4 is patty a amet l : na rt) % why ‘a ' ne “ ‘ we 2 etary * PE tern ase ae Sass , nae Lees . ce 3 Ce reas . eae! pete Pesta a spehers UN eset = SEARS orate aon oe ELSE ¥ Sy ye Aig he ASG 0e ete bt eb mind a hig ase'g sti a Nit ate dee wor a4 Niue Sys! robe * ee ied vsti at egeata ? * ¥ y Sey : . : SASHA oy ee apis Beats a, okt ys ix. a Pore eo Sho. tr ee : ssetes if aise4 heh Awhe - aiatiees Prt sed Vener. Bephe Pe anehy nats te ry ' pusgyi-r ance? terre ares bata yates teers gee tf Ay gh pt te bose a erat se H aaa) 5 ares aie righe f drone ate plain Mas ers td} - Sharonagtieske eter) ae ys roars a we | Uk saee dette ik fee rae. 3 ie u24 53, nen =? habebs aed o Sorte eee ys ijoheiied are + ohne aa? reese ee Ad bel re batty 4 *” 9: adn She shag bod eth bet Sided ” “ A rs > ‘ , 1 v - 2 4 J i dat pics Pg 9) i sik, Aras 4 Eas aeRt 5 ra guar cath F ae fe) Riket 23 RINE r 42! ve: t edits. ie aie Y , Yr +e Sieh Fatiet ye yes Ea if eh Toh Vnbek ws , cores i yhopuls r Sth Grok, aged 3! , 2: site alia Ma yan 9c 4 3 ae 3 ; i 4 . neat arey oo is Ost sated tod ase Be ee 273 oa yyen done eee =e on Seno i Vex ae 4 areata ee wee tye 7 Ad aches a sd pared Be [tere ae * SEgth ee aryites 4 Be Niperde Pets ae Berit Cadi Aye ph AIH OK ied “Mie das Geftirn, Ohne Haft Aber ohne Raft, Drehe fic) jeder Um die eigne Laft.” : GOETHE. ~ TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY VOLUME 7 FOR THE YEAR 1882 PHILADELPHIA, PA. HENRY C. LEA’S SON & CO. 1883 Copyright, 1883, By THE AMERICAN GYNECOLOGICAL SOCIETY. All rights reserved. The Riverside Press, Cambridge: Electrotyped and Printed by H. O. Houghton & Co. NOTE. ee Tue Society does not hold itself responsible for the views enunciated in the papers read at its meetings. This volume contains the Index to the gynecological and ’ obstetric literature of all countries for the year 1881, pre- pared with the codperation of Dr. J. S. Billings, U. S. A, in charge of the National Medical Library in Washington. CONTENTS. BSPSRIGERS FOF FGG2 «10 Vic a! yo) ey she, ey fee's 4G at se) y's! lege eG FIONORAR VE BELLOWS Palstiohi ef voi itetbat ceitweMt st 0) ch tems) var st) oMiNerL omar: FELLOWS... . oiehioh cou Wertegteans Minutes of the ee at the Seventh (a Mecting sees et LS Papers read at the Seventh Annual Meeting. . 2 Annual Address : A New Method of Exploration, wath the pahaloey andl Treatment of Certain Lesions of the Female Urethra. By the Presi- CE SWAG TIED TMA SRSI ET AP HRI OD SE Onto bn ook 8G Be 7 The Proper Use of Ergot in Obstetrics. oseph Taber Fohnson, M.D. . 58 The Ovarian Cell; Its Origin and Characteristics. Thomas M. Drysdale, A. M.,, M.D. Saleen ce 81 Some Remarks on eee mi peecil Reece to a eanment of the Pedicle. &. Stansbury Sutton, M.D... . . - 119 Leucorrhea Considered in Relation to its Gorsnanecal Causes and Treat- MOCNE. eOT ACERT REY, IAs Day Polen Lama iol ie 6) ioe ees ye, + vet ISE Care of the Perineum. Theophilus Parvin, M.D. . . 5 - 145 The Relative Value of Hysterectomy and of the Complete Gao it ie Uterine Appendages for the Cure of Uterine Fibroids. $ Avnowsley Thornton, M.B.C.M... . - . 158 Electricity in Extra-uterine peace eis ¥ Cipriani Pr M, M. D. 184 The History of Twenty-one Cases of Extra-uterine Pregnancy coming under the Personal Observation of the Writer. 7. Gadllard T, oe HST OPS Mee . 219 The Influence of the Caner ie a High: Becta beceneh Shes ate the Health and Form of the Female, and upon the Relation of the Pelvic Organs. Samuel C. Busey, M.D. ... . Bele: Mechanical Therapeutics of Versions and Flexions of the eran: Ely Van De Warker, M.D. . . - 267 A New Method of Operation for the Relief of ‘Ratone of ie Beenie through the Sphincter and Rectum. ¥ Collins Warren, M.D. «. . 322 Measurements of the Uterine Cavity in Childbed, Fourth and Fifth Series of One Hundred and Eight Cases Each. William L. Richardson, HWE IO ho BeBe reo io 62h Surgical Gpeatens on the Pelvic Pneais © Bei Women: ae De Manny ME Dive) oo) 0) 0), ek aie ie ahey 0 evs) 0) 8) 0. 0s: 340 viii CONTENTS. Hyperemia of the Vesico-urethral Membrane. W. H. Baker, M.D. . » 382 A Memoir of Prof. James Platt White. Z. Gaillard Thomas, M. D.. .« 405 Index to Volume VII. . . .. o4a ES Index of the Gynecological and Obstetrical Lieaenre of all Coumuaes for the year SBE 10's vei erm eter on Oo wtf, Index of Obstetric and Gneesioste ioe a) ee cies si Se ne Rg Index of Obstetric and Gynecological Societies . . « « «+ + « « « 420 OFFICERS AND FELLOWS OF THE mMERICAN GYNECOLOGICAL ‘SOCIETY. 1882. VOL. VII. I OFFICERS FOR 1882. (Elected September 23, 1881.) —_—_—— PRESIDENT. THOMAS ADDIS EMMET, or New York. VICE-PRESIDENTS, GEORGE H. LYMAN, or Boston. EMIL NOEGGERATH, or New York. 4 SECRETARY, JAMES R. CHADWICK, or Boston. TREASURER. PAUL F. MUNDE, or New York. COUNCIL. HENRY J. GARRIGUES, or NEw York. JAMES D. TRASK, oF Astoria, N. Y. GEORGE H. BIXBY, of Boston. GEORGE J. ENGELMANN, or St. Louts, Mo. ELECTED. 1877. 1876. 1878. 1877. 1878. 1876. 1881. 1876. 1876. 1877. 1876. 1876. 1880. 1882. 1881. 1883. 1876. 1881. 1876. HONORARY FELLOWS. * DECEASED. JOHN L. ATLEE, M. D., Lancaster, Penn. U..S)\A: ROBERT BARNES, M. D., London, England. JOHN S. BILLINGS, M. D., U. S. Army, Washington, D. C. JOHN C.. DALTON, M.D: New, York,(U.S) 7A; J. MATTHEWS DUNCAN, M. D., London, England. JOSEPH A. EVE, M. D., Augusta, Georgia, U. S. A. J. BRAXTON HICKS, M. D., London, England. THOMAS KEITH, M. D., Edinburgh, Scotland. *ALFRED H. McCLINTOCK, M. D., Dublin, Ireland. CHARLES, PAJOT, M. 1; Paris, France. KARL SCHROEDER, M. D., Berlin, Germany. *GUSTAV SIMON, M. D., Heidelberg, Germany. D. HUMPHREYS STORER, M. D., Boston, Mass., U.S. A. LAWSON TAIT, EsqQ., Birmingham, England. S. TARNIER, M. D., Paris, France. J. KNOWSLEY THORNTON, Esgq., London, England. T. SPENCER WELLS, Esq., London, England. F. WINCKEL, M. D., Dresden, Germany. *MARMADUKE B. WRIGHT, M. D., Cincinnati, Ohio, U. Sua. Total, 16 Honorary Fellows. FELLOWS. * DECEASED. Founder. —* ATLEE, WASHINGTON L., M. D. 1882. — Baker, WiLLIAM H., M. D., Assistant Professor of Gynecology, Harvard University. Surgeon to the Free Hospital for Women. 10 Beacon Street, Boston, Mass. Founder. — BARKER, Forpycr, M. D., LL. D. Professor of Clinical Midwifery and Diseases of Women, Bellevue Hospital Medical College ; Consulting Physician to Bellevue Hospital, etc. President, 1876-77. 24 East Thirty-eighth Street, New York. founder. — BaTTEY, Rosert, M. D. Formerly Professor of Obstetrics, and Clinical Professor of Gynecological Surgery, At- lanta Medical College. Vice-President, 1880. 36 Broad Street, Rome, Georgia. founder. — Brxpy, GEORGE H., M.D. Surgeon to St. Eliza- beth’s Hospital for Women ; Physician to the Out-patient Depart- ment for the Diseases of Women, Boston City Hospital. Councz?, 1882. 143 Boylston Street, Boston, Mass. 1878. — BozEMAN, NatHan, M. D. Surgeon to the Woman’s Hospital of the State of New York. 296 Fifth Avenue, New York. 1881. — Browne, B. B. Professor of Diseases of Women in the Woman’s Medical College of Baltimore, and Gynecologist to the Woman’s and Child’s Hospital of Baltimore. 307 Madison Avenue, Baltimore, Md. founder. —* BUCKINGHAM, CHARLES E., M. D. founder. — Busty, SAMUEL C., M. D. Professor of the The- ory and Practice of Medicine, University of Georgetown ; Physi- cian to the Children’s Hospital, and to the Louise Home; Con- sulting Physician to St. Anne’s Infant Asylum. 1525 I Street, Washington, D. C. 6 FELLOWS. Founder, — BYFORD, WiLLt1AM H., M.D. Professor of Gyne- cology, Rush Medical College. Vice-President, 1876-77. Council, 1878. President, 1881. 125 State Street, Chicago, Ill. Founder. — ByRNnzE, JOHN, M. D., M. R. C. S. E. Formerly Clinical Professor of Uterine Surgery, Long Island College Hos- pital; Surgeon-in-chief to St. Mary’s Hospital for Diseases of Women. Council, 1879, 1883. 314 Clinton Street, Brooklyn, N. Y. Founder. — CAMPBELL, HENry F., A. M., M. D. Professor of Principles and Practice of. Surgery an of Coie University of Georgia; Surgeon to the City Hospital, Augusta. Vice-Prest- dent, 1881. Council, 1883. 715 Broad Street, Augusta, Georgia. Founder. — CHADWICK, JAMES R., M. A., M. D. Clinical In- structor in Gynecology, Harvard University. Secretary, 1876-82. 270 Clarendon Street, Boston, Mass. Founder. — DRYSDALE, THoMAS M., A. M., M. D. 1531 Arch Street, Philadelphia, Penn. 1879. — DuER, Epwarp L., M. D. Lecturer on Diseases of Women and Children at the Philadelphia Hospital ; Gynecologist to the Presbyterian Hospital. 1704 Arch Street, Philadelphia, Penn. 1877.— DuNLAP, ALEXANDER, A. M., M. D. Professor of the Surgical Diseases of Women, Starling Medical College, Colum- bus, Ohio. 22 East High Street, Springfield, Ohio. Founder. — EMMETT, THomas Apopis, LL. D.,M. D. Surgeon to the Woman’s Hospital of the State of New York; Consulting Physician to the Roosevelt Hospital, N. Y., and to the New York Foundling Asylum. Council, 1878-79. President, 1882. 87 Mad- ison Avenue, New York. Founder, — ENGELMANN, GEorGE J., M. D. Professor of Ob- stetrics, Post:Graduate School, Missouri Medical College ; Con- sulting Physician to the Female Hospital, and to the St. Anne’s Lying-in Asylum. Council, 1879, 1882. 3003 Locust Street, St. Louis, Mo. 1881.— Foster, FRANK P., M. D. Physician for Diseases of Women to the Out-patient Department of the New York Hos- pital. Secretary, 1883. 32 East Thirty-first Street, New York. 1877. — GARRIGUES, Henry J., A. M., M. D. Obstetric Sur- geon to the New York Maternity Hospital ; Physician to the Gyne- cological Department of the German Dispensary of the City of New York, Council, 1882. 137 West Twenty-second Street, New York. FELLOWS. o) 1881.— GILLETTE, WALTER R., M. D. Consulting Gynecolo- gist to the Charity Hospital ; Physician to the New York Lying-in . Asylum ; Obstetric Surgeon to the Maternity Hospital; Gyne- cologist to St. Francis Hospital, and Visiting Physician to the Bellevue Hospital. 149 West Twenty-third Street, New York. Founder. — GOODELL, WiLLiaM, A. M., M. D. Professor of Clinical Gynecology, University of Pennsylvania ; Physician-in- charge of the Preston Retreat. Council, 1876-77, 1880. Vice- President, 1878. 500 North Twentieth Street, Philadelphia, Penn. 1877. —GoopMaNn, JoHn, M. D. Professor of Obstetrics, Louisville Medical College. 236 Third Street, Louisville, Ky. founder. — Howarp, WituiaM T., M. D. Professor of the Diseases of Women and Children, and of Clinical Medicine, University of Maryland ; Gynecologist to the University Hos- pital; Gynecologist to the Woman’s Hospital of the State of Maryland; Consulting Physician to the Hebrew Hospital and Asylum Association of Baltimore, Maryland. Vice-President, 1880. Council, 1883. 181 Madison Avenue, Baltimore, Md. Founder. — INGHAM, JAMES V., M. D. Obstetrician to the State Hospital for Women and Infants. 1342 Spruce Street, Philadelphia, Penn. 1877. — Jackson, A. Reeves, A. M., M. D. Professor of the Diseases of Women and of Clinical Gynecology, College of Phy- sicians and Surgeons of Chicago ; Formerly Surgeon-in-chief of the Woman’s Hospital of the State of Illinois ; Consulting Sur- geon to the Dispensary of the Woman’s Christian Association ; Chief of the Gynecological Department of the West-Side Dis- pensary. Council, 1883. 271 Michigan Avenue, Chicago. Founder. — JENKS, Epwarp W., M. D., LL. D. Professor of the Medical and Surgical Diseases of Women and of Clinical Gynecology, Chicago Medical College; Gynecologist to the Mercy Hospital. 170 State Street, Chicago, IIl. Founder. — JouNSON, J. Taper, A. M., M. D. Professor of Obstetrics and of the Diseases of Women and Infants, Univer- sity of Georgetown ; Gynecologist to the Providence Hospital. Council, 1881. 926 Faragut Square, corner K and 17th Streets Washington, D. C. | _1877. — Kimpati, Gitman, M. D. Formerly Professor of Sur- gery in the Berkshire Medical Institution, and in the Vermont Medical College ; Formerly Surgeon to the Lowell Hospital, Lowell, Mass. President, 1883. 8 FELLOWS. 1881. — LEE, CHARLES CarROLL, A. M., M. D. Consulting Surgeon to Charity Hospital ; Surgeon to the Woman’s Hospital of the State of New York; Physician to the New York Found- ling Asylum. 79 Madison Avenue, New York. Founder, — Lusk, Witu1aM T., M. D. Professor of Obstet- rics and of the Diseases of Women and Children, and of Clin- ical Midwifery, Bellevue Hospital Medical College ; Physician to Bellevue Hospital; Obstetric Surgeon to the Maternity Hos- pital ; Visiting Physician to Emergency Lying-in Hospital. 47 East Thirty-fourth Street, New York. Founder. — LYMAN, GEoRGE H., M. D. Physician to the Bos- ton City Hospital. Council, 1876-77, 1881. Vice-President, 1882. 131 Boylston Street, Boston, Mass. 1882.— Mann, Mattuew D., A. M., M. D. Professor of Ob- stetrics. and Gynecology, ee of Budfal ¢ ; Gynecologist and Consulting Obstetrician to the Buffalo Geaena) Hospital. 610 Main Street, Buffalo, N. Y. Founder. —Munvdk, Paut F., M.D. Professor of Gynecology, Dartmouth Medical College ; Clinical Lecturer on Gynecology, College of Physicians and Surgeons ; Obstetric Surgeon to the Maternity Hospital ; Physician to the Out-door Department for the Diseases of Women, Mount Sinai Hospital. Z7zeasurer, 1876-83. 20 West Forty-fifth Street, New York. Founder. — NoEGGERATH, Emit, M. D. Formerly Professor of Obstetrics and of the Diseases of Women, New York Medical College ; late Surgeon to the Woman’s Hospital of the State of New York ; Gynecologist to the Mount Sinai Hospital ; Physi- cian to the Female Department of the German Hospital ; Con- sulting Surgeon to St. Mary’s Hospital for Women. Vice-Presi- dent, i882. 42 West Thirty-fifth Street, New York. 1880. — PALMER, C. D., M. D. Professor of the Medical and Surgical Diseases of Women and Clinical Gynecology in the Medical College of Ohio. 308 West Seventh Street Cincinnati, Ohio. Founder. — Parvin, THEOPHILUS, M. D., LL.D. Professor of Obstetrics and Diseases of Women in the University of Louis- ville. Council, 1876-77. Vice-President, 1883. 143 North Ala- bama Street, Indianapolis, Ind. founder, — *PEASLEE, E. RANDOLPH, M. D., LL. D. founder. — PENROSE, RicHarpD A. F., A. M., M. D., LL. D. Professor of Obstetrics and of the Diseases of Women and Chil- FELLOWS. 9 dren, University of Pennsylvania ; Consulting Obstetrician to the State Hospital for Women and Infants ; Visiting Physician to the Preston Retreat. 1331 Spruce Street, Philadelphia, Penn. 1881. — PoLkK, WiLt1am: M., M. D. Professor of Obstetrics and Diseases of Women and Children, University of the City of New York ; Physician to Bellevue Hospital, and to the Emergency Lying-in Hospital. 13 East Thirty-fourth Street, New York. 1877.— ReaMy, THappeEus A., A. M., M. D. Professor of Obstetrics, Clinical Midwifery, and of the Diseases of Children, Medical College of Ohio ; Gynecologist to the Good Samaritan Hospital. Vice-President, 1881. 252 West Fourth Street, Cincin- nati, Ohio. Founder. — REEVE, JOHN C., M. D. President of the Medical Staff of St. Elizabeth’s Hospital ; Formerly Professor of Materia Medica and Therapeutics, Medical College of Ohio. Councit, 1881. Corner of Third and Wilkinson Streets, Dayton, Ohio. 1877. — REYNOLDS, JoHN P., M. D. Professor of Obstetrics, Harvard University ; Consulting Surgeon to the Boston City Hos- pital. 236 Clarendon Street, Boston, Mass. Founder. — RICHARDSON, WILLIAM L., M. D. Assistant Pro- fessor of Obstetrics, Harvard University ; Physician to the Bos- ton Lying-in Hospital, and to Out-patients, Massachusetts Gen- eral Hospital. 76 Boylston Street, Boston, Mass. 1881. — SAWYER, EDWARD WARREN, A. M., M. D. Lecturer on Obstetrics, Rush Medical College; Surgeon to the Woman’s Hospital of the State of Illinois ; Medical Inspector of the South Division of the City of Chicago. Vincennes Avenue, Chicago, Ill. 1879. — Scott, Joun, M. D., F. R.C. 8. I. “Late Physician to the Black Town Lying-in Hospital, Madras, British India ; Sur- geon-in-chief of the California State Woman’s Hospital. 729 Sutter Street, San Francisco, Cal. founder. — Sims, J. Marton, M. D. Council, 1876-77. Presi- dent, 1880. Formerly Surgeon to the Woman’s Hospital of the State of New York. 267 Madison Avenue, New York. Founder,— tSINCLAIR, ALEXANDER D., M. D. Founder. — SKENE, ALEXANDER J. C., M. D. Professor of the Medical and Surgical Diseases of Women, Long Island College Hospital. Council, 1878, 1880, 167 Clinton Street, Brooklyn, Ns Y: ¢ Resigned, 1882. fe) FELLOWS. Founder. — SmitH, ALBERT H., M. D. Lecturer on Obstet- rics to the Philadelphia Lying-in Charity ; Consulting Surgeon to the Women’s Hospital ; Consulting Accoucheur to the Preston Retreat ; Consulting Physician to the Hospital of the Good Shepherd, Radnor. Council, 1879, 1881. Vice-President, 1883. 141g Walnut Street, Philadelphia, Penn. Founder. — STORER, D. Humpureys, M. D. Vice-President, 1879. 182 Boylston Street, Boston, Mass. 1879. — SutTTon, R. Stanspury, A. M., M. D. Lecturer on Diseases of Women, Rush Medical College, Chicago. 11g Penn Avenue, Pittsburg, Penn. Founder. —'Tayior, Isaac E., M. D. President and Emeritus Professor of Obstetrics and of the Diseases of Women and Chil- | dren, Bellevue Hospital Medical College ; Physician to the Ma- ternity Hospital; Consulting Physician to Bellevue Hospital, Charity Hospital, Woman’s Hospital of the State of New York, Women’s Medical Hospital of New York, etc. Vice-President, 1878. 7 East Thirty-sixth Street, New York. Founder. — Tuomas, T. GaILLarD, M.D. Emeritus Professor of Obstetrics and of the Diseases of Women and Children, Col- lege of Physicians and Surgeons ; Surgeon to the Woman’s Hos- pital of the State of New York ; Consulting Physician to the Nursery and Child’s Hospital, New York, and to St. Mary’s Hospital, Brooklyn, N. Y. President, 1879. 294 Fifth Avenue, New York. Founder. — Trask, James D., M. D. Formerly Professor of Obstetrics and of the Diseases of Women and Children, Long Isl- and Hospital Medical College. Council, 1882. Remsen Street, Astoria, N. Y. 1879. — UNDERHILL, J. W., M. D. Formerly Professor of Ob- stetrics, Cincinnati College ef Medicine and Surgery. 418 Jone Street, Cincinnati, Ohio. Founder. —VaN DE WARKER, Ety, M. D. Professor of Ar- tistic Anatomy, University of Syracuse, N. Y. 45 Montgomery Street, Syracuse, N. Y. Founder, — WALLACE, ELLERSLIE, M. D. Professor of Obstet- rics and of the Diseases of Women and Children, Jefferson Med- ical College ; Consulting Physician to the Preston Retreat, and to St. Christopher’s Hospital for Children. 1130 Spruce Street, Philadelphia, Penn. + Elected Honorary Fellow in 1880. FELLOWS. It founder, —*Wuite, JAMEs P., M. D. 1877. — WiLson, ELLwoop, M. D. Consulting Physician to the Philadelphia Lying-in Charity, to the Woman’s Hospital, and to the Preston Retreat. 212 South Fifteenth Street, Philadel- phia, Penn. Founder. — WILSON, Henry P.C., M. D. Gynecologist to the Union Protestant Infirmary and to St. Vincent’s Hospital ; Con- sulting Physician to St. Agnes’ Hospital and to the Baltimore General Dispensary. Vice-President, 1879. 146 Park. Avenue, Baltimore, Md. Total, 55. et ere : MINUTES OF THE PROCEEDINGS AT THE SEVENTH ANNUAL MEETING OF THE AMERICAN GYNECOLOGICAL SOCIETY, HELD IN THE HALL OF THE BOSTON SOCIETY OF NATURAL HISTORY, Boston, Mass., On SEPTEMBER 2oth, 21st, and 22d, 1882. \ cH Hh, yi mI SEVENTH ANNUAL MEETING. WEDNESDAY, September 20, 1882. Morning Session. The meeting was called to order by the President, Dr. Thomas Addis Emmet, of New York, at ro A. M. The following Fellows were present : — FORDYCE BARKER G. H. BIXBY ~ B. B: BROWNE . SG. BUSEY’! JOHN BYRNE H. F. CAMPBELL . J. R. CHADWICK T. M. DRYSDALE. T. A. EMMET . G. J. ENGELMANN BP. POSTER I”. H. J. GARRIGUES WILLIAM GOODELL W. T. HOWARD A. R. JACKSON J. T. JOHNSON . GILMAN KIMBALL. Gy > TEE nt we. Ho LYMAN... . Pp. F. MUNDE. THEOPHILUS PARVIN . ‘ J. P. REYNOLDS . W. L. RICHARDSON A. J. C. SKENE A. H. SMITH T. G. THOMAS J. D. TRASK E. VAN DE WARKER H. P. C. WILSON Total, 29 Fellows. . NEw York. Boston, Mass. BALTIMORE, Md. WASHINGTON, D. C. BROOKLYN, N. Y. AUGUSTA, Ga. Boston, Mass. PHILADELPHIA, Penn. New York. St. Louts, Mo. NEw YorK. NEW York. PHILADELPHIA, Penn. BALTIMORE, Md. Cuicaco, Ill. WASHINGTON, D. C. LOWELL, Mass. NEw YorRK, Boston, Mass. NEw YorK. INDIANAPOLIS, Ind. Boston, Mass. Boston, Mass. BROOKLYN, N. Y. PHILADELPHIA, Penn. NEw York. Astoria, N. Y. SYRACUSE, N. Y. BALTIMORE, Md. 16 SEVENTH ANNUAL MEETING. After a few cordial words of greeting the President called for the address of welcome upon George H. Lyman, M. D., who responded as follows : — FELLOWS OF THE GYNECOLOGICAL SOCIETY: Owing to the ill- ness of our honored friend, Dr. Storer, the duty devolves upon me of welcoming you to this, your second meeting in Boston. A formal greeting to you as a Society is so much a mere mat- ter of routine that I shall beg you to take it for granted, and al- low me to do that which is much more congenial to me and to all - of your professional brethren of this city, and that is, to assure you, individually, that we are heartily glad to meet you, and that we hope to make your sojourn so pleasant that you will not hesi- tate to come again. Our Society, wisely, as I think, has a twofold design: scientific and social. Its prime object, of course, is to stimulate careful observation, and by free discussion and generous criticism to sift cautiously from the constantly accumulating experience of its members that which may be of lasting value, — something, at least, each year which shall tend to advance scientific medical and surgical treatment, — the secondary and subordinate object being to bring together at stated periods those who, though widely separated, are engaged in similar pursuits, that they may be stimulated and strengthened by the consciousness of that sym- pathy and personal good-will which can only come from direct so- cial fellowship. Boston, as you may perhaps have heard, claims an historic reputation for gatherings of all kinds, from the time of that turbu- lent salt-water tea-party of December, 1773, when “the Boston tea-pot bubbled,” down through all the varieties, military, polit- ical, theological, and medical, all disagreeing with more or less of bitterness about many things, but always harmonizing at the last in a good dinner at the Music Hall. Tea-parties with Attic salt are not yet wholly obsolete ; they can still be found for those who like that kind of diluted refreshment ; for others, differently inclined, I have no doubt that opportunities will be furnished to test our old 4/uve laws without restraint during the intervals which must occur between our more serious occupation. You may at any rate rely upon a cordial reception, and you are entirely at liberty to carry away with you from this city of notions any little bric-a-brac, philosophical, literary, or scientific, which you may SEVENTH ANNUAL MEETING. 17 fancy. Harvard College and the Medical and Technological Schools, over the way, are open to the world and ready to fur- nish anything which you have the capacity to digest, from a lec- ture on food for infants to a solution of the differential calculus, which last would, I am sure, puzzle even Dr. Bigelow’s latest stone breaker. Our chief object is, however, to listen to and discuss each other’s professional experiences, observations, it may be discov- eries, since our last meeting. A year’s added experience is no small measure of our professional life, and it will be strange in- deed if this accumulated observation of so many active profes- sional men, .coming from widely separated States of the Union, some, indeed, from across the Atlantic, should not be fruitful in resulting good to the communities in which we live and move and have our raison d’étre, by adding something to the science and art which we profess. The range surely is wide enough. Gynecology, in our inter- pretation of its meaning, is no narrow specialism ; it embraces all those general and constitutional relations without an intimate knowledge and practical experience of which no treatment, med- ical or surgical, can be successful. Anatomy, physiology, psychology, and pathology are necessary prerequisites to anything but a purely routine local treatment, which is the starting point of all quackery. From procreation to parturition, from puberty to the menopause, the adviser needs these and all the other helps which our still imperfect science and art can furnish in order properly to appreciate the innumer- able functional and organic changes inseparable from the female organism. This being true, you will pardon me if I presume to ask whether there be not danger in the prevailing tendency to minute sub- divisions of our professional work. If so, the influence of this Society, whose members are supposed to be practical men, should surely be in the direction of a sound conservatism. That this annual meeting may be as successful in awakening general scientific interest as its predecessors have been is all that we can reasonably ask for; and in the name of the profession I bid you a hearty welcome to the work laid out for you as well as to the hospitalities which it may be your pleasure to accept. The President announced that no gentleman could be nom- VOL. VII, 2 18 SEVENTH ANNUAL MEETING. inated as guest except by the Council. The following gentlemen were then, on nomination by the Council, invited by vote to participate in the discussions during the sessions of the Society : J. Knowsley Thornton, Esq., of London, England; Dr. E. C. Gehrung, of St. Louis, Mo. ; Dr. M. D. Mann, of Buffalo, N. Y. ; Dr Pei Ingalis..at Beigel Conn. ; Dr. S. Cooper, of West- field, N..J.3 Dr. BF.) E. Stewart, of Bhdadeieiael Dr. R. T. Wil- son, of Baltimore, Md.; Dr. J. T. Whittaker, of Cincinnati, Ohio ; Dr. W. E. Moseley, of. Baltimore, Md.; Drs. H. Marion-Sims and E. H. Grandin, of New York; Dr. W. S. Brown, of Stone- ham, Mass. ; Drs. L. Wheeler and G. E. Francis, of Worcester, Mass.; Drs. L. S. Fox and W. T. Carolin, of Lowell, Mass. ; Drs. F. H. Hooper and A. N. Pierce, of New Bedford, Mass. ; Dr. G. E. Porter, of Providence, R. I. ; Dr. Charles Jewett, of Brooklyn, N. Y.; His Honor, the eee of Boston, Dr. S. A. Green,’ Drs. Hi: i Bigelow, O. W. Holmes, H. I. Bowditch, C. Ellis, G. C. Shattuck, G. B. Shattuck, J. C. White, J. C. Warren, H. W. Williams, R. M. Hodges, R. H. Fitz, J. Homans, F. I. Knight, B. Cushing, H. C. Haven, C. F. Withington, and the members of the Obstetrical Society of Boston, Drs. S. L. Abbott, G. J. Arnold, W. H. Baker, J. G. Blake, W. E.. Boardman, F. H. Brown, H. Curtis, O. W. Doe, F. W. Draper, P. O’M. Edson, W. C. B. Fifield, E. J. Foster, R. L. Hodgdon, C. D. Homans, A. Hos- mer, W. Ingalls, F. Minot, A. D. Sinclair, C. E. Stedman, J. Sted- man, C. W. Swan, W. W. Wellington, and B. E. Cotting. ra President called for papers on — “The Proper Use of Ergot in Obstetrics,” by Dr. Joseph Taber Johnson. Discussion by Drs. Reynolds, Barker, Emmet, Howard, Trask, Engelmann, and Johnson. 2. “Some Remarks on the Treatment of the Pedicle in Ovari- otomy,” by Dr. R. S. Sutton, which in the absence of the author was read by the Secretary. Discussion by Mr. Thornton, of London, England, and Drs. H. P. C. Wilson, Lyman, Emmet, and Kimball. The President appointed as Auditing Committee Drs. H. P. C. Wilson and J. D. Trask. Adjourned at 1 P. M. Afternoon Session at 3 P.M. The President in the chair. 3. “The Care of the Perineum in the Second Stage of Labor,” by Dr. T. Parvin. SEVENTH ANNUAL MEETING. 19 * Discussion by Drs. Smith, Mann, of Buffalo, Chadwick, How- ard, Mundé, and Parvin. 4. “Leucorrhea: Its Constitutional Causes and Therapeutics,” by Dr. Fordyce Barker. Discussion by Drs. Lyman, H. P. C, Wilson, Jackson, Johnson, Smith, Emmet, and Barker. Adjourned at 5 P. M. TuHurspay, September 21. Morning Session at 10 A. M. President Dr. Emmet in the chair. s. “ The Relative Value of Hysterectomy and of the Complete Removal of the Uterine Appendages for the Cure of Uterine Fi- broids,” by J. Knowsley Thornton, M. B., C. M., of London, Eng. Discussion by Drs. Goodell, Thomas, Kimball, Engelmann, and Mr. Thornton. 6. “A New Method of Exploration, with the Pathology and Treatment of Certain Lesions of the Female Urethra.” Annual Address by the President, Dr. T. A. Emmet. Discussion by Drs. Barker, Skene, Lee, and Emmet. Adjourned at I P.M. Afternoon Session at 3 P. M. Vice-President Dr. Lyman in the chair. 7. “ Notes of Twenty-two Cases of Extra-uterine Pregnancy,” by Dr. T. G. Thomas. 8. “ Electricity in Extra-uterine Pregnancy,” by Dr. H. J. Gar- rigues. Discussion of the two papers by Drs. Campbell, H. P. C. Wil- son, Goodell, Smith, Howard, and Mr. Thornton. Business Meeting at the Medical Library at 8.30 Pp. m. with closed doors. The President in the chair. Twenty-eight Fellows present. The Report of the Treasurer, with the affidavit of the Audit- ing Committee, was submitted and accepted. The following Amendments to the By-Laws, presented at the last meeting, were adopted : — 1. That the first Paragraph of Article IX. be so amended as to read, “ Every Fellow shall pay in advance the sum of twenty-five dollars annually.” 2. That the following paragraphs be added to Article IX. : — 20 SEVENTH ANNUAL MEETING. “Each Fellow shall pay on admission an initiation fee of twenty-five dollars.” “ Any Fellow who shall neither attend nor present a paper for three successive years shall, unless he offers an excuse satisfac- tory to the Society, be dropped from Fellowship.” The Secretary, in behalf of the Council, presented a list of names in nomination for Fellowship, of whom the following were elected by ballot : — To be Honorary Fellows, J. KNowsLtey THornNTON, Esq., of London, England; and Lawson Tait, Esq., of Birmingham, England. To be Fellows :— Dr. M. D. Mann, of Buffalo, N. Y. Paper : “ Surgical Opera- tions on the Pelvic Organs of Pregnant Women.” | Dr. W. H. Baker, of Boston, Mass. Paper: “ Hyperemia of the Vesico-utrehral Membrane.” A letter from Messrs. H. C. Lea’s Son & Co., Publishers, and a letter from Dr. H. R. Bigelow, of Washington, were read, request- ing the Society to appoint an editor of the projected “ System of Gynecology,” and to continue the project underits auspices. The proposition was laid on the table. At the suggestion of the new publishers of the “Transactions,” Messrs. H. C. Lea’s Son & Co., it was voted that the Secretary and Treasurer have authority to insure the volumes in stock, and that the publishers have authority to buy such copies of Vol. II. of the “Transactions ” as come into the market. The resignation from Fellowship of Dr. A. D. Sinclair, of Bos- ton, was read and accepted. It was voted that the Publishing Committee have authority to sell the electrotype plates of Vols. I., III., IV., V., and VL., if it deems best to do so. The Election of Officers for 1883, by open ballot, resulted as follows : — eat President, GILMAN KIMBALL, of Lowell, Mass. Vice-Presidents, A. H. Situ, of Philadelphia, Penn.; THE- OPHILUS PaRVIN, of Indianapolis, Ind. Secretary, FRANK P. Foster, of New York. Treasurer, PAUL F. Munp&, of New York. Other Members of the Council, JOHN ByRNE, of Brooklyn, N.Y. ; W. T. Howarp, of Baltimore Md.; A. R. Jackson, of Chicago, Ill. ; H. F. Camppett, of Augusta, Ga. SEVENTH ANNUAL MEETING. 21 It was voted that the sympathy of the Society be communi- cated to Dr. D. Humphreys Storer, Honorary Fellow, in view of the illness which prevents his attendance upon the meeting of the Society. Dr. H. J. Garrigues was appointed to act with the Secretary as the Publishing Committee, with full power to draw upon the Treasurer for such sums as may be needed to publish the seventh volume of the “Transactions.” It was voted that Dr. G. J. Engelmann have the privilege of purchasing, and using as he sees fit, the plates of his paper, en- titled “‘ Posture in Labor,” published in Vol. V. of the “Transac- tions.” It was voted that the President and Secretary address an offi- cial communication to Congress urging (1) that of the two copy- right volumes that now go to the National Library, one copy of all medical books be deposited in the Library of the Surgeon-gen- eral’s Office ; (2) that the application for a fire-proof building for the conjoint accommodation of the Army Medical Museum and the Library of the Surgeon-general’s Office be granted ; (3) that the proposition to transfer the Library of the Surgeon-general's Office to the building to be provided for the National Library is unadvisable ; (4) that this Society approve in the most emphatic terms of the present management of the Library of the Surgeon- general’s Office, and deem that its continued prosperity and the interest of the medical profession of the country will be insured by its remaining under its present management. The Committee appointed at the last meeting of the Society, to advise with the Editors in regard to the publication of the “Transactions” of the Society, reported : — That at the time of the appointment of said Committee the printing of the “Transactions” was already under way in the hands of Houghton, Mifflin & Co., the former publishers. That upon advisement it was considered best to place the publi- cation and sale of the “ Transactions ” in the hands of some house which had greater facilities for increasing the sale and distribu- tion of the volume, and as Messrs. H.C. Lea’s Son & Co. offered to publish upon the same terms as the former publishers, with in- creased facilities for advertisement and sale, the “ Transactions ” were placed in their hands for publication after they had been printed by the Riverside Press. The result of this change has already been detailed by the Treasurer. 22 SEVENTH ANNUAL MEETING. We would advise that in future the printing also be put into different hands. ALBERT H. SMITH, T. GaILLARD THOMAS, Committee. Pau. F. Munpé. It was voted that the same firm be employed to print the next volume of the “ Transactions,” as heretofore. It was voted that the papers read at each annual meeting be handed to the Secretary. within two weeks after the adjournment of said meeting, and that none be accepted after that date. It was voted that the Society pay for the engraving of such il- lustrations as are suitable for insertion in the text, for which drawings accompany the manuscript. It was voted that authors be allowed ten days, in addition to the time required for transmissions by mail, for the correction and return of all proofs. It was voted that the stenographic report of the discussions be printed with a type-writer, and the transcript of each participant’s remarks be sent to him for correction ; that each participant be allowed to make only such changes as do not essentially modify or add to the context of what he actually expressed in the discus- s10n. The following Amendments to the Constitution were proposed for action at the next meeting : — “ That the following be substituted for the fourth clause of the third section: ‘All nominations for Fellowship shall be made to the Council by two Fellows one month before the first day of the meeting ; at that time a list of the candidates shall be sent to all the Fellows of the Society, and such as are recommended by the Council shall be balloted for at the annual business meeting of the Society.’ “That the fourth clause of the fourth section of the By-Laws be stricken out, and from the third section and fourth clause of the Constitution the words ‘on recommendation of the Council’ be stricken out, so that it shall read: ‘ Candidates shall be proposed to the Council one month before the first day of meeting by two Fellows, and shall be balloted for at the following annual meet- ing, a list having been sent to each Fellow, with the notification of the time of meeting.’ “That the second clause of the third section of the Constitu- SEVENTH ANNUAL MEETING. 23 tion be so amended as to read: ‘ The Fellows shall not exceed one hundred in number.’ ” It was voted to meet next in Philadelphia on the third Tuesday in September, 1882. Votes of thanks to the Boston Fellows, to the Boston Society of Natural History, to the Boston Medical Library Association, and to the Obstetrical Society of Boston, for their hospitality during the sessions of the Society, were passed unanimously. Adjourned at 11 P. M. Fripay, September 22. Morning Session at 10 A.M. ‘The President in the chair. The President appointed Dr. T. G. Thomas to prepare a me- moir of Dr. James P. White, deceased, of Buffalo, for insertion in the next volume of the “ Transactions.” The Publishing Committee was authorized by vote to appoint a bibliographer to prepare and edit, under the supervision of the Secretary, the “ Index of Gynecological and Obstetric Literature of all Countries,” published in each volume of the “ Transactions,” with an annual salary of two hundred dollars, who, if he be a Fel- low of the Society, is to have the title of Bibliographer. g. “The Influence of High-heeled French Shoes upon the Female Form, and upon the Relations of the Pelvic Organs,” by Dr. S. C. Busey. Discussion by Drs. Barker, Thomas, Mundé, and Busey. 10. “ The Ovarian Corpuscle: Its Origin and Characteristics,” by Dr. T. M. Drysdale. Discussion by Mr. Thornton, of London, Drs. Engelmann and Drysdale. Adjourned at 1 P. M. Afternoon Session at 3 P.M. The President in the chair. Mr. J. Knowsley Thornton, of London, England, Honorary Fel- low elect, was invited to take a seat on the platform. 11. “The Theory of the Mechanical Treatment of Flexions,” by Dr. E. Van de Warker. Discussion by Drs. Campbell, H. P. C. Wilson, Mundé, Lyman, and Van de Warker. Owing to the lateness of the hour, the following papers were read by title only : — 12. “ A New Operation for Ruptured Perineum,” by Dr. J. C. Warren, of Boston. 24 SEVENTH ANNUAL MEETING. 13. “ Measurements of the Uterine Cavity in Childbed,” by Dr. W. L. Richardson. The President-elect, Dr. Gilman Kimball, of Lowell, Mass., was then inducted into office. After a vote of thanks to the retiring officers, the Society ad- journed to meet in Philadelphia on the third Tuesday of Septem- ber, 1883. James R. CuHapwick, Secretary, PAPERS READ AT THE SEVENTH ANNUAL MEETING OF THE AMERICAN GYNECOLOGICAL SOCIETY, 6 HELD IN BOSTON, MASS., SEPTEMBER 20, 21, and 22, 1882. ANNUAL. ADDRESS OF THE PRESIDENT. A NEW METHOD OF EXPLORATION, WITH THE PATHOLOGY AND TREATMENT OF CERTAIN LESIONS OF THE FEMALE URETHRA. BY THOMAS ADDIS EMMET, M. D., New York. FeLttow Memsers, — As your President, it is expected that I should address you in some form of greeting. In do- ing so it would seem in keeping with a time-honored custom for the presiding officer to present, in an annual address, a digest of special medical progress. But with the existing facility for rapid transmission of medical events to every reading member of the profession, this is deemed no longer necessary. Yet were the observance the more called for, I should hesitate, after looking over the ‘‘ Transactions,” where it is made evident that at each meeting a large num- ber of papers have been read by title only and not dis- cussed. As arule, the discussion, if properly conducted, is of greater value than the paper itself, for it becomes the means of recording a more extended experience and of re- flecting the ideas of others from different stand-points. We have been heartily welcomed by our Boston friends, and we may well congratulate ourselves that this, our seventh meeting, bids as fair as any previous one to bring forth good fruit. The presence of all at any one meeting could scarcely be expected under the most favorable circumstances. But while we note with regret the absent, we should be thank- 28 ANNUAL ADDRESS OF THE PRESIDENT. ful that death has exacted from us but a single tribute since our last meeting. It isa sad duty incumbent on me to an- nounce officially the death of Dr. James P. White, of Buf- falo, N. Y. Dr. White was one of the founders of the Society, and has attended each meeting from the begin- ning, with the exception of the last, at which time his health had become already impaired. The volumes of ‘“ Transac- tions” contain several articles from his pen, and bear full witness to the interest he took in the discussions of almost every subject presented. He occupied too prominent.a position for his professional career to be summed up by me in a few words. It would be appropriate that some mem- ber, more familiar with his earlier professional course, should prepare a suitable memoir for our next volume of “Transactions.” Contrary to custom, but with the object to economize time, I shall postpone the presentation of all other matters pertaining to the business or welfare of the Society until we meet in executive session, where they will come up for discussion. And that you may be fittingly occupied during the time allotted for the usual annual address, I will offer as a substitute a more strictly professional subject. But I must crave your indulgence as to its length, for I have found it impossible to treat the matter in detail within the space I had first contemplated. A NEW METHOD OF EXPLORATION, WITH THE PATHOLOGY AND TREATMENT PERTAINING TO CERTAIN LESIONS OF THE FEMALE URETHRA. The general practitioner has yet gained but little accu- rate knowledge of the diseases connected with the female urethra. In fact, we may hold that the subject has re- mained to this day in as much obscurity, for the profession at large, as existed regarding uterine disease some forty years ago, and before the introduction of Sims’ speculum. Individuals have doubtless attained dexterity in the use of certain instruments, and have been fairly successful in the treatment; but the existence of a profound degree of igno- THOMAS ADDIS EMMET. 29 rance has been the rule, and consequently much damage has resulted from the frequent confusion of cause and effect. We could scarcely credit the fact that the bladder has been heroically treated for disease when the cause of irrita- tion has been due to a fissure of the anus. I have known of several instances where, with a pertinacity of purpose worthy of a better cause, the bladder has been injected with solutions of the nitrate of silver, week after week, until at length cystitis became established. Many of you, and I, have fruitlessly treated a supposed diseased condition of the bladder, or urethra, when the seat of irritation lay in an unsuspected inflammation about the folds of the utero-sacral ligaments. I have opened the bladder for supposed disease, by mak- ing a vesico-vaginal fistula, and have thus subjected the patient to months of annoyance from the escape of urine. Then, after a certain time, when by rest the disease had been removed, as I supposed, I have closed the opening, but with no relief to the patient. I have reopened the fis- tula, and have allowed the urine to escape freely for months longer, with the hope that the bladder might yet recover a healthy condition by a more prolonged rest, in the end to find that the cause of irritation lay in a urethral polypus, which the use of the endoscope, in the hands of an expert, had failed to discover. Several patients have been admitted to the Woman’s Hospital, that the fistula which had been made for the relief of a supposed cystitis might be closed, where the primary cause of irritation, at the neck of the bladder, had been due to a prolapse of the uterus from a want of support at the vaginal outlet. We now know that when the uterus settles below a certain point, or is carried above its natural posi- tion, so that traction is exerted in a direct line from the subpubic ligament, we have the symptoms attributed to irritation of the bladder. A moderate degree of inflammation in any portion of the connective tissue of the pelvis, but more especially in the 30 ANNUAL ADDRESS OF THE PRESIDENT. utero-sacral ligaments, or on either side of the vagina, in front of the broad ligament, will also cause much irritation, and a frequent desire to empty the bladder. We have growths in the urethra; thickening from in- flammation of its mucous and submucous tissues; the canal may be dilated from before backward, and with more or less prolapse of the mucous membrane along the urethra from the bladder ; its lining membrane may be diseased in part or throughout; or fissures may exist at the neck of the bladder; and we have had no efficient means to aid in forming a diagnosis. The true condition was likely to be overlooked entirely, and too frequently we have been misled, as I have stated, by reflex symptoms in locating the supposed disease in the uterus or in the ovaries. It will be unnecessary to consider the various means that have been proposed, from time to time, for examining the urethral tract, for they have all proved inadequate for the purpose and of little practical value, even in the hands of those most experienced in their use. It is now some six years since I first devised the plan of making a button-hole-like opening in the female urethra for the purpose of forming a SETS or for facilitating any operative procedure. In the first edition of my work on the “ Principles and Practice of Gynecology,” published in March, 1879, I sim- ply referred to the procedure as an advisable one, but did not feel myself justified in placing on record the experience which had been gained, even at that time. In the second edition the subject was entered into at greater length, but since, or during the past two years, I have given it very careful study. I have been told by my friends that I hold a fair reputa- tion with the profession for being reliable and moderate in my statements. With the greatest desire to ever maintain such a reputation, I do not hesitate to announce the fact that the method I shall describe is the only one within our knowledge to-day which fulfills every indication, is safe, simple, and within the scope of any one possessing the least degree of surgical dexterity. THOMAS ADDIS EMMET. 31 It is necessary to administer an anesthetic for the oper- ation and then place the patient on the left side, using a moderate size Sims’ speculum to bring into view the vaginal surface covering the urethral tract. An instrument has been devised by me for making an opening into the urethra. It is formed somewhat on the principle of the scissors used for cutting a button-hole, with the exception that the por- tion entering the urethra is made round and like the ex- tremity of a large-size uterine sound. The vaginal blade has a portion removed, as in the button-hole scissors, so as to begin the incision about a quarter of an inch from the urethral entrance, from which point the opening is to be extended, in the median line, nearly to the neck of the blad- der. This instrument answers the purpose, but has not yet been perfected to my satisfaction. When the knife or scissors is to be used, the execution of the operation will be greatly facilitated by first introducing into the urethra a block-tin sound, of a sufficient size to put the tissues within the canal somewhat on the stretch, The instrument may be given the same short curve em- ployed for entering the male bladder. Then, to dispense with the aid of an assistant, the curved portion should oc- cupy the urethra and pass for a short distance beyond into the bladder, while the staff is supported by resting on the lower thigh and between the legs of the patient, which are to be properly flexed. The operation is begun by catching up with a tenaculum the tissues on the vaginal surface, about midway between the mouth of the urethra and the neck of the bladder, and dividing them through to the sound. After thus entering the canal the incision is to be extended, witha pair of straight-pointed scissors, in the median line back- ward, towards the neck of the bladder, and forward to within a short distance of the mouth of the urethra. It is neces- sary to avoid dividing the urethral outlet, as it would then be more difficult to close the openingproperly at a future day. And it is still more important that the incision shall stop short of the neck of the bladder, without involving it, as the patient would then continue, after the operation, with 32 ANNUAL ADDRESS OF THE PRESIDENT. control over the escape of urine. I wish particularly to impress the importance of this precaution, not to extend the incision through the urethral surface too far backward. For if the consequences were no worse even than the tem- porary loss of control, this would prove a serious inconven- ience and an objection to the operation. ‘The line along the vaginal surface should be made nearly a third more in length than the one through the urethral mucous mem- brane, and it is important that the chief difference should be at the end of the line over the neck of the bladder. We thus gain, with the beveled angles, a great advantage for examining the urethral tract. Moreover, from the greater length of line being on the vaginal surface, we free the lower angle of the incision at the neck of the bladder, so that, if necessary, the finger, or a small speculum, can be passed into the vesical cavity with little fear of lacera- tion or loss of control. So long as the vaginal surface is intact, the parts about the neck of the bladder remain bound down and unyielding, from the direct connection of these tissues with the sub-pubic ligament and pelvic fascia. Hereafter it will be shown that it is just at this point, in front of the neck of the bladder, that injury by laceration is sustained when incontinence of urine follows dilatation of the urethra. Should we wish simply to make, by the operation, an ex- ploration of the canal, we can, after doing so, unite the line of incision without delay by bringing the recently divided edges in contact with interrupted silver sutures, as is done when closing a vesico-vaginal fistula. But to unite these properly the urethral edges must be turned out, by means of a tenaculum, that the sutures may be passed so as to include the mucous membrane and bring its divided edges in a close line of contact. To insure this the sutures are to be introduced at some distance from the edge and en- tirely through the flap down to the block-tin sound, then across and through the other side to correspond, thus bring- ing the sides firmly together. In this respect we do not follow the rule observed in closing a vesico-vaginal fistula, THOMAS ADDIS EMMET. 