, and closely adherent to the posterior surface of the broad ligaments. I dissected with my fingers—two being introduced—until the right tube and ovary were released, when they were drawn to the incision, ligated, and removed. The left ovary and tube were released with still greater difficulty, but I finally succeeded in ligating and removing them.

It will be sufficient to say here that the patient recovered without an untoward symptom, and that she has been entirely free from pain—since her recovery—for the first time within the last nine years.

PROGNOSIS.—A very guarded prognosis should always be given as to the course and termination of a case of pelvic inflammation. The disease may run a very acute course, and result in recovery by resolution or suppuration, or it may become chronic and be indefinitely prolonged. An acute parametritis without complications usually runs its course and ends in recovery in from four to six weeks. But the cases which are acute and uncomplicated are vastly in the minority; certainly this is my experience. The course of the disease, as has been stated above, is often chronic, and requires all the patience and fortitude which can be mustered, both by the patient and physician, to bring about a cure. Generally, the prognosis is good where a rational treatment can be pursued. The tendency of the disease is toward recovery, and comparatively few cases die. It is less favorable in cases occurring just after parturition, and which are probably of septic origin. Where the disease is complicated by peritonitis the prognosis, as to life, becomes less favorable.

TREATMENT.—In the acute form, if the patient is seen during the first stage—i.e. before exudation has begun—she must immediately be placed in a warm bed. All sources of excitement must be at once removed, the nervous system quieted, and pain relieved by a full dose of morphia administered hypodermatically. I never give less than a quarter of a grain of the sulphate, and seldom more, but I repeat it within an hour if pain is still severe. If reaction from chill has not yet occurred, it should be hastened by the application of dry heat to the lower extremities in the form of vessels filled with hot water, preferably, while moist heat, in the form of a hot flaxseed poultice or some other convenient vehicle, should be applied to the hypogastrium. Great care must be taken that the moisture from the poultice does not escape and wet the clothing of the patient, for that [p. 220] would not only be a source of great discomfort, but it might also be the means of inducing another chill. The heat and moisture are best retained in the poultice by a covering of waxed paper or oiled silk. At the same time, a hot lemonade, to which may be added a teaspoonful of the sweet spirit of nitre, will often be found useful. According to Emmet, hot water per vaginal injection is a sine quâ non in the treatment of this disease. He says: "It is the only means we possess for aborting an attack of cellulitis, which it will do, if thoroughly employed at the beginning."³ This is strong language, and doubtless the eminent author feels warranted in its use from his experience with the remedy; but I am sure that I have seen reaction brought about and the disease arrested in the first stage by the plan recommended above, and without the use of hot water by injection. There can be no doubt that the first principle to be carried out in the treatment of this disease is rest—absolute and persistent physical and mental rest. This can be obtained by the use of morphia hypodermically or by opium—administered best by the rectum—and probably by nothing else; certainly by nothing else so well. Hot-water injections are objectionable during the first stage of the disease, because of the fuss and movement of the patient necessarily connected with their administration. Further, I think it is impossible to say of any remedy that it aborted an attack of pelvic inflammation, for the disease cannot be said to be unquestionably established until the stage of exudation has been reached. Indeed, intense pelvic congestion may occur, giving rise to symptoms of the first stage of inflammation, and subside spontaneously.

³ Prin. and Prac. of Gynæcology, 3d ed., p. 261.

When it is found that the disease cannot be arrested in the congestive stage, or when it has already passed into the stage of effusion before the patient is seen—which is often the case—exudation should be facilitated by the exhibition of the proper remedies. Happily, the principle to be followed in the treatment of this stage of the disease is the same as that of the first stage—viz. rest, relief of pain, and the local application of heat and moisture, with the addition now of counter-irritation. The first and second are to be obtained by the use of opium. The patient must not be allowed to suffer pain, and immunity can only be secured by the free use of the remedy. This drug is of more value in controlling the heart's action and quieting reflex irritability than all the others combined. The patient should be kept under its influence as long as pain lasts. I usually order twelve suppositories, as follows:

Sig. One to be placed in the rectum every two hours if necessary to quiet pain.

But we should not wait for the rather slow action of the opium administered in this way. It is best to begin with the administration of morphia hypodermically, as stated above, repeating it until the desired result is secured. It is then not difficult to keep up its influence by the use of the suppositories. If the suppositories cannot be obtained, the tincture of opium may be administered by injection into the rectum. The opium should not be given by the mouth where it can be avoided, as it is more apt to interfere with the appetite and digestion when thus [p. 221] administered. The proper action of the skin and kidneys should be maintained by the administration of the liquor ammoniæ acetatis in dessertspoonful doses. Irritability of the bladder is often a troublesome symptom during the progress of the disease, and is best relieved, in my experience, by the following formula, which combines a diaphoretic and diuretic as well as an antispasmodic:

M.—Sig. Dessertspoonful three or four times a day, or half the quantity oftener. I have also known this combination to relieve the persistent nausea which often accompanies this disease.

As soon as the skin becomes moist the remedy should be given at longer intervals, and if sweating is induced it should be discontinued entirely for the time, as that only serves to weaken the patient.

If the pulse does not beat oftener than 112, and the temperature does not rise above 102°, nothing more in the way of medication will be required. The patient will recover best if not treated too much. On the other hand, should the pulse be strong and rapid and the temperature high, quinine becomes a valuable remedy. It is more efficient when given in large doses at long intervals than when given in small doses at short intervals. If the temperature rises above 102°, it is my rule to administer ten grains and wait six hours, when, if it has not decreased, the quinine is repeated. If, however, the temperature has increased instead of diminishing, twenty grains are given at the second dose, and the effect carefully noted. Should marked cinchonism result, the remedy must be withheld, even though it has had no influence on the temperature. Quinine is said to have the power of so contracting the capillaries as to prevent the migration of the white blood-corpuscles. If this is true, the remedy ought to have great value in modifying or limiting the third or suppurative stage of the disease.

The tincture of aconite-root is also of value in controlling the pulse and lowering the temperature in certain cases. But its use should be limited to those cases of marked sthenic character, for, as a rule, the tendency of the disease is toward depression. It may be given in doses of two to five drops, repeated every two hours until three or four doses are taken, when, sometimes, the pulse will be found to have decreased ten to twenty beats per minute. The remedy should then be withheld until the effect is shown to have passed off by an increase of pulse-rate, when it may be again exhibited; provided always that the heart continues strong and vigorous and that it has shown no sign of weakness. In the latter circumstance the continued use of the medicine would be extremely dangerous. Under any circumstances its use should be limited to the first and early part of the second stage of the disease.

The diet should be carefully attended to, and should be of the most nutritious character, as milk, eggs, beef-essence, etc.

Locally, in addition to the poulticing, but not to the exclusion of it, counter-irritation by means of iodine will be found useful. The whole surface of the hypogastrium should be painted each time the poultice is changed until the skin shows signs of irritation, when it should be [p. 222] discontinued and the poulticing alone kept up. The abdomen must not be exposed longer than is just necessary to remove one and place another poultice, which should be at hand and not in another room. The poultice must never be permitted to become cool on the patient. Turpentine may be used instead of iodine, and if tympanites is a troublesome symptom it will be found valuable. A few drops should be sprinkled over the poultice, or its action may be more quickly obtained by the use of the remedy in the form of the stupe until marked redness of the surface is produced, when the poultice can be resumed. Tympanites is most troublesome when the disease occurs during the puerperal state, and in these cases I regard the turpentine as a most valuable remedy, not only as a counter-irritant, but also when administered internally. It should be given by enema in teaspoonful doses, repeated every six hours until the desired effect is produced. It improves the secretions and allays pain by relieving distension. If the bowels should move as a result of the enemata, it is all the better. If fecal matter occupies the lower bowel, it should be removed under any circumstances.

Blistering, by means of cantharidal collodion or by the pure cantharides spread in the form of a plaster, I regard as the most efficacious counter-irritant; and if the beneficial effects of the remedy could be obtained without the discomforts, and often positive suffering, attending its action, I would probably employ it to the exclusion of all others. But these cannot be obtained. During the acute stage of the disease, when the pulse and temperature are high and the skin hot, the blister should not be used. It is then more likely to produce strangury; if not that, the other sufferings of the patient are at least increased in the pain and burning produced on the surface of the abdomen. This is not compensated for by relief of pelvic pain, for we have relieved this long since by opium. I think blistering should be confined to the chronic stage or form of the disease.

Resolution by reabsorption of the effused product may now terminate the disease; but that is not the rule when the process has once advanced beyond the first or congestive stage. If it is found that suppuration is likely to take place, that the disease is following its natural course, the third stage must be facilitated. The therapeutic plan laid down above will serve to limit the amount of pus-formation and tend to concentrate it to one point for evacuation. The hot fomentations should be continued, as well as the counter-irritation by the iodine. It will probably be observed that the patient has rigors of more or less severity, followed by rise in temperature. These symptoms should be looked upon as an indication of pus-formation. The patient should be examined from time to time by the digital touch per vaginam and by the combined vagino-hypogastric palpation for the purpose of determining the presence of an abscess and its location, so that the proper treatment may be applied and at the proper time.

These examinations must be conducted with the greatest care and gentleness, and the patient protected from undue exposure. When the disease has advanced to the third stage means for the disposition of the pus should be kept constantly in view, and the case treated as one of pelvic abscess.

Treatment of Pelvic Abscess.—Authorities differ widely as to the proper method of disposing of the contents of a pelvic abscess. Some [p. 223] favor a let-alone plan, believing that Nature is competent to relieve herself more effectually and better than art can do; others, equally eminent, believe that the pus should be evacuated when pointing has positively occurred and made the evacuation easy and safe; while others, again, more radical in their views, believe that much can be gained by liberating the pus as soon as it is known to exist, although it may be deep-seated and as yet have shown no tendency toward pointing.

The same therapeutic principle should guide us in the management of a pelvic abscess that we would unhesitatingly apply in the treatment of an abscess in any other portion of the body. It is a settled law in surgery that if a pus-cavity is evacuated and not allowed to burrow, much tissue may be saved, the duration of the disease shortened, and the prognosis rendered more favorable. I believe that the pus should be liberated promptly as soon as it is certain that an abscess has been formed and can be reached without danger to important structures—emphatically so when the way is being pointed out. True, Nature is competent in some instances to discharge the accumulation, and usually by the least dangerous channel. But it is also true that in many other cases she is not. Instead of taking the shortest, most direct, and safest course to the surface, the pus frequently takes the most indirect route, riddling and destroying the tissues in its track; or it may rupture into the bladder or peritoneal cavity, in the latter case to be followed by death from peritonitis. Evacuation of the pus by artificial means when the way has been shown, if done carefully by aspiration, is attended with almost no danger. Where, on the other hand, the abscess is deeply seated and there is no tendency toward pointing, the question of evacuation becomes one requiring great deliberation; for the dangers of puncture increase as the thickness of the tissues to be traversed in reaching the abscess is greater. But, even though the pus be deeply located, when a positive diagnosis of its presence can be made I still favor early evacuation. Mere exploratory puncture in the hope of finding pus is a most dangerous practice, and should not be thought of in connection with pelvic abscess. Delay, even at the risk of spontaneous rupture, is the proper course until the diagnosis can be rendered positive; for when the abscess is deep-seated the progress of the disease is often slow. Of course the condition of the patient should always be taken into account in deciding the question whether or not to interfere. If signs of septic absorption appear, or evidences of constitutional failure become prominent in spite of the means used for staying the progress of the disease, prompt measures must be taken to get rid of the product of the inflammation. The strongest argument in favor of early operative evacuation of the abscess is the danger that the disease may become chronic when the pus is not promptly discharged. Many cases have occurred in which abscess after abscess had been formed and discharged, until the patient became a mere wreck of her former self, and finally died from septicæmia or exhaustion. This is the result of non-interference. I am so fully convinced of the value and necessity of operative measures in the treatment of pelvic abscess that the following questions at once present themselves to me when called upon to decide in a case where spontaneous evacuation has not already taken place: 1st. When shall the abscess be opened? 2d. Where shall the opening be made? and 3d. How shall the operation be done?

The first of these questions has been answered in a general way by the preceding remarks, and it is only necessary to add here, by way of recapitulation, that the time for opening the abscess will depend upon its location and the condition of the patient. If the pus is near the surface and can be easily and safely reached, whether pointing has occurred or not, it is ripe for evacuation and should be liberated at once, even though the patient be in the best possible condition and show no evidence of deleterious effect from its presence. Nothing whatever can be gained by permitting it to open spontaneously, but much may be lost. If, however, the situation of the abscess be such that it would be necessary to traverse healthy tissues to a considerable extent in order to reach it, and the patient shows no evidence of septic absorption, it would be highly injudicious to attempt to open the abscess: first, because under the circumstances you could not be positively certain that a collection of pus existed; and, secondly, because it is doing no harm. Delay, with careful observation, is now the proper course. Within a few days the apparent abscess tumor may either show decided signs that it is diminishing in size and undergoing resolution, or it may approach the surface, so that evacuation will become safe. On the other hand, should symptoms of blood-poisoning develop and the patient show signs of rapid exhaustion, our attitude must be one of action instead of delay. The pus must then be liberated even at some risk. I still insist, however, that a positive diagnosis must be established, and that the operative measure shall be in no sense exploratory.

2d. Where shall the opening be made? This question is often decided for us by Nature. The puncture, as a rule, should be made where pointing has occurred. If pointing has not occurred, a position from which the abscess can be most easily reached through the vagina or abdominal wall should be selected. The vagina should be given the preference, because the opening would then be at the most dependent portion. The rectum should not be selected as the channel through which to evacuate the pus artificially, although spontaneous discharge into that tube occurs almost as frequently as into the vagina. The patient does not recover as quickly, however, when the abscess opens into the rectum, and more cases of septic poisoning occur from decomposition of the pus as a result of the entrance of air and fecal matter into the abscess-cavity. Further, it may become necessary to keep the opening patulous and to wash out the cavity of the abscess. This could not be done properly if the opening were in the rectum. I believe it to be the best practice to open from the vagina rather than from the rectum, even at greater risk to intervening structures, because it may greatly facilitate the after-management of the case.

If the tumor should be located high up in the iliac fossa or in the hypogastrium, the point of election for opening must be somewhere on the abdominal surface in the region of the abscess.

3d. How shall the operation be done? The opening of a pelvic abscess should never be regarded as a simple operation. As much care and deliberation should be taken in the selection of the proper method of evacuation of the pus, and in the operation itself, as was previously given to the diagnosis of its presence. Always begin with the administration of an anæsthetic. This not only protects the patient from unnecessary mental agitation and physical pain, but it better enables the [p. 225] physician to confirm his previous opinion of the case, as well as to be more deliberate in the election of the point of puncture. With the patient in the dorsal position, if it be determined that the pus is contained in a single cavity, and there be no evidence of its decomposition, shown by the absence of symptoms of systemic poisoning, it should be liberated by aspiration. By this means a smaller puncture will be required and the entrance of atmospheric air prevented. If, happily, the operation has been performed early, before the formation of the so-called pyogenic membrane, or at least before sinuous tracts have resulted from burrowing, the abscess-cavity may then collapse and disappear. But should the patient not improve after the pus has been removed, or should the cavity again fill up, it is probable either that there is another pus-cavity, which had not been reached by the trocar, or that there has been developed on the internal surface of the sac an unhealthy fungous, granular condition. Under these circumstances a free incision should be made into the cavity of the abscess, so that a drainage-tube may be introduced and the cavity washed out by an antiseptic fluid. The opening should then be kept patulous, so that healing can take place from the bottom of the sac. It may become necessary to introduce a finger and scrape away with the nail the fungosites from the wall of the sac. But great care must be used in this manipulation, as well as in making the incision, for there is danger of wounding large blood-vessels and of rupturing the wall of the sac. If the cavity be now kept pure by daily injections of a 1:1000 solution of the bichloride of mercury or of a 2½-5 per cent. solution of carbolic acid, its surface may become healthy, the secretion diminish, and the sac close up.

The best method of washing out the cavity is by the fountain syringe, to which a long double canula can be attached; or, probably better, the syphon. It would be unsafe to force water into the sac.

It is well for the patient if the situation of the abscess be such as to render its evacuation through the vagina feasible, for then the opening is made at the most dependent portion, and consequently drainage is more easily and thoroughly accomplished; but, unfortunately, the location of the tumor may be so high up as to compel the removal of the pus through the abdominal wall.

Almost the same rules as to the selection of the method of operating and of the election of the point for puncture or incision will apply here as in the operation through the vagina, provided pointing has taken place. I am less favorable to aspiration, however, when the puncture must be made through the walls of the abdomen—first, because reaccumulation is almost certain to take place; and, second, because there is danger of leakage of pus into the peritoneal cavity, since it is difficult by this means to thoroughly empty the sac, and impossible to wash it out and keep it drained.

If pointing has occurred, a free incision should be made at once and the cavity thoroughly emptied, and, if necessary, washed out. The opening must not be permitted to close until the cavity has healed from the bottom.

Where pointing has not occurred and the abscess is so deeply seated that it cannot be safely reached from the vagina, and does not distend the abdominal walls, I would urge greater delay, in the hope that it may [p. 226] approach the surface more nearly. If, however, the condition of the patient be such as to demand immediate action, the operation of laparotomy should be selected as the more thorough and less dangerous method of releasing the pus and of after-treating the abscess.

An incision two inches in length should be made through the linea alba, midway between the umbilicus and pubes, and, after all bleeding is stanched, the peritoneal cavity opened. The index finger should then be passed in and the surface of the abscess-wall explored. It will be a fortunate circumstance if the sac be found adherent to the peritoneal surface, where the incision is made, for it can then be opened without entering the peritoneal cavity. To prevent the escape of pus into this cavity the sac should now be evacuated with great care. For this purpose the aspirator is well adapted, but a small trocar, to which a few feet of rubber tubing has been previously attached, through which to conduct the pus into a convenient receptacle, will answer almost as well. The opening in the sac should next be slightly enlarged by an incision (not torn); it should then be included in the sutures, which are now placed to close the abdominal wound. After the sutures have been introduced the pus-cavity should be washed out with the bichloride or carbolic-acid solution, and a glass drainage-tube placed in the lower angle of the incision, when the edges can be brought together and adjusted around it.

The after-treatment required will be the same as if the opening had been made through the vagina.

The sac must be made to close from the bottom. It may become necessary to stimulate the surface by the injection of a weak solution of nitrate of silver, four to eight grains to the ounce of distilled water, or with the tincture of iodine, one part to four of water.

Cases are sometimes met with in which the pus has burrowed and formed sinuous tracts which are difficult to reach and drain. It may then be necessary to make a counter-opening in the vagina after first cutting through the abdominal wall. These are usually old, neglected, chronic cases, in which the abscess has discharged spontaneously into the bowel too high up to be properly emptied, or which have opened into the bladder or somewhere on the abdominal wall, or possibly taken one of the circuitous routes alluded to under the head of Pathology.

No fixed rule can be set down for the management of these grave cases. Each one must be treated on its individual merits. A ripe experience and judgment are necessary here to decide whether it is best to operate or to pursue a course of masterly inactivity, depending upon the use of hygienic and tonic remedies and time to bring about a cure. I have known instances where patients have recovered spontaneously after having been reduced to the lowest extremity. I have also known others who have died soon after submitting to operative interference. Some of the spontaneous recoveries, however, are only apparent, for the old sinuses often reopen and discharge pus as before, or the pus may be discharged at some new and remote point, the patient finally succumbing to the ravages of a disease from which she flattered herself she had escaped.

The most careful attention must be given to the hygienic surroundings of the patient, the diet liberal and of the most nutritious character. The appetite should be sharpened by the administration of the bitter tonics, [p. 227] the best of which is probably the old tincture of bark (Huxham's). Quinine should be given in doses sufficient to control the temperature when necessary, and for its tonic properties. The blood should be improved by the exhibition of iron, arsenic, and the bichloride of mercury in the form of the mixture of the four chlorides, first used, I believe, by Tilt of London. There can be no doubt as to the value of the combination in cases of plastic exudations. The following is the formula which I am in the habit of using:

M.—Sig. Dessertspoonful, well diluted, after meals.

The dose of the arsenic and bichloride of mercury can be increased, after it is found that the mixture does not disagree with the stomach, to six drops of the former and a sixteenth to a twelfth of a grain of the latter. The effect of the medicine must be carefully watched, however. After the remedy has been taken two weeks it should be discontinued and some other form of tonic substituted for a week or two. The syrup of the iodide of iron, or the iodide of iron in pill form, will serve well as the substitute. If the patient should tire of the above or the remedies should not agree, some other form of tonic must be given. I have found the following an excellent tonic pill:

M. et ft. pil. No. xlviii.—Sig. One to two pills after each meal.

As soon as practicable the patient should have a change of air and scene.

Having treated the subject of inflammation of the pelvic tissues generally, in the acute form, under the head of Parametritis, with sufficient fulness to answer the purposes of the practical physician, whether the disease dominate the connective tissue or the peritoneum covering it, I shall, under the head of Perimetritis, consider the subject in its chronic aspect principally.

DEFINITION AND SYNONYMS.—I have defined parametritis to be an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds—viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. I cannot more clearly or more simply define perimetritis than by stating that it means an inflammation of the peritoneum [p. 228] which serves as a covering and boundary-line for the connective-tissue spaces involved in parametritis. As the term parametritis is used to conveniently express the idea of the existence of an inflammation in the connective tissue near the uterus, so the term perimetritis conveniently and tersely expresses the idea that the inflammatory process exists around the uterus in the pelvic peritoneum. In the acute form it is difficult to differentiate between them clinically, nor is it necessary, from a therapeutic standpoint, to do so. The term perimetritis is synonymous with pelvic peritonitis.

ETIOLOGY.—All of the causes which have been enumerated as capable of producing parametritis may be included in the etiology of perimetritis. If, however, the great predisposing causes of the former—abortion and injury at parturition—be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. Parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. Perimetritis, on the other hand, is frequent in the single and sterile woman. But, as a rule, it does not run the same typical acute course. It is usually subacute or chronic from the beginning, and results in the formation of false membranes which bind the pelvic organs to one another.

Perimetritis of the adhesive form may be produced by the pressure and irritation resulting from displacement of the pelvic organs, as retroflexion of the uterus, incarcerated fibroid or ovarian tumor, prolapse of the ovary and Fallopian tube, fecal impaction, and from ill-fitting and improperly-adjusted pessaries. Under these circumstances the disease usually comes on insidiously, with no acute symptoms, and runs a slow course. It may be discovered accidentally when making an examination on account of pelvic pain obscure in character, or when the attention has not been called especially to it by the presence of specific symptoms.

Perimetritis may result from regurgitation of menstrual fluid through a too patulous Fallopian tube. This is most likely to take place when the egress to the flow has been prevented by a flexion of the uterus sharp enough to practically destroy the calibre of the cervical canal, as when the organ has become retroflexed from subinvolution or some other cause of hypertrophy of the body of the organ. It may, however, occur as a result of the intense engorgement which sometimes attends acute suppression of the catamenia. It may occur from disease in the tube itself, as where a collection of pus or serum has been formed and thrown into the peritoneal cavity either from rupture of the tube or discharge through the natural opening at the fimbriated extremity. Or it may result from hemorrhage following the rupture of a Graäfian follicle, especially where the disease of the tube has resulted in the destruction of its calibre or the power of the fimbriæ to grasp the ovary so as to convey the discharge safely to the uterine cavity. Hemorrhage from any other source, as from the rupture of a blood-vessel or of an extra-uterine gestation-sac, usually results in the development of perimetritis.

Coitus is capable of causing perimetritis when the act is awkwardly performed, or where there is a disproportion in the relative sizes of the organs involved, or where the physiological mechanism of copulation is destroyed by displacement of the uterus, free mobility being lost as a result.

According to Noeggerrath,⁴ a very common cause of perimetritis is what he is pleased to call a latent gonorrhoea in the male. He believes that the disease, once contracted, is probably never entirely eradicated, but that it always exists in a latent form, and that it is capable of producing a specific inflammation of the pelvic peritoneum years after an apparent cure had been effected. It is of course impossible to positively verify this, although he gives some very striking cases in support of his position. That gonorrhoea in the acute form may extend by propagation from a vaginitis through the uterine cavity and Fallopian tubes to the peritoneum, and produce an inflammation of that membrane, is probable. Cases have been met with where a history of specific infection was undoubted, in which an attack of perimetritis followed soon after the initial symptoms and physical signs of gonorrhoea were manifested. But it is quite another thing to believe that the specific poison may remain latent and harmless in the genital system of the male to be transferred years afterward to that of the female.

⁴ "Latent Gonorrhoea, etc.," Trans. Amer. Gynæc. Soc., vol. i. p. 268.

Tuberculous or carcinomatous disease of the pelvic organs is nearly always complicated by a certain degree of perimetritis.

Perimetritis may result from external injuries, as blows, kicks, and the like; and under the head of traumatic agencies most of the causes which have been enumerated would stand as examples; but under this head I wish also to emphasize the statement that I believe that perimetritis may result from an unwarranted and unnecessary force used on the part of the physician in his efforts to outline and locate the position of the pelvic organs, especially that of the ovaries and tubes. When the latter organs are in their normal position and not enlarged, it is usually impossible to outline them by the bimanual touch, nor is it necessary. When they are diseased the greatest care in manipulation should be used; and it is often best to administer an anæsthetic, so that less force may be necessary to determine their exact condition. The disease may also result from injury inflicted in the medication of the uterine cavity and in the various operations on the uterus. A most prolific cause is induced abortion.

Recurrent perimetritis should be regarded as the result of the persistence of one of the above-mentioned causes. It sometimes recurs with each menstrual period. Such attacks are often associated with dysmenorrhoea of the congestive type.

PATHOLOGY, COURSE, AND TERMINATION.—When the pelvic peritoneum becomes inflamed, and the disease runs through an acute course, the pathology and termination will be much the same as that described under Parametritis, for the connective tissue will then be involved in the process, as well as the peritoneum; not to the same extent, however, as when the disease begins as a cellulitis. The position of the exudation tumor, should one form, will be more directly posterior to the uterus in Douglas's cul-de-sac; it is sometimes larger, and may displace the uterus far forward. This is more especially the case where the disease has advanced to the third stage and resulted in abscess.

In the subacute and chronic forms of the disease the course is usually a slow one. The exudation soon becomes plastic, or is so from the beginning. This leads to the agglutination of the pelvic organs to one another, and finally to the production of organized pseudo-membranes [p. 230] of more or less strength. If the Fallopian tubes and ovaries are displaced, which is frequently the case under these circumstances, they are bound more or less firmly in the abnormal position. The adhesions are sometimes extremely delicate, and embrace the displaced organs as a net. At other times, or later, they may be so large and firm as to be readily felt through the vagina. Again, the false membranes may be broad and ribbon-like, and occupy a position so as to imprison the displaced organs as though elastic bands were stretched from the anterior to the posterior portion of the pelvic brim. When Douglas's cul-de-sac is bridged over and shut off from the abdominal cavity proper, serum or pus, sometimes both, may collect within it and give rise, from its round, fluctuating character and rather insidious formation, to the supposition that it is an incarcerated ovarian cyst; especially so since it may progressively increase in size and attain such dimensions as to distend the abdominal walls. This course of the disease is rare, however.

Under favorable circumstances the course and termination of chronic pelvic inflammation would probably be much the same as where the disease is acute—i.e. it would run its natural course and end in resolution by absorption of the effused product. But, unfortunately, the symptoms of the disease are not violent enough to compel the patient to go to bed and remain at rest, so as to place the organs in the most favorable condition for recovery. The affection comes on so insidiously sometimes that when the patient is finally compelled to seek relief it may be found that extensive adhesions and considerable displacement, if not serious disease—especially of the ovaries and Fallopian tubes—exists. The inflammatory process is progressive, and will continue to be so until its cause shall be rendered inactive by the continuous and increasing severity of the symptoms, which force the sufferer to give up the struggle to remain on her feet and pursue her usual round of duties.

SYMPTOMS.—If the attack is acute the subjective symptoms of perimetritis will differ from those described as belonging to parametritis only in the greater violence of their onset and progress. The pain, which is usually preceded by a chill, is likely to be sudden, sharp, and persistent—sometimes agonizing. The pulse, especially during the first stage of the disease, is small, wiry, and quick, ranging from 120 to 140 beats per minute. But its character is likely to change as the affection progresses, and to become full, as when the connective tissue is the seat of the inflammation. The temperature also reaches a higher point, rising frequently as high as 104°-105°, sometimes even higher.

When the disease is chronic from its commencement, the pain is more obscure, and cannot so certainly be relied upon as a diagnostic sign. True, a sharp pain existing low down in the pelvis in either iliac region—pain persistent in character and coming on rather suddenly—should always direct attention to the probable existence of an inflammatory condition. The pain of chronic pelvic inflammation is not attended with the rise in temperature and acceleration of pulse which have been described as accompanying the acute form of the disease. There is, doubtless, a slight degree of increase in both, but not enough to attract attention as a rule. There may be many reflex symptoms, chief of which are irritability of the bladder and stomach, the latter manifesting itself in nausea and sometimes vomiting.

PHYSICAL SIGNS.—Physical examination may reveal no evidence of exudation or of the presence of an inflammatory condition, and may lead the physician to infer that the attacks are not inflammatory in character, but that they are of a neuralgic nature. As a rule, however, examination will show a thickening or an absence of the usual mobility of the surfaces, and deep pressure may elicit considerable tenderness. On the other hand, the physical signs may be marked, and the surfaces may be felt to be quite thickened and very rigid, so that it will be evident that there is exudation on the surface of the peritoneum. Usually, the vaginal examination reveals a fixation and induration posterior to the uterus. If that organ is retroflexed, it is bound firmly in that position. If the uterus is in its normal position, there will not usually be the same amount of fulness posteriorly. If an ovary and Fallopian tube have been displaced, it will probably be fixed in the post-broad-ligament space or in the cul-de-sac of Douglas. The pelvic roof, so called, may be found as hard and tense as a deal board, as was first described by Doherty. The exudation may be so great as to displace the uterus forward or laterally, and to fix it as though it were surrounded by hardened lymph. This is especially felt in the post-uterine space, gluing the uterus, ovaries, tubes, and broad ligaments together. If there is a small ovarian or fibroid tumor, it may be likewise fixed in this posterior position.

A later examination may show a change in this condition. The exudation material may have been reduced by absorption, or there may have been an increase. If the latter, the disease will probably run an acute course and end by resolution or suppuration—more likely the latter—and practically it will then run the course described under the head of Parametritis.

DIAGNOSIS.—The diagnosis of perimetritis is made with comparative ease. The subjective symptoms are sometimes obscure, but the physical signs are perfectly plain. When there is exudation posterior to the uterus, especially if it has bound the organ in a retroverted position or incarcerated a foreign body, it is almost absolutely certain that agglutination is due to peritoneal exudation. This exudation is, as a rule, not so extensive as that which occurs in parametritis, and if a tumor is present—which is uncommon—its location is different. Where a tumor is present as the result of pelvic inflammation, I think that it may be safely ascribed to connective-tissue inflammation rather than to peritoneal. On the other hand, where there is simply agglutination, and where the effusion seems thin and spread out, the organs and ligaments rigid and thickened, instead of a somewhat circumscribed tumor, the disease may be ascribed to perimetritis rather than to parametritis. Where the condition just described is found there can be no doubt as to the existence of perimetritis.

A small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid tumor, fecal impaction, and hæmatocele might be mistaken for this disease, but these tumors are, as a rule, more or less circumscribed, while the exudation due to perimetritis is not often so. Perimetritis, however, may coexist with any of the conditions just mentioned. These tumors may be bound to adjacent tissues, forming one large mass, as the result of intercurrent attacks of perimetritis. In such cases the peritoneal inflammation would exist as a complication.

PROGNOSIS.—When the inflammation is acute, or where the peritoneum becomes largely involved, the disease may run a very violent and fatal course. Those cases in which pelvic inflammation is of such severity as to cause death are usually of this character. As a rule, however, the prognosis, so far as life is concerned, is favorable.

The prognosis regarding the restoration of the ligaments and the thickened surfaces to their natural condition, and the restoration of the displaced organs which complicate the disease, will depend upon the extent and duration of the affection and upon the treatment. As a rule, the prognosis is good where the patient has sufficient courage and fortitude to submit to a prolonged course of treatment, with the abstemious habits of life which may be necessary.

TREATMENT.—In order to present systematically the therapeutics of perimetritis it should be divided into the acute and chronic forms, and the treatment of the latter form will necessarily include to a certain degree the management of the complications. All that has been said under the head of the treatment of parametritis will apply to the treatment of acute perimetritis. As the symptoms of acute perimetritis are ushered in with greater violence than where the connective tissue is simply involved, so the remedies for the relief of these symptoms must be more vigorously applied. The patient must be placed at absolute rest, and be kept there, for the favorable termination of the disease will be largely dependent on the faithfulness with which this measure is carried out. The pain, which is usually great and acute in character, must be relieved at once by the administration of morphia subcutaneously in full dose, and the remedy is to be repeated until the pain is under control, when the effect of the drug may be maintained by the administration of opium in the form of suppositories containing one grain of the aqueous extract. As in the treatment of parametritis, so here, I insist upon the administration of the drug by the above method, rather than by the mouth, because nausea and interference with the function of digestion are less likely to follow.

In the peritoneal form of pelvic inflammation the pulse is usually more rapid and the temperature higher than where the connective tissue alone is involved. Both of these symptoms may be controlled by the free administration of opium. If this is not successful, a resort to the tincture of aconite in small and repeated doses will be indicated. If necessary, quinia should be administered. This remedy, however, should not be given unless the temperature remains persistently high; and, as advised under the head of Parametritis, the dose should not be less than ten grains, repeated in from four to six hours if the temperature is not decreased. The action of the tincture of aconite should be carefully watched, and if its administration is not soon followed by a lowering of the pulse-rate, its use should be abandoned.

If the disease is of a marked sthenic character, the local abstraction of blood by the application of leeches to the hypogastrium is often of great benefit, and poulticing should be most faithfully and persistently carried out, together with hot applications to the lower extremities in the form of hot water, as previously directed. I strongly recommend the application of heat to the hypogastrium in preference to cold. If the patient be seen quite early in the first stage of the disease, which is unusual, the application of cold might be more beneficial than heat; but when the [p. 233] process has advanced toward the second stage, that of exudation, the application of heat will facilitate this process, while cold would probably retard it.

By the above plan of treatment—viz. the immediate relief of pain by full and repeated doses of morphia—it is possible to arrest the disease in the first stage, but this is not the rule. It usually advances to the second stage, that of exudation, if it has not already reached this stage before the patient is seen. A vaginal examination may now show the uterus to be fixed, but there may be an entire absence of tumor. Should an exudation tumor exist, it will probably be found posterior to the uterus, crowding that organ forward rather than laterally, as would be the case were the inflammatory process seated in the cellular tissue; or, what is oftener the case, we have mere fixity of the organ, with thickening of the pelvic peritoneum lining Douglas's pouch and the posterior surface of the broad ligaments. Later an exudation tumor will more likely be found. If this is so, it should be inferred that the connective tissue has become largely involved in the process, and it should rather be expected that the disease will pass through the regular course of pelvic inflammation and advance to the third stage, that of suppuration, as though the disease had originally begun as a parametritis. It should then be treated on the general principle laid down for the management of that form of pelvic inflammation. The case should, however, be regarded with greater solicitude as to prognosis where the peritoneum has been largely involved, and the symptoms should be more carefully watched and counteracted by the application of the proper remedies. There is in such cases more danger of the disease spreading and involving the peritoneum generally, and of course becoming an affection of great gravity. When the peritoneum is largely involved, tympanites, as a rule, becomes a troublesome symptom, more especially if the disease has occurred during the puerperal period, and it requires special attention. The remedy which I have learned to rely upon in the treatment of this troublesome complication is turpentine, administered preferably by enema.

Should the disease advance to the suppurative stage, the case then becomes one of pelvic abscess, and should be managed on the principle enunciated for that stage of the disease. (See Treatment of Pelvic Abscess.)

Treatment of Chronic Perimetritis.—When the disease exists in its chronic form, the uterus, ovaries, and Fallopian tubes may be found fixed either in the normal position or in some form of displacement, usually the latter. The peritoneum lining Douglas's pouch, as well as that covering the uterus, broad ligaments, tubes, and ovaries, will be found more or less thickened, or the ovaries and tubes may be prolapsed and retained by false membranes; or the uterus itself may be retroflexed and fixed by adhesion of the peritoneal surfaces lining Douglas's pouch and that covering the uterus; or false membranes may have been formed so as to roof over the pelvis, thereby incarcerating the uterus and its appendages within that cavity. This condition gives rise to pains which are rather diffused throughout the pelvis, at one time affecting the ovarian region in which the disease exists, and at another being experienced low down in the pelvis and radiating along the course of the sacral nerve down the posterior portion of the thigh, always sharp and distressing in [p. 234] character. Where the ovary and tube are involved the pain usually radiates to the groin and anterior portion of the thigh. Examination should be conducted with great care, because, although the uterus and its appendages seem to be fixed firmly, there are often new adhesions forming or weak ones existing which may be easily severed; and this especially applies to manipulation of the ovary and tube, the adhesions of which are, as a rule, not so firm as those fixing the uterus.

The management of these cases must of course be different from that of the acute form of the disease. The patient often suffers from nervous exhaustion, indigestion, and loss of flesh as a result of the long suffering which she has endured during the course of the disease. I believe that here the most efficacious plan of treatment is that which embraces REST as its guiding principle, for the disease probably had its origin in over-exertion and derangement of the proper relations of the organs one to another, as in those cases in which it is developed as a result of prolapse or retroflexion of the uterus or the ovaries, or from the presence of a tumor incarcerated in the pelvis, which displaces and holds in malposition the above organs. It is unquestionably true that where the patient is allowed to exercise and follow her usual avocation the attrition of the inflamed surfaces upon each other will tend to keep up the inflammatory condition. It is my plan, where I can get the consent of the patient, to place her at absolute rest, and begin the treatment by paying strict attention to the evacuation of the bowels, for constipation is one of the most troublesome accompaniments of perimetritis. It often stands in a causative relation, and nearly always as a complication of the disease; and of course first attention should be paid to the relief of this condition.

Strict attention should be paid to the diet. The food should be of the most nutritious character, calculated to improve the digestive organs, and through them to build up the general system.

The Local Treatment.—The local treatment should embrace those remedies which are thought to possess the power of producing absorption of plastic material, either by a counter-irritant or stimulating action. The persistent use of the tincture of iodine, both to the hypogastrium and to the fundus of the vagina opposite the seat of exudation, is of great value. Where the iodine is found to be so irritating to the skin as to make it necessary to discontinue its use, and also for the relief of pain, I have found the following formula very useful:

Sig. Poison. To be applied externally as directed.

This may also be applied to the fundus of the vagina instead of the iodine alone, either by a camel's-hair brush or by the cotton-wrapped uterine applicator. The vaginal application of iodine should be made not oftener than once in three days, and sometimes a longer interval is advisable, especially if the remedy is used in a concentrated form. If it is found that irritation or ulceration has been produced, its use must be discontinued for a time, and remedies of a milder form substituted, as, for instance, the application of iodoform and glycerin (one drachm to the ounce), or of glycerin alone on the cotton tamponade.

In the intervals between the application of iodine and the other remedies the hot-water douche should be used daily. When the hot water is administered the patient must be in the recumbent position. I am opposed to indiscriminately advising walking patients to use hot water, because, as a rule, it is not given as intended—that is, hot and in large quantity—and the object for which it has been recommended is not attained. The water is either used at too low a temperature or in too small a quantity, or both. When administered by the patient herself she becomes tired of the pumping and of the position which she must assume, and fails to keep it up during the length of time required for the injection of the quantity of water usually advised—that is, a gallon or two—and the constrained squatting position is of itself injurious. I believe that the long-continued use of hot water is followed by relaxation of the pelvic organs, and this would constitute another objection to the indiscriminate recommendation of this measure, for when it is placed in the patient's hands she is apt to continue its use for too long a period. The remedy is no doubt most efficacious in the treatment of these chronic cases of pelvic peritonitis, and great credit is due Emmet for introducing it to the profession. It should, however, be administered in accordance with fixed rules and under certain restrictions, and these I would class as follows: 1, the patient must always be in the recumbent posture; 2, she must not administer the injection herself; 3, the water should be at a certain temperature, which is best determined by the sensations of the patient. It should be used as hot as can be easily borne, and the temperature gradually increased during the administration of the injection, for the patient will be able to bear it at a higher temperature after the current has been flowing a few minutes than when the application is first made. I believe that the douche is better than pumping, as by Davidson's syringe, because the application is more likely to be thorough and the effect to be maintained longer, for even when the injection is given by the physician or nurse the hand is apt to become tired and the application stopped, for a time at least. It is the continuous application of the remedy which is beneficial. In other words, the organs should be kept as it were in a hot bath. For use in my private hospital I have had constructed a tripod five feet high, with a hook in the centre on which a bucket is easily hung. This bucket holds two gallons of water, and near the bottom is placed a stopcock, to which is attached a tube provided with a nozzle and stopcock at its distal end. The patient is placed on a bed-pan, which is modified after that devised by Meriman. The nozzle is then introduced into the vagina, and the stopcock at the bucket turned by the nurse, the water being at a temperature of at least 110°. The patient can then regulate the flow herself. The water is allowed to enter the vagina, dilating it and flowing off slowly, so that the tissues are in a continuous hot bath, which may be kept up as long as desired—from ten minutes to an hour—care being taken to see that the proper temperature of the water is maintained by the addition of a fresh supply from time to time. The important point is not so much the amount of water as its temperature and constant contact. If the vagina could once be filled to distension and the temperature kept up, it would not be necessary to renew the water, but to keep up the temperature a regular flow of hot water must be provided for. The rapidity of the flow may be regulated by the stopcock. The [p. 236] application of this remedy should be made once or twice a day, depending on its effect upon the patient.

After all tenderness has subsided much may be accomplished by gentle massage of the pelvic organs. This is best carried out by the introduction of one or two fingers of the left hand into the vagina, while the right hand is placed upon the hypogastrium; then the contracted ligaments, thickened membranes, and fixed uterus, ovaries, and tubes should be gently manipulated and moved from side to side or upward and downward, care being taken that the force used is not sufficient to lacerate adhesions or even to so stretch them as to cause their irritation. The proper amount of force is best regulated by the sensation of the patient, and if pain is produced by the manipulation it should not be persisted in. This massage may at first be employed at intervals of two or three days, but later it may for a time be used almost daily, and it will almost invariably be found that the organs gradually become more mobile—that the adhesions become attenuated, and in many cases finally absorbed. On the other hand, adhesions of such size and strength may exist that many months may be required to produce any marked effect, and in some cases the adhesions may be of such a character as to be permanently organized and almost incurably fixed.

I have also found the stretching of the fundus of the vagina by firmly packing it with absorbent cotton, sometimes repeated almost daily or at intervals of two, three, or four days, of great benefit in stretching the adhesions and promoting their absorption. Sometimes, where adhesions are persistent, the use of the rubber colpeurynter distended with hot water is of value.

Where there is a foreign body, as a tumor, fixed posteriorly to the uterus, or where the uterus is fixed in a retroflexed position, the patient may be placed in the knee-chest position, Sims's speculum introduced, and the vagina packed with cotton while the patient is in that posture; or, instead, the vagina may be simply distended with air. The air may be admitted by the introduction of Campbell's glass tube or by the separation of the walls of the vagina with the fingers, which may be done by the patient herself. These measures are often of decided benefit.

I wish to repeat what has already been stated, that the treatment of chronic perimetritis, to be carried out successfully, requires that the patient should be in bed and placed under such circumstances and surroundings that the physician may be enabled to pursue personally the plan of treatment. Of course much will be gained if he is aided by a trained nurse. This in many cases involves the removal of the patient from the cares of her home.

Advantage may often be derived from the application of small blisters to the hypogastric and iliac regions, the counter-irritation being kept up almost continuously for two weeks at a time. The blisters should not be larger than two inches square, and should be moved from place to place; for instance, one blister may be placed on the hypogastrium, and before this has healed a second should be placed one side of it. This should be kept up for two weeks at a time, or until four or five blisters have been applied, when, if benefit is to follow, it will be apparent.

When the organs which are agglutinated to one another become more mobile, and the thickened membranes more flaccid, much benefit [p. 237] sometimes results from the application of a pessary if a displacement of the uterus, ovaries, or tubes exists and persists; but before the use of this instrument is thought of, it must be positively ascertained that no tenderness remains as a result of the inflammatory process; the inflammation must have entirely subsided, the effects alone remaining. It is sometimes advised that an instrument large enough to constantly stretch and over-stretch the false membranes and adhesions is advisable. It has also been recommended to over-stretch these adhesions by manipulation. Of the two, I much prefer the latter method; that is, stretching by manipulation rather than by continuously acting upon them by means of a pessary large enough to stretch the vagina and through it the adhesions. In stretching by manipulation, with the patient under ether, you have your own sense of touch to guide you, and the action of your efforts ceases with the cessation of the manipulation, while that carried out by means of a pessary is continuous and may result in great harm from irritation, if not from ulceration of the vaginal surface from pressure; or it may result in rupture of the adhesions. If a pessary is adjusted, it should be used, not for the purpose of over-stretching adhesions, but simply for its stimulating effect on the pelvic circulation, or as a support to the pelvic circulation rather than as a support to the uterus. A larger instrument should not be used than one which will occupy the vagina without stretching it—simply unfold any doubling up which may have resulted from retroversion or prolapse of the uterus—and its action should be carefully watched. It should be learned, not from the sensation of the patient, but from actual examination, that it is not making undue pressure; this examination should be made daily at first, and afterward at longer intervals. The use of the pessary should be discontinued as soon as possible. This statement should be qualified by saying that the words as soon as possible mean when all symptoms have subsided, and the uterus and other organs are maintaining a normal or nearly normal position, or when the pessary seems to have ceased to be of value. It may then be removed on trial.

There is a method of using the pessary, in which it is advised that the instrument shall be large enough to span the angle of flexion which may exist, for the purpose of making pressure on the fundus of the uterus, which is incarcerated in the cul-de-sac of Douglas by adhesions between its peritoneal surface and that lining the sac. This I believe to be a bad principle, for an instrument long enough to do this must either take its point of support against the pubic arch or from an external attachment—a principle of using the pessary which should be most emphatically condemned.

The above treatment should be carried out with the patient in bed, if possible, during which time general measures for the improvement of the muscular and nervous system should also be employed. The application of electricity to the thickened peritoneum and adhesions is another measure which should not be allowed to pass without comment. Much good may be done by the daily application of faradism, with one electrode in the vagina and the other on the hypogastrium, and continued for from fifteen to thirty minutes. I have thought that in some cases great benefit followed this application. Galvanism is also of service, and by some is thought to be of more value than the faradic current.

The time for getting up should be determined by the results of treatment; usually a period of from four to six weeks is sufficient to determine whether or not the treatment at absolute rest is going to be of benefit. Of course it is not to be understood that cure will follow in severe and long-standing cases within this period, because if this hope is entertained disappointment will follow nearly always. What we hope and expect to attain is rest, both physical and physiological, during which time local treatment can be carried out with greater facility and thoroughness and the general condition improved. As a rule, the ligaments soften, the false membranes become attenuated, and during the time stated the patient is very much benefited, and sometimes cured. She should now begin to sit up and to exercise moderately; the amount of exercise should be regulated by its effect. If pain follows walking or riding, it should not be persisted in until such time as exercise can be taken without the production of these symptoms.

There are no specific remedies for internal administration. The general medication of the patient should consist in the use of such remedies as we have learned to depend upon as capable of building up the blood and nervous system, embracing especially that class of tonics which are said to have the power of inducing such changes in plastic material as favors its absorption. To this class belong the chlorides, as the chloride of arsenic, the chloride of iron, the chloride of ammonium, and the bichloride of mercury. These remedies should be placed at the head of the class. The next are the iodides, as the iodide of iron, the iodide of potassium, and the bromide of potassium. Whether or not these remedies have the powers ascribed to them is questionable, and their administration for this purpose must always be, to a certain extent, empirical. As tonic remedies the administration of iron and the bichloride of mercury is of course always indicated. Cod-liver oil is also a remedy of much value in some cases where it can be digested. The whole plan of treatment should rather be of a local than of a general character, while at the same time very great importance should be given to the building up of the general system, without which nothing can be gained by local treatment. The patient should have a change of scene and air as soon as practicable. A sojourn at the seaside for a time, and then in the mountains, will be of great benefit always.

The fact should always be borne in mind by the physician and impressed upon the patient that a previous attack of perimetritis will serve as a predisposing and abiding cause for a recurrence of the disease, so that all exciting causes may be avoided as far as possible.

PELVIC HÆMATOCELE.

HISTORY.—Prior to the present century the pathological condition which we are about to investigate had no place in the category of diseases peculiar to the sexual organs of the female. Very slowly have its pathogenic features, its etiology, and its importance as a not uncommon factor in pelvic disorders, assumed a systematic basis, and even now considerable diversity of opinion exists upon these points. The reasons for this are not far to seek. In the first place, hæmatocele is a symptom of an accident occurring in the pelvis and resulting in hemorrhage; in the second, the source of the flow which creates the hæmatoma or tumor of blood cannot ordinarily be recognized by any diagnostic measures known to science; and in the third, death rarely occurring from the accident and as a direct consequence of it, autopsic evidence is wanting upon which to base accurate and scientific data.

Although these statements are undoubtedly true, it may nevertheless be asserted with confidence that we are to-day no longer in the dark as to the general pathology of this interesting disorder, and that we are in position to map out a plan of treatment which meets the indications which present themselves in an intelligent and reliable manner. There are, however, several sources of hemorrhage which result in pelvic hæmatocele, and it is highly probable that the day will never come when that one which has created the accident can be ascertained with certainty. But while such accuracy of diagnosis would be gratifying to the ambition of the modern diagnostician, neither the prognosis nor treatment of the disorder would be influenced by it.

Long before our day practitioners had recognized by touch the occasional presence of tumors, more or less marked by fluctuation, which occupied the pouch of Douglas, and by their mechanical influence pushed the uterus out of its normal place; but it was not until the early part of our century that it was discovered that these tumors were sometimes, and that not rarely, composed entirely of coagulated blood; and, curious though it may appear, it was not until the year 1850 that pelvic hæmatocele became a well-recognized disorder.

As early as 1737, Ruysch of Amsterdam appears to have come to the verge of discovering it, but it was left for Récamier, to whom gynecology owes so much besides, to make it known when in 1831 he opened a post-uterine tumor, gave vent to a large accumulation of coagulated blood, and described the case in the Lancette Française for that year. In 1850 the [p. 240] subject attracted the attention of Nélaton, became a recognized pathological condition, and has since received a great deal of attention in all the civilized countries of the world.

DEFINITION AND SYNONYMS.—Pelvic hæmatocele—which has likewise received the names of retro-uterine hæmatocele and uterine hæmatoma—may be defined as an effusion of blood into the pelvic cavity of the female, either into or under the peritoneum. Some authors have limited this definition to blood escaping from utero-ovarian vessels and to blood enclosed either by anatomical structures or by previously-existing inflammatory products. I do not adopt these restrictions, because their assumption appears to me to be unwarranted and the validity of the reasons given for their adoption more than doubtful. The location of the blood-mass differs widely in different cases: sometimes, and usually, it is behind the uterus—high up when obliteration of Douglas's pouch has occurred, low down and near to the perineum where such obliteration has not occurred; at other times it exists both behind and in front of the uterus; and at others still, in front of the uterus alone, adhesions preventing its percolation to the posterior parts of the pelvis.

FREQUENCY.—It may be said, in general terms, that this affection is by no means rare, every one of large experience in gynecology meeting necessarily with a large number of cases of it. But no reliable statistics of its frequency have been collected up to the present time. Olshausen of Halle declares that in 1145 gynecological cases he saw 34 hæmatoceles; Beigel in 2000 cases found 38; Schroeder, 7 in 1000; and Seiffert of Prague reports 66 seen in 1272 cases of female pelvic diseases. Barnes says that in ten years' practice he met with 53 cases, and in twenty years Tilt has seen but 12.

Without doubt, the validity of the statistics of this disorder is vitiated by erroneous diagnosis, as is the case with all affections which generally end in recovery. Here cases of cellulitis, pelvic peritonitis, imprisoned cysts, etc. offer prolific sources of error, as I can aver from the results of my own experience.

PATHOLOGY.—It is a fact, thoroughly proved by physiological experiment, that blood injected into serous cavities very soon encysts itself by the enveloping influence of lymph which is poured over it, forming false membranes, or, as the French term them, néo-membranes. The clot, once formed, clings to the serous membrane in contact with it, and soon becomes roofed over by lymph, which, according to Vulpian, begins to show traces of organization as early as the end of twenty-four hours. Should the effused blood be poor in fibrin, the coagulation and encysting do not occur, a rapid absorption taking the place of these processes.

Pelvic hæmatocele consists, as has been already stated, in the collection of a mass of blood in the pelvis, either above or below its roof, without reference to the source of the flow. Such a flow ordinarily occurs from one of the three following sources: first, rupture of vessels in the pelvis; second, reflux of blood from the uterus or tubes; third, transudation of blood in consequence of dyscrasia or pelvic peritonitis.

From this it becomes evident that hæmatocele is not a disease, but a symptom which marks a number of different pathological conditions of quite various significance. As, however, we cannot discover the original accident or pathological condition, we are forced to compromise with [p. 241] taking its most prominent sign as the exponent of a state which is beyond the powers of diagnosis.

Autopsic evidence has revealed the following as the special and most frequent sources of the hemorrhage:

It is then clear that the mere presence of a large clot of blood in the pelvis, apart from general symptoms, is a matter of very doubtful significance, since on the one hand it may be the result of a mere regurgitation of menstrual blood due to imperviousness of the cervical or tubal canal, or on the other of the rupture of a Fallopian tube which has become the nidus of an extra-uterine foetus.

Whatever be the source of the blood which escapes, it coagulates, unless very poor in fibrin, either in the most dependent part of the peritoneum or in the pelvic areolar tissue beneath it. Here the watery portions of the mass are gradually absorbed, leaving a hard, small tumor remaining; or, suppurative action being excited, the hard mass is softened down and discharged into the rectum, vagina, bladder, or peritoneum as a grumous material somewhat resembling currant-jelly in appearance.

CAUSES.—These must be divided into predisposing and exciting, for it is rare to meet with the disease in a woman who has previously been in perfect health. The predisposing causes which can be cited with confidence are—the period of ovarian activity (fifteen to forty-five years); disordered blood-state, plethora or anæmia; the menstrual epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the hemorrhagic diathesis. The exciting causes have been found to be sudden checking of the menstrual flow; blows or falls; excessive or intemperate coition; obstruction of cervical canal; obstruction of Fallopian tubes; violent efforts; and ectopic gestation.

VARIETIES.—The two great classes of the affection are the peritoneal and the subperitoneal. In the former the blood collects in the peritoneal cavity and becomes encysted there; in the latter it collects in the cellular tissue beneath the peritoneum, and there forms a solid mass.

Some authors have opposed the consideration of these two varieties under the same head; among them, Aran, Bernutz, and Voisin. But from a clinical standpoint such a consideration appears to me to be valid. Not only have distinct instances of subperitoneal hæmatocele been recorded by such observers as Barnes, Simpson, Olshausen, and Tuckwell, but [p. 242] cases have been met with in which the subperitoneal variety has ruptured the peritoneal roof of the pelvis, and thus broken down the theoretical barrier which pathologists have been inclined to establish between the two varieties.

Of the two varieties, there can be no doubt that the peritoneal is that which presents itself the more frequently. In 41 autopsies Tuckwell found the tumor to be peritoneal in 38.

SYMPTOMS.—As a rule, long before the occurrence of pelvic hemorrhage the patient will have complained of more or less decided symptoms of disease, or at least of disorder, of the genital system. The symptoms which mark blood-dyscrasia or pelvic peritonitis or menstrual irregularity will probably have attracted attention.

When the accident occurs the gravity of the symptoms will depend in great degree upon the character of the lesion which has taken place. Sometimes the blood-accumulation takes place so insidiously that the existence of the tumor created by coagulation takes the practitioner by surprise. At other times what Barnes has called a cataclysm occurs, and in a few hours puts the unfortunate patient beyond the sphere of hope or the resources of art.

In portraying the symptoms of this affection a writer can therefore merely approximate the truth, satisfying himself with the description of a case of ordinary severity, avoiding the description of cases in either extreme, and guarding the reader against supposing that all attacks give the same intensity of symptoms.

Most prominent among the immediate symptoms are—severe and sudden pelvic pain; pallor, faintness, and coldness of the extremities; a sense of exhaustion; nausea and vomiting; metrorrhagia; uterine tenesmus; enlargement of the abdomen; interference with the bladder and rectum; small and rapid pulse; subnormal temperature.

These are the symptoms of invasion, those which may be termed immediate, and which depend upon loss of blood and a sudden traumatic influence exerted upon living tissues. Very soon, generally within forty-eight hours, a reaction occurs which is sometimes slight, and at other times decided. The secondary symptoms are usually the following: tendency to chilliness; constipation; suppression of urine; tympanites; high temperature; rapid pulse; and tenderness over abdomen.

These symptoms are due to a combination of two causes—loss of vital fluid and the invasion of the peritoneum or pelvic areolar tissue by a mass of blood which becomes coagulated and irritant, on the one hand, and inflammatory processes resulting from such invasion on the other. Half of them might be produced by metrorrhagia, and half by sudden and complete retroversion; but a union of the whole will point toward hæmatocele and prompt a physical examination.

PHYSICAL SIGNS.—A tumor will be felt by vaginal touch, usually, though not always, posterior to the uterus and vagina, and partially occluding the latter. This will, if the examination be made very early, be found to be soft and obscurely fluctuating, but it soon becomes a smooth, dense, and solid body. The uterus is very generally found pressed upward and forward, so that the body lies against the abdominal wall and the cervix is on a level with or a little above the symphysis [p. 243] pubis. In some rare cases the blood-tumor is anterior to or obliquely to one side of the uterus, but these are very rare.

Abdominal palpation reveals the presence of a tumor of varying size, and which sometimes extends up to the navel in peritoneal hæmatocele, but in the subperitoneal variety no tumor whatever may be discoverable by these explorations, unless conjoined manipulation be added to it for the sake of deeper and more thorough search.

DIFFERENTIATION.—Hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst.

The tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia.

Retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms.

The development of extra-uterine pregnancy is slow and gives the signs of gestation.

Fibrous tumors grow slowly, are painless, and move with the uterus, and they are hard, irregular, and do not lift the uterus against the symphysis.

Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia, and yield fluctuation readily to palpation.

COMPLICATIONS.—The complications to be feared in this disease are septicæmia, suppuration and abscess, and peritonitis.

COURSE, DURATION, AND TERMINATION.—The hemorrhage may be so severe as to destroy life immediately. Five such instances have been recorded by Voisin; I have met with one; and Ollivier d'Angers mentions two in which death occurred in half an hour from a varicose utero-ovarian vein. Such a termination is, however, very rare.

As a rule, absorption takes place unaided by art; in some cases suppuration occurs, and the mass is discharged as if it were a large abscess by the vagina, rectum, bladder, or abdominal walls; and at other times septic absorption, accompanied by septic peritonitis, destroys the life of the patient.

PROGNOSIS.—The prognosis will depend in great degree upon the severity of the constitutional symptoms. As a rule, it is decidedly favorable unless the surgical tendencies of the attending practitioner alter its natural inclination. The prognosis of the peritoneal form is graver than that of the subperitoneal, and when the tumor is very large the danger is greater than when it is small. A large tumor argues great loss of vital fluid, which may in itself destroy life, and the necessity for the absorption of a large amount of coagulated material which may poison the blood.

The usual causes of death are loss of blood, shock from sudden invasion of the peritoneum, peritonitis, secondary discharge of the encapsulated mass into the peritoneum, or septicæmia.

TREATMENT.—Should the physician be called in the inception of the attack, the patient should at once be placed in the recumbent posture, all excitement around her be quelled, the head be kept low, warmth be applied to the soles of the feet, and perfect quiet enjoined. An effort should be made to check the flow by applying bladders of ice or cloths wrung out of hot water over the hypogastrium, pain and tendency to [p. 244] shock met by the use of morphia hypodermically, and ammonia and brandy freely administered by the mouth. This is all that promises benefit, and further efforts should be avoided as calculated to do absolute harm.

After reaction has occurred let it be borne in mind that the factors which tend to the production of death are—1st, peritonitis; 2d, septicæmia; 3d, suppuration and discharge through some dangerous outlet; and let all efforts be directed toward the prevention of these events.

All pain should be quieted by opium or one of its salts, hypodermically or by mouth or rectum; the patient should be thoroughly nourished by milk and strong animal broths, given as often as every two hours; febrile action should be controlled by the coil of running ice-water and quinine; and strict quietude observed, all unnecessary examinations being avoided, as belonging to the most pernicious class of perturbing influences.

Should the case progress favorably, no surgical procedure looking toward the artificial evacuation of the accumulated blood either by bistoury or by the aspirator should be thought of, however large the accumulation be; for experience has proved that cases left to nature, as a rule, do better than those interfered with.

On the other hand, the great value of surgical interference in those cases in which suppurative action occurs, or in which septicæmia develops itself either in acute or chronic form, must not for a moment be lost sight of. Should the case not progress toward recovery, should the symptoms of septicæmia develop as a sharp attack or as the insidious hectic fever, the accumulated blood or pus and blood should at once be evacuated, and the nidus from which it is discharged be thoroughly washed out with a 2½ per cent. solution of carbolic acid or a solution of the bichloride of mercury, 1 to 2000 of water. Should the accumulation be attainable, tuto, cito, et jucunde, by the vagina, an exploring-needle should be carried into it, and as soon as the fluid is seen to flow a sharp-pointed bistoury should be slid along this and a free opening be made, all the contents of the sac evacuated, and antiseptic washing be at once practised by means of Davidson's syringe and a glass tube.

Should the accumulation point toward the abdominal walls, the opening may with perfect safety be accomplished there. I have operated thus upon 3 cases, with recovery in all, but the accumulation had at the time of operation assumed the character rather of an abscess than of an hæmatocele. A. Martin of Berlin has operated by abdominal section upon 8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden has done so upon 1 case, with recovery. Zweifel has collected 30 cases operated upon by free vaginal incision, with a result of 3 deaths, giving a mortality of 10 per cent. Mere puncture through the vagina he found followed by a mortality of 15 per cent.

The question of surgical interference in pelvic hæmatocele is still sub judice. In my judgment, the rule of practice may, with the present light which we have to guide us, be safely formulated thus: So long as the symptoms are good and the case progresses toward recovery, avoid surgical interference of all sorts, however great be the sanguineous effusion. So soon as symptoms of decided septicæmia or septic peritonitis develop themselves, evacuate the accumulation by a free opening practised by the safest outlet which presents itself, and use antiseptic washings thoroughly.

FIBROUS TUMORS OF THE UTERUS.

