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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
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A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.



EDITED BY WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.


ASSISTED BY LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE
UNIVERSITY OF PENNSYLVANIA.



VOLUME IV.

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



PHILADELPHIA:
LEA BROTHERS & CO.
1886.



Entered according to Act of Congress, in the year 1886, by

LEA BROTHERS & CO.,

in the Office of the Librarian of Congress at Washington. All rights
reserved.



WESTCOTT & THOMSON,
_Stereotypers and Electrotypers, Philada._

WILLIAM J. DORNAN,
_Printer, Philada._



CONTENTS OF VOLUME IV.


DISEASES OF THE GENITO-URINARY SYSTEM.
                                                                   PAGE
DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS. By
  ROBERT T. EDES, M.D. . . . . . . . . . . . . . . . . . . . . . .   19

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS. By
  FRANCIS DELAFIELD, M.D.  . . . . . . . . . . . . . . . . . . . .   69

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA. By JAMES TYSON,
  A.M., M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . .  104

CHYLURIA. By JAMES TYSON, A.M., M.D. . . . . . . . . . . . . . . .  114

DISEASES OF THE MALE BLADDER. By EDWARD L. KEYES, A.M., M.D. . . .  123

SEMINAL INCONTINENCE. By SAMUEL W. GROSS, A.M., M.D. . . . . . . .  137

DISPLACEMENTS OF THE UTERUS. By EDWARD C. DUDLEY, A.B., M.D. . . .  147

DISORDERS OF THE UTERINE FUNCTIONS, INCLUDING AMENORRHOEA,
  DYSMENORRHOEA, AND MENORRHAGIA. By J. C. REEVE, M.D. . . . . . .  182

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.
  By B. F. BAER, M.D.  . . . . . . . . . . . . . . . . . . . . . .  208

PELVIC HÆMATOCELE. By T. GAILLARD THOMAS, M.D. . . . . . . . . . .  239

FIBROUS TUMORS OF THE UTERUS. By WILLIAM H. BYFORD, M.D. . . . . .  245

SARCOMA OF THE UTERUS. By WILLIAM H. BYFORD, M.D.  . . . . . . . .  271

CARCINOMA OR CANCER OF THE UTERUS. By WILLIAM H. BYFORD, M.D.  . .  274

DISEASES OF THE OVARIES AND OVIDUCTS. By WILLIAM GOODELL, M.D. . .  282

DISEASES OF THE URINARY ORGANS IN WOMEN. By ALEXANDER J. C.
  SKENE, M.D.  . . . . . . . . . . . . . . . . . . . . . . . . . .  339

DISEASES OF THE VAGINA AND VULVA. By EDWARD W. JENKS, M.D., LL.D.   367

DISORDERS OF PREGNANCY. By W. W. JAGGARD, A.M., M.D. . . . . . . .  405

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE. By W. W.
  JAGGARD, A.M., M.D.  . . . . . . . . . . . . . . . . . . . . . .  432

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND
  ENDOMETRITIS, INCLUDING LEUCORRHOEA. By W. W. JAGGARD, A.M.,
  M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  447

ABORTION. By GEORGE J. ENGELMANN, M.D. (Berlin)  . . . . . . . . .  467


DISEASES OF THE MUSCULAR SYSTEM.[1]

[Footnote 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.  . . . . . . . . . . . . .  529

PROGRESSIVE MUSCULAR ATROPHY. By JAMES TYSON, A.M., M.D. . . . . .  540

PSEUDO-HYPERTROPHIC PARALYSIS. By MARY PUTNAM JACOBI, M.D. . . . .  557


DISEASES OF THE SKIN.

DISEASES OF THE SKIN. By LOUIS A. DUHRING, M.D., and HENRY W.
  STELWAGON, M.D.  . . . . . . . . . . . . . . . . . . . . . . . .  583


MEDICAL OPHTHALMOLOGY.

MEDICAL OPHTHALMOLOGY. By WILLIAM F. NORRIS, A.M., M.D.  . . . . .  737


MEDICAL OTOLOGY.

MEDICAL OTOLOGY. By GEORGE STRAWBRIDGE, M.D. . . . . . . . . . . .  807


INDEX  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  843



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.