33 where the suture should only pass to the edge, without en- tering the bladder, through fear of establishing a sinus along its course for the escape of urine. But the condition is very different in the urethra, where the urine is only in the canal for a short time, in transit, and would necessarily escape easier through the natural outlet, with the certainty that each sinus would soon disappear by contraction, after removing the silver sutures. The after-treatment is simple. It consists in the patient remaining quiet in bed for a week, until the sutures have been removed, and in being careful for a few days longer. While in bed she should be allowed to empty the bladder at will, using the bed-pan when possible, and avoiding the passage of a catheter, except under the most urgent circum- stances. When it is desirable to leave the opening patulous, to fa- cilitate the after-treatment, we are to complete the opera- tion by uniting the edges of the divided urethral mucous membrane to the vaginal surface. This is done by means of interrupted sutures, and the best material for the purpose is properly prepared catgut, or a small silk ligature which has been thoroughly carbolized. As the mucous membrane of the urethra is free, with loose connective tissue beneath, it can be easily drawn out and brought in contact with the vaginal surface. By covering the raw edges in this manner, union soon takes place, and the parts are protected from the contact of urine. When these surfaces were left to heal by granulation, as was formerly the practice, the patient was subjected to much discomfort in consequence of the irrita- tion excited by the saline deposit left after evaporation of the urine which so frequently bathed the parts. It is also necessary to keep the patient quiet in bed after this operation, and from assuming the upright position, or the sutures would readily cut out, leaving the surfaces to heal by granulation, and with more or less shortening of the canal afterwards from contraction. This of course could not take place to any serious extent, as after a slough, yet could do so toa degree sufficient to make the subse- VOL. VII. 3 34 ANNUAL ADDRESS OF THE PRESIDENT. quent operation for closure the more difficult. Until union has taken place it is essential that the parts should be kept clean, and the swelling in check, by placing the patient on a bed-pan, and then allowing warm water to flow over the parts, several times a day. This may be done by the jet from a syringe, delivered without force, or by separating the labia with one hand, while the patient’s hips are ele- . vated on the bed-pan, so that a stream of water could fall upon the parts by compressing a saturated sponge. The surfaces should afterwards be carefully dried with a piece of soft linen, and kept smeared with Turner’s cerate or with that made from the impure carbonate of zinc. Its use not only aids in keeping the parts cool, but serves also as a pro- tection from the urine. In the application, the patient must be instructed to pass, by means of the index finger, a por- tion of this cerate into the button-hole-like opening before emptying the bladder, as the urine in its passage must nec- essarily escape from the urethra through this slit. Even after the parts have thoroughly healed, the continued use of the cerate is advisable, to protect the surfaces from excoria- tion. If, during the healing process, granulations should spring up at any point along the line of union formed by the edges of the two mucous membranes, it will be necessary to apply the solid stick of nitrate of silver to cicatrize the surfaces rapidly. Its free use can do no damage by caus- ing induration, even if it be extensively employed, for the whole line must be removed afterwards, when the edges are denuded, preparatory to closing the artificial opening. As arule, these cases require but little additional treat- ment after the edges have once healed. A vaginal injec- tion of several quarts of warm water, administered night and morning, is essential, and should be continued in use until the opening has been finally closed. These injections may be accepted as part of the routine treatment in every case, as it would be an exception to the rule not to find, at some point in the pelvis, cellulitis existing to a greater or less extent. We shall at least discover the product of some previous attack of inflammation, which may have been the THOMAS ADDIS EMMET. 35 original source of irritation, and may yet be an obstruc- tion to the circulation. Whenever the operation is done to relieve an existing inflammation in the urethral tract, or to improve nutrition in the surrounding tissues, rest to the parts and the simple revulsive effect attending the opera- tion, after dividing the tissues, will be sufficient, as a rule, to restore the parts to a healthy condition within the space of afew months. But if more should be required, in the way of local applications, they can be administered at any time, with the greatest facility, through this opening, and equally well to every portion of the urethral tract. In the last edition of my work on gynecology I classified in a general way the diseases of the urethra under the fol- lowing heads : — 1. Inflammation of the mucous membrane, or urethritis. 2. Pedunculated, vascular, and neuromatoid growths, 3. Prolapse of the mucous and sub-mucous tissues. 4. Fissures at the neck of the bladder. 5. Urethrocele. 6. Laceration of the urethra from dilatation. It is advisable that I should still adopt this classification, as the object of this paper is rather to supplement, by a record of additional experience, what I have already written, than to go again over the whole subject. The first section, that of urethritis or inflammation of the mucous membrane from any cause, may be dismissed almost without further consideration. Already sufficient has been advanced to show that the free division of the swollen tissues, as made in the operation for opening the urethra, would be beneficial And this opening would afford, in a serious case, the most efficient means for the application of the needed treatment directly to the seat of inflammation, thus arresting its progress not only in the canal but also its advance into the bladder. The second, treating of pedunculated, vascular, and neu- romatoid growths, has been considered at a greater length than any other division. I can only add, my more recent experience has but confirmed the opinion that no other 36 ANNUAL ADDRESS OF THE PRESIDENT. means gives the same facility for either diagnosis or treat- ment. Unless the operation had been resorted to in each individual case which has passed under observation, we should have remained in ignorance of both the seat and cause of irritation. The case of urethral polypus, to which I have already referred, would have demonstrated the neces- sity for the operation, even if we had no other instance. This patient was sent to the Woman’s Hospital by Dr. Foster Jenkins, of Yonkers, N. Y., and had suffered for sev- eral years while being treated for supposed inflammation of the bladder. During this time she had been under the charge of several physicians who had gained a large experi- ence in the treatment of such diseases. A number of care- ful examinations had been made from time to time with the endoscope, and nothing had been detected beyond the ex- istence of a certain amount of inflammation of the mucous membrane about the neck of the bladder. She had been a school-teacher, and it was supposed that her occupation, which would have necessitated being much in the upright position, with the habit of retaining the urine for too long a time, had been instrumental in establishing the inflam- mation. This diagnosis seemed a rational one, as there ex- isted undue thickening of the urethra and neighboring tis- sues, with great tenderness when pressure was made up against the arch of the pubes. For some time after her admission to the hospital she was treated for this supposed inflammation by injection andapplications to the canal. At length the irritation increased to such a degree that I de- termined to open the urethra, with the hope of finding some clew to the difficulty. The cause of irritation became evi- dent as soon as the urethra was opened. A small polypus was seen attached just at the neck of the bladder, which had been pushed out of the urethra on the introduction of my instrument into the bladder, and was carried back again into the canal with the first passage of urine. Its presence in the urethra excited constant tenesmus, and this had gradually led to undue thickening of the tissues. It was but a question of time, under the circumstances, before se- THOMAS ADDIS EMMET. 37 rious disease of the bladder would have been established, to be followed by dilatation of the ureters and death ulti- mately from some kidney lesion. Nothing could have been more simple than the application of the remedy, in the re- moval, or more satisfactory than the result. During the past autumn an elderly woman, about sixty years of age, was sent to me by Dr. M. C. West, of Rome, N. Y., and was treated in my private hospital. The urethra had been previously dilated, and a growth of some descrip- tion had been successfully removed by Dr. Marion Sims, and she came under my care in consequence of his absence from the city. She had been temporarily relieved after the operation, but in a few months the irritation of the bladder increased, and her general health became much impaired by the loss of sleep, due to being obliged at night to get up so frequently to empty the bladder. As only a moderate de- gree of thickening existed in the walls of the urethra, I was at first disposed to underrate very much the importance of the case by attributing a great deal to nervousness, and to what I supposed was the effect of being confirmed in the habits of an invalid. The only important feature I could detect in her case was a tenderness on introducing a uterine probe into the urethra, and this was confined to a very circumscribed spot, about half way between the en- trance of the urethra and the neck of the bladder. The urethral canal was opened December 3, 1881. I found an elevated mass on the mucous membrane, not larger than the head of a pin, which resembled what might have been the stump or remains of a pedicle, from which a polypus had been removed. This was caught up with a tenaculum, ligated with a strand of fine silk, and cut off. The edges of the urethral and vaginal mucous surfaces were then united together around the button-hole opening, and the case was treated afterwards in the usual manner. She re- turned home as soon as the parts had healed, having been entirely relieved, after the removal of the mass, from all discomfort connected with the bladder. I subsequently closed the opening February 24, 1882, and she has since 38 ANNUAL ADDRESS OF THE PRESIDENT. increased in weight, lost all nervousness, and has continued as well in every respect as any woman could be at her age. The same comments are applicable to this case as to the previous one, for the diagnosis could not have been formed, or any relief afforded, without having resorted to the oper- ation of opening the urethra. Moreover, the consequences attending the cystitis which would have soon supervened would have been as inevitable. I have operated in severdl instances for prolapse from the urethral outlet of the mucous and sub-mucous membrane by drawing back the excess of tissue through the button- hole-like slit and then securing it, as shown by an illustra- tion in the last edition of my book. This operation is perfect, as. it secures, by adhesion, the mucous membrane along the wall of the urethra in the line of union, so that farther prolapse is impossible. The first operation I ever performed of this kind was done June 17, 1879. The pa- tient has remained under observation and had been free from prolapse to the time of my last examination, June 15, 1882. This is the case detailed on page 732, second edition of my “ Principles and Practice of Gynecology.” It seems evident that this condition of prolapse is a con- sequence of child-bearing, where the tissues have been forced into the urethra from behind, causing dilatation of the canal, which may have been partial or have extended to the outlet ; and with this condition splitting, or laceration of the sub-mucous tissues, in the long axis of the passage, is a fre- quent accident. The tissues being in abundance, and free to agreat extent at the neck of the bladder, can be crowded as a plug, under favorable circumstances, into the canal by pressure of the child’s head as it advances from behind, and in the same manner as the rectal canal is rolled out from the anus. Laceration through the sphincter ani and perineum is usually caused by the use of forceps, or, to be more explicit, it may be stated that the accident usually occurs where the instruments have not been removed when the head reached the perineum, and when the delivery has been completed by their aid. But this injury also occurs THOMAS ADDIS EMMET. 39 from the head of the child crowding the tissues in advance through the anus asI have described. During the past twenty-five years I have seen several cases at the Woman's Hospital where the fourchette alone remained intact, while the recto-vaginal septum had been extensively lacerated, with the sphincter ani and the greater part of the peri- neum. We might naturally suppose that the urethra could sustain but little injury from pressure during the progress of labor, as it is situated so close under the arch of the pubes. But since my attention has been directed to this subject I have found evidence of urethral laceration as common as that of the perineum, and far more so than the injury through the sphincter ani. In fact, I have been sur- prised at the number met with where the urethral outlet was too patulous, a condition generally due to laceration on each side below, so that the meatus remained somewhat of a triangular shape with the apex above. More or less prolapse of the mucous membrane still existed in all these cases, as was shown by the deeper red color of the urethral surface presenting at the outlet. But asa portion of the canal beyond had also been lacerated, retraction to some extent had occurred as cicatrization took place. The effect, then, was the same in principle, but the prolapse could not be arrested to the same extent, as would be done by the operation already described, where the excess of prolapsed mucous and sub-mucous tissues is drawn out through the button-hole-like slit and secured. For an indefinite period but little inconvenience may be appreciated after sustaining some such injury, and when realized the symptoms of discomfort may be long attributed to uterine displacement or other cause than injury to the urethral canal. But on close questioning the patient will be able, as a rule, to recall the existence of irritation at the neck of the bladder, coming on after some special labor, from which time more or less difficulty had existed. Thickening of the mucous membrane and an increase of growth are not confined, however, to over-stretching or laceration of the canal. A patient was sent to me by Dr. 40 ANNUAL ADDRESS OF THE PRESIDENT. Lewis Fisher, of New York, in October last, where the first prominent symptom had been hemorrhage for several weeks, from the bladder as it was supposed. The urine had not been free from blood during this period, and after emptying the bladder she suffered from tenesmus, with frequent pain over the pubes and about the thighs. It was feared, after the report made from a microscopical examination of the urine, with the rapid development and symptoms of the case, that it would prove one of malignant disease of the bladder. She had given birth to two children, and the last labor had been about twelve years previous to my first ex- amination. The only point in her history which I could obtain with any bearing on the case was regarding the first labor, which had been a very rapid one, and although she got up well, as it was thought, she realized, when ques- tioned, that more or less irritability of the bladder had ex- isted from that time, with tenesmus often coming on after taking any undue amount of exercise. No stone was found in the bladder, but the presence of the sound in the vesical cavity caused bleeding, contraction of its walls, and much pain. Under the circumstances I determined to administer an anesthetic, that a diagnosis might be established, after exploring the walls of the blad- der in search of an encysted stone. Under ether the ure- thral outlet was found rather smaller than natural, and the canal did not seem to be dilated, but the walls and neigh- boring tissues were much thickened, so that a urethrocele existed, to an unusual degree, near the neck of the bladder. Finding nothing in the vesical cavity, I determined to make the opening into the urethra. A mass of the thickened mu- cous membrane crowded up into the opening as soon as the canal had been entered. It had a cock’s-comb-like appear- ance, bled readily on the slightest touch, and was so free that it could be drawn out of the canal to some distance. In fact, the thickened mucous membrane seemed to be de- tached to a great extent from the sub-mucous tissues. It had © been developed to such a degree that it was thrown into long folds, extending in the axis of the hollow cylinder. THOMAS ADDIS. EMMET. 4! This growth had become an exaggeration, to a remarkable degree, of the longitudinal plicze always found on the pos- terior wall of the urethra, near the neck of the bladder, Between two of these folds the sound had been passed on its introduction, thus giving no indication that the canal had been at all dilated. It was evident that the use of the endoscope would have proved of no greater value than the detecting of an increased vascularity of the lining mem- brane. After some difficulty I introduced a No. 12 block- tin sound through the urethral meatus into the bladder. While this was held in position I drew out, through the button-hole-like incision, this excess of tissue from about the neck of the bladder and on each side of the sound. This was cut away with a pair of scissors, and then I united the raw edges of the mucous and sub-mucous surfaces to- gether, using four interrupted sutures on each side. When the operation had been completed, the appearance of the urethra resembled a large quill or tube from which a nar- row longitudinal section had been removed, and through which was readily seen the interior of the canal. The deep red color of the lining membrane disappeared in a few days after the operation. An application of the nitrate of silver was made several times to some granular points, but she received no other treatment, except the hot water vaginal injections and the zinc ointment, which she applied herself. She had no bleeding or trouble with the bladder after the operation. On February 18th last I denuded the edges of the opening in the urethra and united them with inter- rupted silver sutures, secured by means of perforated and compressed shot. The thickening from the urethrocele had by this time entirely disappeared, leaving the edges of the opening so thin that it was even necessary to include a strip of vaginal tissue in the denuded surfaces. The su- tures were removed at the end of a week, and the line was united throughout. At the present time she is perfectly well, and it would be difficult to detect the line of the oper- ation, were it not for a small pin-hole-like opening situated near the outlet, which gives no inconvenience. Dr. Fisher 42 ANNUAL ADDRESS OF THE PRESIDENT. was present at the operation, and followed afterwards each step in the treatment of the case. But he has been the only family physician who could do so, as my other patients were from a distance. In the classification made of these diseases, urethrocele should have followed properly the consideration of prolapse of the mucous and sub-mucous tissues. For it is but a se- quence, where a degree. of greater thickening has followed the overstretching of the urethral tissues with laceration of its walls. More or less of a pouch has been formed in all these cases, in which a certain amount of stale urine re- mained afterwards to add to the irritation. The formation of a urethrocele is frequently attributed to a previous lacer- ation of the perineum, but this is not strictly correct, for the perineum was lacerated at the same time that the ure- thra was injured. From a want of proper support the con- dition of the urethra could not improve afterwards, and became exaggerated from the condition of the perineum. In the beginning of every case of urethrocele, I believe more or less laceration had taken place between the longi- tudinal muscular fibres of the urethra. I can recall one well marked case where I operated, some twelve or four- teen years ago, and found a slit existed through the walls nearly the whole length of the urethra, and to the vaginal tissue, thus forming a pouch in which:a drachm at least of stale urine always collected. This condition is easily rem- edied by removing, with a pair of scissors, the excess of tissue, and by then denuding the sides of the opening in the urethral tract to a sufficient width, so that when the two surfaces are brought together by sutures the urethral canal will be restored to its natural calibre. By this means all prolapse of the urethral mucous membrane can be ar- rested, and the urethral wall restored to its natural thick- ness. In this connection I might state the opposite condition, that of stricture of the female urethra, is rare in my ex- perience, except as the result of violence. It is near the outlet where narrowing usually takes place, and follows the THOMAS ADDIS EMMET. 43 use of nitric acid, other caustics, and the cautery, or after cutting off prolapsed tissue or a growth from the meatus. Any serious obstruction to the free escape of urine must eventually result in cystitis, and the condition therefore re- quires prompt relief. Where the outlet is narrowed, there is no remedy but to divide it backward sufficiently to re- store it to its natural size. But with any degree of stric- ture it will be necessary to make a button-hole-like open- ing directly over the constricted portion, and after the edges have thoroughly healed it will be easy to form the canal of a proper size —an operation simple of execution in the female, but more difficult in the male; yet I suc- ceeded perfectly in one instance in forming a good-sized canal where the urethra in a male subject had, before the days of the aspirator, been laid open through a number of strictures to relieve retention and urinary infiltration. Where simple hypertrophy has occurred, as a product of inflammatory action ; where from a want of proper support, from hemorrhoids, or from long continued attacks of tenes- mus, due to some other reflex cause, it is only necessary to cut through the tissues, as I have described, to bring about a change of nutrition in the parts, and no other means can accomplish so much. My last operation was at the Woman’s Hospital. The patient had suffered from cystitis, and had been under treat- ment for over four years in Bellevue Hospital and other in- stitutions of the city previous to being admitted to the ser- vice of Dr. C. C. Lee in the Woman’s Hospital. She was then in a most miserable condition, with the urine phos- phatic and filled with pus; she suffered greatly from tenes- mus; the walls of the bladder were thickened, and in fact all the symptoms of long standing cystitis were present. Dr. Lee made an artificial fistula in the base of the bladder, and treated the case afterwards for a year or more. At the end of that time the cystitis had entirely disappeared, the char- acter of the urine was again normal, and the walls of the bladder had been restored by rest to a healthy condition, The fistula was then closed, but the old irritation of the 44 ANNUAL ADDRESS OF THE PRESIDENT. bladder at once returned with all its attendant suffering. I believe a fistula was again made, further back towards the cervix uteri, so that the drainage might be more per- fect, and shortly after I was asked by Dr. Lee to see the case in consultation. The bladder then seemed to be in a healthy condition, and the only apparent lesion was a large urethrocele, with a general venous congestion of the parts. To study the progress of the case, and to investigate the cause of failure, where so much had been gained, I re- quested that she might be transferred to my service. The fistula in the base of the bladder was closed, and then an opening was made through the thickened urethral tissues, over which the mucous surfaces were united, as I have de- scribed. One of the immediate effects of the operation, after cutting through the tissues and relieving the tension, was a speedy restoration of the circulation to a healthy con- dition. The parts were allowed to rest for several months until the urethral walls had regained their normal thick- ness. Early in May last the opening in the urethra was closed, with no return of the bladder trouble, and the result was perfect. Just before her discharge in June I had the pleasure of showing the case to Drs. Garrigues, Lusk, and Lee, members of this Society. The history of this case is of much clinical value. The first symptoms began with a moderate degree of irritation of the bladder, which developed into a constant tenesmus— symptoms beyond question then due to some lesion in the urethra, which gradually, through a series of years, led to the cystitis and its consequences. So long as the urine in this case had a free escape from the bladder through the fistula, the condition of the urethra could not excite sympa- thetic irritation. Yet, notwithstanding the bladder had re- covered its healthy condition, during its long period of rest, it was made to feel the effects of the original source of irritation in the urethra as soon as the fistula was closed. With the distention, from accumulation of urine, reflex irritation was at once excited in the muscular fibres of the bladder, and the tenesmus thus induced would have soon THOMAS ADDIS EMMET. 45 reéstablished the cystitis in its worst form. The history of this case points out, in all probability, the unsuspected cause of irritation in a certain number of cases of cystitis of long standing, which are benefited only while the fistula remains open for the free escape of urine, and where it is asserted sometimes, in such cases of failure, that the artifi- cial opening, with rest alone, cannot cure this disease of the bladder. I can offer nothing more for the treatment of fissures situated at the neck of the bladder. Their exact locality is often difficult to detect, but the opening, when made as I have described, allows of more ready inspection, and by thus freeing so thoroughly the tissues about the neck of the bladder, they often heal without further interference. We will now consider, as briefly as possible, the last sec- tion, that relating to laceration of the urethra from forcible dilatation, an accident which has frequently resulted in a permanent loss of control over the escape of urine. It is not necessary to discuss at any length the propriety of the procedure, for my views, and the experience upon which they have been based, are sufficiently well known. I will, however, state that with more experience I am the more confirmed in the unqualified opinion that the operation of dilating the female urethra is one which should not be practiced under any circumstances. No advantage can be gained by its aid which cannot be obtained by other means free from all danger of injury to the patient. The fact is not questioned, but admitted by all, that, in a certain pro- portion of cases, permanent incontinence of urine continues after the urethra has been dilated. It is well known also that the occurrence of the injury does not always depend upon a want of dexterity on the part of the surgeon ; it can- not be guarded against, and will take place sometimes in the hands of the most careful operator. I have in all probability seen more cases of this injury than any other member of the profession, and I have been many years seeking to relieve the condition through the aid of surgery. For years past my service in the Woman's Hospital has 46 ANNUAL ADDRESS OF THE PRESIDENT. been seldom without one or more of these unfortunate patients under my care. After fifteen years of study, and after having instituted many operative procedures for the relief of this lesion, I am able to claim a number improved, but with only one patient permanently cured, where I had myself produced the injury. Another, rated as improved, kept dry about seven months after her discharge, and then, according to her statement, she suddenly lost all control over the escape of urine, but by a later account I was in- formed she could keep dry at night. The supposed failure must, however, be accepted with some allowance, for she retained full control of the urine from April until the fol- lowing December. At this time she was anxious, I fear, to go into winter quarters by entering the Woman’s Hospital, where she had been an inmate several years. From her knowledge of her own case, and with her dexterity, I feel that I am not uncharitable in the belief that she may have opened the urethra, and I believe may have had a hand in some of the previous failures. She lived at a distance, and has not been readmitted, so that I do not know her true condition. Another patient under observation, with a small opening, may yet be cured, as she has kept dry at night and has done so during several hours in the day. All who have fol- lowed my service in the Woman’s Hospital during the past three years will be able to recall the case of a young girl, who had a stone dragged through a dilated urethra when she was eight years of age. The result of the operation was splitting open the canal and lacerating the vesico-vagi- nal septum obliquely along the sulcus, on the right side, beyond the mouth of the ureter, with extensive sloughing afterwards. She has already taken ether thirty-three times, and has submitted to about thirty surgical operations in- stituted for her relief. I have made the urethral canal some ten times in this case, and have afterwards laid the whole open again, with a pair of scissors, in search of the cause of failure. At length my perseverance has been re- warded by finding the nature and exact seat of injury. As THOMAS ADDIS EMMET. 47 I have detected the same lesion in two other cases, and the only instance I have seen since of loss of urine after dila- tation, we may reasonably hope that the usual cause of difficulty in these cases has at length been ascertained. There exists a superabundance of loose tissue about the neck of the bladder, which disappears, portion after por- tion, in the expanse as the viscus becomes distended. At length, when it is put. on the stretch, the shape about the neck becomes not unlike that of a funnel, with the walls slop- ing on all sides towards the nozzle, and with a portion of it bent under the pubes to form the urethra. I once opened freely the vesico-vaginal septum, in a patient suffering from incontinence after dilatation, and in this instance I detected, by means of reflected light and a laryngeal mirror, a cica- tricial line extending across several of these folds, at the neck of the bladder, which prevented them from coming together. The parts had evidently been lacerated in this instance at least, and I had supposed, until recently, that this was the usual accident occurring where incontinence had followed dilatation of the urethra. It is a practice to leave an opening in the base of the bladder for the free escape of urine during the time neces- sary for forming a new urethra. But after the parts have become firmly united, I usualty close temporarily this vesico-vaginal fistula, but without denuding the edges, to test by this means the retentive power and to dilate some- what the bladder, which may have been long contracted. On one occasion, in the case of the girl who had retentive power for some time, finding that retention had not been gained, although the line of union in the urethra was perfect along the vaginal surface, I removed these tempo- rary sutures, and passed my finger through the fistula into the bladder. During the examination I was struck with the unusual shape of the parts about the entrance into the urethra, which seemed to point or project into the bladder. As the finger was passed down towards the neck, from behind the pubes, the tissues seemed to have rolled out, and felt not unlike the anterior lip of a lacer- 48 ANNUAL ADDRESS OF THE PRESIDENT. ated cervix, but were much smaller in size. Judging from the passage of the sound along the urethral canal, it seemed to be so much dilated, beyond a certain point, that I sup- posed absorption had taken place in ‘part of the line, so I again laid open the urethral tract. I then discovered that the expanded state of a portion of the canal was due toa transverse laceration of the urethra, by which a part of the anterior wall of the bladder had been torn away from under the arch, if not, in addition, partially from the inner face of the pubes. Until I had realized the existence of this lacera- tion it was easy to have overlooked quite a concave surface, when only seen from in front, but a condition which would have been at once apparent if presented in profile. The injury was also less likely to have been recognized after the parts had been put on the stretch by the introduction of the speculum, while the depression entirely disappeared when the edges of the canal were held apart for inspection by means of a tenaculum on each side. But as soon as the lesion was suspected, and the tissues at the neck of the bladder were drawn forward to their natural position by means of a tenaculum, an extensive transverse laceration was at once made apparent. With our knowledge of the manner by which the neck of the bladder is firmly bétnd down under the arch of the pubes, and with its close connection at this point to the unyielding pelvic fascia, it becomes simply a matter of sur- prise that laceration does not occur in every case where the attempt is made to dilate the female urethra. The finger must always meet with resistance along the line of the sub-pubic ligament, where dilatation cannot so easily take place as in other portions of the canal, and the parts must here be put on the stretch, as they are pushed away from the pubes. Then if laceration occurs it will naturally take place along the line of least resistance, which would be across the urethra, at the sub-pubic ligament, and in the connective tissue, so as to separate more or less of the bladder wall from the pubes. I have attempted several times to repair this injury by THOMAS ADDIS EMMET. 49 denuding the sides of the laceration, and then bringing these surfaces together with a number of interrupted sutures in a line transverse to the axes of the urethral canal. But I have never been able to gain a sufficient union of the sides so as to entirely obliterate this concave surface, and have attributed my failure to the close rela- tion of these parts to the muscular action brought into play with each effort to empty the bladder and bowels. To overcome the difficulty, and to fill up this space, I have made the freshened surfaces, which were to be brought to- gether in forming the urethra, much wider at this point, so that the canal might be of a uniform width, and in profile a convexed line would occupy the concavity. By adopting this plan I fully expected that a certain amount of urine would accumulate before it could escape, and before reach- ing that point the bladder would rise sufficiently in the pelvis to give retentive power by drawing back the urethra somewhat and compressing its sides under the arch of the pubes. We should bear in mind that in the case where retention was gained for seven months after the operation, the urethra had been fully developed before being lacerated, and I sim- ply brought together the sides qf the urethral canal, which had been previously laid open, through the meatus back- ward into the bladder, with some object in view unknown to me. It was therefore reasonable to expect that retentive power would be gained under these circumstances, if the operation proved successful in narrowing the canal at the seat of transverse laceration, and that the natural desire to empty the bladder would exist, as was afterwards proved to be the case. But the accident of the laceration occurred to the young girl while a child, with sloughing afterwards of the whole vaginal portion of the urethra. I therefore expected, if retentive power was established, after forming the urethral canal from the neighboring tissues, that there could be no appreciation of the degree of distention, or desire to empty the bladder; consequently it would be necessary to remove VOL. VII. 4 50 ANNUAL ADDRESS OF THE PRESIDENT. the urine by aid of a catheter at regular intervals, and fre- quently to wash out the cavity, to guard against the ac- cumulation of phosphatic urine. These views were not theoretical, however, but based on my previous experience in certain cases where I had formed the urethral canal from distant tissues, after the soft parts under the arch of the pubes had sloughed away to the periosteum. But when I temporarily closed, for a few days, the artificial fistula left after forming the urethra in the case of the young girl, I was surprised to find that the natural desire to empty the bladder, when sufficiently distended, had been but little im- paired. I therefore feel more confident that she will be ultimately cured. The appreciative power in this case was evidently due to the preservation of a long narrow strip or surface, which had formed that portion of the urethral canal in close contact with the sub-pubic tissues. And not- withstanding the anterior surface, or two thirds of the whole calibre of the canal, had been destroyed, and a deep lacera- tion had taken place directly across the remaining portion, indirect communication was established between the neck of the bladder and the urethral tissue through some gan- glion anterior to the seat of injury. This case proves an important one, as from it we may draw the inference that the desire to empty the bladder in the female is due to an impression made upon nerve fibres situated in that part of the urethral canal in close contact with the sub-pubic tissues, and between the neck of the bladder and the urethral outlet. It would therefore seem that along this tract the fibres of the sympathetic are chiefly distributed from the neighboring ganglia, and are sparingly given to the vaginal portion of the urethral canal where they would be more exposed to injury. Moreover, this supposition seems to be confirmed by ob- servation in other instances, for I believe every case, which has passed under my observation, of growth, or other disease of the urethral canal, which has been accompanied with re- flex disturbance, has been situated along the distal portion of the canal, or that part in direct relation with the pubes. os THOMAS ADDIS EMMET. 51 I have been assisted in all the operations bearing upon the subject of this paper by my two assistant surgeons at the Woman’s Hospital, Dr. George T. Harrison and Dr. Bache Emmet, or by my son, Dr. J. Duncan Emmet. Before closing I will briefly reiterate certain points which should be made prominent, and which may have been lost sight of in consequence of the various subjects treated of, and from the length of the paper. I have presented a mode of exploration for the Eadie urethra, the advantages of which are not urged upon the- oretical grounds, but from actual experience and close ob- servation extending over several years. I would therefore ask that, in testing the method, the directions given may be first carefully carried out, to gain the necessary experience before judgment can be impartially rendered. It is claimed that the advantages from the operation for exploration are greater than can be gained by any other method yet known to the profession, as the whole canal can be fully exposed, and any mode of treatment suggested by the condition of the parts can be easily applied. That the operation is perfectly safe, and can be executed without difficulty by any one possessing an ordinary amount of dexterity. It certainly can be performed with safety by any one fitted to take the responsibility of forcible dilata- tion. That if properly performed, and according to the direc- tions given, the control of urine will not be in the slight- est degree impaired, and that the bladder can be emp- tied afterwards at will without difficulty. In this respect the condition is different from where an apparent urethral fistula has occurred in consequence of childbirth, and where, as a rule, the retentive power is lost. In the operation on the urethra the neck of the bladder must never be involved, while sloughing at this point, the one most exposed to pressure, always occurs where the injury has resulted from parturition, and it is only after cicatrization has taken place that the opening would appear to the superficial observer as being confined to the urethra. 52 ANNUAL ADDRESS OF THE PRESIDENT. That no difficulty has been experienced in closing the urethral opening afterwards, an operation which has been performed by the house surgeons in the Woman’s Hospital, and given to them for practice as one of the simplest. Where the fistula has been made, and its closure seems afterwards of too great magnitude, or it may not be convenient to close it, no harm can occur from leaving it open until a favorable opportunity is presented. That on inquiry all who have been operated on have stated that, after the edges had healed, they were unable to appreciate any difference in the passage of the urine, al- though the greater portion, if not all the fluid, must natu- rally have escaped through the opening. More or less urine, however, must pass back into the vagina, and this fact would necessitate the daily use of vaginal injections for cleanli- ness. It occurred to me that the rolling out of the urethral mucous membrane, from the opening, might expose it in sexual intercourse, but on inquiry I learn this even does not seem to have been the case after the parts have-cica- trized. That it is not intended this opening in the urethra should in any manner supersede the forming of a vesico-vaginal fistula for treating cystitis, or for the removal of stone from the bladder. The opening of the urethra cannot be of the slightest advantage for drainage in the treatment of long standing inflammation of the bladder, unless the canal be also involved. Under such circumstances where the open- ing is made in the urethra, and one is also needed in the bladder, the incision is to be extended by a continuous line along the vaginal wall, but not through the neck of the bladder. At least half of the thickness of the septum must be left at this point, and then the base of the bladder can be entered beyond to form the fistula, which opening is to be extended by incision, as far as deemed necessary, towards the neck of the uterus. To keep this fistula in the bladder from closing, its mucous membrane must be drawn out and attached by interrupted suture to the vaginal membrane in the same manner as described for covering the edges in the THOMAS ADDIS EMMET. 53 urethral opening. Not only will the fistula be kept patu- lous by this procedure, but the patient will be saved from much suffering by thus protecting the raw surfaces from urinary deposits. DISCUSSION. Dr. ForDyceE BarKER, of New York. —I wish to detain the Society for a few moments only, with reference to this impor- tant and interesting address to which we have just listened, and it is in behalf of one of our Fellows, who is prevented from being present. It is several years since our President proposed this operation, but it is only about two years since it has been fully described. Since that time it has received but little attention from the profession, and the President’s plan has not been re- ported in print by any one else. This is the reason for making the statement which I am now about to make in behalf of Dr. Lusk. The President referred to one case which had been under Dr. Lusk’s care for a long time, in Bellevue Hospital, and in which this operation was performed. The result was one that so delighted Dr. Lusk that, having another patient in his ser- vice in Bellevue, he at once performed the operation upon her. This patient had been in the hospital for three months, having been a great sufferer for months previous to her admission. She was unable to sit up, and had been unable to walk for several months. He had treated her to the best of his ability, and she had been treated by others for a long time before she came under his care. Dr. Lusk performed the operation just described by Dr. Emmet, namely, making a button-hole slit in the urethra. Now, Dr. Lusk is not apt to be carried away by personal, en- thusiasm, but he said that the result was one of the most aston- ishing he ever saw. The first night after the operation the woman slept, and at the end of the first week she was able to go out and resume her domestic duties. Since that time he has performed the operation twice, and with the same success. It was Dr. Lusk’s great desire to be present, but he was unavoid- ably detained ; and I, therefore, take the liberty to communicate his clinical experience to the Society. Dr. ALEXANDER J. C. SKENE, of Brooklyn.— The unqualified condemnation, by Dr. Emmet, of all preéxisting methods of diag- nosis and treatment of urethral diseases in women would incline 54 ANNUAL ADDRESS OF THE PRESIDENT. any one of ordinary courage to shrink from discussing so positive a paper. But, on the other hand, the extreme liberty which the author takes with all co-laborers in this department invites a like freedom and frankness in dealing with his assertions. In regard to the blunders which he has seen in the practice of others, they only serve to show the incompetence of some who practice gynecology. But this does not, by any means, repre- sent the actual state of our knowledge of the diseases of the female urethra. When he claims that his method of exploring the urethra is the only satisfactory one, it becomes at once apparent that he has been so fully occupied with his own investigations that he has failed to make himself acquainted with the achievements of others. It is certainly a fact that the diagnosis of many dis- eases of the female urethra and bladder has been for years as clearly defined as anything in gynecology. Indeed, surgeons understood this long before gynecology became a special depart- ment in medicine. In view of these facts I may reasonably inquire what the merits of Dr. Emmet’s method of diagnosis are compared with those formerly in vogue in the profession. Laying open the urethra for purposes of exploration is claimed to be a simple, easy, and safe operation. To Dr. Emmet it may be all this, but the general practitioner and even some experts do not find it so. It is, no doubt, as difficult for the surgeon, and more disagreeable to the patient, than any other method of exploration. Inflicting an important injury (which requires to be repaired by a delicate operation) in order to detect a disease is not a “simple ” procedure. As a means of diagnosis this operation approaches perfection in cases of urethral polypus or any of the neoplasms. These can be detected with great facility by this means. For this pur- pose the method of Dr. Emmet surpasses all others, but its claims to superiority, in my judgment, end here. In diagnosti- cating ulceration, and, especially, fissure at the upper end of the urethra, it is certainly very inferior to the endoscope in facility of employment and accuracy of results. The facts are, that in making this button-hole there is hemorrhage, which, although trifling in quantity, keeps on and obscures the surgeon’s view. And when to that is added the flow of urine, which keeps up when the neck of the bladder is held open for inspection, very little can be seen by the ordinary observer. In searching for a DISCUSSION. 55 fissure, under such circumstances, it is very difficult to find it in the loose folds of the mucous membrane. With the endoscope the urethra is distended, and the fissures, which are usually lo- cated in the folds of the mucous membrane, are brought clearly into view, no matter how small they may be. So it is, also, in ulceration at any portion. In fact the endoscope is sufficient for diagnostic purposes in all affections of the urethra, except neo- plasms at the neck of the bladder. This is not a theoretical no- tion of mine, but a matter which can be demonstrated. Some practice is necessary to acquire facility in the use of the endoscope, but I can teach a student how to explore the urethra with this instrument much more easily than he can be taught to perform the operation recommended in the paper. I know that Dr. Emmet does not regard the endoscope as a diag- nostic means possessing any practical value. I might make the same statement regarding my personal experience with the oph- thalmoscope. I have used that instrument, but never have been able to recognize any disease of the fundus oculi with it. Still I should be the subject of your derision if I said that the in- strument was useless. That mistakes are made by those who use the endoscope is true; the case recorded in the paper which came to Dr, Emmet from Dr. Jenkins illustrates that fact. Still that only shows that there are few means of diagnosis that are infallible in the hands of ordinary men. I presume the usual number of such blunders will, in time, be credited to Dr. Em- met’s method when it comes to be practiced by others. As an aid to the diagnosis of diseases of the bladder this method has some value, I believe. I do not understand how the upper end of the urethra and neck of the bladder can be dilated with impunity after making the button-hole opening in the middle third of the urethra. I have always believed it to be dangerous to dilate the neck of the bladder to any great extent. Perhaps Dr. Emmet has made his observations in cases in which the parts were abnormally dilated before he operated. As a therapeutic agent I recognize the very great value of this operation. In the removal of polypi, and the relief of ure- throcele, it is, no doubt, invaluable. I can also understand how the alterative effect of the operation might be quite efficient in arresting some of the irritable states of the urethra. In regard to that injury of the urethra which resembles, in its pathology, laceration of the cervix uteri, I have had no experience. I can 56 ANNUAL ADDRESS OF THE PRESIDENT. say, however, that if Dr. Emmet can, by this or any other oper- ation, relieve that form of downward displacement of the urethra which often follows child-bearing, then surgeons and patients will accord him the highest praise. I would also take exception to some of the doctor’s views in pathology: for example, I do not think that displacement of the urethra and bladder is due to mechanical causes alone, such as occur in labor. I incline to the belief that the development of the cellular tissue in the pelvis which takes place in pregnancy gives an increased laxness to the parts, and predisposes to dis- placement. I also entertain a doubt regarding the existence of pure neu- roma in the urethra, which the doctor has mentioned in his class- ification. In answer to the question in regard to forcible dilatation of the urethra, I would say that I agree with Dr. Emmet in believ- ing that it is a dangerous operation, but I cannot say, as he does, that it should never be performed. With due care, and in properly selected cases, it can be practiced. Finally I may refer to the fact that the doctor reminded us of that which we all knew, namely, that his friends and those who know him best have always given him credit for honesty in all that he does and says. In this respect I desire to be among the foremost to do him honor. At the same time it must be borne in mind that honesty of purpose does not always secure accuracy of observation or soundness of judgment. Knowing this, I have dared to entertain the impression that this remark- able contribution by Dr. Emmet, while it does not embrace all that is known on the subject, will take a high position among the accepted means of diagnosis in gynecology. THE PRESIDENT. —In my closing remarks in the paper I state that it is not intended that this opening in the urethra should, in any manner, supersede the use of a vesico-vaginal fistula in the treatment of cystitis. Of course the existence of cystitis can always be diagnosticated by the use of the microscope determining the presence of pus and casts in the urine, but I have not advanced the method | mentioned in the paper for the cure of cystitis, and I do not know any way of curing cystitis, except by making a vesico-vaginal fistula. The point which I wish to make is this: A serious irri- tation existing in the urethra will, in time, spread to the bladder DISCUSSION. 