RELATIONS AND STRUCTURE.—These tumors grow from the muscular and connective tissues of the uterus, and consequently partake of the character of these tissues. Sometimes the substance of the tumor consists principally of connective, at others of muscular, tissue. The variations in the relative proportion of these two fibrous substances constitute the main differences in the characters and appearances of the tumors, and lead to the different terms applied to them, as myomata, fibromata, myo-fibromata, etc. The firmer the tumor the more connective tissue it contains. When we inspect, either ante- or post-mortem, a uterus with a fibrous tumor attached or contained within its wall, it will be found to present a much darker hue than natural. Instead of the normal light rose-color, it is generally dark, sometimes almost of a purplish tint. The time of menstruation makes some difference; just before it is darker than soon after the menstrual flow. The color also varies with the character and size of the tumor. In large solid tumors the color is darker than in the large fibro-cystic variety; indeed, in some of the latter the pearly color strongly reminds one of an ovarian cyst. We cannot therefore depend on the color or shape of surface for a diagnosis. Even after the abdominal cavity is opened the contour of the uterus is usually not regular. If we make an incision into the tumor, we find that it is surrounded by a distinct capsule, which limits and defines its boundaries and separates it from the adjacent substance. This envelope is not a cyst or other form of membrane: it is continuous with, and inseparable from, the muscular structure of the uterine walls. It, in fact, is a condensed layer of the fibrous substance of the uterus. In cases of true encysted tumors the cyst-wall is the generating portion of the growth. In fibrous tumors of the uterus the growth produces the capsule by displacing the surrounding substance in every direction, pressing it strongly against the unaffected fibrous tissue and condensing it into the smooth capsule. It is thus engendered in, and enveloped by, the muscular walls of the uterus. These latter of course grow to dimensions sufficient to keep pace with the increasing tumor. The growth may, as a consequence of such a connection, be hulled out or enucleated, and will not be reproduced. Inflammation or other degenerating processes may occasionally cause adhesion of the capsule and tumor, but this is an accident of uncommon occurrence. To understand this mode of encapsulation we must remember that the uterine muscles are irregularly stratified, [p. 246] and that the tumors are developed between the strata as between the leaves of a book, separating them sufficiently to gain lodgment and room.

The appearances of the substance of the tumor are not uniform. In many cases the color of the interior of the tumor is dark gray; in some it is dull red; again, sometimes almost livid. The surface of the tumor after the capsule has been removed is often marked by sulci denoting a division into lobules. In other cases the tumor is smooth and symmetrical in shape, and the fibres distinctly visible to the naked eye. The smooth tumor is apt to be very dense and comparatively difficult to destroy, while the lobulated variety is less dense and sometimes easily broken to pieces. But the difference of density does not correspond altogether with the color or shape of surface.

We seldom find large tumors of uniform structure. In some places they are of solid fibrous structure; in others there are cavities of greater or less size, containing a tenacious red serum. These cavities, which seem to be made by localized disintegration of the fibrous tissue, are sometimes of great size, containing several pounds of serum (Atlee). Much more frequently they are small and hold a small amount of fluid. I have met with several where the substance of the tumor seemed to be made up of alveoli filled with a tenacious fluid the color of milk.

Besides this effect upon the density of the tumor resulting from what might be called its usual course, there are numerous modifications in it and in the other properties of the tumors arising from spontaneous degeneration.

It may be said, I think, that without adventitious or supplementary vascular supply the life of a fibrous tumor is self-limited, and it ceases to grow after it has attained to a certain size, and that then it either remains stationary or undergoes degeneration. As I shall have occasion to say farther on, the original supply of blood-vessels cannot be increased to an indefinite degree, and the tumor that grows indefinitely derives a supplementary supply of blood by contracting adhesions to the viscera or abdominal walls. Such adhesions are common and mischievous.

After a tumor has attained its growth, degeneration into the more elementary forms of tissue sets in, as the cartilaginous degeneration, and there is often a deposition of earthy material found in it which reduces it to a hard, dense, stationary, and indestructible body. In such cases there is almost a complete loss of vitality in the tumor, and it becomes a calcified mass.

We may easily demonstrate that the structure of these tumors is essentially fibrous. By maceration and careful dissection the fibres are traceable to a greater or less degree in all of them, the proportion and characters of which, as before said, differ greatly. In the smooth, symmetrically-developed tumor the fibres are usually long and distinctly traceable, while in the lobulated light-gray tumor the fibres are more rudimentary and not so easily followed up by dissection.

MODE OF DEVELOPMENT.—It has already been stated that the fibrous tumor of the uterus grows in or on its wall and originates in the fibrous structure of the organ. The point of beginning is in one or more fasciculi of the muscular system or the connective tissue of the uterus. If in one fasciculus, the point of origin is very minute, as indeed it is generally at first.

The development consists in an hypertrophy of the bundle of fibres [p. 247] affected and a deposit of material similar in structure to that first involved. Sometimes there are numerous nuclei, and nearly all the fibrous structure of the uterus is involved in fibrous degeneration. In the case where the deposit is defined and occupies a small space, it should be borne in mind that the future tumor, however large it becomes, must occupy the same nidus in which it first originated. The nidus becomes enlarged sufficiently to accommodate the growing tumor.

The nucleus of development is enlarged by the accretion of substance similar, if not identical, in character to its own proper material. The nature of the tumor is determined by this fact, and its fibres are rudimentary in organization, instead of being hypertrophied and highly developed, as those of the uterine wall by which it is surrounded. As the tumor grows the fibrous structure surrounding it is pressed aside in every direction in such a way as to completely embrace the growth and encapsulate it. The tumor does not incorporate the adjacent fibres and grow by inducing degeneration in them, but, as before said, it presses them aside. As it thus moulds and shapes a bed in the solid substance of the interior wall, it impresses upon the embracing muscular fibres an increased vitality, and they grow by hypertrophy of a character similar to that of pregnancy. The fibres become longer, and apparently, if not really, more numerous. This hypertrophy of the uterine fibres surrounding the tumor is equal to the capacity demanded by the increasing size of the growing tumor. In this description of the method of development and the embracing capacity of the hypertrophied fibres surrounding it the reader will trace the formation of the capsule in which the tumor is contained. The inner surface of the capsule is smooth, and there are many feeble fibres of connective tissue seen to connect it with the surface of the tumor. There is no adhesion proper between the surface of the tumor and its capsule.

I must call attention to another point that governs the extent and limits of the growth of the tumor—viz. the number and distribution of its vessels. The vessels entering the tumor represent the minute twigs that supplied the fasciculus in which it originated. They arrive at the point of morbid deposit from the parts constituting the capsule, and there are always several of them. The number of these vessels always remains the same, and their calibre is increased with the hypertrophy of the surrounding tissues. They cannot grow at the demand of the trophic energies of the tumor to an unlimited degree, but their size is limited by the growth of the surrounding parts. As the tumor grows and its capsule expands, the vessels are separated farther from each other, until after a while the area becomes so large that the supply of blood will not admit of further growth and the tumor comes to a standstill. Thus their growth, from the nature of their supply, is limited; hence the usual history of the tumor is one of self-limitation. It is all-important in forming an opinion in reference to the greater or less vitality of the fibrous tumor, therefore, to remember that it is not supplied by one large arterial trunk entering at one place and spreading over its capsule, but that the supply is by a number of small vessels penetrating the tumor at different points; that their number cannot be increased and their growth is limited; that as the tumor grows their capacity to supply it grows gradually less until entirely exhausted: then the growth stops.

There is another and adventitious source of nutritious supply, and I think it is essential to very large growths: at least, so far as I know, it is always present. I mean the adhesion of the uterus or tumor to the wall of the abdomen, the pelvic or abdominal viscera, or, what is more common, the omentum. When adhesions occur from whatever cause, the vessels of the tumor increase in size and supply it with a vast increase in the amount of blood. All the large tumors I have had an opportunity of examining were to a greater or less extent covered by a network of large vessels contained in the omentum. These vessels penetrate the uterus, carrying a deluge of blood into its substance. These large vascular adhesions are a source of embarrassment in operations for their removal. Operators allude to them and give instructions how to overcome the difficulty presented by them. The uterine vessels alone would never be sufficient to supply the forty- or fifty-pound tumors so often mistaken for ovarian tumors.

EFFECTS UPON THE UTERUS.—I have already said that the fibres immediately surrounding the growth undergo a true hypertrophy, acquiring dimension, susceptibility, and capacity similar to the hypertrophy of gestation. All the fibres of the uterus undergo a similar change, only less in degree; the more remote from the tumor, the less marked the hypertrophy. This remark must be modified somewhat by the consideration of the locality of the tumor. A polypoid tumor growing from the fundus causes universal hypertrophy of the uterine fibres. A submucous tumor will usually cause a general hypertrophy of the uterine fibres, but greater on the side of the tumor. A subserous tumor is attended by a slight hypertrophy, and in a centrally-located intramural tumor the hypertrophy would be much like that in the submucous variety, only less in degree. But this augmentation of tissue is not confined to the fibrous structure: it extends to the vascular and nervous apparatus and to the serous and mucous membranes. With this growth of the tissues comes change in the properties and functions of the uterus itself. It is more sensitive, the secretions are increased, and almost parturient contractility is acquired.

But probably as remarkable and uniform a symptom as any arising from the general hypertrophy is hemorrhage. The mucous membrane of the uterus is hypertrophied in all its constituents and proportions. The membrane acquires larger superfices and greater thickness, its glands are enlarged, and its blood-vessels augmented. Its functions, as a consequence of these changes, are exaggerated. The glands secrete greater quantities of mucus, and the vessels when ruptured in the processes of menstruation pour out a superabundance of blood. Indeed, I know of no other way to account for the hemorrhages so generally present in cases of fibrous tumors of the uterus, except upon the ground that the endometrium, a natural hemorrhagic surface, has its properties and functions enhanced by a general hypertrophy.

LOCATION OF THE TUMOR.—For the purpose of considering the relation of these tumors to the different regions of the uterus we may call that part situated above the entrance of the Fallopian tubes the fundal zone, and that above the internal os uteri the corporal zone; all below this the cervical zone. Fibrous tumors may and do originate in all of these zones or regions, but they spring more frequently from the corporal [p. 249] than either of the others, and less frequently from the fundal zone. The part of the corporal zone in which these tumors more frequently grow is the lower or cervical portion. There is another important view of the relation of the tumors to the uterus. The muscular fibres of that organ run in every direction with reference to the latitude and longitude of the uterine circumference—transversely, longitudinally, obliquely, spirally, etc. There is probably not much more definiteness in the layers constituting the walls of the uterus. If they cannot be completely separated into regular strata, there is sufficient distinctness in the layers to justify us in employing the term strata in connection with their arrangement, and this term will enable us to get a more exact understanding of the language used in the description of tumors. Authorities differ as to the exact number of strata to be found in the body of the uterus, but for clinical purposes it is convenient to describe them as follows: By drawing a line through the middle of the uterine wall longitudinally we will indicate a central stratum of fibres. A tumor originating in that line or stratum is what is usually called an intramural tumor. The number of tumors growing in this stratum is not very great as compared with those situated nearer the two surfaces.

FIG. 25.

Diagram showing Muscular Strata of Uterus, as divided for clinical purposes.

If we run one line between the serous and another between the mucous membrane and the central line, as in the diagram, other strata with intervening spaces will be indicated. a would represent the centre stratum of the wall; b, the space immediately outside of that; c, a stratum still farther out; e, the subserous; and d, a deeper one. When we look at the inner layers of fibres, we find f situated immediately beneath the mucous membrane; g, farther out; and h, next the median line. The nucleus of a tumor may be first manifested in any of the strata or spaces marked by these lines, and its position with reference to the central line will, to a great extent, govern the direction it takes during development. A tumor the nucleus of which is situated in line a will, as it develops, press the muscular fibres equally in every direction, and when large, the prominence caused by pressure of the tumor would be equal in the uterine cavity and on the peritoneal surface. In marked contrast to this, when the nucleus is at f the growing tumor presses the mucous membrane before it until it becomes pendulous, and then the name of polypus is given to it; or if the origin is at e, the serous membrane is pressed before it, and the tumor is called subserous. When the nucleus is at d, the tumor elevates the serous membrane and becomes a prominent hemispherical protuberance. It is also called a subserous tumor, although situated some distance from the membrane. When a tumor takes its origin at g the mucous membrane is crowded before it, and a marked prominence into the cavity of the uterus is observed. This is the submucous tumor. These illustrations are intended to call the attention of the student to the fact that practically these tumors spring [p. 250] from any one or all the fibrous strata of the uterus instead of only the central, submucous, and subserous layers, and that it is profitable, on account of the difference in their effects upon the shape and functions of the uterus, to study them in this aspect of their growth.

ETIOLOGY.—While we know many of the conditions under which fibrous tumors exist, we have really very little, if any, definite and reliable information as to their causes, either remote or proximate. We know that they occur much more frequently near the time when the uterus begins to undergo senile degeneration, although they do originate in earlier years. They very seldom, if ever, are observed in the foetus or child, nor is it common for them to commence growing after the menopause. Women belonging to the African race are the most frequent subjects of these tumors.

The married or single status does not seem to have any effect in predisposing to these tumors. We do not know what physiological or pathological states of the uterus or other organs predispose to them. There is probably no tumor in the body strictly analogous in structure, mode of origin, supply, or development to the fibroid tumor of the uterus. There is no other organ in the body that undergoes analogous normal trophic changes. The vast multiplication of tissue that takes place in the uterus during gestation, and the more rapid but equally great changes toward degeneration or atrophy, would naturally suggest pathological possibilities of a peculiar nature. The rhythmical changes of menstruation are like no other functional condition. They too involve the processes of hypertrophy and atrophy. When the menstrual and generative changes are normal every part of the body of the uterus is simultaneously and proportionately hypertrophied and atrophied. Local derangements of these processes of hypertrophy and degeneration must sometimes occur, probably from defective or excessive innervation of loculi in the fibrous structure. Congestion or hyperæmia may thus result, and consequently very great influence be exerted upon the nutrition of the parts concerned after the deposit has begun; its presence increases the hyperæmia and thus perpetuates its growth indefinitely.

CLINICAL HISTORY.—Probably the earliest, most frequent, and constant symptoms connected with fibrous tumors of the uterus are hemorrhage and leucorrhoea. They are both the result of active or arterial hyperæmia, and doubtless come from the endometrium. Polypi, submucous, and intramural tumors are more likely to give rise to these two symptoms. The nearer the mucous membrane, and the greater that membrane is expanded, the greater the amount of hemorrhage and leucorrhoea, and, as a counter-fact, the nearer the serous membrane, the less the amount of these two discharges. While this statement in reference to the effects of the proximity of the tumor to the two membranes is usually true, it is not always so.

Hemorrhage is sometimes not very great, but at others it is appalling, and constitutes an imperative reason for the employment of desperate remedies. The hemorrhage is usually first noticed in connection with the menstrual flow, and it may even be confined to the periods: sometimes it extends over the whole of the interval. The leucorrhoea is generally constant, and sometimes thin and watery, especially after the hemorrhagic paroxysm has subsided, and at others it is constituted [p. 251] mainly of mucus with the débris of the mucous membrane and blood-corpuscles.

Other symptoms are pelvic pressure, vesical and rectal, with tenesmus, distension, and dysmenorrhoea. The pelvic pressure and tenesmus are observed early in the development of the growth, and may be relieved as the tumor becomes large enough to rise out of the pelvic cavity. The abdominal distension of course comes later. Solid tumors do not often attain to such a size as to cause great abdominal distension. The fibro-cystic generally are inconvenient, if not fatal, from this cause.

The above are the more direct and common symptoms. A less frequent yet important effect and symptom is oedema of the lower extremities from pressure upon the venous trunk passing through the pelvis. In rare cases this symptom is aggravated to a degree constituting phlegmasia alba dolens. As the tumor rises and enlarges the pressure may embarrass or interrupt the function of any or all the abdominal viscera.

In many cases none of these symptoms present themselves to an inconvenient degree, and the tumor is discovered by accident. Again, we meet with cases in which the symptoms are formidable for a time, and then entirely subside, leaving the patient free from suffering the balance of her lifetime. While this subsidence may take place at any time during the growth of the tumor, it is very apt to take place at the menopause.

The clinical history of the fibrous tumor may be very much modified by the intervention of various circumstances. As organized bodies they are subject to those affecting the organs of the body. We must regard them as adventitious growths acted upon by organs in a state of disease and reacting in turn upon them. They may become inflamed, undergo suppuration and gangrene, and produce symptomatic fever, hectic fever, prostration, gastric, hepatic, and nervous derangement in a degree sufficient to prove fatal.

When situated near the mucous membrane, nature sometimes turns these organic changes into a means of cure by destroying the portions of the capsule near the uterine cavity and permitting the pus or gangrenous material to escape. They are also subject to pressure from the development of other tumors, and either disappear, become inflamed and adherent, or cause great trouble to adjacent organs. Their clinical history is sometimes modified by complication with pregnancy.

This complication is rare, because the uterus in most cases, on account of the effects produced upon its circulation, nerve-supply, and mucous membrane especially, will not retain the ovum, and conception does not take place. The uterus being more vascular, and subject to congestions that affect the placental attachment injuriously, miscarriages are likely to occur. It is also morbidly sensitive to the pressure of the ovum, while the mucous membrane is rendered incapable of decidual changes. The retentive power of the uterus is further interfered with from the irregularity of its growth: the fibres where the tumor exists, being under a morbid influence, cannot partake of the regular hypertrophy necessary to normal gestation. There is something of uniformity in the circumstances under which the coexistence of pregnancy and fibrous tumor is observed. The nearer the tumor is situated to the mucous membrane, the less likelihood of pregnancy—the more remote, the greater the tolerance of pregnancy. Tumors that occupy the wall of the corporal portion [p. 252] are conducive of sterility. Those in the cervical portion of the corporal and the cervical zone are more likely to be accompanied with pregnancy than those situated in other parts of the organ. While the reader will find these statements borne out by his experience as general facts, he will also discover that pregnancy is occasionally compatible with almost any form, variety, or position of tumor. When this complication occurs, it does not generally influence the process of gestation or the condition of the tumor. The main symptoms depending on it are those caused by pressure. When small this is not very considerable.

Complication with labor generally gives rise to more apprehension than difficulty. Most of the cases of labor terminate spontaneously and happily, and the others are generally within reach of the less destructive modes of delivery. Labor more frequently decidedly affects the growth of the tumor, in the majority of cases causing its disappearance during the process of involution. The cervical polypi affect labor less, and are less affected by labor, than any other variety of the tumor. If small, they are sometimes merely pressed to one side or into the hollow of the sacrum, and the head passes by them; if a polypus is large, the head of the foetus carries it before it beyond the vulva, where it remains until the child is expelled, when it may recede into the vagina.

DIAGNOSIS.—The history usually includes hypersecretion, hemorrhage, pressure, and enlargement. These, while suggestive, are not conclusive, hence physical examination becomes indispensable to accuracy. The methods of examination vary with the size of the tumor. It is generally near the truth to say that the uterus is enlarged, and may be shown to be so by the introduction of the sound; yet the cavity is not always enlarged, and it is often so tortuous that the ordinary sound may be arrested before reaching the fundus. The sound, therefore, should in such condition be flexible. The fine whalebone or the sound of Jenks will generally pass obstructions caused by tortuosities. The most skilled and dexterous use of the inflexible sound is often delusive. We may generally determine the size by bimanual examination—one finger in the vagina or rectum while the hand is passed down into the pelvis from above. The uterus of normal size cannot be felt with any distinctness from above in this way, while an enlargement of 50 per cent. may be thus determined. The finger below will sometimes recognize the pressure from above when the upper hand will not feel the fundus distinctly. Small tumors of the uterus may be mistaken for many other conditions, and the converse. If one is situated in the posterior wall, it may be mistaken for retroflexion. We may make the distinction by means of the inflexible sound and the finger in the rectum. If the case is one of retroversion, the finger in the rectum will pass behind it and overlap it above. If a retro-uterine tumor is in the cul-de-sac, the finger will not reach above the uterus. If the case is one of retroflexion, a strongly bent sound may be made to enter it, especially if the fundus is slightly raised by the finger in the rectum. If there is a tumor in the posterior wall, the sound with slight flexion will pass above it; which is clearly ascertained by the finger in the rectum. When the sound is introduced in the case of retroflexion, the fundus may be elevated to its proper position by turning the sound upon its axis. In making these examinations with the sound the finger should be made to co-operate with it by being kept in [p. 253] the rectum. A small tumor in the anterior wall may be distinguished from anteflexion by the sound passing upward instead of forward, or into the part lying on the bladder. When a small tumor is intra-uterine, the uterus will occupy its natural position, with the mouth directed slightly backward; and if the polypus is large, the cervix can be moved forward with considerable difficulty. A flexible sound, especially the thin whalebone, may sometimes be made to partially or wholly surround it, and its size or connections be determined. But the diagnosis may be more definitely made out by dilating the cervical cavity and introducing the finger. The difference between a polypus and an intramural submucous tumor may be determined in this way. In the case of a polypus the finger will pass around it, while if the tumor is intramural or submucous the finger will be arrested at the point of attachment. A polypus or intramural submucous tumor presenting at the os externum may sometimes be mistaken for a partial inversion. Such a mistake may be prevented by using the sound. In the case of a tumor the flexible sound will pass to more than the normal depth. In one of inversion the sound will pass very much less or not at all. When a polypus has escaped from the mouth of the uterus and occupies the vagina, the sound will pass beyond it into the enlarged uterus, whereas in complete inversion it cannot be passed into the uterus in any direction. We cannot rely upon consistence or shape as marks of distinction in these two conditions. When the tumor rises above the pelvic brim and is not very large it generally displaces the os from its normal position. If in the front wall, the os will be too far back; if in the posterior, it will be displaced forward. In the former, when a sound is introduced, it will pass backward and upward; in the latter, the sound will pass forward and upward. In both cases the bimanual examination will enable us to determine that the tumor above the pelvis is continuous with or attached to the uterus. With the hands in this position, if we move the uterus the tumor will move with it, and vice versâ. Tumors of this size are usually more or less uneven in their outline, and of greater consistence than the uterus when enlarged from other causes. Tumors of this size may be generally distinguished from the pregnant uterus by the history of pregnancy, by the consistence, and by the size of the cervix. When pregnancy and a tumor are associated, this may be determined by a part of the enlargement being very hard and other parts quite elastic, and by auscultation. I need not caution the reader against the use of the sound where there is any suspicion of pregnancy. When a doubt exists, we should await the progress of the case until pregnancy becomes obvious. We may generally determine whether a tumor is uninuclear by the fact that a single tumor is nearly round, when if there are several points of origin it will be irregular and nodular.

When the tumor is large enough to nearly or quite fill up the abdominal cavity, the flexible sound may be made to pass a great distance into it. It is not often that a solid tumor grows large enough to fill the abdominal cavity. Before it grows to such dimensions it generally undergoes cystic degeneration. When the tumor is solid, generally its very great hardness, and often its irregular shape, will distinguish it from other abdominal tumors. The condition with which I have seen these tumors most frequently confounded is enlargement of the liver or spleen. [p. 254] In the South and West an enormously enlarged spleen is not infrequently met with. It sometimes spreads over the whole anterior part of the abdomen, completely covering the intestines. Less frequently the liver is found similarly enlarged. In this condition the organ becomes greatly indurated, and sometimes nodular. The distinguishing features of these enlargements are—first, that the abdomen does not present the prominent rotundity it does when filled by a growth; second, that somewhere in the extent of abdominal surface by careful manipulation the edge may be discovered and the fingers be made to sink beneath and grasp it; third, percussion will elicit general deep resonance, in some parts quite obvious, and in others less so. In the case of tumor none of these signs will be present. Again, the enlarged liver or spleen, while it may reach to the brim of the pelvis, does not reach into that cavity far enough to be recognized by the finger in the vagina, while the tumor does.

Sometimes inflammatory effusions form indurated masses in the abdomen that are mistaken for fibrous tumors. These of course have the history of inflammation, are generally if not always tender, and yield obvious intestinal resonance upon percussion. The large fibro-cystic tumor may be mistaken for pregnancy, ovarian tumor, cystic degeneration of the kidney, and omental tumors. Pregnancy can generally be established by absence of the menses, by the shape, size, consistency, and position of the cervix, together with auscultation. It may be said that in case of fibro-cystic tumor the cervix is greatly displaced in some direction, indurated, and not enlarged. In pregnancy none of these conditions prevail.

The fluctuation of the fibro-cystic tumor is more obscure than that of the ovarian tumor, and, although sometimes noticeable over a large space, it is usually more constricted in extent. There is also usually less regularity in the shape of it. In large ovarian tumors the uterine cervix is not changed in shape and size. The whole organ generally lies beneath the tumor, and the elastic sound will not pass very deeply into the cavity. If the uterus is attached to the anterior part of the tumor, which sometimes happens, the elastic sound will pass into it and the depth will not be very great. The fibro-cystic tumor may be distinguished from the enlarged encysted kidney by the facts that the kidney is traceable to one side more than the other, and it cannot be reached by the finger through the vagina or rectum. Still, if we cannot make the differentiation clear in any other way, we can generally do so by aspiration. In most cases we cannot draw the fluid from the fibro-cystic uterine tumor; in almost all cases the quantity removable in that way is small. When fluid is drawn, it usually coagulates, contains hæmatin, and none of the cells so generally found in ovarian tumors.

The fluid drawn from the kidneys presents epithelial cells, is not coagulable, certainly does not coagulate spontaneously. The abdominal cavity is sometimes more or less filled with peritoneal serum. After this is withdrawn from the peritoneal cavity the uterine attachment of the tumor may be made out by bimanual examination, as above directed, if undertaken immediately after the evacuation.

PROGNOSIS.—Less than twenty years ago the general prognosis to be made upon the discovery of a tumor of the uterus was very grave. The profession knew so little about the clinical history and diagnosis of these [p. 255] tumors that they were invested with many of the bad qualities of other tumors, with which they were so often confounded; and we had so little knowledge of their nature and the measures which would influence their growth that we felt an entire helplessness in the treatment of them. Fortunately, there have been many favorable changes in these respects. We understand their clinical history better, and can make a pretty clear diagnosis. We know that relatively few of them prove fatal even when left wholly to nature. Compared to all other uterine and ovarian growths, they are innocuous. Most of them are self-limited in consequence of the mode of blood-supply. A goodly number not only stop growing, but disappear without the application of any remedial measures. Then, as I shall have occasion to show, they may be often cured by the judicious administration of medicines, and the surgery for their extirpation has become a reliable resort in extreme cases. These considerations render the general prognosis of the true fibrous tumor quite hopeful. The menopause generally starves them out, and thus removes all the bad qualities they may possess.

When they lead to fatal results, they generally do so through three different conditions—viz. hemorrhage, pressure, and complicating inflammations—and probably in the order mentioned. Hemorrhage is by far the most fatal symptom. The kind of fibrous tumor accompanied with severe hemorrhage is usually the submucous variety. The submucous tumor with a broad base is the most mischievous, because it induces great hypertrophy in the vascular system of the mucous membrane especially, and also the vessels of the whole organ. A sessile submucous tumor arising from one nucleus is worse than one in the same situation with several nuclei of origin. The intracorporal polypus or pendulous tumor is almost as bad in this respect as the sessile submucous, especially if it originates at or near the fundus. Fortunately, these forms of the tumor are more amenable to the effects of medicine and more accessible to surgical treatment. The tumors located in the central stratum of fibres are next to these in mischievous qualities. The more remote the tumor is located from the mucous membrane, the less hemorrhage will attend its development.

When the tumor becomes cystic the danger from pressure is very much greater; yet the solid form becomes sometimes so large as to do much mischief from pressure upon the abdominal organs; and any of these, except perhaps the polypoid variety, may be so situated as to cause mischievous if not fatal pressure upon the pelvic organs.

It is rare, however, that the pressure in either of these cavities proves fatal, especially when the case is under intelligent management. The supervention of inflammation in the tumor, even to a moderate degree, is very apt to lead to gangrene and death from peritonitis, shock, or septicæmia. Sometimes subacute inflammation of the peritoneal surface of the tumor gives rise to serous effusion or dropsy in the abdominal cavity that proves fatal; and, as before stated, peritonitis sometimes causes adhesions which result in augmented vascularity and consequent increase of blood-supply. This condition, I believe, often changes a solid to a fibro-cystic growth, a more highly vitalized tumor, and consequently a more mischievous one.

Do these tumors ever become sarcomatous or malignant? I do not [p. 256] believe they have any innate tendency of that kind. Where they are found complicated with malignant growths I believe the malignancy is an independent quality, and is an invasion resulting from some cause extraneous to its organization, and in that respect is analogous to an attack on the cervix or other portions of the uterus.

The prognosis when complicated with pregnancy is of course more grave, but experience has demonstrated the practicability of complete and normal gestation. Conception will not often occur where these growths have attained any great size, but may sometimes. Of the nine cases which I have met and had an opportunity to follow, not one has been attended with abortion or premature labor. In one the pregnancy seems to have been protracted at least four weeks. The foetus was in a state of decomposition, and had probably been dead four or five weeks before labor began. What is not less remarkable also is that labor did not seem to be seriously affected in but one case, and in that the difficulty was easily overcome by turning.

Until lately there were several supposititious sources of danger at the time of confinement—viz. inefficient uterine contractions, and consequent tedious or impracticable labor, and after expulsion or artificial removal of the foetus dangerous hemorrhages from the same cause; also, the possibility of the placental connection being made at the site of the tumor, with the imperfect closure of the sinuses that was supposed to follow.

Reports of cases occurring within the last few years, while they have not completely swept away the grounds for such apprehensions, prove that the accidents so greatly feared do not in fact occur. Chadwick reports a case where the placenta was attached to the mucous membrane over the tumor, yet the placenta was spontaneously expelled and there was no considerable hemorrhage. The efficiency of the expulsive efforts were not materially affected in any of the cases I have attended. And this is what we might expect, because conception and gestation would not be perfect where there is not a sufficiency of healthy mucous membrane, upon which a normal decidua could be formed, and of fibrous structure to permit the hypertrophy of gestation.

The apprehension of obstruction from the tumor lying in such a position as to intercept the expulsion of the foetus is not often realized; for those in the cervix, either pendulous or otherwise, are pressed out of the external parts in advance of the head, while those in the body and fundus are lifted up into the abdominal cavity, where there is plenty of room. It must indeed be rare that the tumor becomes impacted in the pelvis so as to interfere with the passage of the foetus.

Neither does the puerperal condition seem to be rendered materially more dangerous in consequence of the presence of these tumors.

What effect does pregnancy have upon the growth of these tumors? It might be supposed, from the plentiful supply of blood afforded them by the growth of the vascular system of the uterus, and from the fact of their being situated in and surrounded by tissues in a state of active hypertrophy, that the tumors would grow in a corresponding degree with the uterus itself; but this is not generally, if it is ever, the case. I have not witnessed a decided increase in the size of the tumor in any of my cases. Pregnancy usually produces the opposite effect; and this can be easily understood when we remember that the tumor is subjected to great [p. 257] and uniform pressure, which prevents its own circulation from becoming as great as it otherwise would be; and I think this pressure often inaugurates a retromorphosis that results in the final disappearance of the tumor. Whether degeneration begins during pregnancy or not, the tumor is very apt to disappear after pregnancy and labor. In six of my own cases the tumor disappeared by a slow process of some kind after labor. Speculating as to what might be, another apprehension of danger arises out of the tumultuous excitement and terrible pressure to which it is subjected during the throes of parturition. But this apprehension is rarely if ever realized.

TREATMENT.—The treatment of fibrous tumors of the uterus consists largely of the means calculated to relieve such symptoms as endanger the life of the patient or materially affect her general health. When these are unavailing resort is had to measures calculated to get rid of the tumor. Some remedies necessary to the relief of symptoms act as very powerful curative agents; hence, while it is convenient to speak of the treatment of symptoms under one division of the subject, and the methods employed for radical cure under another, we cannot, in fact, completely separate these two branches.

Hemorrhage is by far the most important of the symptoms connected with these growths, because it is at the same time the most frequent and hazardous. It is also the symptom that leads to most suffering in consequence of depriving important organs of the blood necessary to support them in their functions. Every reasonable means should be made use of, not only to prevent fatal losses, but also to prevent moderate hemorrhage. In the outset, therefore, I would insist upon watching with great vigilance to prevent any unusual loss of blood. It is not advisable to temporize by adopting the milder and less efficient measures as being sufficient for cases not likely to prove fatal, but we should treat all hemorrhages arising from this cause with promptitude and energy. Fortunately, in many cases we can anticipate the attacks of hemorrhage, because we know when they will occur, and we are generally able to judge of their probable severity. To discharge our duty in this respect effectually, our patient should be properly provided with remedies and fully instructed how to use them. She should be made to understand that unusual hemorrhage at the menstrual period may be checked without endangering her general health. Among the remedies are—dorsal recumbency with the hips elevated, cold to the hypogastric region and cold to the dorsal spine and sacrum, ergot, and some form of tampon. The best fluid extract of ergot in drachm doses, if the stomach will bear it, is probably the most efficacious, but the fresh drug in the form of infusion is also very efficient. Full doses should be given every half hour when there is much loss, until some effect is produced upon the hemorrhage, and then continued every four hours as long as necessary. Compressed sponges saturated with the solution of sulphate of alum make the best tampons for the patient to make use of. These may be made and kept in readiness, so that they can be introduced as soon as they are found necessary. The patient or nurse can make them by taking a fine sponge, large enough to fill the vagina, passing a piece of string through the centre to aid in its removal, and then, after dipping it in the solution, winding it with twine from one end to the other, compressing it into as small [p. 258] a space as possible. The twine should so compress the sponge as to make it assume an elongated form. It should then be laid aside and permitted to dry. Several sponges should be thus prepared. When necessary the twine may be unwound and the sponge introduced. Its size when in the dry condition will allow of an easy passage into the vagina, where the moisture will cause it to expand, and fill up and seal the vagina so as to absolutely check the discharges. If the attending physician is present, he may tampon the vagina with pellets of cotton secured by thread and moistened with a solution of alum. The inconvenience experienced from this plug will be more than counterbalanced by the saving of blood. This form of tampon has the additional advantage of being antiseptic. I have allowed it to remain for three days, and upon removing it satisfied myself that there was no decomposition of the blood or the vaginal secretions. When the tampon is removed it will not be found difficult to wash out all the granular clots caused by its presence. It may be repeated as often as necessary, but usually, if allowed to remain forty-eight hours, the hemorrhage will not return. It may be said that for small losses this is unnecessary, but it is convenient and harmless, and will answer the purpose. In dangerous cases no one will question the propriety of its employment.

Another very important means of arresting hemorrhage which can be used by the physician when necessary is the introduction of a compressed sponge into the cervix uteri. This will temporarily act as a tampon and stimulate the uterine fibres to contraction. The free incision of the cervix, as directed by I. Baker Brown, may be tried between the times of the paroxysms of hemorrhage.

The pressure of the tumor upon the pelvic viscera is another inconvenience which calls for attention. This takes place usually at a time when the tumor has acquired a size sufficient to fill the pelvic cavity. Consequently, the elevation of the tumor above the pelvis is the remedy. This may be done sometimes by placing the patient in the knee-elbow position and pressing the growth upward. The powerful influence of atmospheric pressure called to our aid by the position and opening of the vagina is a very material auxiliary in the process of elevation. If this is not sufficient, we may pass the fingers into the rectum and elevate the tumor. I once succeeded in this operation by using an ivory-headed cane in the rectum when the fingers failed to reach high enough. If we cannot elevate the tumor by any of these means, we may introduce into the vagina or rectum a gum-elastic bag, and by means of a powerful syringe fill it with water to as great distension as the patient will bear, permit it to remain, and thus do the work more gradually.

Dysmenorrhoea is another symptom of fibrous tumors, and sometimes a very distressing one. It depends, no doubt, on the imprisonment of blood in the uterine cavity in consequence of the tortuosity of the canal causing the closure of some part of it. The remedy consists in dilating these narrow places. I know of nothing so well calculated to effect this object as the slippery-elm tent. One or more of these tents, long enough to reach the fundus uteri and of sufficient size, moistened so as to render them very flexible, may be passed up through the tortuous places with great facility. If introduced as soon as the symptom begins to manifest itself, and allowed to remain an hour or two, the relief will be pretty [p. 259] certain. If used once a day for four or five days before the attack, and three or four hours at a time, dysmenorrhoea may be generally avoided.

Curative Treatment.—When we broach the question of the permanent cure of these affections, we find that great difference of opinion exists among the members of the profession as to the value of medicines. One party, perhaps a majority of the profession, believe that no medicine has any direct effect upon them, and these ignore any means of permanent relief but surgical. There is, however, a respectable number of medical men who place great reliance upon the administration of certain medicines, and, if I am not greatly mistaken, recent observation has added greatly to their number. They do not, however, wholly agree as to the therapeutic processes that should be instituted, and consequently do not employ the same kind of medicines. Some gentlemen have more confidence in what I will term the sorbefacient medicines and processes of treatment. They endeavor to institute measures that will cause the absorbents to attack and remove the neoplasm in the same way that tumefactions caused by effusions are removed. This they do by friction, pressure, and the administration of the old-fashioned sorbefacient medicines. The most popular among these are the iodides, chlorides, and bromides of mercury, potassium, sodium, calcium, and ammonium. Reports may be found in books and periodical medical literature of cures by several if not all of these articles and their combinations. The late W. L. Atlee, whose experience was very extensive, had great confidence in the action of hydrochlorate of ammonia. He administered it internally, applied it externally, and used it as vaginal injections. The iodide of potassium has long enjoyed a great reputation in causing the absorption of these and other forms of tumors. There is no professional fairness in assuming that the faith in these remedies derived from the observation of their effects or the promulgation of cures from the use of sorbefacient measures are fallacious. Some of the men arrayed in favor of the opinion that cures may be effected by a patient and long-continued administration of some one of the articles I have mentioned stand high as men of honesty, accuracy of observation, and faithfulness in their records; and therefore I give full confidence to their statements. Yet I must also say that I have not witnessed the good results which I unhesitatingly believe others have seen from the sorbefacient treatment alone.

Others who expect much from medicinal treatment look to that class of medicines which cause contraction of the unstriped muscular fibres as the most promising. With these medicines they expect to diminish the supply of blood to the tumor by causing contraction of the arterioles traversing their substance, and thus disturbing their nutrition to such a degree as to stop their growth, lessen or destroy their vitality, and so render them subject to the influence of the absorbents, whereby they may be removed. Some of the more energetic of these medicines—as ergot and belladonna, for instance—often affect these growths very promptly. Ergot not only lessens the calibre of the small blood-vessels, and thus causes a diminution of their nutrition and disappearance, but it causes strong contractions in the muscular fibres of the uterine walls, which lessen more decidedly their supply of blood. It sometimes squeezes and chafes the tumor until it is disintegrated and rendered a foreign substance. [p. 260] The capsule finally becomes ruptured, and the tumor is expelled either piecemeal or en masse.

When properly administered, ergot frequently greatly ameliorates some of the troublesome and even dangerous symptoms of fibrous tumors of the uterus—e.g. hemorrhage and copious leucorrhoea; it often arrests their growth; in many instances it causes the absorption of the tumor, occasionally without giving the patient any inconvenience: at other times the removal of the tumor by absorption is attended by painful contractions and tenderness of the uterus; by inducing uterine contraction it causes the expulsion of the polypoid variety of the submucous tumor; in the same way it causes the disruption and discharge of the intramural tumor. There are many cases on record to substantiate every one of these propositions.

From what I consider well-authenticated sources, including the cases under my own observation and in the practice of my friends and neighbors, I have collected 136 cases of fibrous tumors treated by ergot. Of these, 25 cases were cured without giving the patients any inconvenience from painful contractions. In 46 cases the tumors were diminished in size and the hemorrhage was cured. In 27 others the hemorrhagic symptom was relieved, while the size of the tumor was not affected. In 8 other instances the tumors were broken to pieces and expelled piecemeal.

For examples of cases in which the first conditions obtained, I would refer to those cured by Hildebrandt; of the other examples, 4 were reported to me by the late J. P. White of Buffalo, N. Y., 1 each by the late Hodder of Canada and Jukes, and 11 that occurred among my immediate acquaintance and in my own practice.

Among those in which the hemorrhage was cured and a diminution of the tumor took place, 11 occurred to Hildebrandt, 2 to Chrobak, 5 to White of Buffalo, and the remainder to gentlemen upon whose veracity I have implicit reliance. The most remarkable case of which I have any knowledge was reported to me by the late G. C. Goodrich of Minneapolis, in which absorption of a large tumor took place under the administration of ergot and belladonna. I subjoin his description: "The treatment was commenced in 1870, and continued two years. The uterus filled the whole space between the ilia, and measured in the transverse diameter twelve inches and in the vertical nineteen inches—extended up under the ensiform cartilage and close up to the margin of the cartilages of the ribs. The treatment was followed by cramps in the uterus, which produced a wild enthusiasm in the mind of the patient and inspired her with strong hopes of recovery. Without consulting me she doubled the dose of medicine, which was administered internally, and as a consequence she was attacked with very strong uterine contractions and symptoms of metritis. This caused me to abandon treatment for about one month, and had it not been for the urgent determination of the patient I would not have resumed it. She insisted that as this was the first medicine which had ever affected the enlarged organ, she believed it would cure her, and promised to obey my directions if I would proceed. She so promptly and rapidly improved that I doubted if it were not a coincidence with, rather than a consequence of, the treatment. Prompted by this doubt, I abandoned the use of the ergot and belladonna and continued alterative [p. 261] treatment. The patient soon assured me that she no longer felt the griping pains caused by the remedy, and that the tumor was softer and larger than when she took the ergot prescription. The ergot and belladonna were again resumed, and in four months she was able to make a trip to Boston alone. While absent she continued to take the medicine. From this time she continued rapidly convalescing, and is now in the enjoyment of fine health."¹

¹ The author's address before the American Medical Association at its meeting in 1875.

I subjoin two cases in which the tumors were expelled piecemeal under the administration of ergot, which came under my own observation:

A woman of Sterling, Illinois, called on me December 13, 1875. She was thirty-five years old, married, and had never been pregnant. On the first of the preceding June she noticed a circumscribed hard lump two inches below and to the left of the umbilicus. She was the subject of serious uterine and sympathetic symptoms, for which she had at different times had treatment. She had profuse menorrhagia, leucorrhoea, and great sense of weight in the pelvis. Upon examination I found a hard, round, movable tumor extending up to within two inches of the umbilicus, filling up the whole of the right iliac, the hypogastric, lower half of the umbilical, and more than half of the left iliac regions. The contour of the tumor was somewhat uneven, though not distinctly nodular. The cervix was long, pointed, and thrown backward and to the left. The sound entered the small uterine mouth and passed upward, backward, and to the left five and a half inches. The diagnosis was a fibrous tumor of the right anterior wall of the uterus. I prescribed thirty drops of Squibb's fluid extract of ergot, to be taken three times a day. She went home, but did not commence taking the medicine until the 20th of December. On the 26th of December J. B. Crandall was called to see her, and describes her condition as follows: "The patient was in a state of great nervous prostration and worn out by severe pain and loss of sleep. The pains commenced soon after taking the second dose of ergot, and were excruciatingly severe for about three hours, after which they continued less severely for two days and nights. She had more or less hemorrhage from the uterus after taking the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin was hot and dry, and she complained of great pain and tenderness over the uterus and lower bowels. The feet were drawn up, and the face wore a pinched and peculiar expression." Under these circumstances the doctor administered anodynes, tonics, and nourishment, to the great relief of the patient. On January 11, 1876, the patient began to pass from the vagina small masses of fibrous substance, from the size of a chestnut to that of an English walnut. The substances thus discharged were firm and gray in color, and were exceedingly fetid. This discharge continued up to the 21st of January, when the uterus was very much diminished in size, the tenderness had subsided, and the patient appeared comparatively comfortable. Up to that time she had taken but three doses of ergot—on the 20th of the preceding month—and the doctor ordered it to be resumed again. This time the ergot produced no pain, and after three or four days was discontinued. From the 21st of January there were no more pieces discharged, but up to February 1st a yellowish, thin, offensive fluid passed from the vagina in considerable [p. 262] quantities. On the first day of February the ergot was again ordered and continued two weeks, when, as no results ensued, it was finally dropped. Crandall states that on the 14th of February the uterus was reduced to its normal size, and on the 26th the patient was up and about her work, completely cured. He remarked, in this connection, that the first three doses of ergot taken by the patient was the cause of her recovery.²

² This case is published in the August (1875) number of the Chicago Medical Journal and Examiner, as reported by Crandall.

Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the anterior wall of the uterus, which, with the enlarged uterus, arose to within two inches of the umbilicus. She commenced taking thirty drops of the fluid extract of ergot on the 22d of September, 1876, and was to increase gradually the dose with the object in view of causing the disruption and expulsion of the tumor. The ergot at first produced no perceptible effect until she had taken it ten days, when she began to experience the pain of contraction. The pain became so severe and continuous that it was necessary to omit it for two or three days at a time. The patient was intelligent and understood the object and mode of action of the ergot, and when the pain entirely subsided she courageously resumed it in the smaller doses, and increased again until the pains became intolerable. On the 13th of January, 1877, small pieces of the tumor showed themselves in the vaginal discharges, and by the 26th of the same month the whole of it had been discharged piecemeal. She wrote me on the 30th of January, saying, "I think I wrote one week ago to-day. At that time the tumor was passing. It continued to pass until the 26th, when, I think, the last was expelled. To-day I send you by express a portion of the last that came. I think the whole of it, including the portion I send you, would have weighed one and a half pounds. I do not believe a quart can would hold it if the whole had been preserved. It commenced to come on Saturday, and from Saturday evening to Sunday morning there was a pint or more. After that the stench was so disagreeable that we could not cleanse it; consequently we threw it away. Wednesday and Thursday it seemed to be in one continuous mass. I cannot better describe it than to say that it came like sausage-meat from a stuffer. I would cut off about four inches a day—that is, on Wednesday and Thursday. On Friday morning the last of it came away." During and for some days after the expulsion she suffered slight symptoms of septicæmia, but recovered from them, and in the course of a month afterward she visited me, when I found the uterus measured two inches and a half in depth. She then had some leucorrhoea, but was fast regaining her health. She is now perfectly well, and has passed in safety the menopause.³

³ This case—the abstract of which I have here given—was in the May (1877) number of the Archives of Clinical Surgery, N. Y.

I have known 9 cases in which the tumors were expelled piecemeal by ergot, with but 1 death. The death occurred in a patient who rode one hundred and fifty miles on a railroad train to see me with pieces of the tumor hanging from the vagina, which she would not allow her physician to remove. When she arrived I passed my fingers up into the contracted capsule and scooped out the remaining portion of the tumor. She was so exhausted, however, by the journey and the sepsis that she died three [p. 263] days afterward. I cannot help believing that if she had remained at home and submitted to the treatment of her physician, her life need not have been sacrificed.

The influence of ergot over the uterus has been a familiar fact to the profession for a long time. It is not long, however, since we were aware of its effects upon the muscular fibres entering into the formation of other organs. We now know that this medicine acts upon the unstriped muscular fibre wherever found, whether in the viscera or in the vessels of the body.

The fibres of the uterine walls, and the arteries supplying them with blood, both belong to this class; this fact in the formation of the uterus renders it particularly susceptible to the action of ergot. The drug acts upon the uterus⁴ in a threefold manner, and causes a diminished flow of blood to the morbid as well as healthy tissues in the uterine structure.

⁴ From the author's address before the American Medical Association, 1875.

First: the calibre of the arterial tubes is diminished by the contraction of the muscular fibres which enter into their composition. Second: the arterioles are diminished in size by compression from the contraction of the uterine muscular fibres which surround them. Third: these vessels are distorted and drawn in diverse directions by both the contraction and compression, and hence are rendered less fit for sanguineous conduits.

Another consideration of prime importance is that, under the influence of these medicines, the nutrition of fibrous tumors is interfered with, not only from diminution of blood in their tissues, but also from compression of their substance by the proper fibres of the uterus, and are therefore made more susceptible in the process of disintegration and absorption.

The great influence exerted by ergot over the circulation of the uterus is rendered more efficacious in the removal of fibrous tumors of that organ, because of the peculiar organization of the growths. It is now pretty well understood that this neoplasm is not very generously supplied with arterial blood, and that its supply is derived from numerous minute vessels instead of one or two of large calibre. From these circumstances it results that its vitality is very low, its circulation easily disturbed, and consequently its nutrition impaired.

I think we are justified from observation in assuming that the action of ergot may be graded from an almost imperceptible to a very intense degree. Probably the first degree affects the vascular supply; the second, in addition to this, causes so much contraction as to merely render the fibres tense without causing pain; and the third prompts the uterine fibres to vigorous and painful contraction.

This inference is plainly deducible, I think, from the several modes by which tumors are made to disappear under its action, as well as from direct observation of the uterine fibres.

I will now venture to call attention especially to the manner of expulsion of the polypoid and submucous intramural varieties. It will be seen that when the uterus contracts all the fibres unite in pressing the polypus through the cervical canal, which is usually already shortened, and rendered dilatable in consequence of its increased vascularity. The cervical canal dilates, and after more or less painful efforts the polypus is expelled entire, covered by the mucous membrane. This membrane is often in a [p. 264] state of gangrene, but so far as I have observed these cases the tumor is not broken to pieces.

A submucous intramural tumor has a thin layer of fibres separating it from the mucous membrane, and a thick and heavy layer spread over its external hemisphere. A greater part of the muscular wall is therefore applied to the outer side of the tumor. If in this position all the fibres of the uterus vigorously contract, the fibres near the mucous membrane must be overcome by the heavy layer outside. But the opposite wall plays an important part by supporting the weaker layer at the fundus of the tumor, and adding its own force in overcoming the capsule, where it usually gives way. The position of the tumor makes its escape from the concentric action of all the fibres of the uterus impossible, and every one knows that when the resistance is partially overcome the uterus is stimulated to more vigorous action, and the pains will not abate until the mass is expelled. If not too large, it is driven out without undergoing great laceration, but if its size and attachments are such as to make this impracticable, it will be broken into fragments and expelled piecemeal.

In subperitoneal tumors there is, next the uterine cavity, a thick and strong stratum of fibres, while immediately under the peritoneum the layer is very thin and comparatively weak. When the uterus is acting with vigor the former contract forcibly, and the mass becomes pedunculated; but that is all, for the tumor lies outside the field of concentric action and escapes the crushing influence to which the submucous variety is subjected. The amount of force exerted upon it is that exercised by the weaker layer of fibres in a state of conquered antagonism, and the rupture of the capsule is impossible.

In the case of a fibroid tumor situated in the central stratum of fibres the antagonism is equal at all points, and it is evident that there is no tendency to rupture of the capsule, and much less crushing influence exerted upon it than if it were situated slightly nearer the mucous membrane. This variety of the tumor, therefore, yields to ergot only as it may be starved out by diminution of its blood-supply and as the effect of pressure, which we all know are the two conditions most favorable to absorption.

Now I think we have arrived at a point in this investigation where we can draw inferences as to the forms of tumors likely to be effected by ergot in different ways, as well as those that will not be effected by it. We do not expect ergot to cause painful and efficient contractions in the healthy unimpregnated uterus; its fibres are not capable of such contraction, and it is not until the fibres have become greatly developed that they are susceptible to the impressions of ergot. In cases of early abortion its action is very unreliable, but after the fourth month of pregnancy it acts quite efficiently.

In tumors of the uterus the development of the fibrous structure is sometimes so slight that it is incapable of contraction; there may be so many nuclei of degeneration that there are not enough sound fibres left for efficient contraction. Then, where there are many small tumors developed in the uterine walls, the circulation is cut off to such a degree that they degenerate into a cartilaginoid substance, and sometimes they are infiltrated with calcareous material. In none of these cases will ergot cause any appreciable results. When, however, there are [p. 265] but one, two, or three nuclei of morbid growths, as they increase in size the fibres undergo the development necessary to enable them to contract with great efficiency and render them susceptible to the influence of ergot.

Another condition which influences the hypertrophic growth of the fibres is the situation of the tumor. Subperitoneal tumors do not cause as great growth in the fibres of their neighborhood as the intramural or submucous varieties. A single intramural tumor causes great development of the whole uterine tissues, but the development of the wall in which it is situated decidedly predominates. The submucous neoplasm so soon gains the uterine cavity that the development is nearly the same in the whole organ. When, therefore, we administer ergot for the cure of fibrous tumors of the uterus, the beneficial action of the drug will depend upon the degree of development of the fibres of the uterus and the position of the tumor with reference to the serous or mucous surface. The nearer the mucous surface, the better the effects. If the tumor is very near the lining membrane, we may hope for its expulsion en masse or by disintegration.

We can often select the cases in which good results may be expected. There are four conditions which are usually reliable for this purpose: they are—smoothness of contour, hemorrhage, lengthened uterine cavity, and elasticity. A smooth, round tumor denotes, for the most part, uniform textural development, hemorrhage, a certain proximity to the mucous membrane, a lengthened cavity, great increase in the length and strength of the fibres; and elasticity assures us of the fact that cartilaginoid or calcareous degeneration has not begun in the tumor.

An even, nodulated tumor may be composed of many separate solid masses. These displace and prevent the growth of the fibres to such an extent as to render contractions inefficient. When hemorrhage is not present the tumor is probably near the serous surface, and consequently not surrounded by fibres. A short cavity denotes short, undeveloped fibres, while hardness is indicative of unimpressible induration.

Although I have no experience in the use of ergot in such cases, I should expect large fibro-cystic tumors to resist the action of ergot.

From this view of the subject it will be seen that I freely admit that there is a large number of cases in which ergot cannot produce any good results, in consequence of the nature of the cases; but there is another reason of equal moment why ergot may fail to act upon such cases as would seem to be favorable—by the worthlessness of the drug and its preparations. Squibb of New York, a high authority, says in reference to this subject: "The molecular constitution of the active portion of the drug seems, however, in its natural condition to be loose, and, like a slow fermentation, to be undergoing slow molecular changes, so that by age its peculiar activity is slowly diminished until finally lost." And again: "The ergot in the grain, however well kept, is known to become inactive without any known change in appearance, though the sensible properties, such as odor and taste, may and probably do not change. Ergot in powder is known to diminish in activity much more rapidly than when in grain, and probably soon becomes inert. The tincture and wine of ergot are believed to change, though more slowly than the ergot in substance, whilst the extracts and so-called ergotins are all supposed to change more rapidly."

When all these causes of failure are considered, the variety of [p. 266] experience met with in the reports upon its trial in the treatment of these tumors is not surprising. It should not, however, be discouraging, but should prompt us to more care in selecting the cases and securing reliable preparations of ergot. I have implicit faith in the action of ergot when all the conditions I have pointed out are present. I do not believe it to be uncertain in its action.

In addition to the above conditions, I believe perseverance an indispensable condition to success, as it often requires several months to get the best results.

The mode of administration should be governed by the objects to be attained. If we desire to cause the painless absorption of the tumor, the doses ought to be moderate in size and not too frequently administered. Hildebrandt administered by hypodermic injection a preparation containing from fifteen to twenty grains of the crude drug to the dose once daily or once every other day; and once a week will often be sufficient, as proven by cases cited in my address, quoted above. If we desire to have the tumor expelled, we should administer full and increasing doses often repeated, and continued until the object is attained. It will sometimes be necessary to vary the quantity and times of giving it to suit the susceptibility of the patient—less or more according to the amount of pain caused by it.

It is not essential to give it hypodermically, although when it does not produce much inconvenience this is a very efficacious method; it may be given by the mouth, in suppositories, per rectum, etc.

In conclusion, I desire to disclaim any expectation that ergot will supplant other modes of treatment. The expert surgeon will, as he always has done, use his instruments to the neglect of remedies less summary in their effects, and in his hands the maximum of safety will obtain; but there are very few general practitioners who ought or would be willing to undertake enucleation of fibrous tumors of the uterus.

Surgical Treatment.—The surgical processes resorted to for the cure of fibrous tumors of the uterus vary in their nature and gravity with the relations of the growth to the different strata of the uterine fibres. The nearer the mucous membrane, the simpler, safer, and more successful the operation for their removal; the more remote from it, the greater the difficulty and danger. Proximity to the cervix is another element of facility and safety. The removal of the cervical polypus is scarcely ever followed by serious consequences. While a polypus situated at the fundus requires greater complexity in the operation for its removal, and must be regarded as a serious one, the difficulty of removing the submucous tumor more remote from the mucous membrane is increased the higher up in the organ it is situated.

Polypi may be removed by torsion, excision, and écrassement; any one of these operations may be successfully and safely employed. No preparation of the patient is usually necessary for the removal of the cervical polypus, because it is accessible under ordinary circumstances. In very rare instances in the virgin or senile condition the vagina may require dilatation. The polypus attached at the body or fundus is not accessible to any of these operations until the mouth of the uterus is sufficiently dilated to permit the introduction of the instruments in the uterine cavity, or until the tumor is in part or wholly expelled.

It will therefore generally be necessary to completely dilate the cervix with sponge, tupelo, or laminaria tents or the fingers. The fingers, when the object can be accomplished by them, are much the better instruments for dilatation. I have several times accomplished the dilatation of the cervical cavity and removed an intra-uterine polypus in the course of half an hour by the fingers.

I prefer torsion, and believe that when properly performed it is the most simple, expeditious, and safe plan of removing a polypus. The tissues entering into the formation of the neck of a polypus are an extremely thin layer of fibres and mucous membrane. We cannot always be sure of placing the écrasseur or applying the knife or scissors exactly at the point of junction between the substance of the polypus and uterine wall; but, as that is the weakest point, it invariably yields to the force applied in the operation of torsion. The tumor is thus completely removed, and without protracted manipulation. No hemorrhage results, for two reasons: (1) there are no large vessels entering the tumor, and the small ones are torn instead of being cut, as in amputations; (2) septicæmia does not occur, for no portion of the tumor is left to slough. In performing this operation the operator must guide a vulsellum with his fingers high enough on the tumor to enable him to fasten the instrument upon or near the central part of the polypus. In two instances, when the tumor was too large to be firmly held by any forceps at my command, I introduced the hand inside the uterus and detached the tumors by rotating them, afterward making traction with the forceps. I brought them into the vagina and delivered them with the obstetrical forceps. One of these weighed forty-six ounces.

To perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position, should be careful to twist it enough to be sure of its detachment before commencing traction. Not less than from four to six complete revolutions should be effected. This procedure will prevent the danger of lacerating the tissues of the uterus.

The greatest objection urged against the operation of torsion is the likelihood of lacerating the wall of the uterus at the point of attachment. If we call to mind what was said about the relative thickness of the muscular strata upon each side of the different kinds of fibrous tumors, we will at once perceive the groundlessness of this objection. In the pendulous variety the whole wall of the uterus is outside the point of attachment, and is strong enough to resist the very few fibres that are carried down with it. Indeed, the polypus has almost no substantial attachment except that formed by the investing mucous membrane. If, therefore, the torsion is performed with sufficient thoroughness before traction is begun, laceration of more than the superficial tissues surrounding the neck of the tumor is next to impossible; consequently the operation is perfectly safe.

Hemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife or scissors, or even by the écrasseur. The danger of hemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. I have never seen hemorrhage succeed torsion. The contractions of the uterus which take place after removing the polypoid growth from the cavity of the uterus in the great [p. 268] majority of cases is as effective in the prevention of hemorrhage as it is when its contents are expelled at the time of labor. I trust that it is not necessary to dilate further upon this part of the subject. However, hemorrhage, although improbable, is yet possible, and we should therefore be prepared for it. After what has been said under palliative treatment about the management of this complication, it will not be necessary to enlarge upon that point. I would therefore refer the reader to the remarks there made.

After an operation of this kind the only treatment necessary is perfect quietude for a few days, cleanliness by injections if needful, and the administration of anodynes to quiet pain. When a tumor has been removed from high up in the uterus, the patient of course should be carefully watched, and if symptoms of inflammation or septicæmia arise they should be treated by suitable remedies.

I will commence what I have to say on extirpation of deeper tumors by assuring the inexperienced that the formidable operations required for their removal are very seldom necessary, and should not be resorted to until all other and less hazardous efforts have been made.

The operation of enucleation is applicable only to cases of sessile submucous tumors, such growths as are nearer the mucous than the serous membrane. If enucleation is practicable in tumors which have their origin in the central stratum of the wall of the uterus, the operation must be regarded as equally hazardous, if not more so, than laparo-hysterectomy. I am aware that such operations have been recorded, but it is so easy to be at fault with reference to the exact point of origin that I must be permitted to doubt—not the honesty of the operators, but the accuracy of their observations. In many cases of submucous tumors the cervix is dilated so much that immediate dilatation with the fingers or hard-rubber olive-shaped dilators will be practicable. When that is not the case, the cervix must be thoroughly opened by sponge, sea-tangle, or tupelo tents or bilateral incision: the more patent the mouth of the uterus can be made the better. The operation is so serious in its nature that the competent surgeon will study his preparations so carefully as to avail himself of every means that will enable him to perform it in the most expeditious and complete manner. Expedition, rendered possible by thorough preparation, is a most important item; for it must be understood that every superfluous moment spent in enucleation increases the peril of the patient. I would not counsel haste, but the earnest and careful despatch acquired by reflection and experience. When the patency of the mouth of the uterus is secured, the uterus should be drawn to or near the vulva by a strong vulsellum and firmly held by an assistant. The operator may then make an incision with scissors entirely across the most dependent part of the tumor, completely through the capsule. After this is done, another incision is to be made from the centre of this cross-cut upward upon the most prominent part of the tumor, as high as the instrument can be guarded by the fingers. The fingers should then be inserted between the tumor and the capsule, and the latter separated as extensively as possible from the former. In some cases a large part of the tumor may be thus detached from its envelope. When the whole of it cannot be detached by the fingers, Sims's enucleator may be made to finish that task. It can be passed up and around the upper and less [p. 269] accessible portion. The detachment should, when possible, be complete before traction is begun. The traction is affected by a strong vulsellum. By that instrument the tumor, after being firmly seized, can often be rotated upon its longitudinal axis to assure the operator that it is loosened at every point. Simple, firm, but slow traction, aided by pressure of the hand on the upper part, will assist the uterus in expelling the growth. Should the tumor be too large to pass the mouth of the uterus and vagina, it may be divided by well-directed efforts with the scissors or knife and removed in pieces. When the tumor is semi-pedunculated the capsule may be separated by Thomas's serrated spoon in a much more expeditious manner. As the tumor is drawn out of its cavity the uterus usually contracts, and thus prevents the hemorrhage that might otherwise occur. The surgeon, however, must always be prepared with plenty of cotton saturated with the subsulphate of iron with which to plug the uterine cavity. It will very seldom be necessary to use the ironized cotton, and it should not be employed until its necessity is apparent. The after-treatment consists locally in detergent and disinfectant injections, and in such general measures as will aid in reaction where there are symptoms of shock and counteract the tendency to inflammation. For both these purposes a liberal amount of opium will be very useful.