FIGURE                                                             PAGE
 1. THE CLASSICAL REPRESENTATION OF THE PELVIC ORGANS  . . . . . .  148

 2. THE CORRECT REPRESENTATION OF THE PELVIC ORGANS  . . . . . . .  149

 3. FIRST DEGREE OF PROLAPSE OF THE POST-PARTUM UTERUS . . . . . .  155

 4. SHOWING EXTREME DESCENT OF THE UTERUS AND OF THE PELVIC FLOOR,
      AND THE HERNIAL CHARACTER OF THE LESION  . . . . . . . . . .  156

 5. DESCENT OF THE VIRGIN UTERUS INTO THE VAGINAL CANAL, SHOWING
      THE REDUPLICATED VAGINAL WALLS . . . . . . . . . . . . . . .  157

 6. 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 .  158

 7. THE EMMET CURVES (PESSARY) . . . . . . . . . . . . . . . . . .  160

 8. THE ALBERT SMITH CURVES (PESSARY)  . . . . . . . . . . . . . .  160

 9. THE FIRST SUTURE BEFORE TWISTING IN EMMET'S OPERATION IN
      PROCIDENTIA  . . . . . . . . . . . . . . . . . . . . . . . .  162

10. FOLDS ON THE ANTERIOR VAGINAL WALL FORMED AFTER TWISTING THE
      FIRST SUTURE . . . . . . . . . . . . . . . . . . . . . . . .  162

11. EMMET'S OPERATION FOR PROCIDENTIA AND URETHROCELE COMPLETED  .  163

12. DIAGRAM OF EMMET'S OPERATION . . . . . . . . . . . . . . . . .  164

13. THE SUTURES IN PLACE . . . . . . . . . . . . . . . . . . . . .  165

14. THE VAGINAL SUTURES TWISTED  . . . . . . . . . . . . . . . . .  165

15. EXTREME RETROFLEXION, WITH HYPERTROPHY OF THE CORPUS . . . . .  167

16. COMMENCING REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
      BY CONJOINED MANIPULATION  . . . . . . . . . . . . . . . . .  170

17. COMPLETED REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
      BY CONJOINED MANIPULATION  . . . . . . . . . . . . . . . . .  171

18. SHOWING THE PELVIC ORGANS SUSTAINED BY THE EMMET PESSARY AFTER
      REPOSITION OF THE PROLAPSED, RETROVERTED, OR RETROFLEXED
      UTERUS . . . . . . . . . . . . . . . . . . . . . . . . . . .  172

19. SCHULTZE'S SLEIGH PESSARY IN PLACE . . . . . . . . . . . . . .  173

20. FRONT VIEW OF SCHULTZE'S FIGURE-OF-EIGHT PESSARY . . . . . . .  174

21. THOMAS'S RETROFLEXION PESSARY  . . . . . . . . . . . . . . . .  174

22. PATHOLOGICAL ANTEVERSION . . . . . . . . . . . . . . . . . . .  175

23. CONGENITAL ANTEFLEXION . . . . . . . . . . . . . . . . . . . .  176

24. ANTEFLEXION WITH POST-UTERINE FIXATION . . . . . . . . . . . .  177

25. DIAGRAM SHOWING MUSCULAR STRATA OF UTERUS, AS DIVIDED FOR
      CLINICAL PURPOSES  . . . . . . . . . . . . . . . . . . . . .  249

26. IMPERFORATE HYMEN  . . . . . . . . . . . . . . . . . . . . . .  374

27. SIMS'S VAGINAL DILATOR . . . . . . . . . . . . . . . . . . . .  387

28. FOLLICULAR VULVITIS (HUGINER)  . . . . . . . . . . . . . . . .  390

29. ABSCESS OF GLANDS OF BARTHOLINI  . . . . . . . . . . . . . . .  397

30. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . .  400

31. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . .  400

32. DEFORMITY OF HAND IN PROGRESSIVE MUSCULAR ATROPHY  . . . . . .  548

33. SHOWING ATROPHY OF THE RIGHT DELTOID AND ARM, AND OF THE LEFT
      ARM  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  549

34. SHOWING ATROPHY OF THE DELTOID, POSTERIOR ASPECT, AND OF THE
      SCAPULAR MUSCLES . . . . . . . . . . . . . . . . . . . . . .  549



{17}

DISEASES OF THE GENITO-URINARY SYSTEM.