57 and cause inflammation ; you may then cure the cystitis, but so long as the irritation in the urethra is not removed, the cystitis will return on closing the fistula. I am perfectly aware how much we are indebted to Dr. Skene for work in this particular direction, but he stands almost alone with his skill, for we know that the knowledge in the profession at large is almost next to nothing. But all cannot place their patients under his charge, nor can all the patients reach him. It is for the general prac- titioner that I advance this method. The paper is not, there- fore, on the treatment of diseases of the bladder, but it is ona new method of exploring and treating diseases of the female urethra, and I do not know of any other means so good. THE PROPER USE OF ERGOT IN OBSTETRICS. BY JOSEPH TABER JOHNSON, M. D., Washington, D.C. THE proper use of ergot in the practice of obstetrics has long been a subject of controversy, and the following con- tribution is modestly offered, to aid in a settlement of this important though hackneyed question. I have nothing new in the line of discovery to offer, but shall hope to bring the knowledge we do possess into such shape as to show the powers of this drug for good and evil, and shall suggest rules for our guidance in its administration to women in labor. With its other varied uses in the general practice of medicine this short paper will not attempt to deal. The history of its early use details the varied experiences of obstetricians of great skill and wide reputation. It was declared by some, after repeated trials, to be without result. Others said it acted only through the imagination. An ef- fect was claimed for which the patient was prepared, and soon after its administration the tired organ would renew its efforts with a vigor which was attributed to the medicine. While still others declared that it was chiefly valuable on account of its inability to do harm. We know now, with the great number of cases of recorded accidents attributed to its abuse, that it is not incapable of doing harm. The failure to produce results in the hands of those declaring it ineffective must have been owing to the employment of impure or spoiled preparations. It is certainly in evidence that the specimens have to be selected with care, and are difficult to retain in their purity after the most skillful man- ufacture, especially when given in the powder or infusion, as is still the habit of many practicing in the country. JOSEPH TABER FOHNSON. 59 That schools differ in teaching the indications for its use, text-books in their instructions, and obstetricians in their practice, none familiar with the subject will deny. Some au- thors advise its exhibition to hasten slow pains in the first and second stages of labor, others say it should never be given in these cases. Some try to overcome uterine iner- tia with it; others say it is little short of murder to give it, when the child is viable, to any woman in labor. Some advise its use to expel a retained placenta, and always give it immediately after the birth of the child’s head, and asa prophylactic against hemorrhage ; others say it does harm in these cases. Some claim it to be the remedy in threat- ened and actual abortion, and especially valuable in causing the expulsion of the fetal membranes, while others say these are the cases in which ergot is positively contra-indicated. Some recommend its use in placenta previa and accidental hemorrhage, while others declare that it seriously damages the chances of the child in its race for life, and prevents the safe and successful manipulation necessary for version and - extraction, should they become necessary. With all of these contradictory statements before us con- cerning the action of and indications for the use of this remedy in obstetrical practice there would seem to be no apology necessary for bringing to the attention of the So- ciety the subject of the use and abuse of ergot in the lying- in chamber, and to appeal for such a discussion of this highly important topic as would authoritatively settle dis- puted points in practice. In the beginning it would be desirable, if possible, to as- certain what is the real effect of this drug upon the muscu- lar fibres of the uterus and upon the child within its cavity. Recent text-books upon materia medica and obstetrics agree in the statement that ergot produces in a uterus already in labor a persistent tonic contraction, which, if sufficient be given, finally becomes tetanic in character; also that the Aizd of contraction produced is diametrically opposite to the in- termittent rhythmical contractions of the normal parturient uterus, 60 THE PROPER USE OF ERGOT IN OBSTETRICS. When naturally acting, expulsion of the fetus is produced by the repeated shortening or contraction of the longitudi- nal uterine muscular fibres, while at the same time the cir- cular ones are retracted over the presenting part as the cer- vix and os become dilated. The phenomena of the labor pains constantly succeed each other in increasing power and rapidity until the organ is finally completely emptied of its contents. ‘ When these pains lose their rhythmical quality and become continuous they cease to belong to the domain of physiology.” Lusk remarks, that “whenever the alterna- ting relaxation ceases, and the uterus passes into a condi- tion of tonic contraction, no work is accomplished, and the pains are ineffective.” In the persistent tonic contraction produced by ergot, 2/7 the muscular fibres of that organ act equally upon its contents, which are held as in a vise, in- stead of expelled as above described. In most cases this effect is produced, but in some instances the child has been suddenly expelled after its use. In these exceptional cases, the uterine forces must have acted energetically dcfore the force of the contracting wave had reached the lower ute- rine segment, causing it also to contract, thus closing in- stead of dilating and retracting. In normal contractions the child and placenta are both compressed with considerable force, but they have time to recover fully during the interval between the pains. The placental circulation, interfered with for a time, goes on naturally as soon as the contraction ceases. —The temporary acceleration of the fetal circulation under the effect of ute- rine contraction is familiar to all who have studied the sub- ject or carefully observed the clinical progress of a normal labor. Not so with the ergot contractions. They, once thoroughly induced, may last for hours. The child, being equally compressed on all sides, cannot advance. The ex- change of gases is prevented in the placenta; its circulation is graduaily suppressed, and the child is as certainly as- phyxiated as an adult when hung by the neck with a rope. If there were no interference with the fetal circulation by the persistent contraction of the placental site, the long con- FOSEPH TABER FOHNSON. 61 tinued compression of the chest and brain of the child might alone so interfere with the operations of vital func- tions as to produce its death. Instances of injurious and fatal crushing, under these circumstances, have been re- corded. Intermittent uterine contractions, together with the soft- ening, lubricating, and dilating processes natural to the par- turient act, gradually prepare the cervix, vagina, and peri- neum for the safe passage of the fetus and its final emer- gence. In the alternating relaxation of these tissues and the re- cession of the presenting part, thus relieving the agony of pressure and distention, does the safety of the process con- sist. No one has shown so satisfactorily and emphatically as our distinguished President, Dr. Emmet, the great danger of continued pressure wxrelieved by the recession of the child’s head in lingering or delayed labor. Necrosis of the soft parts from interference with the circulation takes place, and their more or less complete destruction follows in pro- portion to the amount and length of time the pressure is kept up. Whether vaginitis, pelvic cellulitis, or sphacelus occur will be determined by the length of time these tissues have been compressed and their nutrition has been inter- fered with. We may have so slight a fistula occurring as to be found with difficulty, or the greater portion of the an- terior vaginal wall together with neighboring parts may be- come gangrenous and slough away. Ergot has frequently been substituted as the proper alternative for the forceps in these cases of delay or uterine inertia. Dr. Barker contrib- uted a paper to this subject a number of years ago. A dis- cussion of the danger of its abuse in these cases alone might occupy all the time allotted to my paper, if there were not a number of other points to briefly consider. While the action of ergot, we have seen, is to produce a continued tonic contraction of the uterus, suspending its al- ternate relaxation, undoubtedly cases do occur where, from abundant use, such powerful pains have taken place as to propel its contents suddenly through the unprepared soft 62 THE PROPER USE OF ERGOT IN OBSTETRICS. parts with such force and rapidity as to produce any or all of the lacerations combined, in a single case, from rupture of the uterus to complete laceration of the perineum. I will not stop to quote cases or authorities upon these points. So many accidents have taken place, and have been so fre- quently attributed to the abuse of ergot, that I cannot be far wrong if I take it for granted that proof by the quotation of authentic cases on record is unnecessary. Its uncertainty of action is one of the principal dangers of its use. It may act upon the entire organ, or upon only a portion of its fibres about the cervix, internal os, lower uterine segment, middle portion (constricting it in the centre like an hour- glass), upon the fundus, or one cornu. Upon its reintro- duction into obstetric practice in this country, the same fashion or craze seemed to control its use as has controlled the use of many other remedial agents before and since. There seemed to have been a general acceptance as a fact by the profession at large that ergot would originate and intensify uterine contractions, and therefore was the remedy to administer in cases of uterine inertia before and after delivery. In some quarters warning notes were sent out that ergot was the cause of many still-births and accidents during labor. Cases were reported where it was given to hasten slow pains, and the children were still-born after a labor sometimes not particularly hastened. The text-books have of late taught the correct use of this drug, but still many use it in the first and second stages of la- bor. Upon inquiry among physicians practicing in different parts of the country within the past few years, I have become convinced that the teachings of these authors, if read, are constantly disregarded ; and that it is as true now as when Meigs wrote, in 1867, “that multitudes of unborn children are being destroyed” by the unwise, unscientific, and per- haps I ought to say criminal use of this medicine. There is no lack, within my own knowledge, of cases where its ad- ministration might be made the basis of a charge of mal- practice, and the well-known opinions and practice of men JOSEPH TABER FOHNSON. 6 3 within the sound of my voice could be quoted as first-class evidence against the offenders. I know teachers who lec- ture their classes upon the criminality of the use of ergot be- fore the birth of the child. I know physicians in charge of the lying-in wards of maternity and other hospitals who positively forbid its administration by their internes and nurses until after the birth of the placenta. On the other hand, I so firmly believe the opposite of this custom prevails to an alarming extent throughout the country, that I have ventured to write this paper as an additional warning to those already in existence. My attention was drawn emphatically to this subject by a sad case occurring in the first years of my own practice, the chief points of which are as follows: The lady was a stout German who had previously been delivered of four children safely. The labor had been progressing well for some hours. The parts all seemed dilatable, and the child about to be born, when the pains began to be less effective, and seemed about to stop altogether. A condition of in- ertia was impending. I gave to this patient a teaspoonful of the fluid extract of ergot. Not much effect was noticed, andI gave more. She took in all about half an ounce. No real pains were produced, but the uterus from being soft be- came hard, and continued hard. She was in pain all the time, but occasionally it was intensified. It never, however, relaxed, or went off as in natural abor. J knew, and the mother knew, that the child was alive before she took the ergot. It seemed when given that afew more good pains would expel the child, but this tetanic action of the uterus came on, and the fetus was gradually squeezed to death or asphyxiated. I had finally to send for my forceps, but only then to extract a dead child. Had delivery been accom- plished with it at the time the fatal dose was administered, I believe the child would have been saved. Manual com- pression, or a large dose of quinine, would probably have produced the same result. I subjoin the history of two cases in illustration of this point, kindly furnished me by Dr. A. C. Adams of this city. 64 THE PROPER USE OF ERGOT IN OBSTETRICS. Case I.— Mrs. S., primipara, blonde, aged twenty-three, height five feet three inches, weight 105 pounds, general health good, was awakened with labor pains early on the morning of March 10, 1881. Medical service was summoned at 12 M. Upon examina- tion, the cervix was found dilated to the size of a twenty-five cent coin, and dilatable. 4 Pp. mM. Cervix was dilated to the size of a silver dollar and somewhat attenuated during pains, which were now increasing in strength and duration. 8 P.M. Cervix dilated one half ; bag protruding, but not making firm pressure upon the cervix during the pains. 10 P. M. Pains apparently sufficient, but lacking duration ; pressure upon the cervix almost w#/, and cervix remaining soft during pains; bag artificially ruptured ; small quantity of liquor amnii escaped. 12 P.M. Character of pains unaltered ; degree of dilatation the same; ext. ergote fl. admin- istered in half-drachm doses at intervals of half an hour. Pains became more continuous and attended with a sense of bearing down. March 11,5 A.M. Head tightly embraced by the cervix, but not descending. Patient wearied but strength preserved. By manipulation, internally, efforts were made to increase the dilata- tion of the cervix, and externally, by downward pressure to assist in expelling the fetus. to a. M. Head passed the cervix, and half an hour later escaped the vulva, when labor was speedily com- pleted, with a still-birth. Efforts to resuscitate failed. A bright- red band half an inch wide marked the entire circumference of the child’s head. ‘The mother made the usual recovery. Case II. — Mrs. S., primipara, black, aged thirty. Height five feet seven inches ; weight 130 pounds; general health excellent. Labor pains commenced 6 a. M., August 8, 1882. Medical service called at 3 p. M. Upon examination, the vulva and vagina easily admitted the whole hand ; the cervix was found dilated to the size of a silver dollar, and dilatable ; bag protruding with pains. 5 P.M. An extremity (an arm) was felt descending inside the amniotic bag, and the head not easily reached. Efforts to replace the arm were made during the intervals of pains, after which the head de- scended into the pelvic excavation. 7 P. M. Pains recurred regu- larly, but deficient in duration ; bag protruded, but the pressure upon the cervix was not in proportion to either the strength of the pains or the duration of labor. 10 Pp. M. Pains complained of for the most part in the back. Cervix dilated one half, soft and thick ; bag protruding during pains ; was artificially ruptured ; liquor amnii dribbling away. Ext. ergote fl. was administered JOSEPH TABER FOHNSON. 65 in teaspoonful doses every hour, one ounce being consumed. 12 p. M. Pains in back more continuous and annoying. Cervix not dilating ; thick and soft. Uterus not contracting. Movements of fetus not felt since 6 p.m. August 8, 2 A.M. Dilatation aided by digital movements. Head engaged in pelvis ; elongating and deficient in tone and resistance; not descending with pains. 3 A.M. By forced efforts at digital dilatation and external abdom- inal pressure the head was made to pass the thick cervix, and, owing to the size of the external soft parts, the child was imme- ‘diately expelled dead. The mother made a rapid recovery. In the cases of these patients, one small, the other large in stature, both in the enjoyment of perfect health, there was, in the first place, a failure on the part of the cervix to complete dilata- tion. Second, all efforts to increase the dilatation failed to evoke the action of the longitudinal fibres, Third, after full dilatation was reached, inertia of the uterus was complete. Now, sixteen and twenty hours elapsed before resort was had to ergot with the view to excite uterine contractions, in which it not only totally failed, but, per contra, its entire influence was concentrated upon the circular fibres of the lower segment of the uterus, as was evinced both by the band around the head of one child and the death of both. If the ergot, which undoubtedly was destructive, -was employed too soon in the delivery, could instrumental inter- ference have accomplished more, considering the failure of the cervix to dilate completely, and the inertia of the uterus ? As far back as 1845, Dr. Joseph A. Eve, one of our honor- ary members, wrote a long and exhaustive paper “ On the Proper Use of Ergot in Obstetrics” for the “Southern Medical and Surgical Journal” which was published in June of that year, in which he warned the profession against its too frequent and indiscriminate use, and alleged that many fetal deaths were produced by it. He took the same ground that Beatty, of Dublin, did a few years before, that the fetus might be poisoned, even when no visible effect upon the uterus resulted, by the absorption of the essential oil into its blood, or might die soon after birth, in spasms, from its effects. Hardy, in Dublin, reported 48 cases in which he had given it to hasten lingering labors, and out of this number 34 ended VOL. VII. 5 66 THE PROPER USE OF ERGOT IN OBSTETRICS. in still-birth. McClintock reported 30 cases with 20 still- births. Busche, 175 cases in which the fetus was known to be alive when ergot was given, and of this number 25 were still-born. West reported 64 cases with 9 still-births. Meigs declared in papers and also in his work on Ob- stetrics that “ multitudes of children were dead born from this cause, by the imprudent exhibition of a medicine which as certainly excites spasm of the womb as nux vomica does in other muscles of the body.” As far back as 1850 the Academy of Medicine of Paris di- rected a commission to investigate the influence of ergot on the life of the child, which reported ‘its life endangered both by compression andnarcotism.” In 1853 the Academy form- ally adopted the conclusions of M. Depaul, that “ except in miscarriage, in certain labors attended with hemorrhage, and occasionally at the conclusion of natural labor, parturient women would be the gainers by the complete disuse of ergot.” I cannot help referring to the very full and learned paper of Prof. E. N. Chapman, of the Long Island College Hospital, published in the “ Medical and Surgical Reporter” of Phila- delphia, in January, 1861, vol. v., p. 415. He refers to Dr. Stearns who reintroduced this remedy into notice, and who used it more cautiously than many do at the present day, lost his practice from a strange mortality amongst the chil- dren, and from childbed fever which followed him like an evil genius from door todoor. He declares that “there can scarcely be any doubt that one hour’s ergot pain would be fatal to one half the children born, for they are literally smothered, since they are effectually shut out from the very source whence their blood can be supplied with oxygen.” Beatty placed it at two hours. Chapman said in 1861 that “we should never use ergot as an expulsive agent, never where the pains have been and are vigorous, never to over- come impediments such as a narrow pelvis or rigid peri- neum, and never in a primipara under any circumstances.” No arguments are necessary to prove the correctness of the teachings of our text-books in reference to the danger of its use in cases of mechanical obstruction from tumors, deformed pelvis, and rigidity of soft parts. JOSEPH TABER FOHNSON. 67 I have taken some pains to run over the literature of this subject, which is much more extensive than I had any con- ception of, and I find many instances reported, chiefly in journals, of the administration of this drug in cases of un- dilated cervix, delay in the pelvic cavity from unyielding soft parts, and rigid perineum. It seems therefore to be yet the practice of some to give ergot freely to produce dilata- tion of the os, drive the child more rapidly through the un- prepared cervix, vagina, and perineum of primiparz even, and I hope to attract the attention of this Society to the great harm which is being done in these cases. Among the poor who do not employ physicians in natural confinements, the midwives use this remedy largely. The health officer of our city informs me that the midwives re- port to his office a great majority of the still-births which appear in his monthly reports, and that upon inquiry he believes that their free use of ergot is the cause of many of their fetal deaths. It has been my misfortune to be called to a number of cases where a little delay had induced them to take from their capacious pockets their ergot bottle, which they all carry, and to quicken the pains bya few doses. No progress being made a physician would be sent for, and I have several times extracted a dead child with the forceps, after relaxing the soft parts as well as I could with chloro- form and the warm douche. I am convinced that this subject is not thoroughly under- stood, or, if understood, not fully appreciated. We have seen above that ergot acts in such a manner as not to be relied upon for aid in the class of cases just referred to. We should cause dilatation or relaxation of the soft parts by other means, and not attempt to make an exhausted uterus expel its contents by calling into requisition the powers of an agent which actually causes it to tighten its grip and re- fuse to open its door and let the fetus go. By the time the ergot pain relaxes the child has too often been asphyxiated. Can we hope to benefit a patient by its use in cases of threatened or actual abortion and retained placenta or mem- branes? I think not. 63 THE PROPER USE OF ERGOT IN OBSTETRICS. When we consider its physiological action upon uterine muscular fibre we must be convinced that, instead of expel- Jing the ovum or secundines, we run the risk of securely shutting them up inside the uterus, thus preventing, for a time at least, the use of safer means which should have been employed instead of the ergot. In cases of retained membranes after an abortion I am positive that the labor of their extraction has been made tenfold more difficult, and to that extent dangerous, by giv- ing ergot with the expectation of causing their immediate expulsion. Before its exhibition the examining finger could distinctly feel the retained mass through the partially di- lated cervix. It could be felt, but could not be grasped for removal. Whereas after its effect had been produced I could not even reach or feel it, the fibres of the lower uterine segment and internal os being in a state of firm, tonic, unyielding contraction. If an exact dose could be prescribed which would reproduce suspended pains resem- bling normal intermittent uterine contractions, this remedy would, in such dose, be an unalloyed blessing, but such, un- fortunately, is not the case. In these cases the risk of doing harm is so great that it would be much safer to rely upon other well-known means for extraction, or, if there be hemorrhage, to tampon the vagina securely and await the action of nature, watching meanwhile for any symptoms of danger. As a prophylactic against post-partum hemorrhage it is quite the custom of many to give it as routine practice, but we cannot rely upon it. In the fifteen or twenty minutes which it takes to act the patient might be lost even if her stomach were in a condition to absorb it. Unfortunately for its reputation it frequently produces vomiting, and thus adds to the exhaustion and danger of the patient. If she be much weakened by loss of blood. it will not be absorbed, and the golden moments are lost which might have been profitably spent in the use of better means. Authors who recommend it for this accident advise that no dependence be placed on its controlling the flow, but that, while waiting YOSEPH TABER F¥OHNSON. | 69 for its action, we proceed as though it had not been given. The hypodermic use of ergotine acts more quickly, and with the advantage that it cannot be vomited or lie unabsorbed in the stomach. In desperate cases this advantage would outweigh any damage which it might do. The risks of the intra-uterine injection of Monsel’s solution with its attend- ant evils are to be welcomed rather than speedy death by hemorrhage. In the floodings of pregnancy, namely, threatened abortion, placenta previa, and accidental hemorrhage, I do not see that ergot is indicated. When this drug is prescribed it should be with a full knowledge of its powers, and not with a simple belief that it quickens and intensifies uterine contractions, and is there- fore to be used in all cases where it is desired to accomplish these results. So far as my own opinion is concerned, I am free to say that I think the human race would be better off if ergot should be utterly abolished from the lying-inroom. I be- lieve that as at present employed it does vastly more harm than good to parturient women and their unborn children. It certainly should never be given to a primipara. It would be safer to give it to no woman in labor ; but in care- ful hands, when its powers are fully known and its dangers appreciated, it might perhaps be administered in the second stage with advantage, to overcome uterine inertia, but only then in cases where the soft parts are relaxed, and we are quite certain both from present appearances and the his- tory of former labors that the child will be born in half or three quarters of an hour. Even then for the full protec- tion of the child frequent auscultation should be practiced, and upon its heart becoming slowed or enfeebled it should at once be extracted with the forceps. Similar advice is substantially given in the later text- books, but my advice would be, under such circumstances, to deliver with the forceps without subjecting the mother and child to the dangers of ergot. In the dilated and re- laxed conditions of the soft parts in which these authors ad- 7O THE PROPER USE OF ERGOT IN OBSTETRICS. vise the use of this oxytocic the forceps could be employed easily and safely. In cases, however, where patients fear or refuse to have it applied, ergot could first be employed with the understanding that if the child were not born in half or three quarters of an hour, or exhibited symptoms of as- phyxia, it should be extracted at once. In my case above referred to reliance was placed upon speedy delivery. A few good pains only seemed necessary for its birth, but the uterus was thrown into violent spas- modic action whereby the child’s expulsion was prevented and its only supply of oxygen effectually cut off. When the danger was fully appreciated and the forceps applied, a dead child was extracted. It may be claimed that this is not always the case, and that good results have followed the use of ergot. I am free to admit this, but when we can accomplish the same result by safer means, I hold it to be our duty not to jeopardize the life of the fetus, and the parts of the mother, by resort- ing to a treacherous and, according to abundant testimony, a dangerous remedy. Professor Penrose, in an able lecture on this subject, some time ago, reported two fatal cases of ruptured uterus, in which he attributed the rupture solely to the use of ergot. Many reports of similar and other lacerations could be quoted did time permit and the occasion require, but enough has been said on this topic to prove the danger of ergot in the second stageof labor. It should never be used in threatened abortion so long as there is any probability of saving the conception, and its energy should be invoked only when the fetus is dead, and the safety of the mother becomes our first duty. In cases where the fetus has been expelled and the membranes remain imprisoned within the uterine cavity it has been largely relied upon to cause their expulsion. But in this class of cases I am persuaded that we do harm by its exhibition. The tampon, and the subsequent complete evac- uation of the uterus by mechanical means, accomplishes the desired end in a safer and better way. After the uterus is empty and bleeding continues from atony of its walls, the YOSEPH TABER JOHNSON. 71 unyielding tetanic contraction which ergot produces acts beneficially by occluding the orifices of the bleeding vessels. Lusk advises that “it should be withheld until after the ex- pulsion of the placenta or membranes lest the uniform ute- rine contractions lead to their prolonged retention or inter- fere with manual efforts for their extraction.” The use of ergot is contra-indicated in retained placenta. It keeps up a state of painful contraction after natural labor, annoys and exhausts the patient needlessly, interferes with the normal discharge of the lochia, and perhaps aids in the causation of septicemia. Atony of the uterine walls, which is overcome by ergot in certain cases of abortion, may exist to an exaggerated degree after an otherwise natural labor, and in these cases ergot is an invaluable remedy, when great exhaustion is not present or collapse from loss of blood imminent. It would then make matters worse. Chap- man directs in most emphatic terms that it should not be used until reaction is brought about by opium and stimu- lants, as its sedative tendency would prevent reaction and directly and positively augment the prostration. In placenta previa and accidental hemorrhage ergot is not indicated if the child is viable or the possibility of prevent- ing its birth exists. As the principal indication in all cases of uterine hemorrhage from relaxed muscular fibre is to make the uterus contract and stay contracted, ergot will long re- tain a prominent place in our list of remedies; but in these very cases the woman’s safety consists in an empty and firmly contracted uterus. The action of ergot previous to the complete evacuation of the uterus would interfere with, if it would not for a time prevent, the manual efforts nec- essary for the turning and extraction of the fetus and pla- centa. Should bleeding continue subsequently, ergot is in- dicated, Midwives should be taught in some manner, by legislation if necessary, the dangers of indiscriminate use of this drug. A few convictions for infanticide by a coroner’s jury would have a very salutary effect, if they could be reached in no other way. Its sale might be regulated by law, so that it could be obtained only upon a physician’s prescription. 72 THE PROPER USE OF ERGOT IN OBSTETRICS. DISCUSSION. Dr. Joun P. REYNOLDs, of Boston. — In common, I am sure, with all the members of the Society, I express my obligations to Dr. Johnson for calling attention to the abuses of ergot. Every physician can bear witness to the existence of the facts which have been so carefully stated, and to their importance. I most cor- dially assent to the general teaching of the paper, that ergot ought not to be employed in labor until the uterus has been wholly emptied; but while I do this, I cannot help admitting that cases at times occur in which small doses of this drug, cau- tiously repeated, fulfill, even during labor, a valuable indication. If it is certain that no disproportion or deformity of child or pelvis exists, if especially male children have been previously safely delivered, if the soft parts are thoroughly prepared, and if important delay is, in the judgment of a competent attendant, due only to want of uterine action, as small a dose as ten drops of the fluid extract of ergot, repeated at intervals of ten minutes, will now and then render signal service. Careful watching of the case will soon show whether the remedy promises good results. It cannot be too strongly urged that instances of this kind form excessively rare exceptions, and that they by no means weaken the force of that general rule which the reader of the paper has so impressively laid down. It has seemed to me that in this immediate neighborhood re- sort to the hypodermic use of ergotin as a chief reliance for the control of post-partum hemorrhage has not been as general as its recognized value deserves. I shall be glad to learn, from gentlemen who often employ it, the details of its administration in their hands. The value of ergot, in cases where portions of an early ovum are retained in the uterus, is generally conceded. Theoretically, a judicious resort to opiates would seem as reasonable. If in these accidents due attention is paid to the early use of simple means of restraining loss of blood, the routine of manual interference, which is now so commonly enjoined, will in a large proportion of cases be found unnecessary. Ergot is advantageously given after delivery is complete to lessen the liability to after-pains by insuring prompt and thorough uterine contraction. In common with many of my DISCUSSION. 73 colleagues, I believe this to be good practice, even though these contractions be made, at first, more sharp under its use. Com- mon prejudice especially authorizes this procedure when the long administration of anesthetics has been demanded. I have been glad to follow this habit, though I have seen no reason for think- ing that ether, if suitably used in labor, predisposes to post-partum hemorrhage. Dr. Forpyce Barker, of New York.—I will not take up the time of the Society by any protracted remarks, because the subject is so broad, and affords opportunity for the discussion of so many points, that it will be utterly impossible to enter into any complete discussion of it at this time. All will agree that it is most desirable that we should have formulated if possible, and perfectly fixed, certain rules which will govern us in our practice. This should be the case with reference to all measures to be used in that class of cases in which we are re- quired to act promptly and most decidedly ; but at the same time there is difficulty in laying down positive rules which may not have exceptions that are most important. I suppose it is agreed that ergot should never be administered in advanced parturition under certain circumstances ; that it should never be used to in- duce uterine contraction in the first stage of labor ; that it should never be used except in vertex presentations ; that it should never be used where there is the slightest disproportion between the fetus and the passages of the mother ; that it should never be used unless the soft parts are perfectly prepared for dilatation ; that it should never be used unless all mechanical conditions are such that if sufficient uterine forces are present the fetus will be expelled rapidly, say within half an hour. All these principles are fixed, at the present day, among obstetricians. But when I hear it said, and laid down as an absolute rule, that ergot should never be given for purposes of exciting uterine contraction in labor, I think it is going a little farther than I should deem wise. It is exceedingly rare that I give ergot for the purpose of expelling the fetus, and yet there are some exceptions where, as I think, it can be administered with great advantage. All of us meet with patients in whom labor is retarded by morbid sensitiveness to pain, and often, under the moderate use of anesthetics, labor is assisted by calling into play all the accessory muscles which are under the control of the voluntary powers of the patient. But now and then we have patients who are so sensitive to pain that they re- 74 THE PROPER USE OF ERGOT IN OBSTETRICS. sist, by the voluntary action of their muscles, the progress of labor to a very great degree, and instead of bringing the voluntary muscles to the aid of labor so soon as pain approaches, they shrink from it; and, occasionally, after a certain time has elapsed, and a very great degree of suffering has been endured — perhaps they have been in labor some hours without accomplish- ing anything — the labor ceases, not on account of lack of uterine power, or muscular efforts, but because the nerve forces of the woman have become exhausted. Now, in these cases, I have found ergot, whenever this point has been reached, and there is no mechanical obstruction, or improper condition of the soft parts, to be a drug of very great service. I then put the patient under the influence of an anesthetic, giving chloroform in very minute doses until I overcome the morbid sensibility to suffer- ing, and then I give free doses of ergot to stimulate the uterus to action, and all the accessory muscles soon come into play, and the labor is usually quickly and successfully terminated. If, however, there is any delay, then I apply the forceps, because the conditions implied in the statement which has already been made show that there is no danger in the use of the instrument. Cer- tainly, therefore, I should hesitate about laying down positive rules concerning the use of ergot in the second stage of labor. Now, while I am almost in perfect accord with the paper which Dr. Johnson has read, yet there are certain points in which I feel I must disagree with the author, and upon these I will offer a few words, based upon my own experience in the use of the drug. Dr. Johnson has expressed the opinion that the use of ergot favors after-pains, and contributes greatly to the suffering of the patient. Upon this point I will say that I habitually give ergot after the birth of the child, but it is not chiefly for the purpose of preventing hemorrhage, for, if the danger of this be imminent, we cannot wait for the action of ergot. I give it to secure per- manent contraction of the uterus, and aid its effects by pressure, etc. I therefore give ergot, not expecting that it will prevent hemorrhage, but it is for the purpose of the subsequent effect produced by the drug. It is extremely rare now that I have patients suffer from after-pains sufficiently severe to prevent them from sleeping, and I have ascribed the effect to the attempt at securing fixed contraction of the uterus, and for this purpose ergot assists in preventing relaxation. ‘The fixed contracted con- DISCUSSION. 75 dition of the uterus, therefore, which I aim to procure, is due partly to the ergot and partly to the other means employed ; and when these effects are completely obtained, any effusion of blood into the cavity of the uterus is prevented, and in that way the occurrence of after-pains is avoided. Aside from these points I agree entirely with the author of the paper. I will now refer to one point not mentioned in the paper. In my own estimation, an immediate and valuable result from the use of ergot in parturition is its promoting rapid and speedy in- volution ; and, also, the effect which this drug has in combination with other drugs, such as iron and nux vomica, in cases in which involution has been retarded on account of post-partum hemor- rhages, or from local causes. I think one of the most valuable effects which the drug can produce is the aid which it gives in causing involution, and I almost invariably administer it in the treatment of the puerperal woman during the first few days after labor in those cases in which the woman is feeble and has a slow getting up, as it is called; and I have found ergot, com- bined with stimulants, iron, and strychnia, especially valuable. THE PRESIDENT. —I would suggest that in the course of the discussion some of the members should consider the influence which the anesthetic has upon the action of ergot, such, for exam- ple, as is sometimes seen in connection with the use of opium. I throw out this suggestion because opium sometimes remains in the stomach apparently inactive, and, then, when the anesthetic is administered, the full effect of the opium will be produced, and at the same time the opium will increase the action of the anes- thetic. Have similar results been observed with reference to ergot? Dr. BARKER. — That was just one of the points, Mr. President, that I had intended to speak.of, but it accidentally slipped from my memory, and upon it I will add only a few words. I see it constantly stated in various periodicals, etc., that the use of anesthetics greatly increases the dangers of post-partum hemor- rhages. Now, I wish to say that for thirty-four years I have rarely delivered a woman without the use of anesthetics, never where there has been any considerable pain; yet, I say boldly that I have never had a post-partum hemorrhage in my own prac- tice — and I have certainly used anesthetics in several thousand cases — except in one case in which no anesthetic was used ; but it occurred just at the time of the expulsion of the child, the 76 THE PROPER USE OF ERGOT IN OBSTETRICS. labor being very short, less than one hour. I always, however, exercise the utmost care to prevent the occurrence of post-partum hemorrhage by following up the uterus by manual pressure, and its non-occurrence may be also partly due to the fact that I use ergot immediately after the expulsion of the placenta for the pur- pose of securing firm contraction of the uterus. I believe that instead of the anesthetic being the cause of post-partum hemor- rhage it is, in a large proportion of cases, the best of all meas- ures for preventing it. What is the cause of post-partum hemor- rhage? In many cases it is due to exhaustion of nerve power, and this loss of nerve power is prevented by the use of the anes- thetic. Ihave attended patients who, in previous labors, had had their lives very much endangered by post-partum hemorrhages, and who had been placed under my care for this very reason. All these patients I have watched with the greatest anxiety, and endeavored to see that they were in such conditions as best resisted the occurrence of post-partum hemorrhage when the time for labor had arrived. I questioned many of them, or some of their intimate friends, and found that their former de- liveries had almost invariably been followed by extreme prostra- tion, and that, when labor was completed, they were in an ex- ceedingly feeble condition; that so feeble was their condition throughout the course of the labor the physicians had not dared to give chloroform on account of the peculiar idiosyncrasy and the tendency to the occurrence of hemorrhage — the very reason for which it should be given. In such cases these patients have invariably remarked to me, as soon as they have come from under the influence of the anesthetic, “ How different I am from what I ever was before after confinement.” They take nourishment, and express themselves as feeling comparatively in good spirits ; so that instead of considering the danger of the occurrence of post-partum hemorrhage as being increased by the use of anes- thetics, I consider anesthetics as one of our aids in preventing it. I have taken the liberty of making these remarks because of the so frequent expressions which I have heard that anesthetics in- crease the tendency to post-partum hemorrhage. I may add that chloroform is the anesthetic which I always make use of in ob- stetric practice. THE PRESIDENT. — The point I would like to have brought out in the discussion is the effect of anesthetics in those cases in which ergot has been administered and failed ; and the question DISCUSSION. aT was, whether the ergot which had failed had been aroused to action by the anesthetic administered subsequently? Dr. W. T. Howarp, of Baltimore.—I have always been greatly influenced by the instructions of my old teacher, the late Prof. Charles D. Meigs, with reference to most questions in obstetrics ; and I can say that I have never, in a single in- stance, used ergot for the purpose of increasing the expulsive powers of the uterus. It has always been my practice, when- ever I desired to supplement the expulsive forces, to employ the forceps, and I do so because the action of ergot, when it is established, never ceases. In all those cases in which ergot has been given where there has been an impediment to the exit of the child, it has been, if not criminal, the most hazardous prac- tice which could be adopted. Soon after anesthetics were intro- duced into obstetric practice I attended a lady in her first con- finement. It was the second case in which I had used anesthetics. She had excessive post-partum hemorrhage ; and, upon this point, I am entirely convinced that in cases where chloroform is used it does increase the liability to the occurrence of this accident by relaxation of the uterus in common with that of the other muscles of the body. In all cases, therefore, I have ergot present ; so that if it becomes necessary to use chloroform, this drug can be promptly administered. If I know that the woman is predisposed to post-partum hemorrhage I begin with the hypo- dermic administration of Squibb’s solid extract, five grains to eight or ten minims of water, as the head passes the vulva. And over and over again I have administered it; and yet hemorrhage has threatened, or has occurred to a certain extent. I do not be- lieve that the patient is entirely free from the liability to post- partum hemorrhage when under the influence of the anesthetic, and I very frequently give ergot hypodermically when urgently needed, because it will enter the circulation much more promptly than when administered by the mouth. Usually, when I use chlo- roform, I give, just as the head passes through the vulva, a full dose of ergot at once, a drachm of the fluid extract, for the pur- pose of securing prompt uterine contraction. Some obstetricians prefer hydrate of chloral to chloroform in cases of rigid, undi- latable cervix ; but in a number of cases I have seen relaxation rapidly occur under the influence of that drug, even when ergot had been administered to counteract its effects. There is another point to which I would direct attention, and 78 THE PROPER USE OF ERGOT IN OBSTETRICS. it is that the use of ergot diminishes to a certain extent the lia- bility to some forms of puerperal fever, and it does so by pre- venting the tendency, which exists in some cases, to the retention of blood and putrefactive substances in the cavity of the uterus. In certain cases, when I desire to increase the contractile powers of the uterus, I have often seen good effects follow the use of the sulphate of quinine in ten to fifteen grain doses. I would say, then, that ergot should rarely be given for increasing the expulsive powers of the uterus; but in all cases in which chloroform is administered, it is safe to give it in full doses immediately on the completion of the labor. Dr. J. D. Trask, of Astoria, New York.—It has been my practice of late years uniformly to resort to the forceps as an adjuvant to uterine pains in preference to ergot. In the early years of my professional life I was in the habit of using ergot for this purpose, but it is so uncertain in its effects, and its re- sults are often so unpleasant, that I have given it up altogether. There is a practical point which I may mention, and it is this: I have been in the habit, during the last few years, of giving a drachm of the fluid extract of ergot immediately upon the expul- sion of the head of the child, not to aid the expulsion of the placenta, for, if I had not confidence in the expulsive power of the uterus to eject the placenta before the action of the ergot could be secured, I should be unwilling to administer the ergot, fearing that it might prove a source of embarrassment rather than a help. It has occurred to me in cases of multipare, and I presume the same thing has occurred to others, to have a satis- factory expulsion of the child and of the placenta, and, as I sup- posed, a sufficient contraction of the uterus ; and yet, in the course of three quarters of an hour, possibly, after leaving the house, I have been called back to find my patient suffering from severe but irregular pains in the abdomen, with all the symptoms of serious loss of blood, and, upon examination, found the vagina filled with blood, and the uterus with a hardened mass of coagula, the result of alternate relaxation and contraction. Now, since I have resorted to the practice of administering immediately upon the expulsion of the head a drachm of the fluid extract of ergot, I have not encountered a single instance of this kind. I am greatly surprised at Dr. Barker’s experience in the use of anesthetics. With me there has been a growing mistrust for years concerning the use of chloroform in obstetric practice. I scarcely DISCUSSION. 79 ever administer it without being made aware of the inefficiency of uterine contraction, and I have made up my mind that I will not employ it any more in cases of normal labor. It was only last winter that I was in attendance in a case in which I administered chloroform little by little, because the effects all seemed to be of the most favorable character; but after a short time uterine inertia supervened, which finally compelled me to resort to the forceps. JI administered a drachm of the fluid ex- tract of ergot immediately after the expulsion of the head, and, although the patient was a primipara, there was a profuse uterine hemorrhage which I could not help attributing largely to the in- fluence of the chloroform. ‘These remarks do not apply to the use of sulphuric ether. Dr. G. J. Encetmann, of St. Louis. — There is one point which may be mentioned, and which has not yet been referred to. Dr. Johnson’s paper treats especially of the great dangers of the use of ergot in the hands of unskilled persons, and sec- ondly of its use in the hands of skilled obstetricians. In the first place he has well spoken of the great danger which arises from the use of the drug in the hands of midwives. Now, I think, with reference to the abuse of ergot by midwives, it would be better, instead of preaching concerning its dangers, to give in- formation with reference to some more harmless remedy, such as the sulphate of quinine, or ipecac, or Dover’s powder, which will, in many cases, answer the same purposes as ergot, and be attended with very much less danger. For the guidance of skilled practi- tioners it is difficult to lay down general rules concerning the ad- ministration of ergot. There are a few general principles which have been established and accepted. I have always carried it with me, but I have rarely used it ; and whenever I have done so, I have doubted whether any great benefit has followed its ad- ministration. In cases of subinvolution I have also used it, and in those I believe we have equally efficient remedies in external manipula- tions, hot-water injections, etc. ; and hot water with disinfectants will do much to prevent the dangers which follow incomplete contraction of the uterus after removal of the placenta. I believe that hot water with carbolic acid, or salicylic acid, will answer a better purpose than ergot, and will at the same time prevent any danger which may arise from infection. Dr. JoHnson.