When the symptoms in connection with a tumor situated in or slightly outside the centre of the wall of the uterus are so urgent as to demand surgical interference, the choice of operations lies between laparo-hysterectomy and öophorectomy. In the light of recent observation I have no hesitancy in recommending the former for large tumors and the latter for small ones. As before stated, I regard enucleation in such cases as hardly practicable, and when successful I believe it is attended with as much danger as the entire extirpation of the uterus.

Without entering into details of this operation, I will state that it is so like ovariotomy as to be governed by the same principles and require to a great extent the same methods. The incision should be sufficiently free to permit the removal of uterus and tumor without the necessity of cutting away the tumor in pieces, as thus mutilating it gives rise to great and dangerous hemorrhages and of necessity soils the abdominal cavity. I have always used silk ligatures with which to secure the pedicle. In most instances we will be obliged to ligate the uterus near its junction with the vagina. Extra-peritoneal treatment is probably safer.

Where a small intramural tumor is attended with exhausting hemorrhage, menacing the patient with a probable fatal loss, and other remedies have been found inadequate, öophorectomy may with great propriety be resorted to.

I would refer the reader to the description of this operation as given elsewhere. There is no other surgical operation by which a large fibro-cystic tumor can be gotten rid of than laparotomy or laparo-hysterectomy. Recently I have removed a large fibro-cystic tumor that grew from the anterior surface of the fundus and body of that organ without removing the uterus. The tumor was detached by a sort of enucleation, and the detachment left a large bleeding surface. Hemorrhage from that surface was profuse, and seemed to issue from numerous cavernous openings instead of veins and arteries. The hemorrhage was checked by [p. 270] passing silk ligatures one-eighth of an inch beneath the surface from one side to the other of the bleeding surface in several places. When these ligatures were tightened the tissues were so condensed as to entirely control the bleeding.

This was my fourth laparotomy for fibro-cystic tumor of the uterus, and the only one that recovered. In all the other three I ligated the uterus and removed it at the internal os.

Large subserous, fibrous, or fibro-cystic tumors are almost always covered with a network of great vessels, generally furnished by adhesions to the omentum. These vessels should be ligated in bundles by two ligatures around each bundle at least two inches distant from the uterus. If the two ligatures are not thus widely separated from each other, when the division between them is made the collapse and retraction of the vessels will be so great that they will not hold. If in detaching adhesions a bleeding surface is left on the tumor or abdominal wall, the bleeding should be arrested by ligatures applied before the tumor is lifted from its bed. When it is necessary to remove the uterus, a double ligature around its substance should be applied; also, when practicable, before the tumor is lifted out. In this method of securing the vessels we will avoid the terrible hemorrhage that would otherwise follow the removal of the tumor. The pedicle should then be brought out and secured by pins in the wound. The cleansing of the peritoneal cavity and closure of the wound should be done as in ovariotomy. The after-treatment is also the same as in bad cases of ovariotomy.

I have not thus far mentioned the treatment of fibrous tumors by electrolysis; and as the profession has not generally consented to the adoption of this measure as safe and efficacious, I will refer the reader to an account given of that process and its results in my work and other standard works on gynecology.

SARCOMA OF THE UTERUS.

This disease is as much entitled to the clinical definition given to cancer as any of the varieties of that malignant affection. Miller, as quoted by West, says: "Those growths may be termed cancerous which destroy the natural structure of all the tissues; which are constitutional from their very commencement or become so in the natural process of their development; 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." If we substitute the word malignant for cancerous in the above quotation, the definition would include sarcoma as well as carcinoma. It will be found upon comparing sarcoma with fibrous and cancerous tumors that it possesses clinical and histological features common to both. If it is not indeed the result of a transition of fibrous tumors into a malignant form of disease, it is a connecting link between fibromatous and carcinomatous affections, and illustrates in a remarkable manner a relationship of these two forms of growths—viz. the morbid proliferation of the tissue resembling those of the structure in which they originate. Sarcoma has its origin in the fibrous portion of the connective tissue, as do many of the fibrous tumors. It consists of a redundant proliferation of the cells of that tissue, while the fibrous tumor is constituted of a morbid proliferation of the fibrous element of the connective and muscular tissues. Cancer now is admitted to be an excessive production of the cells of the epithelium; this excessive growth of the cells inhabiting these structures, sarcomatous and epithelial, seems to give to them respectively the feature of malignancy. The fibrous tumor is contained in a capsule; both forms of these malignant growths invade the tissues without any such limitation. In this respect the two latter resemble each other and differ from the former. In sarcoma the cells are mingled intimately with the fibres, and are not generally contained in alveoli, or nests, as they are sometimes called. Cancerous cells are always surrounded by alveoli. Sarcoma in many instances resembles very closely the fibrous tumor. In malignancy it is very much like the cancerous tumor.

CLINICAL HISTORY.—The early symptoms of sarcoma are leucorrhoea, hemorrhage, and tumefaction. The discharge from the genital organs resembles that of fibrous tumors. This does not generally possess an offensive odor, but as the disease advances necrosis of the tumor occurs to a greater or less extent, and then the smell of the discharge comes to [p. 272] resemble that of cancer. The necrosis does not take place at the expense of the uterine tissues, but is a process of disintegration going on in the growth. The ulcer resulting does not corrode the uterus, but it eats away the tumor. It in this respect resembles epithelial fungus. The tumor formed by the sarcomatous deposit is sometimes polypoid, and presents the appearance of the fibrous polypus. In other instances it resembles to the touch a submucous fibrous tumor, and again in others it is diffusely disseminated into the whole structure of the uterus. When thus diffused, like cancer it invades the neighboring organs. When the tumor projects from the inner surface of the womb, and has attained a considerable growth, limited necrosis occurs, and sloughs of varying size take place, and offensive sanious discharges occur very similar to the flow observed in cancer.

The general symptoms at first are slight, consisting of obscure pelvic pains and pressure and increased discharge. Gradually septicæmia is developed, and this is the condition in which the patient usually dies.

DIAGNOSIS.—There is nothing in the symptoms by which we can arrive at a correct diagnosis, as in the early periods they resemble those of fibrous tumors so closely as to be undistinguishable from them, and in the latter cancer neither manual nor ocular examination will give us any more definite information. Their qualities in this respect also are in the early stages of development those of fibrous tumors, and in the latter of some forms of cancer. We are therefore reduced to the evidence afforded by microscopical examination.

When the tumor is in such a position and of such a consistence that we can remove a fragment from it, we can study its histology. There are two varieties, as distinguished by the shape and size of the cells. One variety is called the small-celled sarcoma, from the size of the cells; they are round, or nearly so, in shape. The other is called the spindle-celled sarcoma. In some specimens of this variety the cells are much larger than others; and hence there is the large and small spindle-celled sarcoma. The cells are different among the fibres of the tissues affected, and in rare instances some of the cells are contained in imperfectly-formed alveoli, in this respect showing a further analogy to the growth in cancer.

PROGNOSIS.—The malignancy of sarcoma is now universally recognized in the known facts of its persistency in returning when removed, and its simultaneous existence in many organs of the body. This acquired or innate constitutional dissemination is not constant—no more than in cancer, perhaps less so. Hence when the size of the tumor is small and apparently isolated there is some encouragement to attempt a cure.

The comparative prognosis is also probably better than cancer, as it pursues a less rapid course of development, and hence the patient may survive for a longer time.

The local dissemination of the cells cannot always be measured, and that their dissemination into the surrounding tissues may reach much beyond the boundaries of the apparent tumor must be regarded as an important element in considering the subject of prognosis in connection with treatment by ablation or cauterization. The widespread local dissemination of the cells of this growth is doubtless an explanation of the term at first applied to it—viz. recurrent fibroid.

TREATMENT.—It will not be necessary to consume the time of the reader by giving the treatment of sarcoma in detail, as most of it is identical with that of Cancer, and may be found under that head. I will only call attention to the excellent palliative effects of ergot: this drug will often arrest, and generally modify, the hemorrhage so often one of the most annoying symptoms. When the tumor is in a state of progressive necrosis, protrudes like a submucous fibrous tumor, or is pendulous, resembling the fibrous polypus, it may, by inducing contraction of the uterus, be expelled, partially if not completely, and thus for the time being do away with the source of sepsis. I have in several instances been highly gratified with its effects in this way. In one case, when the patient was so overwhelmed with symptoms of septic fever as to cause apprehension of immediate dissolution, the administration of ergot expelled large masses of sloughing tissue, and so cleansed the uterus that the symptoms subsided, the patient rallied, and lived several months in comfort. Not less than four times this process of expulsion was successful in relieving the same patient for long intervals: each time the medicine was administered relief was so marked that both she and her friends anticipated recovery.

CARCINOMA OR CANCER OF THE UTERUS.

While it is possible that in very rare instances the scirrhous or colloid form of cancer may attack the uterus, the practitioner will seldom meet with either. I will therefore describe but two varieties—the soft or medullary, and the epithelial. Although there is much difference histologically and microscopically, they are so nearly allied in their clinical history that I feel justified in placing them together. In the clinical description of carcinoma I shall be governed more by what I have seen at the bedside than by the observation of others.

I use this term in a comparative sense. By it I mean a tumor caused by a carcinomatous deposit that infiltrates, enlarges, and renders more fragile than natural the parts attacked, which after a greater or less time undergo necrotic ulceration, death, or solution of the morbid growth, giving rise to extensive ulceration. I have never seen this variety convert the uterus into a tumor of encephaloid consistence. The deposit usually begins in the extremity of the cervix and extends up to the body, and without reference to the boundaries of different tissues attacks and involves the fibrous, mucous, and serous tissues, extending to any organ or substance that may be contiguous, thus infiltrating the bladder, rectum, connective tissues in the broad ligaments, and ovaries. The necrotic ulcerations of the part where the disease began, and the extension of the deposit in the more distant parts, progress simultaneously, the one diminishing while the other is increasing the bulk of the parts involved. This kind of progressive local dissemination and necrosis of cancerous matter often results in the more or less complete destruction of the uterus, bladder, and rectum.

Accompanying these morbid processes in the pelvis, cancerous cells migrate to other and distant portions of the body, creating new centres of carcinomatous disease. These multiple centres of disease are probably in all instances caused by the errant products of the pelvic disease. This view of the subject makes the general carcinomatous disease a constitutional infection, the same as the wandering cells of the chancre give rise to constitutional syphilis.

ETIOLOGY.—No one circumstance seems so intimately connected with [p. 275] the origin of cancer of the uterus as age, more than half the cases occurring between the fortieth and fiftieth years, 33 per cent. between the thirtieth and fortieth; this leaves only 20 per cent. for all other ages. It very seldom attacks the young under twenty-five years or the old over fifty. So far as I have been able to examine statistics, I am not sure that cancer occurs any more frequently among multipara than nullipara. The fact that the number of childbearing women far exceeds those who are not married nor fruitful is likely to mislead us in this respect. Race does not seem to afford even comparative exception. The negro and North American Indians seem to be subjects of cancer as frequently as the European races.

If there is anything in the idea of heredity as a causative influence, it must be rather through physiological similitude of children to parents than the transference of taint from the former to the latter. If cancer is a degeneration of tissues, as the effect of a law that organs in certain individuals undergo dissolution at a particular age, we can understand that the child may inherit such physiological effect from the mother. The cell-formation of the organs of the child will be capable of reaching the same period at which the disease was developed in the mother, when the normal histological changes will be interrupted and dissolution begins. In this view of the subject the child would by virtue of its organization inherit the mode of dying evinced in the mother.

Old writers, assuming that cancer was the result of a peculiar dyscrasia, described the state of general health as a causing condition. It does not seem, however, that the majority of people in whom cancer is developed exhibit any signs of ill-health until the local disease has made sufficient advance to account for their symptoms. Indeed, many present the appearance of a faultless condition of general health until the disease is discovered to have made hopeless progress. The same may be said of the local condition. It so often happens that we are assured by a patient that she had been congratulated by her friends as one especially favored by exemption from female weaknesses. I have yet to witness any evidence that chronic inflammation, congestion, or laceration of the uterus predisposes to malignant disease of any kind.

I do not mean by this to say that patients having chronic uterine ailments may not become the subjects of cancer of the uterus. There is nothing in the gross anatomy or the histological construction of cancer to indicate an analogy to inflammation. The allegation that the long-continued irritation of laceration invites a malignant deposit in the tissues involved is mere assumption, and should rank as an unproved hypothesis.

The location of the primary lesions is usually in the cervix, but occasionally it attacks other parts of the uterus, the body next in frequency to the cervix, and less commonly the fundus.

CLINICAL HISTORY.—The early stage of cancerous development is not marked by obvious symptoms. Judging from my own observation, a bloody discharge more frequently attracts the attention of the patient than any other symptom, and this does not appear until the deposit is somewhat extensive, and it indicates necrosis. The loss of blood is sometimes copious, but generally moderate in quantity. It may be intermittent or continuous. Not infrequently in menstruating women [p. 276] it assumes the form of menorrhagia. The next symptom generally is a discharge of ichor, usually colored, sometimes entirely clear. With the appearance of the serous discharge the cancerous odor becomes apparent and continues. These two exhausting and disgusting symptoms continue alternating with each other with the persistence of fate.

Another symptom of cancer of the uterus is pain. It is not, however, generally an early symptom. Often it is entirely absent until the disease has made great progress. When noticed early, the pain is sharp and lancinating, consisting of recurring twinges rather than of continuous pain. When it does not occur until later in the progress of the case, it is such as arises from the accompanying congestions and inflammations.

GENERAL SYMPTOMS.—No general symptoms are manifest until the disease has made considerable advance, and often not until there begin to be degenerations in the tumor. It would seem, indeed, that the growth of cancer was not a morbifacient process, and that constitutional disturbance results from the septic influence exerted by the necrosis of the tumor.

The absorption and circulation of the products of decomposition at the extremities of the tumor through the nervous centres and secreting organs soon induce nervous ailments and derange the functions of all the important vital organs. A continuance of the derangement thus inaugurated, and kept up, eventuates in fully-developed septic fever, by which the energies of the patient are exhausted. The uniformity with which septicæmia terminates the existence of these unfortunate patients renders the exceptions to the above description very rare indeed. While patients think they are being eaten up by cancer of the womb, they are really dying from slow poison caused by absorption of dead tissues.

DIAGNOSIS.—In the great majority of cases the diagnosis of cancer is easily arrived at. For reasons already stated the disease is not suspected until the deposit is extensive and obvious changes in the shape and consistence of the cervix occur. It is enlarged, very hard, and generally irregular in shape. In most instances it is very much enlarged, measuring from one to ten times its natural diameter; the tissues are devoid of elasticity; and nodosities, projections, and sulci deform the cervix in a manner and to a degree that change the shape of the organ as nothing else does. Add to this the stinking sero-sauguinolent discharge, and the diagnosis is complete. By the time these physical changes become diagnostic features of the case the uterus becomes fixed, the immobility being obviously dependent upon the extension of the deposit to the vagina, bladder, and contents of the broad ligament. The invaded tissues become as hard and unimpressible as the uterus. We could hardly mistake cancer in this stage of development for any other disease, and as the general practitioner will seldom see it before the most of these changes have occurred, the diagnosis will generally be easy. When the tissues break down to a considerable extent the ulcers, if they can be so called, are very irregular in shape, greatly excavated, have a hard, rough, granular bottom, and are not tender to the touch. Generally they bleed upon being handled. The hardness, enlargement, irregularity of shape, and fixedness are as conspicuous features during the process of destruction as they are in the stage of deposit.

The demonstrative portion of the diagnosis, however, is derived from the histology of the deposit. "Histological examination of the changed uterine tissues shows, as in every carcinoma, a stroma of small alveoli filled with polymorphous cells, generally arranged without order; sometimes those of the periphery are implanted regularly on the wall of the alveolus. The stroma composed of connective tissues frequently contain also smooth, muscular fibres."¹

¹ Cornil and Ranvier, translated by Shakespeare and Simes, p. 696.

PROGNOSIS.—This form of carcinoma uteri will bear no other than a desperate prognosis. I doubt whether it is ever discovered until the deposit has reached an extent locally that renders complete ablation impracticable. In addition to this consideration the malignant cells are disseminated, if not degenerated, in distant parts.

Nature in an infinitesimal number of cases institutes curative processes. These processes consist of extensive sloughing and a species of atrophy in the morbid growth. The growth ceases to enlarge, becomes smaller, and finally disappears. Very few men are lucky enough to witness the fortunate results of these processes. Art is powerless to cure, but may do much to palliate the suffering connected with the fatal march of carcinoma.

The duration of uterine cancer is greater in the old than in the young. In the former it may last several years; in the latter it often terminates fatally in a few months.

TREATMENT.—Taking the above history of the disease as true, it will not be necessary to say much about curative treatment. If we should find a case of cancer in which the cervix is not enlarged as high up as the junction of the cervix and vagina, I would advise amputation of the cervix and excavation of the uterine tissues as extensively as possible. The amputation and excavation may be performed by means of hooks and scissors, as in epithelioma. Taking the statistics of Freund's operation, as practised and modified by himself and others, as my guide, I am not disposed to sanction or advise the complete extirpation of the uterus for this form of cancer.

The subject of palliative treatment of cancer for the relief of local symptoms, and the amelioration of the general suffering caused by the septic fever, with which the patient usually dies, is more hopeful. The local symptoms requiring palliation are the sometimes disastrous hemorrhages, fetor, acridity of the sanious discharges, and pain.

The tampon made of cotton saturated with the solution of the subsulphate of iron is generally a very effectual means of treating the hemorrhages, while it also temporarily removes the fetor and acridity of the discharges. The tampon saturated with a strong solution of alum is also very effective. Frequent injections and ablutions with a weak solution of carbolic acid or permanganate of potassium will also be very useful in keeping the discharges free from odor. Much comfort may also be derived from small pellets of absorbent cotton introduced just within the vulva to absorb the discharge. Their frequent removal will of course be necessary, but they will be found to protect the external parts from excoriations that would otherwise occur. Applications of tincture of the chloride of iron or solution of hydrate of chloral carefully made to the raw surface upon the cervix very materially correct the foulness [p. 278] of the discharges and lessen the process of necrosis which is continually taking place.

The local and general use of anodynes is about our only means of relieving pain. They may be used locally in suppositories introduced into the rectum or vagina, or hypodermically or by the stomach in such quantities as may be required. Further detail is unnecessary in reference to the use of anodynes, as the quantity, quality, and mode of administering them will depend so much upon the urgency of the pain and the character of accompanying symptoms.

The treatment of the septicæmia is both general and local.

The general treatment consists of such measures as will sustain the vital powers. Tonics of quinine and iron are the remedies that will be of most service, and judiciously used will greatly ameliorate the symptoms of exhaustion. A very important item in the treatment of these prolonged cases of septic fever is a well-selected diet—the more nutritious and easy of digestion the better. It should consist largely of fresh mutton, beef, poultry, game, milk, and butter. The bowels will be generally troublesome in the early part of the time by constipation, and in the later by diarrhoea. For the former a diet containing fruit and coarse flour bread will often enable us to dispense with cathartics, which are generally both exhausting and annoying. For the diarrhoea opiates can be used freely, as also bismuth, pulverized charcoal, etc. etc.

But the most important as well as the most effective measure with which to combat this destructive fever is to keep the raw surface of the tumor as free as possible of necrosed material. This is done most effectively by the sharp curette or Simon's spoon. The whole of the ulcerated surface should be thoroughly scraped off with one of these instruments. The parts completely exposed by Simon's retractors should be scraped energetically until the solid tissue is reached. It should be remembered that the tissues exposed are not sound, but are cancerous deposit. The sacrifice of it, therefore, is not a matter of importance, so that the excavation if not fearlessly should be thoroughly done. An operation of this kind is attended with two dangers. One is the removing so much substance as to open the peritoneal cavity, bladder, or rectum; and the other is hemorrhage. Care will enable us to avoid the former; and, when formidable, the latter may be staunched by the astringent tampon already mentioned.

This operation is only intended as a palliative measure, and it sometimes proves remarkably beneficial. After it the patient will occasionally rally so much and become so comfortable as to indulge in the belief that she is on the road to recovery. The amelioration lasts sometimes months. It will often be profitable to repeat the scraping several times, especially if the case is advancing slowly. It will usually not only make the patient more comfortable, but greatly protract her existence.

This malignant disease differs in several respects from the cancer already described. The morbid cell-growth in that form of cancer takes place in the lymph-spaces of the connective tissues of the cervix [p. 279] and uterine body. The lymph-spaces are converted into alveoli or nests in which the cells are developed until they become greatly distended and changed in shape. The lymph-spaces thus occupied freely communicate with each other, and of course with the lymphatic vessels. Hence, the rapid dissemination of the cells locally and the ease with which they find their way to distant parts of the system.

The cells in epithelioma are developed on the free surface of the mucous membrane. From this surface the cells seldom travel to any great distance, and consequently the disease often does not become general. Epithelioma is cancer of the mucous membrane of the uterus, while the other form is interstitial cancer of the uterus. The dense mucous membrane serves as a barrier to the passage of the cells into the surrounding tissues. After the disease has existed for a long time, the surface of the mucous membrane is impaired, and it does not resist the dissemination of the cells. Then the process of cell-dissemination is a result of partial destruction of the membrane. In cancer of the uterus they are disseminated early, and possibly from the beginning, because they are generated within the lymph-spaces, with which the lymphatic vessels are continuous.

Epithelioma of the uterus very rarely assumes the form of an ulcer; generally it is a deposit upon, or growth from, the surface of the mucous membrane. The growth assumes shapes that vary with the different localities. If the extremity or external surface of the cervix is the seat of the disease, it usually projects into the vagina as a fungus which may grow large enough to fill up that cavity. Much more frequently the cervix is enlarged and is covered with a stratum of epithelial deposit very frail in texture that bleeds freely when rudely touched. This fungous growth or deposit does not affect the mobility of the uterus, even when the cervix is considerably enlarged. When the morbid deposit takes place in the cavity of the uterus, it often does not project from the os uteri to any extent, but is confined to the cavity. When the cavity is filled up by an epitheliomatous growth emanating from the entire surface of its lining membrane, we seldom see anything more than an ashy-looking substance filling up the external os uteri. Sometimes the growth covers the whole of the mucous membrane of the body and neck, including the external covering of the latter part.

CLINICAL HISTORY.—The clinical history of epithelioma is essentially the same as that of the other form of cancer, and consequently need not be given in detail. The main symptom is hemorrhage, with an abundant and stinking sanious discharge.

DIAGNOSIS.—In examining with the finger and with both hands it will be found that the uterus is movable and not much, if any, enlarged. If the case is of the ulcerated variety, the finger may not detect the lesion; if, on the contrary, there is a fungus, it will at once detect it. Should the deposit not project from the os externum, the finger may not recognize its presence. Upon exposing the cervix to view in the ulcerative variety an ulcer of a light ash-color will be seen, presenting an irregular outline slightly excavated, and if the probe is applied to it the bottom and sides of the ulcer will be found of the same firmness and consistence as the uterine tissues. It is not indurated. If a fungus exists, it can be seen and examined. When not bleeding it is also ash-colored. The [p. 280] consistency of the projecting mass is sometimes tolerably firm, but more frequently it is quite frail and gives way under moderate pressure. Should the deposit be inside of the uterus, the os will be slightly dilated and filled with a gray substance.

The probe will readily pass through this frail material and enter the uterine cavity. In cases presenting such an appearance the cavity is generally enlarged and filled with this fungous deposit. These facts may be ascertained by the use of the probe while the parts are exposed to view.

The microscope will verify and correct our diagnosis. For microscopic examination some substance from the surface of the ulcer or fungoid projection may be collected and submitted for inspection. The appearances are nests or spaces of greater or less size filled with epithelioid cells.

PROGNOSIS.—Without judicious treatment practised at an early period epithelioma may be said to be invariably fatal. There is, however, much promise of great amelioration in this form of disease with the present improved methods of treatment, and in some cases we may succeed in effecting a permanent cure.

TREATMENT.—The general palliative treatment is the same as that described in the other form of cancer, and need not be repeated. While I have failed to see any other than palliative effects result from amputation of the cervix and excavation of the body of the uterus in the first form of cancer described, I have seen cures of epithelioma effected by thorough extirpation of the diseased mass. One of these cures was in a case where the disease was confined to the posterior lip of the cervix; another, where the deposit apparently occupied the whole surface of the mucous membrane of the body and cavity of the cervix. In other cases I am sure the life of the patient was prolonged and her comfort greatly enhanced. I am persuaded, from a good deal of observation, that the younger the patient the more promising the result of operations. The worst and most rapidly fatal cases of epithelioma I have seen have been in patients beyond the menopause. This is contrary to what I have witnessed in the other form of cancer, as in it the younger the patient the more rapid the progress of the disease and the least beneficial the operations were.

After a trial of the several methods pursued in the removal of epithelioma, and the different instruments used for the purpose, I prefer using the scissors, aided by hooks and vulsellum, to cut away as much of the diseased tissue and the sound structure upon which it is implanted as possible, and then burn the surface with the cautery in some of its forms or the strong caustics. When the disease is confined to the cervix, the whole of the intravaginal portion should be cut away and the excising process carried as high up as possible, carefully avoiding the peritoneal cavity on the one hand and the bladder on the other. With the cervix exposed and fixed by a vulsellum, the sharp-pointed curved scissors may be insinuated beneath the external covering, and the tissues removed by pieces until the operation is completed. When the utmost attainable portion is thus removed, I prefer applying to the whole of the cut surface pellets of absorbent cotton thoroughly moistened with the solution of the pernitrate of mercury (the acid nitrate, as it was formally called), and then filling the upper part of the vagina with dry absorbent cotton, [p. 281] tightly packing it so as to absorb any of the free acid. This last is necessary to defend the sound parts from the superfluous cauterization which would otherwise follow. The dressing may be removed in twenty-four hours, and the whole of the surgical cavity as well as vagina washed out with pure warm water twice a day afterward. If the cavity thus formed does not fill up, and the surface assumes a malignant aspect, it should be scraped out with a view to remove its entire surface and treated again with the acid. This last operation may be repeated again and again. It will sometimes be found that the cavity will grow less after each scraping with the sharp curette, and finally fill up.

If the disease is developed in the cavity of the uterus, Simon's sharp curette should be used to scrape out and destroy the whole mucous membrane. When this is done the cavity should be carefully filled with the cotton pellets saturated with pernitrate of mercury, as recommended for the cervical operation. And this operation should be repeated also with the same thoroughness as at first as soon as evidence of a return is manifested. When the scraping and cauterizing have been beneficial the uterine cavity will become smaller, and when the discharges indicate a reproduction of the morbid deposit the surface to be operated upon will be sensibly diminished, until finally it will be apparently almost closed. I say almost, because one of my patients, while she seems to have been cured, still menstruates.

While I do not pretend that many of these cases can be thus cured, I am sure some of them can be. Hence I do not hesitate to recommend an effort to be made in all cases in which the disease has not spread to the adjoining organs or tissues. When a cure is not thus effected, such great amelioration will so often occur as to make an operation justifiable.

The hemorrhages encountered in these operations are generally unimportant, but occasionally so much blood will be lost as to require hæmostatic measures. The practitioner should therefore be supplied with an astringent tampon and use it if necessary.

If an operation for the complete extirpation of the uterus is ever justifiable for malignant disease, I think it is in this form. The operation which I think the simplest and easiest to accomplish is that performed first in this country, so far as I know, by S. C. Lane of the Medical College of the Pacific, and in Germany by Langenbeck.

DISEASES OF THE OVARIES AND OVIDUCTS.

The ovaries are two almond-shaped glands attached to either side of the womb by a ligament of contractile tissue called the ovarian ligament, and they are enclosed between the two layers of the peritoneum known as the broad ligament. It has recently been contended that this envelopment in the broad ligament is not a complete one, but that the peritoneum is absent from the posterior surface of the ovary. This has been denied, but even if it be so, the fact does not seem thus far to have any physiological or any pathological bearing.

The ovarian nerves and blood-vessels run between the two layers of the broad ligament, the former coming chiefly from the renal plexuses of the sympathetic, the latter from the spermatic arteries. The ovaries being themselves movable bodies and attached to a movable organ, the exact position of which remains yet a moot question, their own natural situation has not yet been authoritatively determined. His,¹ from an examination of three suicides, holds that the ovary in the adult virgin hangs with its long diameter almost vertical, and with one side against the wall of the pelvis, but below the brim, the free border being behind and the attached end below. Each oviduct is looped over the ovary, rising along the front and falling over behind it. Hence the ovary lies on the fimbriæ which turn back and spread over the summit of the ovary. The ovaries are generally situated on a level with the inlet of the true pelvis, the left one being in front of the rectum, the right one surrounded by a coil of small intestines. When healthy they keep so high up as to be beyond the reach of the examining finger, and consequently they are not impinged upon during coition.

¹ British Medical Journal, Dec. 10, 1881, from Archiv f. Anat. u. Entwick., 1881, Nos. 4 and 5.

The important and special function of the ovaries—that of secreting and excreting the Graäfian follicles or ovisacs—and their monthly engorgements are the causes of many of the diseases to which they are subject. Hence it is that affections of the ovary, being due most commonly to perverted function, rarely occur before puberty.

Absence of the ovaries is a congenital condition very rarely met with. It is usually associated either with the absence also of the womb or [p. 283] with an imperfect development of the other portions of the sexual apparatus. The breasts will be flat, the vagina generally imperforate, the vulva small, the pubic hair absent, and sexual feeling wanting. Menstruation never takes place. Very commonly the growth of the body is arrested, and the stature is dwarfed to that of a child. Occasionally, however, there is an approach to the masculine type in the size, the figure, the voice, and in the growth of hair on the face and on the body.

An arrested development or a rudimentary condition of the ovaries is a more common malformation than the preceding one. The womb is then infantile in size, and the vulva and vagina are small and the pelvis is narrow. Puberty either fails to take place or it is postponed. When menstruation is present it is scant and appears at long intervals. General development is impaired, and the figure and mental characteristics may be those of advanced childhood. Sexual feeling is either wholly absent or very imperfect.

DIAGNOSIS.—Whenever the ovaries are wanting, their absence cannot be positively made out by a digital examination of the parts, for even fully-formed ovaries often elude the finger. The diagnosis depends mainly on the symptoms previously given. If the ovaries are rudimentary, the finger passed high up the rectum while the woman is anæsthetized will sometimes recognize them. But the diagnosis rests usually on some manifestation of puberty, and the greater these manifestations the greater the curability.

TREATMENT.—For the complete absence of the ovaries all treatment is of course useless. Whenever these organs are in a rudimentary condition more can be done for the woman, but success is by no means assured. Every treatment that tones up the body is of service. The rest-cure, with its accessories of massage, general faradization, and over-feeding, promises much. Electricity has done good when one pole is applied directly over an ovary and the other pole placed either on the sacrum or on the cervix uteri. It is still more efficacious when the reophore in the form of a properly insulated sound is passed into the uterine cavity. Should the interrupted current fail to do good, the galvanic current may cautiously be tried.

From the vascular and nervous kinship between the ovaries and the womb all stimulants to the latter tend to invite blood to the former, and from this flux may come growth. It is therefore good practice to irritate the womb by tents, by applications of iodine and of silver to its cavity, and especially by the use of galvanic stems. The marriage relations sometimes quicken dormant ovaries into life, and development, followed by pregnancy, has been the result. But the remedy is a hazardous one, for if the sexual sense be not awakened, as often it will not, the union leads to much unhappiness.

Acute inflammation of the ovary rarely exists per se, but it is by no means an infrequent accompaniment of pelvic peritonitis and pelvic cellulitis, the causes of each being the same. It is then so masked by the [p. 284] greater inflammation that its symptoms are lost in the general ones. Following the same course as that of pelvic inflammations, it begins with fibrinous exudation and ends either in resolution or in suppuration, or in chronic hypertrophy.

The TREATMENT of this inflammation is the same as that of pelvic inflammation—viz. rest, poultices, vaginal injections of hot water, and morphia and quinia in large doses. Sometimes the local abstraction of blood will be useful. Should pus form, it must be evacuated by the aspirator, and preferably per vaginam. After such an inflammation, and especially if caused by gonorrhoea, the ovary usually remains permanently injured, its functions being crippled by fibrous bands, adhesions, hardening of its stroma, and thickening of its investing peritoneum. If both ovaries be thus affected, sterility inevitably ensues.

By chronic ovaritis is meant either persistent congestion of the ovaries, or such tissue-changes in the stroma or in the follicles of the ovary, or in both conjointly, as are brought about from a previous attack of acute inflammation or from persistent hyperæmia. In its early stages it appears to be characterized by passive congestion, followed by infiltration of sero-sanguinolent fluid and by increase in bulk. Later on, if the congestion be not dispersed or it passes the health-limit, it becomes formative, or nutritive; the capsule thickens, the follicles enlarge, and a general hypertrophy takes place. According as the brunt of these changes falls on the stroma or on the follicles, the degeneration is termed either interstitial or follicular. When the stroma is chiefly attacked, the ovary becomes hard and rugous; when the follicles are diseased, they increase in size, and one or two of them are usually found to be distended into miniature cysts. There are indeed good reasons for the opinion that an ovarian cyst is a dropsy of many ovisacs, and is caused by ovaritis. The left ovary is the one more commonly affected—a fact accounted for by the pressure of the distended rectum and by the emptying of the left ovarian vein into the renal vein instead of into the vena cava, which is the course of the ovarian vein on the right side. It is a very common form of disease, very rarely coming from an acute attack, but starting subacutely with all the symptoms of chronicity.

CAUSATION.—Whatever induces a lasting congestion of the reproductive apparatus tends to create ovaritis—a torn cervix, a lacerated perineum, an arrest of involution after labor, dysmenorrhoea, and uterine tumors, flexions, and displacements. Barren women are very liable to this disease, and so especially are women who shirk maternity by preventive methods; for in both the menstrual congestions continue without that much-needed break which gestation and lactation bring, and in the latter the sexual congestions arising from incomplete intercourse are not relieved. So repeated erectility from self-abuse, by ending in a passive congestion of the womb and of the ovaries, will tend to produce this lesion. The prevalence of this habit in unmarried women is, I think, very much overrated, and yet I have seen from this cause several cases of ovaritis accompanied with prolapse of the ovaries. In one the ectropion [p. 285] of the cervical mucosa was so marked that it leads me to think that this is the cause of the occasional inversion of the womb in virgins. My notebook shows also cases of ovaritis from such imperfect sexual relations as come from the ill-health or the advanced age of the husband, and not a few from immoderate sexual intercourse. Some of the most common causes of chronic ovaritis are emotional in character, such as long engagements, disappointments in love, single life, the reading of corrupt literature, unhappy marriages, nerve-exhaustion, and hysteria. These causes operate by producing circulatory disturbances which keep up a constant congestion of such exacting organs as the ovaries.

SYMPTOMS.—Pain in one or in both ovarian regions, especially in the left one, is a prominent symptom. It is increased by walking or by standing, and is lessened by the recumbent posture. Starting usually from the ovary, it radiates to the small of the back or down the inner side of the thigh. It often begins from a week to ten days before the monthly period, and goes on increasing until the flow appears, when it commonly abates. Menorrhagia may usher in the disease, and may continue during the remainder of menstrual life, which then is usually prolonged. Ordinarily, however, menstruation becomes scant and irregular, postponing rather than anticipating. Sometimes amenorrhoea takes place. Sterility is usually present, and so almost always is nerve-exhaustion with all its emotional manifestations. Pressure over each ovarian region elicits pain and causes a contraction of the rectus muscle on the affected side. The finger per vaginam or per rectum will often discover behind the cervix uteri or to one side of it the very tender ovary, of the form and size of an almond. Pressure on it gives a sickening pain, very unnerving in its character. Reflex nervous symptoms are very common, especially those of hysteria. In the form of pain they show themselves in backache, spine-ache, nape-ache, and headache; in pain under the left breast, in the scalp on the top of the head, and in the stomach, bowels, womb, and coccyx. Nervous dyspepsia is common, accompanied by costiveness, nausea, vomiting, flatulent distension, and noisy eructation. Wakefulness and bad dreams are not infrequent. Other reflex neuroses may appear, such as paralysis or spasm of the sphincter muscles, the latter producing asthma, dysmenorrhoea, irritable bladder, and painful defecation. Then, again, there may be nervous disturbances, taking the form of low spirits, violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive mental aberration.

PROGNOSIS.—This disease is rarely fatal, but it is always very stubborn, and often incurable. The patient grows anæmic and she tires on the slightest exertion. Very soon nerve-exhaustion with its protean symptoms sets in. She takes to her back and becomes a sofa-ridden invalid. If the patient has contracted the habit of taking stimulants or anodynes, her chances for recovery will be greatly lessened.

TREATMENT.—The pelvic organs should be carefully examined, and any discoverable lesion of the womb and of its annexes be remedied. Pelvic engorgement must be met by keeping the bowels soluble, by scarification of the cervix, by large vaginal injections of water as hot as can be borne, and by vaginal suppositories of belladonna and by rectal ones of iodoform. Tenderness and hardness in either broad ligament is first treated by applications of a strong tincture of iodine both to the roof of [p. 286] the vagina and to the skin overlying the ovarian regions. Flying blisters may also be placed there with benefit. Sexual intercourse should not be indulged in unless the desire for it be strong or there is a possibility of conception, for, by the prolonged rest which it gives to the ovaries, pregnancy usually brings about a cure. The patient should keep on her back during her menstrual period; but, while rest in the recumbent posture should be taken morning and afternoon, she should be encouraged to move about and exert herself in some light household work, yet not to over-fatigue herself.

As far as medicines are concerned, those should be chosen which lessen the engorgement of the reproductive organs. Thirty grains of potassium bromide and ten drops of tincture of digitalis, given in compound infusion of gentian before each meal, will tend to quench all erectility of these organs. After the patient has been kept for some time on these anaphrodisiacs, alteratives will come into play: very good ones are ammonium chloride and mercuric bichloride, which can be advantageously administered after the following formula:

S. One dessertspoonful in a wine-glassful of water after each meal.

The paregoric in this mixture helps to control the aches; the antimony adds its quota to the needed alterative action; and the licorice disguises the harsh taste of the ammonium chloride.

Another very excellent alterative and nervine is the chloride of gold and of sodium. It is best given in pill and after each meal in doses of from one-eighth to one-quarter of a grain.

As there is in this disease a craving after stimulants and anodynes, which often degenerates into intemperance and into the opium-habit, the physician should be very careful how he prescribes such remedies, reserving their use wholly for emergencies.

In plethoric cases marked with menorrhagia iron is hurtful, but in anæmic cases with scant menstruation it rarely fails to do good, especially when given conjointly with arsenic. An excellent combination is one part of Fowler's solution of arsenic to nine of the syrup of the ferrous iodide. Beginning with ten drops after each meal, the patient increases the dose daily by one drop until thirty drops are reached. She then continues this last dose as long as it does good or it can be borne. In stubborn cases a sea-voyage may prove of lasting benefit.

The best of all treatments, however, and by far the best, is that devised for nerve-exhaustion by S. Weir Mitchell, which goes by the name of the rest-cure. It consists of prolonged rest in bed, seclusion from friends, massage, electricity, muscular movements, and a diet consisting largely of milk. By this treatment the circulation of the blood is made equable and the ovaries and other pelvic organs are thus relieved of their turgescence. I have had wonderful cures from this treatment, and can recommend it with the utmost confidence. Bed-ridden patients have been restored to health and chronic invalids returned to society.

Once in a while, lasting tissue-changes take place in the ovaries which medication cannot reach. The question then comes up, whether the woman shall be doomed to drag out the rest of her menstrual life [p. 287] burdened with distressing ovaralgia, with crippled locomotion, and with pelvic aches and pains and throbs, or whether the source of all these mischiefs, the ovaries themselves, shall be extirpated. This is a very important question, and the removal of these organs should not be decided upon without careful deliberation and without the conviction that the disease is otherwise incurable.

This displacement of the ovary is almost always one of the lesions of chronic ovaritis, and as such might have been discussed under that general heading. But as it displays certain symptoms peculiar to itself, and needs a special treatment aside from the general one, it seems to me best to describe it by itself.

At every monthly period the ovaries become turgid with blood, and from their weight sink low down. They can then be often felt, and even outlined, in Douglas's pouch. When this congestive period is over they discharge their over-freight of blood and again float up out of reach. Unfortunately, however, they sometimes keep turgid—blood-logged, so to speak—and consequently become permanently displaced. Accompanying this dislocation there will generally be some uterine lesion which will stand in the relation either of cause or of effect.

Nor could it very well be otherwise, for very close is the vascular and nervous kinship between the two—so close, indeed, that turgidity in the one means erectility in the other. Hence it is not always easy to decide which lesion was primary and which is secondary. When one ovary is displaced, it is usually the left one, because the left ovary, as explained under the heading of Ovaritis, is the one more liable to disease. When both ovaries are displaced, the left one will be the lower and the more easily reached, because the left round ligament is the longer and the left side of Douglas's pouch the deeper.

CAUSATION.—Any condition tending to a lasting congestion of the reproductive apparatus is very likely to lead to a descent of the ovaries. The causes, therefore, are the same as those of chronic ovaritis, to which subject the reader is referred.

SYMPTOMS.—First and foremost is pain in locomotion. Since the ovary now lies between the womb and the sacrum, it is liable at every step to be pinched between them. This pain is referred to the inguinal and sacral regions, and is of a sickening and an unnerving character. It often occurs suddenly, and then runs down the corresponding thigh along the track of the genito-crural nerve. One of my patients would, while walking, be unexpectedly seized with such a pain, which would either momentarily cripple her or else last so long as to compel her to call a carriage. Her left ovary, until cured by treatment, behaved like a loose cartilage in the knee-joint, and slipped down so low as to get pinched.

A second symptom is a throbbing pain while the rectum is loaded, and an agonizing pain during defecation. This arises from the grating of the hardened feces over these tender glands. In one of my cases² rectal enemata or the presence of hardened feces kindled up sexual throbs of the [p. 288] most painful and exhausting character, which thrilled through the whole body for hours at a time.

² Lessons in Gynæcology, by W. Goodell, M.D., ed. 1880, p. 332.

A third symptom is painful coition, for the ovaries are now so low down as to be bruised by the male organ. A fourth is gusts of pain radiating from either groin. Lastly, there is usually present a morbid state of the mind, accompanied by low spirits. I have seen suicidal tendencies evoked by dislocation of the ovaries and relieved by their replacement.

DIAGNOSIS.—A digital examination will discover in Douglas's pouch a very tender almond-shaped body on one side of the womb. If both ovaries are dislocated, two such bodies will be found; but the left one, for reasons previously given, will be lower down and more easily defined. Pressure upon one of them produces a sickening pain, like that when the testicle is squeezed. If the pressure be increased, and be so made that one of these bodies slips abruptly away from under the finger, such a thrill of indescribable pain darts through the groin and down the side of the corresponding thigh that the woman screams out and grows pale or becomes nauseated.

A dislocated ovary is sometimes mistaken for a pedunculated fibroid tumor of the womb or for the fundus of a retroflexed womb. But the uterine growth is not sensitive to the touch, and the flexion of the womb can always be told by the sound.

TREATMENT.—Whenever the dislocated ovaries are congested or they display signs of chronic inflammation, the same remedies will of course be useful as those for ovaritis. In addition, pessaries are important adjuvants, and especially in those cases in which the womb has a backward displacement. In the simple, uncomplicated cases of ovarian dislocation, in which the womb is in its proper position, a pessary often does more harm than good. To be of service it must be long enough to obliterate Douglas's pouch, and the pressure on the rectum or on the sacral nerves then becomes unbearable. If, on the other hand, it be too short, the ovary slips down behind it and gets badly pinched. These requirements practically exclude the resort to Hodge's pessary or to any of its modifications, with the exception, perhaps, of Fowler's. In the long run, a thick elastic and soft ring-pessary will do the most good, by offering a broad shelf on which the ovaries will sometimes, but not always, lodge. The air-cushion pessary and Gariel's air-bag will often answer the purpose better than any other, but, being of soft rubber, they soon become fetid and soon collapse.

A very excellent way of keeping up the ovaries is the knee-chest posture devised by H. F. Campbell of Georgia. Two or three times a day, or more frequently if needful, the woman unbuttons her dress, unhooks her corset, and loosens her underclothing. She then kneels on her bed with her body bent forward until her chest is brought down to the surface of the bed, while her head is turned to one side and the lower cheek supported in the palm of the corresponding hand. Her knees should be about ten inches apart and the thighs perpendicular to the bed. The trunk of the woman's body is now supported, like a tripod, by her two knees and the upper portion of her thorax. If she now refrains from straining and breathes naturally, a reversal of gravity will be established. With the fingers of her free hand she next opens the vulva. Air will [p. 289] rush in, distending the vagina, and the contents of the abdomen will at once sink toward the diaphragm. This will, of course, draw the womb and the displaced ovaries out of the pelvic basin. As it is rather awkward for a woman while in this posture to free one hand to reach the vulva, Campbell advises that previously to taking this attitude she should insert into the vagina a small glass tube open at each end and long enough to project externally. This will leave an air-way and dispense with the use of the fingers. After staying in this posture for a few minutes, the woman removes the tube and slowly turns over on her side, where she is to lie as long as she can. Such constant replacements are of great service, for they lessen the throbbing and they give the limp ligaments a chance of shrinking and of keeping the truant ovaries at home.

In this intractable disorder an abdominal brace will sometimes do good. It may not cure, but it often blunts the edge of the aches, and thereby gives much comfort. By pressing the abdominal wall upward and inward the brace forms a shelf on which the viscera rest, and thus it takes off a portion of the load from the womb and from its ovaries. By virtually narrowing the pelvic inlet it lessens the space into which the bowels tend to crowd, and to that extent protects the pelvic organs. By swinging the pelvis backward it makes the axis of the superior strait lie more obliquely to the axis of the trunk, and the sum of the visceral pressure now converges, not in the pelvic basin, but on the portion of the abdominal wall lying between the symphysis pubis and the umbilicus.

There is yet another treatment which, combined with the knee-chest posture, I deem the best of all. It is Mitchell's rest-cure, to which I have before referred. After the patient begins to improve and to fatten, as she usually does under this treatment, she is taught how to replace the ovaries by atmospheric pressure, and the result is that in my experience they finally stay up. The explanation is as follows: By this treatment the circulation of nerve-fluid and of blood is equalized, and the ovaries, relieved of their turgescence, grow lighter. Then the increased deposit of fat in the abdominal walls, in the omental apron, and around the viscera, to say nothing of the needful fat-padding in all the pelvic nooks and crannies, increases the retentive power of the abdomen. Finally, by its gravity the now fat-laden and overhanging wall of the abdomen tends to draw toward itself—that is to say, upward—the movable floor of the pelvis. The behavior is like that of a rubber ball half filled with air, in which bulging at one pole causes a corresponding cupping at the other. This explains the ascent of the womb in women who get fat after the climacteric.

In exceptional cases the hypertrophied glands keep heavy and refuse either to go up or to stay up under any treatment whatever. The only known remedy will then be their extirpation—an operation which will be discussed under its appropriate heading.

This is usually a congenital displacement, and, according to Englisch,³ is, when double, almost always so. The ovary is then found either in [p. 290] the inguinal canal or outside of this canal in the corresponding labium majus. The oviduct then accompanies it. When the hernia is acquired, the ovary, with or without the oviduct, makes one of the contents of the sac of an inguinal, a crural, a ventral, or an ischiatic hernia. Of these, the inguinal is by far the most common. Thus, out of 67 cases observed in 9 years by Langlon at the Truss Society, all were inguinal with 1 doubtful exception. Of these 67, 42 were congenital, 25 acquired.

³ New Sydenham Soc.'s Biennial Retrospect, 1871-72, p. 291.

The character of the lesion is told by the peculiar tenderness and nausea following pressure, and by the swelling of the tumor just before the menstrual flux. In one case mentioned by Routh⁴ pressure on the tumor produced distressing sexual excitement; but this is an unusual symptom, although I have seen it produced by the pressure of hardened feces.⁵ It is not always easy to decide whether the displaced glands are ovaries or testicles; and repeated mistakes in regard to sex have thus been made.⁶ So difficult, indeed, is it sometimes that the microscope can alone settle the question.

⁴ Trans. Royal Medical and Chir. Soc., Lancet, Jan. 28, 1882.

⁵ Goodell, Lessons in Gynæcology, 2d ed., chap. xxvi. p. 332.

⁶ Chambers, Trans. London Obstet. Soc., 1881.

TREATMENT.—In a reducible hernia, taxis and an appropriate truss comprise the treatment. If irreducible, a truss with a concave pad may be used to protect the ovary from injury. If the ovary be fixed by adhesions and it give much discomfort, it should be removed by operation.

There are certain forms of diseases of women peculiar to the menstrual period of life. The attendant lesions are found either in the reproductive organs themselves or outside of them in remote organs, but with such monthly exacerbations as show their participation in the catamenial excitement. They are always very hard to cure, and often prove to be wholly unmanageable until the climacteric has been established.

In this category may be classed fibroid tumors of the womb, chronic pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia, ovarian insanity, ovarian epilepsy, and, in short, all those phenomena or those lesions which are embraced under the term of pernicious menstruation.

Fibroid tumors of the womb are, fortunately, pretty manageable. Usually, the womb, like a generous host, hospitably entertains them; but once in a while an unwelcome one presents itself which arouses all the resentment of that organ. If, then, it stubbornly resists all treatment, it slowly but surely destroys life by the pain which it evokes and by the loss of blood it gives rise to. In such a case the woman is virtually bed-ridden from her floodings and sufferings, and she looks forward to the climacteric as her only hope. But the change of life is then always postponed for several years beyond the natural term—oftentimes so many years as to be overtaken by the death of the patient.

Then, again, there are those cases in which, despite all treatment, the ovaries remain turgid with blood, acutely neuralgic, and to the last degree sensitive. They become dislocated and lie in Douglas's pouch, or irremediable tissue-changes take place, attended by follicular or by [p. 291] interstitial degeneration. A woman with such a lesion is usually a helpless invalid, racked with atrocious pains, weakened by exhausting menorrhagia, and wholly unable to fulfil her duties as wife or as mother. Usually she seeks relief in anodynes and becomes a confirmed opium-eater.

There are also many distressing cases of salpingitis or of pelvic peritonitis and pelvic cellulitis which cripple a woman past all hope by monthly exacerbations. Such cases are by no means rare, and the woman, reduced to skin and bone, finally dies, because in spite of all treatment the inflammation is rekindled at every monthly period.

Further, there are cases of epilepsy which seem to come wholly from the sexual organs—cases with an ovarian aura, so to speak. The fits begin at puberty, very generally last through life, and end in impairment of the mind. Often the first convulsion is ushered in by the first menstruation, and ever after it is around ovulation as a storm-centre that future eclamptic attacks revolve. Such an epileptic is the terror of her family and a valueless member of society. Generally she dies insane or with enfeebled mind, and if she marries she is very likely to transmit her infirmities to her children, either in the same form as her own or in kind.

Finally, what insane asylum does not hold incurable women whose mental infirmities seem to depend wholly upon the act of ovulation? Some there are who, indeed, never exhibit symptoms of insanity excepting during the monthly flux.

For these menstrual affections there is a remedy which, while yet in its infancy, promises much—one first proposed and performed by R. Battey of Rome, Georgia. This able surgeon reasoned that, since these disorders are kept up by the monthly afflux of blood to the sexual apparatus, and therefore incurable during menstrual life, the only chance of immediate relief lies in the establishment of an artificial menopause. To bring about this change of life he advocated the extirpation of both the ovaries, and labeled the operation normal ovariotomy. With this name fault has been found, because it does not cover the whole ground, for often the ovaries themselves, together with the oviducts, are found diseased. Now, since it is important to distinguish this operation from that of ovariotomy proper, and since the term spaying, which technically defines the character of the operation, is obnoxious from its association with the lower animals, the terms öophorectomy, or Battey's operation, have been adopted.

In well-selected cases this operation has been followed by wonderful results; but it has been greatly abused. By it I have restored to perfect health cases of otherwise incurable fibroid tumors of the womb, cases of dysmenorrhoea and of menorrhagia, and cases of pernicious menstruation in which the sufferers were reduced to the last degree of emaciation and feebleness. Out of 5 cases of ovarian insanity I have also cured 4; the fifth, while not wholly restored, is yet very much better.

This operation has been performed both by the vaginal and the abdominal section. For some years I was a warm advocate of the vaginal method, but I have wholly given it up, because by this method of operation adherent ovaries cannot be safely dislodged, the ovaries cannot always be reached, the vaginal wound cannot be dressed antiseptically, [p. 292] and because the abdominal mode is more simple and less dangerous. Only when the ovaries are dislocated and low down in Douglas's pouch would I possibly resort to the vaginal incision.

If the abdominal operation be performed, the incision should be made between the navel and the pubes in the median line, and not over each ovary, as advised by some authors. One great caution must, however, be observed, and that is not to wound the intestines. In ovariotomy the cyst is in front of the intestines, and there is very little danger of injuring the latter. But in cases of öophorectomy, no tumor being present, the bowels lie in contact with the wall of the abdomen, and are very likely to be wounded by the knife when the peritoneum is incised. The incision should be long enough to admit two fingers. These, being passed behind the womb, are conducted to the ovary by gliding along the oviduct as a guide. Each ovary, together with its oviduct, is in turn brought up to the opening. It is then seized by a fenestrated polypus-forceps and its stalk transfixed, tied on either side with fine silk, cut off, and dropped back into the abdominal cavity. Should the stalk be so short that ovarian tissue is left behind in the button of the stump, it should be destroyed by Paquelin's cautery, for it is astonishing how small an amount of this tissue will keep up not only menstruation, but even menorrhagia. On the other hand, it will not answer merely to ligate the pedicles without removing the ovaries. This has been tried, and not only did menstruation continue, but in one instance pregnancy took place.⁷

⁷ Murphy, British Medical Journal, April 18, 1885, p. 787.

The dressing is precisely the same as in ovariotomy, and, like it, the operation should be performed with every detail of antiseptic surgery.

In the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. I am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration—an untoward circumstance which cannot happen in the dorsal position. A duckbill speculum is introduced, and the perineum pulled downward. The cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. The post-cervical mucous membrane is next caught up by a uterine tenaculum and snipped open for about an inch. The index finger of the left hand is then passed in, and each ovary brought down to the incision by the finger-tip hooked into the sling made by the oviduct. The ovary is seized by a fenestrated forceps and brought into the vagina, where its stalk is transfixed by passing a needle armed with a double thread between the ovarian ligament and the oviduct, and each half is securely tied. The ovary and the fimbriated end of the oviduct are then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. To close the vaginal opening one or two stitches will be needed, and finally the wound is covered with iodoform and the vagina gently packed with pads of carbolated or salicylated cotton.

It is a fact worthy of note that during the week following the ablation of the uterine appendages a sanguineous discharge from the womb usually takes place. This is in no wise a menstruation, but a metrostaxis [p. 293] set up by the irritation of the ovarian nerves, caused by the means adopted to secure the pedicles. Candor, however, compels me to say that for some inexplicable reason the removal of the uterine appendages—viz. ovaries and oviducts—does not always bring about the change of life. These cases are exceptional, and they are supposed to be due to either the presence of a third ovary or to some small portion of ovarian stroma left behind.

This operation in no wise unsexes a woman or changes her appearance or character. It simply brings on the change of life with its attendant phenomena. Her instincts and affections remain the same, her sexual organs continue excitable, her breasts do not wither up, and she is no less a mother or a wife.⁸

⁸ Lessons in Gynæcology, by Wm. Goodell, M.D., chap. xxvi.

There is a class of tumors which, while not ovarian, lie so near to the ovary as often to involve it, and usually need precisely the same treatment as cysts of that organ. In their extirpation the ovary is almost always also involved. This close anatomical relationship makes it needful to describe them in conjunction with ovarian tumors. They comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called the Hydatid or Vesicle of Morgagni.

These are formed from the dropsical distension of one of the tubules of the parovarium, or organ of Rosenmüller, which lies between the folds of the broad ligament and between the ovary and the oviduct. Usually, one tubule alone is affected, and the cyst is then unilocular; but exceptional cases have been met with in which several of the tubules have become dilated, and the cyst is then bilocular or even multilocular.⁹ These cysts are often called cysts of the broad ligament.

⁹ "Bursting Cysts of the Abdomen," by Wm. Goodell, Trans. American Gynæc. Soc., 1881, p. 231.

By examining cysts in their early stage Albert Doran has demonstrated that "the vertical tubes of the parovarium are lined with epithelium, sometimes ciliated, but oftener cubical, the original, primitive form of the tubes of the Wolffian body. From these tubes and from the hilum of the ovary, full of Wolffian relics, spring the multilocular papillary cysts which give so much trouble to the operator. At the outer end of the horizontal tube of the parovarium is a cystic dilatation which is lined with a structure resembling endothelium. Apart from the parovarium, between the folds of the broad ligament, minute cysts are frequent. It is from these and from the terminal cyst of the parovarium that the simple unilocular so-called parovarian cyst arises. The terminal cyst of the Fallopian tube never attains a large size, and no true cysts of the broad ligament appear, when young and minute, to arise from that tube."¹⁰

¹⁰ British Med. Journal, Oct. 21, 1882, p. 792.

These cysts are more commonly found in young women. From the thinness of their walls and the limpid character of their fluid, they yield very marked waves of fluctuation which are equally distinct at every point. They can usually be distinguished from ovarian cysts either by a lack of that tenseness so characteristic of the latter or by varying conditions of tenseness and flaccidity, as if the fluid were sometimes absorbed more quickly than at other times. They also grow more slowly than the ovarian cyst, and do not exert the same profound constitutional impression. The facies ovariana is absent, and the health of the woman may in no wise be disturbed. They, indeed, in the majority of cases, seem to do no harm, and are merely annoying from their bulk. The fluid they contain is with rare exceptions as limpid and clear as spring-water, but with refractive powers so high as to magnify the fibres of the wooden pail into which it has been drawn off.

Owing to their very thin walls and delicate structure these cysts on very slight provocation are liable to burst. On account of the blandness of the contained fluid this accident is rarely followed by collapse or by peritonitis. The rent heals up and the cyst usually refills; but in a large proportion of cases it does not, and the woman remains permanently healed.¹¹ Sometimes they are pedunculated, but often they lie between the two folds of the broad ligament, having no proper stalk.

¹¹ "Bursting Cysts of the Abdomen," by Wm. Goodell, Trans. American Gynæcological Society, 1881, p. 226.

Cysts of the broad ligament must not be confounded with those ovarian cysts which, instead of growing free in the peritoneal cavity, develop between the two layers of the peritoneum—intra-ligamentous ovarian cysts, as Garrigues very aptly calls them in his paper on the "Diagnosis of Ovarian Cysts."¹² In this excellent paper, from which I have gleaned much, he says that sometimes the anatomical relations are so lost that nothing short of a microscopic examination of the outer epithelium can determine the character of the cyst. Thus, "a tumor covered with columnar epithelium is ovarian, and cannot be anything else; while the cyst of the broad ligament, being covered with peritoneum, has flat peritoneal endothelium. In cases of intra-ligamentous development of an ovarian cyst the lower portion is covered by peritoneum, but the upper part has the columnar epithelium characteristic of the ovary." There are, however, certain macroscopic characteristics which will generally tell the nature of the cyst. For instance: usually by a careful examination the corresponding ovary will be found either stretched out and spread out in the wall of the sac, or, what in my experience is more common, elongated and forming a part of the stalk. These cysts are in the vast majority of cases monocysts, while unilocular ovarian cysts are very rarely if ever met with. Their walls are thin, of a conjunctival blue, and fretted with a delicate network of blood-vessels. The oviduct is usually imbedded in the cyst, and by transmitted light its fimbriæ can be traced out in the cyst-walls in long fronds as delicate as those of dried and pressed seaweed. Then, again, the peritoneal coat is readily stripped off. On the other hand, in an ovarian tumor the oviduct is not ordinarily incorporated in the cyst-wall; in fact, a meso-salpinx usually exists; and, further, the peritoneal coat, being nailed down to the cyst-wall proper by the cicatrices of ovulation, is not capable of being stripped off.

¹² Am. Journ. of Obstetrics, April, 1882, p. 394.

TREATMENT.—Since these cysts do not ordinarily affect the general health or grow to a very large size, they should, as a rule, be let alone. Whenever grounds for interference arise the cyst should be aspirated, for sometimes after being wholly emptied it does not refill. Should, however, the fluid return, the cyst must be extirpated in precisely the same way as an ovarian tumor. When it is without a pedicle it will have to be carefully enucleated from between the folds of the broad ligament, which then cover it. If this cannot be done, all of the cyst possible should be removed, the edges stitched to the abdominal wound, and a drainage-tube put in. This is the advice ordinarily given, but I have not yet met with a cyst of this variety which could not be removed. Were such a one to occur in my practice I should be tempted to remove all of the cyst possible, and to close up the adherent portion in the cavity of the abdomen without resorting to a drainage-tube. The fluid secreted by a parovarian cyst is so bland that I believe no mischief would arise. The late Washington L. Atlee was accustomed to make merely a large circular opening in the cyst, without attempting to remove it.

These tumors may contain either fluid or pus. In the former case the cyst is called hydro-salpinx; in the latter, pyo-salpinx. They are caused by salpingitis, or inflammation of the oviduct, which exists rarely per se, unless of gonorrhoeal origin, but is one of the sequels of pelvic peritonitis. The distension of the tube is due to the occlusion of each of its ends. Thus by pelvic inflammation the fimbriæ become glued to the ovary, sealing up the ovarian end, while an endometritis closes the uterine opening. In addition to the dropsy of the tube, I have repeatedly met with small cysts, or bladder-like bodies outside of the tube proper, very analogous to those found on the umbilical cord.

This affection is by no means an uncommon one, every age being liable to it, and it is often the unrecognized cause of ill-health. Since Tait first called the attention of the profession to the frequency of the disease and the means for its cure, many cases have been reported in which obscure pelvic symptoms were cured by the removal of the ovaries and of the oviducts—the uterine appendages, as they are called.

DIAGNOSIS.—This is difficult, because the symptoms are those of pelvic peritonitis or of pelvic cellulitis, the disease of the oviduct being usually associated with that of the broad ligament. In some cases the womb will be found movable, with a sausage-like tumor behind it; the diagnosis is then easy. Usually, the symptoms are negative, and the diagnosis is based upon constant groin-pains and recurring attacks of pelvic inflammation.

TREATMENT.—Like hydrocele of Nuck's canal, hydro-salpinx occasionally heals spontaneously, but more frequently it will need aspiration, together with injections of iodine or of carbolic acid. When pus is present, absorption probably never takes place, and an operation will be needed. If the symptoms are grave enough to warrant an exploratory incision, and dropsy of the tubes be discovered, both the tube and its ovary should be extirpated, for in the great majority of cases the [p. 296] corresponding ovary will have undergone follicular or interstitial degeneration. Unless there are very good reasons for adopting a different course, both ovaries and tubes should be removed, because the sound ovary, together with its tube, is liable to become diseased. The incision should always be abdominal, and not larger than to admit two fingers. The broad ligament is transfixed between the tube and the ovarian ligament by a double ligature and tied on either side. The operation is, in fact, analogous to that of öophorectomy. When the tubes contain pus, they are liable to become adherent to the sigmoid flexure, to the rectum, or to the small intestines, making their removal very difficult—sometimes, indeed, impossible. The separation of such adhesions requires the greatest care and delicacy.