DISEASES OF THE KIDNEYS, INCLUDING | FIBROUS TUMORS OF THE UTERUS.
  THE PELVIS OF THE KIDNEYS.       |
                                   | SARCOMA OF THE UTERUS.
DISEASES OF THE PARENCHYMA OF THE  |
  KIDNEYS, AND PERINEPHRITIS.      | CARCINOMA OR CANCER OF THE UTERUS.
                                   |
HÆMATURIA AND HÆMOGLOBINURIA OR    | DISEASES OF THE OVARIES AND
  HÆMATINURIA.                     |   OVIDUCTS.
                                   |
CHYLURIA.                          | DISEASES OF THE URINARY ORGANS IN
                                   |   WOMEN.
DISEASES OF THE BLADDER.           |
                                   | DISEASES OF THE VAGINA AND VULVA.
SEMINAL INCONTINENCE.              |
                                   | DISORDERS OF PREGNANCY.
DISPLACEMENTS OF THE UTERUS.       |
                                   | FUNCTIONAL DISORDERS IN CONNECTION
DISORDERS OF THE UTERINE           |   WITH THE MENOPAUSE.
  FUNCTIONS.                       |
                                   | DISEASES OF THE PARENCHYMA OF THE
INFLAMMATION OF THE PELVIC         |   UTERUS; METRITIS AND
  CELLULAR TISSUE AND PELVIC       |   ENDOMETRITIS.
  PERITONEUM.                      |
                                   | ABORTION.
PELVIC HÆMATOCELE.                 |



{19}

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

BY ROBERT T. EDES, M.D.


Anomalies of Shape, Size, Number, and Position.

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
{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 Bartels[1] 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.

[Footnote 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]

[Footnote 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.
{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.


Floating Kidney.

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
{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 {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.

[Footnote 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 {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 (Keppler[4]) 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.

[Footnote 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
{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.

{26} 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. Harris[5] 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.

[Footnote 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.

[Footnote 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]

[Footnote 7: A. W. Smyth, _New Orleans Med. and Surg. Journal_, Aug.,
1879.]

In other cases[8] a dissection has been made until the kidney was
reached, which was then, with its adipose capsule, stitched firmly into
{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.

[Footnote 8: Hahn, "Fixation of Movable Kidney," _Am. Journ. of Med.
Sci._, April, 1882, from _Cbl. für Chirurgie_, 1881.]


Polyuria; Diabetes Insipidus.

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 {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
{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 {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 Teissier[9] 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.

[Footnote 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.

{31} 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.

[Footnote 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.

Guyon[11] states that surgical polyuria occurs under three {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.

[Footnote 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 {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 {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.

[Footnote 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.

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. Semmola[13] 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 {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.

[Footnote 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 {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 work[14] 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.

[Footnote 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 {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:

  Ac. phenic. glacial. (95 per cent.), drachm ij;
  Ac. acet. puri.,                     drachm vij;
  M.  Add liq. potassæ,                ounce ij-drachm vj.
          Millard.

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 {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:

Munn[15] 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 {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.

[Footnote 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 {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 {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.

{42} 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; Renal Calculus.

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. {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 {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 {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.

{46} 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 {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.


Calculous Pyelitis.

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 {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.

[Footnote 16: _Giornale di Anat. e Fis. path._, iii. p. 370.]

[Footnote 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 {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
{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.

[Footnote 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 {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.

[Footnote 19: _Ibid._, Dec. 27, 1884.]

[Footnote 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 {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.


{53} Secondary Pyelitis.

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 {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 {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 {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.

[Footnote 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.


Hydro-nephrosis.

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 {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.

{58} 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 {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.

{60} 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."


Malignant Growths.

As pathological rarities only, and having but little clinical interest,
may be mentioned, as occurring in the kidneys, fibroma, lipoma, {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 {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 {63} pursued.
According to Billroth,[22] out of 33 operations for tumors of the
kidney, 13 have been cured.

[Footnote 22: _Mittheil. der Aerzte in Nieder Oesterreich_, Bd. x. p.
161 _et seq._]


Cysts.

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.

{64} 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.


Tuberculosis.

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.

{65} 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]

[Footnote 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.


Parasites.

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.

{66} 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 {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.


Diseases of the Ureters.

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,
{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.



{69}

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS.

BY FRANCIS DELAFIELD, M.D.


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 {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
{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, {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 {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.
Whitelaw[1] relates a {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.

[Footnote 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 {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 {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, {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
{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.


Acute Parenchymatous Nephritis.

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. {79}

(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.

{80} 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.


Chronic Parenchymatous Nephritis.

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 {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.


{82} Acute Diffuse Nephritis.

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 {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 {84}
administration of iron. In these cases also it is important to guard
against relapses.


The Acute Diffuse Nephritis of Scarlatina.

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.


Chronic 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 {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
{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.

{87} 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 {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 {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 {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 {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 {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
{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 {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.

{95} 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 {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 {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
{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.


{99} 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.

{100} 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
{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. Murchison[2]
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.

[Footnote 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.


{102} 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: {103}

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.