—TI have but a word to say, in closing the dis- 80 THE PROPER USE OF ERGOT IN OBSTETRICS. cussion, referring to a remark by Dr. Engelmann. It was not my intention, Mr. President, to formulate rules for the guidance of members of this Society, but it was my purpose to draw attention to the great danger of the use of ergot in the hands of less skill- ful men who do not fully appreciate its dangers. For skillful men it would be impertinent to lay down further rules than we now have. With regard to the effect of chloroform upon the action of ergot —the point referred to by the President — I have had no experience. I have had little experience in the produc- tion of post-partum hemorrhage by the administration of chloro- form, although I give it very frequently to women in the last part of the second stage of labor. Upon general principles, however, it would seem that chloroform might produce relaxation of the uterine walls, and I have given ergot, as a rule, for the preven- tion of such hemorrhage. With reference to subinvolution — the point mentioned by Dr. Barker — it was a most excellent one, but it was not the intention of the paper to consider the use of ergot in connection with that class of cases. I only desired to draw attention to the use and abuse of the drug in the lying-in chamber. In the treatment of subinvolution it is certainly a most excellent remedy, as has al- ready been mentioned by Dr. Barker. In conclusion, I would return my thanks to the Society for the kind reception which it has given my paper. THE OVARIAN CELL; ITS ORIGIN AND CHAR- ACTERISTICS. BY THOMAS M. DRYSDALE, A. M., M. D.,, Philadelphia. In fulfillment of a promise, made at our last meeting, this paper has been written in reply to the remarks of Dr. Gar- rigues on the ovarian cell. It will be remembered that in his article on ‘ Explora- tory Puncture of the Abdomen,” in describing the histologi- cal elements which are found ina “ Myxoid Proliferous Cys- toma,” or multilocular ovarian tumor, he made the following statement }:— “Besides epithelial cells ovarian fluid contains usually a large number of free nuclei; some of them have dark gran- ules, others shining. The latter are the corpuscles known in this country as Drysdale’s corpuscles. Dr. Drysdale de- scribed them himself under the name of ‘ granular ovarian cells.. They are small, roundish, or slightly angular (2. ¢., globular or polyhedral) clear bodies with a small number of shining granules placed at some distance from one another. They have no nucleus, nor does any appear by the addition of acetic acid. Their size ranges from a little below a red blood corpuscle to a little above a pus corpuscle. In ap- pearance they are entirely like the pyoid bodies described and delineated by Lebert, who, as early as 1846, indicated the test with acetic acid as characteristic of them, but Le- bert says he found these bodies in the peritoneum, in the synovial membrane of the knee, in congestive and metastatic abscesses, and often mixed with common pus corpuscles, 1 American Gynecological Transactions, 1881, vol. vi. p. 54+ VOL. VII. 82 THE OVARIAN CELL. both in extravasations and in the false membranes seen on mucous and serous membranes. In ovarian fluids these bodies were first described and delineated in 1852 by John Hughes Bennett, with indication of the effect which acetic acid has on them. They are not cells but nuclei.” “Dr. Drysdale has himself pointed out the fact that they never have a nucleus, which is quite natural if they are themselves nuclei. These nuclei are in a state of fatty de- generation as seen by the clear, highly refracting globules in their interior, They are never found in the quite young, microscopical cysts, developed in the wall of larger cysts, while we seldom miss them in the latter. In Case XXXII. I was able to observe directly the identity of Drysdale’s cor- puscles, the colorless corpuscles with fine dark granules, and the nuclei of the epithelial cells. The fluid contained flakes large enough to be visible to the naked eye. Some of these showed still indistinct outlines of cells, some of which con- tained nuclei in every respect identical with the Drysdale corpuscles found in the surrounding fluid. In others, most of the cells were no longer recognizable as such, having been dissolved and blended together into a thready mass with holes in it. In this mass and in these holes were found nuclei, —some with fine dark, others with shining, granules. In a few places this nucleus could still be seen embedded in its cell, or a cell was seen without nucleus, but full of large, shining granules, in other words, changed into a large Bennett’s corpuscle. I have followed the same pro- cess in the walls of minute microscopical cysts. When we examine them at their very first appearance, when a cay- ity begins to be formed in an epithelial pouch, we find that they contain exclusively colorless corpuscles without shining granules, and corresponding entirely in size and shape with the nuclei seen in the surrounding epithelium. In these minute cysts, then, a melting process is going on. The bodies of the epithelial cells are dissolved by what appears to be a colloid degeneration, and the nuclei set free. In secondary cysts as large asa hazel-nut, I have found large masses of the epithelial lining thrown off, and forming flakes THOMAS M. DRYSDALE. 83 in the fluid. In due time these are also dissolved, producing a colloid fluid, and the nuclei become free. Later, these may undergo fatty degeneration, and then we have Drysdale’s corpuscles.” “ These bodies are not only not pathognomonic of ovarian cysts, but they do not even prove that the fluid examined has been taken from any kind of cyst. I have found them in a cyst of the broad ligament, in a suppurating cyst of the abdominal wall, in a case of cancer of the peritoneum, in a renal cyst, and in a vaginal cyst ; and similar observa- tions have been made by others. On the other hand, I have looked in vain for them in six cases of ovarian cysts. The result of my researches is, then, that there is zo pathogno- monic morphological element in the fluid of ovarian cysts.” In order to contrast these statements and conclusions with my own, and to point out clearly how they differ, I will make some extracts from a former paper. After stat- ing that my remarks apply only to fluids removed from the abdomen by tapping, and describing the microscopic char- acters of ovarian fluids, I proceed: “ But xo matter what other cells may be present or absent, the cell which is almost invariably found in these fluids is the granular cell,” } “This granular cell, in ovarian fluid, is generally round but sometimes a little oval in form, is very delicate, trans- parent, and contains a number of fine granules, but no nu- cleus. The granules have a clear, well-defined outline. These cells differ greatly in size, but their structure is al- ways thesame. They may be seen as small as the one five- thousandth of an inch in diameter, and from this to the one two-thousandth of an inch ; in some instances I have found them much larger, but the size most commonly met with is about that of a pus cell. The addition of acetic acid causes the granules to appear more distinct, while the cell is rendered more transparent. When ether is added the granules become nearly trans- parent, but the aspect of the cell is not changed. This granular cell may be distinguished from the pus cell, lymph 1 Atlee, Diagnosis of Ovarian Tumors, Philadelphia, 1873, p- 458. 84 THE OVARIAN CELL. corpuscle, white blood cell, and other cells which resemble them, both by the appearance of the cell and by its behavior with acetic acid. The pus and other cells which have just been named are often distinctly granular; but the granules are not so clearly defined as in the granular cell found in ovarian dis- ease, owing to the partial opacity of these cells ; and when the granular cell of ovarian disease and the pus cell are placed together under the microscope, this difference is very apparent. In addition to the opacity of these cells, we fre- quently find their cell wall wrinkled rather than granular ; and further, in the fresh state, they are often seen to con- tain a body resembling a nucleus. But if there is any doubt as to the nature of the cell, the addition of acetic acid dispels it; for if it is a pus cell, or any of the cells named above, it will, on adding this acid, be seen to increase in size, become very transparent, and nu- clei, varying in number from one to four, will become visi- ble. Should the cell, however, be an ovarian granular cell, the addition of this acid will merely increase its transpar- ency and show the granules more distinctly. This ovarian granular cell I consider as diagnostic of ovarian dropsy, and have seldom failed to find it in this fluid. “The compound granular cell, the granule cell of Paget and others, or inflammation corpuscle of Gluge, is also oc- casionally present in these fluids, and might possibly be mistaken for the ovarian granular cell ; but it is not difficult to distinguish them from each other. Gluge’s cell is usually much larger and more opaque than the ovarian cell, and has the appearance of an aggregation of minute oil globules, sometimes inclosed in a cell wall, and at others deficient in this respect. The granules are coarser and vary in size, while the granules of the ovarian cell are more uniform and very small. Again, the behavior of these cells on the addi- tion of ether will at once decide the question ; for while the ovarian granular cell remains nearly unaffected by it, or at most has its granules made paler, the cell of Gluge loses its granular appearance, and sometimes entirely disappears through the solution of its contents by the ether.” THOMAS M. DRYSDALE. 85 In another place! the ovarian cell is spoken of as “ A cell which I have named the ovarian granular cell, to distinguish it from all other cells found in abdominal dropsical fluids ; not meaning to assert that a cell having a similar appear- ance may not be found in cysts met with in other parts of the body. This cell, when found in this location, I believe to be pathognomonic of ovarian disease, and as such its di- agnostic value cannot be overestimated.” Again, “A full and accurate description of this ovarian granular cell has, therefore, never been published, to my knowledge, except by me, nor any tests given by which to distinguish it from others, such as the pus cell, white blood corpuscle, and the compound granule cell, which often closely resemble it. This renders all descriptions of granu- lar cells seen in ovarian fluids, heretofore given, of little value, as these last-named cells are frequently found in fluids removed from the abdomen, which might, on that ac- count, be considered ovarian.” “JT claim, then, that a granular cell has been discovered by me in ovarian fluid, which differs in its behavior with acetic acid and ether from any other known granular cell found in the abdominal cavity, and which, by means of these reagents, can be readily recognized as the cell which has been de- scribed ; and further, that by the use of the microscope, as- sisted by these tests, we may distinguish the fluid re- moved from ovarian cysts from all other abdominal dropsi- cal fluids.” The two statements in regard to the ovarian cell may be summarized as follows : — I assert: 1. That a cell, called the ovarian granular cell, is almost invariably found in the fluid of ovarian cysts. 2. That this cell may be distinguished from the pus cell, lymph corpuscle, white blood, and other cells which resem- ble them, both by the appearance of the cell-and by its be- havior with acetic acid. 3. That it has been named the ovarian granular cell to 1 Transactions of the American Medical Association, 1873, vol. Xxiv., p- 179. 86 THE OVARIAN CELL. distinguish it from all other cells found in abdominal dropsical fluids ; not meaning to assert that a cell having a similar appearance may not be found in cysts met with in other parts of the body. 4. That this cell, when found in this location, I believe to be pathognomonic of ovarian disease. 5. That this granular cell in ovarian fluid was discovered by me, and that it differs in its behavior with acetic acid and ether, from any other known granular cell found in the abdominal cavity. 6. That a full and accurate description of this cell has never been published, to my knowledge, except by me, nor any tests given by which to distinguish it from others which often closely resemble it. On the other hand, Dr. Garrigues asserts :— 1. That the bodies found in ovarian fluids, and known as Drysdale’s corpuscles, ave not cells, as Dr. Drysdale has represented them, but ave nuclez. 2. That in appearance they are entirely like the pyoid bodies described by Lebert as early as 1846, and that the test for them, as given by him, is the same, z. ¢, acetic acid. And further, that Lebert has shown that they can be found in various parts of the body. 3. That in ovarian fluids these bodies were first described in 1852 by John Hughes Bennett, with indications of the effect which acetic acid has on them. 4. That these bodies are not pathognomonic of ovarian nor any other cysts, as they may be found in various parts of the body. It will be perceived that the first and last of Dr. Garri- gues’ statements merely express a difference of opinion, but the second and third amount to grave charges which I will endeavor to refute. Whilst our views are antagonistic on all these points, it will be found that in one thing Dr. Garrigues, in common with the most careful observers, agrees with me. He says,! “Besides epithelial cells ovarian fluid contains usually a 1 Gynecological Transactions, vol. vi., p. 54. THOMAS M. DRYSDALE. 87 large number of free nuclei, some of them have dark gran- ules, others shining. The latter are the corpuscles known in this country as Drysdale’s corpuscles ;” and again, “ The only corpuscles in ovarian fluid I have found it really diffi- cult to distinguish from Drysdale’s so-called ‘ovarian gran- ular cell’ are thorn-apple or rosette-shaped red-blood cor- puscles, the knobs on the surface of the latter, seen from above, giving an appearance which is very like that of the shining granules in the interior of Drysdale’s corpuscles. But, by paying close attention, we will find the contour of a rosette-shaped blood corpuscle scolloped, while that of Drysdale’s corpuscles is even.” He thus admits the exist- ence of a peculiar body in ovarian fluids which can be read- ily identified as the one which I have described as the ovarian cell. The question, then, is not as to the existence of such a body, but as to its true character and diagnostic importance. That the subject may be fully understood, it will be neces- sary to give my own views in regard to the origin and char- actistics of the ovarian cell before replying to the remarks of Dr. Garrigues. The reader of my former papers will have noticed that the origin of the cell was not alluded to inthem. The reason for this omission was that they were intended to be entirely practical, and as concise as was compatible with clearness of description ; the principal object kept in view being simply to point out such peculiarities of the fluids and cells as could be recognized by other observers. I soon discovered, how- ever, that in making the papers so brief, I had made a mis- take. Even experienced microscopists misunderstood what, it was thought, was clearly described. For instance, in an early criticism I was accused of ? ‘‘opening an elementary question in pathology long since settled, and representing as ‘ovarian’ the ordinary compound granule cell formerly im- properly called ‘the exudation corpuscle’ or ‘inflammatory 1 American Fournal of Obstetrics, January, 1882, p. 24. 2 “Proceedings of the Pathological Society of Philadelphia,” 7ed- tcal Times, April 12, 1873, p. 445. 88 THE OVARIAN CELL. corpuscle’ of Gluge, and,” says the writer, “for some time determined to be nothing but a fattily degenerated cell, in whatever locality found, and liable to be found in any local- ity.’ An eminent professor of pathology in Glasgow wrote to me: “I do not quite see how your ovarian cell is to. be distinguished from a cell just at the beginning of the process which ends in the compound granular corpuscle ;” which proved that he did not understand the matter. Pro- fessor Otto Spiegelberg asserted in an article on the sub- ject that I was “not up to the mark of the German re- searches.” ! Others supposed that I was describing a specific cell like the cancer cell. Others, again, believed that it was merely an altered white blood or pus cell,® etc. It may be here stated that many of these writers have since changed their opinion. The author of the first criticism, in a more recent publication, recalled what he had said ;* while Professor Spiegelberg, in a letter to me, which I have here, promised to correct what he had written. But enough has been adduced to show that what had been published was misunderstood. In taking up the subject again, after ten years of silence, IT trust that I shall be able to make my meaning sufficiently clear to convince you that my descriptions of this body were accurate, that my claim of priority of description was well- founded, and that I was correct in considering it a’ cell. Having already reproduced the description of the cell in the opening of this paper, it will only be necessary to treat of its origin. In examining the inner wall of an ovarian cyst it will be found to have, like the Graafian follicle from which it is de- rived, an epithelial lining. This lining serves to secrete the contents of the cyst, and is itself constantly undergoing growth and decay. When we remember the enormous amount of fluid produced by these cysts, and the rapidity of 1 American Fournal of Obstetrics, November, 1873, p. 353- 2 American Fournal of the Medical Sciences, April, 1882, p. 430. 8 Jbid., April, 1882, p. 432. 4 Philadelphia Medical Times, March 28, 1874, p. 411. THOMAS M. DRYSDALE. 89 their growth in most cases, it will be readily conceded that they are possessed of an intense vital activity. The cell ele- ments multiply rapidly, and are cast off, pari passu, with the increase of the cyst. In this hurried growth a great number of the epithelial cells do not come to maturity, but are thrown off before being completely developed, or, in other words, be- fore a nucleus has formed inthem. This rapid growth and shedding is, as is usual in such cases, attended by a partial fatty degeneration of the cells, giving them their granular ap- pearance. Being immediately immersed in the albuminous fluid of the cyst they acquire, by maceration in it, that deli- cacy and transparency so peculiar tothem. In short, the ova- rian cell is not claimed to be a new cell, but an epithelial cell in an immature condition, produced in ovarian cysts by rea- son of their rapid growth. This is the origin of the ovarian cell. But, it may be said, this is merely a theory of their forma- tion. What proof can be given to show the correctness of this conclusion? The evidence may be found in a careful examination of the epithelial lining of an ovarian cyst, and of the contained fluid. This will reveal epithelial cells in all.stages of development. They can be followed from the exceedingly small, aborted cell without nucleus, found in greatest abundance in the fluid, but also found in the epi- thelial layer, to the fully formed columnar epithelial cell, which, from its firmer attachment to the cyst wall, is often absent from the fluid. The various stages of development of these cells is best observed in a thick-walled cystoma of rapid growth, as it has been found that the fluid of a cyst of slow growth and thin cyst wall contains, as a rule, comparatively few of these cells, while that of a thick-walled cyst growing rapidly holds them in abundance. These gradations have been traced by me repeatedly in the numerous examina- tions which I have made of these fluids and cysts. This conclusion in regard to the origin of the ovarian cell can scarcely be regarded as a hasty one, when it is remem- bered that these investigations were pursued by me for twenty years before a word was published on the subject. 90 THE OVARIAN CELL. For many of these years I also believed these cells to be the nuclei of the epithelial cells, but repeated examinations of the cyst walls and contents finally convinced me of my error. I was first led to doubt the fact of their being nuclei by the want of correspondence. between their size and that of the nuclei of the matured epithelial cells, and from find- ing some of these bodies nucleated; and further search proved that in a few of them, apparently destitute of a nu- . cleus, one could be discovered by coloring with carmine. Again, the presence of such an abundance of nuclei, if nu- clei they were, in the fluid would indicate the existence of cells in great numbers undergoing the process of disintegra- tion and leaving their nuclei comparatively unacted upon. But, although numerous epithelial cells which had under- gone fatty degeneration were met with, in most of them the nucleus was still present, and, as a rule, equally degenerated with the rest of the cell. These facts could not be recon- ciled with the belief that these bodies were nuclei, and fur- ther research became necessary. This was undertaken, and resulted in the conclusion, which has been stated, that the ovarian cell is not a nucleus but an immature, or aborted, epithelial cell, which has undergone a certain amount of fatty degeneration. But Dr. Garrigues in his first statement, and in fact all through his paper, asserts that I have erred in describing this as accell. ‘It will be seen,” he says, “that I do not re- gard Drysdale’s corpuscles, as he does himself, as cells. I do not see any reason why this corpuscle should be looked upon as a cell, its most distinctive character being never to have a nucleus, while this peculiarity is quite easy to under- stand when it is itself a nucleus.”! Or, in other words, if it has no nucleus it is not a cell. Many other writers have held the same opinion as to the nature of this body. Spen- cer Wells, for instance, in describing the ovarian cell, says, “We suppose these [bodies] to be simply the nuclei of the epithelial cells which line the interior of the cyst. The scales are thrown off, the cell wall breaks down, and the nu- 1 American Fournal of Obstetrics, January, 1882, p. 29. THOMAS M. DRYSDALE. OI cleus remains.” ! Spiegelberg, and many other observers, also believed this to be true. As this view may be again advanced, even after what has been said in regard to the origin of the cell, and as, in fact, there seems to be a differ- ence of opinion as to what a cell really is, a few words as to its definition will not be out of place. What, then, is meant by a cell? Must we cling to the old definition, and consider a cell only as such when it pos- sesses a cell wall, inclosing a cavity in which are fluid con- tents and a nucleus? Modern physiologists take a differ- ent view of the matter. Max Schultze takes the embryonal cell as the basis and starting point of his definition. ‘The most important cells,” he remarks, “those in which the full- ness of cell life, the unlimited power of tissue formation, is most distinctly evident, are clearly the embryonal cells, which proceed from the division of the cells of the ovum. We may see in these the true archetype of a cell, and yet they only consist of a little mass of protoplasm and a nu- cleus.”2 “ Briicke goes a step farther in his definition of a cell, maintaining that no proof has been given that the nu- cleus is indispensable to our conception of it.’? “But if we desire to be logical,’ says Stricker, “if we do not desire to advance the statement that the non-nucleated bodies of the lower plants and animals and the fertilized ovum occupy an unique and isolated position which is not assumed by any other being in the whole scale of creation, we must ex- clude the nucleus as an unnecessary factor in the ideal type of an elementary organism. We must also in future apply the histological term cell to the morphological elements of the higher animals or to independent living organisms, even if we are unable to discover anything more in their struc- ture than that they are little masses of animal sarcode or protoplasm.” 4 Carpenter, after describing a perfect cell, proceeds: “ But 1 British Medical Journal, January, 1878, p. 883. 2 Manual of Histology, by Prof. S. Stricker, p. 28. 8 Jbid., p. 29. 4 Tbid., p. 29. 92 THE OVARIAN CELL. there is a large number of cases in which the cell shows it- self in a form of much less complete development; the ‘elementary part’ being a corpuscle of protoplasm or ‘ ger- minal matter,’ of which the exterior has undergone a slight consolidation, like that which constitutes the ‘primordial utricle’ of the vegetable cell or the ectosarc of the Ameeba, but in which there is no proper distinction of ‘cell wall,’ ‘cell contents,’ or nucleus. Zzs condition, which is char- acteristically exhibited by the nearly globular colorless cor- puscles of the blood, appears to be common to all cells in the incipient stage of their formation ; and the progress of their development consists in the gradual aifferentiation of their parts, the ‘céll wall’ and ‘cell contents’ being separated (as ‘formed material’) from the ‘germinal matter,’ which last usually remains as the ‘ nucleus,’ — generally, however, contracting, and sometimes (when its work has been com- pletely done) disappearing altogether.’! Am I not correct, then, in naming this a cell, and in considering it an aborted or immature cell in which this differentiation of the parts has not had time to take place? Having presented the proof that there is such a body as the ovarian cell, and that I have correctly defined it, it will be well to answer a question which naturally presents itself. If this is but an immature epithelial cell, why has it been called an ovarian cell and described as having no nucleus? This question has been partially answered in my first paper. Be- lieving this immature cell to be the one which is character- istic of ovarian fluids, it was named the ovarian granular cell to “distinguish it from all other cells found in abdominal dropsical fluids,” or, in other words, for the purpose of iden- tifying it. And, as it was derived from the ovarian cyst, the name was thought to be appropriate. Again, it was described as it existed, not as an epithelial cell, for then a matured, nu- cleated epithelial cell would have been looked for, but as the peculiar cell which I found only, with one exception, and al- most invariably, in ovarian fluids, and which differs so 1 The Microscope, etc., by Dr. William B. Carpenter, London, 1875, Pp. 734- THOMAS M. DRYSDALE. 93 widely from the epithelial cell in size, in appearance, and in having no nucleus, that it required patient and long contin- ued search to discover its origin. Although it was occa- sionally found to have a nucleus, yet this was a rare excep- tion, the greater number, by far, having no nucleus ; therefore the rule and not the exception was described. I now pass on to examine Dr. Garrigues’ opinion in regard to the origin and nature of this body. The first remarks which he makes concerning their origin are contained in the following paragraphs :— “Tf, instead of examining old cysts, we direct our atten- tion to the very beginning of the formation of a microscopic cyst in the centre of one of the epithelial pouches which are developed from the epithelium lining the inside of the main cyst (Fig. 29), we find another process. The cavity is still so small that the opposite walls almost touch one another, and it contains exclusively colorless bodies without shining granules (Fig. 21a) and corresponding entirely in size and shape with the nuclei seen in the surrounding epithelial cells. They are only four or five ». in diameter. In another of these minute cysts (Fig. 30), the cavity of which is a little larger, we find also larger bodies, but still of the same kind, without trace of shining granules. The finely granular bod- ies are here somewhat larger, either circular with a diame- eter of seven p., or oblong, measuring seven by eleven p. One of them has a nucleolus. At the same time we notice in the wall a much enlarged epithelial cell with nucleus and nucleolus. This nucleus corresponds perfectly in size and appearance with the bodies swimming in the cavity. “In these minute cysts, then, a melting process is going on by which the bodies of the epithelial cells are dissolved, and the nucleoli set free. If we examine young secondary cysts which are large enough to form macroscopical tumors, say of the size of a hazel-nut, we may find whole masses of the epithelial lining thrown off and forming flakes in the fluid. In due time these will also be dissolved, and their nuclei set free. The nuclei may later undergo fatty degen- eration, and then they become Drysdale’s corpuscles.” ! 1 American Journal of Obstetrics, January, 1882, p. 28. 94 THE OVARIAN CELL. I have searched these paragraphs of his in vain for any evidence of the existence of this “ melting process ” which he asserts is “going on.” If they are read carefully, it will be found to be mere assertion, for not a shadow of proof is offered to show that these epithelial cells are undergoing colloid degeneration or melting. Closely examined, his statement is simply this, —that he has seen microscopic cysts lined with nucleated epithelial cells, and in the fluid of the cysts free bodies of the same size as the nuclei of the cells, and, without tracing any connection between them, he at once arrives at the conclusion that the epithelial cells have melted and liberated their nuclei —a supposition entirely unsupported by facts, for even his drawings afford no evi- dence of it, but, in truth, serve better to illustrate the de- scription which I have given of the origin of these cells. Now it must be remembered that in most microscopical . observations of these fluids and cysts a very large number of the epithelial cells are visible, and that the number I have seen in over two thousand examinations, made in the last twenty-nine years, must be almost infinite. Then, if the ovarian cell originated in the manner represented by Dr. Garrigues, and this melting process did really exist, it would be impossible not to have seen some cells undergoing the process and in the different stages of melting, from mature growth to final decay, and the liberation of the nucleus, but no such observation ever has been made. Even Dr. Gar- rigues does not assert that he has seen it, and his conclu- sion that the epithelial cell is melted down, liberating the ovarian cell of Drysdale, is not only without a tittle of evi- dence to support it, but the negative evidence against the truth of the assertion is overwhelming. Apparently not entirely satisfied with this explanation of the method by which the nucleus is freed, in another part of his paper, as has been shown, Dr. Garrigues states that the epithelial cell undergoes fatty degeneration, and that in this manner the cell wall disappears, liberating the nucleus. But, it may be asked, what proof is there of the nucleus having a greater power of resistance to the process than the cell itself ? THOMAS M. DRYSDALE. 95 Again, does the cell wall undergo either form of degen- eration, and leave the nucleus comparatively untouched ? Even Dr. Garrigues does not agree with himself here, for in describing the process of fatty degeneration in the epithe- lial cells, he says, “ Usually, the nucleus 1s destroyed, but it may still be visible.” 4 I have seen the epithelial cells in all stages of fatty de- generation, but, as a rule, the nucleus was similarly affected and undergoing the same destruction. In fact the nucleus is frequently destroyed before the rest of the cell, as is well _ illustrated in Dr. Garrigues’ drawings of the formation of Bennett’s corpuscles.2. ~ Having shown that in the descriptions which he gives of the liberation of the nucleus by colloid and fatty degenera- tion no proof can be found of the correctness of his conclu- sions, I pass on to consider the only remaining evidence of their being nuclei offered, which is contained in the para- graph in which he says, “I was able to observe directly the identity of Drysdale’s corpuscles, the colorless corpuscles with fine dark granules, and the nuclei of the epithelial cells.” He discovered this evidence in “a very thick, co/- loid, yellow-gray fluid.” “In this swam flakes of epithe- lium large enough to be seen with the naked eye. Some of these flakes showed still indistinct outlines of cells, some of which had a xzucleus identical with Drysdale’s corpuscles in the surrounding fluid. In other flakes, most cells were no longer recognizable as such. They had been dissolved and blended together to a thready mass with large holes in it. In this mass and in these holes were found nuclei, some of the finely granular semi-opaque variety, others with shining granules, z ¢. Drysdale’s corpuscles. In a few places the nucleus could yet be seen embedded in an epi- thelial cell, or a cell was found without nucleus, with large shining round granules, z. e, changed to a Bennett’s cor- puscle.”’ 8 Let us examine this description. ‘Some of the flakes,” 1 American Journal of Obstetrics, January, 1882, p. 28. 2 Tbid., p. 27. 8 American Journal of Obstetrics, p. 31. 96 THE OVARIAN CELL. he says, “showed still indistinct outlines of cells, some of which had a nucleus zdeztzcal with Drysdale’s corpuscles in the surrounding fluid.” This again is mere assertion. How does he demonstrate the identity of these nuclei, inclosed in a cell with an indistinct outline, with Drysdale’s corpuscles ? He does not say that he applied any tests. In fact, how do we know that these indistinct outlines were the outlines of cells? For nothing is more deceptive than the microscopic appearance of a colloid mass. But admitting that they were cells, and that they inclosed nuclei, does he consider the nuclei identical with the ovarian cell because they resembled them in appearance? Then he should be an able judge of the appearance of an ovarian corpuscle. But examine his drawings of nuclei! entitled, “Transition from Nuclei to Drysdale’s Corpuscles,’ and then read what follows. ‘“Thold,” he says, “most of these bodies to be nuclei of epithelial cells which undergo fatty degeneration. They vary in size from five to sixteen m., and attain exceptionally still larger proportions. Some of them are probably colorless blood corpuscles or lymph corpuscles.” Now even with these cells before him, he acknowledges that he is unable to distinguish what he considers a nucleus, that is, an ovarian cell, from a lymph corpuscle or a white blood cell. How, then, does he identify the nucleus zz the cell with the free nuclei? He does not enlighten us, but merely asserts that such is the fact. “In other flakes,” he says, “most cells were no longer recognizable as such. They had been dissolved and blended together to a thready mass with large holes in it.” Toa microscopist this description is, to say the best of it, peculiar. How did he know that the thready mass which he saw in the field of the microscope had formerly consisted of cells ? It was mere surmise. To prove it from his account of it.is simply impossible. The fact of a few broken down epithe- lial cells being present certainly did not show that the thready mass had formerly been epithelial cells, but rather the contrary. And the presence of Drysdale’s corpuscles, 1 Transactions of the American Gynecological Society, 1881, p. 54. THOMAS M. DRYSDALE. 97 if such they were, entangled in this mass, indicates nothing but the fact of the fluid being ovarian. He falls short, then, of giving any reliable evidence that these bodies originate in the manner which he represents, and of course fails to prove that they are nuclei. Believing that sufficient evidence has been advanced to show that I am correct in describing these bodies as ova- rian cells, and also that Dr. Garrigues’ assertion that they are nuclei is without foundation, I will pass to his next state- ment, which is, that “in appearance they are entirely like the pyoid bodies described and delineated by Lebert, who, as early as 1846, indicated the test with acetic acid as charac- teristic of them, but Lebert says he found these bodies in the peritoneum, in the synovial membrane of the knee, in congestive and metastatic abscesses, and often mixed with common pus corpuscles, both in extravasations and in the false membranes seen on mucous and serous membranes.” Could a statement be more positive? But to show how utterly groundless it is I will quote Lebert. In treating of pus and its varieties, he says:1 ‘The element by far the most important is the one to which we have given the name of pyoid globules, and that we regard as a variety of pus globules, with which one often finds them mixed, but from which notwithstanding they differ by several of their chemi- cal and physical characters.” He then gives the size, which is almost the same as that of the pus cell. ‘They are spher- ical and composed of two elements, of a substance toler- ably transparent, of a consistence rather solid than liquid, and of molecular granules varying from four to ten, and be- yond, irregularly distributed in their substance; but they never show any nuclei, and the acetic acid above all, in ren- dering them a little more transparent, never changes them.” If we stopped here the quotation would certainly con- firm what has been said by Dr. Garrigues, but we will read on: “They are larger and more spherical than the globules of tubercle, smaller and more granular in their substance than the white globules of blood, from which they differ by 1 Lebert: Physiologie pathologique, vol. 1., p. 46, Paris, 1845. VOL. VIL 7 98 THE OVARIAN CELL. another essential character, their yellowish tint.” Is this en- tively like the ovarian cell in appearance? Is not Lebert’s statement clear, that they can be distinguished from the white blood cell by their yellow color, and if from the white blood cell, why not from the ovarian cell, which is even more colorless and transparent ? But another important fact in Lebert’s description, which Dr. Garrigues appears to have overlooked, is that these bod- ies are only discovered in pus. Never are they alluded to as being found alone, or apart from pus; they are always spoken of as one of its constituents. Says Lebert, “We had at first believed that they were only met with in the purulent effusions of cachetic individuals, and principally the tubercular, but we are convinced nevertheless that they are present in many of the different kinds of pus, and in the most diverse constitutions. We have met with this kind in the peritoneum, in the synovial membrane of the knee, in congestive and metastatic abscess. Lastly, we have often found them mixed with the ordinary globules of pus in the extravasations, and in the false membranes of the mucous and serous surfaces.” In no place does he say he found them independent of pus—an important distinction, and one apparently ignored by Dr. Garrigues. In short, Lebert states that he found a corpuscle in pus which he could dis- tinguish from the pus cell by the addition of acetic acid, as the acid causes the pus cell to become transparent and re- veal its multiple nucleus, while the pyoid body is only made a little more transparent and shows no nuclei, and that the essential characteristic of the pyoid body is its yellow color. Hence these misleading statements, founded on an im- perfect quotation from Lebert, are disproved by Lebert’s own words. Nothing is found in his writings to support Dr. Garrigues’ assertions, for the mere fact that Lebert discov- 1 «‘Tls sont plus grands et plus sphériques que les globules du tuber- cule, plus petits et plus granuleux dans leur substance que les globules blancs du sang, dont ils différent par un autre caractdre essentiel, leur teinte jaundtre.”’ Lebert: Physiologie pathologigue, vol. i., p. 46. Paris, 1845. THOMAS M. DRYSDALE. 99 ered a corpuscle in pus which he could distinguish from the pus cell by the addition of acetic acid does not invalidate my statement that the ovarian cell “can be distinguished from the pus cell, lymph corpuscle, white blood cell, and other cells which resemble them, both by the appearance of the cell, and by its behavior with acetic acid.” Dr. Garrigues appears to have also overlooked some remarks of Lebert in speaking of this very cell, which are pertinent to the subject. “It is of the greatest importance,” he says, “to be very ex- act in these investigations, which can serve to enlighten sev- eral doubtful points of pathology with a nearly mathemat- ical precision.” + If Dr. Garrigues placed any faith in his statement why does he say, ‘“‘ The only corpuscles in ovarian fluid I have found it really difficult to distinguish from Drys- dale’s so-called ‘ovarian granular cell’ are thorn-apple or ro- sette-shaped, red blood corpuscles, the knobs on the surface of the latter, seen from above, giving an appearance which is very like that of the shining granules in the interior of Drysdale’s corpuscles. But, by paying close attention, we will find the contour of a rosette-shaped blood corpuscle scalloped, while that of Drysdale’s corpuscles is even.” ? If in appearance they are entirely like the pyoid bodies of Lebert, and the test, acetic acid, is the same in both, how is it that he finds no difficulty in distinguishing them? Of course Dr. Garrigues does not intend to mislead, but his manner of quoting, so as to cause the reader to infer that these bodies were found in the peritoneum, synovial mem- brane of the knee, etc., independent of their admixture with pus, certainly seems disingenuous. Before leaving this part of the subject it may be well to state : — 1. That if an abdominal cyst should be met with which had undergone suppuration we should find in the fluid pus cells in abundance, and, in all probability, many of these pyoid bodies of Lebert. This is also true of the inflammatory effusions in the peritoneal cavity, but the mere fact of the 1 Lebert : Physiologie pathologique, vol. i., p. 47- 2 American Journal, of Obstetrics, January, 1882, p. 24. 100 THE OVARIAN CELL. presence of the pus cells would put us on our guard, and he would be a careless observer who would be misled by these pyoid cells, even if their yellow color should not be sufficient to distinguish them. 2. That there is a cell which resembles the pyoid cell in some of its characters, but which differs from it in its want of transparency and color. It is granular, but the granules are not distinct, their outlines are not sharply de- fined. Acetic acid has very little influence on it. But its general appearance will distinguish it from the ovarian cell to a careful observer, and the acetic acid test will differen- tiate it from the pus cell, white blood cell, etc. I have described this cell in my paper on “ Dropsical Fluids of the Abdomen,” in the following words:! “ Specimens of ascitic fluid are occasionally met with containing objects which, in size and appearance, resemble the pus cell, but which show no nuclei on adding acetic acid. Their surface is generally granular, but occasionally is finely wrinkled. They differ from the ovarian granular cell in being semi- opaque, in their not presenting the clearly defined granules of the ovarian cell, and in their being of an uniform size, one two-thousandth of an inch in diameter. These cells are here described particularly, not that they are believed to be peculiar to this fluid, but in order to guard against an error in diagnosis, as they have been mistaken for the ova- rian cells.” But, as I have shown, there is but little risk of an observer who has an eye well trained to this kind of re- search mistaking the one cell for the other. His third statement is even more calculated to mislead than the last. “In ovarian fluids,’ he says, “these bodies were first described and delineated in 1852 by John Hughes Bennett with indication of the effect which acetic acid has on them.” 2 This is a direct charge that I have claimed credit for what I must have known belonged to another, as Bennett’s writing had been referred to in my first paper. To sustain this charge, Dr. Garrigues says, “In his clini- 1 Diagnosis of Ovarian Tumors, by W. L. Atlee, p. 451. 4 American Gynecological Transactions, 1881, vol. vi., p. 55. THOMAS M. DRYSDALE. IOI cal lectures on the ‘ Principles and Practice of Medicine,’ ! Bennett draws both large granular cells with or without a nucleus, and small bodies invariably without a nucleus, which latter are entirely like Drysdale’s corpuscles. Fig.172 on page 172 shows very distinctly Drysdale’s corpuscles, after addi- tion of acetic acid [the italics are Dr. Garrigues’] without nucleus. The text describes them as ‘pale, round, and oval corpuscles, the outline of which becomes stronger on the addition of acetic acid.’ ” 2 Notice the construction of this paragraph. The reader will get the impression, and it seems to be intended that he should, that the same cell is referred to in the drawing at page I, and the one on page 172. It reads, ‘“ Bennett draws both large granular cells with or without a nucleus, and small bodies invariably without a nucleus, which /atter are entirely like Drysdale’s corpuscles. Fig. 172 shows Drysdale’s cor- puscles after addition of acetic acid.” What could the reader infer from this, but that Bennett had drawn and described the ovarian cell, and had used the acetic acid test as Dr. Garrigues has asserted ? The para- graph is entirely misleading, and is well calculated to de- ceive. Thedrawing on page gt has no connection whatever with that on page 172, and it will be found that they refer to two entirely distinct varieties of cells. To understand the matter clearly, the paragraph must be separated. The frst part of it refers to a drawing on page gi. In regard to this, Dr. Garrigues says, ‘“ Bennett draws both large granular cells with or without a nucleus, and small bodies invariably without a nucleus, which latter are entirely like Drysdale’s corpuscles.” But how does he know that they are entirely like Drysdale’s corpuscles ? Bennett does not describe them, nor even allude to them, certainly he never applied a test tothem. Therefore, it is impossible to say what they were. Dr. Garrigues offers no proof, it is a mere assertion. The fact is simply this: Bennett gave a drawing of some 1 Second edition, New York, 1858, p. 91, Fig. 70. 2 American Journal of Obstetrics, January, 1882, p. 38. 102 THE OVARIAN CELL. nucleated cells which he believed were characteristic of ovarian fluid. Mingled with these cells in the drawing are seen a few granular cells and some granular matter, which are almost always present in ovarian fluid, and for this reason were probably sketched by Bennett, but to which he attached no importance, as he does not mention them in his text. The mere fact of his seeing them in the field of the microscope and drawing them proves nothing, for many other observers had done the same thing before him, but Ze also failed to detect their true character. The cells which he did describe, and which he thought were diagnostic of ovarian tumors, were the /arge nucleated cells. But here are his own words: “The fluid removed by tap- ping from the abdomen of Jessie Fleming,” he says, “ con- tained flocculi which, when examined with the microscope, were found to be composed of numerous cells varying in size from the one hundredth to the fortieth of a millimeter in diameter. The great majority were about the fiftieth of a millimeter. They were slightly granular, of round and oval shape, unaffected by water, but becoming more trans- parent on the addition of acetic acid, and exhibiting a dis tinct nucleus about the one hundred and fortieth of a milli- meter in diameter (see Fig. 170),” 1 the very one alluded to by Dr. Garrigues in support of his assertion. These were nucleated cells, and are the only ones he refers to, which proves that he made no allusion to the ovarian cells, which are destitute of nucleus. That Dr. Garrigues was aware of this fact may be seen from his own words. In speaking of this very description, he says, 2 ‘This applies exclusively to the large bodies we find in ovarian fluid. He (Bennett) ad not notice any of the nuclet which are so important a part of this fluid, and the statements, that the bodies were slightly granular, that they contained a nucleus, and were embedded in a granular mat- ter, apply only to some of these corpuscles, whilst others ex- hibit quite different characters as shown above. But imper- 1 Bennett’s Clinical Medicine, second edition, New York, 1858, p. 700. 2 American Fournal of Obstetrics, January, 1882, p. 37. THOMAS M. DRYSDALE. 103 fect as the description is, it is clear enough to enable us to recognize the bodies the author describes, and, as he is the first who has done this, I have in this paper throughout called these large bodies Bennett's bodies.’ Knowing, then, what Bennett referred to, and also knowing that he made no allu- sion to these small granular cells, yet Dr. Garrigues un- justly attempts to give Bennett the credit of first describing the ovarian cell simply because a few granular cells, the nature of which is unknown, have been included in the drawing. The second part of the paragraph refers to an entirely dif- ferent cell. “Fig. 172 on page 172,” he says, “shows very distinctly Drysdale’s corpuscles, after addition of acetic acid, without nucleus. The text describes them as pale, round, and oval corpuscles, the oztlznes of which become stronger on the addition of acetic acid.” To show how unfair this whole statement is, and to prove that Bennett has refer- ence to an entirely different cell, the colloid corpuscle, which is found in colloid matter, compare this garbled quo- tation with the context, and see what he really says. In describing cystic growths in general, he observes :! “The contents are more or less gelatinous, sometimes slightly so, like weak gelatine, at others firm, capable of being cut with a knife like tolerably strong glue, or firm calves-foot jelly. Sometimes this matter is structureless, at others it may be seen to contain very delicate filaments, combined with pale oval bodies, the outlines of which become stronger on the addi- tion of acetic acid. (Fig. 172). This reagent frequently causes the gelatinous mass to coagulate into a firm white fibrous structure, capable of being separated by needles, and presenting all the structure of filamentous tissue. This kind of contents is common in the thyroid gland and ovary, and we have seen it in the kidney and other organs.” It is stated in a foot-note that the drawing represents “ Deli- cate oval corpuscles in amber-colored, transparent, colloid matter of the ovary.” 1 Clinical Lectures on Medicine, by J. Hughes Bennett, second edition, New York, 1858, p. 172. 104 THE OVARIAN CELL. To call this a description of the ovarian cell is certainly a stretch of the imagination. It is simply that of the cells of colloid matter. Paget! depicts them thus: “ These, the so-called colloid corpuscles, are small, granular, moderately transparent cells of irregular shape, from one five-thousandth to one two-thousandth of an inch in diameter, with small nu- clei or none.” A reference to the drawing in Bennett’s work will show that they have but little resemblance to the ova- rian cell. There is, then, not the slightest proof that Ben- nett was acquainted with this cell, for, as has been shown, he has never alluded to it in his writings, nor delineated it for the purpose of description. And yet Dr. Garrigues con- cludes, “ There is no doubt that Bennett has known these bodies, but he does not claim that they are characteristic for ovarian cysts” 2—a conclusion worthy of the erroneous premises upon which it is founded. That Dr. Garrigues attaches much importance to this statement of the priority of Bennett in this description of the ovarian cell may be seen from a foot-note, in which he says,’ “The first edition [of Bennett’s ‘ Principles and Prac- tice of Medicine’] was published in London in 1852. Through the courtesy of Mr. George Bullen, of the British Museum, I am informed that Fig. 70 of the second edition is found as Fig. 89 on page 218 of the first edition, and Fig. 172 of the second edition as Fig. 92 on page 219 of the first edition. Thus it is proved,” says Garrigues, “that Bennett has known these bodies before Beale’s first edition was published (1854).” From this we might infer that Beale had also described these cells, but in another place +* I have shown that Beale, like other observers, never rec- ognized the true nature of this cell, that his description of it was inaccurate, that no claim was made by him that it was’ peculiar to this fluid, and that he gave no test to distin- 1 Surgical Pathology, p. 775. 2 American Fournal of Obstetrics, January, 1882, p. 38. 8 Jbid., p. 38. 4 Transactions of the American Medical Association, 1873, vol. xxiv., p. 182. THOMAS M. DRYSDALE. 