A little bladder-like body, not larger than a pea, is often found hanging by a thread-like stalk from one of the fimbriæ of the oviduct. It is a relic of foetal life, being probably the remains of the Wolffian body, and sometimes goes by the name of the hydatid or vesicle of Morgagni. The walls are very thin and covered by peritoneum. What rôle these vesicles play in the economy is uncertain, but they have been found to undergo cystic degeneration. They rarely attain to a size larger than that of an orange, and then either remain stationary or else burst. I have met with several examples of cysts which, after reaching the above size, did not grow any larger. I have also met with one case in which, after attaining the bulk of a small apple, the cyst burst, and immediately refilled, to burst again and again at intervals of from four to six weeks.¹³ The collapse of the sac was attended each time by colicky pains, but of no great severity.

¹³ "Bursting Cysts of the Abdominal Cavity," by Wm. Goodell, Trans. Amer. Gynæcol. Soc., 1881, p. 228.

Other small cysts I have met with which either burst under the pressure of the examining finger or were designedly burst by bimanual pressure. These, I am disposed to think, were cysts of the terminal vesicle of the oviduct. These cysts are of but little surgical importance, as they rarely need operative interference. If such should arise, they are to be treated by aspiration, and if this fails by extirpation.

These are occasionally met with, and usually on the right side. They belong to the connective-tissue group, being either myoma, fibroma, or sarcoma. They form at any point of the round ligament, and may therefore be either intra-peritoneal, intra-canalicular—that is, in the inguinal canal—or extra-peritoneal. The symptoms are those arising from pressure, and are not at all diagnostic. The only treatment of these tumors is removal, but, as their growth is very slow, they are not to be touched unless the symptoms become exacting.¹⁴

¹⁴ Medical Times and Gazette, Dec. 1, 1883.

OVARIAN TUMORS.

The morbid growths of the ovary are conveniently divided into the solid and the cystic.

The solid ones are either benign, under the form of fibroma, or malignant, being then either carcinoma or sarcoma.

Fibroid degeneration of the ovary is so rare a form of disease as to be denied by excellent authorities, who contend that all the cases reported under that term were pedunculated uterine fibroids, which had so grown around and so involved the corresponding ovary as to be mistaken for an ovarian fibroid. Yet while such mistakes have undoubtedly been made, there can be no question that ovarian fibroid does occasionally present itself as a rare form of disease.¹⁵ Out of 155 cases of ovariotomy thus far performed by myself, I have met with 4 undoubted cases of ovarian fibroid. The tumors weighed respectively 2, 3, 4, and 15 pounds, and in each, with the exception of the first, abdominal dropsy was the prominent symptom. All but one of these cases promptly recovered.

¹⁵ Brit. Med. Journ., March 18, 1882, p. 384.

According to Francis Delafield,¹⁶ "The structure of a fibroid of the ovary resembles that of the ordinary fibroid tumors of the uterus. That is, they are composed of connective tissue and smooth muscular fibre. The tumor, therefore, is a myo-fibroma. There has been some question whether ovarian tumors ever contain smooth muscle, but the best authorities now admit that it does sometimes exist in such tumors."

¹⁶ Boston Med. and Surg. Journ., Nov. 17, 1881, p. 461.

Occasionally these tumors arise not from a general hypertrophy of the whole ovary, but from a nodule or a tumor growing in and from the stroma of the ovary. Solid ovarian fibroids are of slow growth and rarely attain a large size. When, however, they are of the geode variety, with numerous cystic cavities, they grow rapidly and may reach enormous proportions.

DIAGNOSIS.—The only other abdominal tumor for which it is very likely to be mistaken is a pedunculated fibroid tumor on the peritoneal surface of the womb, and with our present knowledge it seems impossible to tell them apart.

When they float about in ascitic fluid they often give the sign of ballottement in a very perfect manner. From carcinoma of the ovary they can generally be told by their smooth surface.

PROGNOSIS.—Fibroid tumors of the ovary grow so slowly that, like pedunculated fibroid tumors of the womb, they ordinarily do not attain a very bulky size. When the climacteric is reached they tend, like the latter, to stop growing and to undergo a calcareous degeneration. More often, however, they cause by their presence a dropsical effusion of the abdominal cavity, which has to be repeatedly drawn off; and it is for this reason that they usually have to be extirpated. They are removed precisely in the same way as an ovarian cyst, and the prognosis is equally [p. 298] good, but they are liable to have short and broad pedicles which need to be tied very carefully in sections.

These affections are either primary or secondary. When secondary, they follow analogous diseases of the womb or of the pelvic structures. When primary, they appear under different forms, as in other portions of the body, being either encephaloid, scirrhous, melanotic, or papillary. Colloid cancer of the ovary may be practically excluded, because it is of extreme rareness. The term colloid when applied to ovarian cysts refers more to the gluey consistency of the contained fluid than to the question of malignancy. In my experience the most common form is that of papilloma, which, however, like villous growths elsewhere, is not always malignant. I have removed papillary cysts and villous growths of the ovary, yet the subsequent history of the cases proved that the tumors were benign. The only macroscopic distinction between the benign and the malignant form which I have hitherto attempted to make is, that in the malignant form papillary growths will be found in patches upon adjacent structures, or else the womb and the broad ligaments are also involved in one cauliflower-like tumor. But Tait observes that he has had two cases of ovariotomy in which he left large masses of papilloma, fixing the womb, yet in each case these masses wholly disappeared, and the patients are both in perfect health.¹⁷

¹⁷ Diseases of the Ovaries, 4th Am. ed., p. 147.

There is, however, no question that malignancy lurks in many ovarian cystomata which present to the naked eye an innocent appearance.

The patient recovers promptly from the operation for their removal, but dies a few months later from cancer of the peritoneum or of other organs. Every ovariotomist has met with such examples. In one of my own cases, in which not the slightest sign of malignancy was apparent, the patient wholly recovered from the operation. Shortly after her convalescence an effusion took place in the right pleural cavity. The chest was tapped three times before her death, which was due to cancer of the liver and of the broad ligament at the site of the ablated ovary. In my first case of ovariotomy, one in which the clamp was used, menstruation took place regularly for several months from the cicatrix, which within a year became affected with cancer.

Both ovaries are usually involved in cysto-carcinoma, and this fact should be borne in mind in making a diagnosis. From the marvellous changes often produced progressively in the epithelial linings of ovarian cysts, by which they are transformed into tufts of villous cancer, Tait inclines to the opinion that their growth is associated with a tendency toward malignancy. He believes that tapping hastens on this degeneration, and that after an accidental rupture of such a cyst the peritoneum will be found studded with patches of papillary cancer. Hence he argues that ovarian cysts should never be tapped, and that they should be removed in the earlier stages of their existence, before these malignant transformations have taken place.¹⁸

¹⁸ Op. cit., p. 148.

DIAGNOSIS.—Since, as has been shown, this cannot always be made [p. 299] out, even by the eye, after the removal of the cysts, it follows that in a large proportion of cases the malignant character of the degeneration cannot be recognized. There are, however, certain symptoms pointing to malignancy which will often throw much light. These, in the order of their frequency, are—

TREATMENT.—Whenever no doubt exists as to the malignancy of an ovarian growth, an operation looking to its removal should not be urged by the physician. On the other hand, since a positive diagnosis on this point is rarely attained, and since cancer of the ovary tends for a long time to remain localized, whenever a suspicion of malignancy exists ovariotomy should be performed early, before adhesions have been contracted with neighboring structures. In such a case I should incline to burn off the pedicle in preference to using the ligature.

In those cases in which, on account of adhesions, no operation is justifiable, palliative treatment can alone be resorted to. This comprises the removal of the ascitic fluid or the contents of the cyst by the aspirator whenever the pressure becomes uncomfortable. Symptoms should be treated, and, that of pain being the most urgent, opium will be needed up to the last in increasing doses.

A dermoid cyst is a congenital tumor having a wall composed of elements like true skin, with its appendages of hairs, sebaceous glands, etc., and contains teeth, hair, bone, cartilage, muscle, and a cheesy material very like vernix caseosa. These cysts are solitary, two never being found in the same person, and, further, they are always unilocular. They are either external or internal—that is, they affect either the surface of the body or else the cavities of the body, as "under the tongue, in the pharynx, oesophagus, cranial cavity, peritoneal cavity, lung, ovary, testis, bladder, and kidney."¹⁹ No tumors are more curious, and none are more puzzling to explain. The theories accounting for their origin are very remarkable, and are as follows: Excess of formative nisus. Parthenogenesis, or virgin birth; that is to say, imperfect imitation of transmitted fertility—a property peculiar to many insects, by which, without any renewal of fertilization, successive generations of procreating individuals start from a single ovum. Inclusion of abnormal structures, [p. 300] where there is a dipping in of the epiblast to meet the hypoblast during foetal life, and the pinching off of the same. Foetus in foetu—viz. the inclusion of an imperfectly developed ovum within another which matures perfectly. Hypererchesis; which means that "the ovum has in it the origin-buds of certain tissues, which under exceptional hypererchetic action may go on to the rudimental formation of these tissues without a fusion with the male germ."²⁰ According to Elsner, who has written last on this subject, and to whom I am indebted for much information, "dermoids occur externally and internally in places where the epiblast dips down to meet the hypoblast, and where by processes of grooved involution new bodies are formed, such being, first in order, the testicle and ovary, and that they are therefore all (without exception) embryonal in their first structure."

¹⁹ Elsner, Dublin Journal Medical Sciences, May, 1882, p. 380.

²⁰ Diseases of Ovaries, by L. Tait, 4th ed., p. 177.

SYMPTOMS.—These congenital tumors begin early in life, and usually remain dormant until puberty. Then the periodic congestions of menstruation usually stimulate them into growth. Sometimes they need the increased vascularization of pregnancy. They are more liable than ovarian cysts to inflammation and suppuration, but they grow much more slowly, and very rarely reach the large size of the latter. They are also very liable to contract adhesions to every structure they touch, making their extirpation very difficult and sometimes impossible. Often they create pain out of all proportion to their size. Occasionally, they break and empty their contents through fistulous communications with the intestines, bladder, or the abdominal wall. But collapse of the usually thick walls of the cyst does not take place, and a cure results far less frequently than in pelvic abscesses, which empty themselves through analogous channels. The cyst ordinarily does not lessen in size; suppuration goes on with hectic fever and exhaustion, which finally carry off the patient.

DIAGNOSIS.—Quiescent or slow-growing pelvic tumors, semi-solid to the feel, and first discovered at the age of puberty, are usually dermoid cysts. Their small size is also an aid to diagnosis, for they very rarely reach the bulk of the adult head. On several occasions I have found them in Douglas's pouch, fig-shaped and flattened in their antero-posterior diameter. From its attachments to neighboring structures a dermoid cyst is very liable to be mistaken for the cyst of an extra-uterine foetation. But the exclusion of the history of pregnancy and the slow growth of a dermoid cyst, unless suppuration has taken place, ought to distinguish the one from the other.

TREATMENT.—While quiescent the cyst should not be touched, as it is very vulnerable and liable to resent the slightest injury, even from the slender trocar of the aspirator. If suppuration takes place and the tumor points to the surface, it should be treated, like any other abscess, by a free incision, by the evacuation of its contents, by the introduction of a drainage-tube, and by the injection of antiseptic solutions. Small cysts lying in Douglas's pouch can sometimes be cured by aspiration; at least I have twice succeeded in obliterating them in this way. The operation was, however, followed by suppuration of the cyst, the abscess bursting into the vagina. If after an exploratory incision an abdominal cyst turns out to be dermoid, it should be extirpated. But if extensive adhesions [p. 301] preclude such an operation, the cyst should be opened, evacuated, and thoroughly cleansed. The edges of the opening should then be stitched to those of the abdominal wound and a drainage-tube put in. The after-treatment of such a case will be analogous to that of an ovarian cyst under like conditions, to which the reader is referred.

These represent by far the most frequent variety of ovarian tumors, and as such demand our best attention. They consist, in probably the majority of cases, in a dropsical enlargement of one ovisac or of more—viz. in a follicular dropsy. Indeed, as Cazeaux has aptly said, the ovisacs, or Graäfian follicles, are ovarian cysts in miniature. These cysts are divided into three classes, which depend wholly upon the number of ovisacs involved. Thus, a single, or barren, cyst, containing merely fluid, is called a monocyst or unilocular cyst. Such a cyst would be due to the dropsical enlargement of but one ovisac. It is extremely rare—so much so that its existence is denied. The probability is that a one-chambered sac does not begin as such, but it becomes so through the breaking of the walls of other contained cysts. A multiple cyst is caused by the simultaneous growth of two or more ovisacs, one of which usually takes the lead in growth and keeps the others dwarfed. This form of cyst is by far the most common. It grows with great rapidity, and may reach a weight of over one hundred pounds. I have successfully removed one weighing one hundred and twelve pounds. A proliferous cyst is a mother-cyst packed with innumerable child-cysts of varying size. These endogenous cysts multiply by exogenous and endogenous growth. The proliferous cyst rarely attains to the size of the multiple cyst, but surgically it is a solid tumor, because it cannot be emptied by tapping, and therefore often needs a long incision for its removal. It also usually possesses a very thin wall, which is liable to be torn during the needful manipulation for its removal. Racemose cysts are occasionally met with. They consist of a number of isolated cysts of varying size attached to one common stalk like a bunch of grapes. I have met with two such examples. Tait thinks that they are "produced by the retention of the ova in the Graäfian follicles, and the distension of their cavities by a continuous secretion of the liquor folliculi."

The pedicle or stalk by which an ovarian cyst is attached to the womb consists of the corresponding broad ligament, oviduct, ovarian ligament, and vessels. The pedicle is sometimes long and slender, at other times short and broad. There is one form of ovarian cyst which has no proper pedicle. It grows between the two layers of the broad ligament, and tends to develop downward into Douglas's pouch. It is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. Sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown.

The contents of ovarian cysts vary very greatly in color and in consistency. In monocysts the fluid is often limpid and colorless. In multiple cysts the contents are usually syrupy, thick, and turbid. Sometimes the [p. 302] color is quite dark, as much so as weak coffee. The surface of the fluid, after standing, will be covered with a pellicle of cholesterin crystals, which sparkle in the sunlight. In proliferous cysts the contents are usually viscid, sometimes as much so as jelly, and to this the term colloid is applied. Foulis, who is an authority on this subject, states that he has "never found that an ovarian fluid, however long kept, ever deposited a precipitate spontaneously. Whereas very frequently in the case of an ascitic fluid such a spontaneous precipitate appeared within a period varying from a few hours to a few days."²¹ Again he observes: "After ten years of observation made on fluids withdrawn by the aspirator, I found that ovarian fluids never throw down a precipitate of a fibrinous character. An ovarian fluid was always a pure cellular secretion. An ascitic fluid was always the result of obstruction to the circulation or of inflammatory action in the peritoneum, and ascitic fluids allowed to stand for a short time nearly always showed a precipitate with the character of felted material under the microscope. If they tapped the patient and subjected the fluid to this test, two or three days would suffice to tell in cases in which there was doubt. The deposit in ovarian fluids showed cellular, not fibrinous, elements under the microscope."²²

²¹ Edinburgh Medical Journal, July, 1885, p. 76.

²² Ibid., June, 1885, p. 1131.

Chemically, the contents are mucous and albuminous, the albumen being readily detected by the tests of heat and nitric acid. Microscopically, ovarian fluid is found to contain fat-globules, epithelial, granular, and pus-cells, crystals of cholesterin, blood-corpuscles, and compound granular cells, also called the inflammatory globules of Gluge.

Whether ovarian fluid contains a cell or corpuscle peculiar to itself is yet a moot question. Drysdale contends that it has a characteristic cell. He describes it as "an albuminoid body containing little fatty particles which give it a granular appearance. It resembles in some particulars many other granular cells, but can be distinguished from all other cells found in the abdominal cavity.... The principal test I employ is acetic acid. If the cell is ovarian, the acid changes it but little, perhaps rendering it only a little more transparent. But if it be a white blood-cell, a lymph-corpuscle, or any of those granular cells which resemble them, it will nearly always take on a different appearance, the cells almost vanishing perhaps, and multiple (2-5) nuclei appearing, as in the pus-cell. Then, if the cell be suspected to be fatty, degenerated, or Gluge's cell, ether may be added, by which the fatty materials will be dissolved and disappear. If no fatty degeneration be present, it is sufficient to add acetic acid."²³ Garrigues, on the other hand, contends that the ovarian fluid does not contain a characteristic cell.²⁴

²³ Trans. Amer. Gynæcol. Soc., vol. i. p. 195.

²⁴ Ibid., vol. vi. p. 54.

If I am not mistaken, the opinion of the best microscopists of Philadelphia is that the Drysdale cell, while not characteristic of ovarian fluids, is not found in any other fluid in such large numbers, and to that extent it is of diagnostic value.

CAUSATION.—In probably the very great majority of cases an ovarian cyst is a dropsy of several ovisacs, but the cause of such growths has never yet been ascertained. In the majority of cases it seems to depend upon some sexual disturbance.

Very recently the relation of the sexual condition to disease has been [p. 303] made the subject of scientific inquiry. From a careful examination of the registrar's tables for France, M. Bertillon shows that marriage, by giving a comparative immunity from diseases of the sexual organs, prolongs life in both sexes. This statement is confirmed by the statistics of ovarian tumor. Of Lee's 136 cases, 88 were married, 37 were unmarried, and 11 were widows. Of Sir Spencer Wells's first 500 cases, 260 were married, 221 were unmarried, and 19 were widows. Out of 155 completed cases of ovariotomy performed by myself, 91 were married, 48 were single, 16 were widows. Of the married, 24 were sterile, 10 had one child, and 26 had but two children, and several confessed to using preventive measures. Out of a total of 791 cases of ovarian tumor, there are, then, 352 without husbands to 439 with husbands. Now, when one considers how small the proportion of single women and of widows is to married women whose husbands are living, the significance of these figures goes to show that childbearing women, and especially the prolific ones, are less liable to cystic degeneration of the ovaries, and that, unless the cycle of reproduction is completed in a woman, she is plainly violating some law of her being.

SYMPTOMS.—There are no symptoms pathognomonic of this affection, for they are mainly those of pressure, and therefore belong in common to all fluid collections in the abdominal cavity. But in proportion as the abdomen swells there is a marked emaciation of the extremities. The limbs waste away, the face becomes pinched, the eyes are hollow and staring, deep wrinkles and furrows appear on the forehead and around the mouth, and the nostrils are wide open. This facial expression is termed the facies ovariana. Sometimes, when both ovaries are simultaneously affected, hair will grow on the chin and on the upper lip.

THE NATURAL HISTORY.—The natural course of an ovarian cyst is to grow rapidly, and in about two years from the time of its discovery to destroy life by exhaustion through the embarrassing pressure which it makes upon the organs of respiration, circulation, and nutrition. Malignant cysts grow more rapidly than the benign, while the latter will, on the other hand, occasionally remain for years in a state of quiescence. I have kept stationary cysts under observation for ten years, and others have been reported which lasted twenty years without change.

As a cyst develops it is very likely to contract adhesions to the organs with which it lies in contact. The most common adhesion is that of the omentum. Next to this is adhesion to the abdominal walls. Then will happen more rarely adhesions to the bowels, womb, bladder, pelvis, liver, and stomach. A loop of intestine will sometimes be found fastened to the front wall of the cyst, but usually the bowels lie packed behind the tumor.

Rupture of the cyst sometimes takes place, either spontaneously, through over-distension, or through violence, as a kick, a rude fall, or from being run over by a carriage. This accident, if the fluid happens to be bland, may be followed by a cure; but more often a violent peritonitis sets in, which carries the patient off in a few hours. From a study of 257 cases, Aronson²⁵ rates the fatality at 41 per cent.; but without question the very great majority of cases of bursting cysts of the abdomen in which this accident was followed by a cure were cysts of the parovarium, which being [p. 304] thin-walled are likely to burst, and which contain a bland, unirritating fluid. Bursting of the sac can be recognized by more or by less collapse and pain, by the disappearance of the cyst, and by the lessened size of the abdomen. If the patient does not at once succumb, excessive diuresis usually occurs.

²⁵ American Journal of Obstetrics, Nov., 1883, p. 1210.

It happens occasionally that the inner cyst-wall inflames, either spontaneously or in consequence of being tapped or from other injury. Suppuration then takes place, the contained fluid becomes fetid, and offensive gases are generated which give a tympanitic sound on percussion. There will be creeping chills, a red tongue, night-sweats, a frequent pulse, a general rise in the temperature with evening exacerbations: in one word, all the well-known symptoms of blood-poisoning will be present in a greater or less degree. Unless the cyst be at once removed the woman will speedily die.

Ulceration of the cyst, with perforation of its wall, may also occur. The decomposing contents will then be discharged, either into the peritoneal cavity or into any viscus to which the cyst may have contracted adhesions. In this way the purulent contents of an ovarian cyst have been discharged through the bowels, the bladder, the vagina, and even into the womb through the oviducts.

Hemorrhage within the sac is an occasional accident. When it takes place the tumor rapidly enlarges, great abdominal pain is caused by this sudden stretching, the complexion grows pale, the features become pinched; there will be collapse and all the symptoms of internal hemorrhage. If the bleeding does not stop, the patient will die in a few hours. On the other hand, if she survives the immediate danger, she is liable to succumb later to septicæmia, which arises from the decomposition of the now bloody fluid. The immediate removal of the cyst gives the woman, then, her sole chance of life.

Twisting of the pedicle of an ovarian tumor by axial rotation is another serious complication, which leads to its strangulation and gangrene, with consequent fatal peritonitis. The chief factors of this accident are, probably, the filling and emptying of the bladder and rectum, which may rotate an unadherent cyst with a long stalk. The symptoms of axial rotation, as carefully noted by Tait²⁶ and Aronson,²⁷ are sudden accession of severe abdominal pain and tenderness, a rapid increase in size, and incessant vomiting, the matter thrown up soon becoming green. The pulse rises, but the temperature is not always affected, and rigors are absent. Such a train of symptoms should lead at once to the abdominal section.

²⁶ London Obstet. Trans., vol. xxii. p. 97.

²⁷ American Journal of Obstet., Nov., 1883, p. 1211.

DIAGNOSIS.—The diagnosis of ovarian cysts is often beset with so many difficulties that very humiliating blunders have been made by the best surgeons of the day. Lizars of Edinburgh performed laparotomy on a woman in order to remove a suspected ovarian cyst, and found nothing but fat. Others have done the same thing, and to their dismay have discovered merely an accumulation of wind in the intestines. The great Dieffenbach once opened the belly of a woman for supposed extra-uterine pregnancy, and found neither fat nor wind—not even, indeed, a trace of a tumor. Once an enormously distended bag of waters [p. 305] broke just as a deservedly eminent British surgeon had rolled up his sleeves and was about to wheel his patient into an amphitheatre crowded with spectators to witness an ovariotomy. A surgeon of whom Great Britain can well be proud once drove his trocar into the shoulder of a foetus under the idea that he was tapping one of these cysts. These facts show the importance of knowing how to make an examination for a suspected ovarian cyst, and how to distinguish such a cyst from other tumors and other fluid collections in the abdominal cavity.

The usual history of an ovarian cyst is—a tumor first discovered in one groin, rapidly enlarging, without tenderness or soreness, giving no inconvenience save from its bulk. The general health remains good until the tumor begins to distend the abdomen; then emaciation takes place, the strength becomes impaired, and the features begin to assume that pinched expression described on a preceding page as the facies ovariana. By inspection and palpation there will be found an elastic but somewhat irregular tumor, yielding the sense of fluctuation. By percussion a dull sound will be elicited at every point, except in the flanks, which are more or less resonant. If the contents of the tumor are colloid or the tumor is thick-walled or very tense, the sense of fluctuation may be either obscure or wanting. Sometimes a feeling like that of fluctuation is conveyed by a fat-laden wall of the abdomen. To muffle this fat-thrill the ulnar edge of the hand of an assistant is laid along the linea alba while the surgeon percusses the abdomen. The pressure thus exerted acts precisely like the damper-wedge of the piano-tuner, which muffles the sound of one string while its fellow is being tuned. By these means fluctuation can be detected and the diagnosis of a collection of fluid unhesitatingly made out.

By the amount of solid and fluid portions of a cyst correct diagnosis can often be made out, whether it is simple or multiple, compound or proliferous; but this is a matter of comparatively little practical importance, because when once a growing tumor has been ascertained to be ovarian, its removal must follow as a matter of course.

There are, however, certain enlargements or tumors of the abdomen which are very liable to be mistaken for an ovarian cyst, and to these, in the order of their frequency, we shall call attention.

Ascites.—When the fluid is not encysted, but free, as in ascites, it is at liberty to go to the most dependent portions of the body. Hence changes in the posture of the woman will make corresponding changes in the level of the fluid. These level-changes are made evident by percussion. When the woman lies on her back the intestines float up to the surface, and the fluid gravitates to the flanks, making them bulge. In other words, percussion in the dorsal position elicits a clear note in the umbilical region and a dull note in each flank. In this posture the front surface of the abdomen is symmetrical and somewhat flattened. But when the woman sits up the belly becomes convex. Further, ascitic fluid is displaceable by pressure on the abdomen. But even these signs are not always trustworthy, because the intestines, glued down by adhesions, may not float up, and there will be dulness over the front of the abdomen, or a distended colon may make each flank resonant. For instance, I have known a papillary cancer of the omentum attended with dropsy of the abdominal cavity to give such signs of ovarian cyst as dulness in front and resonance [p. 306] in the flanks. When the fluid is ascitic the floating or false ribs are not pushed outward. The womb is usually low down and movable; there will also be more or less of bulging in Douglas's pouch.

On the other hand, in an ovarian cyst the womb is usually not very movable, and it is displaced to one side, generally behind the cyst. While the woman lies on her back the front surface of the abdomen is convex and unchanged in form. The floating ribs bulge out, making the chest conical. There will also be dulness in the front wall over the tumor, but usually more or less resonance in the flanks and over the region of the stomach: this clearness on percussion has been aptly termed coronal resonance. These areas of dulness and of resonance remain constant whatever the posture of the woman. Yet in suppurating cysts or after a careless tapping, or in cysts communicating with the intestine, the sac may contain gas, which will give a tympanitic sound over all the elevated portions of the abdominal surface.

It must, however, be borne in mind that ascites may exist concurrently with an ovarian cyst, and especially if the tumor be malignant in character. This can usually be detected by deep palpation, when the cyst will be reached and recognized by the fingers; or by pressing lightly, and then more firmly during percussion, an upper and a lower stratum of fluctuation will be detected.

Pregnancy.—The question of pregnancy is a very serious one, for it is sometimes a most difficult one to decide, especially when dropsy of the amnion (hydramnios) exists. In making a diagnosis nothing must be taken for granted, not even the woman's statement. She may be mistaken, or, indeed, she may be wilfully deceiving in the hope of having a cheap abortion induced by the examination. She may be pregnant and yet menstruate. On the other hand, an ovarian tumor will sometimes arrest menstruation. A healthy, ruddy complexion coexistent with abdominal enlargement should always excite a suspicion of pregnancy. There is sometimes a jaded look in pregnancy—the facies uterina—but never the facies ovariana.

The various signs of pregnancy should be searched for, especially ballottement and the foetal heart-sounds. The cervical region should be most carefully examined per vaginam. A good broad rule to remember is, that when the womb is gravid the cervix is as soft as one's lips; when it is empty the cervix is as hard as the tip of one's nose. In all doubtful cases any operation should be postponed until time has revealed the true condition of things. Of course the introduction of the sound will settle the question of pregnancy, but this procedure is not to be thought of when any doubt exists, and it is therefore useless as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and may have to be tapped or be extirpated before the delivery of the woman. The history of the case, the unusual size of the abdomen, the sulcus between the two tumors, will generally reveal the condition.

Fibroid Tumors of the Womb.—These tumors often reach a very large size, and if of the soft variety give an obscure sense of fluctuation which so closely resembles that of a colloid ovarian cyst or of a tense thick-walled cyst as to make the differential diagnosis very puzzling. The hard myoma gives no sense of fluctuation, but, on the other hand, if pedunculated it can be very readily taken for a solid ovarian tumor. A [p. 307] fibroid tumor of the womb can very generally be told by the history of menorrhagia, by its slow growth, by the uterine souffles and colics, by the effacement of the cervix, and by the tumor being felt to be continuous with the cervix and inseparable from the womb. Then, again, women burdened with a fibroid tumor so far from losing flesh usually become more fat, and their complexion, like that of many pregnant women, is mottled with patches of brown pigment. Further, the uterine cavity is usually much longer than natural, and when the tumor is moved from side to side the motion is communicated to the sound passed within the cavity. But every rule has its exceptions, for when an ovarian cyst has a close attachment to the womb the latter may become elongated and also follow the movements communicated to the tumor.

The positive diagnosis between an ovarian cyst and a fibro-cystic tumor of the womb is impossible, but, fortunately, the latter disease is exceedingly rare. The existence of the latter may be inferred if the woman's face has a jaded appearance and is disfigured by brown patches—the facies uterina—if the growth of the tumor has been very slow, and if the womb is implicated with it. After tapping there will be a partial collapse of the tumor, and the fluid withdrawn is usually bloody and it coagulates on being cooled. After an exploratory incision the tumor presents to the eye a dark-blue and vascular capsule covered with interlacing fibrous bands.

Renal Cysts.—Cysts of the kidney are very commonly mistaken for ovarian cysts. I have made this mistake, and it was not until after breaking up adhesions and emptying the cyst that I discovered the character of the tumor. It was successfully removed. Renal cysts start from below the floating ribs and extend downward and forward, while an ovarian cyst begins from below and grows upward. The former, being generally caused by impaction of a calculus in the ureter, are usually associated with urinary disturbances. They also push the intestines before them, which give a resonant sound on percussion, while the contrary holds good with an ovarian cyst. Since the transverse colon lies between the cyst and the liver, the line of resonance caused by it will show that the cyst is not hepatic. The fluid withdrawn from a renal cyst contains urea and the other constituents of urine, but the urinous odor will be either very faint, or, as in my case, wholly absent. It may as well be stated here that when renal cysts present great difficulties in the way of their removal, they had better be treated by a large drainage-tube.

A floating kidney may be mistaken for a small ovarian tumor. But the latter has a pelvic attachment and can readily be pushed down into the basin, while the former is kept from being pushed very low downward by an upper attachment. Again, the floating kidney usually keeps its peculiar shape, and it is frequently lost by slipping from under the fingers into its natural bed in the flank.

Spina Bifida.—Strange as it may seem, this spinal cyst, when internal on account of a deficiency in the anterior parietes of the lower vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am cognizant of two such errors of diagnosis made by two distinguished gynecologists. In each the sac was emptied by the aspirator, and the patient perished shortly afterward with the same kind of cerebral symptoms which follow the sudden withdrawal of the fluid from the cavity of an external spina bifida.

Phantom Tumors.—In the diagnosis of an ovarian cyst one must be on guard not to mistake for it a phantom tumor. In this imaginary kind of tumor, which hysterical women have the knack of creating, the whole belly will be uniformly distended to the size of the gravid womb at term. This is caused partly by flatus and fat, and partly by the arching forward of the spinal column, with the recti muscles drawn so tense that they cannot be indented. I have frequently had patients with this kind of abdominal enlargement sent to me from a distance, under the impression that it was due to some kind of tumor. But the diagnosis is easily made from the uniform resonance all over the belly; if, moreover, the patient's attention be engaged by conversation, the rigidity of the recti muscles disappears, the abdomen becomes flaccid, and the hand can be made to sink in so as to feel the spine. In very nervous women it may be needful to administer an anæsthetic, when all the tokens of a tumor will promptly disappear.

Obesity.—A large accumulation of fat on the abdominal wall and in the omentum has frequently given rise to the suspicion of the existence of an ovarian cyst. This condition occurs, usually, at the climacteric, and on percussion the vibratile thrill of the fat-laden wall of the abdomen conveys a very misleading impression of fluctuation. Further, to add to the difficulty, if the layer of fat be a very thick one, the abdomen, instead of being resonant on percussion, yields a dull note. But in obesity the fat is not limited to the abdomen, for the breasts, face, and limbs partake of the general enlargement. The abdominal wall hangs in folds when the sitting posture is assumed, and the umbilicus is indented and not protuberant. My own method of making the diagnosis is to grasp the abdominal wall with both hands and ascertain the amount of fat. When this amount is excluded, there will not be found room enough behind it for a tumor of any size, and the enlargement will thus be satisfactorily accounted for.

A dilated stomach, cystic tumors of the omentum, and encysted abscesses of the peritoneal cavity, and, indeed, of the abdominal wall, have been mistaken for ovarian tumors; but these are very exceptional cases. In all doubtful cases an exploratory incision should be resorted to.

SURGICAL TREATMENT OF OVARIAN CYSTS.—In the consideration of this subject it may be divided into the palliative treatment and the radical treatment.

Palliative Treatment.—Tapping either by the trocar or by the aspirator comprises the only palliative treatment of ovarian cysts; yet, as a broad rule with but few exceptions, an ovarian cyst should not be tapped. The objections to this operation are—that, slight as it may seem, it is by no means devoid of danger. Even when the smallest hollow needle of the aspirator has been used inflammation of the cyst may follow, which will compel the immediate resort to ovariotomy and very greatly compromise the success of this radical operation.²⁸ This has repeatedly happened—once in one of my own cases, in which, however, the removal of the cyst saved my patient's life. Further, the fluid of a polycyst is usually acrid—so much so sometimes as to irritate the hands of the operator—and the escape of a few drops into the cavity of the peritoneum may set [p. 309] up a violent and rapidly fatal peritonitis. Then, again, a fatal hemorrhage may take place from some wounded vessel, either in the cyst-wall, or in the adherent omentum, or in the vascular pedicle which may lie spread out in front of the cyst-wall, or, indeed in the abdominal wall itself, for the vessels here are often varicose from impeded circulation. In the fourth place, adhesions are very likely to form after tapping. Fifthly, innumerable child-cysts, which were very small before the tapping, being now relieved from pressure are liable to take on rapid growth and make the tumor more solid; and the more solid the cyst the longer the incision needed for its removal. Sixthly, in polycysts not only are the dangers attending the operation enhanced, but the cyst rapidly refills, and the woman becomes exhausted by the drain on her system. At the very best, 2 per cent. of cases of tapping in polycysts are fatal, even when performed by the most skilled specialists. Seventhly, a cyst once tapped rapidly refills, and soon needs repetitions of the operation. This drain on the system quickly tells upon the woman, and she is sometimes left too weak to have the radical operation performed. The first tapping, indeed, greatly hastens on this crisis, and it should therefore be put off as long as possible. Eighthly, a cyst emptied by tapping tends to rotate on its axis, and torsion of the pedicle may result, ending in gangrene and peritonitis. Ninthly, repeated tappings tend to convert benign papillary growths into malignant. Finally, Lawson Tait²⁹ draws attention to the fact that "repeated tappings deprive the blood of some element or elements included in the infinite variety of albuminous substances found in ovarian cysts, the deficiency of which predisposes to coagulation of blood." Hence after the removal of the cyst deaths have been "due to the formation of a firm white clot which started from the point of ligature of the pedicle, and slowly traversed the venous system until it reached the heart, death ensuing in from thirty to forty hours after the operation. The symptoms which precede death are swelling of the legs, rapid rise of the pulse, and its disappearance from the extremities some time before death, and breathlessness, ending in suffocation and slight delirium." He has met with several such cases of venous thrombosis starting from the pedicle, and they all occurred in patients who had been previously tapped. There are, however, cases in which tapping cannot be dispensed with; for instance—

1. Many women with ovarian tumors, having heard of cases of abdominal effusion or of cyst in which tapping was followed by a cure, will not submit to the radical operation until repeated tappings have proved to them the futility of the trocar.

2. Cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts.

3. When an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. Sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied.

4. In very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or [p. 310] dyspnoea, tapping is a useful prelude to ovariotomy. By the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre.

5. In cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. But it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. It is well, therefore, to put off the first tapping as long as possible.

²⁸ American Journal of Obstetrics, Nov., 1883, pp. 1169 and 1189; also Transactions American Gynæcological Society, vol. ii., 1877, p. 270.

²⁹ Midland Medical Society, Lancet, Feb. 18, 1882.

Tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best.

Tapping through the Abdominal Wall.—For this operation either the aspirator may be used or else Wells's trocar with a long rubber tube attachment. Of the two, I much prefer the former. In aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. The preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. But if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. The reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. The skin is now thoroughly cleansed with soap and water and washed with a 5 per cent. solution of carbolic acid. The painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. After the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. Should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. Sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. This accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. Should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. When the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. A pad of cotton wool is now laid over the [p. 311] scaphoid abdomen and a flannel binder applied. These afford a grateful feeling of support and take away that sense of goneness which is likely to occur. To avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly.

When Wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. The skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. This rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by Wells's trocar than by the aspirator. Yet I cannot help believing that the latter by its small size is by far the safer instrument, and I always use it when a simple tapping is aimed at. Should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. The same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. For it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. In such a case the pin ought to include the lips of the wound in the cyst. To avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. This is a rule without an exception. It is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. Several cases of death from this cause have been reported.³⁰ I lay stress on this point because in my Lessons in Gynæcology I advocate the practice.

³⁰ American Journal of Obstetrics, April, 1876, p. 146.

Tapping through the Vagina.—This operation is sometimes a very tempting one to perform when one of the cysts of a polycyst is pressing downward behind the bladder and causing dysuria. But it is by no means so safe as the supra-pubic mode of tapping. The reasons for this are—(a) The vessels are larger and lie closer together in the lower wall of the cyst near the stalk; (b) in a polycyst the larger cysts, growing where they have most room, usually develop in the abdominal cavity, while the more solid portion remains below in the pelvic region; (c) other organs, such as the bladder, womb, and rectum, are liable to become dislocated and lie in the track of the trocar; (d) the roof of the vagina responds to every respiratory movement of the diaphragm, and a cyst low down is not, from pelvic adhesions, so likely to collapse when tapped as one higher up: hence the cyst is liable to act as a pair of bellows, sucking in air and forcing it out. This inevitably causes suppurative inflammation with all its attendant evils. For these reasons this mode of tapping is never resorted to, except in cases of pelvic adhesion or in those in which the cyst starts from the lower side of the broad ligament and grows downward. Even then it is done only to relieve the distress caused by the double pressure upon bladder and rectum. In such cases the aspirator should be used, as it lessens all the risks. Should suppurative inflammation set in, the sac must be again emptied, the wound kept open by a [p. 312] drainage-tube, and the cavity thoroughly cleansed by daily injections of antiseptic fluids.

Tapping through the rectum has long ago been abandoned by the profession, as it ought to be, except in some very rare cases of atresia vaginæ. It was at one time supposed to possess advantages over the vaginal method, because the subsequent offensive discharges could be retained at will like the other contents of the bowel. But the cavity of the sac always became distended with fecal gas, and fatal septicæmia was pretty sure to set in.

Radical Treatment.—Tapping, followed by the injection of iodine into these cysts, has sometimes been rewarded with a cure, and at one time this mode of treatment had very warm advocates. After the cyst is wholly emptied by aspiration the action of the instrument is reversed, and from two to ten ounces of the officinal tincture of iodine are thrown in. The tincture is used of full strength, because the residual fluid in the cyst will be enough to dilute it. The cyst-wall is next kneaded, and the patient made to turn from side to side and from back to chest, so that the tincture may come in contact with every portion of the secreting surface of the cyst. The fluid is then pumped out, but all cannot be brought away; enough usually remains behind to produce some slight constitutional disturbance. While the canula is being withdrawn, in order to prevent the escape of any of the irritating injection into the abdominal cavity the thumb and fore finger are made to grasp the fold of abdominal wall at the puncture-site and to press it firmly down on to the collapsed cyst-wall. Good and lasting cures have followed such a treatment; but since they can happen only in monocysts, which are almost always parovarian, and not ovarian, it is probable that the mere emptying of the cyst would have done as much. In polycysts such a treatment is not to be thought of, for it would be attended with far more hazard than even the operation of ovariotomy. At the present day injections of iodine are practised only by physicians who do not operate; ovariotomists never resort to them.

Tapping, followed by enlarging the wound in the cyst, stitching its edges to those of the abdominal wound, and permanently keeping it open by tents or by a large drainage-tube, has frequently been attended with success. But since extensive and prolonged suppuration must inevitably ensue, this operation has proved to be a far more dangerous one than that of ovariotomy. It should, therefore, not be resorted to excepting in cases of cysts which are too adherent to be removed. The after-treatment consists in treating the case precisely as if it were an abscess. The cyst is kept empty by draining, and sweet by such deodorizing agents as solutions of iodine, carbolic acid, potassium permanganate, and the liquor sodæ chloratæ. Early this year I had one such case, a patient of C. A. Currie, in which the cyst was wholly adherent to all the pelvic organs and structures, and had besides a communication with the bladder. Not daring, under such circumstances, to remove it, I treated it successfully by incision, drainage, and disinfecting injections; but it was a long time before the drainage-tube could be removed and the woman be released from her bed. Cases, indeed, have occurred in which six months elapsed before the drainage-tube could be taken out and the woman pronounced well.

Another exception in favor of this operation may be made in the case of small cysts growing downward and bulging out the hind wall of the [p. 313] vagina. It may then be advisable to follow Noeggerath's plan. He snips open the vagina transversely behind the cervix to the length of one inch, and makes a corresponding incision in the cyst-wall. The edges of the two incisions are then stitched together and a drainage-tube put in. Thus, the cyst is left with a free and permanent opening into the vagina, through which such antiseptic solutions as have been noted above are thrown up. In time the collapsed cyst-walls adhere to one another and cease to secrete.

Electrolysis has of late also been lauded as a sure and harmless remedy for these cysts. But a careful examination of the subject made by Mundé shows that this agent has been greatly overrated as a specific, and that it "can in no wise supplant ovariotomy."³¹

³¹ Transactions American Gynæcological Society, vol. ii. p. 435.

Rupture of ovarian cysts has occasionally taken place, either through over-distension or through such violence as a rude fall or an upset from a carriage. This accident, if the tumor were a monocyst or if the fluid happened to be bland, sometimes ended in a lasting cure. The hint was not thrown away, and several surgeons cut circular openings into the cyst to establish a permanent communication with it and the abdominal cavity. But this practice was soon given up, because it was found that the intrusion of ovarian fluid into the serous cavity usually set up a violent and rapidly fatal peritonitis. For such an accident, when followed by inflammation, there is but one remedy—the immediate removal of the cyst by ovariotomy. Desperate as this remedy seems, it has repeatedly been followed by success. The only cyst in which it might be held warrantable to establish a communication with the abdominal cavity is that of a cyst of the parovarium recurring after repeated tappings, and so bound down by adhesions or so covered by the broad ligament as to be irremovable. The fluid it contains is so limpid and bland as not ordinarily to inflame the peritoneum.

OVARIOTOMY.—The term ovariotomy comes from [Greek: ôarion], ovary, and [Greek: tomê], an incision. It is a barbarous compound of Latin and Greek, which is forced into meaning the operation for the extirpation of an ovary on account of some disease of its own structures which causes it to increase in bulk. A fibroid or a sarcomatous degeneration of this organ, as has been shown, will sometimes happen, but cystic degeneration is by far the most common form of disease to which the ovary is liable. When both ovaries are enlarged and removed the operation is called double ovariotomy. The terms ovariotomy and öophorectomy ([Greek: ôophoron] and [Greek: echtemnô], to cut out the ovary) really mean the same thing, the latter word, indeed, being the more appropriate. But by modern usage the former is limited to the operation for the removal of an ovary greatly enlarged by some intrinsic disorder. By öophorectomy is now meant the operation for the removal of both ovaries for the purpose of bringing on the menopause, and thus curing diseases kept up or caused by the functional existence of those organs, while they themselves may or may not be diseased.

Before the eighteenth century the operation of ovariotomy as a radical cure had been suggested by a number of physicians, but had never been put into practice. Later, John Hunter and John Bell both advocated the operation, but neither ventured to perform it. This honor was [p. 314] reserved for Ephraim McDowell, a Virginian practising in Kentucky, who had attended Bell's course of lectures delivered in Edinburgh in 1794, and had imbibed the opinions of his teacher. He returned to Kentucky in 1795, and began at once to practise his profession, but it was not until 1809 that he first met with the opportunity for performing ovariotomy. The operation was successful, his patient having lived thirty-two years longer and having died at the end of her seventy-eighth year. Before his own death, which occurred June 25, 1830, in the fifty-ninth year of his age, McDowell had performed 13 ovariotomies, with 8 recoveries.

In spite of McDowell's success, and in spite of a large and growing percentage of recoveries reported by Atlee, Clay, and Spencer Wells, this operation was condemned so violently by the profession that its advocates were fairly ostracised, and fifteen years have hardly elapsed since it has been put upon as firm a basis as any other capital operation in surgery. "In 1843, Dieffenbach, the boldest of all surgeons then living, wrote that ovariotomy was murder, and that every one who performed it should be put into the dock. Now," writes Nussbaum, "we save lives with it by the hundred, and the omission of its performance in a proper case would in these days be looked upon as culpable negligence."³²

³² British Medical Journal, Oct. 26, 1878, p. 617.

The most common causes of death after ovariotomy are septicæmia or septic peritonitis, traumatic or frank peritonitis, shock, exhaustion, and hemorrhage; and it is against these foes that the operator must from the first aim all his efforts. In no other operation does the issue depend so largely on the experience of the surgeon. Every ovariotomist finds that his success grows with the number of his cases. Of 1000 successive ovariotomies, Wells lost 34 out of the first group of 100 cases, and but 11 out of the last group of 100. Out of his first 50 ovariotomies, Lawson Tait had 19 deaths.³³ The mortality of his last 313 cases was as low as 4.76 per cent.³⁴ Keith, who began with a mortality of about 20 per cent., lately had a series of 100 cases with 97 recoveries; 70 of these were successive. Schroeder had in the first 100 of his Berlin cases 17 deaths; in the second 100, 18; and in his third 100, 8 deaths.³⁵ Of my own first cases, I lost about 1 in every 3. Out of my last 22 cases there was but 1 death, and that occurred in a lady operated on at her home, too distant for me to see her again. In July, 1884, Peruzzi collected statistics up to date of Italian ovariotomists. Out of the first series of 100 cases, they lost 61. In the second 100 there were 36 deaths, but in the third series only 26 died.³⁶

³³ Medical Record, Jan. 3, 1885, No. 2, and British Medical Journal, April 15, 1882, p. 544.

³⁴ Medical Record, Jan. 3, 1885, p. 2, and American Journal of Obstetrics, July, 1882, p. 547.

³⁵ Maryland Medical Journal, July 1, 1882, p. 110.

³⁶ British Medical Journal, Sept. 16, 1882, p. 528.

The statistics of the leading ovariotomists up to January, 1883, are as follows:³⁷

³⁷ Medical News, Jan. 27, 1883, p. 117.

The statistics of general hospitals are by no means so good. In the Vienna General Hospital during the year 1881 "ovariotomy was performed 64 times, with 38 complete recoveries, 25 deaths, and 1 woman was discharged with marasmus."³⁸ Taking the profession at large, out of 5153 cases of ovariotomy collected by Baum, there was a mortality of 29.13 per cent.³⁹ Out of 2023 cases collected by Younkin, the mortality was 27 per cent.⁴⁰ By operative skill, by cleanliness, by wise hygienic measures, and probably by the use of antiseptic precautions, the fatality may be said to have been reduced by skilled specialists to about 10 per cent.; which, considering the size of the wound, the importance of the parts involved, and the delicacy of the exposed structures, is a remarkably low average. The average is indeed better than that of amputations. Before 1869, Sir James Y. Simpson stated that the average mortality of amputations of the extremities was 39.1 per cent. In the Glasgow Royal Infirmary the average mortality has been 25.5 per cent.—viz. of thigh cases there were 380 cases, with 113 deaths = 29.7 per cent.; of the leg, 182 cases, with 54 deaths = 29.6 per cent.; of arm cases, 167, with 33 deaths = 19.7 per cent.; of forearm cases, 93, with 12 deaths: mortality = 12.9 per cent.⁴¹

³⁸ Medical News, Dec. 30, 1882, p. 745.

³⁹ Agnew's Surgery, vol. ii. p. 811.

⁴⁰ The New York Medical Record, Nov. 11, 1882, p. 560.

⁴¹ Lancet, Sept., 1882.

This brings up the question of simple or of aseptic ovariotomy—a very important question and one not yet fully settled. The objections to Listerism are—that it is very troublesome; that it is liable to poison the patient fatally, as well as to injure the health of the operator; that it is useless, indeed merely a surgical craze; and that it is not the carbolic acid which does good, but the cleanliness enforced by this system. But there is no doubt that since the introduction of antiseptic surgery the mortality has been much lessened in every land. For instance, "in Germany, where the success of ovariotomy has not been so good as in other countries, the mortality by means of the antiseptic treatment has been reduced from 90 to 20 per cent."⁴² From an analysis of all the cases of ovariotomies performed by American surgeons, "the percentage of recoveries is overwhelmingly in favor of Listerism."⁴³ During the year 1881 in the Samaritan Hospital two of the surgeons used the carbolated spray of a strength of 1 in 40, and followed out every detail of antiseptic surgery. They had a mortality of 7 per cent. A third surgeon of that institution, after gradually lessening the strength of the spray until water was alone used, finally gave even it up altogether. He, however, for purposes of cleanliness always covered the instruments in the tray with water. The mortality of his operations showed the high rate of 30 per cent. The house committee, a body of laymen, thereupon "expressed a strong opinion against the performance of ovariotomy for the future without full antiseptic precautions."⁴⁴

⁴² Agnew's Surgery, vol. ii. p. 800.

⁴³ H. C. Bigelow, American Journal of Obstetrics, July, 1882, p. 651.

⁴⁴ British Medical Journal, May 20, 1882, p. 747.

On the other hand, Tait of Birmingham and Keith of Edinburgh, with a recent mortality each of only 3 per cent., have abandoned the spray. The latter claims now "to get as good results without it, and better results than any one has yet got with it."⁴⁵ My own practice is to adhere [p. 316] to the spray and to every detail of antiseptic surgery; and I fully agree with Bigelow that "it would be a grave error to abandon a practice which has achieved brilliant results until something shall be brought forth which shall be as thoroughly protective, and in the use of which there may be no possible dangers. Time alone can demonstrate satisfactorily the relative values of Listerism and of perfect cleanliness without Listerism. The results of a large number of cases in which cleanliness and attention to detail have alone been used are the only criteria upon which we can strike a judicial balance."⁴⁶

⁴⁵ Brit. Med. Journ., May 27, p. 796.

⁴⁶ Am. Journ. of Obstetrics, July, 1882, p. 651.

Contraindications for Ovariotomy.—An operation should be declined in far-advanced tuberculosis, in cancer of the ovary or of any other part of the body, in grave structural lesions of any of the vital organs, in ascites if caused by disease of the heart, the liver, or the kidney, in gastric ulcer, or in any serious disease of the alimentary canal. Extensive adhesions should not count as a contraindication, nor should age, since young girls and very old women have been successfully operated on. Albuminuria is often due to the pressure of the tumor on the kidneys, and, unless it existed before the appearance of the tumor or is positively known to be caused by Bright's disease, should not preclude the operation. Extreme debility dependent upon the ovarian disease makes the prognosis grave, but it should not prevent a resort to ovariotomy. I have indeed had several recoveries when the patient was so reduced in strength as to make it a very anxious and difficult task to keep her from dying on the table.

Indications for Ovariotomy.—This operation should not, as a rule, be performed when the cyst has first been discovered, but when it has grown so large as to distend the belly, and when the woman has become thin and her health has begun to fail. The reasons for waiting are—that the woman will have lived longer should the operation turn out to be a fatal one; that, the abdominal wall having become thinner both by being overstretched and by the absorption of fat, the incision will be proportionately shorter and shallower; that, the patient being now less full-blooded, both hemorrhage and inflammation will not be so likely to occur; that the bowels are crowded away from the line of incision; and that the pressure and rubbing to which the peritoneum has been for some time subjected will make it less vulnerable, and therefore less likely to take on inflammatory action. When, however, a woman broods over her condition and is anxious to have the tumor removed, the operation should be performed much earlier, especially if the surgeon be experienced.

Again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. Pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. Schroeder and Olshausen performed 21 ovariotomies in pregnant women, with only 2 deaths.⁴⁷

⁴⁷ Brit. Med. Journ., Dec., 1880, p. 1027.

When septic peritonitis sets in; when the contents of the sac become purulent, as they sometimes do either spontaneously or after an unprotected tapping; when the cyst bursts and serious symptoms arise; when torsion of the pedicle occurs or when a free hemorrhage into the sac takes [p. 317] place,—the radical operation should unhesitatingly be performed, and that without any delay.

Preparation of the Patient for the Operation.—The operation having been decided upon, every precaution must be taken to ensure a favorable result. The patient should avoid all exposure to contagious or to zymotic diseases, and she should be put in the very best condition of health possible under the circumstances. If the kidneys be inactive and the urine highly concentrated, depositing mixed urates in abundance, it will be well for the patient to make use of warm baths and to take saline cathartics in quantities sufficient to secure a daily action of the bowels. The alkaline carbonates, largely diluted, will also prove beneficial, and so will also the effervescent citrate of lithia. Sometimes, and especially when anasarca and oedema of the legs occur, it will be advisable to relieve the pressure-congestion of the kidneys by a preliminary tapping. Other organs will also be relieved, and valuable time for the action of medicines is often gained by emptying the cyst. Tonics, iron in the form of Basham's mixture, a generous diet, and fresh air may be needed. A trip to the seashore or to the country will often do much good in preparing a broken-down patient for the operation. If the patient comes from a malarial district, from twenty to thirty grains of quinia should be given during the twenty-four hours for two or three days before the operation, and ten grains a few hours before the time of the operation. If this be not done, a severe explosion of malarial fever after the operation may put the patient's life in jeopardy.

An operation of election should not be undertaken during a monthly period. It should be performed either about ten days before one or about a week after one. The very best time is midway between two fluxes. When, however, through some lesion or some accident, immediate relief is demanded, no regard whatever should be paid to the factor of menstruation. Some surgeons operate, indeed, in any case whether the woman is menstruating or not, and profess to find no difference in the result.⁴⁸

⁴⁸ T. Savage, Brit. Med. Journ., April 14, 1883, p. 712.

For several days before the operation the bowels should be kept open, and the diet should consist largely of milk, eggs, rice, and of wholesome and easily-digested food. On the day preceding that of the operation the upper portion of the pubic hair should be cut off and the abdomen, if hairy, shaved. In the evening the patient takes a warm soap-bath, and is washed perfectly clean by her nurse, who must be an experienced woman, able to pass the catheter and take the temperature. She then puts on clean clothing and goes to bed, where she stays until the hour fixed upon for the operation. To ensure sleep, I am in the habit of giving at bedtime thirty grains of potassium bromide, combined sometimes with opium. Early next morning a dose of castor oil is administered, and it is much more easily swallowed if disguised in some vehicle and brought to the patient without any previous warning. When oil cannot be taken, I give, at bedtime of the previous evening and in one dose, two compound cathartic and two Lady Webster pills. To avoid ether-vomiting, breakfast should consist merely of one piece of dry toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk, and afterward she must eat nothing more. To calm the nerves another thirty-grain dose of [p. 318] potassium bromide may be given, with or without opium as the case may be, and especially if the woman be at all agitated.

A very good time for operating is from noon to two o'clock in the afternoon, for by that time the oil will have acted and the light breakfast will have been digested. Some surgeons operate as early as nine and ten o'clock in the morning, in which case the cathartic will have to be administered in the afternoon of the previous day. At the hour fixed upon for the operation the woman puts on a flannel sacque, warm stockings, and drawers, and her nurse then passes the catheter.

The bedstead on which the woman is to lie after the operation should have a horse-hair mattress, and should be wide enough to permit her attendants to move her on a draw-sheet from one side of it to the other. I formerly placed my patients on narrow single bedsteads, so that they could be reached and be waited upon equally well from either side; but I found that an unchangeable position on the back soon became intolerably irksome. Next, indeed, to the thirst following the operation, my patients complain mostly of the supine posture which they are compelled to assume.

The room in which the operation is to take place ought to be a separate one, so that the lady can be etherized in her sleeping-room, and may not be unnerved by witnessing the needful preparations. Several days beforehand the carpet of the operating-room should be taken up and the curtains taken down. Every useless piece of furniture should be removed, the closets and bureau-drawers emptied, and the whole room thoroughly cleansed and ventilated. Several hours before the time of the operation this room ought to be heated to a temperature of 75°, and the air disinfected and made moist by a solution of carbolic acid kept boiling in a dish on the stove or over an alcohol lamp. Let me here say that, if possible, this operation should not be performed within the walls of a crowded general hospital nor in unhealthy localities, but, as statistics well show, in private houses or, far preferably, in small special hospitals.

Articles Needed for the Operation.—The following articles should be provided by some member of the patient's family. Following the example of the late Washington L. Atlee, I have a printed list of them, which is sent to the family physician some days before the operation:

One yard of rubber plaster; two rolls of raw cotton, made aseptic by being baked in the range-oven just before the operation; two yards and a half of fine white flannel, for two binders; six one-grain rectal suppositories of the watery extract of opium; two pounds of the best ether; two gallons of a 5 per cent. solution of the best carbolic acid, made at least two days beforehand; four ounces of Monsel's solution of iron; twelve ounces of undiluted alcohol for the spray-producer; some old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap; a pin-cushion, with large pins; two kitchen tables, or two dressing-tables; one small stand for the spray-producer; one small table for the basins and sponges; one chair without a back for a bucket of hot water; two new tin basins and one tin cup; a new bucket and a jug of hot water; a kettle of boiling water, ready on the range; a small tub and an empty bucket; six bottles filled with hot water and tightly corked; an empty wine-bottle for the aspirator; a rubber ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard and a quarter square, with an oval hole in the centre six inches wide and eight long; one kitchen apron for the operator; one [p. 319] clean blanket for the patient's lower extremities; two large platters or two meat-dishes, to be used as trays for the instruments;⁴⁹ clean towels, clean sheets, clean blankets, clean comfortables, and clean pillows.

⁴⁹ These platters are usually too shallow to hold a solution of carbolic acid deep enough to cover the bulkier instruments. It would therefore be well to have a tin tray made especially for the purpose, measuring nineteen inches long, twelve wide, and three deep; or a nest of smaller trays can be carried in the operator's bag.

Instruments.—In simple cases very few instruments are needed; but as one never knows beforehand what complications may be met with, it is best to be always prepared for every emergency. One must therefore have on hand every instrument likely to be wanted in the most formidable operation. The following list comprises all the instruments and other articles that I carry with me in my operating-bag, but it will not suit every surgeon, who will after a few operations choose his own favorite instruments:

One steam spray-producer, which will work two hours; assorted silk ligatures on spools; Lister's antiseptic gauze or salicylated cotton; two dozen straight surgeon's needles; assorted needles with varying curves; two large needles for transfixing pedicles; an aneurismal needle; one needle-holder; one hypodermic syringe; two dozen assorted pressure-forceps; one uterine tenaculum; assorted hair-lip pins and acupressure needles; one grooved director; two scalpels; Baker-Brown's cautery clamp; ten fine surgeon's sponges of different sizes; two long and flat sponges; one wire écraseur; one wire clamp or Koeberle's serre-noeud; Paquelin's cautery or three cautery-irons; one Wells's trocar with rubber tubing; one aspirator; two Nélaton's cyst-forceps; one straight pair of scissors; one pair of scissors curved on the flat; one right-angled pair of scissors; Allis's improved ether-inhaler; one flexible male catheter; three glass drainage-tubes of different sizes and lengths, together with the rubber sheeting and the sponge used with them.

The twenty-four needles should be threaded, two on one thread of fine silk eighteen inches long—viz. No. 1 or 2, of an excellent quality furnished by Messrs. J. H. Gemrig & Son of Philadelphia. To keep these threads from becoming snarled they are rolled up in a strip of muslin gauze, each pair of two needles with their thread being covered up by one fold of the gauze. The two pedicle-needles should also be threaded, but with stouter thread (No. 4), fully two feet long. All these armed needles should be put into a 5 per cent. solution of carbolic acid for several hours before the operation. Assorted needles of varying curves come occasionally into use, and it is always well to have several very fine needles on hand, together with the finest Chinese silk, in order to close a wounded viscus, such as the bladder or the bowels.

As an aid to the memory it is well to have invariably at every operation the same number of sponges and the same number of pressure-forceps, for these are the only articles likely to be left behind and closed up in the abdominal cavity. The cautery-irons should be wedge-shaped; the iron spreader used by apothecaries in making plasters forms an excellent substitute. In my hands the best pressure-forceps is Koeberle's. Its pointed beak catches the tissues far better than that of Wells's forceps, which looks like a crocodile's muzzle. The ordinary hæmostatic bulldog clips, or the serres-fines, must on no account be used, because if [p. 320] they should lose their hold and drop into the abdominal cavity they would be too small to be readily discovered, and might indeed be hopelessly lost in the coils of the bowels. Long strings attached to each one would, however, overcome this objection.

The ten sponges must be of the best quality and about the size of one's fist. Two of them should be flat, long, and thin, such as are called by the trade potter's sponges. When first bought, sponges almost always contain sand. To rid them of this they are beaten, then soaked for twenty-four hours in a 3 per cent. solution of muriatic acid, and afterward washed out in clear running water. Sponges should never be put into boiling water, which destroys their elasticity, shrivels them up, and spoils them. After every operation the sponges should be thoroughly cleansed in cold water and immersed for forty-eight hours in a solution of washing soda (sodii carbonas) containing four ounces to the gallon of water. They are then rinsed out in running water, and placed in a 5 per cent. solution of carbolic acid. At the end of a week they are to be taken out and hung up in a bag. Instead of a solution of soda, some prefer an 8 per cent. solution of sulphurous acid, in which the sponges are soaked for from two to four hours. This bleaches the sponges, but does not cleanse them so well as the alkaline solution.

Only three assistants are needed—two are enough if they are experienced—and they and the surgeon should take a soap-bath, and not see on that morning any patient ill from a zymotic or a contagious disease. Their clothes should also be scrupulously clean. To ensure still further protection, each one takes off his coat, waistcoat, and neck-tie if they are of a material which cannot be washed. The nurse must also wear clean clothing which can be washed. A few bystanders may be permitted, but they should wear clean clothing and take off their overcoats. They should also be cautioned not to visit before the operation any case of contagious disease.