{104}

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA.

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


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
{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.


Causes which give rise to Hæmaturia and Hæmoglobinuria.

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 {106} the blood-vessels. There is implied, however,
in all these conditions an alteration of the vessel-walls which permits
such transudation. Indeed, Ponfick[1] 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.

[Footnote 1: "Ueber die Gemeingefährlichkeit der essbaren Morchel,"
_Virchow's Archiv_, Bd. lxxxviii. S. 47.]


Hæmaturia from Local Causes.

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.


{107} Malarial Hæmaturia and Hæmoglobinuria.

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 Harley[4] 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.

[Footnote 2:  "Ein Fall von intermittirender Albuminurie und
Chromaturie," _Virchow's Archiv_, Bd. vi. S. 264, 1854.]

[Footnote 3: "Clinical Lecture on Diseases of the Heart, with Ague (and
Hæmaturia)," _London Lancet_, 1832, p. 500.]

[Footnote 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 {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 Mackenzie[5] reports a case which lasted
twenty-three years.

[Footnote 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
Gull[6] and Grainger Stewart, and a hæmatin crystal once by Strong.[7]

[Footnote 6: _Guy's Hosp. Reports_, 1866, p. 381.]

[Footnote 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, {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.

[Footnote 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. Ponfick[9] goes
so far as to say that the exudation of hæmoglobulin is not possible
without the concurrence of marked diffuse nephritis. Recently
Lebedeff[10] 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 Litten[11] and
Lassar.[12]

[Footnote 9: "Ueber die Gemeingefährlichkeit der essbaren Morchel,"
_Virchow's Archiv_, Bd. lxxxviii. S. 476, 1882.]

[Footnote 10: "Zur Kenntniss der feineren Veränderungen der Nieren bei
der Hämoglobinausscheidung," _Virchow's Archiv_, Bd. xci. S. 267, Feb.,
1883.]

[Footnote 11: "Verhandl. des Vereins für innere Medicin," _Deut. Med.
Wochenschr._, No. 52, Dec. 29, 1883.]

[Footnote 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
{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 {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 {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]

[Footnote 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.


Malignant Malarial Hæmaturia.

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 {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.



{114}

CHYLURIA.

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


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:

  Water . . . . . . . . . . . . . . . . . . . . . . . . . . .     947.4
  Solid matter  . . . . . . . . . . . . . . . . . . . . . . .      52.6
                                                                  -----
  Urea  . . . . . . . . . . . . . . . . . . . . . . . . . .   7.73
  Albumen . . . . . . . . . . . . . . . . . . . . . . . . .  13.00
  Uric acid . . . . . . . . . . . . . . . . . . . . . . . .   0.00
  Extractive matter with uric acid  . . . . . . . . . . . .  11.66
  Fat insoluble in hot and cold alcohol, but soluble
    in ether  . . . . . . . . . . . . . . . . . . .   9.20 |
  Fat insoluble in cold alcohol . . . . . . . . . .   2.70 | 13.90
  Fat soluble in cold alcohol . . . . . . . . . . .   2.00 |
  Alkaline sulphates and chlorides  . . . . . . . . . . . .   1.65
  Alkaline phosphates . . . . . . . . . . . . . . . . . .  |
  Earthy phosphates . . . . . . . . . . . . . . . . . . .  |  4.66

[Footnote 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 {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:

  Water . . . . . . . . . . . . . . . . . . . . . . . . . . .     978.8
  Solid matter  . . . . . . . . . . . . . . . . . . . . . . .      21.2
                                                                  -----
  Urea  . . . . . . . . . . . . . . . . . . . . . . . . . .   6.95
  Albumen . . . . . . . . . . . . . . . . . . . . . . . . .   0.00
  Uric acid . . . . . . . . . . . . . . . . . . . . . . . .    .15
  Extractive matters with uric acid . . . . . . . . . . . .   7.31
  Fat insoluble in hot and cold alcohol, but soluble in ether|
  Fat insoluble in cold alcohol . . . . . . . . . . . . . .  | .00
  Fat soluble in cold alcohol . . . . . . . . . . . . . . .  |
  Alkaline sulphates and chlorides  . . . . . . . . . . . .   5.34
  Alkaline phosphates . . . . . . . . . . . . . . . . . . .   1.45
  Earthy phosphates . . . . . . . . . . . . . . . . . . . .    .15

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.

[Footnote 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.

{116} 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.

[Footnote 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. Waters[6] says that "the main
pathological feature of the complaint is a relaxed condition of the
capillaries of the kidney," which permits the transudation.