105 guish it from other granular cells. ,Thus all of Dr. Gar- rigues’ laborious attempts to prove that Bennett described these cells, either in 1852 or at any other time, fail, as it has been shown by Bennett’s own words that he never even alluded to them. Having now proved from the evidence which has been adduced, — 1. That the bodies found in ovarian fluid and described as ovarian cells ave cells and not nuclet, and that, from the na- ture of their origin, they are diagnostic of this fluid ; 2. That they are easily distinguished from the pyoid bodies of Lebert by what he describes as their “essential character,’ their yellowish tint ; 3. That John Hughes Bennett never referred to these bodies in his writings, nor represented them for the purpose of description in his drawings, — It follows, that Dr. Garrigues’ statements in regard to these points being proved to be erroneous and without founda- tion, his conclusions, “ That these bodies are not pathog- nomonic of ovarian nor any other cyst, as they may be found in various parts of the body,” and “ That there is no pathog- nomonic morphological element in the fluids. of ovarian cysts,” are entirely destitute of value. There are some other statements in regard to the ovarian cell in Dr. Garrigues’ paper which may be briefly alluded to. The first is that concerning the tests which I have recommended to distinguish it from other cells. He ques- tions their practical value. To the acetic acid test, he ob- jects that it is the same as that used by Lebert to distin- guish his pyoid cell, but, as Lebert states that this is never found except in pus, and as the color of this cell is suffi- cient to identify it, the objection is groundless. But it may be here remarked that cells, which have some resemblance to the ovarian cell, are occasionally met with which remain almost unaffected by acetic acid, and are far better calcu- lated to deceive than Lebert’s. I would, therefore, put ob- servers on their guard against them. For instance, the cells which I have described as being found in ascites may 100 THE OVARIAN CELL. also be present in other fluids, but a close study of them will show that in appearance they differ so materially from the ovarian cell, that a careful observer cannot mistake them. As they have been already treated of in this paper it is unnecessary to say more about them now. In addition to these cells we sometimes meet with pus cells, which have been retained in collections of pus in the body for a long time, and have undergone fatty degenera- tion. These do not become transparent and show their nuclei when acetic acid is added to the fluid, and conse- quently may be mistaken for the ovarian cell, but their uni- form size, and the comparative dullness or paleness and want of clearly defined outlines of the granules, will help to distinguish them ; besides, it is exceedingly rare to find all the pus cells thus changed. Generally, a sufficient number remain which show their true character on adding the acid, and thus put us on our guard. Should there, however, be any doubt in regard to the nature of the cell, the observer may distinguish them from the ovarian cells by first adding acetic acid, and following it by ether. Under this treat- ment the pus cell, which has undergone fatty degeneration, is dissolved, while the ovarian cell remains comparatively unaffected. The test which I recommended to distinguish the ovarian from Gluge’s or Bennett’s cells isether. Dr. Garrigues says he has found this a difficult agent to use, but his experience differs from my own. Ifa small quantity of ovarian fluid is put on the glass slide, and a few drops of ether added, and mingled with it by means of a tubular pipette, and the cover at once put on, there is but little more difficulty with this than with any other reagent. A few drops of ether occasionally applied to the edges of the cover will keep the specimen immersed long enough to discover its effect upon the cells. In another place I have stated that “the ovarian gran- ular cell remains nearly unaffected by it, or, at most, has its granules made paler, while the cell of Gluge loses its granular appearance, and sometimes entirely disappears THOMAS M. DRYSDALE. 1C7 through the solution of its contents by the ether.”! To this statement, Dr. Garrigues objects. He says, “ When ether is added we see some of Bennett’s corpuscles almost dissolved, but other corpuscles of the same kind are not affected at all, probably because they have not been reached by the ether, which mixes with great difficulty with the colloid fluid.” ? This objection has but little weight, for if a sufficient number are acted upon to show their true character, the evidence is sufficient. But, he adds, “ Drysdale’s corpus- cles are affected in the same way as the large granular cells. They become pale, their contour becomes irregular, their granules disappear, they shrivel and seem to become dis- solved. Thus ether affects both kinds of bodies or none at all.” This differs entirely from my own experience. I have never seen ether produce such an effect on the ovarian cells, nor do I perceive how it can. Gluge’s or Bennett’s cells are epithelial cells which have undergone fatty degen- eration. In other words, they are almost wholly converted into fat, which is soluble in ether, while the ovarian cell is an aborted epithelial cell, composed mainly of protoplasm, including in it minute globules of fat, the greater number of which are protected from the action of the ether by this albuminous covering. Of course, a few of them may be so far advanced in fatty degeneration as to be acted upon in the same manner as the cell of Gluge, but the majority of them are no more affected than has been stated. I main- tain, then, that my description of the action of this test is correct, but this question can be readily settled by the fur- ther examination of the matter by other observers. The last statement of Dr. Garrigues which I shall notice is, that “ Drysdale’s corpuscles seem to have a little more value than Bennett’s, but they are by no means pathogno- monic, not even of the presence of any kind of cyst, and still less of an ovarian cyst.”? “I have,” he says, “found 1 Transactions of the American Medical Association, 1873, vol. xxiv., p- 181. 2 American Fournal of Obstetrics, January, 1882, p. 24. 8 Jbid., January, 1882, p. 35. 108 THE OVARIAN CELL. them in one of my cases of cyst of the broad ligament, in a case of suppurating cyst of the abdominal wall, in the above mentioned case of cancer of the peritoneum, in a case of renal cyst, in a congestive abscess extending from the spine to the femur, and in a vaginal cyst. Similar observations have been made by others. Dr. A. Erich, of Baltimore, has found these corpuscles in a case of encysted ascites. They were likewise disclosed to be present ina case of Dr. J. Byrne, of Brooklyn, which turned out to be hob-nailed liver with ascites. On the other hand I have missed these corpuscles in cases of simple ovarian polycyst, in another where the cyst wall showed cancerous degeneration, and in a case of sarcomatous cyst.” , The assertion that he has found the ovarian cells in cysts of the broad ligament carries no weight with it, and needs proof, for in his twenty-third conclusion he makes the posi- tive statement that “cysts of the broad ligament cannot be distinguished from those of the ovary,’! and again, “as to cysts of the broad ligament, I do not know of any charac- ter by which they can be distinguished from ovarian.” 2 In another place he asserts, “ It is impossible to tell, by the fluid alone, if a tumor is ovarian or a cyst of the broad liga- ment.” ? Now if the cysts cannot be distinguished, and if the fluids arg identical, how did he know that these cysts which he describes as those of the broad ligament were not ovarian ? After such statements he should at least make it evident how he identifies these cysts, and that he has not mistaken an ovarian monocyst for one of the broad ligament, else his assertion that he has found the ovarian cell in cysts of the broad ligament is valueless. Observe, also, the discrepancy between these conclusions and a former statement in which he says, ‘‘There are two ways in which we can tell a cyst of the broad ligament from an ovarian cyst: one is the fact that we find the ovary beside the tumor, and the other is the 1 American Fournal of Obstetrics, July, 1882, p. 672. 2 [bid., January, 1882, p. 37. 8 Jbid., April, 1882, p. 396. THOMAS M. DRYSDALE. 109 character of the outer epithelium. 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.” ! As he does not state that he found the ovary beside the tumor in either of the cases which he describes, he must have relied upon the character of their epithelial coverings to distin- guish them. Here is a very simple test which, if it proved reliable, would be conclusive, but it has proved fallible even in his own hands. The history of a case of the removal of an abdominal tumor will be found recorded in the Amer- ican Journal of Obstetrics, October, 1881, page 876. This tumor, Dr. Garrigues, basing his diagnosis upon the charac- ter of the epithelium found upon its outer surface, pro- nounced a fibro-cystic tumor of the ovary. But Dr. Thomas, the operator in the case, stated that it was a fibrocyst of the uterus, growing almost exactly from the fundus of that organ, and showed that “it had no attachment whatever ex- cept to the fundus of the uterus.” The test, then, is not conclusive. But, leaving these contradictory statements out of the question, that he is not familiar enough with these cysts and their contents to warrant him in making such positive as- sertions may be inferred from his own words. He states that he has examined the fluid of three cysts which were re- moved by operation, but only ¢wo of the cysts. He further gives in his list of tapped cases ten, which he entitles fluid from “cysts of the broad ligament or ovary,” or, in other words, doubtful. Yet from these few examinations, fortified by the opinions of various other observers, he arrives at the conclusion, which he has had printed in italics, that ‘zt zs tmposstible to tell by the fluid alone tf a tumor ts ovarian or a cyst of the broad ligament.” NWaving had considerable expe- rience in the examination of these fluids and cysts, I can as- sert with the confidence lent by that experience, that all of these conclusions are unfounded, and that cysts of the broad ligament can be distinguished from ovarian by the fluid 1 Jéid., April, 1882, p. 392. 110 THE OVARIAN CELL. which they contain. This fluid I have described, in a former article, as perfectly colorless, transparent, and thin, like pure water. Its specific gravity is very low. Under the micro- scope a few epithelial cells are sometimes discovered in it, but generally it proves to be free from objects. I regard it as peculiar to cysts of the broad ligament as I have never found it in any other abdominal cyst, and further, in the examination of ninety-seven specimens of it, I have never met with the ovarian cell in an uncomplicated case. But there is another variety of these growths in which an ovarian element adds to the difficulty of diagnosis. In these cases I have found the ovary incorporated in the wall of the broad ligament cyst, and, having itself undergone cystic de- generation, discharging its contents into that of the broad ligament. In this manner a tumor which commences as a cyst of the broad ligament may apparently be converted into an ovarian tumor, and lead the operator to suppose that his first diagnosis, based upon the character of the fluid, was erroneous. Case XXXIIL, in Dr. Atlee’s book on diagnosis, gives an excellent example of this complication, and I have met with a number of other instances of the same kind. For this reason a mistake is easily made by an inexperienced observer. Case LI., described by Dr. Garrigues as a mul- tilocular ovarian cyst with watery fluid and ciliated epithe- lium, which he uses as a proof that this colorless, watery fluid can be found in an ovarian cyst, has every character- istic of a broad ligament cyst with the ovary intimately at- tached, and spread over its wall. In his description of the cyst, he says, “ At the bottom of the main cyst was found a finger-thick solid mass, a development of the ovary.” In his cases V. and XI., where he discovered the ovarian cell in the fluid, an ovarian element was probably present. See- ing, then, how readily a mistake might be made by one hav- ing but a limited experience in these cases, and having shown by his own words that he is unable to distinguish a cyst of the broad ligament from an ovarian cyst, but little importance can be attached to Dr. Garrigues’ statement that he has found the ovarian cell in cysts of the broad liga- ment. THOMAS M. DRYSDALE. II! Dr. Garrigues tells us that he has also met with a cell re- sembling the ovarian cell in cysts of the kidney. This agrees with my own experience. In Dr. Atlee’s work, page 140, will be found a description given by me of a fluid from a renal cyst, which reads as follows : “ It was of a dirty light- brown color. Its specific gravity was 1.020. Its reaction was alkaline. Under the microscope it was seen to contain plates of cholesterin, coagulated fibrin, blood-cells, oil glob- ules, and great quantities of granular cells, which, in ap- pearance, resembled those found in ovarian fluid.” Another specimen of the fluid, passed a few days later, was examined, and found to contain less cholesterin, and but few gran- ular cells were present. Casts of the uriniferous tubes and crystals of uric acid were also discovered in the specimen, in these renal cysts, then, can be occasionally found cells which cannot be distinguished from the ovarian cell. It forms the only exception that I know of to the rule that the ovarian cell is diagnostic of ovarian fluid. In the examination of these fluids for the purpose of di- agnosis this exception must be borne in mind. But, for- tunately, the exception is not such an important one as at first sight might appear, and for the following reasons: Renal cysts seldom attain such a size as to be mistaken for ovarian, and are rare in comparison with them, for in over two thousand specimens of abdominal fluids examined by me, but four were renal, and of these, but one contained this granular cell. The other characters of the fluid of these cysts are generally sufficient to distinguish it from that of ovarian disease, and if any of the constituents peculiar to urine are found in any quantity in the fluid, or if, as in the second specimen from the above mentioned case, casts of the uriniferous tubes are present, they will point out its true nature. In addition to these peculiarities the history of the case will usually indicate the origin of the cyst. Dr. Garrigues also says that he has found the ovarian cells in a case of suppurating cyst of the abdominal wall, in a case of cancer of the peritoneum, and in a congestive ab- scess. These were all met with in accumulations of pus, and ‘ I1l2 THE OVARIAN CELL. are therefore unreliable. The fluid in the cases of Drs. Erich and Byrne, and in the vaginal cyst mentioned by Dr. Garrigues, are just the ones in which are found the cells which I have described as existing in ascitic fluid, and which have been so frequently mistaken for the ovarian cell. It requires a practical familiarity with all of these cells to distinguish one from another, for just as mistakes are made in the diagnosis of ordinary diseases for want of care in the examination of their characteristics, and want of practical familiarity with them, just so will mistakes occur in the diagnosis made by means of the microscope. Are we to condemn auscultation because many fail to recognize the sounds which indicate morbid changes? Would it not be equally absurd to condemn this sign of disease, indi- cated by a cell, because some observers have failed to iden- tify it or have mistaken another cell for it ? And last, Dr. Garrigues states that he has missed the ovarian cells in a simple ovarian polycyst, in another where the cyst wall showed cancerous degeneration, and in a case of sarcomatous cyst. In the first, judging by the descrip- tion of the growth, a cyst of the broad ligament was mis- taken for an ovarian, and in the other, the cancerous degen- eration in the wall of one, and the pathological character of the other, would account for the absence of these cells. Having answered the statements of Dr. Garrigues in re- gard to the ovarian cell, I will briefly reply to the remarks made by Dr. Noeggerath during the discussion of the paper.? Dr. Noeggerath spoke as follows: “I would say a few words regarding the so-called ovarian corpuscle, which Dr. Drysdale considers characteristic of ovarian cysts, and Dr. Garrigues does not. I think the position which that ques- tion occupies is illustrated by the following incident: I sent a specimen to two of the best men in the country, whose names are connccted with this subject, and they both sent me back the answer that it contained the ovarian corpuscle, and was, no doubt, the result of an ovarian tumor. Now what were the facts? The specimen was taken from a 1 American Gynecological Transactions, 1881, vol. vi., p. 85. THOMAS M. DRYSDALE. 1 Gi ke suppurating cyst of the thigh, and yet it contained the ovarian corpuscle in such numbers, and in such perfection, that the best judges in the country mistook them for it.” I inquired if Dr. Noeggerath had sent me one of the specimens. He replied, “I did.” This requires explanation, which would then have been given had I had the necessary evidence with me. I hold in my hand three letters from Dr. Noeggerath. The first} asking me to send him another copy of my paper on the ovarian cell, as he had loaned his to a friend. The copy was sent. This shows that he was familiar with the paper. In that paper it is distinctly stated that my re- marks apply only to fluids removed from the abdomen. For instance : “ This cell, when found in ¢hzs location, I believe to be pathognomonic of ovarian disease, not meaning to assert that a cell having a similar appearance may not be found in cysts met with in other parts of the body ;” and, again, it is spoken of as a “granular cell which differs in its behavior with acetic acid and ether from any other known granular cell found in the abdominal cavity.” Now, asking you to bear these words in mind, I will state what occurred. Dr. Noeggerath sent me a bottle of fluid, and with it this note =— New York City, 42 WEST 35TH ST., 5, 5, “81. My pDEAR Doctor, —I herewith send you a specimen fluid, drawn from a tumor, the origin of which is obscure. It looks to me as if it contained a large amount of ovarian corpuscles. Would you please examine, and let me know. Some of the crystals are probably from the addition of thy- mol. Truly yours, E. NOEGGERATH, M. D. The fluid was examined, and my doubts about its being 1 The following is a transcript of this letter : — DEAR Docror, — Will you permit me to ask you the favor of send- ing me another copy of your paper on the ovariancorpuscle. I lent my copy to one of my confréres who failed to return it after he left the city. Have you made any addition to the subject since the publication of your pamphlet ? I am, yours truly, E. NoEGGERATH, M. D. New York, 42 W. 35th Street, October 20, 1879. VOL. VII. 8 II4 THE OVARIAN CELL. ovarian were so decided that I wrote to Dr. Noeggerath, and asked him if the fluid had been removed from a tumor of the abdomen. I received this reply : — My pear Doctor, — If I did not mention the fact that the tu- mor in question came from the abdomen, it was because I thought you knew that I am a specialist, only dealing with matters con- nected with the female genital organs. Truly yours, E. NOEGGERATH. Supposing that Dr. Noeggerath was an honorable man, I took it for granted that his statement was true, and applied no further tests to the fluid. By this deception he obtained the reply that the fluid was ovarian. The facts are before you, and speak for themselves. In the letter to me, he states that the fluid was from an abdominal tumor. To the - Society, he says it was from a suppurating cyst of the thigh. Comment is unnecessary. DISCUSSION. Mr. THornTOoN, of London, Eng. —I think that Dr. Drysdale has entered a field in which questions are in a decidedly unset- tled condition, because of the great diversity of opinion among pa- thologists and histologists as to what constitutes a cell, and what _is the mode of its growth. Without this definite basis of investi- gation it may, almost as a matter of course, be expected that I should differ with Dr. Drysdale in what he has said concerning the manner in which ovarian cysts grow and this ovarian granular cell is produced. I had reached the conclusion long ago that the nucleus, perhaps the nucleolus, in the formation of the cell was the first and not the last element, and that the cell body fol- lowed. As to whether or not the body described by Dr. Drys- dale should be called a cell, I had, long before Dr. Garrigues read his paper, reached the conclusion that it was the nucleus of a rapidly degenerating cell of the cyst membrane. Then, coming to the action of reagents, or rather the lack of reaction, that fact of itself favors the view that it is a degenerated cell, and not, as Dr. Drysdale thinks, an immature cell, because in immature or rapidly growing cells the protoplasm is especially prone to take on the action of staining agents, and to react promptly when DISCUSSION. 115 treated with acetic acid. With reference to the ovarian cyst be- ing derived from the Graafian follicle, I have thought my own ob- servations, as well as those of recent authorities, seemed to prove that in the great majority of cases it had an origin independent of the Graafian follicle, and that it could be distinguished from it especially by its lining membrane. As to the aid this body, or Dr. Drysdale’s corpuscle, may afford in making a diagnosis, I have finally found my failures so numerous that I have been obliged to abandon it, notwithstanding the great success which attended my earlier examinations. From my own experience in the matter, I think it must be accepted that the practical value of this body is often at least immaterial. I have found in cysts of the omentum and mesentery, and also in a multilocular cyst of the spleen, cells which could not be distinguished from Dr. Drysdale’s corpuscle. However, I am prepared to go back and study the field over again in view of the positive statements made by Dr. Drysdale, and I hope that the results of further investiga- tion may be confirmatory of Dr. Drysdale’s views. Dr. ENGELMANN, of St. Louis. — Mr. Thornton has touched so thoroughly upon the points which I should have spoken upon that I have but little to add. Dr. Drysdale’s paper is one which is so highly scientific, and gives us the result of so many years of study and careful examination, that it seems almost im- pertinent with the small experience which I have had to ven- ture to differ with him, especially as I am myself much more at home in the mucous than in the serous membranes. Dr. Drysdale differs with all observers, and I would very seriously question whether any one has been able to see these bodies as he has seen them. He has had either great good fortune or scientific certainty in determining the nature of fluids which have been sent him ; for he has rarely made a mistake in diag- nosis, a rather deceptive success which reminds me forcibly of Lostorfer’s syphilitic corpuscle which was brought forward some years ago, and for which it was claimed that in ninety-nine one hundredths of the cases, almost invariably a correct diagnosis of syphilitic disease could be made, and yet what do we now hear of the syphilitic corpuscle? It has disappeared entirely. There were curious reasons, which I cannot here detail, why Lostorfer could make his diagnosis correctly, but there was certainly noth- ing in the syphilitic corpuscle, and without much experience I have entertained the same ideas with regard to this body. How- 116 THE OVARIAN CELL. ever, accepting the position taken by Dr. Drysdale, how few there are who will be enabled to make a diagnosis. He stands alone. At present there is scarcely a single experienced micros- copist who thoroughly agrees with the doctor. Either those sufficiently skilled otherwise have not had the experience with these bodies which is necessary to detect them or they have not been able to see them at all. As not every one is able to see with the ophthalmoscope or explain what he does see, so it is with the ovarian corpuscle. Now be it so, were we to accept the position which Dr. Drysdale takes, no one, unless he has devoted a lifetime to the use of the microscope and the especial study of these bodies, will be able to make a diagnosis from the examina- tion of ovarian fluids. I can readily understand that it is an aborted epithelial cell of rapid formation and degeneration be- cause that membrane is one which is active, constantly secreting, but the same is true of all other cysts and a great many other pathological formations. But I cannot understand why — yet he says it is so, and we must accept his experience — the lining membrane of ovarian cysts should form this body, while cysts of the broad ligament and cysts of the kidney with a similar mem- brane, and under similar circumstances, should not form the same body. I have not been able to see this cell and to make a diag- nosis of fluids by it ; I have failed entirely. I have seen bodies which I think I have seen in other cysts, and I do not under- stand why or how this body should appear so persistently in that one place. Dr. Drysdale has given us a means of diagnosis, but I have failed as others have, by inexperience perhaps, and I can only say if it is so, as his long experience seems to prove, I with others have been unable to see it and cannot accept the position, cannot myself use the test practically, nor have I found others who have been able to do so for me. Dr. DryspaLe. — Mr. Thornton has stated that physiologists are in doubt as to what a cell is. As so much has been already said concerning this subject in the paper just read, all I would add is, that I have given as my authority some of the best phys- iologists living, and whom, I think, he will recognize as such, as Carpenter, Max Schultze, Stricker, and others. In fact, most of the present authorities in physiology agree with me upon this point. With regard to the ovarian cell being a nucleus, — twenty years ago I would have agreed with Mr. Thornton in considering it as DISCUSSION. 117 such, but prolonged and laborious investigation of the matter has convinced me that this view was erroneous, and that it is a cell and not a nucleus. I therefore feel confident that the further study of this subject by others will prove that I am correct, and that they will agree with me that it is an aborted epithelial cell. I regret that in many instances observers have been unable to distinguish this cell, or have been mistaken in regard to it. In many of the published cases this was certainly due to a want of care in the examination, or want of experience in this line of research, and, consequently, the error was the fault of the ob- server. Indeed I have made the same mistakes myself when I have not been sufficiently thorough in the examination. A striking instance of this happened to me in a case of omental cyst, one like those referred to by Mr. Thornton. Some years ago a woman having an abdominal tumor came under my care, from whom I removed some fluid by tapping. This I examined carelessly and applied no tests ; for, from the history and physical examination of the case, I was so confident that the tumor was ovarian that I did not think it necessary to confirm the diagnosis by any other means, so that I attached but little importance to the microscopic examination of the fluid ; consequently I was led into a serious error and taught a useful lesson. I exposed the cyst and found it covered with a network of large vessels which gave it the ap- pearance of a huge placenta. The mass really consisted of two tumors, formed by a cystic degeneration of the greater and lesser omentum. ‘There was a loop of small intestine apparently run- ning into the upper tumor and forming a part of its wall, and again appearing on the opposite side. ‘This, of course, was quite different from what I expected to find, and I was led into this dif- ficulty by neglecting to make a thorough microscopic examination of the fluid. In order to avoid these errors I have attempted to point out, in the paper just read, how to distinguish the ovarian cell from others which resemble it. It has been asserted that this is impos- sible, but that it may be done has been proved by my own suc- cess in this matter, and I am confident that others may be equally fortunate if they will use the same care in the examina- tion. If this is done the pyoid cell will not be mistaken for the ova- rian, for, I may repeat, the ovarian is a white, transparent cell ; you can almost see through it, apparently, while the pyoid cell of Lebert is yellow. The other cells spoken of may be distinguished 118 THE OVARIAN CELL. from the ovarian by their being semi-opaque and wanting in the small, strongly refracting and sharply defined granules so char- acteristic of this cell. If you add acetic acid to a pus cell which has undergone fatty degeneration and to the ovarian cell, the effect is almost identical ; but if, after treating the cells with the acid, you add ether, the pus cell will be dissolved, while the ova- rian cell will be comparatively but little affected. But it is need- less to further repeat what I have already dwelt upon. Mr. Thornton disagrees with me in regard to the fact of ova- rian cysts originating from the Graafian follicles. This is simply a difference of opinion, and although much might be said to prove that the majority of these cysts have this origin, yet our limited time forbids the discussion of the subject. Now with regard to the existence of the ovarian cell in a renal cyst: The fact that it has been found in one I put upon record years ago in Dr. Atlee’s work on diagnosis. I have met with no other instance of it, although I have examined over two thousand of these fluids. In many of these cases I have been able to fol- low them to the time of operation, and in only four were cysts of the kidneys discovered, so that the occurrence of renal cysts is certainly not very common. The fact of the occasional pres- ence of cells of this character in renal cysts is the single excep- tion that I know of to the rule that these cells can only be found in ovarian cysts. As to the syphilitic cell spoken of by Dr. En- gelmann, practically I do not know anything about it. SOME REMARKS ON OVARIOTOMY, WITH SPECIAL REFERENCE TO THE TREATMENT: OF THE PEDICLE, BY R. STANSBURY SUTTON, M. D., Littsburg, Pa. To review this subject with historical accuracy requires more time and literature than are at present at my com- mand. But if what appears in this paper will lead to a profitable discussion, my object will be largely attained. From a careful study of the celebrated case of Robert Houston, of Glasgow, Scotland, I am unable to find that he treated the pedicle in any specific manner. That he did, in 1701, attack and destroy a cystic tumor of “the left ovary ” there is no doubt. There was no return of the disease, and his patient lived for thirteen years after his operation. He must, through the four-inch incision which he made, have seen the pedicle, for he says it was a cyst “ of the left ovary.” There is no evidence that he ligated the pedicle. It is clear that he did not clamp it. He says he closed the wound with sutures, excepting the lower angle, which he left open, and in which he inserted a tent. Had he simply evacuated the contents of the cyst, and thus dressed the wound, the secreting membrane of the cyst must have con- tinued to pour out its fluid into the cavity of the belly, and this fluid would have escaped through the lower angle of the wound, which was kept open by the tent. This did not occur. He says there was only a serous discharge through the lower angle of the wound for “four or five” days. Then, what became of the lining membrane of the cyst? 120 OVARIOTOMY: TREATMENT OF THE PEDICLE. He answers the question. Describing what he removed from the cyst, he says, “This was followed by nine full quarts of such matter as I have met with in steatomatous and atheromatous tumors, with several hydatids of various sizes, containing a yellowish serum, the least of them big- ger than an orange, wrth several large pieces of membranes, which seemed to be parts of the distended ovary.” 3 ' Assuming it is clear that the secreting surface of the cyst must have been destroyed, and that these “pieces of membrane”’ constituted that surface, I have concluded that he performed, unconsciously, exzcleation of the lining mem- brane of the cyst, and thereby cured his case, and directed no further treatment to the pedicle. After Robert Hous- ton’s achievement the interest in the case was kept alive by both John and William Hunter, and subsequently by the pupil of one of them, Prof. John Bell, of Edinburgh, Scot- land. In 1794, Ephraim McDowell was a student of Prof. John Bell, and heard him defend, in the light of Robert Houston’s case, and post-mortem examinations on women who had died of ovarian cysts, the feasibility of removing these cysts by abdominal section. In 1809 McDowell performed ovariotomy in Kentucky. It was the first systematic operation ever done for the removal of an ovarian cyst, and was nearly as perfect an operation as we do to-day. He tied the entire pedicle with a single ligature, the end or ends of which he left hanging out at the lower angle of the wound. For eleven years after this operation no other method of treating the pedicle was suggested. In 1820 Chrysmar, of Wiirtemberg, tied the pedicle in two portions, but left the ends of the ligatures hanging out through the lower angle of the wound. In 1821 Nathan Smith, a New England surgeon, tied separately the arteries of the pedicle with “ strips cut from a kid glove;” he cut the ligatures off close to the knots, dropped the pedicle in, and closed the wound. During the following sixteen years the three methods enumerated were followed. 1 The italics are mine. Rk. STANSBURY SUTTON. I2I In 1837 Stilling, of Cassel, in the Province of Hesse Nassau, Germany, used the cautery, and suggested stitch- ing the pedicle in the wound. Nine years, again barren of new suggestions, elapsed, when, in 1846, Dr. Handyside, of Edinburgh, Scotland, carried the ligatures through the cul-de-sac of Douglas into the vagina. In 1848 Stilling again appears, and treated the pedicle, for the first time, outside of the peritoneal cavity. Two years later, in 1850, this method was inaugurated in London by Mr. E. W. Duffin. The inauguration of the extra-peritoneal method of treating the pedicle, by Stilling, in 1848, began a long and serious conflict, which is only dying out with the method at the present time. In 1849 Maisonneuve, of Paris, had twisted the entire pedicle in one case, and Martin, of Jena, had stitched the pedicle in the wound. About this time Langenbeck stitched the pedicle in the wound, and covered it with the skin from the margins of the incision. Eight years later, in 1850, Dr. John L. Atlee, of Lancaster, Pennsylvania, introduced the écraseur to divide the pedicle. He was imitated by a number of prominent operators: notably, by his brother, the late Washington L. Atlee ; Mr. Spencer Wells; Dr. Keith ; Professor Pope, of St. Louis, Mo.; and Professor Billroth, of Vienna. The year proved to be an unfortunate one for ovariotomy, for in the autumn of it Mr. Jonathan Hutchinson invented the clamp, which has perpetuated the extra-peritoneal method of treating the pedicle. ; In 1860 Sir James Y. Simpson secured the pedicle within the cavity of the abdomen by means of acupressure needles passed through the abdominal wall. About 1865 Kceberlé, of Strassburg, invented his “ serre- noeud,”’ or wire constrictor, with which he grooved the ped- icle prior to applying the ligature. In 1864 Mr. I. Baker Brown, of London, reverting to Stilling, of Cassel, began the use of the cautery, of which I shall speak at length. In 1868 Masslovsky, a Russian, amputated the pedicle * 122 OVARIOTOMY: TREATMENT CF THE PEDICLE. by double flaps, one on either side, and stitched the flaps together. In 1869 Dr. McLeod, of Glasgow, Scotland, by means of two pairs of strong forceps, twisted the pedicle entirely off. During the same year Dr. J. C. Miner, of Buffalo, New York, successfully performed enucleation of the cyst, and the late Dr. Peaslee, of New York, devised and recom- mended his scabbard and knife, by means of which the ped- icle was secured, and the ligatures were easily removed, after they had constricted the pedicle for forty-eight or sixty hours. Torsion of the separate vessels of the pedicle had ‘also been practiced. In 1870 Dr. Thomas Addis Emmet reported eighteen cases in which he had secured the pedicle by means of silver wire. What the practice of my countrymen has been during the last decade I leave for those who are present to-day to say. But up to the present time every conceivable thing has been done with the pedi- cle. It has been tied entire, tied in sections, been twisted off, burnt off, crushed off, cut square off, cut off in flaps, left inside, left outside, and been made to slough off. The ingenuity of operators has found it a fertile field for experi- ment. At last surgeons have concluded to do with it what McDowell did with it at the beginning, namely, to tie it with a ligature and leave it inside of the belly, but follow- ing Nathan Smith (1821) in cutting off the free ends of the ligature. The extra-peritoneal methods of treating the pedicle have had their day. The question is now resolved into the merits of the ligature cut short, or the clamp cautery, as in- troduced by Mr. I. Baker Brown in 1864. What the practice on the Continent of Europe, and in Great Britain, is, I will illustrate by giving the method of each operator whom I have visited during the last year. Professor Billroth, of Vienna, uses both ligature and cautery to secure the pedicle, but no clamp cautery. When the cyst is delivered, the pedicle is grasped low down, at right angles to its vertical axis, with a pair of long-handled lock forceps. ta varying distance above this pair of forceps ; R. STANSBURY SUTTON. 123 another pair is similarly placed across the pedicle. When the width of the pedicle is too great to be included within the jaws of a single pair of forceps, two pairs are used below and above. They are applied from opposite sides of the pedicle, and their points meet, so as to include the en- tire width of the pedicle. A well boiled, double, carbolized silk ligature is now passed through the centre of the pedicle below, but touch- ing the lower pair of forceps. The ligature is now divided into two equal parts, one for each half of the pedicle.’ As each half of the pedicle is firmly constricted by the ligature the forceps is lifted, and the former sinks into the groove made by the latter. A wet sponge is now placed beneath the pedicle, and it is divided with Paquelin’s cautery below the upper forceps, which is removed with the cyst. The free ends of the ligatures are cut off near the knots, and the pedicle is dropped in. Professor Nussbaum, of Munich, ties the pedicle in sec- tions with carbolized cat-gut ligatures, cuts off the free ends of the ligature,and drops the pedicle in. Professor Schroeder, of Berlin, holds the spread-out pedicle between his eye and the light as he passes carbolized silk ligatures through it; he thus avoids wounding its vessels. He cuts off the free ends of the ligatures, and drops the pedicle in. Professor Kiister, and Dr. Martin, of Berlin; treat the pedi- ‘cle in the same manner. Mr. Lawson Tait secures the pedicle with a double silk ligature, free from carbolic acid or wax, cuts the free ends off, and drops the pedicle in. His method of applying the ligature is peculiar, and I give it more fully. It is a constricting double noose, which he calls the “Staffordshire knot.” A long-handled needle, with the eye near the point, is armed with a strong silk ligature, its middle point resting in the eye of the needle. Holding the pedicle with his left hand, with his right he passes the needle through the centre of the pedicle, slips his left index finger through between the ligature and needle, withdraws the latter, leaving the ligature caught 124. OVARIOTOMY: TREATMENT OF THE PEDICLE. over the finger. Taking hold of the loop at the point where it is held by the left index finger, he draws the ligature through the pedicle sufficiently far to get a large noose, which he carries over the top of the pedicle, and places it between the free ends of the ligature. Taking hold of the free ends of the ligature, and winding them around his hand, he draws firmly upon them, and the pedicle is at once constricted by a double noose, which cannot slip. Taking the free ends of the ligature, one in each hand, he ties firmly against the pedicle a surgeon’s knot, close to which the free ends of the ligature are cut away, and the pedicle is dropped in. The following wood-cut will illustrate the “ Staffordshire knot.” Tait’s STAFFORDSHIRE KNOT. Mr. Thornton, of the Samaritan Hospital, treats the ped- icle with the ligature, which is always carbolized. He cuts off the free ends of the ligature and drops the pedicle in. Dr. Bantock, of the Samaritan Hospital, treats the pedicle in the same manner, but the ligature is not carbolized, nor is it waxed. Dr. Bantock abandoned the use of the clamp in November, 1875; and Mr. Thornton, according to the “Transactions of the Medico-Chirurgical Society,” aban- © doned it in July, 1876. Other operators whom I have seen in London use the ligature carbolized and cut short. Mr. Spencer Wells,! in the last edition of his book, still recommends the use of the clamp,? and also the ligature. I think, therefore, that Iam safe in saying that Mr. Wells? is the only prominent representative of the extra-peritoneal method of treating the pedicle, a method which began with Stilling in 1848. Mr. Wells has been the great apos- tle of the clamp, or of the extra-peritoneal method, ema- nating from Stilling. 1 Second edition, p. 316. 2 Ibid, p. 317. 8 I have not yet seen him operate. Rk. STANSBURY SUTTON. 125 Dr. Thomas Keith has been the great apostle of the cau- tery as used by Mr. I. Baker Brown, who for its suggestion also reverted to Stilling. Thus the two greatest of living ovariotomists have followed directly opposite methods of treating the pedicle, both methods emanating from the same mind. The best results in ovariotomy yet obtained are those of Dr. Thomas Keith. They have been obtained by the use of Baker Brown’s cautery, aided by drainage, as taught Dr. Keith by Keeberlé, of Strassburg, about 1865. Had it not beén for Dr. Keith, the teachings of Mr. Baker Brown would have been lost, and the intra-peritoneal method of treating the pedicle would have lacked the powerful argu- ment of this great operator’s experience. His method of using the cautery is as follows: When the cyst is delivered, Dr. Keith places Brown’s clamp around the pedicle, and screws the blades firmly together. He now cuts away the cyst, severing the pedicle a full half- inch above the clamp. He now loosens the blades slightly, and, with the forceps, draws the tissues of the pedicle to- ward the centre of the clamp, and again tightens the blades. With a cautery iron at a dull red heat he slowly cooks all that portion of the pedicle above the clamp, slowly heating the latter at the same time. With a second iron he slowly burns away the already cooked end of the pedicle. The charred edge, still remaining over the line of junction of ’ the blades of the clamp, is now entirely burned away with a third iron, having a hatchet shape. The clamp has now been heated to a degree sufficiently high to cook that portion of the pedicle between its blades, and to convert it into a substance resembling cold glue or a bit of cutting from a horse’s hoof, and having upon its surface all the indentations of the serrated edge of the clamp. The clamp is now carefully and slowly cooled, and the pedicle, having been secured from escape into the pelvic cavity sufficiently long for examination, is released. Only once in his experience has a vessel bled after the clamp was 126 OVARIOTOMY: TREATMENT OF THE PEDICLE. removed. In this case the pedicle was very short, and was burned off under extreme tension. This case occurred dur- ing my visit to him. The question of spray in ovariotomy is still an unsettled one. During the three months I spent with Dr. Keith he used spray in only two cases. Both patients died, and they were the only deaths he had during my visit. In one of the cases a spray of boro- glyceride was used, in the other a two and a half per cent. solution of carbolic acid. Both operations were done in the Royal Infirmary. I believe if they had been done outside» of the Infirmary the patients would have escaped sep- ticemia. At this time there were deaths occurring to other operators in the Infirmary from septicemia. Dr. Keith told me that the operations done by him in the infirmary were ruining his results, and that he would cease operating there. In general surgery he uses carbolic spray, and speaks well of it. But he does not like it in abdominal sur- gery, so far as he has given it atrial. His experience was limited to the use of a five per cent. solution in the bottle attached to the spray apparatus, excepting in the case I have already spoken of, in which he used a two and a half per cent. solution. He says the five per cent. solution poi- soned some of his patients. The assertion that he used so- lutions of carbolic acid a tenth stronger than Mr. Lister advises, Dr. Keith pronounces “a lie.” Leaving out or including his spray operations, his results are still the best which have been obtained. But as he treats the pedicle with the cautery, he probably requires antiseptic precau- tions less than other operators. Mr. Lawson Tait ridicules the whole Listerian practice, and he is as honest in his practice as he is in earnest in his denunciations. He uses only plain tap water for instruments, sponges, and ligatures. This I assert from a long personal observation of his opera- tions, both at the Woman’s Hospital and at his private hos- pital. If he has any regard for Listerism, I have not seen it. Carbolic acid does not touch his intra-abdominal cases. He is particular to have clean sponges, ligatures, and in- R. STANSBURY SUTTON. 127 struments. Dr. Bantock says that carbolic spray produces high temperatures, and has given up Listerism. Dr. Keith and Mr. Lawson Tait have had excellent results without spray. Dr. Keith has done fifty operations with but one death. Mr. Lawson Tait has done one hundred and four with only three deaths. These operations were all for the removal of ovarian cysts, parovarian cysts, and myomata. Of those who operate with the spray, I will mention first Professor Schroeder, who has done one hundred operations with only seven deaths. Dr. Savage, of Birmingham, has done, up to June 30, 1882, one hundred and twenty-five oper- ations for the removal of diseased ovaries, cystic ovaries, and diseased Fallopian tubes. One hundred and twenty patients recovered ; the five who died had large ovarian cysts removed. All these were done under spray. Dr. Martin, of Berlin, told me that the spray had proved of ad- vantage to him in improving his record of recoveries. Mr. Thornton saved ninety out of his last one hundred pa- tients, and Mr. Wells saved eighty-eight out of his last hun- dred, all under spray. Dr. Keith did one hundred operations under the spray with only six deaths, then fifty without the spray with only one death; and if we add one case done by son and father together, it would have been fifty cases with- out a death. My own conclusion, from this year’s obser- vation, is that the spray, in a large number of cases, will make very little difference. The number of deaths from carbolic poisoning will not, under a proper spray, exceed two or three in a hundred cases, and it may save others who would die without it. This constitutes the enigma. Time will settle it. Adsolute cleanliness ts the great thing after all, At the present time, with all this conflicting testimony in regard to the spray, it is difficult to be sure of anything. When I left Germany, at the close of last April, I would scarcely have dared to do an intra-abdominal operation without spray. My observations during the last four months have been to diminish my estimate of it zz zztra- abdominal surgery. Independent of the spray, I hope I may 128 OVARIOTOMY: TREATMENT OF THE PEDICLE. never lose my appreciation for the teachings of Mr. Lister. On the Continent of Europe, spray or irrigation is met with everywhere, and with surgeons generally Listerism is not losing ground. In intra-abdominal operations Professor Billroth fills the room with spray prior to operating, but turns the spray off during the operation. I saw Professor Langenbeck operate without it in a public clinic. But Pro- fessor Nussbaum, Professor Schroeder, Professor Kiister, Professor Esmarch, Dr. Martin, and others, all use it, and give unanimous testimony in its favor. I regret that I cannot be present to enter into the discus- sion of this paper, but I would ask my countrymen to weigh all the points of difference between clean and skilled oper- ators and careless and unskilled operators in reference to the necessity for any theory of special protection from ordi- nary surroundings. Certain other things there are, which we call conditions, that are favorable or unfavorable in reference to ovariotomy leading to success or failure, and of great importance. Among the conditions leading to success I would place the following :—’ 1. Climatic influences. 2. Avoidance of the clamp. 3. Drainage. 4. The judicious use of purgatives after the operation, dangerous ground. 5. The judicious use of opium. 6. The presence at the operation of only those whose presence is required. 7. A good assistant, and always the same assistant. 8. A careful administrator of the anesthetic. 9. Absolute cleanliness, as to person, sponges, instru- ments, and ligatures. 10. Avoidance of the operation in public hospitals. 11. Doing the operation in well-regulated private hospi- tals. 12. Avoidance by the operator and his assistant of all septic diseases, and of the examination of women who are menstruating, or having lochial discharges. R. STANSBURY SUTTON. 129 13. Proper application of the ligature or cautery. 14. Complete cleansing of the cavity of the peritoneum after operating. Among the conditions leading to failure I would place prominently the following : — 1. Climatic influences. 2. Extra-peritoneal treatment of the pedicle. Insufficient regard to proper drainage. Constipation not relieved prior to the operation. The injudicious use of opium. The presence of a crowd. Want of cleanliness. Overdoses of anesthetics. . Hospitalism. 10. Septic contamination of operator, assistant, or nurse. 11. Insufficient experience in operating, or want of prac- tical knowledge of the operation. 12. Changing assistant and nurse. 13. Doing the operation at any time or place the oppor- tunity offers. 