Upon arriving at the patient's house the surgeon, together with his assistants and the nurse, proceeds at once to get everything in readiness. The two tables may be arranged in the form of a T, covered with several thicknesses of quilts, and with a pillow on the cross-table. When the tables are thus arranged a third one will be needed for the instruments and the spray-producer. In order to economize room and furniture, I am in the habit of putting one table at right angles to the other—viz. with its short arm to the left instead of to the right, thus: _|. The woman lies on the long arm of the _|, with her feet directed to the short arm, and on the projecting and free portion of the table forming the short arm are placed the tray of instruments and the spray-producer. As it takes time to get up steam in the necessarily large spray-producer, hot water should be poured into the boiler, and it should be one of the first things attended to. In order not to chill the patient, the spray solution of carbolic acid should also be heated before it is used. The edges of the oval hole in the rubber cloth are next smeared with some adhesive preparation, but a plaster suitable for all seasons of the year is not easy to devise. Keith's formula is the following, but it will not always stick:

After many trials, W. D. Robinson of Philadelphia has succeeded in making for me a very good plaster according to the following formula:

I must, however, add that I now very rarely use this rubber cloth.

Not all the instruments in one's bag, but only those likely to be needed, are now placed in the tray or in the platters, and covered over with boiling water, to which in a few minutes is added the same quantity of a 5 per cent. solution of carbolic acid. The best plan would perhaps be to pour into the tray a boiling 2.5 per cent. solution of carbolic acid. Into the same tray is also laid the roll of gauze containing the threaded needles. By its side on the table, and within easy reach, is placed a small bottle filled with a 5 per cent. carbolated solution in which are kept two small spools of Nos. 1 and 2 silk. The adhesive or rubber plaster is cut into strips of appropriate length, and the antiseptic dressing put in readiness. The trocar with tubing attached is hung on a nail near by. The sponges are carefully counted and placed in one of two basins arranged side by side on a table to the left of the patient. The other basin is one-third filled with a 5 per cent. solution of carbolic acid, which later on is reduced by the addition of pure hot water to a strength of 2.5 per cent. On a chair is placed a bucket of clean warm water.

Let me here say, once for all, that throughout the operation the assistant who looks after the sponges attends to them in the following way: Every soiled sponge returned to him is first cleaned in the bucket of warm water, next rinsed in the carbolated solution, then squeezed out and placed in the empty basin. This sequence must be rigidly observed, because, if the soiled sponge be plunged first in the carbolated water, the blood and serum which it contains will at once coagulate in its meshes, and become liable to be dislodged in the abdominal cavity as foreign bodies.

Meantime, the woman, in another room, has been inhaling the anæsthetic—the best being, in my opinion, the ether fortior of our leading manufacturing druggists. It should be administered by Allis's inhaler, which largely dilutes it with air. Wells and Thornton employ the bichloride of methylene; Keith uses pure ether; Bantock resorts to chloroform, and Tait to a mixture of two parts of ether and one of chloroform, given by means of Clover's apparatus.⁵⁰ When the patient is wholly unconscious her water is drawn off, and she is carried into the operating-room and laid on the table. To this table she is strapped down by a belt over her thighs, and her hands are also secured to the same belt. Her legs are wrapped in warm blankets, and her clothes are drawn up out of the way. Her chest and body are then covered by the rubber sheet, but the edges of its oval opening are made to adhere to the skin from just above the navel to the pubic hair, thus exposing only a limited portion of the abdomen. After this the spray is turned on, and the 5 per cent. solution of carbolic acid in the tray and in the basins is diluted with hot water down to 2.5 per cent. The operator and his assistants now take off their rings and cleanse their hands very carefully with carbolated soap and a nail-brush. They may clean and pare their nails with a penknife [p. 322] before the use of the nail-brush, but not after, because the knife not only does not remove all dirt, but it loosens up that which remains. Arranging themselves in their places, the operator stands to the right of the woman, his chief assistant to her left, the one who gives the ether at her head, while the other, who attends to the sponges, takes his place near the basins at the side of the chief assistant. The nurse holds herself in readiness to hand towels when called for, and especially to see that a third basin always contains warm water, so that at any stage of the operation the surgeon can wash his hands without delay.

⁵⁰ The Medical Record, Jan. 3, 1885, p. 2.

When everything is ready the door is locked, and the exposed portion of the abdomen washed with the solution of carbolic acid. An incision about three inches in length is made with a free hand, and not by nicks, in the median line below the navel, where the blood-vessels are few in number. It should end about one inch and a half above the pubes; that is to say, low enough for the pedicle to be easily reached, but high enough to avoid cutting the fold of peritoneum reflected from the bladder to the abdominal wall. The brown line running below the navel is the surface guide, but after cutting through the skin and fat one cannot always hit the linea alba beneath. When the cyst is large the recti muscles have become separated from one another, and there is no difficulty in keeping within the wide tendinous interspace. But when the cyst is small the linea alba is, as its name indicates, a mere line, and the knife will often go astray into the anterior sheath of one of the recti muscles. The red muscular fibres pouting out of the opening will be the danger-signal of one's having got off the track into more vascular regions. To recover it a probe is passed in across the muscle to the right and to the left, and the nearest point of arrest will note the linea alba. The disadvantages arising from the wandering from the linea alba are—that the sheath of the rectus muscle being cut open, or the muscle itself being wounded, there results hemorrhage; that the wound is more jagged, and therefore less easily coaptated; that suppuration in the suture-tracts is more liable to take place; and, finally, that in cases of small cysts with but little abdominal enlargement a spasmodic contraction of the wounded muscle is very likely to embarrass the operator both in removing the cyst and in introducing the sutures.

Again, one cannot on a grooved director cut canonically through the different layers of tissue described with so much precision in the textbooks. On the contrary, all that one needs is to know when the knife is approaching the peritoneum. An excellent landmark is the thin layer of fat overlying the peritoneum. So, after pinching up the abdominal wall to estimate its thickness, the surgeon can boldly cut down through the skin and its underlying fat, but somewhat cautiously through the aponeurotic structures until the second layer of fat is reached. Practically, therefore, he need regard but the following layers: skin with its underlying fat, the intermediate tendinous or muscular structures, the supra-peritoneal fat, and the peritoneum.

Before the abdominal cavity is opened all bleeding is stopped by the use of pressure-forceps, of which one dozen will sometimes dangle from the wound. When the hemorrhage has been wholly stayed, and not until then, the peritoneum is hooked up by a delicate uterine tenaculum and nicked open. On a broad grooved director or on the finger this opening is slit up for a distance of about two inches, either by a [p. 323] right-angled pair of scissors or by a probe-pointed bistoury. A little serum usually escapes and the nacreous wall of the cyst comes into view. This is called an exploratory incision, for by it the diagnosis is confirmed, the presence of adhesions ascertained, and the possibility of completing the operation determined. When it has been decided to go on with the operation, more working room will be needed, and the wound is therefore enlarged by the scissors, the finger being used as a guide to prevent injury to the omentum or to any chance knuckle of bowel that may lie in the way. The size of the incision will depend upon the character of the cyst and on the number of its adhesions. Hence it may range from a length of three inches to the distance from ensiform cartilage to symphysis pubis. An incision contained between the umbilicus and symphysis pubis is technically called a short incision, and one extended above the umbilicus a long incision. Should it be found needful to prolong the wound to a point above the umbilicus, the incision is usually carried to the left of the navel and brought back in a curved line to the linea alba. This is done to avoid the round ligament of the liver and its vessels, which come in there from the right side. Keith, however, cuts directly through the navel; and I find this straight incision to be superior in every respect to the curved one. Other things being equal, the short incision is safer than the long one; but it is a good rule to have an opening large enough for easy manipulation and for the easy withdrawal of the cyst. For instance, a large monocyst without adhesions after being emptied can, like a wet rag, be pulled out, hand over hand, through a very small opening, whereas a much smaller polycyst, which cannot be wholly emptied, and which is more or less adherent, will need a long incision. I once removed an oligo-cyst weighing one hundred and twelve pounds through an incision barely admitting my hand; while I had to open the abdominal cavity from ensiform cartilage to symphysis pubis in order to remove a solid ovarian fibroid tumor weighing but eighteen pounds. Both patients recovered, but the chances were, of course, more against the woman with the long incision. To avoid the escape into the abdominal cavity of any blood from the wound, and to prevent the soiling of the operator's hands, a clean napkin wetted with the carbolated water is doubled over each edge of the incision.

Whenever the cyst-wall in the line of the incision is glued by adhesions to the parietal peritoneum, the latter is liable to be mistaken for the former, and accordingly to be stripped off from the abdominal wall. To avoid this very serious error, either proceed with the cutting until the cyst-wall unmistakably comes into view or is opened, or else extend the incision upward until a point is reached where the cyst is free from adhesions. Adhesions binding the cyst to the abdominal wall are of importance only from the troublesome oozing their rupture often gives rise to. To lessen this risk, they are to be sundered by the finger whenever possible. Should the scissors be used, the adhesion bands must be snipped close to the surface of the cyst, and not to that of the abdominal wall. Thus, a free end is gained, which may, if needful, be subsequently tied or in which the dangling blood-vessels may the more readily constringe. All thick and long bands of adhesion should be tied in two places and be divided between the ligatures. These ligatures should consist either of very fine silk or of gut. For isolated vessels the latter [p. 324] are the better ones, but the silk is more suitable for tying en masse a group of bleeding vessels or for pursing up an oozing surface by an in-and-out stitch. A very important rule, on the observance of which one's success greatly depends, is, never to let a bleeding point or an oozing surface get out of sight. It must either be ligatured at once, or else caught by pressure-forceps and tied later if needful. If the delicate omental apron be found glued to the cyst, it should be carefully detached with as little tearing and splitting as possible, for each shred will bleed, and so will the fork of the split. It should then be turned out of the abdominal cavity on a clean napkin wetted with the carbolated solution. If its bleeding vessels be few, each one may be tied with gut; but if they are many, the torn portion of the omentum should be tied en masse or in sections, and the ligatures cut off close to the knot. All shreds and ragged ends of omentum must be trimmed off, and it is then returned to the peritoneal cavity.

When all the adhesions within reach, and those that do not demand great force, have been severed, it will be time to tap the cyst. This should be done with a large-sized trocar, such as Wells's, which is furnished with spring teeth to prevent it from slipping out of the cyst. Any trocar will do, provided it has a large bore, so that the vent may be free and that none of the acrid fluid can escape along its side into the abdominal cavity. In order to save time, neither Schroeder nor Martin use a trocar. They incise the cyst, and try by pressure and the lateral position to direct the contents externally. Frequently, however, some of the fluid escapes into the abdominal cavity, but they contend that if antiseptic precautions be taken no harm accrues.⁵¹ Although dissenting from this opinion, I must confess to having had the contents of the cyst escape repeatedly into the abdominal cavity without doing any harm whatever. Always tap at the upper angle of the wound, because as the cyst collapses the trocar is drawn downward toward the lower angle. Hence, were the trocar entered low down it could not travel with the collapsing cyst, which would therefore slip off. While the fluid is flowing flat sponges should be packed in between the abdominal wall and the cyst, and the edges of the incision should be pressed firmly against them, so that the peritoneal cavity may not receive a single drop of that which frequently escapes along the side of the trocar. To avoid this accident—which, without being a very serious one, is yet not to be invited—some ovariotomists before tapping turn the woman well over on her belly and over the edge of the table; but this is liable to cause a protrusion of the bowels; which is, in fact, a more dangerous accident than the entrance of some of the fluid into the abdomen. Rosenbach, indeed, reports that during the extraction of biliary calculi through an abdominal incision a cure resulted, although several calculi were lost in the peritoneal cavity.⁵² Should the mother-cyst not collapse on account of its containing a few other large cysts, the point of the trocar, without being withdrawn, can be made to enter each one. But if the child-cysts are many and small, the trocar is withdrawn, the opening enlarged, its edge seized by several pressure-forceps, and the hand introduced to break up these cysts.

⁵¹ Berlin. klin. Wochenschrift, 1883, No. 10.

⁵² Medical News, Feb. 3, 1883, p. 130.

Before this hand can again be used for separating adhesions it must be [p. 325] carefully cleansed with soap, and dipped into the carbolated solution in the tray of instruments.

The empty cyst is next gently pulled out through the abdominal wound. It is, however, so slippery that this cannot ordinarily be done with the hands alone. A strong forceps with a firm grip is needed, and one of the best is Nélaton's. While the cyst is being withdrawn the bowels are sheltered from the air and the spray by one large flat sponge, and the abdominal cavity must also be packed with smaller ones at every exposed point; and one of them should always be placed between the womb and the bladder.

In the majority of cases there is not much difficulty in freeing the cyst from its ordinary attachments and in reaching its pedicle. But should adhesions bind the cyst to the adjacent viscera, matters will not go on so smoothly. Such adhesions to bladder, liver, bowels, or to other important organs sometimes present difficulties which are insurmountable. The problem here is to sever these bands of adhesion without injuring the viscera to which they are attached. When these adhesions are numerous or very firm, much advantage will be gained by having the assistant put his hand within the cyst and stretch its wall while the operator severs the adhesions over it. By this means the adhesions can be better broken off close to the cyst, which is the all-important course to pursue in visceral attachments. Sometimes it will be needful to peel off the outer and non-secreting layers of the cyst and leave them behind—sometimes to cut off the adherent portion of the cyst and scrape off or strip off the secreting surface. Whenever the stalk of the tumor can be reached before all the adhesions are severed, it will be well to catch it with one or two pressure-forceps, or even to tie it and cut it off between two ligatures, like the umbilical cord. This will prevent bleeding from the torn surfaces of the cyst. When the cyst is closely adherent to the edges of the abdominal incision, either extend the wound upward until a free point is reached, and work downward on the adhesions, or else cut into the cyst, empty it, and seize with strong forceps its inner surface just beyond where the adhesions begin. The sac is then inverted by traction, which will break up its adhesions to the abdominal wall, the last portions to be freed being those attached to the edges of the incision. This prevents the stripping up of the peritoneum. Should the appendix vermiformis be so adherent to the cyst as not to be detached, it must be ligated in two places, between which it is to be cut, in order that its contents may not escape into the abdominal cavity. The fecal plug in each distal end should also be carefully squeezed out. Double ovarian cysts sometimes fuse together, and, rupturing at the point of fusion, form apparently one cyst. Such a cyst will have two pedicles, and will be very puzzling to the inexperienced operator.

When the cyst has been freed from its attachments and turned out of the wound, the very important question comes up of the treatment of the stalk or pedicle. Shall it be secured by a clamp? shall it be burned off by the actual cautery? or shall it be tied, cut off, and dropped back? The first is called the extra-peritoneal method; the others, the intra-peritoneal. For many years the clamp claimed the most advocates, but it has lost ground on account of possessing the following disadvantages: By keeping the wound open it prevents a strictly antiseptic treatment; [p. 326] the stalk sometimes sloughs below the line of constriction and conveys putrilage into the abdominal cavity; the stalk always becomes united to the abdominal wall, hence when it is short the womb is dislocated or it is too much dragged upon. Then, again, in one-third of the cases the oviduct has a trick of remaining open, and the woman will menstruate indefinitely from the abdominal cicatrix. This is owing to the fact that the clamped portion sloughs off too early for a firm plug of cicatricial tissue to be formed, and the oviduct is therefore liable to stay open. In my first case of ovariotomy this happened, and one year later the cicatrix degenerated into a malignant growth which destroyed the life of my patient. It is, however, probable that in this instance the cystic disease of the ovary was malignant, although the sac did not look so at the time of its removal. Another disadvantage arising from the use of the clamp is the subsequent weakness of the cicatrix at its site, and the liability of ventral hernia to form there. These are the objections to the clamp, and they are so valid that at the present time all distinguished ovariotomists have abandoned its use.

The actual cautery, performed by Paquelin's instrument or by platinum-tipped irons, which do not scale off or discolor the tissues, is theoretically the very best way of dealing with the stalk. No foreign body besides the charred portion of the stalk is left within the abdominal cavity; but, on the other hand, it cannot always be trusted to close the vessels. On this account it is looked upon with disfavor by all ovariotomists with the exception of Keith. His method is as follows: The pedicle is spread out evenly within Baker-Brown's clamp, so as to get equable compression. The cyst is cut off, leaving a stump about an inch in height above the clamp. To protect the parts from heat a folded napkin wetted in the carbolated solution is tucked under the clamp. The stump is next carefully dried, and then burned slowly down to the level of the clamp by wedge-shaped cautery-irons at a brown heat. They give off a whistling sound during the process. The thick end of the stump can be more quickly burned down, but the thin end should be burned very slowly, and the blades of the clamp by prolonged contact with the cautery-iron must also be made hot enough to dry up and shrivel that portion of tissue which they compress. In order not to disturb the stump after it has been cauterized, it is best to clean out the peritoneal cavity first, and to leave this treatment of the pedicle for the last thing. Before removing the clamp, which is to be unscrewed very slowly and carefully, one side of the pedicle is seized by a pressure-forceps, by which it is kept in sight and out of harm's way if the peritoneal cavity needs further cleansing.

The plan of treating the pedicle most in vogue, and the one which I adopt, is that of the ligature—one of fine carbolated silk, the finest compatible with safety. The ends are cut off close to the knot, and the stump is dropped into the peritoneal cavity, where the silk, being animal tissue, will in time become disintegrated and absorbed. Now, when I say silk, I mean silk, and not silver or gut ligature. Silver, being inelastic, cannot bind a shrinking stalk, while the gut is a treacherous ligature, and will sooner or later bring one to grief. It slips in the tying, it is liable to untie, it gives instead of shrinking, and it is too short-lived for the obliteration of large vessels.

The reasonable objection has been urged that since the abdominal cicatrix left by the use of the clamp is liable to reopen every month to give vent to menstrual fluid, the same phenomenon will by this intra-peritoneal method happen within the abdominal cavity and expose the woman to all the risks of a hæmatocele. But fact is here opposed to theory, for it has been found that either the oviduct in the stump atrophies into an impervious cord of fibrous tissue, or that its raw end, by contracting adhesions with the surrounding tissues, becomes hermetically sealed. It might also be supposed that the distal end of the ligatured stalk would slough and expose the woman to septic peritonitis. But such sloughing rarely happens, and for the following reasons: From shrinkage of the stump the constriction is lessened, and the capillary circulation is re-established; or the peritoneal surfaces on each side of the narrow and deep gutter made by the fine silk will bulge over and touch one another. Adhesion then takes place between the two, and the blood-vessels which shoot over from the proximal or uterine side of the ligatured stump will carry life into the distal end; or lymph exuded by the irritation of the ligature will throw a living bridge across the gutter in the stalk; or, what is the least desirable, the raw end of a long stalk glues itself to any peritoneal surface with which it may come in contact. I say least desirable, because sometimes such an adhesion makes a kink in the bowel, and may so constrict it as to give rise to fatal obstruction. To prevent this accident, Thornton stitches with gut the raw end of the stump to the broad ligament, to which it adheres; while Bantock catches it up out of harm's way by including it in the lowest abdominal suture, which, being of silkworm gut, can be left in for a long time. If the stump be short, it stands upright, and does not then need this treatment.

If the stalk be a thick one, it is transfixed by a blunt needle threaded with a double ligature, and is tied on either side, each half by itself, and then the whole is further tied by the free ends of one of the ligatures, or the Staffordshire knot, recommended by Tait, may be used. If it be a broad one, it is tied in three or more sections by cobbler's stitches. In thick or in broad stalks it is a good plan to catch the stalk in Dawson's clamp, which compresses it circularly, and to transfix and tie it in the furrow made by the clamp. This lessens the risk of secondary hemorrhage, which is usually caused either by the slipping off of the ligature or by its loosening through tissue-shrinkage. When this clamp is used the pedicle need not be tied until the wound is ready to be closed. The stalk must be cut off at a distance from the ligature of not less than three-fourths of an inch, so as to leave a button of tissue sufficiently large to prevent the loops from slipping off. In short and broad stalks the outer or broad ligament portion, which is thin and membranous and sustains most of the tension strain, is liable to slip out of its ligature and cause a fatal hemorrhage. To avoid this accident the ends of the corresponding ligature may, before being tied, be repassed in opposite directions through the stalk very near its margin to form the cobbler's stitch. Another way is to pass a fine silk thread through the thin portion of the stalk about one-third of an inch from its edge, and tie it. In the notch thus made, and below the knot, is laid and tied the outer ligature.

In anæmic cases Thornton ties the arterial side of the pedicle first, but in young and vigorous women he ties the venous side first, so as to [p. 328] deplete the woman by gorging the tumor with blood. While cutting off the cysts the abdominal cavity must be so protected by sponges that not a drop of blood shall fall into it. A dilated oviduct in the pedicle tends to suppurate; hence in such a case the ligature should be applied as close to the womb as possible, so as to get below the expanded portion. Before the cyst is cut away the pedicle should be seized on one side by a pressure-forceps, and kept more or less in sight until the wound is ready to be closed up. This will also prevent the ligatures from being rubbed off by the sponges while the abdominal cavity is being cleansed.

Sometimes the cyst has no stalk, but lies between two folds of the broad ligament, or else it is bound to the bladder, womb, and the pelvic tissues by intimate adhesions which cannot be safely severed. Formerly, under such circumstances the abdominal wound was hastily closed up and the case abandoned. Now, thanks to Miner of Buffalo, New York, we can fall back on enucleation, and need rarely be foiled.⁵³ This operation is performed by slitting open the peritoneal capsule of the sac at points close to its attachments, by introducing one finger or more into the opening, and by stripping off this serous and vascular envelope up to where the vessels enter the cyst-wall and become capillary. The artificial stalk thus made is to be treated precisely like a natural one—that is to say, by clamp, ligature, and cautery, or, if it does not bleed, by nothing whatever. This operation I have repeatedly performed, but it is seldom easy, and is always anxious work. Should the cyst be so wholly adherent to the viscera as not to be even enucleated, an incision is made into it. It is then emptied, thoroughly cleansed, and the child-cysts are also crushed by the hand. The edges of the opening thus made in the sac are now included in the stitches of the abdominal wound, but the latter is kept open either by a large cloth tent at the lower angle or by two glass drainage-tubes, one at each angle running down into the sac. Sometimes it may be needful to tie the adherent portion in sections and to cut the free portion away. A drainage-tube must then be inserted at the lower angle of the wound. This expedient has the sanction of Atlee and Olshausen, who have reported successful cases thus treated.⁵⁴ My own practice in such cases would be, after breaking up the child-cysts, to gather together the free portion of the cyst and bring it out at the lower angle of the wound. A short nickel-plated steel drainage-tube of large bore is inserted, the sac firmly clamped to it by a small wire écraseur, and the redundant portion cut away. Into this metal tube is passed a glass drainage-tube long enough to touch the lowest portion of the sac.

⁵³ Transactions International Med. Congress, 1876, p. 801.

⁵⁴ Monthly Abstract, July, 1877, p. 334.

In such cases, when feasible, I think it would also be well to adopt Freund's plan of tying the pedicle and severing it, in order to lessen the blood-supply to the cyst.⁵⁵

⁵⁵ Boston Med. and Surg. Journal, Aug. 24, 1876, p. 219.

The sac having been removed, the other ovary should be examined, and, if diseased, be tied and cut off. From the sundered bands of adhesion more or less bleeding has been taking place, which must now be attended to. It can usually be stopped by pressure with a sponge or with a finger, or with sponges wrung out of very hot carbolated water. For single vessels torsion will usually succeed, but if it does not, fine [p. 329] carbolated silk or gut ligatures must be used; and it is wonderful how many can be applied without materially compromising the safety of the woman. I once tied over thirty vessels in a lady sixty-eight years of age, who recovered without any symptoms of peritonitis. The free ends of the ligatures should always be cut off close to the knot. Stubborn oozing surfaces can very generally be stanched by searing them with Paquelin's thermo-cautery, or by passing a needle armed with fine silk under and ligating any vessel that may be detected leading up to the seat of the oozing. In some cases nothing answers so well as the pressure of the finger moistened with alcohol or with a drop or two of the ferric subsulphate or of the tincture of iodine. In oozing from inaccessible points in the pelvis a sponge dipped in the undiluted solution of iodine or in Monsel's solution of iron, and afterward well squeezed out, may be pressed firmly down for a few moments into Douglas's pouch. When the oozing comes from a large surface of the abdominal wall, it may finally be arrested by the doubling of the raw surface on itself. The fold thus made is then secured either by a long acupressure needle or by cobbler's stitches passed through from skin to skin. Forty-eight hours after, this needle or these stitches should be removed. For this ingenious device we are indebted to the late Kimball of Lowell, Mass. Should all these measures fail, put in a drainage-tube, close up the abdomen in the manner about to be described, and temporarily lay over the dressings some heavy weights, such as bags of sand or of shot. This plan I have not been obliged to resort to, but it has the sanction of Nussbaum, who uses two large bricks, and it is worthy of being borne in mind.⁵⁶ In my hands an elastic flannel binder pinned very tightly over a large roll of cotton wool has made pressure enough to check the hemorrhage.

⁵⁶ British Med. Journal, Oct. 26, 1878, p. 617.

The toilet of the peritoneum next comes in order. By this is meant the peeling off from the peritoneum of plastic deposits, the removal of the sponges packed into its cavity, and the careful cleansing away of all fluids and of every blood-clot. In the search for all such foreign bodies, or, indeed, for obscure oozing-points, the reflector of the ophthalmoscope or Colin's illuminating lamp will give much aid. Douglas's pouch and the peritoneal fold between the bladder and the womb are favorite localities for the collection of blood or of serum, and should therefore be thoroughly mopped out by small sponges on holders, otherwise peritonitis or septicæmia may result, which are the two great factors of death in unsuccessful cases. When this has been thoroughly done, a clean sponge is placed in Douglas's pouch, another in the sulcus between the bladder and the womb, and a third, a large and broad flat one, is laid over the intestines under the wound to catch the blood that may drop from the needle-tracks. Each needle is passed from within outward a quarter of an inch away from the peritoneal edge of the wound, and is made to emerge at the same distance from its cutaneous edge. If the recti muscles are included in the sutures, there is said to be a liability to the formation of abscesses in the suture-tracks. Hence almost every ovariotomist advises that the peritoneum and skin should be pinched together, and that the needle should be passed through them alone without perforating the muscles. Yet I believe that from a too close observance of this rule come many cases of hernia in the track of the wound, and that were the recti muscles [p. 330] more closely coaptated they would not recede from one another and thus aid in the formation of a rupture. My own rule is to include these muscles in the suture wherever they are exposed to view. The sutures should lie about one-third of an inch apart. The needles should be lance-pointed and held by a needle-holder. In fat women it is not always easy to get the two surfaces of the wound in exact coaptation; consequently, more or less puckering and eversion of the edges may take place. To avoid this, it will be well, before passing the needles, to bring the edges of the wound together, and make with a fountain-pen transverse lines at proper intervals across the incision as landmarks for the introduction of the sutures. These cross-lines are also of advantage whenever the abdominal walls are too tense for accurate coaptation, as after öophorectomy, after the removal of a small abdominal tumor, or after an exploratory incision for a solid tumor which cannot be removed. In these cases, indeed, it would be well to make the cross-lines the first step of the operation, before even the abdominal incision has been made.

The reasons why the needle is made to enter the peritoneum first are, that the stitches are lodged more evenly on that vulnerable surface, and with less injury to it, such as the stripping of it off from the abdominal wall; and, further, that a stray knuckle of bowel is not so likely to be wounded by the upward as by the downward thrust of the needle. The object of including the peritoneum in the stitches is to bring in contact two long and narrow ribbon-like surfaces of a membrane, which will quickly unite—so quickly as to forestall any formation of pus in the overlying tissues, and to bar the entrance of this or other septic fluids from the wound in the abdominal wall. Another advantage is, that this inclusion of the peritoneum by presenting an uninterrupted surface of parietal peritoneum to the visceral peritoneum prevents the adhesion of the omentum and of the intestines to the internal lips of the wound, which otherwise takes place.

When all the sutures have been passed, their ends on one side are loosely twisted together into a single strand, which is securely caught by a pressure-forceps. The same thing is done with the ends on the other side. A finger of each hand is now passed down into the centre of the wound, and the middle portion of all the upper sutures and of all the lower ones are separated from one another by being drawn to opposite angles of the wound. This permits the removal of the sponges, and, if they are stained with blood, the further search for some overlooked bleeding vessel. To guard against twisting of their convolutions, the bowels, still further disturbed by these final manipulations, are now restored to their natural position, and the omentum, after being again examined for some bleeding vessel, is gently spread out over them. The forceps and sponges are then counted to see that not one has been left in the abdominal cavity. The importance of this cannot be too strongly impressed upon the operator, for distinguished ovariotomists have overlooked these articles, and have left them behind in the abdominal cavity—a sponge and a bulldog forceps in one case.⁵⁷ Tait has heard of ten such cases.⁵⁸ It is indeed sometimes no easy task to find a missing sponge when lost in the [p. 331] convolutions of the intestines. The sponges therefore should not be much smaller than the fist.

⁵⁷ Lancet, May 26, 1877, p. 783; British Med. Journ., Jan. 28, 1882, p. 115; Ibid., Dec. 25, 1880; also, Ovarian and Uterine Tumors, by Spencer Wells, London ed., p. 336.

⁵⁸ Diseases of the Ovaries, by Lawson Tait, 4th ed., p. 261.

Before closing the wound the operator removes the pressure-forceps and catches in one hand all the ends of the sutures on his side, his assistant does the same thing on the other side, and the edges of the wound are brought together by a firm pressure, which also chases the air out of the abdominal cavity. To stop the bleeding from the needle-tracks as soon as possible, each suture is rapidly tied and by the surgeon's knot. When the whole wound has been closed, and not till then, the ends of all the sutures are gathered together in one hand, and they are cut off about two inches from the knot by one snip of the scissors. This saves precious time, which would be lost were each suture by itself to be cut after being tied. At gaping points of the wound intermediate superficial stitches should be put in. In fat women several such stitches will usually be needed.

Dressing of the Wound.—After the wound has been closed the rubber apron is removed and the abdomen cleansed and dried. The wound may now be dressed according to Lister's plan. This consists, first, of a narrow protective of prepared oiled silk, moistened by a 1:40 solution of carbolic acid; next, of one broad layer of antiseptic gauze wetted with the same solution; and over this eight folds more of the dry gauze, having a piece of mackintosh interposed between the seventh and the eighth layer. The lamp is now blown out, and the spray-jet being directed away from the abdomen, the dressing is secured by an elastic flannel binder, the rucking of which can be prevented by tapes pinned to it around each thigh. Most of the leading ovariotomists, however, employ simpler dressings, which have been found equally antiseptic. Wells covers the wound with a dry dressing of thymol cotton, kept in place by long strips of adhesive plaster, going two-thirds of the way around the body. Over all is pinned a flannel binder. The thymol cotton is prepared by steeping absorbent cotton wool in a solution of one part of thymol to one thousand of water, and drying it. Keith dresses the wound with gauze wrung out of a 1:8 glycerole of carbolic acid. On this are laid several layers of dry carbolated gauze, next some cotton wool, and over all a flannel binder. Thornton uses Lister's gauze and the mackintosh, but without the protective. This dressing is secured by adhesive straps. On these are laid several folded napkins, and over all a flannel binder is pinned very tightly. Bantock resorts to dry thymol gauze. Tait uses nothing but ordinary absorbent cotton. Salicylated cotton I have found to answer so well that for years I used nothing else. It is made by steeping two parts of absorbent cotton in a solution of one part of salicylic acid to two of commercial ether, and afterward drying the cotton by a low heat. Lately I have been resorting to Keith's dressing, but it probably possesses no greater advantages.

The flannel binder having been pinned on, the night-dress is pulled down and the patient put to bed. The opium suppository containing one grain of the watery extract is slipped into the rectum, the six bottles of hot water are applied to different portions of the body, and she is covered with warm blankets. The tables, tubs, and other articles used in the operation are now removed, the room is darkened, and she is left alone with her nurse, who has positive instructions to admit no one besides the physician.

Drainage.—When blood in small quantities is effused into the peritoneal cavity, coagulation usually takes place, the serum is then absorbed, the clot becomes organized, and no harm results. But when blood in large quantities collects in Douglas's pouch, it may behave as a foreign body and cause mischief. When, also, blood is mixed with serum, coagulation is not so likely to take place; the blood-corpuscles then are liable to break down, the fluid to become putrid, and septicæmia to set in. For these reasons the removal of these fluids by different modes of drainage has long been put in practice. The best mode is by a glass tube passed down to the bottom of Douglas's pouch through the abdominal wound, and not, as has been recommended, through a special opening made for it in the roof of the vagina. Drainage is at present very rarely resorted to by those operators who use strict antiseptic precautions, for they contend that septic changes in the blood do not then take place. Wells and Thornton have virtually given it up, while Keith, Tait, and Bantock, who have abandoned Listerism, are warm advocates of it. This question is a very important one, because a drainage-tube tends to the formation of a ventral hernia, and, being a foreign body, is in itself hurtful, and therefore should not be resorted to unless it will do more good than harm.

After a careful consideration of the subject I am forced from experience to believe that between the two extremes there lies a golden mean, and that drainage, even when the spray is used, is needed under the following conditions:

Should it be deemed needful for some of the above reasons to make use of drainage, a glass tube, open at both ends and about six inches in length, is passed through the salicylated cotton or other dressing, then between the two lowest stitches, down to the bottom of Douglas's pouch. A wire suture is first introduced between these sutures and left untwisted, its object being to close firmly the opening left by the removal of the tube and to hasten its union. Otherwise, a weak cicatrix results, tending to the subsequent formation of hernia. Keith's drainage-tube of three sizes is the one that I prefer. Its lower end is perforated with holes, and its upper end has a shoulder which keeps it from slipping into the abdominal cavity, and also enables it to hold a piece of thin rubber sheeting about eighteen inches square. In the centre of this a small circular hole is made, which, by stretching, is sprung over the tube. The mouth of the tube is covered by a cup-shaped sponge wrung out of a 5 per cent. solution of carbolic acid, and over this the sheeting is folded four times. The flannel binder may either be pinned over the drainage-tube, or else [p. 333] it may be slit at the site of the tube and passed on each side of it, leaving the sponge and rubber sheeting outside of the dressing. They are then best held in place by a narrow strip of flannel, so as to permit inspection without interfering with the main dressing. Several times a day the sponge is removed, squeezed out, cleansed in a 5 per cent. solution of carbolic acid, and replaced. This in a hospital had better be done under the spray. Bloody serum collecting in this tube is sucked out either by a fine rubber tube attached to a syringe, or else by the long nozzle itself of the ordinary uterine syringe.

To prevent injurious pressure on the rectum, the tube must be lifted up occasionally about half an inch, and allowed to slip back of its own accord. It can be removed whenever the discharge has been reduced to not more than one or two drachms, and this usually happens within the first forty-eight hours. After its removal the opening left in the wound is closed by twisting the free ends of the wire suture placed there for this purpose.

AFTER-TREATMENT.—The subsequent treatment needs the greatest attention. The first care is to establish reaction. This is best done by stimulants, such as brandy and whiskey given in iced soda-water. Enemata of beef-tea and brandy or of milk and brandy will also be of advantage, while artificial heat is kept up. For the vomiting, which comes partly from the anæsthetic and partly from shock, repeated deep inspirations should be tried. They help by getting the blood rid of the anæsthetic as soon as possible. Chloral may also be given, or small lumps of ice may be swallowed. Sips of very hot water, or a tablespoonful every hour of a mixture containing equal parts of lime-water and of cinnamon-water, may also do good. A hypodermic of morphia will often allay vomiting, and I have seen it yield to small doses of atropia, and also to two grains of pure pepsin given every two hours in a tablespoonful of raw-beef juice. Twenty drops of ether given by the mouth will sometimes relieve it, and so also will a few drops of chloroform confined by a watch-glass over the pit of the stomach. In some cases I have tried, with the best results, the following effervescent mixture, recommended by Chèron:⁵⁹

A dessertspoonful of the former is added to a tablespoonful of the latter, and given every hour. For vomiting, especially of the bilious variety, Lawson Tait recommends Monson's pepsin wine, given every ten minutes in drachm doses with a little ice-water.

⁵⁹ Archives de Tocologie, Février, 1883, p. 122.

Flatus is another annoying symptom, which, however, can very generally be dispelled by turning the patient over on her side and inserting a flexible catheter high up in the rectum. If this fails to relieve it, enemata of turpentine may be tried, or five-drop doses of the tincture of nux vomica may be given every two hours. Should the abdomen become painfully bloated, the binder must be loosened and the adhesive straps [p. 334] nicked in several places. The painful tension on the stitches can be relieved by drawing the knees up and supporting them over a pillow doubled on itself. Should the flatus not yield, and symptoms of obstruction set in, the bowels must be opened at all hazards. Castor oil and Epsom salts are good cathartics for this purpose. When vomiting accompanies obstruction, calomel answers best, because it is not so liable to be rejected.

For the first thirty-six to forty-eight hours after the operation nothing whatever should be given to the patient excepting cracked ice, sips of hot tea or of barley-water, and an occasional teaspoonful of old whiskey. After that time tablespoonful doses of milk, of beef-tea, of thin oatmeal gruel, or of barley-water can be given every hour or two. The diet may then be cautiously increased, and especially after wind begins to escape from the rectum, the patient being enjoined not to hold it back from motives of delicacy. If the condition of the patient is such as to demand more nourishment, it had better be taken by the rectum. For a week the urine should be drawn off by the nurse, and the bowels kept quiet by a morning and an evening suppository. No other anodyne need be given unless called for by pain, wakefulness, or restlessness. Should the body-heat indicate a temperature of 101° or over, a bladder filled with broken ice, or, what is far better, a rubber ice-cap, should be kept on the head of the patient as long as it feels comfortable and does not chill her. If the temperature does not fall, and peritonitis or other septic symptoms set in, ice should also be applied to the pit of the stomach. Quinia and morphia must then be given in very large doses, preferably by the rectum, together with ten drops of the tincture of digitalis every hour until the pulse-rate is lessened and the temperature falls.

When a full week has elapsed the bowels should be opened; and, as this is a matter of importance, and is occasionally attended with symptoms of obstruction and with a good deal of constitutional disturbance, a few words will not come amiss. If the hardened feces can be softened down and dislodged by enemata, this is perhaps the best plan, clysters of ox-gall and water or of glycerin and water being the most efficient. But in my experience enemata have so often failed that I rarely resort to them in the first instance. If the woman's stomach is not irritable, I prefer to give her an ounce of castor oil. This is disguised in the compound syrup of sarsaparilla or in some other suitable vehicle, as warm milk, and is brought to her without any previous warning early on the morning of the eighth day. Should it be deemed unwise to try the oil, two Lady Webster pills and two compound cathartic pills can be given at bedtime of the seventh day, or a pill containing three grains of the compound extract of colocynth with one grain of the extract of hyoscyamus may be swallowed every four hours. The compound licorice powder of the German Pharmacopoeia, to which has been added potassium bitartrate, also answers well, provided the patient's stomach will bear teaspoonful doses every four hours. Should these remedies fail to act, they must be supplemented by enemata.

Fatal obstruction of the bowels from matting or from constricting bands of organized lymph has been frequently reported. Thus far, I have met with one fatal case, which, however, passed out of my hands after the operation. But occasionally I see cases of obstinate [p. 335] constipation which give me great uneasiness and put me to my wits' ends. In one case, after the failure of other remedies the obstruction was overcome by broken doses of calomel combined with sodium bicarbonate, and by the distension of the lower bowel with very large enemata slowly given. Another desperate case yielded to repeated doses of tincture of belladonna. A third case, complicated by obstinate vomiting, was saved by ten grains of calomel given every two hours until the bowels were moved. Seventy grains were thus administered before the desired effect was attained, yet salivation did not occur.

When symptoms of obstruction once present themselves, they are likely to recur. The contents of the bowel should therefore be kept fluid, and for this purpose I know nothing better than the German compound licorice powder, given in teaspoonful doses at bedtime.

Suppression of urine sometimes follows ovariotomy, and in cases of diseased kidney is an alarming complication for this condition. For this symptom digitalis and the acetate of potassium should be given. Thornton treats it by baring the arms and packing them in towels which are kept wet with ice-water.

Tetanus may destroy the life of a patient while convalescing from the operation of ovariotomy. J. M. Bennett reports such a case.⁶⁰ The symptoms first showed themselves on the sixteenth day, and the woman died two days later. Chloral in drachm doses, administered by the bowel in the yolk of an egg, is perhaps the only remedy from which any good can be expected.

⁶⁰ Lancet, Dec. 3, 1881.

Occasionally, a few days after the operation, without any septic symptoms whatever or without any marked rise in the temperature, the parotid glands grow tender, swell up, and run through a course precisely like mumps, ending in resolution. This complication has been met with so frequently by myself and others that it cannot be a mere coincidence, but must be due to a reverse sympathy between the ovaries and these glands. It does not appear to increase the risk of the patient, for recovery took place in all the reported cases, of which three occurred in my own practice.⁶¹ Parotid bubo may also take place after ovariotomy, but this sign of blood-poisoning, being a general one, happens as well after other grave surgical operations and during the course of specific fevers. Yet from the sympathetic relation between the parotid glands and the sexual organs it seems to occur more frequently in the septicæmia following ovariotomy.

⁶¹ Wm. Goodell, Transactions of American Gynæcological Society, 1885.

Acute mania sometimes follows ovariotomy, especially when both ovaries have been removed. The attack is usually temporary, but it sometimes ends in insanity, and even in death, as in one of my own patients. Keith, Thornton, Tait, and other leading ovariotomists report analogous cases.⁶²

⁶² The British Medical Journal, March 21, 1885, p. 597.

SURGICAL TREATMENT.—The dressings, being antiseptic, need not, as a rule, be removed until the day following that on which the bowels are moved. Every other stitch may then be removed, and especially all that are loose or are cutting the tissues. The wound is then washed with a 2.5 per cent. solution of carbolic acid, and dressed anew with salicylated [p. 336] cotton. I usually find the first dressing so sweet that I am able to reapply the unsoiled portion of it for a second dressing. A clean binder is now pinned on and the woman's clothing changed. Three or four days later all the stitches should be removed, the wound secured by narrow adhesive strips, and dressed as before. For fear of a weak cicatrix and the formation of a hernia at the site of the wound, the patient should not get out of bed until fully three weeks have elapsed, and should for as many months wear some kind of close-fitting gored binder or abdominal supporter.

If, before the week is over, the dressings become soiled or give out a bad odor, they should be at once renewed. They should also be removed whenever a high temperature, without being accompanied by tympanites, leads to the suspicion of cutaneous abscesses.

THE ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY.—When by the breaking up of adhesions to it the liver is wounded, the bleeding surface can usually be stanched, as Koeberle has shown, by the ferric subsulphate applied to the raw surface by the finger. If this fails the actual cautery at a dull heat should be used.

If, unfortunately, an adherent portion of the bowel is torn open, the wound should be carefully closed with very fine silk by the continuous suture. The sutured portion is then fastened to the lower angle of the abdominal wound as a safeguard in case of the subsequent formation of stercoral fistula.⁶³ Should the intestine be injured to any extent, the wound must be closed by two sets of fine silk sutures, the first set uniting the mucous edges of the wound by the continuous suture, the other set uniting one serous coat to the other at a line about one quarter of an inch distant from the wound. An ordinary cambric needle with fine sewing-silk will answer admirably for this purpose. In small wounds one continuous suture, carried through all the coats but the mucous, will suffice. A mere puncture can be closed by hooking it up and surrounding it by a single fine ligature.

⁶³ "Discussion on a Paper by Garrigues," Am. Gynæcol. Soc. Trans., 1881.

Wounds of the bladder have frequently happened, but they are by no means necessarily fatal.⁶⁴ These accidents are liable to occur when the bladder, being adherent to the cyst and carried upward by it, lies directly under the line of incision, or the bladder may be torn open while adhesions to it are being severed. The wound should at once be grasped by a pressure-forceps, the bladder emptied by the catheter, and the operation proceeded with. When the operation has been completed the wound in the bladder is attended to, and in one of the following ways: Either the vesical wound is brought up within the lips of the abdominal incision, and is closed by being included in the abdominal stitches, or it is closed by the continuous or Glover's suture, without including the mucous membrane in the stitches. A self-retaining catheter, such as the Skene-Goodman, must then be kept in the bladder for at least a week.

⁶⁴ Eustache, Archives de Tocologie, April and May, 1880, pp. 193, 277; Boston Med. and Surg. Journal, Feb. 16, 1882, p. 153; British Med. Journ., Jan. 28, 1882, p. 115; Am. Journ. Med. Sci., Jan., 1883, p. 123.

One of the ureters will sometimes be torn across while pelvic adhesions are being broken up. This accident is most likely to happen during the enucleation of a cyst growing downward because enveloped in the folds [p. 337] of the broad ligament. It is almost always fatal, and is usually not discovered during the life of the patient, and, I am disposed to think, not often discovered after her death. Sometimes, however, urine will ooze out of the abdominal wound, and in rare cases the patient has recovered with a urinary fistula. In such a case Simon⁶⁵ successfully removed the corresponding kidney; Nussbaum⁶⁶ constructed an artificial ureter leading from the fistula to the bladder; and Tauffer⁶⁷ inserted the upper end of the divided ureter into the bladder by an artificial opening. It, however, failed to unite, and he later made an artificial ureter.

⁶⁵ Annales de Gynécologie, June, 1877.

⁶⁶ Edinburgh Medical Journal, July, 1876, p. 1.

⁶⁷ Archives de Tocologie, Avril, 1880, p. 201.

When an umbilical or a ventral hernia of moderate size is present at the time of the operation, efforts should be made for its radical cure. This is done by cutting out the thinned-out sac by two incisions meeting below and above, and by bringing together the thick edges of the abdominal wall in the final closure of the wound.

In cases of ascites complicating ovariotomy the ascitic fluid should not be wholly removed until the cyst has been cut off and the wound is ready to be closed. By this means any blood oozing from broken adhesions, or any fluid escaping from the cyst into the abdominal cavity, being diluted, is less likely to irritate the peritoneum, the cavity of which can also be more readily cleansed.

When a patient seems in danger of dying on the table from shock or from exhaustion the anæsthetic should be withheld while hypodermic injections of ether and enemata of brandy are given. Warmth should also be applied to the body by bottles of hot water, or, what is better, by rubber bags of the same. Theoretically, atropia administered subcutaneously would be the proper remedy, but I have not yet tested it. In all cases of ovariotomy, especially if prolonged, the woman should not be kept profoundly under the influence of the anæsthetic for any length of time, but should be allowed from time to time to come to at least enough to make her flinch or move about. This caution should especially be observed in very feeble patients and in those with very large cysts.

Whenever both ovaries are diseased there can be no question about the extirpation. But when only one has undergone cystic or other degeneration the question of the removal of the sound one may come up. There always is a tendency to the subsequent degeneration of the sound ovary after the diseased one has been removed. More especially is this tendency observed in sterile women and in those with malignant affections of the ovary. Many women, therefore, whose lives should have been imperilled but once, have been compelled to face the dangers of a second operation. In view of these facts, it seems to me wise to remove the sound ovary in all cases of sterility, in every case of malignant degeneration of one ovary, and in all women who have either passed the climacteric or are approaching it, provided its removal is not attended with great additional risk. Double extirpation should also be performed whenever the womb [p. 338] contains a fibroid tumor or whenever it seems desirable to hasten on the climacteric. In these convictions I am further strengthened by the disappointment often expressed to me by my patients that one ovary had been left behind, and by their great fear afterward lest the remaining organ should also become diseased. On the other hand, in women who are in the prime of their menstrual life the sound ovary should be left untouched, unless there exist grave reasons for its removal.

DISEASES OF THE URINARY ORGANS IN WOMEN.

ORGANIC DISEASES OF THE BLADDER.

This is an acute congestion of the mucous membrane due to a disturbance in the balance of the circulation. It may be common to both bladder and urethra, or limited to either; may terminate within a short period of time (a few hours), or it may go on and end in hemorrhage or inflammation. If the mucous membrane is seen with the endoscope, it appears of a bright-red color; the blood-vessels are distended, more prominent, and apparently more numerous. The arteries are the first to be affected. If the cause is transient, this is all that is seen, the membrane returning to its usual color. When the congestion is of a higher grade, rupture of some of the vessels occurs either on the free surface or beneath the epithelium. The venous side of the circulation now becomes more prominent. In a few cases the above order may be reversed, the veins being the first congested, as in the case of a sudden interference with the portal circulation.

SYMPTOMS.—The attack occurs suddenly. Frequent but painless urination is the most prominent feature. There is a sense of heat and heaviness in the bladder, aggravated by standing. When the urethra is involved the patient complains of scalding during urination. The pulse and temperature are practically normal. The composition of the urine is but little changed; there may be excess of mucus and a few blood-corpuscles.

DIAGNOSIS.—This has to be made by exclusion. It is apt to be confounded with a neurosis of the bladder or a displacement.

ETIOLOGY.—The most frequent cause is exposure to cold, especially during menstruation; over-taxation in walking or using the sewing-machine; excessive venereal indulgence; disorders of the portal circulation; and the use of improper articles of food.

TREATMENT.—Every means should be employed to equalize the circulation. The most important element is rest in the recumbent position. Diaphoretics and warm applications to the feet and epigastrium, and, as a rule, a saline laxative. Where there is frequent urination and vesical tenesmus and pain, Dover's powder and camphor should be given, or a suppository of morphia and belladonna by the vagina.

This is a symptom rather than a disease itself. It is usually due to acute congestion or ulceration occurring in advanced inflammations, new growths, or the lacerations caused by foreign bodies and instruments. Hemorrhoids of the bladder due to obstructed circulation is not infrequently the source of the bleeding. The amount of blood transuded varies very greatly, though it is seldom so great as to prostrate the patient. In all cases when it is considerable it is of great importance to localize the bleeding point. The urethra can be excluded if there is no bleeding between the acts of micturition. The differential diagnosis between hemorrhage from the bladder or kidney is less easy. The old rule, that the blood and urine are more intimately mixed in renal hemorrhage than in cystic, is of little service. Sir Henry Thompson's method of detecting the source of pus in the urine may be employed in cases of hemorrhage. He introduces a soft catheter, and then washes out the bladder gently with warm water; if after a time the water comes out clear, the inference is that the bleeding point is higher up. To make sure, he corks the catheter until a drachm of urine has collected; if this is bloody, the diagnosis of its being extra-cystic is tolerably certain. With the endoscope it is occasionally possible, and always desirable, to locate the bleeding point.

The symptoms in hemorrhage from the bladder, besides the actual appearance of blood in the urine, are much the same as those in hyperæmia. Other symptoms liable to arise are from blood-clots forming and either being passed by the urethra, causing its distension and impeding micturition, or else such clots may be retained and accumulate in the bladder, giving rise to still greater functional disturbance, until they are either broken into small pieces by the surgeon and extracted, or else by the slower agency of decomposition they break down and come away.

TREATMENT.—The first thing is to obtain the advantages, both mechanical and physiological, of the recumbent position. A large number of hæmostatics have been used—tannic and gallic acids, ergot, and aromatic sulphuric acid. These are doubtless of some value, but we prefer giving opium in sufficient doses to allay the desire of too frequent micturition, and at the same time to render the urine more bland by alkaline diluent drinks. When the bleeding points can be discovered with the endoscope, they may be touched with caustic acid, nitrate of silver, or persulphate of iron. But such applications must be made with the greatest care, lest inflammation and ulceration result. Ice in the vagina and at the hypogastrium may be tried when other means fail. When the hemorrhage is hemorrhoidal, due to impeded venous return owing to pressure of the gravid uterus, the treatment will have to be purely palliative in the mean time, as the pathological condition of the veins usually rights itself after delivery. When a large blood-clot forms in the bladder, experience has abundantly shown that it is better not to meddle with it, but to let it break down itself and come away, the patient being kept easy—if necessary by opium and alkaline diluents.

Inflammation may be limited to the bladder alone, in which case we call it cystitis, or to the urethra alone, when it is termed urethritis. But, practically, the pathological processes and the causes of cystitis and urethritis are so closely allied that it will be convenient in our limited space to consider them together. Like inflammation of other mucous membranes, various forms or degrees of cystitis and urethritis are described: these classifications are useful clinically, but it should not be forgotten that the pathological conditions presented are only different stages of the same process. Inflammations of the bladder are divided according to the cause of the disease and the character of structural lesions into—the acute, including the catarrhal and the suppurative; and the chronic, including the ulcerative, interstitial (and peri-cystitis); and the specific, embracing the gangrenous, croupous or diphtheritic, and gonorrhoeal, in which the inflammation is the result of a special poison.

ETIOLOGY.—The causes of cystitis may be classed under four heads: (1) Direct injuries, such as blows in the vesical region, falls, fracture of the pelvic bones, violent copulation, sudden uterine displacements causing pressure, foreign bodies, rough catheterization, over-distension from retention of urine, and, above all, contusions and injuries during labor. (2) Abnormal urine, from improper food or malnutrition and certain irritating drugs (cantharides) and irritating deposits of urine salts. (3) Certain constitutional diseases (eruptive fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due to cold.

PATHOLOGY.—The acute forms always begin with hyperæmia, then follow swelling, perverted or hyper-secretion, then exfoliation of epithelium, giving rise to a roughened and denuded state of the mucous membrane, particularly on the top of the rugæ, the products of inflammation accumulating within the sulci, and finally the formation of pus. A description of these, the ordinary phenomena of inflammation of mucous membranes, it is quite unnecessary to give here, but there are one or two modifying conditions in cystitis that are of great importance and need consideration. The first of these is the effect which the function of the bladder as a reservoir of urine has on the inflammation. Normal urine is irritating to an inflamed mucous membrane, and in cystitis it soon undergoes decomposition, becomes alkaline, and hence more irritating. The main agent in producing this decomposition is mucus, which is secreted abnormally both in quantity and quality. It acts injuriously in two ways, its fixed alkali tending to neutralize the acid of the urine, which in the early stages of cystitis is often hyper-acid, and in promoting the decomposition of the urea and thereby liberating the volatile carbonate of ammonia. As the urine becomes more alkaline the precipitation of the phosphates of lime and magnesia occurs, and the formation of the triple or ammonio-magnesian phosphate.

The irritant effect of these salts, really deposits of foreign bodies, on the inflamed mucous membrane completes the vicious circle, the effect now aiding the original cause.

Another most important point in the pathology of cystitis is the effect of over-distension of the bladder. This is itself sometimes the primary cause of the trouble, as in certain neuroses, but more frequently it is the [p. 342] effect of certain injuries during delivery. The mechanism of its production is not very clearly made out. It usually follows long, tedious deliveries, during which either the child's head or sometimes the forceps crushes the urethra against the unyielding pubic bones, giving rise to an acute urethritis, with swelling of the membrane and blocking up of the canal, causing retention. The primary injury is not done, as a rule, to the bladder in these cases, for if it were we should find the vesical neck the seat of sloughing of the mucous membrane; but, as a fact, this is the part (owing to its more loose connections with the underlying connective tissue) that most frequently escapes. This danger of over-distension is so clearly recognized that the catheter is nearly always used both before and after delivery if there should be retention. But a condition more apt to mislead both the doctor and the nurse is the urine dribbling away either constantly or intermittently. This is too often ascribed to an irritable bladder causing frequent micturition, when it is a sign of over-distension, the dribbling always occurring as soon as the mechanical pressure of the urine is sufficient to overcome the resistance of the swollen parts.

We have already referred to this condition of over-distension as a cause of inflammation; it will suffice to say that it may, if unrelieved, produce a partial or even total slough of the mucous membrane of the bladder; but, fortunately, this is rare.

Thus far we have spoken of the common forms of acute and subacute cystitis; it only remains to say a word with regard to its rarer manifestations. The inflammation may extend to the submucous coats, becoming interstitial cystitis. Again, this may limit itself here, or it may extend still deeper to the serous coat, in which case it is known as peri- or epi-cystitis. Peri-cystitis is almost always a secondary disease, arising sometimes from deep ulcerations of the inner coats of the bladder, such as occur in chronic cystitis. More frequently it is but a part of a pelvic peritonitis which originated outside of the bladder itself. The final result of peri-cystitis is to form adhesions between the bladder and the neighboring organs, and thereby prevent distension of the bladder.

A very rare form of gangrenous inflammation has been described, but it is more than doubtful if this ever occurs in women except as the result of mechanical violence or pressure, already described. The specific lesion of croupous or diphtheritic inflammation has occasionally been diagnosticated, either from shreds of false membrane passed by the urethra or by means of the endoscope. Gonorrhoeal inflammation of the bladder has been less carefully observed in women than in men. Still, it is known that this specific inflammation extends to the bladder in some cases, but it does not differ essentially in its pathology, history, or treatment from that arising from other causes; hence it is unnecessary to dwell upon it here.

The pathology of chronic cystitis is characterized by ulceration and sloughing of the tissues involved. They do not differ materially from the same processes elsewhere, except that the salts of the urine are apt to be deposited upon the shreds of dead tissue the products of destructive inflammation. The hard masses thus formed are passed with great pain. They block up the urethra, and are only expelled by extra strong efforts which cause intense suffering.

Lastly, the ulceration may extend through the bladder into the peritoneal cavity and give rise to septic peritonitis and death, or the perforation may take place into the cellular tissue of the roof of the pelvis, and cause a fatal cellulitis.

SYMPTOMS.—The various forms of cystitis being but different stages and degrees of the same disease, their symptoms may be discussed all together. For convenience we shall consider them under three heads: (1) Referable to the organs themselves; (2) Symptoms referable to the neighboring organs; (3) General symptoms.

(1) In all forms of cystitis there is more or less derangement of function, as shown by pain, tenesmus, and frequent micturition. In the mildest form of the trouble there is a frequent desire to pass water, which often comes with unusual force. Micturition is followed by a desire to strain, as if the organ was not fully emptied. This sensation may pass off in a few moments, and not arise again till the next micturition, but in the severer cases it may last continuously. When urethritis is also present there is the additional and characteristic symptom of painful scalding as the urine passes over the inflamed track.

In urethritis alone there is often a desire to urinate frequently, but if the desire is resisted it passes off, and the patient can retain the urine for a long time. This symptom should not be mistaken for the tenesmus of cystitis. In the more advanced stages of the disease, especially as ulcerative changes occur, the tenesmus becomes more violent. The pains also are more diffused, often shooting to the umbilical region. There is often a dull, aching pain in the perineum, and in nearly all cases there is continuous backache, or, more correctly, sacral pain.

The composition of the urine is of great importance. The specific gravity in cystitis does not present any constant change, except that in the chronic forms it is often a little below the normal. The reaction in acute cystitis, at first, at least, is usually acid, whereas in the chronic forms it is almost invariably alkaline. The color at first is not particularly altered; later, unless discolored by blood, it is a pale, dirty yellow. The odor is normal in the acute type, unless where retention has been followed by decomposition, but in the chronic form it is not only ammoniacal, but has a characteristic fleshy or organic smell. The sediment in the acute varieties is mainly light and yellowish, composed of mucus, with some pus generally; in addition there may be blood, epithelium, and the amorphous and triple phosphates. In the chronic forms the sediment is usually heavier and of a darker brownish color. Flakes of pus, shreds of tissue, blood, and epithelium in all stages of growth are more or less present, and in the intensely alkaline conditions of the urine the pus and mucus form a jelly-like, ropy, opaque mass.

Albumen will be found if there is pus in the urine without there being any kidney disease. As the result of a careful analysis of a number of cases of chronic cystitis, the amount of albumen varied from one-sixteenth to one-fifth of the volume of urine. Microscopically, in addition to the pus, mucus, organic shreds, phosphatic and other crystals already spoken of, the most interesting appearances are the various kinds of epithelium. In the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. It is only in the earlier stages that normal and transitional forms of vesical epithelium are present, and again they [p. 344] reappear on the subsidence of the inflammation. This fact is of great importance, because the transitional forms of bladder-epithelium are often indistinguishable from the permanent forms of the urinary tract higher up. It is thus often impossible to make a differential diagnosis between pyelitis and cystitis from this symptom alone. When renal disease is superadded to cystitis, the characteristic casts will be found and albumen will likely be increased in amount.

(2) The symptoms accompanying cystitis in women referable to the neighboring organs are of some importance, but they very often arise from some coexisting disease of other pelvic organs. It is therefore needless to give a list of all the pelvic pains coincident with cystitis which have been enumerated in the literature of this subject.

(3) The general symptoms are of two classes, toxic and nervous. While all agree that there is no doubt of direct blood-poisoning in cystitis, there has been a great deal of difference of opinion as to how this is effected. I think that there are various agencies at work in this. First, there may be organic renal disease or sympathetic renal hyperæmia leading to imperfect elimination. In cystitis caused by over-distension from long retention the kidneys simultaneously take on acute inflammation, which usually passes off when the bladder is emptied, but it may continue and give rise to all the constitutional symptoms of renal disease. Again, in chronic cystitis the thickening of the bladder-walls obstructs the ureters, so that the urine is dammed back upon the kidneys. This arrests their function, and in time leads to organic disease with all the consequent derangements of the nutritive and nervous systems. Secondly, absorption of the products of decomposed urine, or of pus and other septic materials the result of decomposing shreds of tissue, may take place.

Anæmia is another of the blood-changes which occur in chronic cystitis. In its origin and continuance it probably is much like anæmia due to long-continued inflammation elsewhere. The only peculiar symptom in this connection is the appearance of urohæmatin in the urine.

With this slow deterioration and poisoning of the blood various symptoms are developed. There is an effort made to eliminate urea by the mucous membrane of the alimentary canal. This is manifested by attacks of vomiting or diarrhoea. But when it does not come to these explosions, there is apt to be lack of appetite, especially at the morning meal, or there are perverted taste and constipation, interrupted by occasional attacks of diarrhoea. The skin in the chronic cases is at times sallow and clammy, and at times there is a distinct urinous odor about the body. Various more or less marked nervous symptoms are apt to be present. One set is characterized by the sluggishness of the patients, an inclination to sleep, despondent spirits, and occasionally dizziness and fainting. There can be little doubt that these and allied symptoms are referable to cerebral anæmia, for they are much aggravated by bromide of potassium, whilst digitalis and out-door life improves them. A second set of nervous symptoms are fairly attributable to blood-poisoning of one kind or another, and in the most severe cases are often promptly relieved by diarrhoea. Finally, a number of the irregular, wandering neuralgic pains and the headache are due to the general depression produced by bladder-pain and loss of sleep.

DIAGNOSIS.—Cystitis is easily made out, except in certain mild cases. [p. 345] Similar symptoms, especially frequent urination, occur in prolapsus uteri, often in anteversion and in cases of pelvic adhesions and pregnancy and abdominal tumors, and lastly in certain neuroses. In most of these the recumbent position lessens the desire for frequent urination much more than when cystitis is present. Again, in the neurosis the attacks are irregular. Tenesmus is usually only present in cystitis, and lastly the examination of the urine and exploration of the parts should settle the question. We have spoken above of the method of differential diagnosis of blood coming from the bladder or the kidneys: the same method applies to localizing the source of pus. Urethritis with fissure at the neck of the bladder simulates cystitis in clinical history, and in the fact that pus in small quantity is found in the urine. To differentiate, the urine examined should be taken directly from the bladder with the catheter, when it will be found free from the products of inflammation. In addition to this, in some cases it will be necessary to make use of the endoscope, by which a good view can be obtained of the whole urethra and a portion of the mucous membrane of the bladder sufficient for diagnostic purposes.