[Footnote 4: _Stomach and Renal Diseases_, 4th ed., London, 1843.]

[Footnote 5: _Lectures on Pathology and Therapeutics_, 1868, p. 256.]

[Footnote 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
{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.

[Footnote 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.

Gubler[8] 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.

[Footnote 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.

[Footnote 9: _Med.-Chir. Trans._, vol. xlv., 1862.]

[Footnote 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.

[Footnote 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.]

{118} 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 {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.

{120} 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
{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, {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.



{123}

DISEASES OF THE BLADDER.

BY EDWARD L. KEYES, M.D.


Inflammation.

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--

                                | suppurative;
                     | Acute----| diphtheritic;
  1. Cystitis mucosa |          | gangrenous.
                     |
                     | Chronic--| catarrhal;
                                | membranous.

  2. Interstitial cystitis, where the muscular coat of the bladder is
       involved.

  3. Peri-cystitis, para-cystitis, where the peritoneal surface or
       surrounding structures are inflamed.

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.

{124} 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 {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 {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.

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.
{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 Walsham[1]
in a case of cystitis due to over-distension. This last complication is
happily exceptionally rare.

[Footnote 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.


{128} Chronic Cystitis (Catarrh of the Bladder).

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 {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 {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
{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 {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 Thompson[2]--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.

[Footnote 2: _Brit. Med. Journ._, Dec. 9, 1882, p. 1131.]


Neurosis of the Bladder.

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 {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 and Paralysis.

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 {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.


Hemorrhage from the Bladder.

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
{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 {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.


New Growths in the Bladder.

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).



{137}

SEMINAL INCONTINENCE.

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


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 {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 {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 {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 {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 {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
{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 {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 {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, {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.



{147}

DISPLACEMENTS OF THE UTERUS.
BY E. C. DUDLEY, A.B., M.D.


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.


Normal Location and Position of the Uterus.[1]

[Footnote 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 {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.

[Illustration: 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 {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.

[Footnote 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.]

[Illustration: FIG. 2. The Correct Representation of the Pelvic
Organs.]


Normal Movements of the Uterus.

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.

{150} 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.


Normal Supports of the Uterus.

The uterus is maintained in its normal position and location by the
following agents:

_a_. The uterine ligaments;

_b_. The pelvic floor.[3]

[Footnote 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
segment[4] 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
segment[5] 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.

[Footnote 4: Hart and Barbour's _Manual of Gynecology_.]

[Footnote 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
{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 {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 left[6] 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.

[Footnote 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
{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.


Ascent of the Uterus.

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.


Retro-location of the Uterus.

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.


Ante-location 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.


Lateral Locations of the Uterus.

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
{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.


Descent or Prolapse of the Uterus.

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 {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.

[Footnote 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.

[Illustration: 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 {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.

[Illustration: 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 {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.

[Illustration: FIG. 5. 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'_.]

[Illustration: FIG. 6. 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
{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.

{159} 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.

{160} 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.

[Illustration: FIG. 7. The Emmet Curves.]

[Illustration: 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 {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 {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.

[Illustration: FIG. 9. The First Suture before Twisting in Emmet's
Operation for Procidentia (Emmet).]

[Illustration: 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 {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.

[Illustration: 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_), {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.

[Footnote 8: _Trans. Am. Gynæcological Society_, 1883; _Principles and
Practice of Gynecology_, 3d ed.]

[Illustration: 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.]

[Illustration: 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.]

[Illustration: 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 {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
rupture[9] and the tissues involved to be incorrect, or at least
inadequate.

[Footnote 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.

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 {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.


Retroflexion.

ETIOLOGY AND PATHOLOGY.--Retroflexion is that displacement in which the
organ is bent backward upon itself. It usually results from, {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.

[Illustration: 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
{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: {169}

  "_Ordinary Method of Application_. | "_Proper Method of Application_.
                                     |
  "I. Ordinarily, the douche is      | "I. It should invariably be
  applied with the patient in the    | given with the patient lying on
  sitting posture, so that the       | the back, with the shoulders
  injected water cannot fill the     | low, the knees drawn up, and the
  vagina and bathe the cervix uteri, | hips elevated on a bed-pan, so
  but, on the contrary, returns      | that the outlet of the vagina
  along the tube of the syringe as   | may be above every other part of
  fast as it flows in.               | it. Then the vagina will be kept
                                     | continually overflowing while
                                     | the douche is being given.
                                     |
  "II. The patient is seldom         | "II. It should be given at least
  impressed with the importance of   | twice every day, morning and
  regularity in its administration.  | evening, and generally the
                                     | length of each application
                                     | should not be less than twenty
                                     | minutes.
                                     |
  "III. The temperature is           | "III. The temperature should be
  ordinarily not specified or        | as high as the patient can
  heeded.                            | endure without distress. It may
                                     | be increased from day to day,
                                     | from 100° or 105° to 115° or
                                     | 120° Fahr.
                                     |
  "IV. Ordinarily, the patient       | "IV. Its use, in the majority of
  abandons its use after a short     | cases, should be continued for
  time."                             | months at least, and sometimes
                                     | for two or three years.
                                     | Perseverance is of prime
                                     | importance."