14. Repeated tapping of the cyst. 15. Delaying the operation too long. 16. Operating in the presence of organic disease of other organs, especially of the kidneys. I am only too well aware of the positiveness that charac- terizes this paper. My apology for it is a long and consci- entious study of intra-abdominal surgery. A year ago I became dissatisfied with my own results,! and came abroad with the view of extending my study of the subject among ONAN YW Xe) 1 Three successful ovariotomies out of five completed operations. One of the fatal cases was an old dermoid cyst, frequently tapped. The second fatal case was diagnosticated as one of twisted pedicle, and proved to be such with a rotten cyst ; local jealousies prevented, in this case, an operation a week earlier. The cyst was free from a single adhesion, but the patient’s blood was already poisoned. My sixth case was an incomplete operation, and the patient died. My seventh case proved to be a mistake in diagnosis. An incision revealed a case of chronic peritonitis, with the small intestines glued into a mass, which, floating in the fluid in the cavity of the peritoneum, VOL. VII. 9 - 130 OVARIOTOMY: TREATMENT OF THE PEDICLE. the most successful operators on the Continent of Europe and in Great Britain. Through the courtesy of these oper- ators, whose names are nearly all mentioned, I have had the opportunity of witnessing one hundred and two opera- tions involving the abdominal cavity, of examining the growths after removal, and of observing the after-treatment and results of a large number of the cases. If this paper will aid my colleagues: in their respective fields of labor, I feel sure it will prove no less a source of gratification to these operators than their wxbounded kindness has proved beneficial to me. was mistaken for a tumor. A post-mortem in this case, soon after- wards, revealed the tubes of Rosenmiiller’s body full of small cysts, varying in size from that of a small pea to that of a large grape, and their contents appeared to be a clear serum, slightly viscid. These con- stitute all the operations I ever did for the removal of ovarian cysts. Two of the patients have since given birth to four children, the third was unmarried a year ago. LEUCORRHEA CONSIDERED IN RELATION TO ITS CONSTITUTIONAL CAUSES) AND TREATMENT. BY FORDYCE BARKER, M. D., LL. D., New York. Ir is probable that many feel an apology is due for tak- ing up the time of this Society in discussing so common a disorder, with which every medical man is familiar. But it has seemed to me that as leucorrhea is not a distinct disease, but a symptom of many different and even oppo- site pathological conditions, there has been a neglect of its study by gynecologists for some years past, and prac- tically a forgetfulness of the fact that it not rarely origi- nates from constitutional causes, and that when long con- tinued it becomes itself a cause of local and important pathological changes. In the works of Sir Charles Mansfield Clark, Drs. Ash- well, Henry Bennet, and Tyler Smith, this affection is fully and most ably discussed ; but the work of the last of these writers was published more than a quarter of a century ago, and no writer on diseases of women since that time has considered it, except incidentally as a symptom of some iocal disease, with the exception of Courty, Stoltz, and Dr. Robert Barnes, who call attention to some of its constitu- tional causes. I find this to be equally true of American, English, French, and German gynecologists. After a care- ful examination of all the writers in these different lan- guages, and a thorough search for anything written on the subject referred to in the “ Index Medicus,” and the bibli- ography of the “ Nouveau dictionnaire de médecine et de 132 LEUCORRHEA: ITS CAUSES AND TREATMENT. chirurgie,’ I have been greatly surprised at the meagre- ness of the literature of the past twenty-five years on this subject. The great improvement in physical exploration resulting from the introduction of Marion Sims’s instruments and methods, and the use of the uterine sound, tents, bimanual examinations, and microscopy, have led to a careful study of organic changes as to structure and relative position, but seems to have been attended with a corresponding neglect of some other equally important points, and consequently their associated therapeutics. If I may be pardoned for referring to personal experi- ence, I will say that my opportunities for appreciating this fact,encompassed as I am by some of our most eminent sur- gical gynecologists, are probably somewhat exceptional, from the fact that for years past I see annually many patients who have previously been under the care of, and no doubt have received the best of surgical treatment from, men whom all regard as most eminent. Some have had the cer- vix incised, others have had it sewed up; others have had the cavity of the uterus scraped out, and others have only been treated by pessaries. Most have believed themselves, and no doubt have been, greatly improved for a time; but find- ing that their symptoms have returned, they have gone back to their former physician, and have again received local treatment. A large proportion of them have again thought themselves cured, but after a period varying from months to years, the leucorrhea, the back-ache, the irritability of the bladder, and the nerve disturbances have returned as badly as before, and the patient has been wrongly inclined to regard her physician, whom she at first enthusiastically adored, as after all a fraud. In a smaller number of cases I have had occasion to suspect that it was the physician who wrongly believed the patient to be a fraud. The regularity and persistency of her visits have worn him out, until he has come to that point that he would rather take an emetic than see her enter his consulting room, as the “damnable iteration” of FORDYCE BARKER. 133 her symptoms is sure to give him a warning of Trousseau’s vertigo a stomacho leso, and so he gets rid of her the best way he can, perhaps by sending her to me. It must be frankly confessed that this class are not gen- erally interesting either’ as patients or cases, and I always feel a deep sympathy and pity for myself when I have such to treat, although I know of some, more happily organized, who seem to build up a fine practice from just this class. It is a melancholy fact that duty demands of us to regard such from the stand-point of our patient and not from our own. Leucorrhea is the most constant of all the symptoms complained of by this class of patients, and usually it is re- garded by them as the most important, and as being the cause of the debility, the back-ache, neuralgic pains, and menstrual disturbances from which they suffer. I am in- clined to the belief that there is a larger measure of truth in their theory on this point than is usually considered by the profession, for in many but slight evidence of any organic disease, either from change of tissue or position, is found to explain the symptoms. Such disease probably had existed before I saw the patient, and had been cured by treatment. In a certain proportion careful inquiry would bring out the fact that for a while after treatment they had been quite free from all symptoms of disease, and that the first which attracted attention was the recurrence of the leucorrhea, followed by back-ache, debility, various reflex pains, and menstrual disturbances — in some painful and scanty men- struation, in others profuse discharges, or diminished inter- vals between the catamenial periods. In this class there was always found some pathological condition of the organs in the pelvic cavity, and in many this disappeared after constitutional treatment, without any local applications ex- cept vaginal injections. For many years I was an entire disbeliever in the opin- ion of Tyler Smith that leucorrhea was in many cases the primary cause of morbid states of the os and cervix uteri; and while now I am not at all disposed to accept the state- 134 ZLEUCORRHEA: ITS CAUSES AND TREATMENT. ment that this is the fact in a majority of cases, in the past few years I have been convinced that this is true in some. My observation and clinical experience have confirmed some of his views which I formerly rejected. He expressed the belief that he was the first to call at- tention to the fact that long-continued leucorrhea slowly induced inversion of the canal of the cervix, thus causing increased pain and distress. He asserts that “when the canal of the cervix uteri is thus inverted or everted so as to bring the penniform rugze into view, an appearance is pre- sented which might readily be mistaken for ulceration,” and he suspected that “what has been called the cockscomb granulations or ulcerations is often formed in this way, the serrated edges of the so-called ulcer being in reality the pen- niform rugee presenting at the os uteri denuded of epithe- lium, florid and enlarged.” All remember that Dr. Emmet has graphically described this condition as generally one of the results of old lacerations of the cervix uteri, and I deem it quite probable that this was the unrecognized fact in the cases of Tyler Smith. I distinctly recall the circumstance that when Dr. Em- met first had the kindness to show me one of his patients, I remarked, ‘“ Why, this is exactly what I have been accus- tomed to show to students as Evory Kennedy’s cockscomb granulations,” when Dr. Emmet reposited the canal, and, quite to my surprise, the apparent granulations disappeared. I have seen two cases of this character in patients in whom Emmet’s operation for the cure of laceration had been previously performed, in one by Dr. Emmet, and the other by Dr. Sims. In both the operation was successful in relieving them from all distressing symptoms; in one for over four years, and in the other for nearly three years. The history of these patients was singularly alike, in that both were afterwards broken down by attendance and nursing of ill members of their family. Soon after, they were an- noyed by a profuse and irritating leucorrhea. Then fol- lowed too frequent and prolonged menstrual periods, back- ache, and reflex neuralgias. From the appearance of the FORDYCE BARKER. 135 cervix I should never have suspected that either ever had laceration, but in both the so-called cockscomb granulations were very characteristic, but I could only in a very slight degree reposit the canal of the cervix, as can be done when this condition is the result of an existing laceration. In both the general health was perfectly restored, the menstrual irregularities were overcome, the leucorrhea en- tirely disappeared, and the os tincez regained a perfectly healthy color and form from constitutional treatment and the use of vaginal injections. In neither case was there any other local treatment. I may add, as a fact of some interest, that one of them gave birth to her only living child sixteen years before the operation. She afterwards had eight miscarriages, which, as she told me, Dr. Sims thought due, no doubt correctly, to the laceration. Emmet’s opera- tion was performed nearly three years ago, since which she has not again become pregnant until now, when, at the age of forty-three, she expects her confinement in November. The influence of leucorrhea in developing disease of the pelvic organs may have been over-estimated by Tyler Smith, who believed that in a majority of cases in which morbid states of the os and cervix were present, cervical leu- corrhea, or, in other words, a morbid and augmented secre- tion from the mucous glands of the cervical canal was the most essential part of the disorder, and that the diseased conditions of the lower segment of the uterus were often secondary affections resulting from the leucorrheal malady. In the cases that I have just mentioned, as well as in many others that I have seen, his assertion seems to have been confirmed, that a morbid condition of the cervix uteri may be remedied again and again with a tolerable certainty of the recurrence of the disorder, unless the cervical secre- tion be brought to a healthy condition. He believed that “leucorrhea was often not only the cause of epithelial ab- rasion of the os and cervix and superficial ulceration, but, when long continued, by its consequent irritation it gener- ally induced induration and enlargement of the os and cer- vix.” 136 LEUCORRHEA: ITS CAUSES AND TREATMENT. It is often very difficult to determine which given con- dition bears the relation of cause, and which of effect. But clinical experience has convinced me that his views on this subject have more foundation than I formerly supposed. Some years ago a lady from a Western town called on me in June only a few days before I was to leave the city for the summer. She had long suffered from uterine disease, and had been treated by many able physicians with tempo- rary benefit. Two years before she had passed the winter in New York under the treatment of an eminent gynecolo- gist and particular friend of mine, now dead, who had made applications to the cervix every fifth day — except during menstruation, which was profuse and prolonged —for sev- eral months. She returned to her home in the spring very much better, so that she thought herself cured, although the leucorrhea was not perceptibly less. All her bad symp- toms soon returned, and when I saw her she was in a mis- erable condition—extremely debilitated and anemic, a great sufferer from neuralgic pains, and from profuse but very ir- regular menstrual losses. The cervix was very low, resting on the perineum, very much enlarged, and painful on the slightest pressure. The vagina was filled with an offensive muco-purulent fluid, and the os patulous, presenting as marked an appearance of the so-called cockscomb granula- tions as I ever saw, which bled on the slightest touch. She also suffered greatly from gastric disturbances, obstinate constipation, and painful hemorrhoids. I may mention that I was obliged to put her under the influence of chloroform in order to make a satisfactory examination. I did not much care to have the responsibility of the case, and vainly endeavored to induce her to place herself under the treat- ment of the late Dr. George T. Elliot, who was to be in the city during the summer, but she was not transferable. So, after seeing her for a few days, I gave her such prescrip- tions as I hoped would be useful in overcoming her gas- tric troubles, the constipation, and the hemorrhoids, and, if these means proved successful, she was then to take con- tinuously for months the chlorate of potash and the lactate FORDYCE BARKER. 137 of iron in the infusion of columba. I advised her also to pass the summer at Long Branch. She had not been able to walk, and had been carried up and down stairs for more than eighteen months. Sea bathing was therefore impos- sible, but I directed that she should be sponged with sea water, and afterwards thoroughly rubbed, and that she should use a quart of sea water as a vaginal injection every night and morning, except during menstruation and the two days preceding and following this period. In Sep- tember this lady greatly surprised me by walking into my consulting room so entirely changed in her. appearance that I did not in the least recognize her. The change in her pelvic organs was equally remarkable. The cervix was still enlarged, but was reduced at least one half in size, and much higher in the vagina, and the os presented a healthy color and form. She had not been conscious of leucorrhea for several weeks, an exemption which she had not had before for many years. She remained in New York for a few weeks only. I will add that this lady in early married life had two children, but lost both when young by scarlet fever. She had not been pregnant for twelve years, when I saw her first. She came to New York in January, two years afterwards, to be attended by me in her confinement, which terminated happily, and she has been in excellent health since that time. This case has been a most instructive lesson to me, and in several others where circumstances have not permitted the use of any local treatment. I have seen leucorrhea, and various morbid conditions of the os and cervix, disap- pear by the use of proper hygienic measures, and such treatment as was indicated for the improvement of the general health. Tyler Smith in positive terms states his belief that what is called the “irritable uterus” is nothing more than leucorrhea, attended by a neuralgic condition of the os and cervix uteri. It must be understood that he uses the term leucorrhea as signifying the same condition which Scanzoni calls “chronic catarrh of the uterine mu- cous membrane.” I have long given up the treatment of 138 LEUCORRHEA: ITS CAUSES AND TREATMENT. this troublesome class of cases which Gooch designated as irritable uterus, by topical agents, but I have had some suc- cess in constitutional treatment, and will presently refer to the physiological and anatomical reasons for this course. While all accept the statement that local and constitu- tional causes combine to develop leucorrhea, yet I think it may be questioned whether the latter be not too often dis- regarded in the present day, both in the diagnosis and the treatment of this disorder. Many of these constitutional causes, such as atmospheric changes which develope other and general catarrhal affections, a cold damp climate or residence, plethora in some, anemia in others, everything which induces defective nutrition and debility, as_pro- longed lactation, excessive fatigue from certain employ- ments, the continued standing position for many hours of shop girls, are all so well understood as causes, that further reference to them would be a waste of time. The influence of nerve disturbance as a consequence of defective nutrition in causing this affection, is perhaps not so generally appre- ciated, although most practitioners know the fact that in some of their patients strong mental emotion is sure to bring on a troublesome leucorrhea. The anatomy and physiology of the organs of reproduc- tion in women are no doubt well known to all practitioners, but I suspect that many overlook the bearing of certain points on the affections we are now considering. Mayrhofer calls attention to the fact that in virgins the arteries of the uterus have a straight course, but during pregnancy they are turned spirally, and after confinement they never re- cover their straight direction. He suggests that this may explain the reason why disturbances in the uterine circu- lation which have the character of retardation are more easily remedied in virgins than in parous women. But the veins are of much more importance in the ques- tion of impeded circulation than the arteries, not only be- cause they are much more numerous, but because they have no valves. They debouch into the uterine and pampini- form plexuses, which are situated outside of the peritoneum, FORDYCE BARKER. 139 and when the pressure of the abdominal cavity is greater than that of the atmosphere it prevents them from being emptied. Preparations of the uterus injected with wax show an enormous preponderance of veins over arteries. Then it must be remembered that the uterus is a muscular organ, and that when there exists a deficiency in contrac- tile power, as in an enlarged and flabby uterus, this contrib- utes. to a blood stasis and venous congestion, and conse- quently a morbid condition of its glandular secretions. It must be obvious that anemia, defective nutrition from bad blood, all the so-called cachectic conditions, any disease of the heart which weakens its propulsive force —all these conditions diminish the power of overcoming the impedi- ments in the way of the removal of the venous blood from the pelvic vessels, and especially those of the uterus and its surroundings, The importance of the liver and its portal circulation has long been known and insisted upon, notably by Rigby and Mackenzie. There are numerous cases which come under the obser- vation of medical men in which all these physiological and anatomical considerations have an important bearing, where local treatment is not practicable, or would be worse than useless. I will only allude to a few which may be men- tioned as distinct classes. Leucorrhea to such a degree as to attract attention, with its associate symptoms, menstrual irregularities, back-ache, and irritable bladder, is not at all rare in young unmarried ladies. Every year many such are brought to me, chiefly from those who have come to the city to finish their educa- tion, as it is termed. . I may be permitted to remark parenthetically, that, con- trary to what I believe is the general impression, my obser- vation leads me to the conclusion that a large majority of such greatly improve in their appearance and health by com- ing to the city, when they have sufficiently large and well ventilated dormitories, and are not crowded in study rooms warmed only by furnace heat, or in an atmosphere vitiated 140 LEUCORRHEA: ITS CAUSES AND TREATMENT. by gas-lights, and are not over-stimulated to study and prac- tice at the piano; for they have an abundance of well-pre- pared food and regular open air exercise, and some, for the first time in their lives, have an intelligent supervision of their hygienic habits and conditions. There has been a wonderful change in these particulars in our New York schools within a few years past. But exceptions are. found under the most favorable sur- roundings, and the disorders we are now discussing are not rare, particularly during the first year of their school resi- dence in the city. The moral depression from home-sick- ness, and exhaustion of nerve power exercised in unaccus- tomed directions, seem to me the most common of the constitutional causes in these cases. I suspect the most frequent error in the treatment of such cases is found in a disregard of the necessity of such remedial agents as will secure a healthy performance of all the organic functions — a neglect of the morale, and a routine prescription of some preparation of iron, which, under these circumstances, is sure to destroy the appetite and produce headache, sleep- lessness, and other nerve disturbances. I have had many brought to me, taken away from school by anxious parents, where this has apparently been the history. In very many cases in which leucorrhea and other ute- rine disorders have been the consequence of parturition, local treatment is useless, and often positively injurious, but a cure results from appropriate constitutional treat- ment. Of course, a careful and thorough examination should be made of the organs in the pelvic cavity in all such cases, and if any lesion be found which local treat- ment can cure, it should be resorted to. But local treat- ment will not effect involution of a large flabby uterus, or contract its enlarged veins, and, to my mind, it is very doubtful whether it be useful in effecting restoration of de- fective tissue. But I do believe that these results may often be accomplished by proper constitutional treatment. In women who have passed the climacteric, leucorrhea is not an uncommon disorder, which not only greatly annoys FORDYCE BARKER. I4!I them, but often causes great anxiety of mind. I think that such women are generally much more averse to a physical examination of the pelvic organs than at an earlier period of life—I may even say than some of the virgins — partly from a fear that malignant disease may be found, but chiefly from psychological reasons. Fortunately, in a vast majority of cases, such examination is not necessary, as the disorder arises from constitutional causes. If it be due to such local conditions as prolapse of the vagina or uterus, vaginal cystocele, rectocele, or hemorrhoids, there will be other symptoms indicating the necessity for exami- nation of the organs. If the leucorrheal discharges are oc- casionally sanguinolent, or there are occasionally small losses of blood from the genitalia in women who have for months or years ceased to menstruate, I think that an ex- amination is absolutely imperative. I deem it quite unnecessary to take up the time of the Society in describing the numerous constitutional disturb- ances which cause this affection in women who have passed the climacteric, or in mentioning the various indica- tions for treatment. I have been tempted to detail some cases illustrating the various points which have been discussed, but before such a society as this, I deem it wholly unjustifiable to rehearse well-known elementary facts, and my only excuse for this paper is the belief that the very rapid advance which gyne- cology is making in other directions has led to a neglect of some considerations of great importance. DISCUSSION. Dr. G. H. Lyman, of Boston.—I have long been convinced that such a paper would be of great service to the Society, as I think we are too much in the habit of giving up old views con- cerning constitutional causes, and trusting too much to local treatment. The cases are numerous, and must come into the experience of every man, in which we can find no cause for the leucorrhea, unless it can be accounted for by anemia, or the gen- cral relaxation of tissues with positively no local disturbance re- 142 LEUCORRHEA: ITS CAUSES AND TREATMENT. quiring anything more than simple cleansing local treatment. If I understand the author of the paper correctly, he has made a step in the right direction, and has pointed out to us the necessity of more and more employing constitutional measures in these cases, rather than trusting to local treatment. Dr. H. P. C. Wixson, of Baltimore. — I was greatly interested in Dr. Barker’s paper. Leucorrhea is a condition which we fre- quently see. It may be a symptom of an overtaxed brain in a school-girl, a symptom of indigestion, or it may occur from vari- ous other causes. I have learned to regard it as merely a symp- tom of some other condition, which is the one requiring special treatment. I think we have all of us become too much absorbed in the local treatment of leucorrhea, and that we have all forgot- ten the constitutional treatment which belongs to every case in gynecology. We find a retroverted, or a sharply anteflexed ute- rus, and we expect to rectify these mechanical troubles, and to cure our patients, but we very often fail. Frequently in these cases, after having resorted to general therapeutics and the proper hygienic management of the patient, and then having rec- tified the local trouble, if it be required, we find that we have succeeded the best. We all know that the woman who has local uterine trouble gets into a demoralized state of mind, more or less. Even after you have rectified a retroverted uterus this con- dition of things continues for a long time, her entire vital force is concentrated upon her genital organs, and she goes for months and years together from one medical man to another, and very often her mechanical trouble is finally removed, and she gets well by means of something which suddenly shocks her and brings about an entire change in her mode of life. If these patients could be occupied busily in such matters as divert their attention, and receive only such treatment as was necessary to keep their bowels in good condition, and correct indigestion, and be induced to take sufficient exercise, they would improve from hour to hour, and I am beginning to feel more and more that general thera- peutics in gynecology are as important as local therapeutics. Dr. A. REEVES Jackson, of Chicago. —TI find myself always surprised to see the interest excited by old subjects, when they are presented by those who can make them attractive. Twice to-day I have been thus surprised. All of us have had cases of leucorrhea which depended upon some local cause, and yet, al- though the local cause was apparently removed, that miserable DISCUSSION: 143 symptom still remained. I have had such cases, and have treated them topically by every means known to me, hoping that they were cured, but back the patients came soon afterwards, and at once spoke of the recurrence of the leucorrhea. I have given attention to their bowels, but no benefit has followed, although the condition of constipation was improved ; and in many cases I have been unable to remove the leucorrhea after having carefully corrected all the local causes which I was able to find, and after resorting to such constitutional treatment as I thought the case required. All of our patients are not able to go to Long Branch, as was the patient referred to by Dr. Barker — some of them are not even able to obtain the tincture of columbo — and what we need is some instruction as to how they shall be managed. I had hoped that Dr. Barker would give us a little more explicit instruction with reference to general management in these cases. However, I think it is impossible to tell how to manage all of them, and, as I understand it, the principal object of the paper was to direct attention to the necessity of combining the two plans of treatment, namely, the local and the constitutional. The sermon which he has preached was a good one — just such a one as we need —and was as good as could be preached from the text. Personally, I am grateful to him for the opportunity of hearing his paper. Dr. JosePpH TaBER JOHNSON, of Washington. —I have nothing special to add to what has already been said, except to express my interest in the subject, and to say, with others, that I have seen cases of leucorrhea which have already been through various kinds of treatment, and, in a number of instances, un- successfully. I have been surprised in one or two cases, where it was necessary for patients to withdraw from treatment and re- turn to their work, that they finally got well, apparently at least, as the result of an entire change in their modes and habits of life. Whether it was the exercise, or the change in occupation and change of thought, etc., which produced the cure, I am not positive ; but I think they had a great deal to do with their re- covery. I recollect one patient particularly, whom I was unable to cure with any of the remedies which I had administered, but who got well after all treatment was stopped. I am certain that considerable constitutional treatment must be combined with local treatment, in order to cure these cases. If there is a local lesion it would seem to be common sense to direct our efforts 144 LEUCORRHEA: ITS CAUSES AND TREATMENT. toward its cure, and, when constitutional remedies are necessary to complete the result, to administer them. It is certain that leucorrhea continues after local lesions have disappeared, and leucorrhea also occurs without local lesion; and both these classes of cases may require constitutional treatment. I am pleased to have heard the paper, and I have been very much in- structed by it. THE PRESIDENT. — The great point in this subject is that we should find out the cause of the leucorrhea, and then the burden of responsibility remains with the surgeon as to the cure. There is one point which Dr. Barker includes, but which has not been fully elaborated, and it is that we must look upon the symp- tom leucorrhea as caused by perverted or impaired nutrition in every instance. We can understand why the effect should centre upon the uterine system, be the cause whatever it may, whether too much grammar, too little exercise, or a constipated condition of the bowels. The sympathetic nervous system presides over nutrition, and also over the organs of generation ; and the rela- tion being so close, the one sympathizes with the other. We find that the blood vessels which go to supply the erectile tissue form- ing the organs of generation are covered with a network of fibres from the sympathetic, the same nervous system which presides over the organs of nutrition; and I can, therefore, understand fully why a young girl should have a functional disturbance, with a leucorrheal discharge, if over-worked by mental labor, and that it would be a condition of perverted nutrition. Dr. BARKER. — It was not my intention to depreciate a most careful physical exploration, but simply to call attention to the fact that there are cases where, on account of peculiar .circum- stances, local treatment and a local examination are not possible, practical, or useful. CARE OF THE PERINEUM. BY THEOPHILUS PARVIN, M. D., Indianapolis, Ind. OnE of the most important duties of the accoucheur in the second stage of labor is the preservation of the vulvo-vaginal orifice from injury during the passage of the head and shoul- ders of the fetus, or if injury must be, to have it the least possible. Matthews Duncan suggests that in the Darwinian prog- ress of the species, the head of the fetus has increased in size more rapidly than the orifices and passages through which it has to come have increased in size and dilatability, Be this as it may, both he and Schroeder have shown that in primipare some tearing of the vaginal orifice is inevitable, only thirty-nine per cent. of women in their first labor, ac- cording to Schroeder, escaping rupture of the fourchette. Beside, there may be serious rents of the anterior margin of the vuival orifice, such rents sometimes causing fatal hem- orrhage. The perineum is especially liable to rupture from the direction of the propelling force, the lesion generally being in the median line, for there is the greatest distention, and there the tissues are furthest from their points of at- tachment. Even where the perineum receives no injury at once ap- parent, it may have been subjected to such pressure and dis- tention that though entire even for a few days after delivery it finally gives way, and the resulting condition is similar to laceration. Dr. James F. Hibberd! has recently reported two cases of the kind; similar cases were previously? published 1 American Practitioner, August, 1881. 2 Papers on the Female Perineum, London, 1879. VOL, VII. 10 146 CARE OF THE PERINEUM. by Matthews Duncan, but long before this the late Dr. Dewees! recorded in his well-known work an example due to delay in the use of the forceps. The frequency with which rupture of the perineum occurs is an unsettled question, for even careful and experienced observers differ in their statements, while many practition- ers after attending hundreds of cases of labor assert that they have never had a case of this accident, an assertion which can never be accepted unless the person making it can also state that he has carefully examined the perineum in every case immediately after labor. The following are among the statistics of eminent obstetricians : 34} per cent. for primi- pare, 9 per cent. for the parous, Schroeder ; 115 in 1,011 de- liveries, Winckel ; 21 per cent for primiparz, 4.7 for parous, Olshausen ; 7} per cent., Hildebrandt ; 31 partial, and only one complete in 400 deliveries, Swayne; on the other hand, Marduel, from whose paper? the preceding statistics have been taken, states that in 300 deliveries at the Lyons Obste- tric Clinic he has not seen a single rupture of the perineum, a fact which is certainly very remarkable. The causes of the lesion relate to the pelvis, the condition of the soft parts, to the fetus, to the conduct and the char- acter of the labor. As to the pelvis, the pubic arch may be acute, the sa- crum too straight, or there may be lateral deviation of the coccyx. Infiltration of the perineum, “rigidity from cicatrices re- sulting from traumatism, or consequent upon scrofulous or syphilitic disease, or from the advanced age of a primipara,”’ and great prolongation of the perineum, are generally ac- cepted causes. In regard to the fetus, the chief causes are face and brow presentations, occipito-perineal delivery, great size of the head, as from hydrocephalus ; nevertheless, mere size of the head is not, according to Hecker, in proportion to the frequency of perineal lacerations. 1 Compendious System of Midwifery, 8th ed., p. 287. 2 Nouveau dictionnatire de médecine et de chirurgie pratigues, vol. XXvi. THEOPHILUS PARVIN. 147 As to the conduct of the labor, delivery with the forceps offers a large contingent. But it should be remembered that in many of such cases the delivery was delayed until the tis- sues had become infiltrated, swelled, and the perineum had thus lost all facility or possibility of being stretched ; in other cases immediate delivery was demanded in the inter- - est of the mother or of the child, and art could not imitate nature in causing a gradual dilatation of the vulvo-vaginal opening. The use of ergot in the second stage of labor has often caused tearing of the perineum; fortunately such use is much less frequent now than formerly, though obstetricians may hesitate to accept the rule of Pajot, “ergot is never to be given when there is anything in the womb.” Dr. Madden! regards a failure to properly support the perineum as the most frequent cause. Finally, the great majority of perineal lacerations are caused by precipitate deliveries —force too great, time too short, the expelling power overcoming the resisting part not by stretching but by tearing. It follows from the statement just made that in order to prevent these injuries, or to reduce them to a minimum, the most important duties of the accoucheur are to hinder the abrupt expulsion of the head of the fetus, and to promote gradual dilatation of the passage it goes through. In attaining these objects one of the first things to be done is to have the patient lie on her side; generally the left side is preferred, though for other reasons than those rela- ting to the protection of the perineum. The advantages of the side position are chiefly lessened abdominal pressure, and preventing wide separation of the knees; besides, in many cases a woman may prefer this position as being less offensive to her modesty, and in all it is the only one which permits inspection of the parts should this be necessary. Pressing with the feet on her part, or that upon the knees by another, must be forbidden. Frequent respiration and ab- staining from all bearing down efforts must be enjoined, and 1 Transactions of the Edinburgh Obstetrical Society, vol. ii. 148 CARE OF THE PERINEUM. if she does not refrain from the latter, chloroform or ether is to be inhaled; the anesthesia has, according to some au- thorities, the additional advantage of promoting relaxation of a rigid perineum. If the dilatation be insufficient, the head is to be held back, and to be guided during its exit in the axis of the vul- va. Hohl directed grasping the head, after the occiput has passed under the symphysis, with the hand, the thumb above and the fingers below extending to the anterior mar- gin of the perineum, and thus holding the head back during a pain. Others apply a guiding pressure to the head with one hand, and with the other support the perineum in a way hereafter to be mentioned.} Kleinwiichter states that we have in the forceps an excel- lent means for regulating the descent of the head, and giv- ing the soft parts time to dilate; and Barnes? suggests that occasionally the long double-curved forceps, by carrying the head well forward, may preserve the perineum. Dr. John Harvie,’ the author of a brief tract, London, 1767, entitled ‘Practical Directions shewing a Method of Preserving the Perineum, and Delivering the Placenta without Violence,” taught that the perineum was to be preserved by preventing its lengthening, and to this ‘end he directed that “the peri- neum is by the palm of the left hand to be carried back toward the anus, and to be kept so all the time of apain.” Others have advised furnishing more material to the peri- neum, some counsel pressing the tissues from about the anus, Siebold from the thighs toward the vulval orifice. Dr. Goodell directs hooking two fingers in the rectum and drawing the perineum forward, while the thumb on the head restrains, if necessary, its advance. Pugh taught that the vulval orifice was to be dilated with the fingers, “stretch- 1 Grundriss der Geburtshilfe. 2 Obstetric Operations. 8 This gentleman was more famous from having married the niece of Smellie, and succeeding him as a teacher of obstetrics, than from his contributions to medical literature, the little volume from which I have quoted and two cases found in Smellie’s J/idwifery being probably all that came from his pen. THEOPHILUS PARVIN. 149 ing lengthways when the pains are off, circularly when the pains are on.” Smellie advised, not however with any thought of pro- tecting the perineum, in certain cases where the head was drawn back after a pain, by the cord being round the child’s neck, or by the shoulders being retarded at the brim of the pelvis, or when the uterus contracted around the child’s neck, that one or two fingers be introduced to the rectum before the pain goes off, and pressure made upon the fore- head of the child at the root of the nose; this measure de- tains the head till the return of another pain, which will squeeze it farther down, while the fingers pushing slowly and gradually turn the forehead round outwards and up- wards. Ritgen, and more recently Olshausen and Ahlfeld have commended this method for the preservation of the perineum. It is used only at the close of the second stage of labor ; the patient may be upon her side or upon her back, though the latter position is preferred ; the index and mid- dle finger are passed:as far as possible into the rectum, and pressure made upon the forehead of the child, while the thumb is close to the fourchette to control that part of the head already born; as the head emerges pressure is made upon the superior, then upon the inferior maxilla until it is quite pushed out. The perineum is protected by de- livering the head not during a pain but during an interval. Dr. Lusk states that in cases of rigidity of the perineum he is in the habit of “alternately drawing the chin down through the rectum until the head distends the perineum, and then allowing it to recede,” and that the parts become rapidly distensible by this to-and-fro movement. Criticisms are not wanting as to the use of the fingers in the rectum to effect delivery of the head. Gardien objected because the coccy-pubic diameter was thus lessened, and because tending to impress on the head a different direction from that which nature gives it in disengagement. Niagele and Grenser class it among maneuvers that are painful or injurious; Kleinwiichter says there is danger of injuring the rectum, and the method is not to be recommended ; 150 CARE OF THE PERINEUM. Tarnier, that neither the Olshausen-Ahlfeld plan nor that of Dr. Goodell gives better results than others, and that they are painful. Already the pressure of the child’s head upon the rectum increases voluntary expulsive efforts, and the fingers within the rectum add to its resentment, as shown by these efforts, and thus a greater liability to precipitate delivery is caused. Finally, the protection of the perineum is to be sought by supporting it during the expulsion of the head and of the shoul- ders ; this practice is in accord, as remarked by Matthews Duncan, with that of the immense majority of the profes- sion both now and in past times. Nevertheless, it is con- demned by some of the most eminent living obstetricians, among whom may be mentioned Depaul, Leishman, Hewitt. Depaul says’ that the first effect of supporting the perineum is to hide the part which it is important to inspect; the practitioner believing in complete security is deprived of cer- tain indications which announce the imminence of danger, and very considerable rents occur under his hand which might have been prevented if a different course had been taken. He further says that attention should be directed not to increasing the resistance of the perineum, but to giv- ing it time to be gently stretched ; all our care is to be given to this, and for it to take place a certain time is required. Moderate the efforts when too violent, hold back the head when it receives too strong an impulsion, there is the secret ~ of being master of the situation, and of doing something really useful. Supporting the perineum is strengthening the weak part of an elastic ring, and relieving it of excessive strain. The hand should be applied directly, and with no interven- ing napkin; support is given only at the close of the sec- ond stage, and only during a pain. Supposing the patient to be lying on her left side, and with her hips near the edge of the bed, the practitioner applies his right hand so that the con- cave palm receives the convexity caused by the bulging peri- neum, the thumb is upon the right, the four fingers upon 1 Dictionnaire encyclopédique sciences médicales. THEOPHILUS PARVIN. ISI the left labium majus, while the fold between the thumb and index finger corresponds with the anterior margin of the perineum. Great pressure is avoided, lest a thinned part of the perineum may rupture, but moderate resistance made to the driving force, and at the same time the head is gen- tly pressed toward the pubic symphysis. The left hand passed over the patient's right thigh, grasp- ing the head after the method of Hohl, holds it back if necessary during a pain, and when it comes out guides it in the axis of the vulvo-vaginal orifice. As to pressing the perineum forward or drawing it back, it is to be remem- bered, as so admirably set forth by Dr. Garrigues,! that the orifice through which the head now moulded into somewhat of a cylindrical form, must pass, is an elastic ring, and that a cylinder will go through a ring most readily when the lat- ter is at a right angle to the former : “Only if this relation be- tween them does not exist, canit be of use to displace the posterior part of the ring forwards or backwards, accord- ing to circumstances.” In some cases the expulsive force and the resistance are so suitably related, the former not violent, and the latter gradually yielding, we may be confident there will be no tear even if the perineum be unprotected ; nevertheless, it is better to have the hand applied to the fetal head after Hohl’s method. When rupture of the perineum is otherwise inevitable it is advised to prevent the accident by incision or incisions. This operation, though generally credited to Michaelis, 1810, was really first proposed by Ould in his “ Treatise on Mid- wifery,”” 1742, as the following extract from this work shows : “Tt sometimes happens, though the Labour has succeeded so well, that the Head of the Child has made its way through the Bones of the Pelvis, that it cannot however come for- ward, by reason of the Extraordinary Constriction of the Va- gina ; so that the Head, after it has passed the Bones, thrusts the Flesh and Integuments before it, as if it were contained in a Purse; in which Condition if it continues long, the 1 American Fournal of Obstetrics. 1880. 152 CARE OF THE PERINEUM. Labour will become dangerous, by the Orifice of the Womb ° contracting about the Child’s Neck; wherefore it must be dilated if possible by the Fingers, and forced over the Child’s Head ; if this cannot be accomplished, there must be an In- cision made toward the Anus with a Pair of crooked Probe- Sizars ; introducing one Blade between the Headand Vagina, as far as shall be thought necessary for the present Purpose, and the Business is done at one Pinch, by which the whole Body will easily come forth.” Ould also advised stitching the wound if the incision was made so near the rectum as to weaken its contraction. Most advocates of the operation have advised lateral incisions, but Tarnier! observes that they do not always prevent quite extensive lacerations, they may leave deformity and a painful cicatrix, or the duct of one of the vulvo-vaginal glands may be injured, causing a fistula; and he therefore advises an incision of the perineum ° beginning at the raphe, and then not passing directly back but turning obliquely toward the side, so that if a laceration follow it will not involve the anal sphincter; he wisely cau- tions against episiotomy unless it be quite indispensable, for -he has sometimes seen the incised parts covered with es- chars and become the medium of grave infectious accidents. The late Dr. McClintock? stated that he had so often seen the perineum escape laceration where this accident seemed inevitable, he was led to doubt the possibility of recognizing the cases where incision is an absolute necessity. In view of this statement one might require conditions for episiot- omy similar to those which Coleridge did for the Czesarean operation: ‘I think there are only two things wanting to justify a surgeon in performing the Czesarean operation: first, that he should possess infallible knowledge of his art ; and, secondly, that he should be infallibly certain that he is infallible.” Playfair? says that when a distended perineum ruptures, its structures are so thinned that the tear is al- ways linear; and as a matter of fact the edges of the 1 Traité de PArt des Accouchements. 3a fasciculus. 2 Sydenham edition of Smellie’s Midwifery. 3 System of Midwifery. THEOPHILUS PARVIN. 153 tear are always as clean and as closely in apposition as if the cut had been made by the knife. Of course the wound then heals as readily under favorable circumstances as will one made by the knife. Notwithstanding this high author- ity, ragged rents of the perineum sometimes do occur, and besides episiotomy might save the anal sphincter, whereas there is no security as to how far the rent may extend; it may also prevent bruising of tissues from the possible pro- longed pressure before the rent happens. As to the frequency with which the operation is required, obstetricians differ greatiy: for example, it was resorted to by Dr. Johnston at the Rotunda Hospital three times in 2,246 deliveries, while in the Woman’s Hospital, Philadel- phia, it was done 56 times in 212 deliveries, that is to say in more than twenty-six per cent. In case rupture occur, the importance of an immediate operation has been conclusively shown by the statistics ad- duced by Dr. Noeggerath.? While not included in the title of this paper, a brief refer- ence is made to the operation and to the after-treatment. In case sutures are used it is probable that horse-hair will answer quite as well as any other material; certainly it is generally readily had, for though the obstetrician may not always have good silver wire in his pocket-case, he usu- ally has at the door a true cauda equina from which to draw his sutures. Further, I believe it unnecessary to bandage the patient’s knees together, for even if she were to widely separate them, a movement very unlikely to be made, it is doubtful if there would be any strain upon a single suture uniting tissues which have recently undergone such great stretching. The fixed approximation of the knees usually made after peri- neorrhaphy, is a great discomfort to the patient, and hinders the escape of the lochia as well as the thorough washing of the external sexual organs ; possibly the use of the bandage might also be omitted after perineoplasty. It is well to have the patient lie upon her side when sleeping, and this is 1 American Journal of Obstetrics. 154 CARE OF THE PERINEUM. the only precaution against separation of the limbs that is necessary. If the patient can pass urine while resting upon her knees and face, the catheter ought not to be used. DISCUSSION. ~Dr. James R. Cuapwick, of Boston. — I have always regarded the term “supporting the perineum ” as a misnomer. The whole secret of preventing laceration of the perineum lies in retarding the passage of the child, by which act the soft tissues will have time to stretch rather than tear. ‘The orifice, being of nearly uniform thickness and pliability, stretches equally in all directions until it receives some support laterally from the ischio-pubic rami. The soft parts fit tightly over the child’s head as it descends, and their so-called support by the hand does not in the least diminish the extent to which they must yield to allow the escape of the child. Such pressure by the hand does, however, unwittingly retard the advance of the head, and thus always accomplishes that end which I designedly seek. The head should be restrained in its passage through the vulva until the operator is satisfied that the parts have been sufficiently distended to enable the head to emerge without rupture. To render this procedure possible the head should never be permitted to escape during uterine contraction, but in- variably in the interval between the pains. I have had very few ruptures, in consequence, as I believe, of acting upon this prin- ciple. Dr. Parvin alluded to another point of great importance, that separation of the legs, unless extreme, does not put the perineum on the stretch ; consequently that the tying of the knees together is a useless precaution. Flexion of the thighs upon the body does, however, drag upon the perineum ; this is so noticeable dur- ing the operations for closure of a torn perineum that the thighs must generally be extended at the close of the operation while the deep sutures which approximate the denuded muscular tis- sues of the perineum are being tied. Dr. W. T. Howarp, of Baltimore. — I think that laceration of the perineum is less apt to occur when delivery is completed with the woman upon the side than when she lies upon her back. This is a point which I obtained from “ Schroeder’s Midwifery,” DISCUSSION. 