TREATMENT.—The female bladder is so accessible, owing to the shortness of the urethra, that it is peculiarly amenable to local treatment. This is by no means, however, all that is required, for in all forms of cystitis, irrespective of the cause, the urine plays a very important part in keeping up the irritation. There are, therefore, always three indications to be met: (1) Removal of the cause; (2) constitutional treatment (diminishing the irritating character of the urine); (3) the cure of the local lesion.

(1) In many cases, of course, the cause is transient. The injury is done, and the inflammation resulting runs its course, longer or shorter according to the modifying influence of treatment. In a smaller number of cases, again, the cause is not removable, as in certain constitutional diseases or permanent pelvic adhesions, tumors, and the like. In such cases of course the treatment is but palliative, and, while relieving the immediate symptoms, aids the organs till a certain amount of toleration of the abnormal conditions is established. But in a large class of cases the cause, though more or less persistent, is removable. This includes the numerous cases of uterine displacement. Lastly, there is a certain number of uncomplicated cases which tend to recovery without treatment.

(2) The constitutional treatment should be first directed to reducing the amount of work the bladder has to do. For this purpose the bowels should be kept rather freely open, saline laxatives being the most valuable for this purpose. The skin too should be kept healthy and active. Next, the character of the urine should be as bland as possible. Food and drugs which are known to cause or keep up cystitis should be carefully avoided. Milk diet has proved successful in the hands of George Johnson. In all cases the diet should be carefully attended to, and should consist largely of fluid foods—milk, yolk of eggs, soups, etc. Lean meat in small amounts and easily-digested solids are allowable. Articles such as asparagus, alcohol, beer, and wine generally are to be avoided. Fruits, such as lemons and oranges, are usually grateful and at least harmless. The alkaline diluents, such as citrate of potassium or the alkaline mineral waters (Vichy), answer an admirable purpose. An infusion of buchu is an excellent agent, and may be combined with nearly [p. 346] all other drugs employed in treating cystitis. Where pain is an urgent symptom in acute cases, it should be relieved by hot applications and by anodynes. Dover's powder is an excellent form in which to give opium. To relieve tenesmus vaginal suppositories of morphia, with or without belladonna, may be given. But in certain cases twenty-grain doses of potassium bromide every four hours relieve pain where opium fails. Benzoic acid or benzoate of ammonium in ten-grain doses in infusion of buchu, three times a day, is a most valuable remedy. The usual remedies, such as balsam of Peru or copaiba, oil of turpentine, etc., which are given in gonorrhoeal inflammation, are very useful in the chronic catarrhal forms of cystitis. To prevent or lessen the decomposition of the urine a vast number of remedies have been employed, all of the astringents and most of the antiseptics, but as a rule these remedies are much better administered locally than constitutionally. In various acute and transitory cases the constitutional remedies above described will be all that is necessary, but in the greater number local treatment is absolutely required.

(3) In local treatment the first point is not to do harm to the parts by the use of instruments. Dirty catheters and rough catheterization so often cause cystitis that it is easy to see that the same causes often perpetuate the mischief. Great care, then, should be used in selecting instruments for injecting. The ordinary metallic catheter with one or two large openings is much more liable to wound the sensitive mucous membrane than one with a number of small holes made either of hard or soft rubber. It should have a stopcock or something similar at the outer end, the better to regulate both the injections and the escape of the solution injected. In ordinary injections only about an ounce at a time should be in the bladder; this can be repeated four or five times, and the injection should be as slow as possible. To meet these indications I use a double perforated catheter made as follows: A small tube runs from one of the bifurcations to the extreme point. This is the supply-tube, and the catheter acts as the exhaust. The central tube can be removed for the purpose of cleaning the instrument. A piece of rubber tubing attaches the supply-tube to a fountain syringe, and this completes the whole apparatus. The calibre of the supply-tube being small and that of the exhaust large, a great quantity of fluid can pass through the bladder without distending it. The fingers can pinch the rubber tube and act as a stopcock to regulate the entrance and escape of the fluid used.

An injection of borax and water is often highly beneficial, and is alone sufficient in many cases. It should be frequently employed. It should always precede any topical application or medicated injection. Lukewarm water alone is employed, but the addition of a little salt (drachm j to pint j) or chlorate of potassium renders it more bland. Very often hot water is a most useful application. Of the medicated injections a vast number might be described, but they are referable to two classes, anodyne and astringent. The painful nature of cystitis suggests the use of opium preparations and chloral hydrate for injections, and they do give some relief. They should be well diluted to prevent their causing irritation.

Of the astringents, acetate of lead, sulphate of zinc, tannic acid, nitrate of silver are the most valuable. Many others—perchloride of iron, chlorate of potassium, hydrastis canadensis, salicylic acid and its preparations, carbolic acid, etc.—have been commended. In all cases the strength of [p. 347] the injection should be short of causing the patient much pain. It is always best to begin with a mild solution and gradually feel the way up to stronger ones. Of all the astringents, I prefer nitrate of silver, which I use in strengths varying from one grain to twenty to the fluidounce. The general rule to be observed, if a strong solution is used, is to employ only a few drops; if a large injection is made, the solution should be weak.

Various antiseptics—iodoform, salicylate of sodium, etc.—have been used to prevent the decomposition which so complicates obstinate cystitis; but, as a rule, I think frequent washings out and astringent applications act much better. One of the most distressing obstacles encountered in making any such injections is where there is a tender or inflamed urethra. It is well then to carry the catheter only up to the sphincter of the bladder (as advised by Braxton Hicks), overcoming its resistance by the pressure of the injection. As a rule, the urethritis will not long survive the cystitis, but in some cases it exists as an independent affection; it is then usually gonorrhoeal, and should be treated as in the male. But when not, the same principles apply as in the local treatment of the bladder. Great care is needed, as the female urethra will only hold ten or fifteen drops at a time, and if a large injection is used it is almost sure to enter the bladder. To meet this difficulty I devised a reflux catheter for douching the urethra. It is grooved on the outside, and at the point there is an opening in each groove which lets a jet of the fluid used flow outward, bringing the injection in contact with all parts of the urethra.

In cases of ulceration, such as occur in bad cases of cystitis, applications should be made, if possible, to the part affected only. This can be accomplished by means of the endoscope when the ulceration is seated where it can be reached. Having located the point exactly by means of the endoscope, the inner or glass tube is withdrawn, and the application made directly to the required spot through the rubber tube. A glass pipette properly curved or any ordinary insufflator will answer perfectly, and when a solid is used a delicate long curved forceps will answer.

In chronic cases of cystitis in which all the above methods of treatment fail, it becomes necessary to give the parts complete rest by securing continuous drainage of the urine and products of inflammation. There are two ways of doing this—the one, to use a self-retaining catheter which may keep the bladder empty: this method answers very well when the inflammation is confined to the upper portions of the bladder, but when the neck of the bladder is involved the presence of the catheter gives rise to pain and irritation and cannot be tolerated. The other plan is to establish an artificial vesico-vaginal fistula, and keep it open for some months, until the bladder-walls have become normal again. This secures efficient rest to the inflamed parts; complete drainage is established, the patient wearing a cup, as she would a pessary, to catch the urine. If the inflammation is limited to the upper portion of the bladder, the drainage by the fistulous opening is all that is required; but if the neck of the organ is involved, frequent and continued medication will be required. This can be done by injecting through the urethra and letting the fluid escape through the opening in the bladder. This is not the place to discuss the steps of the operation or the indications when and how to close the artificial fistula. For these the reader is referred to works on this department of surgery.

Suffice it to say, in conclusion, that this by no means easy operation should be only undertaken as a last resort, but that if properly done in well-selected cases it will cure where all other known methods of treatment have failed even to relieve.

This lesion may be partial or total, involving any or all three coats of the viscus. But the term usually refers more particularly to increase of the muscular walls. As a rule, the hypertrophic changes are not confined to one portion of the viscus, all being more or less affected. The affection is much less frequent in the female than the male.

ETIOLOGY.—There are two varieties of this affection—one, concentric hypertrophy, in which the bladder is contracted as well as having its walls thickened; the other eccentric, in which there is dilatation. Its principal causes are—obstruction to the outflow of urine from stricture of the urethra, tumors, or foreign bodies; cystocele, preventing complete evacuation; cystitis, causing too frequent or too forcible contraction; and irritable bladder in certain of the neuroses. Accompanying such dilatation diverticulæ are sometimes formed, though rarely in the female.

SYMPTOMS.—There is sometimes present vesical spasm, some pain, and forcible ejection of urine. A certain amount of cystitis is almost always present, aggravating the original disorder. In the eccentric form there are sometimes superadded symptoms of over-distension.

DIAGNOSIS.—This is readily made by measuring the thickness of the bladder-wall between the finger in the vagina and the sound in the bladder. The capacity of the bladder is easily noted by measuring the urine passed at each micturition or by injecting a bland solution of salt and lukewarm water.

TREATMENT.—The treatment should be directed to the removal of the cause. When this is not possible, palliatives may be sought for in the use of the catheter, at regular intervals, to prevent over-distension. Cold baths, astringent injections, and electricity are often of use. By these means the evil results of the disease may be overcome, but the hypertrophy is usually permanent.

Atrophy of the bladder is a rare disease in early life. In women, in addition to the ordinary decay of age, there is a special predisposition to degenerative changes in the pelvic viscera, the bladder-walls included, after the menopause. Extreme distension of the bladder is usually the exciting cause, giving rise to temporary or even permanent paralysis, and eventually causing either inflammation or atrophy and fatty degeneration. Interrupted nutrition, due to impaired circulation, is the immediate cause, but such altered nutrition may be purely nervous and due to atrophy of certain ganglion-cells in the spinal cord.

SYMPTOMS AND DIAGNOSIS.—Patients complain of difficulty in emptying their bladders, the urine coming away in interrupted jets. They are [p. 349] apt to be irregular in their times of urinating, and are liable in consequence at times to have retention and over-distension. Pain and sometimes a slight cystitis are present. Finally, they completely lose the power of urinating and a catheter has to be used. The diagnosis is to be made as in hypertrophy, by a finger in the vagina and a sound in the bladder.

TREATMENT.—Regular catheterization, strychnia in full doses, electricity, and tonics, combined with washing out the viscus. Where the atrophy is due to nerve-degeneration these measures are purely palliative, in other cases they are of more avail.

FUNCTIONAL DISEASES OF THE BLADDER.

Under the name of functional diseases of the bladder are included a large number of varied affections of which the pathology is as yet very obscure. Where there are marked symptoms of vesical disorder, while no organic lesions are found in the tissues of the bladder, the affections must be classed under the name of functional derangements. As our knowledge increases the number of these is constantly diminished, and a still further and more rapid diminution will occur as the physiology and pathology of the nervous system innervating this viscus become better known. These diseases are much more common in children and women than in men—in children, because the controlling power of habit is only in process of formation; and in women, mainly because of the more complex organization of the genito-urinary organs, which are the more easily exhausted and deranged, especially by the functions of maternity. True, neuralgia of the bladder has been described under a variety of names, irritable bladder, cysto-spasm, etc., but it is rather a rare affection. The most prominent symptom is the painful micturition, and attendant on this a desire to pass water too frequently.

There is no particular change in the character of the urine, and no appreciable visible alteration in the appearance of the parts, though they are more sensitive than normal to the touch. This condition is best met by warm fomentations locally and sedatives either locally or generally, while nutrition is improved by appropriate tonics, nervines, and by the use of the galvanic current.

A much more common class of affections of the bladder accompany hysteria, sometimes grouped under the name of hysterical bladder. A great number of pathological conditions are grouped under this vague term, but they are held together by all having, as a more or less prominent symptom, varying degrees of incoördination. The disturbing effect of strong sudden emotion, as fear, upon the bladder is familiar to all, and in various organic diseases of the spinal cord and brain, such as myelitis and locomotor ataxia, a disturbance in the functional action of the bladder is among the first symptoms. It then becomes a matter of great difficulty, and yet of great importance, to make a differential diagnosis.

In hysteria the urine usually diminishes in specific gravity; it is apt to be increased in quantity, and, though clear in appearance, is irritating [p. 350] to the mucous membrane. In such cases frequent urination, sometimes almost continuous, sets in; but it is an important point that during sleep the patient retains her urine the normal time. In others we get, on the contrary, retention, and this may be due to various causes. In some it is doubtless involuntary, as they say they cannot urinate, but in others it is assuredly will not. Many of these latter derive a morbid pleasure from catheterization. These are the patients who are given to the introduction of hair-pins, slate pencils, etc. etc. into the urethra.

Some authors claim that in the intense sexual excitement of hysteria the chronic erection of the clitoris makes pressure on the urethra, and so prevents the escape of urine, but this seems somewhat apocryphal.

Another class of cases resembling the hysterical in the frequency of urination are those addicted to masturbation; these are, fortunately, not very common.

In all of these cases the frequency and irregularity of urination is a much more prominent symptom than the pain. This latter is usually a slight scalding from the urine passing over the chafed and irritable urethra, especially at the meatus. (These symptoms sometimes occur in the miasmatic affections.) A number of neuroses of the bladder are reflex and dependent on peripheral irritation elsewhere. A typical example of this class of affections is what has been described under the title of ovarian irritation. In this condition there is very much heightened reflex irritability accompanying the increased tenderness and vascular engorgement of the affected ovary. It is difficult to explain the bladder symptoms which sometimes accompany the recurring crises of this disease, except as due to a nervous excitation spreading from the ovarian centres in the spinal cord to the adjacent bladder centres.

The diagnosis of this group of affections must be made by exclusion. We have some of the same symptoms—increased frequency of micturition, pain during and after the evacuation, tenesmus and shooting pains in the pelvis—as in organic disease. The most important guide is a careful examination of the urine, which shows the absence of abnormal constituents, thereby excluding organic disease. This diagnosis will be much strengthened by a digital examination, by the vagina, of the neck of the bladder, and the passage of a urethral sound, neither causing pain, as they would do in cystitis.

The PROGNOSIS is usually good, but it depends upon the length of time the affection has lasted.

The TREATMENT is mainly tonic and nutritive. The diet should be nutritious and simple, and the bowels regulated by mild purgatives. Constitutionally, small doses of strychnine are most valuable in improving the nerve tone; so also the constant electric current is of service. Locally, sedative suppositories in the vagina or enemata are advantageous, conium combined with belladonna or hyoscyamus seeming to act best. The liberal use of the bromides gives good results in some hysterical cases.

This is the most grave of the functional affections, and, like paralysis elsewhere, it may be either peripheral or central. When the latter, as in [p. 351] certain injuries of the brain or in certain well-marked lesions of the spinal cord, it hardly calls for more than mention here. Often, however, the cause is not recognizable in any organic lesion either of the bladder-walls or the central nervous system, and is to be sought for in more temporary and transient influences; thus as a result of over-distension most frequently, of impaired or lost nerve-conduction in fevers involving serious derangements of nutrition, all of which may be described as functional or temporary paralysis.

The invasion is usually gradual, except in apoplexy or traumatism. The patients, who are usually advanced in years, first observe that the urine is expelled from the bladder with less force than usual; the stream is smaller and comes slower, and straining takes place, the aid of the abdominal muscles being invoked. After a while the stream intermits, and finally partial or complete retention occurs. Then, if this condition continues, the sphincteric resistance gives way and constant dribbling occurs. In rare instances dilatation of the bladder-walls takes place, and finally cystitis. Dilatation of the ureters and hydro-nephrosis are not uncommon under these conditions.

Where the condition of retention obtains the DIAGNOSIS ought never to be difficult; the introduction of a catheter will conclusively settle it.

The PROGNOSIS in uncomplicated paralysis is usually good. When accompanying fevers, dysentery, peritonitis, etc. it usually disappears with the original disease. When due to centric lesions the outlook is about hopeless.

In all cases the bladder should be emptied at stated intervals. If the patient cannot do this herself, the surgeon should resort to the systematic use of the clean soft Jacques catheter. A most important point, too often overlooked, is the method of emptying an over-distended bladder. It is not safe to empty the bladder at once: the patient ought to be tapped at intervals, an abdominal binder being gradually tightened meanwhile. The too sudden removal of pressure from the vesicle walls which have been rendered anæmic allows of intense congestion, and in a condition of paralysis is the sure prelude to cystitis. The diet in these cases should be generous and stimulants are not contraindicated.

I cannot agree with those authors who recommend washing out the bladder with medicated solutions and forcibly distending the urethra, nor with those who use tincture of cantharides as a vesical excitant. Both plans are apt to produce cystitis. A far more rational though somewhat impracticable treatment is the use of electricity as recommended by Winckel—one pole (thoroughly insulated up to the point) in the bladder, the other on the symphysis or loins. The sitting should last about five minutes. But by far the most valuable therapeutic agent is strychnia, which should be exhibited in full doses, many of the reported failures with this drug being due to too small doses. In urinating the upright position is generally preferable to lying down, as the pressure of the abdominal organs to some extent compensates for the lack of tonicity in the bladder-walls.

Lastly, in these hopeless cases of complete paralysis an artificial vesico-vaginal fistula and the adaptation of an apparatus to catch the urine may be of service.

Functional disorders of the bladder are frequently met with, due to [p. 352] abnormal constituents in the urine. As was mentioned above, these may be so grave or their irritant action continued so long as to give rise to cystitis. In the slighter forms, due to transient cause, the local trouble will speedily right itself, but in other cases, such as those dependent on functional derangements of other organs, as dyspepsia, the irritation is apt to return at varying intervals. In almost all these cases the immediate mechanism of the trouble is the presence of some urinary deposits. To this may be added the constitutional impairment, as in oxaluria, when the minute octahedral crystals are probably not more to blame for the local difficulty than the impairment of the nervous tone. Similarly, the poison of malaria and of certain of the exanthemata, and of many diseases marked by faults of assimilation and elimination, causes functional disturbance.

The prime indication in treating these cases is to render the urine more bland by dilution. For this purpose water, aided by the salts of potash and the alkaline mineral waters, is the best. This should always be given on an empty stomach, and the addition of infusion of buchu is excellent. In the condition known as oxaluria the alkaline salts are not called for, but instead thereof acids. Nitro-muriatic diluted and tincture nucis vomicæ tend to correct the faults of nutrition, and they should be largely diluted to relieve the local condition.

The last class of functional diseases are caused by lesions of position either of the bladder or of some of the neighboring organs. Here, again, we have conditions which if sufficiently prolonged may lead to organic vesical changes or may simply be temporary or intermittent. By far the greater number of these are dependent on malpositions of the uterus, which either drags or presses on the bladder. Either of these classes may be complicated with adhesions arising from a former cellulitis or pelvic peritonitis, the adhesions resulting therefrom maintaining a fixation of the pelvic organs which impairs the functions of the bladder.

Other causes of displacements are uterine and ovarian tumors, pelvic deformities, and fecal impactions of the rectum. Of the various displacements of the bladder it is needless to speak in much detail. The most important is the downward one. Various degrees of this are found up to complete cystocele, most commonly associated with prolapsus uteri. The bladder naturally sags inferiorly as age advances, and by far the most potent agent in causing this to become pathological is repeated pregnancy and injuries during labor.

It is a well-known fact that the first stage of vesicle prolapsus is apt to be marked by as great discomfort as the third, for after a while the organ seems to become accustomed to its altered relations. The treatment of this condition is difficult. The bladder should be replaced and kept there. As this usually necessitates the reposition and maintenance of the displaced uterus, it is extremely difficult, and in case of existing adhesions it is impossible. A great variety of mechanical means have been tried to furnish an artificial support to keep the parts in position. If the bladder alone is prolapsed, the pessary used for anteversion of the uterus will sometimes answer. The instruments devised by Thomas, Grailly Hewett, and myself are most commonly used.

This affection may be simple or gonorrhoeal, and it is often difficult to tell the one from the other. There is a difference in history when we can get correct testimony from the patient. Simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease, while gonorrhoea comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. The chief symptom is painful urination. Sharp scalding is produced by the urine passing over the tender surface. There is often a frequent desire to urinate, but not so urgent as in cystitis. In some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. In quite a number of cases I have noticed hemorrhage, the source of blood being evidenced from the fact that it was not intimately mixed with the urine, and after micturition it oozed from the meatus urinarius.

An examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. Occasionally there is a discharge seen coming from the urethra, but if the parts have been recently bathed this may not be apparent. Introducing the finger into the vagina and pressing upon the urethra from above downward will cause a discharge, unless the patient has passed water immediately before. The appearance of the discharge corresponds to that of gonorrhoea in its various stages.

Cystitis, which is liable to be confounded with urethritis, may be excluded by using the catheter, and, after letting urine flow for a time, collecting the remainder for examination. The mucous membrane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. The instrument cannot be used in all cases, owing to the acute tenderness of the parts. Bleeding is very likely to occur in the examination, simply from the contact of the endoscope.

The TREATMENT of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. This will suffice in most cases of acute disease, but when it assumes the subacute form from the beginning, then the use of injections becomes necessary. I have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. For this purpose I use a catheter made like the fluted roller of a crimping-machine. The catheter conveys the water to the rounded point of the instrument. Behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. By this arrangement the water, as it flows back through the grooves, is brought in contact with every portion of the mucous membrane. The instrument is passed up to the neck of the bladder, and a fountain syringe attached to it, and the water as it flows away is caught in a cup.

The injection of solutions of nitrate of silver and sulphate of zinc will often prove useful. It must be borne in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where very slight force is employed while injecting. I use a large syringe, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. When the case is [p. 354] of long standing, and the neck of the bladder appears to be involved also, I use a weak injection of one or two grains of nitrate of silver to the fluidounce, and inject it through the urethra with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. In old cases which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. While the bougie is passed once or twice a week, I apply to the vaginal portion of the urethra oleate of mercury or the unguentum hydrargyri. This will often suffice to stop the gleety discharge, as well as remove the thickening of the urethral walls.

These glands rarely, if ever, take on inflammation primarily, but vulvitis and vaginitis, especially if gonorrhoeal, often extend into them. When they do become inflamed, the disease usually remains without any tendency to subside. More than that, when a gonorrhoea affects these glands the inflammation will remain there after all traces of the disease have left the vagina, vulva, and urethra, and in time the discharge from these glands will light up the original vaginitis and vulvitis again. The symptoms of this inflammation are not diagnostic. The physical signs are the swelling and redness around the mouths of ducts which are located just within the labiæ of the meatus urinarius. This give a general redness to the meatus. By pressure made upon the urethra from above downward a purulent discharge from the ducts will be produced and can be seen escaping. The only effective treatment is to lay open the glands their whole length. They run upward in the posterior wall of the urethra, so that by passing a fine probe-pointed scissors they can be laid open on the vaginal surface. Care should be taken to prevent the incision from reuniting, and if the inflammation does not promptly subside applications should be made, as in the ordinary treatment of inflammation.

Another very troublesome affection of the urethra which usually results from urethritis is granular erosion, as it is called. The mucous membrane is covered with young, imperfectly-developed epithelium; the papillæ are hypertrophied and extremely sensitive. This gives rise to the most excruciating pain during micturition, and generally keeps up a distressing tenesmus. This disease is rarely seen except among old people. The diagnosis is made from the history and appearance of the urethra. The treatment is cauterization of the whole surface. The milder washes and injections do not accomplish much. Pure carbolic acid may be tried first, brushing it over the surface and repeating it in eight or ten days. This is the least painful application, and generally answers very well. When it fails a solution of nitrate of silver (one drachm to the fluidounce) should be used. In obstinate cases it is desirable, before using strong caustics, to dilate the urethra, and then touch it with a 50 per cent. solution of carbolic acid.

Among the inflammatory affections of the female urethra there are mild forms which fall short of well-marked urethritis. Indeed, some of these attacks amount to little more than congestion or slight catarrh. In others circumscribed patches of the urethra become inflamed, the rest of the canal remaining normal.

The cause of this affection is generally some inflammation of other pelvic organs, such as cellulitis. In one case it occurred in a saleswoman who had been upon her feet many days from early morning until late at night. I found several small ecchymoses on several parts of the mucous membrane with zones of inflammation around them. The long-continued passive congestion had caused some of the small vessels to rupture, and the small blood-clots started the inflammatory process.

These cases tend to recovery if the patient is placed under favorable conditions. If there is much pain, and if the trouble appears to be tending to become chronic, mild injections may be employed.

Dilatation of the whole urethra is not so common as dilatation of a portion of it. Even when the whole canal is larger than it should be, it is not, as a rule, uniformly so. In general, the urethral walls and the urethro-vaginal septum are usually enlarged, relaxed, and flabby. After a considerable time they may become indurated by infiltration or hyperplasia of the connective tissue. The mucous membrane is usually soft and loosely adherent to the subjacent tissues. Beneath the membrane there are sometimes masses of enlarged veins which give a dark bluish appearance to the parts. If the meatus be distended like the rest of the urethra, the mucous membrane with the large veins beneath it may protrude and form a tumor or tumors, which have quite the appearance of rectal hemorrhoids. This is especially so when the veins are large and numerous and the mucous membrane thin, so that the color of the veins can be seen through it. On the other hand, if the meatus remains normal in size, nothing will be seen by the examiner until the catheter or sound is passed into the urethra, when the distended or distensible condition of the canal will be detected. The dilatation can be easily detected, even when the meatus is normal in size, by observing that the sound can be moved about in the urethra, conveying the same impression obtained when the sound passes into the bladder. By making a digital examination of the vagina the enlarged urethra can be felt, and it is usually elastic and compressible. Through Sims's speculum the abnormal fulness or bulging of the anterior vaginal wall can be plainly seen and distinguished from displacement of the urethra. The points of difference between dilatation and displacement will be brought out more in detail farther on.

When the dilatation has existed for any length of time, the mucous membrane is usually hyperæmic, and sometimes catarrhal, secreting a muco-purulent material, which may be seen escaping from the meatus or lodged in the folds of the membrane, where it can be seen through the [p. 356] endoscope. When the mucous membrane is prolapsed and forms a tumor outside of the meatus, it soon becomes fissured and ulcerated, and consequently very tender and painful. This condition is produced by the retarded circulation, chafing, and the irritation from exposure to the air and the urine passing over it.

Dilatation of the anterior or lower third is the rarest of all forms of urethral dilatation, and occurs usually as a consequence of some enlargement or swelling of the mucous membrane, neoplasm of the urethra, or mechanical dilatation. The dilatation may or may not include the meatus. In rare cases it does not at first, but in time the enlarged mucous membrane slowly, sometimes rapidly, dilates the orifice. The general appearances of the parts are the same as those of which I have spoken under the head of dilatation of the whole urethra. When the dilatation is due to any new growth in the urethra, the tumor can be seen on inspecting the parts.

I have only seen one case where the lower end of the urethra was dilated without any recognizable cause for it. This was a single lady, thirty-five years of age, a school-teacher. She had displacement of the uterus and catarrh of the cervical canal, for which she consulted me. She had no trouble with her urinary organs. While examining the uterus I noticed that the meatus urinarius was peculiarly formed. In place of the concentric corrugations of the mucous membrane which form the closed meatus, the orifice was funnel-shaped and lay open when the labia minora were separated. About half an inch of the lower end of the urethra admitted a No. 21 (Eng.) sound. The remainder of the urethra was normal, and there were no signs of disease about the mucous membrane of the dilated portion. I could obtain no history which pointed to the origin of the trouble, and it caused no discomfort to the patient.

Dilatation of the posterior or upper third occurs in connection with other pathological conditions, such as prolapsus of the bladder and urethra. On this account we will defer what is to be said on this subject until we come to dislocations of the urethra.

Dilatation of the middle third of the urethra is more common than that of any other portion of the canal. In this form the anterior wall of the urethra maintains its normal position, but the central position, being distended, settles down, so that in time the urethra, in place of being a straight or slightly curved canal, becomes triangular, the upper wall being the base, and the central portion of the wall (that is, midway between the neck of the bladder and the meatus) the apex. A sac or cavity is thus formed in the central portion of the urethra.

In the earlier stages of this affection the urethra in front and behind the pouch is really or apparently contracted; but as the disease progresses the upper part of the canal and the neck of the bladder become dislocated downward, and finally the upper portion of the urethra becomes also dilated to some extent.

There is in this as in the other forms of urethral dilatation frequent urination, usually more marked, but, unlike the others, there is difficulty in passing water. This frequency of urinating, and the straining efforts necessary to do so, affect the bladder, producing irritation, and in time hypertrophy of its walls. Cystitis also follows in the order of morbid developments; but whether that comes from the frequent and difficult [p. 357] urination, or from extension of the inflammation from the urethra to the bladder, is a question.

ETIOLOGY.—The hyperæmia of the urethra which occurs in pregnancy, and which tends to produce over-distension of the veins, favors dilatation of the whole urethra. There is an apparent increase of tissue in the walls of the urethra during utero-gestation, and the dilatability of the canal is often increased also. Now, this condition of the parts disappears during the involution which takes place after delivery; but when from any cause the process of involution is interrupted, the enlarged vessels and relaxed condition of the urethral walls remain and sometimes increase. When to this state of the parts a catarrh of the mucous membrane is added, the enlargement of the membrane by swelling still further increases the calibre of the canal.

The dilatation caused by the passage of calculi may remain permanently, and the same may be said of the use of large sounds. Neoplasms obstructing the meatus or stricture at that point may so obstruct the escape of the urine as to cause dilatation at all points above. This is no doubt one of the most important and frequent causes of dilatation.

I have already stated that dilatation of the lower third of the urethra is rare, and is usually due to inflammation of the mucous membrane at that point or to abnormal growths, the distension remaining after the causes that produced it have been removed. This and mechanical dilatation from any cause cover the etiology of this form of the trouble. Baker-Brown says that the meatus is always dilated when there is stone in the bladder.

Regarding dilatation of the upper third of the urethra, I am inclined to believe that it occurs in consequence of a partial prolapsus of the bladder and the upper end of the urethra. The displacement of these parts implies a relaxation of the tissues, caused originally, it may be, by injuries during confinement, and the prolapsus permits an unusual pressure of the urine upon the upper end of the urethra, and dilatation is the result. On the other hand, the prolapsus and accompanying relaxation of the urethral walls may be sufficient to cause the dilatation. In all the cases that I have critically examined there has been displacement as well as dilatation, and the whole trouble could invariably be traced to childbearing or anteversion of the uterus.

One cause of dilatation of the middle third of the urethra (urethrocele) has been sufficiently dwelt upon in Bozeman's description of the pathology of that affection—that is, narrowing of the lower end of the urethra. This does not explain the etiology of all cases, however, for I have seen this form of dilatation where there was no stricture or hypertrophy of the lower end of the urethra. In such cases I have traced the cause to childbirth, during which the posterior wall of the urethra had been pushed downward and contused, while the upper remained in its normal position. The relaxation caused by this over-stretching of the urethral wall formed a small pocket in the central portion, which gradually dilated more and more by the pressure of the urine until the urethrocele was fully developed. This explanation of the cause may be rather hypothetical, but, so far as my observations go, it agrees with the facts found in those cases which cannot be accounted for by Bozeman's views on the pathology of this affection.

SYMPTOMATOLOGY.—The symptoms vary according to the extent of the dilatation, the portion of the urethra involved, and the condition of the mucous membrane. When the whole urethra is dilated the only symptom present may be frequent urination. When there is inflammation or prolapsus of the mucous membrane, then pain will be caused by passing water, and the desire to do so will be more urgent and frequent. The patient may also be annoyed by a slight loss of control of the water, under the pressure of lifting heavy weights, coughing, or the like.

Dilatation of the lower third of the urethra does not cause any derangement of function, unless accompanied with inflammation or ulceration; then there will be frequent urination possibly, and painful urination certainly. The symptoms in this form of dilatation are less marked than in the other varieties.

When the trouble is located in the upper third of the urethra, the symptoms are sometimes very distressing. In addition to the frequent—it may be constant—desire to pass water, the patient is tormented with partial incontinence. Coughing, laughing, sneezing, stooping to lift anything, a jar on stepping from the curbstone in crossing the street, causes an escape of urine. This distresses the patient very greatly. From the constant wetting of the external parts they become inflamed, unless very great care is taken to keep them dry and clean. In some of these cases the mortification of mind is sometimes more distressing than the physical suffering.

The symptoms occuring in dilatation of the middle portion of the urethra are the same as those already given, with the addition of a slight mechanical obstruction which causes difficult urination; that is, more voluntary effort is necessary on the part of the patient to empty the bladder. The forcing, straining efforts made by some of these patients while urinating are even greater than the mechanical obstruction appears to account for. This may be due to the accumulation of urine in the urethra, which excites extra reflex action in the bladder and urethra out of proportion to the obstruction. This is the only way that we can account for the difficult urination and muscular hypertrophy found in those cases in which there is no great obstruction from stricture.

The constitutional symptoms arising from these urethral troubles are the same as those produced by urethritis, and are not peculiar to this class of affections. In fact, the symptoms here given may all be produced by other pathological conditions, and consequently cannot alone guide to a correct diagnosis. The true character of the trouble can only be discovered by physical exploration.

DIAGNOSIS.—A digital examination by the vagina will detect the increased space occupied by the urethra. The canal encroaches upon the anterior vaginal wall, and feels like a ridge extending from the meatus to the neck of the bladder. This elevation or thickening of the urethra is elastic and compressible in recent cases; in those of long standing the tissues are firm to the touch, but still the canal is compressible. The extent of the dilatation, if general or located in the lower parts, can be measured by the size of the sound that can be easily passed. If at the middle or upper portions, an ordinary female catheter or sound may be used to explore it. By introducing that instrument and pressing it first against the anterior wall and then upon the posterior, the distance between [p. 359] the two can be approximately made out. While the catheter or sound is in the urethra the finger should be introduced into the vagina to ascertain the thickness of the urethral wall. This will differentiate between dilatation and hypertrophy.

When the meatus is dilated and the mucous membrane and enlarged vessels are prolapsed, care is necessary to distinguish that condition from urethral neoplasm. This can be done by observing that in prolapsus the opening is situated either at the upper side or in the centre of the protruding mass, whereas in abnormal growths of the urethra the meatus surrounds the tumor or its pedicle. More than that, by making pressure the distended vessels can be reduced in size and the prolapsed membrane pushed up into the canal. This cannot usually be accomplished with tumors.

PROGNOSIS.—There is no natural tendency to recovery in these affections. If left alone they generally get worse. Recovery under treatment depends upon the location of the dilatation and the duration of the trouble. The conditions upon which an unfavorable prognosis is to be based are—bladder complications, inflammation or ulceration near the neck of the bladder, great varicosity of the veins, and fatty degeneration of the muscular tissue. In the absence of all these complications a complete recovery may be expected. In all cases great relief can be secured by treatment and the patient guarded from getting worse.

TREATMENT.—In the management of all forms of urethral dilatation attention should be given to any inflammation of the mucous membrane that may exist, employing the usual treatment. When there is a relaxed and prolapsed condition of the mucous membrane, astringents should be used. Tannic acid or alum will answer well. When these fail, the redundant membrane should be retrenched, either by touching it with the thermo-cautery or excising a portion with the scissors. In employing the cautery for this purpose the long pointed tip of the instrument should be used, and, having protected one side of the urethra with the speculum, cauterize a narrow strip of the membrane parallel to the axis of the canal. Two or more of these cauterizations may be made at points equidistant on the circumference of the urethra. By operating in this way pieces of normal membrane are left between the portions cauterized, which prevents stricture from occurring after healing—a misfortune which is sure to follow if the mucous membrane is destroyed by cauterization all around.

In excising the prolapsed portion I prefer to remove one or more V-shaped portions on opposite sides and bring the edges together by sutures. This is preferable to clipping off the whole of the protruding mass, because the cicatrices left are less likely to give after trouble.

When the dilatation is caused by varicose veins it may be well to follow the example of Gustave Simon. He exposed the vessels by cutting through the vaginal wall, ligated the largest, and arrested the hemorrhage from the smaller ones by applying liquor ferri perchloridi. He repeated this operation several times on the same patient, who experienced little or no inconvenience from the proceeding and made a good recovery.

Dilatation of the lower third of the urethra is usually secondary to some other trouble, as I have already stated; and all that is necessary [p. 360] to do for such cases is to remove the cause and treat any inflammation that may exist. The dilatation will then disappear; and if it does not, but little if any trouble will be caused by it.

The treatment of dilatation of the upper third consists simply in supporting the parts. This can be effectually done by using the pessary already recommended for the relief of prolapsus of the bladder. It may be necessary to have the instrument so formed as to bring the pressure where it is required. This is done by placing the pessary in position and observing what change of form, if any, is necessary, and then directing the instrument-maker to make the alteration. If the parts are well supported in this way, recovery will follow unless atrophy of the muscular wall has previously taken place. Even then the patient can be kept comfortable by wearing the pessary. If there is urethritis present, it may be necessary to remove that before using the pessary; otherwise the pressure of the instrument may cause pain and aggravate the inflammation.

In dilatation of the middle third Bozeman has proposed to make an opening into the most dependent part of the urethra through the vaginal wall, and maintaining it until all inflammation has been relieved, and then closing the opening by the usual plastic operation. By this means the urethra is perfectly drained of urine and the products of inflammation which accumulated there before. This, with appropriate cleansing and topical applications, soon restores the mucous membrane to its normal condition, and the removal of the redundant tissue during the operation of closing the opening effectually cures the whole trouble. This treatment is admirably adapted to marked cases of long standing, and should be employed. By using the thermo-cautery to make the opening the operation is easily performed. In recent cases of less magnitude I have obtained satisfactory results by dilating the lower part of the urethra and supporting the dilated portion either with a pessary or a tampon of marine lint. This permits the urethra to keep itself empty, and then, by frequently washing it out and applying such remedies as will cure the urethritis, recovery will sometimes follow.

This is one of the affections most frequently met with in practice. I have found very few cases recorded in medical literature. This neglect of the subject by authors is perhaps due to the fact that in many cases of displacement of the urethra the bladder is also dislocated, and the whole trouble is described under the head of vesicocele or cystocele. Now, it is true that displacement of the two occurs together, but either may take place alone.

The extent of displacement varies exceedingly, but I shall describe only the partial and the complete. A clear comprehension of these two degrees will cover all intermediate forms. In partial displacement downward the upper two-thirds of the urethra are prolapsed, so that the direction of that portion of the canal is backward, instead of curving upward, as in the normal condition. In complete prolapsus the urethra runs from the meatus (which is in its normal position) backward, and rests upon the [p. 361] perineum, or in extreme cases, accompanied with prolapsus of the bladder and uterus, its direction is backward and downward, the position of the vesical end of the urethra being below the level of the meatus. In this degree of displacement the urethra and bladder can be seen presenting at the vulva or lying between the labia minora. The urethra is usually shortened considerably when the prolapsus is marked.

ETIOLOGY.—Utero-gestation and delivery are the most important causes of this affection. In the advanced months of pregnancy I have observed that while the bladder rose above the pubes the urethra was pushed slightly downward by the settling of the enlarged uterus into the pelvis. In such cases when labor occurs the head of the child dislocates the urethra still more by pushing it still farther down. This process I have often watched in forceps delivery. When there is a partial prolapsus of the urethra existing before labor, the urethra and anterior vaginal wall are forced down before the advancing head, and that, too, while the attendant is making counter-pressure to prevent it. The displacement produced in this way is often restored during convalescence if proper care be taken to push the parts back into place and the patient is kept at rest until the tissues regain their tonicity. But in many cases the trouble is overlooked, and by permitting the patient to get up and be on her feet while there is still prolapsus it will slowly increase until the dislocation is complete. This will surely be the case if there is any loss of perineum. Indeed, rupture of the perineum is an accident which permits the urethra to descend from its place. The perineum supports the vaginal walls, which in turn support the urethra; and if it be lost, even in part, the vaginal walls become relaxed, or perhaps never regain their tonicity after delivery, and, settling down more and more, carry the urethra with them.

SYMPTOMATOLOGY.—The symptoms arising from displacement of the urethra are much the same as those found in dilatation and other urethral diseases. I need not, therefore, repeat them in detail. Suffice it to say that in dislocation of the upper portion of the canal there is, in addition to frequent urination, a partial loss of control of the bladder. Under the extra pressure of coughing, for example, the urine will escape. This loss of control does not exist, as a rule, in complete displacement. On the contrary, there is usually difficult urination, which requires increased voluntary efforts to empty the bladder. In all degrees of displacement the symptoms are increased in the erect position, and are markedly relieved on the patient's lying down.

DIAGNOSIS.—An examination of the vagina, either by touch or speculum, will reveal the downward projection of part or all of the urethra, which will show that there is either dilatation or prolapsus. The change in the direction of the canal will be shown by passing the sound, and dilatation can be excluded by observing that the urethra grasps the instrument firmly at all points. In dislocation of the upper two-thirds of the urethra the sound passes in the normal direction, but is arrested at a half or three-quarters of an inch from the meatus; but by pushing up the vaginal wall and the urethra the sound will then pass into the bladder. When the prolapsus is complete the instrument passes in easily, but takes a downward and backward direction.

PROGNOSIS.—Uncomplicated displacement of the urethra can be remedied in the great majority of cases. By placing the parts in proper [p. 362] position, and holding them there, the relaxed tissues will usually contract sufficiently to support themselves. Should they fail to do so, the patient can at least be made comfortable by wearing some supporter.

TREATMENT.—When the displacement of the urethra is caused by any other trouble, such as defective perineum or prolapsus uteri, then these things should first be attended to. Should there be urethritis, that also should receive appropriate treatment. But the chief indication is to retain the urethra in place; and this can be easily accomplished by using the pessary which has been recommended for supporting the prolapsed bladder. Prolapsus of the upper part of the urethra can be relieved in this way quite satisfactorily. When the whole urethra is displaced, this pessary, while it supports the upper part, will still permit the middle portion of the urethra to settle down. This difficulty may be overcome by making the anterior portion of the pessary long enough to engage in the introitus vulvæ, and in that way keep the whole canal where it should be. Should this cause the patient much discomfort, a tampon of marine lint should be used to keep the parts in position until some restoration of the parts is obtained, and then the pessary will complete the treatment.

The prolapse may be limited to one side or extend all around the canal. The size and extent of the protrusion vary considerably. If the meatus is of full size, the prolapsed portion will usually preserve its natural color for a time; but after a little, from chafing when wet with urine, and especially if not kept clean, it will become red and oedematous. When the meatus is small these changes occur sooner and in a more marked degree, because the prolapsed portion is partially strangulated. The longer the membrane remains exposed the more sensitive it becomes, and the frequency of urination and pain attending it increase. It also becomes very tender and painful to the touch. In marked cases the ordinary movements of the body irritate the parts, and in that way render walking painful.

These are symptoms that closely resemble those of irritable growths at the meatus urinarius, and, so far as history is concerned, it is not easy to make a differential diagnosis. To do this it is necessary to make a local examination. The physical signs and the points in the diagnosis between this affection and other diseases have been given briefly but sufficiently under the head of Dilatations of the Urethra, and need not be repeated here.

The causes of prolapsus of the urethral mucous membrane are numerous, but those that are best known are long-continued congestion of the membrane, urethral and cystic irritation causing frequent urination and vesical tenesmus. Chlorotic and greatly debilitated women are said to be predisposed to it, as also old prostitutes. The few cases that I have seen were in women over fifty years of age, and all of them were weak, nervous patients who had suffered from some organic disease or functional derangement of the urinary organs.

PROGNOSIS.—This disease does not yield promptly to mild treatment, [p. 363] unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. But in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means.

TREATMENT.—When a case is first seen it is well to remove any inflammation or other complicating conditions. The prolapsed membrane should be replaced, and the patient kept quiet in bed to favor the retention of the parts in situ. Astringents, such as tannic acid, alum, or persulphate of iron in a weak solution, should also be used. Should these fail, the prolapsed portion of the membrane should be removed. The methods of doing this (by excision and the thermo-cautery) have already been described.

PATHOLOGY.—Obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. Still, it occurs sufficiently often to demand attention. There are some facts in the pathology of urethral stricture peculiar to women which we will first notice. Passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. Stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal.

SYMPTOMATOLOGY.—Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. In almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. The previous [p. 364] history of cases in which stricture is suspected will aid in settling the diagnosis and etiology.

DIAGNOSIS.—A digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be detected in the same way. The use of the sound will determine the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascertained.

The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations.

PROGNOSIS.—Stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state.

TREATMENT.—The treatment of stricture will depend upon its location and cause. If it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. When due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. Dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as the stricture has given way dilatation should be suspended.

Incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively.

In contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation, and pass the sound from time to [p. 365] time to see if there is any tendency of the stricture to return. The brilliant results obtained in the treatment of stricture in the male with electrolysis by Robert Newman should warrant a more extended trial of this method.

This form or location of stricture is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations have been limited, but sufficient, I think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal.

The causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. The point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. Contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. This is contrary to the history of stricture of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. It is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ.

The symptoms presented in this form of stricture are difficult urination and in some cases complete retention. I have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder.

In this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. Our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal.

Having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. To distinguish these from the stricture, the catheter should be passed when the bladder is well [p. 366] distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. On the other hand, in paralysis and atrophy the stream is slow and without force—so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diagnosis may be confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. There is a slight yielding at all points except at the stricture, where a decided resistance is met.

Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. Rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present that is all that I have to offer on this subject.

DISEASES OF THE VAGINA AND VULVA.

DISEASES OF THE VAGINA.

The subject will be considered in the following order: Anatomy, Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina, Growths, and Vaginismus.

The vagina is a musculo-membranous canal extending from the neck of the uterus—which it embraces—to the vulva. It is usually attached to the uterine neck at a point midway between the os internum and the os externum. This canal is composed of three layers or coats: the outer one is of fibrous and elastic tissue; the middle, of unstriped muscular fibre and fibre-cell; the inner coat or lining is mucous membrane, composed of connective tissue and elastic fibre and covered with squamous epithelium. The outer and middle coats spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. One of the peculiarities of the middle coat is that during utero-gestation it becomes much hypertrophied like the same structure in the uterus, and following labor undergoes a similar process of involution. The inner or lining coat extends to the fourchette.

Savage¹ has described the general form of the vagina as similar to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. The ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum; it is about two inches long, while the posterior wall or posterior column is twice that length. The anterior column or cord causes the investing mucous membrane to be puckered and thrown into folds or rugæ which run transversely toward the posterior column. "This mucous membrane is studded with papillæ which are covered with pavement epithelium. The papillæ of the vagina, which were first fully described by Franz Kilian, were regarded by him as having for their function the transmission of sensation. He represents them as being thread-like and filiform."²

¹ Anatomy of the Female Pelvic Organs, London, 1870.

² Thomas on Diseases of Women, Philada., 1880.

Anatomists have differed regarding the existence of muciparous glands [p. 368] in the folds of the vaginal mucous membrane, some asserting that they are present, and others being equally positive that there are none. Notwithstanding this lack of uniformity, the fact that some have discovered muciparous follicles, while others have failed, enables recent writers to state that there is no doubt of their existence.

The vagina is lined with mucous membrane and covered with pavement epithelium, studded with projecting filiform papillæ. This membrane lies in folds, between which are numerous muciparous follicles.

DEFINITION.—Vaginitis is a term used to designate inflammation of the mucous membrane of the vagina.

SYNONYMS.—Colpitis, Elythritis.

VARIETIES.—Three distinct varieties of vaginitis are met with—viz. simple, specific, and granular.

ETIOLOGY.—Predisposing Causes.—Young girls are not unfrequently the subjects of vaginitis in consequence of want of cleanliness, exposure to cold, ascarides migrating from the rectum into the vagina, or the introduction of foreign substances. It also frequently appears in consequence of smallpox, measles, and scarlatina. In adults it may be caused by exposure to cold or wet, more particularly at or near a menstrual period. The insertion of a sponge into the vagina, as is not uncommon for the purpose of topical medication or uterine support, acts as an irritant if allowed to remain a few days, which may cause severe inflammation. Pessaries, irritating vaginal injections, gonorrhoeal infection, certain conditions of the urine, as in diabetes, acrid uterine discharges, childbirth—more particularly if there has been retention of putrefying secretions—and chemical agents used in treatment of uterine diseases, are sometimes causes. Uterine discharges which cause vaginitis are not generally irritating until they reach the vulva, where by exposure to the air they become changed, first causing vulvitis, and next inflammation of the vaginal mucous membrane.

Some women have slight attacks of vaginitis after each menstrual period, but they are generally slight and soon subside; others will have attacks after each coition or after great physical exertion, but with such patients the disease is not severe, and usually passes off without any signs remaining. It is quite common among prostitutes, independent of specific causes, in consequence of excessive coition. Chronic vaginitis or vaginal leucorrhoea is not uncommon with newly-married women in consequence of excess or awkwardness in coition.

Granular vaginitis is generally caused by pregnancy, but occasionally it seems to be produced by simple or specific vaginal inflammation. A strumous diathesis or a disordered state of the blood, as in phthisis or other constitutional disorders, are predisposing causes.

Mention has been made by some writers of diphtheritic and senile vaginitis. Diphtheritic inflammation of the vagina is sometimes seen during epidemics of the disease or among puerperal women in crowded lying-in hospitals. Senile vaginitis is occasionally met with in women after the climacteric period. Its cause is wholly in consequence of the physiological retrogressive processes incident to the change of life. The [p. 369] epithelium is shed in patches, and, according to Hildebrandt, the raw surfaces adhere, causing contraction of the vagina.

SYMPTOMATOLOGY, COURSE, DURATION, PATHOLOGY, TERMINATION, AND COMPLICATIONS.—The subjective symptoms of the three varieties of vaginitis which have been mentioned are nearly identical, but in their physical signs a marked difference is perceptible. In the outset there is a sense of heat and burning in the vagina, a feeling of pain and weight in the perineum, and a frequent desire to urinate. The passage of urine causes pain and a feeling of scalding in the urethra. It is believed by many authorities that the sense of scalding is more pronounced in the specific variety. Not unfrequently there are backache and pain radiating down the thighs into the hips, along the spine, and into the head. Sometimes, with the other symptoms mentioned, there will be a decided febrile disturbance, chilliness alternating with heat, a rapid pulse, and a foul tongue. With such symptoms the thermometer will show an elevated temperature. Coincident with the beginning of pain and irritation the patient has an itching sensation, which sometimes becomes intolerable, and is generally worse at night when she is warm in bed. Emmet states that some cases are so severe as to require anæsthetics before relief can be obtained. After the lapse of from twenty-four to seventy-two hours these symptoms subside, and there is a profuse purulent discharge, yellowish or greenish in appearance and of an offensive odor. In many cases the discharge is of so acrid a character that it excoriates the vulva and surrounding parts. Walking, or even standing, is often painful, particularly the former, owing to the attrition of the inflamed or excoriated surfaces.

A physical examination causes pain, and if the inflammation has extended to the vulva, urethra, or the vulvo-vaginal glands, it will often produce intense suffering. When the vaginitis is acute, the labia are swollen, the vagina assumes a more or less intense red color in place of the light or pale rose-color of health; it will also be swollen, and at the beginning seem unnaturally dry, but very soon, although still red, it will be covered with a yellowish or greenish-yellow, muco-purulent discharge of an offensive odor. By careful examination with the speculum the vaginal canal will be seen to have a congested appearance, with abraded points, and sometimes follicular ulceration will be found. Generally, the appearance of thick mucus within the os uteri indicates an extension of the inflammatory process into the cervical canal.

Sometimes in gonorrhoeal vaginitis the full force of the disease seems to be chiefly expended in the urethra; when this is the case, and patients complain of intense scalding in passing urine, a finger pressed against the anterior vaginal wall will usually cause pus to exude from the urethral canal.

The duration of vaginitis depends largely upon the treatment. If appropriate treatment is begun early in the course of the disease, a cure can be effected in two or three weeks. On the other hand, it may continue an indefinite length of time or assume a chronic form, constituting a catarrhal condition of the vaginal mucous membrane, or vaginal leucorrhoea.

Sometimes inflammation of the lining of the vagina, more especially specific vaginitis, extends beyond the cervix into the cavity of the uterus, [p. 370] along the Fallopian tubes to the ovaries and to the pelvic peritoneum, or it may travel along the mucous membrane until it reaches the lining of the bladder, causing a cystitis, or in a similar manner involve the vulvo-vaginal glands.

It is not unusual after all the signs of a vaginitis have entirely disappeared that the inflammation recurs without any apparent exciting cause, but wholly in consequence of a diseased condition of the mucous lining of the cervix uteri, designated cervical endometritis, chronic inflammation, or uterine catarrh. In consequence of this there is an increased and changed secretion, which acts as an irritant and causes vaginitis. These recurrent attacks of vaginitis can be prevented only by a successful treatment of the cervical disease.

Chronic vaginitis or vaginal catarrh occurs after repeated attacks of the acute form in persons of a strumous diathesis, and from uterine disorders, such as catarrh, displacements, or polypi of the uterus.

Vaginal catarrh from any cause may lead to other difficulties; thus, if it is the primary affection it may lead to catarrh of the uterus and of the Fallopian tubes. Its long continuance with or without the co-existence of uterine disorders may lead to relaxation and subsequent prolapsus of the vaginal walls.

In the beginning of vaginitis, as in inflammations of mucous membranes elsewhere, the vaginal lining becomes first very vascular, presenting a congested and swollen appearance, with a diminution in the quantity of normal secretion; but within a few days portions of the epithelium are cast off, leaving abraded spots which sometimes ulcerate and become covered with exudation. Occasionally complete casts of the epithelial lining of the vagina are desquamated. In lieu of the natural secretions, within thirty-six hours after the inception of the disease the vagina is filled with an acrid, foul-smelling muco- or sero-purulent fluid, having the appearance of unhealthy pus. The discharge consists of serum, numerous epithelium cells, pus-corpuscles, blood-globules, and infusorial animalculæ designated Trichomanas vaginalis, and mucus. When an attack is very severe a true phlegmonous inflammation is often developed in consequence of the submucous cellular tissue first becoming involved.

In specific vaginitis it not infrequently occurs that the disease is confined to the vaginal cul-de-sac—a fact which, according to Guérin,³ explains how sometimes apparently healthy women communicate gonorrhoea to the male.

³ Mal. des Organes génitaux, Paris, 1864.

In granular vaginitis the mucous membrane extending throughout the entire canal and over the neck of the uterus is covered with numerous minute elevations or granulations of about the size and shape of half a millet-seed. Thomas says: "This variety of the disease appears to bear about the same relation to simple vaginitis that follicular vulvitis does to the purulent form of that affection."⁴ The same author mentions having seen a patient with granular vaginitis so striking in its features that the family physician believed it to be malignant disease developing, until convinced to the contrary.

⁴ Thomas on Diseases of Women, 5th ed., p. 219.

Simple acute vaginitis frequently causes and remains associated with [p. 371] vulvitis, urethritis, and less frequently endometritis, salpingitis, and pelvic peritonitis. The chronic form is not unfrequently complicated with uterine catarrh. Acute specific vaginitis is often complicated with buboes from inflammation of the femoral and inguinal glands and inflammation and abscess of the vulvo-vaginal glands. This variety more frequently than the others is liable to give rise to violent urethritis, cystitis, salpingitis, ovaritis, and pelvic peritonitis.

DIAGNOSIS.—If one is familiar with the symptoms which have been mentioned, the diagnosis of vaginitis is not a difficult task; but it is sometimes not only difficult, but quite impossible, to determine whether a case is one of simple inflammation or of gonorrhoeal contagion.

The symptoms which are most liable to lead one to decide that a case is specific are their severity, the sudden development of virulency, the scalding micturition, urethritis with pus in the urethra, the greenish-yellow discharge of a foul odor, the very irritating quality of this causing gonorrhoeal ophthalmia if applied to the conjunctiva or gonorrhea in the male following coition; the occurrence of buboes, inflammation of the vulvo-vaginal glands, peritonitis, and salpingitis. We meet with cases where it is extremely difficult to decide as to the nature of the disease, and especially when we have every reason for believing that the subject herself is chaste; on the other hand, the mere fact of a woman infecting her husband and causing him to have a urethral discharge is not always sufficient proof of her having gonorrhoea, as it is well established that certain forms of leucorrhoea will produce such a result. It is not necessary for us always to express an opinion of the character of the disease, even when convinced that it is specific, but it is always our duty "to lean to the side of charity when the question is one of chastity."⁵

⁵ Edis, Diseases of Women, Philada., 1882.

PROGNOSIS.—If appropriate treatment is instituted, the disease will usually subside in the course of a few weeks, or it will assume a chronic form, lasting indefinitely.

Acute vaginitis causes more pain and actual suffering than the chronic variety, but is less rebellious to means of cure. Simple vaginitis, of itself, cannot be considered a grave disease, but the consequences may prove of a most serious character—viz. extension of the inflammation to the bladder, uterus, Fallopian tubes, ovaries, and peritoneum.

Specific vaginitis is more virulent than the other varieties, and consequently there is more tendency to the extension of inflammation than with them. Sterility is not infrequently a sequel of specific vaginitis in consequence of contiguous parts, more especially the Fallopian tubes, being implicated in the disease. Such patients, even long after the acute symptoms have passed, are unfavorable subjects for surgical operations, even of a trivial character.

TREATMENT.—The treatment of acute vaginitis is the same in the different varieties. From the commencement of the attack until the severest symptoms have subsided patients should rest in a recumbent position, walking and coition being forbidden. If the inflammation is severe, with febrile symptoms and a furred tongue, saline laxatives, cooling drinks, and a non-stimulating diet should be prescribed. If pain exists, anodynes of some kind should be given. The best mode of administering [p. 372] anodynes is by means of rectal suppositories. Warm hip-baths every six or eight hours for the first twenty-four hours of the disease ought to be employed, and at the same time quite warm water should be thrown into the vagina with a syringe; this is beneficial in curing the disease and contributing to the patient's comfort.

A much better mode of irrigating the inflamed parts is as follows: The patient is to be placed on her back with her hips slightly elevated over a bed-pan, and then by means of a syringe a stream of warm or hot water should be thrown into the vagina for fifteen to thirty minutes. It has been advised by Emmet that the temperature of the water should be raised rapidly from blood-heat to 110° F., or as hot as the patient can well bear. By elevating the hips venous congestion is considerably lessened through gravitation of the blood, and, the hot water causing contraction of the blood-vessels, the mucous membrane will present a blanched appearance. The vagina becomes distended by the weight of water, and somewhat with air, by reason of position, so that with the hips elevated the injection comes in contact with every portion of the vaginal mucous membrane.

In addition to hot water or after its use, other injections are useful, as a decoction of flaxseed alone, or one of the following remedies, either in the decoction of flaxseed or in water: viz. borax, bicarbonate of sodium, hyposulphite of sodium, chlorate of potassium (drachm j ad pint j), or permanganate of potassium (gr. viij ad pint j). Hydrate of chloral and fluid extract of eucalyptus, either alone or combined, have proved useful quite a number of times in my own practice.

Mild attacks will usually subside in a few days without further treatment than has already been mentioned; but in severe cases, when the disease has got under full headway before treatment is begun, more heroic measures become necessary, especially in specific or granular vaginitis, where there is itching and a greenish offensive discharge. The vagina should be exposed by means of a speculum, the mucous membrane thoroughly dried by the use of absorbent cotton, and a solution of nitrate of silver (gr. xl ad fluidounce j) be applied to every part of the inflamed vagina. Wherever it is applied the mucous membrane presents a whitened appearance. If the vulva is involved, the same application should be made to it. After the parts thus treated become dry a piece of soft linen or a small roll of absorbent cotton should be thoroughly smeared with vaseline or soaked with carbolized glycerin, and inserted within the vagina. The pain caused by the nitrate of silver is usually better borne than the intense itching which it takes the place of. After the lapse of eighteen to twenty-four hours the linen or cotton can be removed and an injection of carbolic acid drachm ss, sulphate of zinc and borax each drachm j, in a quart of warm water, is to be used three times a day for two or three days; then a weaker solution of nitrate of silver is applied and the tampon inserted as before. This is to be followed the next day by the carbolized injection, and three days later a weaker solution of nitrate of silver is applied. The alternate use of these remedies is to be continued until the mucous membrane appears pale, and the discharge instead of being a greenish-yellow is white, when it should be discontinued, and borax alone or combined with hyposulphite of sodium is to be used as an injection; and immediately after the injection the tampon [p. 373] is inserted, or instead of the injection tannin dissolved in glycerin is to be painted over the vaginal walls and followed by the tampon.

The cure of vaginitis in many instances is obtained by securing rest to the parts. One of the chief objects of the tampon is to give rest to the inflamed walls by keeping them apart, rather than to make it the medium of a topical application. Some gynecologists instead of using a tampon insert one of Sims's glass vaginal dilators to keep the walls from coming in contact, directing that it shall be worn most of the time and that the patient shall rest in the recumbent posture.

The treatment of chronic vaginitis or vaginal leucorrhoea, when caused by acute vaginitis alone, should be essentially the same as in the latter after the severest symptoms have subsided, as clinically the distinction between acute and chronic vaginitis is one of degree.

Generally, vaginal leucorrhoea is an accompaniment of other affections, notably uterine diseases, and hence a consideration of its treatment and its complications would necessarily include everything pertaining to the therapeutics of leucorrhoea.

DEFINITION.—The term atresia ([Greek: a] privative, and [Greek: trêsis], perforation) means, in its literal sense, an imperforate condition or an entire absence of an orifice or a canal, but custom has sanctioned a more liberal use of the word; thus, atresia is the term sometimes made use of to designate a partial obliteration of a canal; e.g. atresia vaginæ, which means literally an absence or obliteration of the vagina, is also applied to a partial imperforation of the canal; hence atresia of the vagina, like that of any other portion of the generative passages, may be either complete or incomplete.

Atresia of the vulva cannot in a strict sense be considered under the head of vaginal malformations or disease, but it seems quite necessary in writing of occlusion of the vagina not to omit a consideration of similar conditions of the vulva. The writer of this article, therefore, has followed the lead of most medical authors in including vulvar under the head of vaginal atresia.

The labia majora may be adherent, and for a long time no suspicion arise of the condition, as such adhesion does not prevent the exit of menstrual blood; but, on the other hand, it does sometimes interfere with micturition, and then calculi are formed, which require surgical interference for their removal. The adhesion of the labia minora, like the same condition of the greater lips, is usually the result of accident or disease, giving rise to the same difficulties in voiding urine. Unlike adhesion of the labia majora, adhesion of the lesser lips may cause retention and accumulation of the menstrual blood. Atresia of either the greater or lesser lips may be consequent upon smallpox, measles, scarlatina, or any constitutional or local disorder that can cause inflammation of these mucous surfaces. Such occurrences are, without doubt, more common in infancy and childhood. This affection is occasionally found to be congenital, and [p. 374] is due to a simple agglutination of the contiguous mucous surfaces of the labia. The nurse in washing the child sometimes discovers that the vulvar orifice is closed, and it is thus brought to the notice of the physician.

Although included under the head of Vulvar Atresia, this will be considered chiefly in connection with atresia of the vagina. This is a congenital condition of more frequent occurrence than the other forms of vulvar atresia.