"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 {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.

[Illustration: FIG. 16. Commencing Reposition of the Retroverted or
Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).]

[Illustration: 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
{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, {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.

[Illustration: 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
{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.

[Illustration: 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 {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.

[Illustration: FIG. 20. 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.]

[Illustration: FIG. 21. 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.


Lateral Versions and Flexions.

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.


Pathological Anteversion.

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).

[Illustration: 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.

{175} 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 {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.


Pathological Anteflexion.

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.

{177} 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.)

[Illustration: 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.)

[Illustration: 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 {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 {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
contribution[10] 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.

[Footnote 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 {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 {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.

[Footnote 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.



{182}

DISORDERS OF THE UTERINE FUNCTIONS.

BY J. C. REEVE, M.D.


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 {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.


Amenorrhoea.

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:

  A. Amenorrhoea (absent menstruation) from
      _a_, anatomical conditions: want of development of organs,
           atresia of passages;
      _b_, physiological influences: delayed puberty, idiopathic;
      _c_, pathological causes: constitutional diseases, disease of the
           sexual organs, the cachexiæ.
  B. Amenorrhoea (secondary or suppressed menstruation):
      _a_, anatomo-pathological: atresia of passages, atrophy of
           organs;
      _b_, physiological: pregnancy, nursing, premature change of life;
      _c_, pathological: besides those given above--A-_c_--are
           psychical influences and exposure or taking cold during
           menstruation.

{184} 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, {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 {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 {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 {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 {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 {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 {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 {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.

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.
{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 {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 {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 {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 {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. {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
{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.

{200} 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.


Menorrhagia.

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 {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:

  CAUSES OF MENORRHAGIA.--
       I. Diseases of the General System:
          Plethora;
          Chlorosis and anæmia;
          Debility, as from excessive lactation;
          The exanthemata and typhoid fever;
          Hæmophilia;
          Scorbutic, uræmic, and malarial cachexiæ.
      II. Local Affections, not Uterine:
          Cerebral, as psychical influences;
          Cardiac and pulmonary affections, as valvular disease,
            emphysema, and phthisis;
          Hepatic diseases, as cirrhosis and the changes produced by
            residence in tropical climates;
          Splenic and renal disease;
          Abdominal tumors and loaded bowels;
          Peri-uterine inflammations;
          Ovarian influences.
     III. Uterine Causes:
          Subinvolution;
          Areolar hyperplasia;
          Endometritis, with fungous growths;
          Laceration of the cervix, with eversion;
          Ulceration of the cervix;
          Displacement of the uterus;
          Polypi and fibroid tumors;
          Retention of products of conception;
          Malignant disease;
          Congestion.

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 {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; {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 {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 {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 {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 {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."



{208}

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.

BY B. F. BAER, M.D.


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.


{209} Parametritis.[1]

[Footnote 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.

{210} 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 {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 {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 {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.

[Footnote 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 {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
{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 {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 {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 {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 {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 {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.

[Footnote 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:

  Rx. Ext. opii aq.,   gr. xij;
      Ol. theobromæ,   q. s.;
  M. et ft. supposit., No. xij.

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 {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:

  Rx. Tr. belladonnæ,                  fluidrachm j;
      Sodii bicarbonatis,              drachm iij;
      Spts. etheris nitrosi,           fluidounce j;
      Mist. potass. citratis, q. s. ad fluidounce vj.

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
{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
{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?

{224} 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 {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 {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, {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:

  Rx. Hydrarg. chloridi corrosivi, gr. j;
      Liq. arsenici chloridi,      fluidrachm j;
      Tr. ferri chloridi,
      Acid. muriatici diluti,  aa. fluidrachm iv;
      Syr. simplici,               fluidounce ij;
      Aquæ,               q. s. ad fluidounce vi.