155 in 1873 ; and since that time, whenever I meet with a lacerated perineum, I almost always ask the woman whether she was de- livered upon the side or upon the back, and it is very rare she says, “I was delivered upon the side.” If the rupture is very bad I find that it is almost invariably the case that she was deliv- ered while lying upon the back. There is one point to which Dr. Parvin has not alluded, and it is this: when the perineum is rigid, it seems to me that the best method of preventing rupture is to put the patient profoundly under the influence of anesthetics. When the perineum is fran- gible, place the patient upon her side with a pillow between the knees, and profoundly anesthetize her, which will relax the peri- neum. There is another point, and it is one that the author of the pa- per has not alluded to, the fact that the shoulders are the most efficient agent in producing rupture of the perineum. I first had my attention directed to this point by Dr. Ferdinand Chatard, Sr., of Baltimore, who had ascertained that out of more than fifty- five hundred labors he attended the large proportion of perineal lacerations was produced by the shoulders ; and, if I am not mis- taken, Dr. Barker’s experience will bear out the same statement. I invariably therefore pull out the shoulder which is nearest to the pubes, and since I have adopted that practice, I have avoided shoulder lacerations of the perineum. How long after laceration has occurred is it proper to wait before performing the primary operation for restoration? There seems to be a wide diversity of opinion upon this point. Dr. Graily Hewitt is of the opinion that there is very little use in the intro- duction of sutures some hours after the laceration has occurred, as then the operation is almost sure to fail. Dr. Thomas teaches that if the rupture has occurred through the recto-vaginal septum to such an extent as to make the operation serious and lengthy, the secondary operation should be performed. As far as my own opinion is concerned, I think the operation should be done as early as practicable. But there may be an error with regard to that ; for there are lacerations which, when they are examined the next day, will be found not to require any operation. In the perform- ance of this operation I have latterly used the silk-worm gut, and with very satisfactory results. While, as a general rule, it may be best to unite the laceration by suture at the earliest possible time, I know perfectly well that sutures introduced on the second day 156 CARE OF THE PERINEUM. after the accident will give most excellent results. In general, if the sutures are inserted well, good results will follow this opera- tion. Dr. Paut F. Munpf, of New York. — Dr. Parvin speaks of the use of the forceps in connection with prevention of rupture of the perineum, and I think the point in the use of the for- ceps for this purpose is that it prevents rupture in precisely the same manner as Dr. Chadwick has figured, and that is that the head of the child is checked from passing through the vulvo-vagi- nal orifice too rapidily, and therefore the perineum is less likely to be ruptured, no matter what means may be used for retarding the progress of the head, whether by the fingers or by the forceps ; the longer you can make the head rest upon the perineum until it is thoroughly distended, the child’s head gradually dilating it bit by bit, gradually allowing the head of the child to slip slowly along, the better it is for the perineum. The usual method which I employ is to put the patient upon the side, generally upon the left, draw up the knees, put two fingers into the rectum, and, as soon as it can be reached, into the mouth or above the chin of the child, and manipulate the head gradually, endeavoring to keep it back in the pains, and between the pains endeavoring to ex- tend it. If too hasty in this manipulation a brow presentation may be made, but if ten or fifteen minutes are consumed you may save a perineum which would otherwise be sure to be ruptured. The same can be done with the forceps. I will relate briefly the history of a case: A lady was sent me with complete lacer- ation of the perineum through the sphincter and one inch up the rectum. I operated successfully according to the operation which Dr. Emmet has so fully described in his book, and cau- tioned her that she should not become pregnant during the next two years. She obeyed my directions so closely that when she found herself pregnant again the time for her delivery fell exactly two months beyond the two years allowed. She engaged me to attend her in labor, and was confined early last August. I was exceedingly anxious concerning the perineum. At the time of her labor the pains went on in the usual manner, and the head came down, but when it reached the floor of the pelvis it re- mained there. Finally I found that the proper rotation had not taken place. I applied the forceps and drew it down well upon the perineum, so as to protrude the latter, and then removed the instrument. Just here is where I wish to make a point which I DISCUSSION. 157 do not think the generality of practitioners observe. I removed the forceps at the moment the head of the child was well down upon the perineum, as soon as I could catch hold of the mouth of the child with the fingers in the rectum, and I then placed the patient upon the side, and in about half an hour gradually worked the head through the vulva without the slightest injury to the re- paired perineum. I felt and plainly saw at that time that the danger of rupture depended entirely upon allowing the head to come through too rapidly. The child weighed eleven pounds, and was born without injury of any kind. With reference to the treatment of laceration after it has occurred, I should always per- form the immediate operation. Dr. Parvin. —I wish Dr. Barker had spoken as to the use of the forceps in preventing rupture of the perineum, and especially as to taking off the instrument before the head is delivered, a practice which, though highly commended by some obstetric au- thorities, seems to me questionable. By the forceps we can make the sub-occipital region hug the sub-pubic ligament ; we can retard the exit of the head until the vulvo-vaginal orifice is sufficiently stretched to yield without tearing. Dr. Matthews Duncan has pointed out the important fact that the sub-occipito-frontal diam- eter is the longest vertical diameter of the fetal head, and there- fore while the perineum may be entire during the passing of the other sub-occipital diameters its greatest danger occurs from this. As to the use of the fingers in the rectum to facilitate the exit of the head and to save the perineum, I doubt the accomplish- ment of the latter object. The fingers in the rectum decrease space and increase irritability ; the voluntary efforts at expulsion, efforts which you often at this stage of labor would prefer less- ened, are almost inevitably made greater by the presence of the fingers in the rectum; the practice therefore seems to me objec- tionable on this ground, even without reference to the injury that may be done the organ. The criticism made by Dr. Chadwick upon the term “ support- ing ” the perineum I cannot think correct. If we strengthen by a proper application of the hand the weakest part of an elastic ring, throwing the force which drives against that part elsewhere, and retarding the exit of the head until the ring is dilated, it seems to me we “support” the perineum; the old term is the best expression of the fact. THE RELATIVE VALUE OF HYSTERECTOMY AND OF THE COMPLETE REMOVAL Ver THE UTERINE APPENDAGES FOR THE CURE OF UTERINE. FIBROIDS BY J. KNOWSLEY THORNTON, M.B.C.M., Surgeon to the Samaritan Hospital, London. Mr. PRESIDENT AND GENTLEMEN, — In bringing before you the relative value of two very different surgical pro- cedures for the cure of fibroid enlargements of the ute- rus, I feel that I am confronting one of the most difficult questions in abdominal surgery, armed with imperfect weapons. Medicine has, however, long and vainly endeav- ored to deal satisfactorily with this disease, and now the surgeon’s aid is invoked. Ido not deny that many cases have been relieved by medical treatment, and that some have been cured while under such treatment. I do think, however, that it is an open question how many of the cases cured while under treatment were cured by the treatment ; and I believe the majority of such cures have been due to the coincident interposition of Dame Nature, Be this as it may, a large number of cases remain altogether unaffected by the physician’s art. The majority of these receive such relief in their more prominent and distressing symptoms, that they remain properly within the province of the physician. A very large number of patients never suffer pain, or even inconvenience enough to make them consult either physician or surgeon. But admitting all this, there undoubtedly remain a large number of cases urgently demanding surgical aid. Some patients are brought face to face with death from hemorrhage, excessive growth of 9. KNOWSLEY THORNTON. 159 the morbid elements, or constant interference with rest from pain and discomfort. Others are gradually but surely re- duced in strength, and have lesions of vital organs as the result of constant pressure and displacement. When sur- gical treatment is spoken of, we are told that we have no right to interfere with fibroids, as we do with ovarian tu- mors, because the latter surely kill if left alone, and the former do not. I am certain that this argument is only partly true, and every one who sees a large number of cases will bear me out in the statement that numbers of women die every year from the direct and indirect effects of fibroid enlargements of the uterus. I would ask, How much of the general surgery of the day which is dangerous to life would continue if surgeons ceased to perform operations of expediency, z.¢., to operate for deformities and diseases which do not endanger life in themselves, though they deprive their victims of all the pleasures of life ? I affirm then that there are many cases of fibroid en- largement of the uterus which endanger the lives of their bearers, and that there are many more which make these poor suffering women so miserable and useless that ¢hey are justified in running the risks of operation, and that the surgeon is justified in operating. I may say at once that polypoid tumors which can be removed by the vagina are not now to be considered. I wish to direct your attention solely to those cases which, if treated surgically at all, may be best” treated by abdomi- nal section. 1. Fibro-cysts of the uterus. 2. Fibroid outgrowths from uterus: a. Pediculate; 2. Sessile. These are outside our present field, as they can be dealt with, in many cases, without either hysterec- tomy or removal of the appendages. These are:-— 3. Groups of outgrowths surrounding and involving the whole organ. 4. Intra-mural fibroids. 5. Submucous fibroids, 160 REMOVAL OF APPENDAGES TO CURE FIBROIDS. 6. General fibroid enlargement of the whole or the greater part of the uterine wall. Now we will first take these altogether, and examine the records of those operators who have treated enough cases to make their statistics valuable, excluding reports of single cases, because it is unfortunately too much the fashion to report single successful cases, and hold back the unsuccess- ful. If, under these circumstances, we take the single cases, we shall get statistics which give too great a per- centage of success on the total number of operations tab- ulated. I have arranged the names of the operators accord- ing to the number of cases :— Operators. Operations.| Recovered. | Died. Péan, up to November, 1879 . : 46 30 16 Spencer Wells, up to November, 1881 . : 39 19 20 Billroth, up to March, 1880 . : 25 Io 15 Knowsley Thornton, up to August, 1882 Bantock, up to August, 1882 . 5 . Keeberlé, up to December, 1877 Schroeder, up to December, 1879 . Hegar and Kaltenbach, to September, 1881 . Savage, up to August, 1881 : Thomas, up to September, 1880 Total b 3 A F ;: These are very imperfect statistics, and probably they do not give the best results of many of the ten surgeons, but they are the best at hand at present, and the result is certainly not very encouraging, as the mortality is over forty — per cent. We must remember, however, that these opera- tions are usually undertaken in extreme cases, and when the patients are worn out with disease and suffering, and still we have one hundred and thirty-one lives preserved. I fear that if the real mortality of ovariotomy could be pub- lished, it would be found to be not so very far behind the above. And if we look back to its first ten years, in the hands of the greatest of ovariotomists, Mr. Spencer Wells, SF. KNOWSLEY THORNTON. 161 we find a mortality of 31.97 per cent., only 9 per cent. lower than that of these ten surgeons in operations for fibroid. Now we will glance briefly at results in some of my special classes; unfortunately statistics here are still more imperfect, for so few of the operators accurately describe the nature of the operation, and state how far the uterus itself was involved in it. FIBRO-CYSTS OF THE UTERUS. Spencer Wells. . . 8 cases. 5 recovered. 3 died. Knowsley Thornton . 6 cases. 6 recovered. o died. Bantock .. . . . 8 cases: 6 recovered. 2 died: Total < «.. + 22\ cases. 17 recovered. 5 died. Per cent. '22.72 This is the disease which most closely resembles ovarian tumor, and most urgently calls for operation, and we find that the mortality is only about half that of the mixed cases. Wells, Bantock, and Thornton, 85 cases, 35 deaths, per cent. 40.70. If we now take the complete hysterectomies, so far as the statistics enable us to pick them out, we find the mortality still higher, so that we must conclude that in many of the operations only outgrowths with or without one or both ovaries were removed, the uterine cavity not being opened. We may then, I think, say that up to the present time the mortality of abdominal section for fibroids of the uterus is somewhere between 30 and 40 per cent., and that in cases in which the supra-vaginal portion of the uterus is removed, or in which the uterine cavity is cut ‘into, the mortality is considerably higher than this. I have then affirmed that surgical aid is justifiable, and even necessary in a certain number of cases, and yet I have to admit this grievous mortality. Clearly we must improve our methods, or the operation will not hold its own. This necessary improvement has already commenced ; for the operation of complete supra-vaginal hysterectomy with removal of both ovaries has become, when properly per- formed, one of the most successful of the great operations. VOL. VII. II 162 REMOVAL OF APPENDAGES TO CURE FIBROIDS. Hegar and Kaltenbach, by their new extra-peritoneal method, have saved eleven cases out of twelve, and the surgeons at the Samaritan Hospital have in the last year had equally successful results, also by the extra-peritoneal method, using Koeberlé’s wire serre-noeud in much the same way that Hegar uses the elastic ligature. These operations of hysterectomy and complete supra- vaginal hysterectomy still remain, however, very formidable operations. They are terrible mutilations, the patients are slow in convalescence, and there is the objection which must always be taken to any method which leaves a stump in the abdominal cicatrix, z. e., the risk of ventral hernia. Is there then no operation of less danger, of quicker con- valescence, and of better and more perfect results, which we as conservative surgeons can recommend to our pa- tients? Thanks to American surgery, the brilliant concep- tion of Blundell in 1823 was made a recognized surgical procedure by Battey in 1874, and from the labors of Hegar, Trenholm, Tait, Savage, and others, I am able to present to you a perfected operation which will render this formida- ble hysterectomy still less often necessary in the future than it has been in the past. The complete removal of the uterine appendages, when efficiently performed, cures fibroids of the uterus with a rapidity and certainty that Blundell, in his most sanguine moments, could not have dreamed of. I propose briefly to record cases in support of this assertion ; but first I will place before you the statistics of this operation as far as I have been able to collect them, and we will compare them with those we have been studying. And I will ask you to remember that this operation is not such a serious mutila- tion, and does not leave behind it any mark except a small linear scar on the perfectly closed abdominal parietes. STATISTICS OF REMOVAL OF THE UTERINE APPENDAGES FOR FIBROIDS OF THE UTERUS. Battey’s table, p. 285. “Transactions of Inter. Med. Congress, 1881,” vol. iv., 46 cases, 32 recoveries, 14 deaths. 5% KNOWSLEY THORNTON. 163 Add to this cases published since, or now published for first time : — Tait, 13 cases, 12 recoveries, 1 death. Savage, 9 cases, 9 recoveries, no deaths. Thornton, 8 cases, 8 recoveries, no deaths. Grand total, 76. 15 deaths, just under 20 per cent. mortality. There are 25 complete operations by Tait and 5 by Sav- age included in Battey’s table, so that we have as the totals for three operators : — Tait, 38 cases, 33 recoveries, 5 deaths. Savage, 14 cases, I4 recoveries, no deaths. Thornton, 8 cases, 8 recoveries, no deaths. Total, 60 cases, 55 recoveries, 5 deaths. Mortality 8.16 per cent. Three surgeons perform 85 operations of various kinds for fibroid, and lose 35 patients, a mortality of 40.70 per cent., and the same three surgeons perform 22 operations for fibro-cystic disease of the uterus, the least dangerous of all these operations, and lose 5 patients, or 22.72 per cent., a mortality more than three times as great as that of three surgeons who remove the uterine appendages in 60 cases for fibroid. I know that it is said that statistics can be made to prove anything, and those which I am able to place before you are very imperfect. I think, however, that they show quite clearly that the removal of the uterine appendages is at- tended with infinitely less danger to life than are the vari- ous operations for the removal of uterine fibroids. I have already pointed out other advantages possessed by the less dangerous operation.. Are we then justified in subjecting our patients to the formidable operation of supra-vaginal hysterectomy, when we can cure them by removal of the . uterine appendages? Some will ask, Can we cure them with any certainty by the latter operation? Iwas myself extremely skeptical at first, and watching the results in the hands of other operators did not increase my faith. Then I met with a case in which Battey’s operation seemed to me to offer the only hope of saving a valuable life. Dr. Mat- thews Duncan saw the patient with me, agreed that the danger was great, and that the operation should be tried. 164. REMOVAL OF APPENDAGES TO CURE FIBROIDS. The result was so perfect that I tried again, this time se- lecting a different kind of case ; again the result was equally satisfactory, and I was encouraged to try what the opera- tion would do for a fibro-cyst of the uterus. In a few months this patient also presented herself with a perfectly normal uterus. In my two last cases the operation has been too recently performed to speak with certainty as to the result, but the diminution in the size of the tumor has been so rapid, and the other changes have so exactly fol- lowed the course of those which I have observed in the other six cases, that I have no reason to doubt that the cure will be as complete. Having thus briefly glanced at the leading features of my own cases, I wish to say a few words in conclusion as to the selection of cases, the method in which the operation cures, and the special points to be attended to in its per- formance to insure a good result. Before I attempted the operation myself I had carefully studied what had been written about it, and I had watched other surgeons perform it, and I had come to the conclusion that it was no use merely removing the ovaries. In some cases this succeeded by bringing on the menopause, but it was a slow and un- certain cure. It was still less useful to remove parts of the ovaries, but I have seen this done many times, and then the operator complains that the operation is a failure. The most important point to secure is the complete liga- ture of all the enlarged vessels, which will be found in the broad ligament between the ovary and tube. As soon as these are tied the chief blood supply is cut off ; but in order to tie them efficiently the tubes and ovaries are also so thoroughly strangled at their bases, that they are better cut away. Whether the removal of the tubes is so impor- tant as Lawson Tait thinks I am not prepared to say; but my own faith in success hangs entirely upon the great dimi- nution of blood supply. The removal of the ovaries is necessary to check the monthly rush of blood to the uterus, and thus complete the work which is started by the stoppage of the regular sup- ' '% KNOWSLEY THORNTON. 165 ply. Either an imperfect removal of the ovaries or an im- perfect ligature of the enlarged vessels may cause the failure of the operation. The mere removal of the ovaries, even with the chief part of the tubes, does not, in every case, entirely stop menstruation, as some of my own double ova- riotomies have proved, but it does in the vast majority of cases ; and in the few exceptions the function is so imper- fectly and irregularly performed, that I doubt whether it will interfere with the success of the operation under dis- cussion ; and so far as my own experience goes, the opera- tion efficiently performed thoroughly disposes of men- struation. It is better to transfix deeply, and make the ligatures include all the large vessels, tying the inner loop on the tube as close to the uterus as possible. It may be necessary to transfix more than once, but, as a rule, the two interlocking ligatures are sufficient. No. 3 Chinese silk soaked in one to twenty phenol solution for an hour before the operation is strong enough, and has the great advantage of being thin and quickly absorbed. In every case where it is possible both sides should be securely ligatured, and the peritoneum sponged out before anything is cut away, as the distal por- tion of the pedicle is often much shorter than in ovariotomy, and the strain upon the ligatures much greater, for they are tied at the apex of acone. I always apply a separate liga- ture round the whole stump over the interlocking ligatures just after cutting away the ovary and tube. Before carefully observing the condition of the pelvic vessels in cases of fibroid of the uterus, I had thought that the ligature of the uterine arteries in their continuity might be the best method, but observation shows that even with very large tumors they are seldom large; it is the ovarian and tubal arteries and veins which are so enormously di- lated, and fortunately they are much easier to get at than the uterine arteries, and in tying the latter there must always be great risk of including the ureters. As to the selection of cases it is better to operate before the tumor has attained any great size, or it may be extremely difficult or impossible 166 REMOVAL OF APPENDAGES TO CURE FIBROIDS. to reach the ovaries. There is no difficulty in turning out and replacing a tumor of moderate size, and this procedure greatly facilitates the efficient application of the ligatures ; but it also, I am convinced, greatly 1 increases the shock of the operation. My small experience would seem to prove, what theory would lead us to expect, if the stoppage of blood supply is the important factor in the cure, namely, that the operation is applicable to all the varieties of fibroid enlargement of the uterus, and also to fibro cysts, if provision be made for the drainage of the latter during the shrinking and absorp- tion of the solid material. Possibly farther experience may show that this drainage is not necessary. I should in future prefer this operation to that of enucleation per vaginam for intra-mural and submucous tumors, unless they had already become partly exposed by thinning or necrosis of the mu- cous membrane. I trust that to most of those who are interested in this special subject my faith in perfect Listerism is too well known to need any reference; but I will say, that I hold this to be an operation of all others in which Lister’s method should be rigidly adhered to. It is one of which the mortality should be zz/, and though good results may be obtained for it without Listerism, and with occasional drainage, I do not think it will be possible to avoid mishaps from some variety of septicemia, unless we make our oper- ations rigidly aseptic. To sum up a paper which has far exceeded the limits I had assigned to it, and has trespassed too long on your patience, — the operation of complete removal of the ute- rine appendages for fibroid and fibro-cystic tumors of the uterus is indicated in all cases which need the surgeon’s aid, as an equally certain cure, and a more conservative and less dangerous operation than that of supra-vaginal hyster- ectomy. The latter operation should only be performed in cases in which the former has been tried and failed, — if larger experience should prove that such cases do occasion- ally arise, — or in cases in which, during the removal of the ¥. KNOWSLEY THORNTON. 167 uterine appendages, some accidental complication, such as uncontrollable hemorrhage from uterine surface, should render the major operation absolutely necessary. It occurs to me, on reading over my paper after it has been laid aside for a few weeks, that I have hardly suffi- ciently defined the operation of hysterectomy. I would include then all cases in which the uterine cavity is laid open, and more or less of its wall removed along with the fibroid. Whether one or both ovaries is also removed is a matter of no consequence. Sometimes it is more conven- ient to remove one or both. I would reserve the term “complete supra-vaginal hysterectomy” for cases in which the fibroids, the uterus, and the uterine appendages are all removed, and it is therefore a combination of the two opera- tions which we consider as rivals to-day. 168 REMOVAL OF APPENDAGES TO CURE FIBROIDS. AaSivep jOU snz0jn ay} punoy puv ‘Moz Suarez a10zoq ysnf{ queyed siyy pauruiexe J . *soSUOL JO UIN}a1 ONT “TQULIY pur 1a]yeus sniejn pue ‘ssot JAOJWOOSIp 19}e, YJUOUL Y ‘uinjoar ay) Uo Suissord pue poy1eao.y -91 JRYMOUIOS SNA1ajN JUS adv] eB ‘UOT}eU -lurexa uo ‘punoy J pue 4azozwoostp orAjed auios Jo Surureduioo ‘A[nf{ ul owt 0} outed *‘Suisvaisap ATpr -der ynq ‘qeurou uvy} s9S1e[ APYysys snt -2}7) ‘sasuowl jo uInjat ON ‘TJM azINb sT *SoIpUy ISAAA SY} 0} pouNjoyy *AeM AloAd UL pooS Arisa yyeoFy ‘sasuaur JO WINjoI ONT ‘snioyn afIqow [[vuis ev punoy pue juealy -ed oy} pourmexa yf ‘zggr ‘Se youre uO *yooysod YyeoyT = ‘syJuour ay ye Aypeuorsv990 saysny pue sayseproy WsyS ‘sesuewt Jo wml ON ‘T[eUS SEA SNA9jN Vy} IwaA dy} UIYIIM Uses UD AA ‘ATTeuoIsvI00 Surysny 3YySI[S *yyeoy ysnqod ur stjuajed oy} pure ‘orydorye Apysys 10 ‘feuriou Apoez1od st snzayn ayy, ‘soSUIUI JY} JO UINjot OU UVEeq sey a9], "SYAVUTOY ‘susan ay fo aswasigg 14sho-oAguy puv prorgny sof sasvpuaddp auisag ay, fo yoaouay fo sasw7y “pong “pain ‘pang “pong *poing “pong ‘qpnsoy [eal “pargA0d9y *PoI9AOIOY *par9A0s9 x] *patoAoooyy *P2toAOdoY *pardAodoyy *y[NSAX Avewug ‘syJMOIS]NO JO sseUr Ie[NZo1IT *SOYOUL ANOF A9AO APLAV JULIAN}. | “Zggr ‘ALT “TETMOSBA pue }jOS A1vA pue ‘ynu-v0909 ase] & S¥ OBIE] SB SEM SNi9yN VY} YORa Ul ‘A pue'] saseg ext] Apex | ‘zggr ‘Tudy *T aseg apy Apoexy ‘STLIO]N JO JUSWASIE[US ALT -NOS¥A [R1oUaD) “BIUIOUR OUIAI} -xo9 pue ‘soseyOWay “o19A9G| *I1ggr ‘AON *e1ur -aue pue soSeyoUlsy o10A0s yam 4sh0 orqy Sutmois Ajpidey| ‘1ggr “sny “ae nai wonenijsusyy asa “wey ou ynq ‘ealt1oususAp yon, ‘sploaqy yeinui-e1jU1 pue Jeeuojztiadqns Sutmois Aypidey] “1ggr *qo.7 ‘sni9jn oy} jo jyuowsiepua reno “SBA [eloUNy) = "eIWIAUe 9UId1} “xo pue ‘saseyiowley e19AaG}| ‘oggr "90 ‘uoneisdO sq} : Sulpueulep uonipuos med T ATavl (PenIeIN pou *3[2U1S *3[3uIS ‘a3arg “2[SUIS “uoT}Ipuor) Lad FE gz or ef ze ‘33 ‘TA ‘AI ‘TIT ‘Il ‘ON 169 jf. KNOWSLEY THORNTON. DS ————————————_—___ LEE EE *sxoyjo oy} jo Aue ut uey} aSLd SIy} ut prides arow usaq sey 1OUINy oY} JO azIs 9y} UL WOTNUTUTp ULL *pat} 19M S[aSsaa oY} tayye ‘paatasqo SunjuLtys owes ay} pue ‘Arvssovou ainpaooid outes oy], _ *patdA0d9y *moresodo JO OUI} Je OZIS St Jey uey} ssoy Apvouye sy *QOLJANS S}t UO payesnii09 pue yuniys Ajpoyreu pey yt paurinjar sem 7 a10jaq pue ‘uoyeiado snotAaid ze yay au yo uonsod pue Areao ay} }e 495 0} UsUIOp -qe aq} JO jno passaad aq 0} pey 10UM} oY, _ *paraA0da yy *sasuout JO WINjaI ON ‘auTNO Jo Aye Sau apy] nq YIM pue *£350q pur yyos AraA ‘aSueio air] & ULL} sured ULLIVAO JUR}SUOD YIM “YI[eIY jO oinjrey yerouas pur ‘1oun} jo yyMous pidea ‘oseyrsoursyzy] ‘eggx ‘ 100, HENRY 7 GARRIGUES. 207 countries in their dealings with this sad condition. But the difficulties may also be overrated, and when we so fre- quently find it asserted in text-books and special papers that the diagnosis, especially in the earlier months, that is to say before the movements of the fetus are felt and its heart heard beating, is shrouded in the greatest obscurity, nay utterly impossible, such teachings are apt to exercise a bad influence on the general practitioners, who, of course, meet much more frequently with these cases than those who make a specialty of obstetrics and gynecology. De- spairing of the possibility of making a diagnosis, they neither try to do it themselves, nor do they seek the advice of those who are more familiar with the anatomy of the pelvic organs in health and disease, and thus the period in which the best and simplest, and most innocuous treat- ment might be undertaken is lost never to return. I think, therefore, it is not amiss to point out that if there are difficult cases there are others in which the diagnosis is very easy, and that certain symptoms are so common in extra-uterine pregnancy that they ought to arouse a strong suspicion of its existence, and call for the most careful ex- amination and steady watching of the case, It is painful to read the by no means rare histories of cases in which no physical examination was made. The first time the patient is sent home with a prescription for an anodyne for her colic; the next time she is found dying; and the last act in the tragedy is the autopsy revealing a small ruptured fetal cyst, with internal hemorrhage. It is no less painful to read! of an autopsy revealing a cyst measuring “from seven to nine inches in diameter,’ which had not been found, although a vaginal examination was made. It is not here the place to treat in detail of the diagnosis of extra-uterine pregnancy. I shall limit myself to recalling the chief symptoms of the early stage, namely, mammary, gastric, and nervous signs of pregnancy, cessation of men- struation, severe colicky pain, often dysuria and dyschezia, irregular bloody vaginal discharge, expulsion of the de- 1 New England Med. Gaz., Oct., 1878, vol. xiii., p. 419. 208 ELECTRICITY IN EXTRA-UTERINE PREGNANCY. cidua, or parts thereof, enlargement and emptiness of the uterus, and, finally, the presence of the tumor, in which sometimes even the fetus can be felt. The late Stephen Rogers, of this city, in an otherwise meritorious paper ! on the subject, says that when the patient is fortunate enough to pass on to the fourth month the fetal tumor will add an almost positive element to the diagnosis. The tumor may be felt much earlier, as proved by my own and other cases. I should even be inclined to think that in some re- spects it is easier to recognize its nature earlier than when, by its size, it becomes so intimately blended with other organs that its outlines can no longer be made out. Before leaving this subject I would call attention to a warning set forth by Ernst Friinkel ? against the use of the sound. In his case he thinks it provoked contractions of the uterus and the fetal sac, the first resulting in the ex- pulsion of the decidua, the second in rupture and fatal peritonitis. Similar effects, says he, were observed in cases of Gervis, Guichard, Williams, and A. Martin. Our new Fellow, Dr. B. B. Browne, in his interesting paper on ‘‘Combined Intra-uterine and Extra-uterine Pregnan- cy,’? points to the important fact that the expulsion from the uterus of parts of the chorion— and the same may be said of the fetus —does not remove the possibility of the existence of extra-uterine pregnancy, since the two kinds of pregnancy may be combined, twin conceptions being even much more frequent in extra-uterine than in uterine pregnancy. SAFETY OF ELECTRICITY COMPARED WITH OTHER METHODS. _Almost universally it is thought to be not only justifia- ble but proper, in the earlier months of pregnancy, to leave the right to life of the fetus entirely out of consid- eration. Yet there are dissentient voices to be heard. William H. Wathen,’ professor of obstetrics in the Ken- 1 Extra-uterine Fetation and Gestation. Philadelphia, 1867, p. 35. pe EAN AN 0h Gon 8 Trans., vol. vi., p. 445. * Medical Herald, Louisville, 1882, iii., 556. HENRY F. GARRIGUES. 209 tucky School of Medicine, objects to the destruction of the fetus in any way and under any circumstances, and ad- vises to operate just before term, both in the interest of the mother and of the child. We have seen above that similar views are advocated by A. Martin. Even Dr. Thomas! seems to be opposed to the destruction of the fetus if the extra-uterine pregnancy be of the abdominal va- riety, while he recommends it in the tubal variety. I must say that I cannot convince myself of the validity of any objection to the destruction of the life of the fetus in extra-uterine pregnancy if we thereby can benefit the mother. We need not here repeat the old discussion about the relative rights of the mother and the child, although even in common obstetric cases the great majority of ob- stetricians, at least in this country and in England, un- trammeled by the doctrines of a certain religious body, which have no relation to scientific observation, do not hesitate to sacrifice the unborn child in the interest of the mother. But here we have to do with an entirely different class of cases. Apart from those exceedingly rare cases, if they exist, in which an extra-uterine pregnancy termi- nates by the birth through the uterus of a living and viable child,? the fetus is doomed to certain death except by opera- 1 Trans. Am. Gyn. Soc., 1879, iv-, 329. Diéseases of Women, 5th ed., Philadelphia, 1880, p. 775. 2 There are several cases on record of the ea peleion of the non-viable fetus in this way: Dr. Mundeé’s case, seen with Dr. Cornelius Williams (New York Med. Four., 1878, xxviii., 595, and Am. Four. Obst., 1879, xii., 330) ; two cases of Dr. John Graham, of Philadelphia, in the first of which the diagnosis was confirmed by Dr. Elwood Wilson and the late W. L. Atlee; and the case of Spencer T. Smyth (B72. Med. Four., October 18, 1879, ii., 615), in which a six months’ fetus was born alive and lived for an hour. Then there are cases in which living children were drawn ott from the tube (Laugier: Archives générales de méde- cine, 1832, Ist series, xxviii., 333), or delivered by scraping or cutting through a part of the uterine wall (H. Lenox Hodge, of Philadelphia, in 1867, see Parry, l. c., p. 266; and D. D. Gilbert, of Boston, Boston Med. and Surg. Four., 1877, xcvi.. 284). We may imagine that nature might overcome the obstacle, and a viable child be born without interference of art, but so far as I know no such case has ever been observed. VOL. VII. 14 210 ELECTRICITY IN EXTRA-UTERINE PREGNANCY. tive interference. A fetus thus situated, and imperiling in the highest degree its mother’s life, does not seem to me to possess any right of existence important enough to weigh anything as compared with that of its unfortunate mother. I would, therefore, feel perfectly authorized, under all cir- cumstances, to sacrifice its life, if thereby I had some pros- pect of bettering the condition of the mother. Next arises the question, which is the best way of killing it? Five methods are at our command, which conven- iently can be grouped under two heads. In the first class sharp instruments are used to reach the cyst through the abdominal wall, or through the roof of the vagina; in the second, no part of the body is wounded. The first com- prises puncture, injection, elytrotomy, and laparotomy. The second consists of dilatation and electricity. Puncture of the fetal sac has been successfully performed by E. Martin, Stoltz, Greenhalgh, Al. Simpson, Tanner, and Keeberlé,! but has given rise to death by hemorrhage (Braxton Hicks?), or septicemia (Goodell?). The latter might probably be avoided by antiseptic precautions (wash- ing of the place to be punctured with five per cent. car- bolized water, and immersion for at least five minutes of the instrument in the same fluid), but the danger of hem- orrhage is very great on account of the arterial net which develops on the surface of the sac. Besides B. Hicks and Goodell, J. Y. Simpson, Conrad, E. Martin, Netzel, Hutch-. inson, John Scott, Gallard, and Depaul, have all reported fatal results. And, after all, this method is uncertain in its results. Spencer T. Smyth* has published an interesting case, which shows that the fetus may develop without being surrounded by liquor amniii The water had been draining away for almost two months, sometimes tinged with blood. Finally a six-months’-old fetus was pushed from the right tube into the womb, and born by an entirely 1 Cohnheim, Archiv f. Gyndk., 1877, xii., 366. a Case 111; 8 Am. Four. Obst., 1881, xiv., 133. * Brit. Med. Four., October 18, 1879, ii., 615. HENRY F. GARRIGUES. 2I1 dry birth. The case of Ernst Frankel! is still more to the point. Toward the end of the fourth month of tubal preg- nancy he punctured from the vagina, with a trocar one fourth centimetre thick, carefully trying to avoid the much developed arteries. The trocar entered five and a half cen- timetres, and about twenty grammes of liquor amnii were evacuated, and followed by a rather thick column of ar- terial blood. Nevertheless the fetus did not die, but was four months later removed living by laparotomy, but died the next day, as the mother had done shortly after the operation. Injection has been used twice with success by Friedreich, of Heidelberg.2 In the first case the exact age of the fe- tus was not known, but it belonged probably to the third month. Four injections of from one tenth to one sixth of a grain of morphia were made, and the cyst reduced in a month from the size of a fist to that of a walnut. The second patient,’ although only in the third month of pregnancy, had to stay eight months in the hospital. Five injections of one or two centigrammes of morphine, four times preceded by aspiration, besides one aspiration without injection, were made, and the patient was at a time de- cidedly hectic. The danger of producing hemorrhage is smaller than by the preceding method, since only a hypodermic syringe is used, and, we may guard against septicemia by antiseptic precaution. Still, the tediousness of the recovery, and the dangerous condition of the patient in the last case, does not invite to imitation as long as a better method is avail- able. Elytrotomy. — Dr. Thomas’s* splendid success in opening the fetal sac in a tubal pregnancy and removing the fetus is known all over the world, and nevertheless this bold 1 Archiv f. Gynak., 1879, xiv., 208. 2 Virchow’s Archiv, 1864, xxix., p. 312; Archiv fir Gynik., 1877, xii, 355. ® Archiv f. Gyn., 1877, Xii., 355. 4 New York Med. Four., June, 1875. 212 ELECTRICITY IN EXTRA-UTERINE PREGNANCY. operator, when called in consultation in Dr. McBurney’s and Dr. Lusk’s cases, strongly advocated electricity in pref- erence to operative interference. Dr. Albert H. Smith,! in a case of Dr. M. O’Hara, used the thermo-cautery toward the end of the fourth month of abdominal pregnancy, but the patient died of gangrene of the peritoneum on the fourth day. Ina case of tubo-ovarian gestation in the fifth month, Dr. Robert Battey? opened the cyst with a curved trocar and Chassaignac’s écraseur. The patient died of exhaustion on the fourth day. Doran? has made autopsies in several cases, and warns against a particular danger in vaginal incision, the rectum often being pushed down by the tumor, especially in the later stages. The danger of hemorrhage, due to the living fetus, is perhaps not always overcome by the use of the incandescent knife, especially if the placenta be situated on the line of the incision, and then this organ has to be left till it is loosened by suppuration, or comes off piecemeal by disintegration, a period in which the woman, in spite of antiseptic injections, is much exposed to absorption of septic material. Thus this method is beset with dangers. Laparotomy. — According to Parry,* Brown, Routh, Play- fair, Meadows, and Greenhalgh, in England, and Darby, in this country, have proposed to perform laparotomy, and extirpate the sac before rupture occurs. We have above seen that Thomas Savage, of Birmingham, likewise recom- mends this procedure, and so does Lawson Tait,® adding that if the fetus was living, it would not be wise to wait until it had reached the age of viability. But in spite of 1 Am. Four. Obst., 1878, xi., 827. 2 Trans. Am. Med. Ass., 1879, xxx., 240.— Dr. George Harrison, of New York (Am. Four. Obst., 1878, xi., 811), made a simple incision from the vagina in an abdominal pregnancy of four months’ duration, but as the fetus was dead, and decomposition beginning, the case does not come within the scope of operations with intent of destroying the fetus. 8 Brit. Med. Four., 1880, i., 736. ig Corel etsy toler 5 Lancet, November 15, 1879, p. 731. HENRY F§. GARRIGUES. 213 so many recommendations, the operation has never been tried, and weighty voices have been raised against it, among them that of Spencer Wells. The operation would proba- bly prove dangerous on account of the development of ar- teries, which takes place around the fetal sac, and there would be all the common dangers incident to laparotomies in general, augmented by the greater vulnerability induced by pregnancy, Dilatation.— It has been recommended! to dilate the cervix and the uterine ostium of the Fallopian tube, and thus reach the fetal sac through natural canals. This method might be used with success toward the end of preg- nancy, but I do not see how it should be possible to dilate the tubal orifice in the earlier month of pregnancy. In Dr. McBurney’s case Dr. Thomas? endeavored to penetrate the mass containing the fetus with the uterine sound, but found it impossible. Besides this, the dilatation with sponge tent or similar materials, although performed without harm in Dr. B. Emmet’s case, must be very apt to bring on con- tractions of the uterus and the tubes, and thereby expose the fetal sac to a pressure which may rupture it. Electricity. Against all these dangerous or doubtful meth- ods stands electricity, with a record unblemished by a single failure or any dangerous consequences, It has been used in quite a number of cases. In every case the pregnancy has been promptly interrupted, and every single patient has definitely recovered within a short time. This success has been so uniform that it seems the time has come to put it. down as an axiom based on experience that in the early part of pregnancy electricity is the remedy, and that it is the duty of the physician to give his patient the benefit of its application. Two objections have been raised against it. When Bernutz® asked Duchenne (of Boulogne) for his 1 Dr. Williams attributes this proposal to Hodge and to Dr. Emmet. Hodge dilated only the cervix, and scraped through the septum be- tween the uterine cavity and the fetal sac. I have been unable to find where Dr. Emmet has made the suggestion. 2 Beard and Rockwell, 1. c., p. 607. 8 Gazette obstétricale, 5 février, 1879, No. 3, p. 33 214. ELECTRICITY IN EXTRA-UTERINE PREGNANCY. opinion on this agent, that celebrated electrician answered that it was not reliable, and, besides, apt to cause the rup- ture of the cyst. The first can only be based on the case of Braxton Hicks, but he did not carry the treatment through, although he saw that it temporarily arrested the fetal movements. The second is purely aprioristic, and cannot have any weight against the teachings of experi- ence. It appears from the histories I have collected that this treatment has been successful in every case up to the middle of the fourth month. The question is only if it has a still wider range of usefulness. The common doc- trine! is that this, and other methods intended to destroy the fetus, should be limited to the first four months, this being the time within which the rupture of the tube, when that is the seat of the ectopic pregnancy, is most apt to occur. But the rupture may take place, and has in fact taken place, at any time. It seems not improbable that the formulation of this dogma has been somewhat influenced by the circumstance that during the first four months the woman, as a rule, does not quicken, nor does the physician feel the active fetal movements and hear the pulsation of the heart. But advanced physiological knowledge has taught that the wonderful development caused by life is going on in the ovum from the very moment of its fecunda- tion as an imperceptible little cell. If, then, we destroy the fetus during the first four months of its existence, we certainly kill it in the full sense of the word as effectually as at a later period of its existence, and if that is justifia- ble, which almost all concede it is, then it must likewise be justifiable to do so after the end of the fourth month, if by so-doing we better the chances of the woman. The first question is, therefore, how late we can kill the fetus by electricity ; the second, if it is advisable to do it? Expe- rience only can answer these questions, and, so far, there is nothing to lead us, since the method has never been tried after the end of the fifteenth week. It would seem possi- ble, by using a strong current, and anzsthetizing the patient, 1 Parry, |..c.,; 199. Deschamps, l.\c¢., 123: HENRY F. GARRIGUVES. 215 to kill the fetus at any time by external application, and if that should prove impossible, then by electro-puncture, as in Bachetti’s case. In order to form an idea if it would be advisable to attempt the destruction by electricity in the middle and last part of extra-uterine pregnancy we must consider the chances for mother and child if we let preg- nancy go on unchecked. The cyst may burst at any time, and, although not absolutely fatal, this accident jeopardizes in the highest degree both lives concerned. Laparotomy may be undertaken at the end of thirty-two weeks, when the child is vital, as recommended in abdominal pregnancy, by Gusserow,! or in the tenth lunar month, as preferred by Litzmann.? But how miserable the prospects of success by these operations are appears from the excellent article of the latter, in which he has collected ten operations, per- formed while the fetus was living. Of these ten, only a single mother (Jessop’s case) recovered, and only four of the children survived, if, by a surviving child, we under- stand one who lives more than a few hours or days. To Litzmann’s list may be added a case of Lawson Tait’s ? and one of Netzel’s,t of Stockholm, both ending in the loss of the mother and the recovery of the child. Thus it would seem that there is a small chance for the child and hardly any for the mother to be saved by the operation at or near term. On the other hand Litzmann has collected thirty-three cases of laparotomy after the death of the child, of which seventeen, or more than one half, recovered. Would it not, therefore, be not only justifiable, but wise and humane, if possible, to kill the fetus by electricity, whatever its degree of development may be? We know that there is a fair chance that it will be entirely absorbed, except the bones, or become mummified. Among many other cases I shall only quote two: recently observed by Matthews Duncan? 1 Archiv f. Gyn., 1877, p. 84. 2 Archiv f. Gyn., 1880, xvi., 398. 8 Brit. Med. Four., 1880, i., 737. 4 Centralbl. f. Gyn., 1881, v., 349- 5 Lancet, November 15, 1879, p. 731. 216 ELECTRICITY IN EXTRA-UTERINE PREGNANCY. in which the fetal heart was audible. The fetus died before it had reached the term of viability, and both patients were well at last accounts. But even if the worst should come to the worst, and the fetal sac suppurate, causing septice- mia, there would still be a fair chance of recovery by lap- arotomy, and, at all events, an infinitely better chance than by laparotomy performed during the life-time of the fetus. The chances will even be better than in those cases in which suppuration sets in after the end of gestation, for the smaller the fetus and its envelopes the less trouble is to be anticipated. KIND AND STRENGTH OF ELECTRICITY. Burci used electro-puncture. Although the fine needles used for that purpose scarcely can do much mechanical harm, and the case proved a success, we know that the same method applied to ovarian cysts has proved fatal in more than one case.!_ It would, therefore, only be in cases ° where other means of applying electricity failed to produce the desired effect that it would be advisable to try this method. Dr. A. D. Rockwell, who kindly has informed me that he has treated five cases with electricity (McBurney’s, Billing- ton’s, Bache Emmet’s, Herrick’s, and a fifth case), has al-. ways used the galvanic current, and, on physiological grounds, believes it to be far superior for this purpose to the faradic current. Asa rule he believes the fetus is de- stroyed on the first application, if a strength of twenty-five or thirty volts ? be used. Duchenne, consulted by Lesouef,’ is said to have recom- mended the Leyden jar, but this has never been tried. In at least six cases (Allen’s . first, Landis’s two, Reeve’s, 1 Mundé, “Electrolysis of Ovarian Tumors,” Am. Gyn. Trans, 1877, vol. ii., pp. 408-422. 2 A volt is the unit of electromotive force, and is equal to about the force of a Daniell’s cell. (Beard and Rockwell, 1. c., p. 66.) 8 “ Remarques sur trois cas de grossesse extra-utérine.” Thése de Paris, 1862. Spiegelberg, 1. c., p. 324. HENRY § GARRIGUES. 217 Lusk’s, and Garrigues’), success was obtained by a simple one-cell electro-magnetic faradic machine. As this appa- ratus is much more common, easy to transport, and simple to apply, it seems to merit special recommendation, In some cases the pain caused by the treatment has been intense (Burci,-Allen, Landis, McBurney, B. Emmet), This would seem to be due to the use of an unnecessarily strong current. Lusk used the full force of a one-cell apparatus. Dr. Reeve and myself were only guided by the feelings of the patients, and succeeded quite as well. Application. The negative electrode is introduced either into the vagina or the rectum, the positive on the abdominal wall. A moderate current may be used for ten minutes or more at atime. The sittings ought, as a rule, to be re- peated every day, until the diminution of the fetal cyst and the retrograde changes in the breasts show that pregnancy has been definitely arrested. As arule it is best, for safety’s sake, to make at least four or five applications. Nature of Effect. Several authors ascribe the effect of electricity in killing the fetus in extra-uterine pregnancy to electrolysis.1 This may be the true working principle when the galvanic current is applied. But the electrolytic power of the faradic machine is so small that in those cases, at least, in which that was used we must look for another ex- planation of the death of the fetus. I have applied my ap- paratus to a bladder containing water, with a little albumen and salt, which might be taken for a fair representative of liquor amnii, but I failed to see any electrolytic effect, nor seemed the exosmosis increased by the current. I suppose, therefore, that the effect is not chemical, but dynamical, something like that of a strong discharge from an electric machine, or of lightning of an adult. But, however this may be, practice has shown the value of the remedy. 