SYMPTOMS.—If the age of puberty has been attained and the subject has all the symptoms of menstruation excepting the characteristic sanguineous flow, an imperforate condition of the genital canal is suspected. Monthly pain of a bearing-down character in the hypogastric region, and pain in the back and thighs or uterine colic, are among the symptoms. At such times the abdomen may become tender and tympanitic, the pulse more frequent, and slight febrile reaction with nausea and vomiting may occur.

These symptoms closely resemble those of an attack of peritonitis, but usually, after a few days of great distress, they gradually disappear. After a lapse of three or four weeks they again return with increased severity. The girl's general health is impaired, the appetite is poor, there is constant nausea and sometimes vomiting, the bowels are constipated, the eyes lose their brilliancy, the skin presents a dirty appearance and is often covered with an eruption. Headache is almost constant. The abdomen is often very prominent from intestinal tympanitis. Later the lower extremities become oedematous, and there are indications of septicæmia, and great constitutional disturbance. The gradual accumulation of menstrual fluid, first filling and then distending the uterus and vagina, causes a gradual enlargement of the abdomen, often giving rise to a suspicion of pregnancy.

FIG. 26.

Hæmatometra.—Imperforate Hymen, causing distension of uterus and vagina: H. Hymen; V, Vagina; U, Uterus; B, Bladder; R, Rectum.

DIAGNOSIS.—If there is an accumulation of menstrual fluid in consequence of an imperforate hymen; the latter can be observed as an elastic tumor of a red color protruding outwardly between the labia. A rectal examination is necessary in order to complete the diagnosis, as by this means the presence of menstrual fluid is determined, for if it be present in sufficient quantity to distend the hymen a finger in the rectum can detect fluctuation in the vagina.

If there is no escape of the menstrual fluid beyond the vulva on account of an imperforate hymen, the vagina first becomes gradually distended, then the uterus, and finally the Fallopian tubes. As this distension increases, fluid may be forced beyond the fimbriæ of the tubes into the peritoneal cavity, or, instead, one of the tubes may rupture from the pressure within. In other instances the uterus itself ruptures from over-distension and thinning of its walls. Cases are on record where, the accumulation increasing for years, the uterus has become distended to the size attained in the latter months of pregnancy; under such circumstances its walls as well as the walls of the Fallopian tubes become thinned.

PROGNOSIS.—The physician should be careful and guarded in his prognosis. The health may become much impaired, and sometimes this is the case prior to the cause being ascertained. The chief dangers are in connection with the accumulation of menstrual fluid, such as its discharge at the fimbriated extremity of the tubes, or rupture of the tubes or uterus, and consequent escape of the fluid into the peritoneal cavity. There is also great danger in incising the hymen to permit the exit of the fluid, as will be shown under the head of Treatment. Therefore the longer has been the retention, the greater is the liability of rupture and danger in treatment.

TREATMENT.—As this is of necessity surgical, but brief allusion will be made to it. A simple incision of the hymen will permit the escape of the fluid, but the admission of air by this means is liable to cause sudden contraction of the uterus and a reflex escape of the fluid at the fimbriated extremity of the Fallopian tubes, with all the severe consequences of an intra-peritoneal hemorrhage.

The admission of air is liable to cause decomposition of retained fluid, and this in time produces septicæmia. Further, the sudden admission of air where there has been none before is liable to cause inflammation of the lining membrane of the uterus and tubes, resulting in septic peritonitis. To avoid such risks as have been enumerated two plans are recommended by authors—one being a slow draining away of the menstrual fluid and the other its rapid evacuation and washing out of the uterus and vagina. Graily Hewitt makes an opening of a valvular character in the hymen, permitting only a slow escape of the fluid. Others use a small trocar and draw off the fluid slowly, and at different times if there is a large quantity.

The aspirator is to be preferred to the trocar for emptying the vagina, and of late years has been more generally used; either instrument, but especially the former, permits of the discharge of the fluid at different times, and in such quantities as the physician may desire, without the admission of air. The rapid evacuation is best represented by Emmet's mode of procedure. He first cuts the protruding membrane sufficiently to admit the index finger, and tears the tissues enough to allow the fluid to escape rapidly, and then washes out the vagina and uterus with warm water, after which he introduces a glass plug for the purpose of dilatation and to prevent the action of air upon the parts.

Atresia of the vagina may be congenital or accidental, and, like atresia of any other portion of the genital canal, may be partial or complete. In complete congenital atresia of the vagina an examination per rectum with the index finger fails to discover the fluctuation of menstrual fluid, as in atresia from imperforate hymen, but in its place can usually be felt what seems like a hard fibrous cord. If, however, this cannot be discovered, no doubt remains of entire absence of the vagina. Sometimes the cord can be felt a portion of the distance, which indicates that there is a corresponding portion of an undilated vagina.

In case of complete congenital atresia of the vagina an operation should be avoided, unless there is an accumulation of menstrual fluid or a uterus can be distinctly felt by rectal and vesical examination, or the patient is suffering from the absence of menstruation. To these may possibly be added instances, as mentioned by Thomas, where there exists an imperative necessity for sexual intercourse. Where there is no menstrual molimen or distension of the uterus cannot be detected, and there is non-development of the uterus and ovaries, as shown by the condition of the external organs, surgical interference should be indefinitely postponed.

Accidental atresia of the vagina may be produced by causes heretofore mentioned. When the canal, which has previously been pervious, is entirely obliterated from any cause, an operation becomes, as a rule, an imperative necessity by reason of the accumulation of menstrual fluid and consequent distension of the uterus and Fallopian tubes.

In partial or incomplete atresia it frequently happens that a sinuous canal remains which serves as a guide to the surgeon.

The reader is referred to systematic treatises on surgical diseases of women for the details of the various modes of operating for these affections.

Displacements of the vagina are usually secondary, either in consequence of relaxation of the walls or of some form of uterine displacement. Prolapsus of the vagina is usually associated with prolapsus of the uterus, yet it may exist independently. It may be present for some time without prolapse of the uterus, or exceptionally it may be the exciting cause.

DEFINITION.—When the tonicity of the vaginal walls is from any cause impaired and they protrude downward in the direction of the vulva, the condition is called prolapsus.

SYNONYMS AND CLASSIFICATION.—Owing to the anatomical arrangement, it is impossible, with one exception, for any form of prolapsus of the vagina to occur without the coincident prolapse of some viscera. The single exception is the rare occurrence of prolapsus of the posterior wall without the rectum being similarly displaced. These displacements of the viscera with prolapsus of the vagina are commonly described by medical writers as vaginal herniæ, of which there are three different forms, as follows: cystocele vaginalis, rectocele vaginalis, and enterocele vaginalis or hernia vaginalis posterior.

ETIOLOGY.—The causes of displacements of the vagina and the different varieties of vaginal herniæ can very properly be considered together, as they are identical. Laceration of the perineum, an enfeebled condition of the vaginal structure, and a retarded involution of the vagina and uterus in consequence of pregnancy or childbirth are the most frequent causes. Other occasional causes may be mentioned, as former distension of the vagina from repeated childbirths or by tumors, and senile atrophy.

PATHOLOGY.—Following childbirth, the vagina, like the uterus, undergoes a process of involution, but if this is retarded from any cause the vagina is rendered more capacious, its tonicity is impaired, and the uterus, being heavy, crowds down upon it and causes it to be displaced. If the vaginal sphincters or the posterior wall are torn or enfeebled or the perineum lacerated, in addition to the presence of a heavy uterus, prolapsus of the vagina, associated with some form of vaginal hernia, is quite sure to follow.

There is a condition which acts as a common cause in producing vaginal and uterine displacements that has failed to receive on the part of medical authors the notice it deserves—namely, a relaxed condition of the vaginal walls and the perineum, in which there may be observed, in many instances, all of the disturbances caused by a laceration, and yet a careful examination fails to reveal where any tearing has taken place. The continuance of this excessive relaxation and atony of the vaginal walls and the perineum for a long time after parturition is, doubtless, due to subinvolution.

SYMPTOMATOLOGY AND COURSE.—The patient will complain of a bearing-down sensation in the vagina, with a sense of fulness and heat in that locality, sometimes extending to the vulva. These symptoms are aggravated by any muscular exertion, particularly by walking. A physical examination will show the presence of an elastic, globular tumor between the labia. In case it protrudes beyond the vulva, it is not unusual to find scattered over its mucous surface excoriated patches of various sizes. Sometimes these become ulcerated. In other instances the tumor has a smooth, shining appearance. Where there is simply prolapsus of the vagina without the coexistence of a hernia, it will, as a rule, be found that it is the posterior wall. If there is a prolapsus of either the anterior or posterior wall with a hernia, there will be additional symptoms to those above mentioned, which will be referred to in connection with cystocele and rectocele.

This is sometimes designated as prolapsus of the bladder, and consists of a descent of the bladder and the anterior wall of the vagina, the two being closely adherent to each other. In consequence of such a descent a pouch is formed which becomes filled with urine. The pouch is in the outset quite small, but gradually becomes larger, so that it is not unusual for one to become of sufficient size to protrude beyond the vulva. In consequence of the pouching of the bladder only a portion of the urine is evacuated by the effort of micturition, and, remaining in the bladder, it decomposes, causing cystitis or vesical catarrh.

The SYMPTOMS are a frequent desire to urinate, with tenesmus and [p. 378] scalding; there is also a sense of heat and pain in the bladder. There is usually more or less ropy mucus discharged with the urine. If a uterine sound or catheter is passed into the bladder with its point downward, and can be felt protruding into the pouch, there remains no doubt as to the case being one of cystocele vaginalis.

This consists in a protrusion inward of the posterior vaginal wall and a pouch of the rectum, which is carried with it. The tendency to rectocele is seen in the natural bulging of the rectum caused by its expansion just above the sphincter ani. This is more readily perceptible in cases where the perineum has been torn. If from perineal laceration or any cause the posterior wall of the vagina fails to give adequate support to the anterior wall of the rectum, the bulging just mentioned increases, forming a pouch which becomes filled with fecal matter. The bowel becomes more distended with feces, which usually accumulate and harden, and, acting as an irritant, produce tenesmus with mucous discharges. The venous circulation being interfered with, hemorrhoids are common, adding to the patient's suffering.

On examination a tumor is found, sometimes as large as a man's fist, which can be felt projecting from the posterior vaginal wall and over the perineum; sometimes it is soft and compressible, while at other times it is quite solid, depending on the absence or presence of hardened feces. To leave no room for doubt in diagnosticating a case of rectocele, the rectum should be explored with the index finger.

This consists in a portion of small intestine dilating the cul-de-sac so that the peritoneum is carried down with the intestine between the vagina and rectum as far as the perineum, sometimes forming an elastic tumor at the vulva. The chief dangers arising from this form of vaginal hernia are from its being strangulated or lacerated during childbirth.

Enterocele vaginalis is not frequently met with, but it is important for the physician to know that such a condition is possible and difficult to differentiate from some forms of vaginal tumor. A thorough and careful rectal examination is requisite for diagnosis. An enterocele has the peculiar elastic feeling of a tumor distended with air, a tympanitic resonance on percussion, and a peristaltic movement. If there remains any room for doubt, aspiration with the smallest needle will enable the physician to perfect his diagnosis, for if the needle enter the intestine it is not in any sense a dangerous procedure.

TREATMENT.—The treatment of prolapsus and hernia of the vagina is similar to that of prolapsus of the womb.

If a prolapsus of the vagina has existed but a brief period or has come on suddenly, it should be immediately reduced and proper measures taken to prevent its recurrence. To accomplish this the patient should assume the genu-pectoral position, while the physician with well-oiled fingers [p. 379] restores the parts to their normal position. The patient should then lie upon her back with the hips elevated; astringent vaginal injections ought to be used every four or six hours; and quiet secured or discomfort or pain relieved by opiates. Sudden displacements of the vagina not being of frequent occurrence, the physician more frequently meets with cases of long standing which have come on gradually and slowly.

Attention to the general health is an important requisite: with this in view tonics should be prescribed in many cases, the bowels regulated by means of proper diet or if necessary by medicine, and the bladder more frequently evacuated than in health. Astringent injections are fully as useful in cases of long-standing displacements of the vagina as in those of more recent occurrence; among those more generally used are solutions of tannin, sulphate of zinc, or alum (drachm iv ad pint j). Sea-bathing and injections of sea-water into the vagina are beneficial. It is sometimes more convenient to make topical applications with vaginal suppositories containing one of the astringents just mentioned.

Where cystocele exists it is important that the bladder be completely emptied when the patient urinates; to accomplish this she may assume the genu-pectoral position, and at the same time push the tumor up into the vagina. If after this urine remains in the bladder, a catheter should be employed.

If in any form of vaginal displacement the means which have been alluded to fail, then some form of support or some surgical procedure will be necessary. In very fleshy women considerable benefit is sometimes obtained by means of an abdominal band with a perineal pad attached to it. Pessaries, which have been heretofore quite generally depended upon, are now considered as of secondary importance. Sometimes, however, when the hernia is not of great size or when associated with uterine displacement, a pessary proves of service. A Hodge's pessary with a cross-bar, or the one devised by Skene of Brooklyn, will often prove of great benefit in cystocele. For either cystocele or rectocele the most serviceable form of pessary is one like Cutter's or McIntosh's cup pessary, which is retained within the vagina and supported in position by external attachments. To effect a radical cure in either cystocele or rectocele, especially in the latter, some surgical procedure generally becomes requisite.

Of the different operations which have secured the general approval of gynecologists, the most common is perineorrhaphy: this is the name given to the operation for a torn perineum. Another operation sometimes performed with success is colporrhaphy or elytrorrhaphy, which consists of lessening the calibre of the vagina by removing a portion of the mucous membrane and bringing the edges of the wound together by sutures. This can be performed on either the anterior or posterior wall, depending on which seems to demand it the most; and if the operation on one wall is not likely to be sufficient, it should be made on both. Not unfrequently the most perfect success can be attained by a surgical procedure designated as colpo-perineorrhaphy, which combines the two operations that have been mentioned. Full descriptions of these different operations and the best modes of performing them can be found in all late standard works on surgical gynecology.

Cicatrices of the vagina may occur in consequence of lacerations or injuries received in childbirth, surgical operations, wounds from accident, or the use of caustics about the uterus. If any of the causes named excite inflammation, there may be more or less sloughing of the parts, and, as healing must take place by granulation, cicatrices of various dimensions are formed. These cicatrices may be sufficient to cause partial or complete atresia, or they may be merely in the form of projections or bands, dragging the uterus out of its normal position or interfering with its natural mobility, and cause dyspareunia and other discomforts.

Recently, since attention has been directed to the reflex symptoms produced by cicatricial tissue in the neck of the uterus, there has been a growing belief that similar symptoms are often caused by cicatrices in the vagina. Thus it is the opinion of some who have investigated this subject that many cases of remote neuralgia and other nervous disturbances may often be caused in this way.⁶

⁶ Vide Skene on "Cicatrices of the Cervix Uteri and Vagina," Amer. Gynæc. Soc., vol. i., 1876.

TREATMENT.—This is of necessity surgical, although some cases can be successfully treated without having recourse to cutting operations, but are treated by pressure. One method is to tampon the vagina with cotton or marine lint previously saturated with carbolized glycerin. The tampon can be left in position four or five days, when the vagina may be washed out and again tamponed. Another method of treating with pressure is by means of a Sims's dilator, either worn continuously or a few hours at a time. Generally a quicker and more effectual mode of treatment is to nick the bands with scissors or a knife in several places sufficiently for the vagina to assume its natural shape, and then insert the dilator. In some instances it is advisable to cut away portions of the adventitious membrane. On account of the tendency to hemorrhage after operations in the vagina the physician should avoid cutting more than is requisite, and must use a finger as a guide in cutting, to inform him when he has cut sufficiently.

If there is considerable hemorrhage it may be necessary to use a styptic, but usually the glass dilator, by putting the walls on the stretch and by pressure, will check the bleeding. It is important that the dilator be worn for several hours each day after the nicking, for fear that there will again be contraction. After each removal of the dilator the vagina should be syringed out with warm carbolized water or a very weak solution of permanganate of potassium (gr. ss ad fluidounce ij), that no septic matter may be retained and so that healing of the cuts may be more rapid.

Among the congenital deformities occasionally met with is a vagina divided by a longitudinal septum, constituting a duplex or double vagina. The septum is not always so situated as to make the passages of equal size, nor does it invariably divide the canal through its entire length. It is stated by most writers on the subject that usually with a double vagina [p. 381] there will also be a double uterus. The author has met with only two cases of duplex vagina, neither of which was associated with a double uterus. The treatment is of necessity surgical, and consists in dividing the partition with scissors, and inserting a tampon with some styptic or a Sims's dilator for the arrest of the bleeding which invariably occurs from cutting operations in the vagina. If there is persistent hemorrhage, a galvano- or thermo-cautery may be used.

New formations of any kind are not of frequent occurrence in this locality. They consist almost exclusively of cystic tumors, fibroid tumors, papillary excrescences or vegetations, sarcomata, epithelioma, and carcinoma.

are sometimes observed, but are by no means common. Their origin and nature has not seemed to be well understood. Hugier and Guérin are of the opinion that they are caused by the mucous follicles being obstructed. In this view they are sustained by Preuschen.⁷

⁷ "Die Cysten die Vagina," Centralblatt für Med., 1871, p. 775.

Sinéty remarks that there are two varieties of vaginal cysts—one superficial and the other profound. The superficial are developed in the mucous membrane, are small in size, and contain fluid which is watery or clear and glairy. The profound cysts are developed in the vaginal walls, and are of various dimensions, from the size of a walnut to an orange, and capable of attaining to much greater dimensions than is possible for the superficial variety. Their contents vary greatly; sometimes clear, mucous, and ropy, in other cases they are colored brownish or chocolate.

Cysts of the vagina are not to be confounded with those of the vulva or those which develop in the vulvo-vaginal glands, nor are they as common.

TREATMENT.—Cysts of the vagina can often be cured by laying them freely open with a bistoury and wiping out the cavity with tincture of iodine, carbolic acid, or a solution of nitrate of silver. The tincture of iodine preferred by the author is Churchill's or a saturation tincture, either being much more effective than the simple tincture. Nitric acid and the actual cautery are mentioned by Barnes as having been used for destroying vaginal cysts. Entire removal of these formations can be effected by cutting into or through the mucous membrane and dissecting them out in the same manner as they are removed from other localities.

Fibrous or fibroid tumors are by no means as common in the vagina as in the uterus. It has been observed that they are frequently but not invariably associated with the latter. They are developed in the [p. 382] muscular or fibrous structure of the vagina in the same manner as similar formations in the muscular tissue of the uterus.

Some authorities assert that they frequently have the point of departure from the uterus, and then descend little by little between the walls of the vagina.

Sarcomatous tumors are developed in the same tissues and similarly to fibrous growths of the vagina. They are, however, of less frequent occurrence. They sometimes appear primarily in the vagina, but more frequently are consecutive to sarcoma of the uterus.

It is a difficult and often impossible task to make out the differential diagnosis of sarcomatous and fibrous growths in the vagina except by means of the microscope. The symptoms of each are similar to those which indicate sarcomatous and fibrous growths of the uterus, it being accompanied by profuse leucorrhoea, more or less sanious, and occasional hemorrhage. If tumors acquire much size, they interfere with the functions of the rectum and bladder, and cause pain and discomfort by their pressure in the pelvis; sexual intercourse is difficult, frequently painful, and followed by a flow of blood.

DIAGNOSIS.—If of a large size, diagnosis is easily made. Uterine tumors and prolapsed uteri have been mistaken for vaginal growths. By using a uterine probe and inserting a finger in the rectum there need be no error in these respects. By careful examination there is little difficulty in diagnosis.

TREATMENT.—This consists of removal by the knife, scissors, écraseur, or galvano- or thermo-cautery. If there are reasons for believing that a tumor is sarcomatous, it is important that every particle be removed. For this purpose scissors or the galvano- or thermo-cautery are preferable to the ordinary écraseur, which by its action crushes and bruises tissues, and is liable to draw into the chain or wire and crush off more than the operator desires. Serious accidents, such as opening into the peritoneal cavity or the bladder, have occurred in this way in the practice of distinguished and experienced surgeons.

Papillary growths and vegetations in the vagina will receive merely a brief allusion, as they are rarely seen even in the practice of gynecologists. They are not commonly limited to the vagina, but are of more frequent occurrence about the vulva and on the cervix uteri. Vegetations of considerable size sometimes develop in consequence of pregnancy or of granular vaginitis. Sometimes papillary growths within the vagina assume a cauliflower shape with well-defined stalks, or about the ostium vaginæ they may take the form of condylomata. These formations may be confounded with epithelioma.

Treatment consists of removal by scissors or with the thermo- or galvano-cautery, and to guard against hemorrhage some styptic and a vaginal tampon will be required.

Carcinoma or epithelioma rarely occurs as a primary affection in the vagina; it is generally secondary, extending from the neck of the uterus. The author has met with only three cases which were primary cancer.

In a recent work Kustner⁸ has collected statistics of twenty-two cases of primitive cancer of the vagina. The result of the analysis of these observations is, that nearly always the posterior wall is first affected in primary cancer, while in secondary cancer the anterior wall is the first to be attacked.

⁸ "Ueber den Primären Scheidenkrebs," Arch. f. Gyn., t. ix. p. 279.

The symptoms after the disease is somewhat advanced are similar to uterine cancer—viz. a sanious, watery discharge of an offensive odor or sometimes a veritable hemorrhage. There is no pain peculiar to or pathognomonic of the disease. It is not until infiltration causes pressure on nerves or there is considerable ulceration that pain is experienced; in either of these conditions the sufferings are often excruciating. Occasionally in women of advanced age, in consequence of cancerous infiltration before ulceration has occurred, the vagina is found to be contracted and there is roughness and induration of the walls.

Epithelioma generally occurs in young women. The early symptoms are pain and hemorrhage following coition. A digital examination will show the friable nature of the formation and an indurated base: the examination will cause blood to flow. In the early part of this stage, before there has been much ulceration, the disease is sometimes mistaken for syphilis and the growths for syphilitic condylomata. It is not an uncommon occurrence for the disease to propagate itself by contact, the opposite wall from which it primarily appeared becoming in this way affected. Later, deeper tissues are infiltrated, the bladder or rectum becomes implicated, ulceration occurs, and subsequently perforation. The progress and terminations are similar to uterine cancer.

TREATMENT.—In carcinoma there seems to be no opportunity for anything more than a palliative course of treatment. Medicine or surgery is here of but little avail. If epithelioma be detected sufficiently early, there is some hope of cure, but this lies only in complete removal. For this purpose the knife or scissors or the galvano- or thermo-cautery can be used. When there is much hemorrhage, some styptic, like the perchloride of iron, should be applied, or the cautery or curette may be of service. Unfortunately, the physician is seldom consulted early enough—prior to the cellular tissue being too much infiltrated—for the thorough eradication of the disease.

Death occurs from exhaustion, hemorrhage, septicæmia, uræmia, or from infiltration interfering mechanically with the function of the bladder, kidneys, or intestine.

For the purpose of correcting the offensive odor and lessening pain there seems to be nothing superior to chloral and glycerin (drachm j-drachm ij ad ounce ij) on a tampon of cotton; the fluid extract of eucalyptus combined with the chloral and glycerin (ounce ss ad ounce ij) has proven an excellent deodorizer in the author's hands.

DEFINITION.—This affection, which was first called vaginismus by our distinguished countryman the lamented J. Marion Sims, consists in a hyperæsthesia or peculiar sensibility of the site of the hymen and vaginal [p. 384] outlet, associated with involuntary spasmodic contraction upon irritation of the sphincters of the vagina.

ETIOLOGY.—Predisposing Causes.—This is sometimes an idiopathic affection, but more frequently is symptomatic of some other disorder. When idiopathic, it is due to a diathesis generally termed hysterical, or an excessive nervous irritability affecting the entire system. The symptomatic causes are quite numerous—more frequently some insignificant local disorder than any grave form of disease. The more common causes are irritated or inflamed carunculæ myrtiformes, excoriation, and irritable ulcers and eruptions about the vulva, vaginitis, uterine catarrh, inflammation, growths and fissures of the urethra, disorders of the bladder, fissure of the anus, and inflamed hemorrhoids. Other less frequent causes have been mentioned by writers, as neuromata, an unusually rigid perineum, and a disproportionately large male organ. Neftel of New York asserts that lead-poisoning has been the cause of some cases under his own observation.⁹ It is sometimes associated with or apparently caused by congestive dysmenorrhoea and uterine displacements and engorgements.

⁹ N. Y. Med. Journ., vol. ix. p. 81.

Emmet's views regarding the etiology and pathology of this affection differ from those of the majority of writers on the subject. He regards it as purely a symptom denoting reflex irritation, and says that with it he has never failed to find some condition, as a displacement, a limited cellulitis, or a fissure in either the rectum or the neck of the bladder, as the exciting cause.¹⁰

¹⁰ The Principles and Practice of Gynæcology, by Thomas Addis Emmet, M.D., 2d ed., Philada., 1880, p. 607.

SYMPTOMATOLOGY, COURSE, DURATION, TERMINATION, AND COMPLICATIONS.—The most prominent symptom is excessive pain upon the sexual intercourse; this is often so marked that subsequent attempts, or even a digital examination, will throw the patient into a state of extreme nervous trepidation and apprehension. If attempts at coition are persevered in, the symptoms are further intensified, so that the spasm and violent contraction of the sphincter vaginal muscles induce agonizing pain. Besides having the characteristic pain, patients with this disorder are, as a rule, sterile. If a physical examination be made in a well-marked case of vaginismus, it frequently occurs that the slightest touch on the part of the physician about the site of the hymen will bring on painful contraction of the vagina and sphincters, and cause the patient to spring up and show much nervous disturbance. In the same class of cases it may be brought on by walking. Thomas says that "in some cases a marked tendency to spasm will have been noticed upon sudden changes of position or washing the genital fissure."¹¹

¹¹ Op. cit., p. 206.

Barnes remarks that in some women the irritability of the nervous centres becomes so great, the sensitiveness of the peripheral nerves at the vulva so acute, and reflex action thereby so intensified, that the attempt at intercourse will induce convulsion or be followed by syncope.¹²

¹² Edis, Diseases of Women, p. 533.

One case came under the writer's observation where the sensitiveness was so marked that a slight touch with cotton or a camel's-hair brush would bring on severe painful contraction.

Course and Duration.—This is an affection of indefinite duration; [p. 385] unless relieved it may continue through years of discomfort and misery. Cases are reported as lasting twenty-five or thirty years. There is a mild form sometimes occurring among the recently married which will either disappear of itself or yield to simple treatment. More generally, the discomfort and pain continue unless successfully treated, and in well-marked cases attempts at intercourse increase the suffering; there is nervous exhaustion, the health breaks down in consequence and from what has been called "the disappointment of nature under an unfulfilled function."

PATHOLOGY.—In certain morbid conditions the nerves distributed about the outlet of the vagina may possess such a high degree of irritability that a foreign substance coming in contact with them will cause contraction and spasm of the tissue in which they are distributed and connecting muscles.

Sinéty¹³ is of the opinion that "in milder forms of the disorder the constrictor vaginal muscles alone may be the seat of the spasm; but more generally all of the muscles forming the floor of the perineum, the constrictors of the vulva and vagina, muscles of the anus and of the urethra, superficial and deep," in truth, "all the muscles of the region," can "simultaneously be the seat of spasm." Emmet¹⁴ considers vaginismus as kindred to neuralgia, for the reason that it more frequently occurs among anæmic and excessively nervous women, and those who have in some manner overtaxed their nervous systems, the locality being determined as it were by accident, and that only in exceptional instances can there be any local exciting cause. Thomas¹⁵ says that it is curious to perceive how, from different standpoints regarding the pathology, "both parties were led to the same surgical resource."

¹³ Manuel pratique de Gynécologie, par L. de Sinéty, Paris, 1879.

¹⁴ Op. cit., p. 607.

¹⁵ Op. cit., p. 205.

The author's own observation will not permit of his ascribing the majority of cases wholly to morbid constitutional conditions, to the exclusion of local lesions. The reason of his belief is that the greater number of cases he has observed have been treated and cured by surgical measures, having in view the relief of morbid conditions of some pelvic structures.

DIAGNOSIS.—The diagnosis is attended with no difficulty, as there is no other affection presenting similarities.

PROGNOSIS.—Sims remarks that he knows of "no serious trouble that can be so easily, so safely, and so certainly cured." Scanzoni, Tilt, and others, who hold different views as to the pathology and means of cure, express themselves as favorably regarding prognosis. Thomas has never met with a case that he could not relieve or cure. Nearly all gynecologists are of the opinion that a favorable prognosis is warrantable in the majority of cases.

TREATMENT.—In cases where it seems quite difficult to ascertain the etiology and pathology a palliative course may at first be pursued, such as vaginal injections of acetate of lead or borax in warm water (drachm j ad pint j), to which may be added carbolic acid or laudanum or the wearing of the vaginal rest or dilator, and total abstinence from any attempts at coition. If the chief cause seems to be in some constitutional trouble, then as complete physiological rest as possible should be enjoined. With [p. 386] this in view, all attempts at sexual intercourse must be discontinued, as it will keep up nervous suffering and local pain and discomfort. The vaginal dilator of Sims secures a rest by keeping the walls apart; it also dilates and benumbs the parts, thus rendering them more tolerant of a foreign body. With every mode of treatment or in cases occurring from any cause the vaginal dilator is required; this is to be worn for two or more hours at intervals of six to twelve hours, according to the degree of tolerance with which it is borne. It should be smeared previous to insertion with some soothing lubricant, as iodide of lead and glycerin (drachm j ad ounce j) or atropia and vaseline (gr. ij ad ounce j) or stramonium ointment. Vaginal suppositories containing morphia, extract of opium, belladonna, hyoscyamus, or stramonium will usually prove of great benefit as local sedatives. In some instances suppositories containing five to ten grains of iodoform may be of service. Copious vaginal injections of warm or hot water alone are beneficial in the majority of cases, as they wash away irritating discharges that aggravate the disease, and by lessening the congestion frequently do away with the necessity of surgical operations.

A careful examination should be made in every case for the purpose of ascertaining whether the vaginismus is not caused or aggravated by fissures, ulcers, or excoriations about the parts; if any are found, they should be properly treated. If any symptoms point toward the rectum or urethra, they should be examined. A patient of the author's suffered from vaginismus during some years, owing wholly to a fissure of the anus, and was cured by an operation for the anal disease alone.

Owing to the pain an ordinary examination produces, it will generally be necessary to etherize the patient before attempting to make a thorough and careful examination.

In anæmic or excessively nervous patients other treatment than local is necessary. Tonics, such as iron, quinia, strychnia, sea-bathing, etc., change of scene, and such kinds of exercise as improve the tone of the nervous organism, should be prescribed. If the trouble is due to some uterine or pelvic disorder, a cure can be effected only by attention to the primary affection.

Some of the modes of treatment that have been mentioned, if persevered in, will succeed in curing many cases without having recourse to any surgical procedure. If, however, a case has not yielded to any of the means heretofore suggested, then some form of surgical operation becomes necessary. The simplest is the one advocated by Scanzoni and Tilt, and consists in a forcible dilatation of the ostium vaginæ with the thumbs, after the manner first practised by Récamier of forcible dilatation of the sphincters in fissure of the anus. Temporary paralysis of the vaginal sphincters is by this means effected, and should be followed by the insertion of a large vaginal dilator, to be worn for several days and held in position by a T-bandage. This sometimes effects a permanent cure, but if a single trial fails to accomplish it, yet the patient is considerably benefited, it ought to be repeated; in the mean time the use of the dilator with one of the ointments previously mentioned should be persevered in.

When the disorder has existed a long time, the muscular power has increased, and the forcible dilatation may require more exercise of strength than can be exerted by the thumbs alone; under such [p. 387] circumstances the writer has been in the habit of using Symes's universal speculum or a tri-bladed rectal speculum, and gradually dilating the vagina to the extent required.

If any of the modes of treatment that have been mentioned fail to effect a cure, or reasons exist for not making use of them, then the radical treatment of Sims or some one of its modifications will be requisite.

A full description of the various surgical procedures and the views of different authorities cannot with appropriateness be presented in this work.

Sims's operation is made as follows: The patient is fully anæsthetized and placed upon her back; then with curved scissors every vestige of the hymen is removed. It is important that this be most thoroughly done, for it has occurred that by leaving a small portion success has not been complete. As soon as the bleeding has stopped the fourchette is put upon the stretch by inserting the middle and index fingers, and with a scalpel a Y-shaped incision is made through the mucous membrane and part of the muscular fibres on each side of the perpendicular line extending into the perineum. After this a glass vaginal dilator is placed in the vaginal canal and worn two hours each morning and night, or as much of the night as it can be tolerated. This should be continued for about a month. There are several sizes of the dilator, and in selecting one to be worn care should be taken not to use one that is too large. Morphine suppositories per rectum should be used as often as is requisite for the relief of pain. A copious vaginal injection is necessary for the sake of cleanliness after each removal of the dilator.

Sims's dilators are made of glass, the outer end open, the inner closed, and of a conical shape; on the upper side is a depression to avoid pressure on the urethra.

FIG. 27.

Sims's Vaginal Dilator.

Emmet's operation is a modification of the above, and consists in inserting an index finger in the rectum, and then putting the sphincter on the stretch, when with scissors he divides the fibres encircling the vagina on each side just within the fourchette and about three-fourths of an inch apart. He claims that this method "does not allow a prolapse of the vaginal wall, as when the perineum is lacerated, but does permit of an equal extent of dilatation of the outlet by the glass plug."¹⁶

¹⁶ Op. cit., p. 609.

The plan of dividing the pudic nerve, as practised by Sir James Y. Simpson, has met with little favor.

The author has been successful in several instances by a less formidable operation than any herein described. His operation has simply consisted of entire removal of every vestige of the hymen or carunculæ myrtiformes with scissors, followed by wearing of the glass plug such length of time [p. 388] as is requisite. This procedure is simply the first part of Sims's operation.

Parturition would, as a rule, cure this affection in an effectual manner but its subjects are generally sterile. The reason of sterility in vaginismus is often owing to the extreme suffering whenever there is an attempt at coition; this pain prevents its perfect performance, and often all further attempts are abandoned. When we are convinced that such a condition is the cause of sterility, the patient may be etherized, and while in that condition complete coition may result in fruitfulness and ultimately perfect cure of the vaginismus.

DISEASES OF THE VULVA.

The subject will be considered in the following order: Anatomy, Vulvitis, Phlegmonous Inflammation of the Labia, Furuncles, Pruritus, Hyperæsthesia of the Vulva, Tumors, Atresia, and Eruptions.

As regards the anatomy of the generative organs of women in this and the preceding chapter, it has not been deemed necessary by the author to consider the subject in extenso, but to give a brief résumé, as better suited to the needs and wishes of the busy practitioner.

The generative organs of women external to the hymen, in their relative order from before backward, consist of the mons veneris, clitoris, vestibule, meatus urinarius, and orifice of the vagina, and the labia majora and minora on either side. All these are known under the name of pudendum or vulva.

The mons veneris is a rounded cushion of fatty tissue immediately over the os pubis, and from puberty is covered with hair.

The labia majora are two folds of skin extending longitudinally from the mons veneris to the perineum. In them are found all the elements of the skin. The subcutaneous tissue is of loose texture. A noticeable fact is that here the sebaceous glands are remarkable for their size, some of them being 0.5 millimeters in diameter and opening directly on a free surface. The labia majora resemble the skin of other portions of the body in that they contain papillæ, nerves, vessels, and Pacinian bodies. Internally they are lined with mucous membrane in which are numerous sebaceous follicles. A quantity of fat, areolar tissue, and tissue analogous to the dartos of the scrotum, including vessels, nerves, and glands, constitutes the contents of the labia, and gives them a rounded appearance, larger in front and decreasing in size toward the perineum. The extremities of these folds, joining together, form the anterior and posterior commissures of the vulva.

The labia minora, sometimes called nymphæ, are two membranous folds of erectile tissue within the labia majora, beginning at the anterior commissure and passing down and disappearing midway between the two commissures. They also contain sebaceous glands.

The clitoris is an erectile organ covered with mucous membrane, and is the analogue of the penis. It arises by two crura, is situated beneath the anterior commissure, and is partially concealed by the labia minora.

The vestibule and the fossa navicularis are triangular spaces on the mucous membrane, the first immediately posterior to the clitoris, the second anterior to the perineum.

The meatus urinarius is the external orifice of the urethra, and is situated in the vestibule about one inch posterior to the clitoris. The mucous membrane is slightly raised above the meatus, giving it prominence, and thus serves as a guide to the introduction of the catheter without exposing the person.

The orifice of the vagina is an elliptical opening just below the meatus urinarius. It is partially covered over in the virgin by a fold of mucous membrane called the hymen.

The vulvo-vaginal glands, or the glands of Bartholin, are two in number, situated anterior to the hymen, each with a single duct opening on the inner side of the nymphæ. They are analogous to the glands of Cowper in the male.

The bulbi vestibuli, on either side of the vestibule, extend downward from the clitoris for about one inch. They consist of a thin layer of fibrous membrane ensheathing a plexus of veins.

DEFINITION.—Vulvitis is the term used to designate inflammation of the vulva. It may be purulent, follicular, or occasionally but rarely gangrenous.

ETIOLOGY.—The purulent form may be specific or the result of want of cleanliness, exposure to cold, over-exertion, the strumous diathesis, pruritus, urinary fistula, or cancer. It is also produced by awkward or excessive coitus and masturbation, the irritation of urine, and frequently is caused by pregnancy. Vulvitis is not uncommon with little girls, resulting from some of the innocent causes mentioned, though the symptoms may expose the patient unjustly to the suspicion of having been tampered with.

SYMPTOMATOLOGY, COURSE, AND DURATION.—At first there is heat, dryness, and more or less pain in the affected parts, followed by a profuse flow of yellow pus. There is also tumefaction, hypersensitiveness, and often pruritus. Follicular vulvitis is the term employed to indicate an inflammation of the mucous or sebaceous glands and of the hair-follicles of the vulva. This disease may be the result of any of the causes of purulent vulvitis, as alluded to in the preceding clause. The subjective symptoms are common also to the purulent form. Objectively, the mucous membrane will appear to be very red in spots, resembling in this respect the raised papillæ of the tongue. These spots frequently bleed on slight provocation. The internal surface of the nymphæ and vestibule is the seat of the disease when the mucous glands are involved, but where the sebaceous glands are mainly affected the inflamed papillæ will be found on the surface of the labia and at their juncture anteriorly. In the course of the inflammation a drop of pus will exude from the papules, and they then gradually [p. 390] disappear. Occasionally, collections of exudate from the diseased glands accumulate beneath the labia minora, concealing the diseased surfaces and becoming quickly very offensive. The disorder, though sometimes persistent, is seldom chronic. The acute affection may be the cause of urethritis in the male closely resembling gonorrhoea if coition occurs during its existence, and thus not infrequently giving rise to suspicion of infidelity.

TREATMENT.—In the matter of treatment, touching the inflamed points with carbolic acid or caustic sometimes favorably influences the course of the disease. Cleanliness is the most important item in the treatment of the two forms of the disease, for without it the application of remedies will be of little avail. Strict attention to this, with perfect rest of the parts, will not infrequently be all that is requisite to effect a cure, but in cases that do not yield to this treatment sedative, astringent, or alterative applications are indicated. These should be applied after bathing. In the purulent variety such remedies as the lead-and-opium wash after the following formula will prove serviceable:

Lint may be saturated with this lotion and applied between the labia. If the disease does not yield to the treatment already mentioned in the course of two or three days, a solution of argentic nitrate (gr. x to ounce j) should be brushed upon the parts, and between the intervals of its application bismuth or starch may be kept constantly on the parts. In cases associated with vaginitis a much stronger solution is sometimes required. (Vide chapter on Vaginitis.) The author has used powdered iodoform in some cases with very good results.

FIG. 28.

Follicular Vulvitis (Huginer).

In the follicular variety the disease is more severe and usually of longer duration than the purulent, although the principles of treatment are essentially the same. In this as in the other variety cleanliness is of paramount importance, frequent washing being very essential. To the inflamed follicles such applications as nitrate of silver, persulphate of iron, and carbolic acid are the more frequent remedies used in this disease. After the application of any of these remedies the parts should be rendered dry, and then a piece of soft linen or a roll of absorbent cotton should be smeared with vaseline or soaked with carbolized glycerin and inserted within the vulva in a way to keep the labia apart. Occasionally the practitioner will meet with a chronic form of vulvitis, and the rareness of its occurrence is fortunate, for the reason [p. 391] that it is a very obstinate and intractable variety of the disease. Vulvitis is very frequently associated with vaginitis, owing to the fact that the mucous membrane is continuous in both vulva and vagina. On this account the principle of treatment of inflammation of either locality is essentially the same. To avoid repetition, the reader is therefore referred to the section on Vaginitis for a more detailed description of treatment.

There is a form of this disease described by Vinay¹⁷ as ulcerous or aphthous vulvitis. This is an affection peculiar to childhood, occurring only when the general health is much impaired. It is often a sequel of fevers, and may even become epidemic. It attacks children of any age, but is of more common occurrence in infancy. The disease appears first upon the mucous membrane in the form of small and round patches of a white or grayish-white color, which soon ulcerate, and at a more advanced stage are liable to become gangrenous. This variety of vulvitis has long been known, and is mentioned in the works of Hippocrates. This disease is rarely met with in this country.

¹⁷ Nouveau Dict. de Méd., tome xxxiii., 1885.

DEFINITION.—The adipose and areolar tissue which compose the greater bulk of the labia majora often become the seat of acute inflammation, in consequence of direct injury, excessive or awkward coition, exposure to cold, from irritating discharges, scratching in pruritus, vulvitis, or that peculiar blood-state which predisposes to the formation of boils or carbuncles.

SYMPTOMATOLOGY AND DIAGNOSIS.—The patient will first complain of heat and pain, increased by standing or walking, and later throbbing and shooting pains in the affected parts. In the outset the part is congested, followed by induration from effusion in the loose tissues, and next suppuration ensues. An examination in the last-named stage will reveal the existence of an abscess in one labium. The diagnosis is by no means difficult, but the physician, however, should bear in mind that this same locality may be the site for pudendal hernia, a dislocated ovary, hæmatocele, or vulvitis.

TREATMENT.—In the outset the inflammation may be caused to disappear by resolution, by means of cold and sedative lotions, such as the lead-and-opium wash, saline laxatives, non-stimulating diet, and perfect rest. In the majority of cases the disease proceeds to suppuration. When it is found that resolution is unattainable, then means should be taken to promote and hasten suppuration. This is best effected by the frequent application of hot poultices. The mistake is often committed of permitting too long intervals to elapse between the application of poultices, and allowing the one applied to become cold before another one takes its place. The patient can be saved many hours of suffering by keeping hot applications constantly on the inflamed labium. As soon as suppuration is detected the abscess should be opened, for two reasons aside from the one of affording relief: First, the tissue resists early natural evacuation; second, owing to the laxity of the tissues, pus will sometimes force itself upward toward and through the abdominal ring.

DEFINITION.—Closely resembling phlegmonous inflammation are the furuncles or boils which are quite common on the labia. They occasion much pain and distress, for the reason that they are very obstinate and apt to recur, one forming as soon as its predecessor has apparently healed. In many instances these boils seem to be consequent upon inflammation of sebaceous glands. They differ in size, some being no larger than a pea, while others are the size of a filbert.

TREATMENT.—This should be constitutional and local. Quinine, arsenic, cod-liver oil, and other remedies of a tonic character should be administered. The bromide of arsenic has been used by the author in a few cases with quite satisfactory results. As soon as one of these furuncles shows that it contains pus, it should be freely opened and a crucial incision made to prevent immediate healing; after which poultices should be applied. These small boils are extremely painful, and are very troublesome, owing, as previously stated, to their liability of recurrence. To prevent their recurrence is one of the reasons why immediate healing of the incisions should be prevented. If contraction of the sacs of the abscesses does not occur, pus will continue to be formed and the tissues in their immediate neighborhood will become indurated. In this way the furuncles may become of a chronic character. To further facilitate healing and aiding their contraction the sacs should have applied to them some stimulating remedy, such as carbolic acid or nitrate of silver. Edis says that painting the surface of the affected labium with tincture of iodine is beneficial in some instances.

One of the most important requisites in treatment is perfect cleanliness.

DEFINITION.—Pruritus vulvæ, although merely a symptom of disease, characterized by itching of the vulva and contiguous neighborhood at times wellnigh intolerable, has, because of its occasional obscure etiology and severity, always been considered by medical authors as a disease of itself, instead of a symptom of other disorders, in treatises on diseases of women.

ETIOLOGY.—Predisposing and Exciting Causes.—It frequently occurs from external irritation, as animal parasites, or such as may be produced by acrid discharges, particularly in gonorrhoea and uterine cancer, changes in the normal composition of the urine, especially diabetic, and not infrequently during the menstrual flow. Pruritus may occur in connection with inflammation of the uterus and vagina without any irritating discharge; likewise it occurs in diseases of the urethra, bladder, and kidneys. Sometimes masturbation may be the cause as well as the effect of pruritus. Secondarily, there may be an insufferable itching in consequence of the continued titillation or irritation of the parts, although masturbation by no means invariably leads to pruritus. The habitual use of opium or alcoholic drinks often causes intractable forms of this disorder. Edis states "that the custom of immoderate tea-drinking is a by no means infrequent cause of pruritus." But instances of pruritus occur where all [p. 393] of the causes mentioned are lacking, and they are instead purely of a reflex character, such as are met with in women about the time of the change of life and during the latter months of pregnancy, or from the presence of worms in the rectum. If the worms migrate to the vulva, as they sometimes do, the irritation then becomes direct. Interference with the circulation of the vulva by pregnancy and tumors may cause pruritus: unquestionably, certain varieties of the disorder are idiopathic or neurotic.

SYMPTOMATOLOGY AND COURSE.—When the complaint has existed for some time, the itching will be pretty well diffused from the pubis backward, but in more recent cases it may be localized at the perineum, nymphæ, clitoris, or portions of labia. The itching is not always constant, but subject to exacerbations. It is usually much worse when the patient becomes heated from exercise or is warm in bed, thus preventing comfort or sleep, and thereby adding an additional complication to treatment. The sufferer naturally seeks relief by scratching the involved tissues, and for this very transient satisfaction spreads the disease by increasing the irritability of the parts and inducing a condition closely resembling eczema.

TREATMENT.—Inasmuch as the etiology of the complaint is often uncertain, as heretofore stated, it is highly important that the physician should ascertain if possible the cause of the disease, and thereby be better enabled to treat the complaint intelligently. In case the itching can be traced to the animal parasites most common in this region, such remedies as the black or yellow wash, mercurial ointment, or the oleate of mercury will usually prove sufficient; but if it be found that the Acarus scabei is the cause of the itching, the application of the ordinary sulphur ointment will destroy this parasite and the itching will consequently cease. If due to uterine catarrh or any vaginal affection, attention should be directed to the removal of the primary disorder by appropriate means, for it cannot be expected that itching of the vulva can be relieved so long as there is any irritating discharge constantly exciting it. The most important measure of all is perfect cleanliness. This can be secured by sitz-baths, sometimes several being necessary daily. At the same time, the vagina should be syringed with warm water or water with the addition to it of such remedies as are used for the relief of leucorrhoea. The irritated surfaces of the vulva should be prevented from coming in contact by vaseline spread upon absorbent cotton or lint, or by powders, such as bismuth, starch, etc.

In case there is an unmistakable acrid discharge from the uterus causing pruritus, proper topical applications should be made to as much of the endometrium as is diseased; the vagina should be thoroughly douched night and morning, and then there should be placed against or around the neck of the womb one or more tampons of cotton saturated with the boro-glyceride or with glycerin, in which has been dissolved borax or acetate of lead in the proportion of ounce ss of one of these salts to ounce ij of glycerin.

In some instances, where there is a profuse discharge, simply packing the vagina with dry salicylated or borated cotton will suffice. This should never be allowed to remain longer than twelve hours without removal. In those cases where the discharge is less acrid a single tampon saturated with one of the remedies named or glycerin alone, and placed [p. 394] against the cervix daily, will suffice, as it will prevent the discharge from coming in contact with the vulva. In severer forms of this affection a number of tampons saturated in the same manner will be more efficacious, and still permit the patient to move about. When several tampons are used they should be loosely rolled, and each one should have a string attached for convenient removal. In the mean time, topical applications can be made to the vulva, and washing of the parts will not interfere with the tampons. The author has found the following prescription of Thomas very efficacious as a vaginal injection and wash for the vulva:

Another prescription which has demonstrated its value is:

Sig. Add water to the consistency of cream and apply frequently with a brush.

A somewhat similar prescription, to be applied in the same way, is the following:

or,

In all cases of pruritus, except from parasites, much benefit can be derived from washing the parts two or three times daily in a weak solution of bicarbonate of sodium (half a tablespoonful in a quart of water, with a tablespoonful of eau de Cologne).

In pruritus from diabetes some relief may be afforded by the administration of alkaline mineral waters or salicylate of sodium. In pruritus associated with chronic cystitis the last-named remedy is very useful.

In pruritus of a neurotic character a solution of the muriate of cocoaine of the strength of 4 per cent., sprayed upon the parts or applied with a camel's-hair brush, has often in the author's hands afforded relief when every other application has failed.

One of the latest publications relating to the treatment of pruritus vulvæ is a paper by Kustner,¹⁸ agreeing with Schroeder that the results of operative treatment for pruritus vulvæ are encouraging. This author publishes several cases resulting successfully. A synopsis of one will suffice to show his mode of treatment. A patient, unmarried, suffered for a long time from uterine catarrh and pruritus vulvæ: the former was relieved after prolonged treatment, but there still remained two symmetrical spots between the hymen and labia minora which were the seats of most troublesome itching and were exceedingly sensitive to touch. These portions of the mucous membrane were rich in sebaceous glands, and were also studded with small retention-cysts. The author dissected off [p. 395] the two elliptical portions of mucous membrane, each 1 cm. broad and 3 or 4 cm. long, and containing the small retention-cysts, and then united each wound with interrupted sutures. The pruritus entirely disappeared, and did not again return, though some years after the patient again suffered with uterine catarrh. Other cases are related by the same author, notably one case of pruritus where there was a lacerated perineum. The operation for repair of this perineum was performed, with the result of the permanent disappearance of the pruritus. The author does not give any definite rule as to how and in what cases he should have recourse to operative treatment, but, admitting that pruritus may arise from causes heretofore mentioned in this article, he asks whether those cases where secondary pathological changes have occurred in the vulvar mucous membrane cannot be definitely cured by excision of the affected portion. Not enough cases of cure of pruritus by surgical treatment have been reported to fully establish the theory of Kustner, yet it is a matter of sufficient importance to merit our attention and warrant further investigation.

¹⁸ Centralbl. f. Gyn., No. 12, 1885.

DEFINITION.—This is a disorder first described by Thomas under the above caption.¹⁹ It consists of a hypersensitiveness of the nerves supplying some portion of the mucous membrane of the vulva. Sometimes the area of tenderness will be confined to one of the lesser lips or it will be limited to the vestibule, and in other cases a number of parts may be simultaneously affected. "It is a condition of the vulva closely resembling that hyperæsthetic state of the remains of the hymen which constitutes one form of vaginismus," and doubtless is often confounded with the latter.

¹⁹ Op. cit., p. 145.

ETIOLOGY.—It is more common about the time of change of life, and occurs more frequently among women of hysterical diathesis where there exists a morbid mental condition with a tendency to melancholia. In some instances the disease seems to be excited by vulvitis or vascular growths in the urethra.

SYMPTOMATOLOGY.—The slightest friction causes intense pain and nervousness, and even a current of cold air produces very great discomfort. Coition causes such severe pain that for this cause the subject usually consults her physician. As in vaginismus, the mental distress is often of an exaggerated character, in some instances bordering upon monomania.

PATHOLOGY.—In this disorder there are no indications of inflammation except occasional spots of erythematous redness. It is not a neuralgia in a true sense of the term, but an abnormal sensitiveness of diseased nerves supplying the vulva.

DIAGNOSIS.—The affections most liable to be confounded with this are vascular growths (or irritable caruncles) of the urethra and vaginismus, but ocular inspection and digital examination will enable the physician to determine the character of the disease.

TREATMENT.—This is far from satisfactory in many cases. Thomas speaks most discouragingly concerning it, and states that "the treatment of this condition is most unsatisfactory."

The author has at this time a patient with hyperæsthesia of the vulva who has been treated by him for many months, and up to the time of this writing has obtained no relief. Thomas recommends sending the patient "away from home, where, in addition to enjoying changes of air, scene, and surroundings, she would live absque marito."

In this, as in all disorders which depend on or are associated with the hysterical diathesis, galvanism and massage are, as a rule, of decided benefit. In addition, general tonics, such as arsenic, strychnia, quinia, and iron, should be prescribed. If any local affection exist, such as vulvitis or urethral vegetations, it should be cured first. Warm fomentations, the frequent use of warm water, sedative lotions, and ointments consisting of opium or its salts, carbolic acid, chloroform, and iodoform, are useful topical remedies. Much benefit may be derived by the application of a 4 per cent. solution of hydrochlorate of cocoaine by means of a spray or soft brush. Strong solutions of alum and tannin have sometimes proved beneficial.

No good results have been derived from the use of the knife or caustics in cases where they have been used.

Under this head will be included any enlargement, neoplasm, or adventitious growth which has the vulva for its site. The most common are the following, which will be considered in the order named: viz. Cysts, Hydrocele, Hernia, Hypertrophy, Elephantiasis, Hæmatoma, Cancer, and Urethral Caruncle. There are other growths of the vulva, such as fibroma, lipoma, sarcoma, lupus, etc., but they are of such rare occurrence that their discussion is necessarily omitted.

The frequent concomitance of cysts and abscesses in these glands has caused the author to consider them here under the same caption.

The most frequent cysts of the vulva are those springing either from the ducts or glands of Bartholini, or, as more commonly known, the vulvo-vaginal glands, situated near the lower part of the labia. Cysts having their origin in the ducts are single and are invariably of an oval form; such also is the more common shape of those springing from the gland, yet sometimes they are lobulated, of an irregular form, and comprise one or more in number. Inasmuch as this same locality is sometimes the site of hernia, and cysts of the labia often of a similar form, the physician should be positive that the tumor is a cyst before having recourse to any active mode of treatment.

If fluid accumulates in a cyst in such quantity as to cause the subject inconvenience or discomfort, surgical treatment will be required, of which there are three different modes in common use.

The first mode is to remove by scissors a segment of the sac, allowing escape of its contents, after which the cavity is filled with marine lint or carbolized cotton, which is allowed to remain for about forty-eight hours [p. 397] before renewal. By this plan of treatment the sac will usually be obliterated. Another method is to freely open the cyst and apply some caustic, preferably the galvano- or thermo-cautery. In the absence of either of the last named nitric acid may be used with good effect. The third and last method has in the author's experience proven the most efficacious, though objection has been made to it on account of its being a more bloody operation—namely, complete extirpation of the gland.

The causes of inflammation of these glands are the same as those that cause vulvitis; in truth, they are often accompanying disorders. The symptoms are pain, heat, itching, and an increased redness, particularly about the opening of the duct. If a finger be pressed over the location of the gland, it will elicit signs of pain.

FIG. 29.

Abscess of Glands of Bartholini.

In the outset of the inflammation it is felt hard and unyielding, but two or three days later a fluctuating tumor may be easily discerned. An abscess of the gland should be easily distinguished and rarely mistaken for a cyst. There are the history and ordinary signs of inflammation to aid in diagnosis. If, on the contrary, there is simply a cyst, it can be rolled about under the finger and no indications of pain produced. Further, it may exist an indefinite length of time, and unless the gland from some cause become inflamed no great inconvenience is experienced. It is not an infrequent occurrence, from some cause, for inflammation to attack a cyst-wall, in which event the symptoms of inflammation ensue. Where such is the case the treatment should be the same as in inflammation of the gland—namely, absolute rest and any soothing or anodyne lotions which favor restoration. Should indications of suppuration occur, it should be promoted by the frequent application of hot poultices. If the pain is not severe, the abscess may be left to nature; but if it be severe, then the abscess should be emptied by a free incision at the most prominent point.

DEFINITION.—An accumulation of fluid in the canal of Nuck, constituting a hydrocele or cyst, is of rare occurrence. It is to be found in the upper part of the vulva. Owing to the rarity of this affection the greatest caution should be exercised in its diagnosis. The absence of inflammatory symptoms, of resonance when percussed, and the ordinary signs of hernia, together with a gradual growth of the tumor without constitutional disturbance, would by the exclusive mode of diagnosis leave but little room for doubt as to its character. If, however, the physician still feels uncertain, the means which are used for the cure of this disorder will also aid in diagnosis—namely, aspiration with a fine needle about the size of those used on a hypodermic syringe. Even where hernia exists no harm will be done, for this is not an uncommon practice for the reduction of hernia in this locality.

TREATMENT.—Frequently nothing further is required in the way of treatment than the reduction of the tumor by aspiration. If, however, additional treatment seems to be necessary, it is best to inject tincture of iodine by reversing the action of the syringe. The use of iodine in this manner is for the purpose of obliterating the sac by inducing adhesive inflammation, as is done in the treatment of hydrocele in the male.

DEFINITION.—If the process of peritoneum surrounding the round ligaments as they emerge from the inguinal canal to become lost in the dartos-like tissue of the labia is not obliterated at birth, the channel thus formed is known as the canal of Nuck, and furnishes a path for hernia. Besides a loop of intestine or portion of mesentery the ovary or bladder may descend through this canal and constitute an inguinal or labial hernia. The uterus has even been said to have descended by this route. The infrequency of pudendal hernia makes it all the more important to recognize it when it does occur, that serious injury may be avoided when operating on supposed cases of labial abscesses or cysts.

ETIOLOGY.—Pudendal hernia may be produced by blows, falls, coughing, or sneezing, and by violent muscular exertions, as in the male.

SYMPTOMS.—The presence of a part of the intestine can be diagnosticated by the peculiar crackling feeling, the impulse communicated on coughing, and sometimes the disappearance of the tumor on taxis. Occasionally reduction is very difficult, and exceptionally it may become strangulated.

TREATMENT.—The patient being placed on her back with her hips elevated, a gentle taxis will usually suffice to cause reduction. The physician should be positive that the tumor has been returned to the abdomen. After this is accomplished a truss should be adjusted so as to press on the inguinal canal. Usually a perineal band will be necessary to keep the truss sufficiently low to accomplish the purpose for which it was adjusted.

If taxis has proved inefficacious, and strangulation has occurred, a surgical operation will be necessary.

Hypertrophy of the vulva occurs among certain peoples, as the Bushmen and Hottentots, so commonly as to constitute a race-peculiarity, and on account of size and form has been designated as the Hottentot apron. There is also said to be a peculiar deposit of fat in the nates of Hottentot women, but this should not be confounded with the vulvar peculiarity of the same race. Occasionally in our own country hypertrophy of one or more labia will be met with. Sometimes the nymphæ are hypertrophied, so that they hang down much lower than the greater lips; owing to this dependency and their usual pigmentation of a brownish color they bear some resemblance to elephantiasis. In simple hypertrophy the progress is gradual, and there is an entire absence of the inflammatory attacks to [p. 399] which a labium affected with elephantiasis is subject, nor are there any superficial abscesses as in the latter affection. Although there is usually the brown color on the surface in simple hypertrophy, the color is not the same as in elephantiasis. In the latter there is the peculiar pigmentation, also roughness and deep crevices in the skin, so closely resembling in appearance an elephant's skin that there need be no difficulty in the differential diagnosis of simple hypertrophy and elephantiasis of the vulva.

Hypertrophy of the clitoris sometimes occurs as a congenital deformity, and sometimes it is acquired. There has seemed to be quite a general belief that masturbation is one of its most common causes, but there are no substantial grounds for such belief. On the contrary, it has been frequently observed where women were known to have indulged in this habit that no increase in the size of the normal clitoris could be perceived.

TREATMENT.—If a subject of hypertrophy of the vulva suffers any degree of inconvenience therefrom, the affected parts should be removed. A surgical operation for this purpose is an exceedingly simple one and demands no special description.

An operation for the removal of an hypertrophied clitoris is more bloody than one for the removal of the labia; still, with ordinary precautions it need be neither a severe nor dangerous one. Clitoridectomy for the purpose of curing masturbation or various neurotic affections is happily not of as frequent occurrence as formerly. The author is firmly of the opinion that neither in cases of masturbation, epilepsy, nor hystero-epilepsy is the removal of the normal clitoris beneficial or even justifiable.

DEFINITION.—The vulva is sometimes the site of neoplasms known as elephantiasis arabum. The labia may become so hypertrophied that they hang down to the middle of the thighs in the form of tumors; the clitoris and perineum may also be affected. The skin is generally of the peculiar brownish color of an elephant's skin, and hence the name of the disease. The surface of the skin will present many tuberosities due to hypertrophy of the cutaneous papillæ. Superficial abscesses and ulcerations often occur, causing discomfort and pain.

ETIOLOGY.—It is said that elephantiasis of the nymphæ sometimes results from onanism; it is also congenital. Scrofula, malaria, syphilis, and filth are generally considered as among the direct causes of elephantiasis arabum in the countries where it is the most common. Occasionally it is produced by a blow or contusion. Although this disease is not very common in this country, yet a sufficient number of cases have been seen from time to time to call forth a number of articles in the medical periodicals of our country.

PATHOLOGY.—The pathological changes, according to Mayer, consist in a dilatation of the lymphatic spaces and ducts with secondary formation of connective tissue and thickening of the layers of the cutis vera; sometimes the papillæ are specially enlarged, producing swellings which resemble condylomata in form. The labia majora are most frequently affected, next in frequency the clitoris; more rarely are the labia minora [p. 400] hypertrophied. This affection is developed during that period of life when sexual activity is the greatest.

FIG. 30.

L, Right labium majus, healthy; A, upper part of pachydermatous tumor, covering a part of the mons veneris; B, lower portion of the tumor, occupying the perineum. This tumor measured from anterior to posterior margins nearly nine inches. In its widest portion it measured three inches.

TREATMENT.—The treatment of elephantiasis of the vulva must necessarily be surgical, and therefore will be omitted here, excepting that which is embodied in the following report of cases by the author in the Detroit Review of Medicine in December, 1875, and are briefly reproduced here:

Case No. 1.—Fig. 30 shows the condition of Mrs. ——, aged thirty, the mother of several children and four months advanced in pregnancy at the time she came to my clinic. She walked with difficulty and complained of pain on the left side of the genitalia. She had been troubled with the tumor hereafter described for more than two years, and during her last pregnancy, because of its becoming larger and more painful, it proved a serious impediment to childbirth. For these reasons she wished it removed before being further advanced in pregnancy. The contiguous parts were irritated by fluid discharged from small integumentary abscesses. I removed the tumor by a surgical operation, and the patient made a perfect recovery without any return of the growth. A feature of the case observed during the operation was that an incision made in any portion of the tumor caused a serous discharge to exude, so that at [p. 401] all times it was possible to tell whether I was cutting beyond the diseased tissue or not.