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:

  Rx. Strychniæ sulphatis, gr. j;
      Acidi arseniosi,     gr. j;
      Quininæ sulphatis,   gr. xlviii;
      Ferri sulphatis,     gr. xlviii;
      Ext. hyoscyami,      gr. xij;
      Ext. gentianæ,       q. s.

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.


Perimetritis.

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 {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.

{229} 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.

[Footnote 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
{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.

{231} 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.

{232} 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 {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 {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:

  Rx. Tincturæ aconiti,
      Tincturæ opii, aa. drachm j;
      Tincturæ iodinii,  drachm vj. Misce.

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.

{235} 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 {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 {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.

{238} 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.



{239}

PELVIC HÆMATOCELE.

BY T. GAILLARD THOMAS, M.D.


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 {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 {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:

  1st. Rupture of blood-vessels in the pelvis:
                  Utero-ovarian;
                  Varicose veins of broad ligaments;
                  Vessels of extra-uterine ovisac.
  2d. Rupture of pelvic viscera:
                  Ovaries;
                  Fallopian tubes;
                  Uterus.
  3d. Reflux of blood from the uterus:
                  Menstrual blood.
  4th. Transudation from blood-vessels:
                  Purpura;
                  Scorbutus;
                  Chlorosis;
                  Hemorrhagic peritonitis.

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
{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 {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
{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.



{245}

FIBROUS TUMORS OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.


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, {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
{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.

{248} 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 {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.

[Illustration: 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 {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
{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 {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 {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. {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 {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 {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 {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 {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 {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. {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 {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]

[Footnote 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
{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]

[Footnote 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]

[Footnote 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 {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 uterus[4] in a threefold manner, and causes a
diminished flow of blood to the morbid as well as healthy tissues in
the uterine structure.

[Footnote 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 {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 {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 {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.

{267} 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
{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
{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 {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.



{271}

SARCOMA OF THE UTERUS.

BY W. H. BYFORD, M.D.


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 {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.

{273} 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.



{274}

CARCINOMA OR CANCER OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.


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.


Medullary or Soft Cancer.

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 {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
{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.

{277} 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]

[Footnote 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 {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.


Epithelioma of the Uterus.

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 {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 {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, {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.



{282}

DISEASES OF THE OVARIES AND OVIDUCTS.

BY WM. GOODELL, M.D.


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.

[Footnote 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.


Malformations.

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
{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.


Inflammation of the Ovary; Ovaritis.

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 {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.


Chronic Ovaritis.

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 {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 {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:

  Rx. Hydrargyri chloridi corrosivi, gr. j-ij;
      Ammonii chloridi,              drachm ij-iv;
      Misturæ glycyrrhizæ comp.      fluidounce vj.  M.

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 {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.


Prolapse of the Ovary.

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 cases[2] rectal
enemata or the presence of hardened feces kindled up sexual throbs of
the {288} most painful and exhausting character, which thrilled through
the whole body for hours at a time.

[Footnote 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 {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.


Hernia of the Ovary.

This is usually a congenital displacement, and, according to
Englisch,[3] is, when double, almost always so. The ovary is then found
either in {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.

[Footnote 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 Routh[4] 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.

[Footnote 4: _Trans. Royal Medical and Chir. Soc., Lancet_, Jan. 28,
1882.]

[Footnote 5: Goodell, _Lessons in Gynæcology_, 2d ed., chap. xxvi. p.
332.]

[Footnote 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.


Öophorectomy; Battey's 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
{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, {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]

[Footnote 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 {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]

[Footnote 8: _Lessons in Gynæcology_, by Wm. Goodell, M.D., chap.
xxvi.]


Extra-Ovarian Cysts.

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.


Cysts of the Parovarium.

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.

[Footnote 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]

[Footnote 10: _British Med. Journal_, Oct. 21, 1882, p. 792.]

{294} 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.

[Footnote 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.

[Footnote 12: _Am. Journ. of Obstetrics_, April, 1882, p. 394.]

{295} 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.


Cysts of the Oviducts, or Fallopian Dropsy.

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
{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.


Cysts of the Terminal Vesicle of the Oviduct.

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.

[Footnote 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.


Solid Tumors of the Round Ligament.

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]

[Footnote 14: _Medical Times and Gazette_, Dec. 1, 1883.]


{297} 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 Tumor of the Ovary.

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.

[Footnote 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."

[Footnote 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 {298} good, but they are liable to have short and broad
pedicles which need to be tied very carefully in sections.


Malignant Diseases of the Ovary.

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]

[Footnote 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]

[Footnote 18: _Op. cit._, p. 148.]

DIAGNOSIS.--Since, as has been shown, this cannot always be made {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--

  (_a_) The presence of ascitic fluid or of oedema of the lower
          extremities when the tumor is too small to produce such
          pressure symptoms.

  (_b_) General cachexia, rapid emaciation, and grave constitutional
          disturbance out of all proportion to the size of the tumor.

  (_c_) The hardness and solidity of the tumor, together with its
          nodulous and irregular surface.

  (_d_) The concurrent development of two ovarian growths.

  (_e_) The retraction and burying of the cervix in the vaginal vault.

  (_f_) Pain in stabs, starting from the groin and running down the
          inside of the thigh. But pain is not a trustworthy symptom,
          as it is often absent, especially in cysto-carcinoma, and may
          be caused by benign growths as well.

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.


Dermoid Cyst, or Piliferous Cyst of the Ovary.

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, {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."

[Footnote 19: Elsner, _Dublin Journal Medical Sciences_, May, 1882, p.
380.]

[Footnote 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 {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.


Cystic Tumors of the Ovary.

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 {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]

[Footnote 21: _Edinburgh Medical Journal_, July, 1885, p. 76.]

[Footnote 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]

[Footnote 23: _Trans. Amer. Gynæcol. Soc._, vol. i. p. 195.]

[Footnote 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
{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, Aronson[25] 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 {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.

[Footnote 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 Tait[26] 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.

[Footnote 26: _London Obstet. Trans._, vol. xxii. p. 97.]

[Footnote 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 {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 {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 {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.

{308} 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 {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 Tait[29] 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 {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.

[Footnote 28: _American Journal of Obstetrics_, Nov., 1883, pp. 1169
and 1189; also _Transactions American Gynæcological Society_, vol. ii.,
1877, p. 270.]

[Footnote 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 {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.

[Footnote 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 {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 {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]

[Footnote 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 {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]

[Footnote 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]

[Footnote 33: _Medical Record_, Jan. 3, 1885, No. 2, and _British
Medical Journal_, April 15, 1882, p. 544.]

[Footnote 34: _Medical Record_, Jan. 3, 1885, p. 2, and _American
Journal of Obstetrics_, July, 1882, p. 547.]

[Footnote 35: _Maryland Medical Journal_, July 1, 1882, p. 110.]

[Footnote 36: _British Medical Journal_, Sept. 16, 1882, p. 528.]

The statistics of the leading ovariotomists up to January, 1883, are as
follows:[37]

                     Cases.  Recovered.  Died.  Mortality,
                                                per cent.
  Clay                 93        64        29     31.11
  Sir Spencer Wells  1088       847       241     22.15
  Keith               381       340        41     10.76
  Knowsley Thornton   328       293        35     10.67
  Lawson Tait         226       199        27     11.94

[Footnote 37: _Medical News_, Jan. 27, 1883, p. 117.]

{315} 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]

[Footnote 38: _Medical News_, Dec. 30, 1882, p. 745.]

[Footnote 39: _Agnew's Surgery_, vol. ii. p. 811.]

[Footnote 40: _The New York Medical Record_, Nov. 11, 1882, p. 560.]

[Footnote 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]

[Footnote 42: _Agnew's Surgery_, vol. ii. p. 800.]

[Footnote 43: H. C. Bigelow, _American Journal of Obstetrics_, July,
1882, p. 651.]

[Footnote 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 {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]

[Footnote 45: _Brit. Med. Journ._, May 27, p. 796.]

[Footnote 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]

[Footnote 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 {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]

[Footnote 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 {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 {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.

[Footnote 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 {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:

  Rx. Emplastri saponis, ounce iv;
      Emplastri resinæ,  ounce iij;
      Olei olivæ opt.,   ounce i.   M.

{321} After many trials, W. D. Robinson of Philadelphia has succeeded
in making for me a very good plaster according to the following
formula:

  Rx. Emplastri saponis, ounce ij;
      Resinæ,            drachm vi;
      Terebinthinæ albæ, drachm ij.  M.

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 {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.

[Footnote 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 {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 {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.

[Footnote 51: _Berlin. klin. Wochenschrift_, 1883, No. 10.]

[Footnote 52: _Medical News_, Feb. 3, 1883, p. 130.]

Before this hand can again be used for separating adhesions it must be
{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; {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.

{327} 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
{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.

[Footnote 53: _Transactions International Med. Congress_, 1876, p.
801.]

[Footnote 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]

[Footnote 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
{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.

[Footnote 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 {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
{331} convolutions of the intestines. The sponges therefore should not
be much smaller than the fist.

[Footnote 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.]

[Footnote 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