FIG. 31.

FF, Folds of anterior portion of labia majora, the remaining portion of the great lips being hidden from view; L, anterior part of the left labium minus; R. middle part of the right labium minus; M, enlarged left labium minus; N, enlarged right labium minus. A B, the light line between these letters, is designed to indicate the introitus vaginæ, but the actual opening to the canal had its anterior boundary immediately backward of the nodule seen near the letter B. The urine was voided just above the nodular point, near the letter C. The figure does not well exhibit the elongated clitoris, which was fully an inch and a half long, and could be felt in the mass like a hard cord. The tumor seemed to begin at the clitoris and the anterior portions of the labiæ minora, and as it increased in size the introitus was filled by it anteriorly.

Case No. 2.—Miss ——, æt. twenty-two, a brunette of French parentage, came to the clinic for the purpose of having removed from the vagina a tumor of a year's growth, which she said was still rapidly growing, making it difficult and painful for her to walk or engage in any pursuit. The tumor of which she spoke is the one represented by Fig. 31. The operation for the removal of the tumor simply consisted in excising the entire mass and putting a ligature around the base of the hypertrophied clitoris. Three days after a hard-rubber vaginal dilator was inserted, and ordered to be worn most of the time until the parts were healed.

In the first case here reported there was no evidence of any syphilitic taint, but the woman lived in a markedly malarial district. In the last one there were indications of a syphilitic taint. A microscopic examination of the tumor of each case plainly showed its pachydermatous character. Both women were very dark brunettes, each having a coarse, tawny skin, and neither was over-cleanly in her habits.

An important indication relating to operative treatment in this locality is the use of the galvano- or thermo-cautery, particularly the latter, owing to the great vascularity of the parts and the lack of points upon which to exercise counter-pressure to control hemorrhage.

DEFINITION.—Hæmatoma of the vulva is also designated as thrombus or pudendal hæmatocele. This affection consists of an effusion of blood in subcutaneous or submucous cellular tissue of the vulvo-vaginal region; the effusion occurs usually in one labium or in the cellular tissue surrounding the vaginal walls, and, later becoming coagulated, forms a tumor which may vary in size. The tumors sometimes attain the size of a foetal head.

ETIOLOGY.—Hæmatoma generally occurs during pregnancy or during labor, usually from some injury, but rarely spontaneously or in the non-pregnant. Muscular effort during childbirth, blows, kicks, falls, the passage of the foetal head, or anything which can obstruct the return of venous blood or produce rupture of the veins, may be a cause.

SYMPTOMATOLOGY.—The patient will have a feeling of discomfort, later pain of a throbbing character, and often difficult urination on account of the tumor encroaching upon the urethra. If the tumor is very large she will experience some degree of faintness.

DIAGNOSIS.—The sudden appearance of the tumor with the symptoms alluded to usually renders diagnosis an easy task. The affections which may possibly be confounded with this are abscess of the labia, inflammation or cysts of the glands of Bartholini, and pudendal hernia.

TREATMENT.—If the effusion should be small and the symptoms light, but little is demanded except quiet and cooling lotions, like the lead-and-opium wash. If there is effusion in the labia and there are indications of suppuration, it should be treated as phlegmonous inflammation by hot poultices, etc.²⁰

²⁰ Vide Phlegmonous Inflammation of the Labia, p. 391.

It is sometimes necessary during labor, in order to complete it, that a free incision is made in the tumor and the clot turned out with the fingers. This same treatment is often requisite when the tumor is very large and there are good reasons for believing that it will not undergo absorption. It is generally advisable to pursue the same course if a thrombus has existed for some time and there are no signs of absorption or suppuration, by reason of the continued discomfort and pain to which the patient is subject.

After the clot is removed there is often a renewal of the bleeding, in which case the cavity should be plugged with lint or surgical cotton and pressure applied by means of vaginal tampons and external bandages. Sometimes it is requisite to saturate lint or cotton with liquid persulphate of iron, and finally pack the cavity with it in order to check the bleeding. If there is no hemorrhage after the evacuation of one of these tumors, then there is no need of packing or making use of styptics, but it is necessary to prevent phlegmonous inflammation or septicæmia. For this purpose iodoform or carbolic acid should be used and a free outlet provided for the discharge of pus. Washing out the cavity with a weak solution of the permanganate of potassium²¹ also serves a good purpose.

²¹ The author usually directs that from 4 to 8 grains of this salt shall be added to each pint of warm water when it is to be used as an injection or wash.

Cancer is not a common disease of the vulva, yet as a primary affection it attacks this locality more frequently than the vagina.

Epithelioma is the most common form, and generally appears in the outset near the clitoris or on one labium as a small hard and warty growth, which at first itches and later smarts, but is not painful.

After an indefinite length of time the growth, which has increased somewhat in size, becomes painful, ulcerated, and there is more or less of an offensive ichorous discharge. If the disease pursues its natural course, the ulceration will rapidly extend until neighboring tissue becomes involved; the inguinal glands become affected, and after the characteristic cachexia becomes apparent there is no known remedy or means of treatment that can prevent the progress of the disease to a fatal termination.

If the clitoris becomes affected with this form of malignant disease, it can be detected earlier than epithelioma of any other portion of the organs of generation on account of its more external position, its greater sensitiveness, and the increasing pain which the affection and its enlargement produce.

TREATMENT.—If the disease is detected sufficiently early, an entire removal of all the affected parts, including a wide margin of healthy tissue, will generally effect a cure; but postponement until neighboring parts, more particularly the lymphatic glands, are implicated leaves little or no hope of cure through any mode of treatment. Carcinoma of the vulva is generally an extension of the same disease from the uterus or the inguinal glands, and rarely occurs as a primary affection.

This painful affection, commonly included by medical authors as among diseases of the vulva, will be very briefly considered.

DEFINITION.—The most common neoplasm to which the urethra is subject is known as urethral caruncle, vascular tumor, or irritable vascular excrescence of the urethra. These growths consist of all excrescences located at the mouth of the urethra, and sometimes extending within the canal for a short distance. They are of a deep-red color, soft and friable, sometimes regular in shape, but more frequently irregular, and then resemble a small cockscomb. They vary in size from the head of a pin to a raspberry, occasionally attaining that of a walnut.

ETIOLOGY.—No definite cause can be given for the development of urethral caruncle. These growths occur among married and single, old and young.

SYMPTOMS.—The first symptom generally is that the patient experiences a severe smarting pain during or immediately after voiding urine. Pain is also caused by walking, pressure, friction, or even the slightest contact of clothing. Also sleep is frequently disturbed in consequence of slight movements of the body. Coition not only causes a severe pain, but, owing to the friable and vascular character of the growth, it often causes a flow of blood, which leads the subject to believe she has cancer or some other serious disorder. In addition to the foregoing symptoms the patient usually becomes fretful, nervous, hysterical, and melancholy. The severity of one's suffering when thus affected is very much out of proportion to the size of the growths giving rise to it.

Occasionally there will be a feeling of weight and pain in the pelvic region, extending down the thighs. There will also be a muco-purulent discharge from the urethra.

PATHOLOGY.—Urethral caruncles may be briefly defined as consisting of "dilated capillaries in connective tissue, the whole being covered with squamous epithelium."²²

²² Hart and Barbour.

DIAGNOSIS.—(This has been given in part under head of Symptoms.) If there is protrusion of any portion of the caruncle the diagnosis is easy. Yet a prolapse of the urethral mucous membrane or of the urethra may be mistaken for a vascular tumor, but there will not be the characteristic pain attending either of these conditions that invariably accompanies caruncle of the urethra.

Syphilitic growths are sometimes located here, but they are wart-like and painless, and generally have companions in the same neighborhood.

By placing the patient on her back in the lithotomy position and carefully inspecting the parts a diagnosis is by no means difficult. When the growths are within the meatus slight dilatation may be requisite to see them, for which purpose a pair of ordinary dressing-forceps will usually suffice.

TREATMENT.—Owing to the liability of the recurrence of caruncles their simple removal by a cutting instrument will not, as a rule, suffice. Various modes of treatment have been recommended, but the most efficacious can be very briefly stated as follows: The patient being anæsthetized and placed on her back, the growths are then removed and their bases [p. 404] thoroughly cauterized by Paquelin's thermo-cautery at a dull heat; if of a large size it is a better plan to first remove them by scissors and then apply the cautery. If a thermo- or galvanic cautery is not at hand, a knitting-needle heated in the flame of a spirit-lamp will serve a good purpose.

Although the subject is referred to here in its regular order, yet for the greater convenience of the reader vulvar atresia has been included by the author in the preceding section on Diseases of the Vagina (see p. 373).

The skin and mucous membrane of the vulva may develop eruptions common to such tissues in other parts of the body. Those most often found are eczema, erythema, herpes, and acne. They are not distinguished from eruptions located elsewhere, except it may be their greater obstinacy in responding to treatment.

DISORDERS OF PREGNANCY.

"Gestation," says Mauriceau, "is a disease of nine months' duration." Robert Barnes¹ more truthfully remarks: "Since in pregnancy every organ and the whole organism are specially weighted, undergoing extraordinary developmental and functional activity, so any defect or fault inherited or acquired, however latent, will be liable to be evolved or intensified under the trial. Hence pregnancy is the great test of bodily soundness." The pregnant woman is liable to many disorders which can be distinctly traced to the existence of pregnancy. The study of the natural history of gestation renders it highly probable that these disorders are merely pathological exaggerations of physiological functions. Then, pregnancy confers upon the individual no immunity from the diseases to which the non-pregnant woman is liable. But certain acute and chronic diseases, sustaining the relation of accidental complications, are variously modified in their course and effects by pregnancy, and accordingly are of interest to the general practitioner.

¹ Obstetric Medicine and Surgery, 1884, London, p. 205.

For convenience of discussion the disorders of pregnancy may be classified under two headings: I. The Pathological Exaggerations of Physiological Processes; and II. The Peculiarities of Certain Accidental Acute and Chronic Diseases occurring in the Course of Pregnancy.

I. THE PATHOLOGICAL EXAGGERATIONS OF PHYSIOLOGICAL PROCESSES.

It is always difficult, frequently impossible, to draw the boundary-line at which normal functional activity becomes pathological. As remarked by Spiegelberg, all the diagnostic penetration of the physician is demanded to recognize this transition. Then, a high exercise of judgment is necessary to determine when to preserve a wise and masterly inactivity, when to adopt measures of active interference.

Recent investigations show that qualitative and quantitative changes occur in the constitution of the blood of the normal pregnant woman. The [p. 406] red corpuscles, albumen, and iron diminish, while the white corpuscles, fibrin, and aqueous elements increase. Virchow describes this increase in the number of white corpuscles as a physiological leucocytosis dependent upon the growth of the lymph-vessels and corresponding hypertrophic changes in the pelvic and lumbar lymphatic glands. The total blood-mass is also increased—a change especially notable in the second half of pregnancy. When the number of red blood-corpuscles is abnormally diminished the woman becomes chlorotic. If, in addition, the albumen is abnormally diminished, hydræmia results. Chlorosis and hydræmia can only be regarded as independent affections in the absence of cardiac and renal lesions. They are seldom traceable to pregnancy in the absence of individual predisposition. Effusions into the subcutaneous connective tissue, pleural and peritoneal cavities, are liable to occur. Sudden exudations into the pleural cavity are particularly dangerous, while effusions into the subcutaneous tissue of the abdomen, vulva, and lower extremities are annoying and may interrupt pregnancy.

TREATMENT.—The indications for treatment are obvious. The quality of the blood must be improved, elimination of the aqueous elements attempted, and local disturbances alleviated. Nutritious food, iron in combination with non-irritant diuretics, fulfil the first two indications. Blaud's pill, which Niemeyer and Spiegelberg extol so highly, is an excellent tonic preparation. Basham's iron mixture is admirable in its effects.

Gusserow² was the first to observe and describe a peculiar form of progressive pernicious anæmia occurring during gestation. The disease is of rare occurrence, and nothing is known as to its etiology. Chlorosis and hydræmia, however, may be mentioned as predisposing causes.

² Arch. f. Gyn., ii. p. 218.

PATHOLOGY.—The alterations in the constitution of the blood are identical with those in anæmia and hydræmia, and produce similar effects. Evidences of fatty degeneration are found in the musculature of the heart, intima of the arteries, and portions of the capillary walls; retinal hemorrhages are constant lesions. The number of white corpuscles is not increased, and signs of leukæmia—splenic tumor, swelling of the lymphatic glands—are wanting. The condition is that of oligæmia or oligocythosis.

The prodromal symptoms occur during the first half of pregnancy, are obscure, and cannot be distinguished from the effects of chlorosis and hydræmia. After the disease has passed through its incipient stages, food, iron, and tonics seem to have no influence upon its course. During the second half of pregnancy abortion or premature labor usually occurs spontaneously. Under these conditions the shock and hemorrhage resulting from parturition are sufficient to cause a lethal issue in many cases.

PROGNOSIS.—Graefe³ has collected 25 cases of this rare affection: 1 case recovered, 2 cases were discharged improved; the others died before or shortly after labor. The prognosis is obviously grave.

³ Diss., Halle, 1880.

TREATMENT.—As food, iron, and tonics have little or no effect upon the disease after it has passed through its incipient stages, therapeutic resources are limited. The evacuation of the uterine cavity, as shown by [p. 407] Graefe's cases, exercises a favorable influence upon the course of the affection. Gusserow advises the artificial interruption of pregnancy whenever grave symptoms occur, and the weight of professional opinion is very decidedly in favor of such a course. Negative results have attended all efforts at transfusion.

Kehrer⁴ has recently called attention to the apparent influence of pregnancy in the development of the hemorrhagic diathesis. This influence, however, is seldom observed, and then only in cases of distinct, individual predisposition.

⁴ Arch. f. Gyn., x. p. 201.

TREATMENT.—The induction of premature labor, or, at times, of abortion, is indicated.

The experiments and observations of Spiegelberg⁵ and Gscheidlen prove the possibility of the occurrence of plethora during gestation. Actual increase of the red corpuscles, albumen, and iron in the blood is observed during the second half of pregnancy, and then only under the most favorable conditions. As described by Spiegelberg, the symptoms are—mammary and cerebral congestions, palpitation, vertigo, constipation, hepatic torpor.

⁵ Lehrbuch d. Geburtshülfe, Lahr, 1882, p. 58.

TREATMENT.—Restricted diet, muscular exercise, and an occasional saline purge will relieve the troublesome symptoms. Spiegelberg is convinced of the value of bleeding in selected cases.

Among the circulatory disturbances due to pregnancy, mechanical oedema and the varices of the pelvis and lower extremities deserve attention.

De Cristoforis of Milan describes a mechanical inferior venous hyperæmia, the result of the pressure of the gravid uterus on the iliac veins. The mechanical oedema of the abdominal walls, vulva, and lower extremities, intensified by chlorosis and hydræmia, is usually associated with venous ectasis. The oedema may become so excessive that locomotion is rendered difficult, while the labia are enormously distended and the subcutaneous tissue of the abdominal walls becomes pendulous. Toward the end of pregnancy, when the uterus sinks into the pelvic cavity, the oedema and varices frequently abate.

Active measures for the relief of the symptoms produced by oedema are frequently indicated. Threatened gangrene of the skin from hyper-distension may render puncture of the hydropsical regions necessary. It is quite possible to interrupt pregnancy by this little operation, especially if the labia are punctured. Elevation of the lower extremities, rest in the horizontal position, elastic bandages and stockings, local hot packs, mild diuretics, usually fulfil all indications for treatment.

Varices are observed more frequently among multiparæ, but may occur in primiparæ. They are usually developed during the second half [p. 408] of pregnancy. The principal trunk of the saphena is first involved, and subsequently the lateral branches. Congeries of veins are observed on the inner sides of the legs and thighs, especially in the vicinity of the knees. The iliac veins may become dilated, as shown by the condition of the vulvar veins and the occurrence of hemorrhoids. Varices incommode the patient, but seldom cause serious disturbances. Sometimes, however, their tunics are lacerated, and serious even fatal hemorrhage may result. Spiegelberg⁶ records four cases of fatal hemorrhage from the rupture of varices in pregnancy. Then there is always the danger of phlebitis and the processes of thrombosis and embolism, even when the loss of blood is insignificant.

⁶ Lehrbuch d. Geburtshülfe, Lahr, 1882, p. 235.

TREATMENT.—The regular and gentle evacuation of the bowels will frequently relieve the distressing symptoms due to hemorrhoids. Fordyce Barker points out the fact that aloes is not contraindicated by pregnancy. A pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, is a very good remedy. Frequent hot fomentations in conjunction with narcotic ointments will relieve the pain from the congestion of the piles. Attempts at reduction must be instituted with extreme care. It is usually impossible to completely cure the condition during pregnancy, and there is danger of interrupting gestation. Elevation of the lower extremities and equable compression by an elastic bandage or rubber stocking relieve the symptoms caused by varices of the saphena. P. Ruge⁷ and A. Martin have seen favorable results from the hypodermatic injection of ergotin.

⁷ Berl. Beitr. z. Geb. u. Gyn., Bd. iii. p. 7.

Nausea, even vomiting, in the morning, before or shortly after meals, during the early months of gestation, is so common and devoid of injurious effect that it is regarded as physiological. Robert Barnes views it as a normal means of discharging superfluous nervous energy. The uncontrollable vomiting of pregnancy, in which the stomach retains absolutely nothing, is a grave disorder. The patient vomits glairy mucus, clear or colored by the bile. Ultimately the vomit is mixed with blood. Violent retching, intense nausea, pyrosis, and hiccough are constant and distressing symptoms. The woman becomes emaciated. The buccal cavity is dry, the tongue red and shining, the teeth and gums covered with sordes, the breath horribly fetid, the skin dry and harsh. Salivation is frequently observed. Constipation and extreme thirst usually coexist. The epigastrium is tender upon pressure. The woman becomes restless and irritable from loss of sleep and painful efforts at vomiting. A fever of typhoid type is developed, with a quick, rapid, thready pulse. The urine is sparingly secreted, concentrated, and contains albumen and tube-casts. Jaundice is frequently noticed. Extreme marasmus supervenes, and the woman succumbs to some intercurrent disease or dies of exhaustion in muttering delirium. Phthisis and diarrhoea are intercurrent affections which may hasten the lethal issue.

Between the slight nausea upon rising in the morning and the state of extreme marasmus thus briefly sketched every degree of pathological variation may be observed.

It is a remarkable fact that the incessant vomiting, retching, and hiccough seldom interrupt pregnancy until near its end. The muscular effort and loss of blood at this time may precipitate the fatal termination.

Occasionally, spontaneous abortion or premature labor occurs before the patient's condition is desperate. Under these circumstances the severe symptoms may disappear immediately. The same sudden cessation of the vomiting is frequently observed after quickening, rapid excentric hypertrophy of the uterus, and death of the foetus.

The COURSE of the disorder is chronic. Cases terminate by recovery or death in from two to three months. Alarming symptoms are usually developed from the second to the sixth month—very seldom during the seventh and eighth months.

Fortunately, the uncontrollable vomiting of pregnancy is a rare affection. So few cases are recorded in German medical literature that Hohl⁸ has denied the existence of the condition. Carl Braun⁹ in a fabulous experience of over one hundred and fifty thousand obstetrical cases has never seen a fatal case.

⁸ Grundriss d. Geburtshülfe, Kleinwächter, 1881, p. 197.

⁹ Lehrb. d. Gynaekologie, Wien, 1881, p. 842.

PATHOLOGY AND ETIOLOGY.—As the essential predisposing cause of this disorder it is necessary to bear in mind the increased functional activity of the nervous system in general, and of the spinal cord in particular, during pregnancy. Increased reflex mobility is apparent in all the so-called sympathetic affections.

Peripheral irritants are not wanting. The growing ovum stretches the uterine fibres, and consequently irritates the uterine nerves. Bretonneau adduces many facts in favor of this theory. Vomiting is severer in first pregnancies, and occurs during the first half of pregnancy. Vomiting is observed in connection with passive distension of the uterus caused by the unusually rapid growth of the ovum, as in hydramnion and multiple pregnancy. Immediate cessation of all symptoms is frequently noted after quickening, rapid excentric hypertrophy of the uterus, death of the foetus, evacuation of the uterine contents. Henry Bennet directs attention to the importance of congestions, inflammations, and lacerations of the cervix uteri as etiological factors. Graily Hewitt maintains that uterine displacements, with or without incarceration, producing irritation of the uterine nerves, are potent causes. The round gastric ulcer, chronic catarrhal gastritis, are sufficient causes in many cases.

Diseases of the endometrium, decidua, foetal envelopes, or of the foetus itself may supply adequate excentric irritants.

Frerichs has pointed out the connection of hyperemesis with the renal insufficiency of Bright's disease. Kiwisch finds a sufficient cause in the relation between the hyperæsthetic gastric nerves and the hydræmic condition of the blood of the pregnant woman. Lebert and Rosenthal are of the opinion that hyperemesis is symptomatic of extreme general inanition of nervous tissue. Numerous other theories more or less ingenious, and adequately explanatory of certain cases, exist in the literature of the subject. Notwithstanding the extent and accuracy of etiological research [p. 410] into the uncontrollable vomiting of pregnancy, a large class of cases remains in which no organic change capable of objective demonstration can be found.

DIAGNOSIS.—The diagnosis of the uncontrollable vomiting of pregnancy is not so easy as at first apparent. Guéniot¹⁰ pertinently calls attention to three distinct elements: (1) The diagnosis of pregnancy; (2) the diagnosis of the adjuvant or determining cause of hyperemesis; (3) the differential diagnosis between the uncontrollable vomiting of pregnancy and obstinate vomiting from some other cause entirely independent of the pregnant condition.

¹⁰ Thèse Agrégation, Paris, 1863.

Experienced clinicians have committed mistakes, particularly in the third element. Trousseau once made the diagnosis of uncontrollable vomiting of pregnancy in a case in which the autopsy revealed cancer of the stomach. This case was observed by Depaul. Charpentier¹¹ reports a serious error in diagnosis made by Beau. The case was diagnosticated as hyperemesis of pregnancy. The autopsy showed that the obstinate vomiting was probably due to tuberculous meningitis.

¹¹ Traité pratique des Accouchements, Paris, 1883, t. i. p. 621.

PROGNOSIS.—Severe vomiting in pregnancy is always ground for anxiety, and the prognosis must always be guarded. The majority of cases terminate in recovery without the interruption of pregnancy. Guéniot records 118 cases: of these, 46 died; of the 72 survivals, 42 recovered after the spontaneous or artificial evacuation of the uterine contents. Recovery usually, though not always, rapidly follows the cessation of pregnancy. The prognosis is absolutely unfavorable after the appearance of fever and typhoid symptoms.

TREATMENT.—The treatment of hyperemesis may be effective. Its efficiency, however, depends largely upon the accurate recognition of the adjuvant and determining causes. A rational therapeusis must consist in the elimination of these etiological factors. The treatment naturally resolves itself into (1) hygienic; (2) medical; (3) gynæcological; (4) obstetrical.

Hygienic.—The hygienic treatment is of avail in the minor degrees of the disorder, although not without influence in the more serious cases. Diet is of primary importance. Let the patient breakfast upon a small cup of strong coffee or tea, half a cup of milk and lime-water, a morsel of cracker or toast early in the morning, in bed, and lie quietly for one or two hours following the meal. Small quantities of easily-digestible food at short intervals will be tolerated when the patient has given up all pretence at keeping to regular meals. Liquid foods, as sparkling koumiss, egg-albumen in water, iced milk with lime- or soda-water, commend themselves. Absolute dietetic rules, however, cannot be maintained. The stomach of the pregnant woman is proverbially capricious and fanciful. Charpentier narrates the history of a case suggestive in connection with this subject. The patient, four months advanced in pregnancy, in a critical condition from uncontrollable vomiting, came under the care of Beau in the Hôpital de la Charité. One day she asked for Bordeaux crawfishes. Beau granted her request. On the first day two crawfishes were retained; on the second, six; on the third, crawfishes ad libitum, bouillon, and milk. Within six days [p. 411] the vomiting disappeared. Cazeaux and Guéniot cite cases in which ham and paté de foie gras were retained after the rejection of easily-digestible foods. It is necessary to respect these caprices and fancies.

When everything is rejected absolute stomach-rest is indicated. Then nutrient enemata may be tried. Of the great value of rectal alimentation under these conditions there can be no doubt. Henry F. Campbell of Georgia relates the history of a case in which he nourished the patient for fifty-two days by the rectum alone. There is danger, however, of irritating the rectum and causing diarrhoea—a peculiarly unfavorable complication at this time; and this fact must be clearly borne in mind. Of the various nutrient enemata, peptonized milk, cream, defibrinated blood, Leube's beef-and-pancreas mixture, eggs, and beef-tea containing albumens are among the best. From four to six ounces should be exhibited not more frequently than once every six hours.

Inunctions of oil are of undoubted value. Absolute moral and physical rest frequently exercises a favorable influence. Seyfert advised his patients to go home on a visit to their mothers, and return to the conditions to which they were accustomed prior to marriage. Coitus may be a disturbing factor. Rest in the horizontal decubitus exercises as favorable an influence as in sea-sickness.

Medical.—There are few drugs in the Pharmacopoeia which have not been vaunted as specifics by some and found utterly worthless by others. This fact indicates, as remarked by Schroeder, that all remedies are unreliable, and that spontaneous cures frequently occur. Various effervescent liquids, as dry champagne, carbonic-acid water containing one drachm of potassium bromide to the siphon, are sometimes grateful. Subnitrate of bismuth and the antacids are of great value in cases of excessive gastric acidity. Oxalate of cerium, a much-vaunted remedy, is of very little value. Small doses of the tincture of nux vomica are useful in cases of gastric catarrh. The various local anæsthetics are of great importance. Small doses of creasote, carbolic acid, tincture of aconite-root, hydrocyanic acid, and the volatile oils have been used with varying degrees of success. Of this class of remedies cocaine hydrochlorate deserves especial attention. On a priori grounds there is much in its favor. Clinical experience with the drug is not such as to warrant very positive deductions. W. Otto¹² has employed cocaine in sea-sickness, especially in pregnant women, with favorable results. Manassein¹³ reports several cases of hyperemesis of pregnancy cured by its exhibition. The subject is certainly worthy of thorough investigation. G. Gaertner of Vienna states that 0.1 cocainum muriaticum has no toxic effect upon adults. Doses of 0.015-0.02 of the solution (cocain. muriat. sol. Merck, 1.0; aq. destill. 9.0) may be given to an adult three times daily without fear of toxæmia. Goodell recommends drop doses of wine of ipecacuanha and tincture of belladonna, repeated every fifteen minutes.

¹² Berl. klin. Woch., 1885, No. 43.

¹³ Ibid., 1885, No. 35.

Of all medical agents, however, opium, the bromides, and chloral are the most reliable. A clyster containing thirty or forty drops of the deodorized tincture, or a half-grain suppository of the aqueous extract of opium, sometimes produces a happy effect. Hypodermatic injections of morphine will frequently allay the distressing symptoms after the failure of other measures. In the German hospitals large doses of the bromides [p. 412] and chloral are exhibited per rectum with gratifying success in many cases.

Flying blisters, the ether spray, and the faradic current applied to the pit of the stomach may give relief in the milder forms of the disorder.

Gynæcological.—Under the gynæcological treatment of hyperemesis quite a number of important operative procedures are included: 1. If bimanual examination reveals a displacement of the uterus capable of producing symptoms, the organ must be replaced if possible, and retained in position by a properly fitting pessary. 2. Henry Bennet suggested the cauterization of the cervix in all cases, basing his therapy upon his peculiar views of the pathology of the condition. Welponer, Sims, and Jones recommend the application of a 10 per cent. solution of argentic nitrate to the vaginal portion of the cervix in all cases, irrespective of the condition of the cervical tissues, when other means have proved useless. Carl Braun¹⁴ bears testimony as to the value of this procedure. 3. As an ultimate resource before artificially interrupting gestation, the plan of dilating the os externum and cervix uteri with the index finger should be tried. Copeman¹⁵ of Norwich, England, desirous of inducing abortion in the case of a patient afflicted with hyperemesis, pushed his finger through the cervical canal to the membranes and attempted to puncture the amnion with a sound. Failing to accomplish his purpose, he went home for assistance, and returned at the expiration of two hours. To his surprise, the uncontrollable vomiting had ceased. Since 1875, when he published the results of this experience, cases have accumulated proving the great value of this method. W. Gill Wylie¹⁶ of New York has devised a steel dilator to substitute the finger. When the os externum is at all patulous, the index finger is the safest and most efficient dilator. The method is a purely empirical one, does not always secure the desired result, and frequently causes abortion or premature labor. Still, as the ultimate gynæcological resort it has important functions.

¹⁴ Lehrb. d. g. Gynaekoloqie, 1881, p. 841.

¹⁵ Brit. Med. Journal, 1875, 1879.

¹⁶ N. Y. Med. Record, Dec. 6, 1884.

Obstetrical.—The evacuation of the uterine contents, if effected before the development of the febrile stage, is usually followed by immediate disappearance of all distressing symptoms. In the large majority of cases, however, the same end may be secured by a judicious combination of the hygienic, medical, and gynæcological methods of treatment to which attention has been directed. The weight of professional opinion is decidedly opposed to the procedure. For practical purposes the induction of premature labor may be excluded from consideration. The woman usually recovers or dies before the period of foetal viability. Carl Braun¹⁷ gives expression to the very general professional conviction upon this subject in the following words: "I myself have never observed a lethal issue in consequence of the uncontrollable vomiting of pregnancy, lay the greatest weight upon the expectant management and more modern medicamentation, and am of the opinion that after a conscientious estimate of all considerations and contraindications, artificial abortion can be omitted, notwithstanding its permissibility from a scientific point of view when extreme danger to maternal life has been determined by several physicians."

¹⁷ Lehr. d. g. Gynaekologie, 1881, p. 842.

The excessive secretion of saliva is a rare disorder of pregnancy. At all times distressing, it may seriously endanger the patient's life when the quantity of fluid amounts to several quarts per diem. The parotid and submaxillary glands are swollen and tender. The buccal mucous membrane is red and tumid. The absence of fetor serves to distinguish the salivation of pregnancy from the ptyalism of mercurial poisoning. A generous diet and the free exhibition of iron mitigate in some degree the distressing symptoms. Dewees recommends a strictly animal diet. Astringent mouth-washes, small doses of potassium iodide, and subcutaneous injections of atropine over the submaxillary glands are indicated, but seldom influence the condition.

Toothache in pregnancy may be a purely functional disorder. In the majority of cases, however, actual caries is present. During gestation the secretions of the buccal cavity are sometimes altered, and become sufficiently acid to dissolve the lime salts out of the enamel. Again, when for any reason an insufficient quantity of lime salts is ingested with the food, the foetus is supplied with ossific materials derived in part from the maternal teeth. The condition of pregnancy is not infrequently detected in the dentist's chair from these changes. Popular recognition of these dental changes gave origin to the familiar saw, "For every child a tooth." The indications for treatment are obvious. Quinine and local anæsthetics relieve the symptoms of the functional forms of the disorder. Caries may be prevented, to a certain degree, by extreme attention to the teeth and secretions of the buccal cavity and a free, generous mixed diet. Doubtless, the popular belief, that an absolute fruit diet will limit the deposition of ossific material in the foetal skeleton and render labor easier, is responsible for much of the caries observed in American women. It is needless to say that such a belief is utterly without foundation in fact. When structural changes in the teeth have occurred the decalcified dentine should be excavated, and temporary fillings of oxyphosphates or gutta-percha inserted. This little operation can be performed rapidly, without pain or fatigue, and preserves the contour of the teeth.

Constipation is a usual, sometimes a troublesome, attendant upon gestation. The etiological factors are mechanical interference of the gravid uterus with intestinal peristalsis, defective innervation of the bowels, and alterations in the intestinal secretions. When the rectum becomes filled with scybalous masses the condition predisposes to abortion or premature labor. Diet is of primary importance in securing regular evacuations of the bowels. Fresh fruits, brown bread, oatmeal porridge are useful to this end. Enemata have obvious advantages over all drugs. In the selection of aperient remedies care must be taken to choose laxatives and avoid drastic cathartics. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia, Hunyadi, Friederichshalle, and Pullna mineral waters, may be included in the list.

Diarrhoea is a less frequent but more dangerous disorder during pregnancy than constipation. In the early and latter months of gestation diarrhoea is liable to occur from mechanical compression of the rectum by the gravid uterus. Dysentery, with tormina and tenesmus, is a particularly unfavorable complication. The dangers are apparent. Not only is the blood impoverished, but abortion or premature labor may be induced. Every diarrhoea occurring during pregnancy demands immediate attention. Small doses of argentic nitrate in combination with opium, in pill form, are useful in mild cases of diarrhoea, while the deodorized tincture of opium in starch-water enemata is indicated in dysentery.

In normal pregnancy the functions of the liver in the secretion of bile and the excretion of cholesterin are not materially modified. The case is different with the glycogenic function. Blot in 1856 detected the presence of glycogen in the urine of nearly half the pregnant women examined. He concluded that this glycosuria was physiological. Tarnier in 1857 called attention to certain structural changes in the liver occurring during normal gestation. The liver is enlarged in volume, and a peculiar fatty infiltration within the lobule is perceptible. De Sinéty confirmed Tarnier's observations, finding the fatty infiltration within the centre of the lobule, seldom near the periphery. Robert Barnes and Ewart have added corroboratory testimony. Tarnier ascribes the physiological glycosuria announced by Blot to the fatty infiltration observed by himself. Each of these three functions of the liver, the secretion of bile, the excretion of cholesterin, and the glycogenic function, may undergo pathological exaggeration during pregnancy.

Icterus is observed with relative infrequency during gestation. Two distinct forms are recognized—simple jaundice, with bright-yellow coloration of conjunctivæ and skin, without fever and cerebral symptoms; and malignant jaundice, with dull-yellow coloration of conjunctivæ and skin, with fever and cerebral symptoms.

Simple Jaundice.—Simple icterus may occur at any time during pregnancy, runs its usual course, and exercises, as a rule, no serious influence upon the maternal health. The effect upon the foetus is grave. If the icterus is intense and lasts for a considerable period of time, the foetus dies and gestation is interrupted. All the foetal tissues are found to be stained with the biliary coloring matters—a condition termed by Lobstein cirrhonosis.

ETIOLOGY.—The causes of simple jaundice in pregnancy are identical with those which produce the condition in the non-gravid state, and are frequently obscure. It is in a high degree probable that pressure from the gravid uterus is without influence, since the symptom may appear at any time during gestation. The pathological condition usually present is catarrh of the mucous membrane of the duct or of the duodenum in the vicinity of the orifice, causing a narrowing of its lumen.

SYMPTOMS.—The conjunctivæ, skin, and urine are colored bright yellow, and there is entire absence of febrile and cerebral symptoms.

The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the same as in the non-pregnant state. In view of the possible causative relation between simple and malignant icterus, and the injurious effect upon the foetus, medical treatment should be instituted at once. Restricted diet, mercurials or ipecacuanha, followed by saline cathartics, are the more important measures. Artificial abortion or the induction of premature labor has no effect upon the condition. This operative procedure is indicated in the interest of the child, however, when the icterus is intensive, of long duration, the foetus living and viable, the frequency of the foetal heart-beats diminished, and there is reason to fear its death. Carl Braun recognizes very distinctly the force of this indication.

Malignant Icterus.—Malignant icterus, due to the acute yellow atrophy of the liver of the pregnant woman (Rokitansky), is a very rare disease. Carl Braun has observed the condition only once in twenty-eight thousand cases from 1857 to 1863.

ETIOLOGY AND PATHOLOGY.—Very little is known as to the causes of acute yellow atrophy of the liver. Virchow ascribes one case coming under his own observation to compression of the lower half of the liver and gall-bladder by the growing uterus. The rarity of the affection and its occurrence irrespective of the time of pregnancy prove the limited operation of this etiological factor. It is in a high degree probable that the disease may have its starting-point in simple catarrhal icterus.

The liver is ochre-colored, shrunken to one half its volume, and flaccid. On section no signs of lobular structure are visible. Microscopical examination reveals total destruction of the acini and hepatic cells. In the place of the glandular elements, fat-globules, fine granular detritus, crystals of leucin and tyrosin are noted. The spleen is enlarged and the kidneys show acute inflammatory changes. Extensive ecchymoses are observed under the skin, pericardium, and gastric mucous membrane.

SYMPTOMS.—The prodromal symptoms of acute yellow atrophy of the liver are usually overlooked. A trivial jaundice with slight elevation of temperature may precede by several days the development of cerebral symptoms. Difficulty in speech, headache, disorders of the senses followed by delirium, convulsions (cholæmic eclampsia), and coma are the more important symptoms of cerebral origin. The pulse is remarkably frequent and small. The temperature is at first elevated several degrees, but becomes subnormal prior to death. The urine is sparingly secreted, highly colored by the bile-pigments, and contains albumen, tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the urates are diminished. The combination of symptoms points to the retention within the system of the waste products usually excreted by the liver and kidneys. Ultimately, a condition of complete hepatic and renal insufficiency obtains.

DIAGNOSIS.—The dull yellow color of the skin and conjunctivæ, with fever and cerebral symptoms, is a sign of greatest diagnostic value. Physical exploration reveals tenderness on pressure over the hepatic region, and rapidly diminishing area of hepatic dulness on percussion. Care must be taken to exclude acute phosphorus-poisoning—a toxæmia [p. 416] simulating very closely acute yellow atrophy, and repeatedly confounded with that affection.

PROGNOSIS.—No case of recovery has been recorded up to the present time. The disease pursues a rapidly fatal course, terminating within a few days after the development of the icterus.

TREATMENT.—Therapeutic measures must be addressed to prophylaxis. It is necessary to regard simple icterus as a possible prodrome of the malignant form of the disorder.

The most superficial discussion of the disorders of pregnancy would not be complete without some mention of diabetes. The existence of physiological glycosuria during pregnancy and lactation has been demonstrated. Bernard has shown that sugar appears in the placenta of calves at an early period, attains its maximum in the third or fourth month, and when the glycogenic function of the foetal liver is established entirely disappears. The relation between physiological glycosuria and that pathological exaggeration of a normal process, diabetes mellitus, is very obscure. It is, however, a clinical fact that diabetes mellitus occurs more frequently in the pregnant than in the non-gravid woman. Diabetic women are less apt to conceive. When conception does occur, pregnancy is liable to interruption from the death of the foetus. Under these circumstances glucose is found in the amniotic liquor and foetal urine. A case related by Bennewitz and cited by Matthews Duncan indicates that diabetes mellitus may be developed during successive pregnancies, and entirely disappear during the intervals. The influence of pregnancy in developing a latent diabetic tendency may be accepted as established. A clinical observation of some importance is that diabetic coma is seldom developed.

PROGNOSIS.—Matthews Duncan¹⁸ has collected the histories of 22 pregnancies in fifteen women varying in age from twenty-one to thirty-eight years: 4 of the 22 pregnancies terminated fatally by collapse, rather than by coma. The majority of the children died during pregnancy after attaining to the age of viability. Two children were feeble at birth, and died a few hours later. One infant was diabetic.

¹⁸ Obstet. Trans., vol. xxiv. p. 256.

TREATMENT.—The hygienic and medical treatment of diabetes mellitus occurring during pregnancy does not differ from the therapy in the non-gravid state. There is great diversity of opinion upon the subject of the induction of premature labor. On a priori grounds it would seem to be indicated in the interest both of the mother and the child in the graver cases. In the entire absence of authoritative clinical experience, however, the operation must be resorted to with an extreme degree of caution.

Albumen is found in the urine of from 3 to 5 per cent. of all pregnant women.¹⁹ In parturient women albuminuria is of much more frequent occurrence. Leube's researches indicate the existence of physiological [p. 417] albuminuria in the pregnant as in the non-gravid state. It is a matter of great practical difficulty to determine the limits of this normal functional activity. In a large proportion of cases the boundary-line between health and disease is passed. The physiological function undergoes pathological exaggeration, and various forms of nephritis are produced.

¹⁹ Schroeder, Lehrb. d. Geburtshülfe, Bonn, 1884, p. 373.

ETIOLOGY AND PATHOLOGY.—The types of renal disease to which pregnancy stands in more or less direct causal relation are numerous.

1. Leyden describes a condition, the kidney of pregnancy, which may be regarded as the intermediate stage between health and disease. The amount of albumen is increased; hyaline and granular casts, with renal epithelium, showing fatty changes, appear in the urine. This fatty degeneration of the cells covering the glomeruli and lining the uriniferous tubules is not of an inflammatory nature. Anasarca of the lower extremities is usually present. The condition may last for an indefinite period of time without causing serious symptoms. With the expiration of the term of pregnancy it may disappear, leaving no trace of its former existence. On the other hand, the kidney of pregnancy may be the starting-point of some serious renal lesion.

2. Latent chronic interstitial nephritis, chronic tubal nephritis, and lardaceous degeneration of the kidney are usually influenced unfavorably by pregnancy, and, in turn, may lead to the interruption of that state. Chronic interstitial nephritis and chronic tubal nephritis may have their origin in the kidney of pregnancy. The cirrhotic kidney is distinguished from the other forms by the abundant aqueous urine, containing comparatively little albumen—none at all at times—cardiac hypertrophy, and hard pulse. In the differential diagnosis of chronic tubal nephritis and the kidney of pregnancy chief reliance must be placed upon the history of the case and the course of the affection. Albuminuria is a very inconstant symptom of the lardaceous kidney, especially in the beginning and ultimate stages of the disease.

3. Mixed types of chronic Bright's disease are frequently observed. Thus, the interstitial and tubal forms of the disease may be combined. Lardaceous degeneration may be present with either form, and fatty changes are common in all the types of Bright's disease. Eclampsia is of relatively infrequent occurrence in chronic Bright's disease, although anasarca and its consequences may cause the interruption of pregnancy.

4. Acute Bright's disease is one of the most serious disorders occurring in the course of pregnancy. The urine is diminished in quantity, and contains a large amount of albumen, tube-casts, and red blood-corpuscles. Eclampsia is of frequent occurrence, and usually induces abortion or premature labor.

The causes of renal disease and of its symptom albuminuria are not always evident. In the kidney of pregnancy there is no inflammatory change. The cells covering the glomeruli and the glandular cells lining the uriniferous tubules undergo fatty degeneration, and are cast off as the result of anæmia.

In the acute and chronic forms of renal inflammation there is a variety of probable etiological factors. Mechanical pressure from the gravid uterus may impede the return of venous blood and determine congestion of the kidneys. This explanation is rendered more probable by the fact [p. 418] that albumen usually appears in the urine after the fifth month, when the uterus has attained considerable size. Albuminuria is of comparatively more frequent occurrence in primiparæ with tense abdominal walls. It is frequently observed in cases of large ovarian cysts and uterine fibroids. The increased functional activity of the organs, the elevation of blood-pressure, the alterations in the constitution of the blood, are doubtless potential factors. When any latent tendency to Bright's disease exists, exposure to cold and impeded cutaneous functional activity are more likely to develop the disease in the pregnant than in the non-gravid state. Compression of the ureters is regarded by Halbertsma as a cause of great importance.

SYMPTOMS.—The symptoms of Bright's disease in pregnancy are neither uniform nor constantly present. Anasarca frequently directs attention to the patient's condition long before the appearance of more significant signs. Oedematous swellings of the face, hands, arms, feet, legs, and labia majora are always suspicious, and should lead to an examination of the urine. These oedematous swellings are wandering—appear when the patient is lying down, and disappear when she rises and walks about. Sometimes, toward the end of pregnancy, they become less marked, not infrequently entirely disappearing, while the albuminuria is increasing. The skin covering the oedematous portions of the body is dry, of a chalkish-white appearance, and the surface temperature is depressed.

Anomalous nervous phenomena, such as headache, vertigo, dimness of vision, spots before the eyes, ringing in the ears, sudden deafness, obstinate nausea and vomiting, sleeplessness, neuralgia, are often observed, and should always excite suspicion. These various nervous symptoms may be viewed as produced by the retention within the blood of certain substances normally excreted by the kidneys.

Convulsions, due to renal insufficiency, may occur during pregnancy, but are observed more frequently during parturition and the puerperium.

Attention has already been called to the characters of the urine. It is necessary to remember that in the granular, contracted kidney and lardaceous degeneration albuminuria may escape observation.

Bright's disease strongly predisposes to abortion or premature labor.

PROGNOSIS.—Any organic disease of the kidneys is serious. When the disease is extensive and involves both organs the prognosis is especially unfavorable. Accurate conclusions as to the dangers of Bright's disease during pregnancy are not justified by the present state of our knowledge. It is only possible to say, in a general way, that the prospect of recovery is less favorable than in the non-gravid state. Owing to the strong predisposition to abortion and premature labor, the chances of the foetus surviving pregnancy are relatively slight. Even if the child is not prematurely expelled from the uterus, it usually succumbs to the influence of the excrementitious products retained within the maternal blood.

TREATMENT.—In view of the serious complications arising in pregnancy from interference with the functions of the kidneys, the absolute necessity of chemical examination of the urine at regular intervals in every case, especially during the latter half of gestation, is apparent. When pathological albuminuria is present, rational therapy will be directed to the removal of the cause. Evacuation of the uterine contents is the only mode of removing the pressure from the gravid uterus, but [p. 419] we have a variety of expedients, hygienic and medical, which must be invoked before resorting to such a radical procedure.

Hygienic.—The diet should be restricted, as far as possible, to milk, and nitrogenous articles of food must be forbidden. The functional activity of the skin can be maintained by frequent baths in lukewarm water. Vapor baths are of still greater value. Hot-water baths are employed on an extensive scale in the obstetrical clinics of the Vienna General Hospital. Carl Braun, Josef Spaeth, and Gustav Braun give testimony to their efficacy. Indeed, in Vienna chief reliance is placed upon the hot-water bath as a prophylactic and remedial agent. Breus²⁰ has recently described the method usually practised. The patient is placed in a bath-tub filled with water at a temperature slightly above 99° F. The tub is then covered with a heavy blanket, leaving the face free, and the temperature of the water is gradually elevated to 110° or 112° F. She remains in the bath thirty minutes. A towel wrung out of ice-water and placed upon the head relieves any distressing cephalic sensations. While in the bath the patient drinks large quantities of water. Upon emerging from the bath she is covered with a warm sheet and enveloped in an upper and lower layer of thick blankets, so that only the face is exposed. Within a very few minutes free perspiration is observed. The sweating is continued for two or three hours. According to the gravity of the case the hot-water bath may be repeated once daily for an indefinite period. The relief of all threatening symptoms under this simple plan of treatment alone is surprising. Sometimes the hot-water bath acts as an efficient excitant of uterine contractions, and premature labor is induced. A. Sippel²¹ calls attention to this fact, and proposes hot-water baths as a harmless method of induction of premature labor. Although such an event is not undesirable, it is unusual, and occurs only when the temperature of the water reaches a great elevation or the baths are frequently repeated, or, finally, when there is a very decided predisposition to the interruption of pregnancy. The lateral or latero-prone posture during sleep serves to relieve in some degree the kidneys of the pressure from the gravid uterus, and should be advised.

²⁰ Arch. f. Gynaek., vol. xix. p. 219.

²¹ Centralb. f. Gynaek., No. 44, 1885, p. 693.

Medical.—The exhibition of non-irritating diuretics, such as the acetate and bitartrate of potassium, in large quantities of water, causes an increased secretion of urine and lessens the congestion of the renal vessels. Among the mineral waters Bilin, Giesshübel, Preblau, Selters, and Vichy deserve commendation. Benzoic acid, in conformity with Frerichs' suggestion, is employed in Vienna. The tincture of the chloride of iron, alone or in combination with small doses of tincture of digitalis, is an efficient diuretic, and at the same time an excellent tonic.

Cathartics which produce large, watery stools without much irritation supplement the action of diuretics. The compound powder of jalap and the saline purges fulfil this indication. Care must be taken, however, to avoid the drastic effects of too large a dose.

Jaborandi and pilocarpine have been, and are at the present time, extensively used to aid in the elimination by the skin of retained excrementitious matters. The weight of authority is decidedly against the exhibition of this remedy. At best, it is uncertain in its action. It is a cardiac depressant, and frequently stands in a causal relation to [p. 420] pulmonary oedema. For these reasons the drug has been condemned in unequivocal terms by Carl Braun and Fordyce Barker. The same effect, with less risk, can be produced by the hot-water baths.

Local Treatment.—In the acute forms of Bright's disease various modes of counter-irritation are useful. Wet and dry cups and leeches applied to the loins are indicated. Frerichs recommends pills of the extract of aloes and tannin with the view of restoring the normal tonus to the blood-vessel walls.

By a judicious combination of these varied therapeutic resources, hygienic and medical, threatening symptoms may be averted. Cure of Bright's disease, acute or chronic, is seldom if ever achieved during pregnancy. Not unfrequently, however, notwithstanding all efforts, the amount of albumen steadily increases, hydræmia becomes more pronounced, hydropsies appear with threatening cerebral, cardiac, or pulmonary symptoms. More active treatment is demanded, and the subject of the induction of premature labor must be seriously considered. Without entering into a detailed discussion of the arguments for and against the artificial premature interruption of pregnancy under these conditions, let it suffice to say that clinical experience furnishes overpowering evidence in favor of the operation. The weight of professional opinion is also very decidedly in favor of the artificial induction of premature labor. In the selection of the method for the induction of premature labor it is well to bear in mind the possible excitant effect on uterine contractions of hot-water baths, as pointed out by A. Sippel.²²

²² Centralb. f. Gynaek., No. 44, 1885, p. 693.

Diseases of the skin occur with comparative frequency during pregnancy. Latent diatheses are roused into activity. The graver forms of skin disease usually disappear during or shortly after the puerperium. These facts point to some causal relation between the diseases and gestation. Under the increased activity of the glandular system the growth of hair may be stimulated, giving origin to a condition termed by dermatologists hirsuties gestationis. Slocum²³ relates the history of a case in which a woman in successive pregnancies grew a full beard. Anomalous deposits of pigment, constituting the condition known as chloasma uterinum, are observed, more especially among pregnant women exposed to sunlight. Chloasma is interesting from a diagnostic point of view, since it is liable to be confounded with pityriasis versicolor, an affection of frequent occurrence during pregnancy. The red nose of acne rosacea may be one of the first signs of pregnancy. General pruritus, a rare affection, belongs to the class of idio-neuroses (Hebra). Spiegelberg relates the history of a case of general pruritus occurring in an old primipara. The affection made its appearance in the second month, and continued without material abatement of symptoms throughout the period of gestation. Pruritus of the vulva is a common disorder of pregnancy. It is usually symptomatic of eczema, some inflammatory condition of the genitalia, or diabetes mellitus. The treatment must be directed to the removal of the cause. Vaginal douches containing vegetable or mineral astringents will [p. 421] afford relief when the itching is due to acrid vaginal secretions. Dilute solutions of corrosive sublimate in water or alcohol (1:100 or 200), followed by compresses saturated with tar-water, are recommended very highly by Spiegelberg.

²³ New York Medical Record, 1875.

Pregnancy cannot be regarded as a cause of psoriasis. When that affection exists, however, it is usually aggravated. The elder Hebra²⁴ in 1872 described a rare form of skin disease occurring in the course of pregnancy which he called herpes impetiginiformis, and of which he encountered five cases. Grouped vesicles upon inflamed bases appear about the genitalia, and subsequently diffuse themselves by successive crops over the body. Great prostration, rigors, and intense fever accompany the eruption. Four of the five cases terminated fatally. Milton and Duncan Bulkley a few months later described a rare skin affection peculiar to pregnancy which they designated herpes gestationis. Erythema, papules, vesicles, and bullæ are developed. Vesicles predominate, appear on the lower extremities, subsequently spreading over the body. Intense itching and burning attend the vesicles. Urticaria, neuralgia, and other neurotic troubles accompany the affection. The disease appears early in pregnancy, continues until after delivery, and is apt to recur with succeeding pregnancies. The constitutional symptoms are much less severe than in the condition described by Hebra. At the meeting of the American Dermatological Society, 1885, L. A. Duhring²⁵ called attention to the relation of impetigo herpetiformis, herpes gestationis, pemphigus, and certain other forms of disease to dermatitis herpetiformis. Attention was briefly directed to the identity of the impetigo herpetiformls of Hebra with dermatitis herpetiformis. Herpes gestationis was a misnomer, the affection being found in men as well as in women. The disease was the vesicular variety of dermatitis herpetiformis. The peculiar forms of pemphigus observed during pregnancy, not of syphilitic origin, may be viewed as examples of the same disease. Duhring thinks that "we stand on the threshold of our knowledge of the disease."

²⁴ Wiener Med. Woch., No. 48, 1872.

²⁵ Journal of Cutaneous, etc. Dis., October, 1885, p. 317.

Of all the neuroses occurring in the course of pregnancy, puerperal eclampsia is of chief clinical importance. Puerperal convulsions, however, occur more frequently during labor and the lying-in period than during gestation. For this reason the subject is usually discussed in connection with the pathology of the puerperium. The various psychoses are referred for a similar reason to the same chapter.

Tetanus, a rare affection, especially in women, is occasionally observed in pregnancy. It occurs with greatest relative frequency in hot climates after abortion and the removal of placental or decidual remains. Sir James Y. Simpson collected 28 cases which sustained some relation to abortion or labor. Mr. Waring²⁶ has collected 232 cases occurring in a tropical climate.

²⁶ Indian Annals, 1855.

The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases, only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.

In the entire absence of knowledge of the pathology of the disease, TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite of amyl are the remedial agents usually employed.

Chorea occurs in pregnancy as an accidental complication or as the direct result of that state. It is a rare disorder of pregnancy. Spiegelberg has observed 3 cases; Barnes has collected 56 cases; Fehling²⁷ brings the number up to 68; altogether, 84 cases are on record.

²⁷ Lehrb. d. Geburtshülfe, 1882, p. 239.

ETIOLOGY.—The investigations of Robert Barnes show that where chorea arises in pregnancy in the large majority of cases there is a history of chorea in childhood, acquired predisposition prior to pregnancy, or hereditary "nervous diathesis predisposing to chorea." The connection between rheumatism, endocarditis, and chorea is a well-established fact. The precise nature of this relation is unknown. Hughlings Jackson has constructed the theory of "embolism of the small branches of the middle cerebral artery supplying the structures near the corpus striatum." Robert Barnes²⁸ calls attention to the following facts, which invalidate this ingenious theory: "(1) The frequent recovery of choreic patients; (2) the occasional immediate cessation of choreic fits upon delivery; (3) the progressive character of the disease during pregnancy, convulsions increasing in severity, and the gradual development of mania in some cases; (4) the fact that embolism is rare during pregnancy." In the absence of any definite cause, Spiegelberg refers a large number of these cases to the class of reflex neuroses. All the elements essential to a reflex neurosis are present. We have (1) a predisposition to chorea, inherited or acquired; (2) inanition of the central nervous system incident to the hydræmic state of the blood in pregnancy; (3) various potential peripheral irritants in connection with the sexual organs. Intense emotions, terror and the like, may act as exciting causes.

²⁸ Obstetric Medicine and Surgery, London, 1884, p. 379.

COURSE AND SYMPTOMS.—Chorea usually makes its appearance in the course of the first half of pregnancy, and continues until the beginning of labor. Sometimes choreic attacks are witnessed during parturition. In only 3 out of the 84 recorded cases the disease continued after the puerperium. Primiparæ are more frequently affected than multiparæ. The disease is liable to recur with succeeding pregnancies, entirely disappearing in the intervals. The choreic movements are the same as in the non-gravid woman affected with the disease. They are usually bilateral. As in chorea in the non-gravid state, transitory albuminuria and glycosuria may be observed. The increase of urates and phosphates in the urine is interpreted as the result of nervous excitement and muscular activity. Pregnancy is interrupted in about one-half the cases. The child may be born alive and affected with the disease.

PROGNOSIS.—Out of the 84 cases, 23 terminated fatally as the result of complications. Mania, loss of memory, grave cerebral and spinal lesions are occasionally traceable to the chorea of pregnancy. The [p. 423] prognosis with reference to the child is unfavorable, from the tendency to the premature interruption of pregnancy.

TREATMENT.—The palliative treatment of chorea occurring in pregnancy is unsatisfactory in the extreme. All the specifics of greater or less value in the non-gravid state are frequently without influence during gestation. The diet must be nutritious and easily digestible. Large doses of iron and quinine are indicated. As in other convulsive disorders, during the paroxysms chief reliance is placed upon anæsthetics, subcutaneous injections of morphine, potassium bromide, and chloral. Charcot recommends the exhibition of large doses of bromide of potassium through a considerable period of time. Clifford Albutt extols succus conii. In over one-half the recorded cases the most judicious combinations of hygienic and medical therapeutic resources have proved of no avail. In view of the prognosis, the induction of premature labor is usually indicated, in the interest of both the mother and child, at an early stage of the disease. Sometimes the question of the artificial induction of abortion comes up for consideration. In view of the grave cerebral and spinal lesions which may result from the affection, the mother is justly entitled to the benefit of the doubt. It may not be amiss to add that this indication for the induction of abortion is not generally recognized.

Epilepsy is usually an accidental complication of pregnancy. Spiegelberg²⁹ is responsible for the observation that in chronic epilepsy pregnancy sometimes modifies the course of the affection in a favorable manner. The seizures occur less frequently and are not so violent in character. Acute epilepsy may be developed as the result of pregnancy when a latent predisposition, inherited or acquired, exists. The epileptogenous zone in acute epilepsy comprehends the distribution of the ischiatic nerve. Acute epilepsy disappears with the cessation of pregnancy, but is apt to recur with succeeding gestations.

²⁹ Lehrb. d. Geburtshülfe, 1882, p. 241.

The occurrence of acute or chronic epilepsy during pregnancy is of great diagnostic interest from the resemblance of the epileptic seizures to the convulsions produced by renal inadequacy. The urine secreted during or after an epileptic fit is usually free from albumen. In the severest forms of puerperal eclampsia the urine may also be entirely free from albumen and tube-casts. In the ultimate stages of amyloid degeneration³⁰ and atrophy of the kidney, the most formidable forms of Bright's disease, albumen may not appear in the urine.

³⁰ Carl Braun, Lehrb. d. g. Gynaek., 1881, p. 827.

The DIAGNOSIS is usually cleared up by the history of the case and the course of the affection.

The PROGNOSIS with reference to mother and child is favorable. Epilepsy rarely leads to the premature interruption of pregnancy.

The TREATMENT is the same as in the non-gravid state.

Disorders of the special senses usually occur in the course of pregnancy as symptoms of acute or chronic Bright's disease. Amblyopia, amaurosis, [p. 424] ringing in the ears, sudden deafness, loss of taste and smell, may be developed under the influence of renal inadequacy before or after the occurrence of puerperal convulsions. Apart from the disorders of the special senses dependent upon lesions of the kidney, disturbances of vision are of chief clinical interest.

Amblyopia, hemeralopia, and color-blindness are occasionally observed as the result of nutritive disturbances in the retina. Nyctalopia, Spiegelberg says, is not recorded in the literature of the subject.

The PROGNOSIS is favorable as a rule. The disorders of vision usually disappear during the puerperium, and evince no tendency to recurrence.

Generous diet, iron, and a tonic plan of treatment are indicated.

II. THE PECULIARITIES OF CERTAIN ACCIDENTAL ACUTE AND CHRONIC DISEASES OCCURRING IN THE COURSE OF PREGNANCY.

The older obstetricians believed not only that pregnant women possessed a certain immunity from accidental diseases, but also that the course of such affections was favorably modified by gestation. Modern research has demonstrated the groundless nature of this belief. It is an established fact that pregnancy confers upon the individual no immunity from the disorders to which the non-gravid woman is liable. Moreover, such accessory diseases are usually aggravated by pregnancy, and, in turn, exercise an unfavorable influence upon gestation, frequently leading to its interruption.

Of all the so-called accessory diseases occurring in the course of pregnancy, the acute infectious diseases are of the gravest clinical significance. These diseases are peculiarly dangerous complications for two reasons:

I. They have a marked tendency to cause the death of the foetus and the interruption of pregnancy, when the loss of blood and the muscular exertion consequent upon the expulsion of the product of conception from the uterine cavity seriously imperil the mother's life.

II. Hemorrhagic endometritis, caused in part by changes in the constitution of the blood, is not an uncommon symptom in the course of acute infectious diseases in the non-gravid state. In pregnancy this symptom is of more constant occurrence, just as it is of graver prognostic moment, both with reference to the mother and to the child.

I. The death of the foetus and the interruption of pregnancy may result from the operation of a variety of etiological factors.

1. The foetus usually dies in consequence of the elevation of maternal temperature. The case is a veritable example of that condition which H. C. Wood of Philadelphia terms heat-stroke. The normal foetal temperature is slightly more elevated than the maternal. The foetus in its membranes, surrounded by maternal tissues, must possess at least the [p. 425] same temperature as the maternal body. But it has its own heat-producing apparatus in addition. A very slight elevation of the maternal temperature produces a disproportionate rise in the temperature of the foetal body. Kaminsky³¹ has shown that an elevation of maternal temperature to 104° F. imperils foetal life. Increased frequency of the pulsation of the foetal heart and abnormally active foetal movements are followed by diminished cardiac and muscular activity, and the foetus dies. The autopsy reveals the characteristic lesions of heat-stroke.

³¹ Moskauer Med. Z., 1867, Nos. 13-19.

2. Runge³² has demonstrated the occurrence of foetal death from asphyxia when the maternal blood-pressure is seriously lowered. This lowering of the maternal blood-pressure occurs as the result of diminution in the force and frequency of the heart's action observed in the course of acute infectious diseases or from the sudden loss of blood. Asphyxia may also be caused by structural changes in the epithelium covering the foetal placenta, due to the state of the maternal blood.

³² Arch f. Gyn., Bd. xii. p. 16.

3. The foetus may perish in consequence of infection with the specific poison of the acute disorder. Death as the result of acute infection has been observed in variola and relapsing fever.

4. Pregnancy may be interrupted, independently of the condition of the foetus, as the result of the thermic irritation of the uterine muscular fibre by the maternal blood. Spiegelberg on a priori grounds asserted the possibility of this event. Runge³³ has since demonstrated by experimental methods its actual occurrence.

³³ Volkmann's Sammlung, No. 174; Arch. f. Gyn., Bd. xii. p. 16.

II. Hemorrhagic endometritis in the course of acute infectious diseases complicating pregnancy has been demonstrated by Slavjansky's³⁴ researches. In cholera this symptom is observed with relative frequency. Following hemorrhage into the decidua, according to the time, extent, and site, pregnancy may be immediately interrupted, or secondarily as the result of the pathological changes in the placenta or membranes induced by the extravasated blood. The hemorrhage may be so severe as to jeopardize the life of the mother.

³⁴ Arch. f. Gyn., iv. p. 285.