1 Allen, Am. Four. Obst., 1878, xi., 830 ; Skene, Brooklyn Proceed- ings, 1879, iv-, 353; Roberts Bartholow, Medical Electricity, Philadel- phia, 1881, p. 229. 218 ELECTRICITY IN EXTRA-UTERINE PREGNANCY. CONCLUSIONS. ist. Experience has proved electricity to be an effica- cious and safe agent to arrest extra-uterine pregnancy dur- ing the first three months, and perhaps the pregnancy in some of the cases had even advanced more or less into the fourth month. 2d. It seems likely that the same agent might be profit- ably used at any period of fetal life. THE HISTORY OF TWENTY-ONE CASES OF EXTRA-UTERINE PREGNANCY COMING UN- DER THE PERSONAL OBSERVATION OF THE WRITER. BY T. GAILLARD THOMAS, M. D., New York. Untit the last decade very little special attention has been paid to the clinical study of extra-uterine pregnancy. In a general way it had received some attention in works upon obstetrics, and the physiology and pathology of the subject had been carefully investigated; but its clinical bearings, the symptoms which should arouse the fears and suspicions of the practitioner and the most appropriate treatment, had received an amount of attention entirely in- commensurate with their paramount importance. I do not, of course, mean to ignore the numerous and very interesting cases of ectopic gestation found scattered through the serial literature of medicine for many years ; I simply desire to assert the fact that the clinical histories of these cases had not been carefully collated and analyzed so as to give the practitioner reliable data and distinct land- marks. : During the past ten years, however, all this has been changed. The subject of extra-uterine gestation has at- tracted a great deal of attention, and a work upon obstet- rics or gynecology written to-day would of necessity con- tain a chapter devoted to the consideration of its physiology, pathology, symptoms, differential diagnosis, natural history, and treatment. Foremost among those who have effected this result are Bandl, Barnes, Hecker, Schroeder, Spiegelberg, and Hen- 220 EXTRA-UTERINE PREGNANCY. nig in Europe ; and Parry, Allen, Goodell, Reeve, and Lusk in this country. In spite of this gratifying advance, however, our knowl- edge of the subject is even now elementary, our means of diagnosis still uncertain, and our methods of treatment unsettled. At the end of another decade it is highly prob- able that the diagnosis of this abnormal condition will have become as certain as that of abdominal tumors in the-female is at present, and our treatment as fully settled. When that much to be desired consummation has been reached it is certain that many lives which are now sacrificed in conse- quence of our imperfect knowledge will be preserved. The paper which I have the honor of presenting to-day is one of purely clinical character based upon what I be- lieve to be an exceptionally large clinical experience in the subject under consideration. : During the first sixteen years of a practice of thirty years I met with no case of extra-uterine pregnancy. During the past fourteen years I have been called upon to treat twenty- one cases. It isto an effort to draw deductions for prac- tice from these that this paper is to be devoted. For the pathologist there are many varieties of ectopic gestation, including ovarian, tubo-ovarian, etc., etc. For the practitioner at the bedside there are virtually but three: the tubal, interstitial, and abdominal varieties ; for he lack- ing the sense of sight, which is at the disposal of the pa- thologist, must draw his conclusions from clinical evidences alone, and these do not suffice for the determination of such niceties of differentiation as those alluded to. Indeed in many cases it is impossible to decide as to the variety, even of the three simpler forms above mentioned, to which a case belongs, when the most efficient means at our command have been called to our aid. I shall now give short histories of the cases which I have seen, commenting upon important features as I proceed, and ending with an effort at general deductions based upon the mass of material presented. CasE I.—I was called in great haste by Dr. Mourraille to see ZT. GAILLARD THOMAS. 221 Mrs. A., aged about twenty-eight years, multipara, who had ad- vanced to the end of the third month of pregnancy. For five weeks past she had presented as symptoms: paroxys- mal pelvic pains in the right iliac fossa shooting down the right thigh, lasting from two to three hours, which she likened to labor pains, and occasional attacks of metrostaxis. Upon physical exploration Dr. Mourraille discovered a very distinct and slightly sensitive tumor in the right iliac fossa, close to the uterus. Prof. Willard Parker was called in consultation. One day after the iliac pain had lasted for between two and three hours the pa- tient rapidly passed into a state of collapse. Dr. Mourraille at once recognizing that the rupture of an extra-uterine cyst had oc- curred sent for me to perform laparotomy. A physical explora- tion convinced me that this was the state of affairs, but the pa- tient was iz articulo mortis, and died before any effort could be made in her behalf. No post-mortem examination could be ob- tained, and of course some doubt may exist as to the correctness of our diagnosis. This I can only meet by stating the strong con- viction with which the physical and rational signs impressed me ; for that an immense hematocele was the immediate cause of death there could be no doubt, as there could be none that preg- nancy existed at about the end of the third month. It must be remembered that this case occurred fourteen years ago, at a time when such premonitory symptoms as those recorded were uni- versally allowed to pass without exciting suspicions of the exist- ence of abnormal gestation. CasE II. — Mrs. B., aged thirty-eight, a multipara, was seen in consultation with the late Dr. Charles Henschel. This was in every particular so perfect a counterpart of Case I. that I shall not give it in detail. Case III. — Mrs. C., a German woman, the wife of a mechanic, living in a poor tenement house, aged about thirty, and a multi- para, I saw also with Dr. Henschel. She had nearly arrived at the end of the third month of pregnancy, and had complained of severe intermittent pains in the pelvis, and neuralgic pains down one thigh, for which she had sent for her medical adviser. Ex- amination convinced him that something was wrong, but he was unwilling to decide as to the nature of the difficulty. When I saw her I found her giving undoubted evidences of pregnancy. Upon physical examination I found the enlarged uterus pressed towards the right side by a soft doughy tumor, which very dis- tinctly gave to my finger the sense of ballottement. 222 EXTRA-UTERINE PREGNANCY. I advised tapping per vaginam by a very small trocar and can- nula. At Dr. Henschel’s request I did this, and upon passing the instrument got no fluid but found the cannula, upon withdrawal, stopped up with a pultaceous mass which the microscope proved to be brain matter. I tapped again and drew off a straw-colored fluid, which had all the appearances of liquor amnii. The patient did well after this as far as her recurrent iliac pains were con- cerned, but gradually symptoms of septicemia developed, and of these she died in about three weeks. Dr. Henschel was unable to obtain a post-mortem examination. Case IV.— An unmarried Irish woman, about twenty-two or twenty-three years of age, presented herself at my clinic, at the College of Physicians and Surgeons, giving unmistakable evi- dences of pregnancy at about the third month. She was examined by my clinical assistant, the late Dr. James L. Brown, on account of intermittent iliac pains on the left side, which would last for two hours or more, and he discovered a tu- mor of small size in one iliac fossa which yielded to his percep- tion the sense of ballottement so distinctly that he positively an- nounced the existence of extra-uterine pregnancy. I examined the patient without knowing of Dr. Brown’s diagno- sis, and at once came to the same conclusion. ‘Three or four other practitioners saw and examined the case and were entirely in accord with us as to its nature. I have seen no other case in which ballottement was as distinct as it was in this. Although I had had a bad result in the case recorded as hav- ing been seen with Dr. Henschel from a resort to tapping per vagi- nam, I was induced again to try it here by the fact that a very brilliant result had been about that time reported from London. I tapped with a small trocar and cannula and drew off a clear, straw-colored fluid which was, after chemical and microscopical examination, pronounced to be liquor amnii. At nine that night my assistant called to see the patient, and found her taking part in a carouse, drinking, dancing, and shouting with the most vig- orous of her companions. A few hours afterwards he was sent for to see her, found her suffering from all the rational and phys- ical signs of hematocele, and was forced to produce seminarcosis in order to control the pain of which she complained. Internal hemorrhage appeared to go on very rapidly after this, and in a few hours the patient died, after remaining for some time in a com- plete state of collapse. T. GAILLARD THOMAS. 223 Thus far every case of extra-uterine pregnancy with which I had met had proved fatal. Case V.—I was requested to visit Mrs. C., of Elizabeth, N. J., in consultation with Drs. Greene and Crane of that city. She was a multiparous woman, thirty-two years of age, and of very delicate conformation. She presented all the symptoms of preg- nancy at the end of the third month, but in combination with these the following abnormal symptoms: slight metrostaxis, and continuous pain in the left iliac fossa that developed into a “cramp,” which occurred about every four or five days. Physical examination revealed the following state of things: the uterus was enlarged and pushed over to the right, the vagina was soft and elastic ; and to the left of the uterus a tense, elastic cyst, which filled the whole iliac fossa and extended down to the 6s in- ternum, could be distinctly felt. Within this mass ballottement was perfectly attainable. I incised the tumor through the vagina with the incandescent knife, removed the fetus, and filled the empty sac with carbolized cotton. Half of the placenta was re- moved at the time of the operation, and on the fifteenth day the rest followed. This patient recovered. Case VI.—I saw, with Dr. W. T. Walker, Mrs. R., a French lady, who after suddenly occurring amenorrhea of four months’ duration, began to suffer from pelvic pain and: severe backache. This prompted an examination, when a tumor was discovered pos- terior to the uterus, which was pushed forward and upward by it. While the case was being kept under supervision for the purpose of diagnosis, this was made clear by an effort of nature, one of the fetal metatarsal bones being passed by the rectum. Very slowly and painfully, after many months, all the fetal bones were expelled by the rectum, and the patient entirely recovered. For several years afterward, however, her health was greatly depre- ciated. Case VII.— This case was almost identical with that just re- lated, except that the diagnosis was made by art and not by na- ture. The diagnosis of abdominal pregnancy was based upon the following data: the existence of pregnancy was complicated by metrostaxis ; severe pains in pelvis, back, and thighs ; and in- terference with defecation; while the uterus was lifted up and pushed forwards by a soft, elastic tumor which did not present the physical aspects of an imprisoned ovarian cyst, or of a hemat- 224 EXTRA-UTERINE PREGNANCY. ocele. In a short time after this diagnosis was arrived at, and very probably in consequence of the thorough examination to which the patient was exposed, the débris of a dead fetus were discharged by the rectum ; the cyst, above mentioned, gradually emptied itself, and the patient slowly recovered. CasE VIII.—I was called by Dr. James Hadden to see Mrs. H., aged twenty-six years, and the mother of one child. The pa- tient presented all the appearances, rational and physical, of a woman suffering from an ovarian cyst. She gave, however, a very distinct history of all the symptoms of pregnancy which had existed up to full term, and she had now gone eleven months from the period when she supposed that it had occurred. Although she was at this time convinced that she was mistaken in supposing herself to have been pregnant, so clear were her statements in reference to her having felt the fetal movements, that I was put upon my guard with reference to diagnosis. Draw- ing off with the aspirator four quarts of sero-purulent fluid from the abdominal cavity, I could distinctly feel a mass, like a child, rolling around within it. I felt warranted in making a positive diagnosis of abdominal pregnancy, and soon after performed the operation of laparotomy and removed a finely developed girl weighing seven pounds, and measuring eighteen and a half inches in length. The abdominal wound was kept open by a glass drainage tube, which was kept in place to give egress to the pla- centa, which came away five weeks after the operation. The pa- tient entirely recovered. The death of the child in the abdomen was due to the winding of a long human hair repeatedly around the umbilical cord, which completely cut off its circulation. Case IX.— Dr. Charles Young, of Newark, sent into my ser- vice, in the Woman’s Hospital, a negress, twenty-four years of age, who had borne one child. Seventeen months before I saw her she had, as she supposed, become pregnant and had gone on without any very decided symptoms to the end of utero-gestation. At this time, however, labor did not occur, and she was now im- pressed with the idea that her opinion had been a mistake. Clearness of the patient’s statement as to the existence of pregnancy, combined with the presence of a solid, rolling mass within the abdominal accumulation of fluid, led me to the diagno- sis of abdominal pregnancy ; and in a short time after her admis- sion I performed laparotomy. I removed a girl weighing nine pounds and left the placenta undisturbed. This came away grad- T. GAILLARD THOMAS. 225 ually in from two to three weeks, and the patient entirely re- covered. CasE X. — This ‘patient was sent into my service in the Wom- an’s Hospital through the kindness of my friend, Dr. Fordyce Barker, to whose care she was committed by Dr. Coates, of Mys- tic Bridge, Conn. She* presented all the appearances of preg- nancy which had gone to the full term without labor having been accomplished, and now had extended a little more than three months beyond it. Her physician had made the diagnosis of ab- dominal pregnancy before the patient was brought to me, and I had merely to corroborate it. The constitutional state of the patient was so much depreciated that for some time after her en- trance into the hospital I was afraid to operate, and when I did so I felt almost hopeless of a successful result. I performed lap- aratomy, removed the débris of a full-grown dead fetus, and drained the sat by means of a glass tube ; and very much to the surprise of all connected with the case the patient made a com- plete recovery without the development of a bad symptom. Case XI.—I was called by the late Dr. Giberson, of Brooklyn, to see Mrs. B., a multipara, who, having arrived at the end of the third month of pregnancy, had suddenly developed the symptoms of peritonitis. The cause for this disease we were at a loss to de- termine. The patient was so nervous and excitable a woman that little ‘stress could be placed upon the symptoms of pelvic pain, etc., from which she declared that she had suffered during the past three months ; and, although the question of extra-ute- rine pregnancy was carefully considered at the consultation, no diagnosis of that condition was arrived at. After an illness of three days the patient died, and a post-mor- tem examination revealed the fact of the existence of tubal preg- nancy, the partial rupture of the sac of which had allowed the escape of two or three pints of blood into the peritoneal cavity, which had resulted in peritonitis and death. CasE XII. —I was called to see the wife of a physician of New York, a primipara, about thirty-five years of age, who, after sev- eral years of married life, had developed the symptoms of preg- nancy and had advanced nearly to the end of the third month. No peculiar symptoms had shown themselves during this time until one day, without assignable cause, she was taken with sud- den, violent pelvic pain and became partially collapsed. I saw her, in consultation with four eminent practitioners of New York, VOL. VII. 15 226 EXTRA-UTERINE PREGNANCY. and arrived positively at the diagnosis of extra-uterine pregnancy with rupture and progressive hemorrhage. Impressed with this view I favored laparotomy, which, although I regarded it as a most dangerous resource, I considered the only chance of saving the patient’s life. In this I was overruled, and the patient grad- ually sunk and died on the third day. Post-mortem examination revealed tubal pregnancy developed near the fimbriated extremity. Upon the surface of this vicarious uterus one artery somewhat smaller than the ulnar had ruptured, and from this a steady sanguineous flow had occurred, which had caused the collection of over three quarts of blood in the peri- toneal cavity and had destroyed our patient’s life. Had laparot- omy been performed, as had so recently been maintained that it should be by the late Dr. Stephen Rogers, there is no reason whatever why the patient’s life should not have been saved. Case XIII. — This case I saw with Dr. Wilhelm Frankl. The patient was thirty years of age, a native of Austria, and the mother of one child nine years old. She had all the symptoms of pregnancy at the end of the third month, accompanied by pseudo-menstrual discharges containing membranous shreds, to- gether with great pelvic pain and discomfort. Before I saw-her Dr. Frankl had made the diagnosis of abdominal pregnancy, which he based upon the rational signs above mentioned, and the following physical signs, in the enumeration of which I quote his language : “The cervix uteri was behind the symphysis ossium pubis ; corpus uteri slightly enlarged, easily felt through the ab- dominal walls above the os pubis. Passing my fingers into the vagina, I felt in the back wall, more to the left, a swelling in- creasing towards the fornix vaginee behind the cervix, forming a tumor, round, not tender, but dense. This tumor could be felt by bimanual manipulation in the right iliac region. On macro- scopical and microscopical examination I found the expelled membranes to be ‘ deciduze.’ ” ' Influenced by these rational and physical evidences I fully co- incided in Dr. Frankl’s diagnosis, and we watched together with great interest the weekly development of the rapidly-growing tumor. . After keeping the case under observation for three months the tumor, which had grown to the size of a child’s head at birth, be- came less tense, and all growth seemed checked in it; the symp- toms of pregnancy instead of becoming more pronounced, as T. GAILLARD THOMAS. 227 they had all along been doing, rapidly diminished in number and significance and gradually disappeared. ‘The fetus appeared to have died without assignable cause, and, although the tumor re- mained fully as distinct, though less tense and resisting than it was, the patient felt sufficiently well to attend to her daily avo- cations. Dr. Frankl kept her under observation for something over a year, and during all that time the tumor was constantly discoverable. Since this time I have lost sight of the patient, and I cannot say whether any evidences have been established set- tling the validity of the diagnosis. Case XIV. —I was requested by Dr. Janvrin to see with him- self and the late Dr. Peaslee the following case: Mrs. S., thirty- two years of age, and mother of two children, the elder fifteen years of age and the younger thirteen. The patient menstruated regularly until March 20, at which time irregular hemorrhage came on and continued with greater or less violence for two months. At the end of this time Dr. Janvrin was called to her and found her suffering with very severe uterine pains of contrac- tile character, accompanied by profuse flooding. He discovered the uterus about as large as it should be in a two months’ preg- nancy, and the os so much dilated as easily to admit one finger. Under astringents and opiates the hemorrhage and pains at once ceased, and the patient was comfortable until June 8, when a similar attack occurred and I saw her in consultation. The uterus had behind it a large, hard tumor which presented very much thé appearance of the retroflexed fundus of a gravid uterus. On July 2 another similar attack occurred, and the tumor, which had heretofore been behind the uterus, was discoverable more towards the left side, and I suggested the possibility of its being a tubal pregnancy of that side which had fallen down into Douglas’s pouch. On the 12th she was seen by Dr. Peaslee, who thought that the tumor was a rapidly developing uterine fibroid. Dr. Janvrin agreeing with me passed, with my concurrence, a sound to the fundus, and found that the uterus measured three and a half inches in depth. On December 19 another severe paroxysm of pain came on, just nine months from the last regular menstrual period, which resembled very much the pain of ordinary labor. At this time Dr. Peaslee introduced the sound and found that it passed five and a half inches. In the early part of March offensive diarrhea came on, and, a number of small fetal bones being mingled with the discharge, the diagnosis was now put beyond a question. 228 EXTRA-UTERINE PREGNANCY. Dr. Janvrin then made a rectal examination and readily discov- ered communication between the intestine and the fetal sac. Things continued to progress in this way until towards the last of May, when, symptoms of septicemia coming on, Dr. Janvrin di- lated the sphincter ani and by means of the fingers removed all the fetal bones from the sac.. The operation lasted only fifteen or twenty minutes, but the patient was greatly exhausted by it. She did not fully rally, although everything was done to make her do so, and gradually sinking she died at the end of fifteen hours. Case XV.—I was requested by Dr. Charles McBurney to see with him Mrs. C., a primipara, who presented all the rational and physical signs which mark the third month of utero-gestation. With these symptoms occasional discharges of blood had oc- curred from the uterus at about the following intervals, her last menstruation terminating about October 5: slight flow took place on the 22d and 23d of November, ceasing on the 24th, and re- curring with violence on the 25th. It recurred on the 1st and gth of December, then ceased, and again showed itself on the 16th and 2oth of December, lasting for a few hours. These discharges, though unaccompanied by pain, prompted Dr. McBurney to make a careful vaginal examination. Upon doing this he could not map out the fundus of the uterus, but on the left side he could distinctly feel a smooth tumor, apparently of about the size of a large hen’s egg, which was very tender to pressure. The uterus appeared but slightly enlarged and in a condition of decided right lateroflexion. He made the diagnosis of extra-uterine preg- nancy, and requested me to see the case with him. I agreed with him fully in his conclusions, as did also Dr. T, A. Emmet, who, at my request, was added to the consultation. Before proceeding to adopt treatment we explored the uterus thoroughly with a sound and satisfied ourselves that the cavity contained neither sac nor fetus. We were now perfectly convinced of the validity of our diagnosis, and as the pregnancy had arrived at the end of the third month we decided to risk no further delay, but to inter- fere immediately. The methods which were discussed were (1) laparotomy, (2) elytrotomy, and (3) the destruction of fetal life by a strong galvanic current, a plan of treatment which we owe to our countryman, Dr. I. G. Allen, who first employed it in the year 1869. Dr. A. D. Rockwell, the eminent electrician of New York, was requested to take charge of the galvanic current, I myself T. GAILLARD THOMAS. 229 fixing the electrodes ; the negative in the rectum, just under the most protuberant point of the tumor, while the positive was placed on the abdominal surface, just over the anterior face of the tumor. The current was generated by zinc-carbon elements immersed in a mixture of bichromate of potash, sulphuric acid, and water. A circuit of seventeen cells being closed, a succes- sion of interrupted currents, one hundred and twenty to the min- ute, were passed, and with short intervals the current was contin- ued for about three minutes. This was at two P. M., and the next day at nine A. M. the galvanic application was repeated. After this the patient suffered a good deal of pain, the tempera- ture went up to a little above 100° F., and the pulse to 96 ; nausea and vomiting occurred, and a slight flow of blood established it- self. The next morning, at nine, we found the tumor hard, prom- inent, painful, and tender ; the patient’s expression haggard ; and the pulse rapid and feeble. At 10.30 A. M. there was a sudden gush of blood, the tumor disappeared from the iliac fossa, and the uterus, before this scarcely perceptible, could now be readily mapped out, a little larger than it should be at the third month of normal gestation ; the os externum was distended and the fetal shell could be distinguished within it. Violent uterine contrac- tions now took place, and the uterus expelled its contents, the cervix being torn through up to the vaginal junction. After this Mrs. C. made an excellent recovery. Although I know that a very excellent and exhaustive pa- per upon the treatment of extra-uterine pregnancy, by the use of thé galvanic or faradic current is to follow that which I am now reading, I have described the method employed in this case rather fully because I shall have to report a number of others similarly treated, and this will avoid the necessity of again entering into such a description. This case, at the time of its publication, excited a good deal of skepticism, and gave rise to criticism as unpleasant as it was unjust. I think that this was due to an erroneous view taken concerning the variety of pregnancy with which we had to deal by Dr. McBurney. He regarded it as of the tubal variety, and so delineated it in a report which he published of the case. I did not at the time, nor do I now, agree with him. Had it been of this character the oxytocic 230 EXTRA-UTERINE PREGNANCY. influence developed by galvanism would have caused rup- ture of the tube and destroyed the life of our patient. It was, I think, unquestionably an interstitial pregnancy ; the fetus developing in that part of the tube intervening be- tween the endometrium and peritoneum, contraction of the uterine fibre forced the fetal ball into the uterine cavity, and thus the uterus was enabled to expel it into the vagina. CasE XVI.— Dr. George T. Harrison requested me to see with him Mrs. P., a multipara, who had arrived very nearly at the end of the third month of utero-gestation. The occurrence of inter- mittent pelvic pains with occasional gushes of blood had induced Dr. Harrison to make a vaginal examination, which revealed to him the existence of a tense and tender tumor, of about the size of a large duck’s egg, to the right of the uterus. Upon examina- tion of the case I thought that I distinguished an obscure sense of ballottement in this, but of that I could not feel sure. I fully agreed to the existence of tubal pregnancy, and urged the use of a strong interrupted current to be repeated once a day for three or four days in spite of Dr. Harrison’s belief that the fetus was already dead (an opinion which I did not share), The doctor readily agreed with me, however, that if the fetus were dead no harm would be done, while if it were living a great deal of good might be accomplished ; and the current was employed. After ten days the patient left her bed, the tumor gradually but steadily diminished, and complete recovery took place. Case XVII. — This case I saw with Dr. Billington, of New York. It resembles the case just related so very closely in ra- tional and physical signs, and in treatment and results, that I shall not give it in detail. A strong interrupted current was em- ployed four times, with intervals of twenty-four hours. After the treatment the decrease of the tumor was very steady, and com- plete recovery was rapidly accomplished. , ~Casr XVIII. —I was called in consultation in this case by Dr. Lusk. The patient was twenty-eight years of age, and had been twice married. During the first marriage she had an abortion at the fourth month, but during the eight years of her present mar- riage she had never been pregnant. She called upon Dr. Lusk in consequence of excessive nausea and vomiting, which he sus- pected to be the results of some sexual disorder, and therefore made a vaginal examination. This revealed to him slight in- T. GAILLARD THOMAS. 231 crease in the size of the uterus, but nothing else which specially attracted his attention. Upon questioning her carefully he found that she had not menstruated for two months, and in place of the menstrual flow an irregular aaa scanty sero-sanguinolent dis- charge had existed. Two weeks after Dr. Lusk first saw her she expelled a de- cidual cast of the uterus. Up to this time he did not suspect the nature of the case. She had at intervals during the last fortnight suffered from occasional attacks of abdominal pain which were called colic, and the recurrence of one of these of such severity as almost to induce collapse caused him to recognize the truth. I saw her, with Dr. Lusk, early one morning after he had passed almost the whole night with her, quieting her pain by the hypo- dermic use of morphine. I agreed fully in the diagnosis, and was so much impressed by the imminence of the danger that I urged immediate destruction of the life of the fetus by the faradic cur- rent. This was applied three or four times by Dr. Lusk, one pole being in the rectum, and one on the abdominal wall. I quote Dr. Lusk’s report of the efficacy of the method; “ The result jus- tified the most sanguine expectation ; the next day the sac felt flaccid, and by the end of a week it had lost its regular outline. On the tenth day the last application was made ; the shrinkage had become so unmistakable that no doubt was now left as to the death of the embryo. The patient thenceforward made an entirely uninterrupted convalescence, and is now in the enjoyment of perfect health. A small, hard, painless mass not much larger than an English walnut alone remains as a monument of the murdered embryo.” Case XIX.—I was called to this case by Dr. Bache Emmet. The patient had been married three years but had never borne a child. Skipping a period on the 25th of December, she had a slight flow on the rgth of January following. After this nothing remarkable occurred until the 11th of the following March, when uterine contractions, hemorrhage, and expulsion of deciduous membranes took place. An examination made at this time by Dr. Emmet revealed the uterus in a partial condition of retrover- sion with a mass equal in size to a fetal head in front of it, and filling the right portion of the pelvic cavity. The mass was soft, giving the impression of a thick-walled cyst, and did not jut up- wards above the brim of the pelvis. Dr. Emmet was convinced that extra-uterine pregnancy existed, but I did not feel nearly so 232 EXTRA-UTERINE PREGNANCY. confident, my mind being divided between this idea and the ex- istence of normal pregnancy in a uterus in the wall of which a fibroid existed. I persuaded Dr. Emmet to destroy fetal life, whether the fetus existed inside or outside the uterus, by the use of an interrupted current of electricity. The interrupted galvanic current was used on three occasions. After this Dr. Emmet in- troduced a sponge tent three inches in length, and passing his finger found the uterine cavity entirely empty. » The patient suffered. from chills, high temperature, and di- arrhea, but in the end she entirely recovered. Case XX.—I was called in great haste by Dr. H. F. Walker to see Mrs, A., a multipara, thirty-two years of age, of whom he gave me the following history: She had advanced without remarkable symptoms to the end of the third month of pregnancy, with the exception of slight efforts at menstruation and the existence of a globular mass behind and a little to one side of the uterus. This mass he had regarded as the fundus uteri in a state of re- tro-lateroflexion. He had occasionally replaced it by pushing it upwards with the finger, but it had demanded little interference. Symptoms of abortion had come on in the morning of the day upon which I saw her with him, and very suddenly she had been taken with agonizing abdominal and pelvic pains, and had almost at once become collapsed. » Both the rational and physical signs pointed to the existence of a very large hematocele at the time of my visit, and I felt sure, as did Dr. Walker, that the globular mass obliquely behind the uterus was a tube, enlarged by a growing fetal mass which had ruptured and caused the existing sanguineous effusion. On the day following corroboration of this view was given by the discharge of a mass of deciduous membrane by the uterus. After this the patient was quite ill for three months, all evi- dences of advancing utero-gestation disappeared, and without sur- gical interference the effused blood mass was gradually absorbed, It was a year or eighteen months, however, before the patient re- covered from the terrible shock to which she had been exposed. CasE XXI.—I was requested by Dr. Everett Herrick to see with him Mrs. L., a multipara, aged about thirty-five, of whom he gave me the following history: For the past two and a half months the menstrual discharge had been irregular, steady oozing with occasional sharp gushes of blood taking its place. It was for this loss of blood that Dr. Herrick got me specially to see the case. ~ 7 Fee ZI. GAILLARD THOMAS. 233 Upon examining I found a tumor lying in the right oblique direc- tion from the uterus, which on my first visit I took to be the flexed fundus, as Dr. Walker did the globular mass in the case which precedes this one. I advised Dr. Herrick to keep the flexed body in position, to give styptics, and to keep the patient very quiet. In two weeks I was called to see her again and found that she had grown worse rather than better, paroxysmal pains of a very severe character having added themselves to the symptoms al- ready existing. After these attacks the patient would become very much exhausted. A careful examination of the general and local symptoms presented by the patient now convinced me that she was pregnant, and that the pregnancy was tubal and not uterine. Dr. Herrick agreeing in this, it was decided at once to check the rapidly advancing growth of the fetal mass by the use of the in- terrupted galvanic current. I placed one electrode in the rectum under the fetal ball, and the other on the abdominal surface, while Dr. Rockwell passed the current. Four applications were made at intervals of twenty- four hours. After the first the patient was somewhat disturbed, temperature and pulse running up a little above roo, but the re- sult of the treatment was in the highest degree satisfactory. The extra-uterine mass steadily diminished, and the patient entirely re- covered, Having finished, what I set out with the intention of giving, a rapid outline sketch of all the cases with which I have personally met, of extra-uterine pregnancy, without go- ing into detail or referring to the experience or the views of others, I shall now endeavor to draw certain deductions as to symptomatology and treatment from them. I shall not try to classify these cases as tubal, interstitial, and abdominal, for I am satisfied that such an effort, unsup- ported by laparotomy upon the living or dead subject, would lead to error. The symptoms which in these cases have most frequently led to a diagnosis are the following : The symptoms of nor- mal pregnancy accompanied by (1) irregular gushes of blood, ceasing, and suddenly recurring without assignable cause ; (2) fixed grinding pain in one iliac fossa, and per- 234 EXTRA-UTERINE PREGNANCY. haps down the corresponding thigh ; (3) paroxysmal pains occurring with severity, marked by constitutional symptoms, and in a short time passing off, to recur with increased vio- lence in a few days; (4) symptoms of abortion without ap- pearance of the fetus; and (5) expulsion of membranes without accompanying fetus. The physical signs which have sustained the validity of these symptoms are: (1) increased size in the uterus and displacement of it upwards, forwards, or laterally ; (2) evi- dence of vacuity in it yielded by the sound or by a tent; (3) the presence either to one side of the uterus or behind it of a cystic tumor, somewhat painful to the touch, rather immovable, giving to palpation the sense of obscure fluc- tuation, and in some cases yielding the sign of ballottement. In a few of my cases this sign has been plainly distinguisha- ble, but this has been an exception to a rule, and the ab- sence of it should never be relied upon as evidence against the existence of the condition. In cases of advanced gestation of the ectopic kind the placental murmur, the fetal heart, and the movements of the fetus will of course present themselves as valuable signs ; but in tubal pregnancy, the kind most commonly en- countered, death will very generally occur from rupture of the fetal nest before they become available. Should differentiation between normal and tubal preg- nancy become necessary, the best method at our disposal, and one to which I have several times resorted, is the dila- tation of the cervical canal by tents, and the exploration of it by the finger. Even this is, however, not conclusive if a fetus be found in utero, for cases of combined normal and extra-uterine pregnancy have repeatedly been met with, as was shown in the very able paper read by a Fellow of this Society last year detailing twenty-four such cases. Should the signs of pregnancy exist, however, and the enlarged uterus be found without a fetus within it, while a tumor exists behind or alongside the organ, the evidence thus yielded would possess very great value indeed. As to treatment no one can at the present time speak —_— T. GAILLARD THOMAS. 235 with anything approaching positiveness, and I propose sim- ply to give the rules which I| think that the experience here related would induce me to adopt in the future. 1. If the ectopic tumor be discovered, and its nature be pretty well settled, before the end of the fourth month of gestation, I would destroy the vitality of the fetus by elec- tricity in preference to all other methods which have ever been proposed. It has these great advantages: if an error of diagnosis has been made, this remedy will do no harm ; if the diagnosis be correct, experience proves it to be suffi- ‘cient in its effects ; it is almost painless, and causes none of the nervous disturbance created by a cutting operation ; and it requires no surgical skill in its use. Should the fourth month of gestation be passed, and sur- gical interference be called for, I think that laparotomy, or, if the tumor be low down in the pelvis, elytrotomy, should be preferred to the use of electricity, which leaves a large fetal body to undergo absorption inside the body of the mother. Should the pregnancy be abdominal the practitioner may watchfully await the full term of gestation, and de- liver then by laparotomy or by elytrotomy combined with the forceps or manual delivery. Should full term be passed and the fetus be dead, the practitioner should wait and watch, if possible, until nature demonstrates the outlet by which she desires extrusion to be effected; then she should be aided. If, on the other hand, bad symptoms under these circum- stances at any time showed themselves, laparotomy, with strict antiseptic precautions, should be promptly resorted to. Should rupture of the fetal nidus have occurred before diagnosis has been fully made, the, practitioner should wait and see whether nature is powerful enough to overcome shock and to control hemorrhage ; then, further, if the pa- tient is going to escape the dangers of peritonitis and sep- ticemia. If these favorable results do not occur, if hem- orrhage is about to destroy the patient immediately, or if septicemia attacks her later, laparotomy, followed by anti- septic cleansing, should be promptly adopted. 236 EXTRA-UTERINE PREGNANCY. Out of my twenty-one cases rupture of the sac occurred in five cases; out of these four died and one recovered, none being operated upon. Out of the twenty-one cases seven were interfered with by surgical means ; of these, three died and four recovered. Out of the twenty-one cases two were treated by vaginal _ tapping with a very small trocar and both died. Of the twenty-one cases six were ae by electricity, all of which recovered. In three cases spontaneous death of the fetus occurred with expulsion of the fetal bones through the rectum. Of these two recovered and one died. DISCUSSION. Dr. H. P. C. Witson, of Baltimore. —I think the members of this Society are under great obligation to Drs. Thomas and Gar- rigues for having brought this most important subject before them, We all know how frequently it occurs that pregnant women die suddenly in a condition of collapse. Within the last few years two of my brother practitioners have called on me to express an opinion with reference to the cause of death under these circum- stances. In one case the patient was a lady who had been to market, was apparently perfectly well, came home, suddenly went into a condition of collapse, and was dead within an hour. She was pregnant, and the case was probably one of extra-uterine pregnancy in which the cyst had ruptured. My personal experience has been limited to two cases. In one of these there was a twin pregnancy. The woman went to term, and one of the children was born at the eighth month in the natural way. I cut into the abdominal cavity and extracted the second child at the end of the ninth month, and this child lived: to be two years old, and then died of cholera infantum. My second case occurred in the person of a woman who was the mother of two children. She was in the early period of preg- nancy when I first saw her, and she sent for me on account of severe pain from which she was suffering, so severe that it re- quired repeated subcutaneous injections of morphine to relieve her. Without entering more into the details of the history of the case I may say that she went on casting off occasional shreds of DISCUSSION. 237 membrane, with occasional gushes of blood from the uterus, and I finally discovered a tumor behind the uterus. There was no bal- lottement. I diagnosticated extra-uterine pregnancy, and at two and a half months I used electricity as has already been suggested, except that I placed one pole upon the tumor in the vaginal cul- de-sac, and the other above the pubes. ‘The electricity was ap- plied in that manner for six or eight days until the tumor was evidently diminished in size, and it finally disappeared. The woman made a good recovery and is still living. Dr. GoopELL, of Philadelphia. —I have seen thirteen cases of extra-uterine pregnancy, but before relating them let me briefly premise a few remarks with reference to diagnosis. It is often most difficult to diagnosticate even a normal pregnancy, but the difficulties are much enhanced when the pregnancy is abnormal. Certain diagnostic landmarks are therefore very desirable. The following are some which a bitter experience has taught me: If after a long cessation of fruitfulness or after a long continued sterility the woman becomes pregnant, I should at once suspect extra-uterine fetation. Another point is that the forward dis- placement of the cervix and the bulge in Douglas’s pouch often mimics a retroflexion of the gravid womb. A third landmark is the occurrence of paroxysmal pains or of cramp-like colics con- nected with pregnancy. A fourth is the continuance of pregnancy after a supposed abortion. The last one is that the supposed uterine globe is very much smaller than that of normal preg- nancy of corresponding length of time. As already stated I have seen thirteen cases, and the histories of these I will mention briefly: The first was one of tubal preg- nancy which occurred many years ago, and the woman died from internal hemorrhage in the eighth week of gestation. Had I known then as much as I do now, I would have tried to save her by laparotomy. The second case was one of ventral fetation which occurred in the practice of Dr. S. Perkins, of West Philadelphia, and which I saw in consultation in the second month. It was also seen later by Dr. Parry, and it led him to write his most excellent book on the subject. Several eminent men in the city of Philadelphia saw the patient. Two of them diagnosticated pelvic cellulitis. At the time of my visit I believed it to be a case of pelvic peritonitis. Some months later Dr. Parry was called in; the same day he came in to my office and said that it was a case of normal preg- 238 EXTRA-UTERINE PREGNANCY. nancy, and laughed greatly at my blunder. But, I said in reply, I am sure there is something abnormal there. As the child died and labor did not come on I was again called in and made up my mind that it was a case of pregnancy in a retroflexed womb. But on the next day it suddenly flashed across my mind that it was a case of extra-uterine fetation. Then I took no lit- tle satisfaction in asking Dr. Perkins to again invite Dr. Parry in consultation. In that case an operation could have been easily performed per vaginam, but it was refused, and the woman died. Dr. Parry removed the parts at the post-mortem, and as already stated, it led to his study of the subject. The third case was one in which the diagnosis was easily reached, but no operation was permitted, and the woman died. The fourth case was analogous to the third —a case also of ven- tral fetation, and the woman going to full term without an opera- tion. She would not listen to any argument and died. The fifth was very puzzling to me with reference to diagnosis. There was an abdominal tumor apparently filled with air, and I thought at first that it must be of a malignant character. I per- formed an operation, using every antiseptic precaution. As soon as an incision was made through the abdomen fetid air and de- composed fragments of a child escaped. After the completion of the operation the woman went on very well indeed for several days and then died of heart clot, after an altercation with her husband. The sixth case occurred in a mulatto woman. I operated with all antiseptic precautions, but placed too much dependence upon them. The child was alive, but died a few hours after birth, the woman being advanced to the sixth or seventh month in preg- nancy. I did not, as I should have done, use a drainage tube. The patient died of septicemia. At the post-mortem examina- tion the liver was found riddled with abscesses. In the seventh case the woman had paroxysmal pains and symptoms which led to the inference that extra-uterine fetation existed. I performed laparotomy, and found and extracted a dead fetus, and also removed the placenta. The child being dead hemorrhage did not occur, and she went on perfectly well, the wound healing perfectly. On the fourteenth day she suddenly had a convulsion and died. In this case the kidneys were found riddled with abscesses from chronic disease. The eighth case was one which puzzled several of our leading DISCUSSION. 239 men. The patient had been betrayed, and was sent from the South to hide her shame. Various opinions had been expressed with reference to diagnosis, such as anteflexion of a pregnant womb, pelvic peritonitis, pelvic cellulitis, etc. She was dying when I first saw her and diagnosticated extra-uterine fetation. In making the diagnosis I passed the uterine sound, following the introduction of which a pint of liquor amnii escaped. This led me to think that intra-uterine pregnancy also existed. At the autopsy the womb was found much enlarged, and apparently without a fetus. There was also an extra-uterine fetation. An analogous case has been reported by Dr. Braxton Hicks, and also, I believe, by Dr. Pallen —cases in which liquor amnii escaped from the unimpregnated womb. In the ninth and tenth cases nature interfered and the bones were expelled by the rectum, and the women recovered. In the eleventh case the extra-uterine pregnancy was diagnosticated before death, but the woman refused to have an operation. The twelfth was a case which I was called to see in consultation, but death occurred before my arrival. At the autopsy tubal preg- nancy was found to exist. The thirteenth case was a remarkable one. The history of it, in brief, is this: An Irish woman, at term, stepped upon a chair with a broken back. It upset and she fell upon one of the stand- ards. ‘The abdominal muscles and the muscle of the uterus were ruptured, but the peritoneum was not injured. The fetus es- caped from the womb, pushing its peritoneal coat before it, and lodged in the ventral hernial sac. The woman’s life was in jeop- ardy for several months. She then gradually recovered, and was able to work for a number of years. Finally she came to this country, where she was seized with typhoid fever, and not long after convalescence from that disease a fetid discharge came from the vagina. Upon passing the sound into the womb I found that it rattled among denuded bones. I succeeded in effecting a suf- ficient amount of dilatation by mechanical means and by incis- ions of the cervix, and at two sittings removed all the bones of a fully formed child together with the scalp covered with hair, and also the intestines. The stench, as may well be imagined, was very great. It poisoned the whole floor of the hospital. In spite of disinfectant uterine enemata she was seized with septi- cemia, and an abscess formed behind the left eye and destroyed it, but the patient finally recovered perfectly. I took special 240 EXTRA-UTERINE PREGNANCY. pains to ascertain the previous history of this case by correspond- ing with her physician at Killaloo, in Ireland, and found that her story was true. It will be noticed that in all of these cases ex- cept those with which nature interfered the women died. Dr. H. F. CaMpBELL, of Augusta, Georgia. — I have observed only a single case of extra-uterine pregnancy. A patient came to the hospital suffering from irregular uterine pains and sup- posed to be in premature labor, but could not be delivered. Her condition was not made.out before coming to the hospital, nor - was it really made out until after her death, eight months after- wards, when she died of pulmonary edema. At the autopsy one remarkable fact was revealed, namely, that the child was fully de- veloped, the mother having gone to full term before the death of the fetus occurred. The pregnancy was of the tubo-ovarian variety. On further inquiry it was found out that the patient was supposed to have a dropsical accumulation, and had been tapped. ‘The case was interesting as illustrating, with only two or three others, the point, that it is possible for a woman with ex- tra-uterine pregnancy of this variety to go to full term with com- plete development of the fetus and without rupture of the cyst taking place. The autopsy and report of this case were made by Dr. A. Sibley Campbell, and will be found in vol. ix., “ American Journal of Obstetrics.” A woodcut of the dissection was copied into the second edition of Playfair’s “ Midwifery.” Again, with regard to diagnosis, one point may be mentioned, namely, the growth of the breasts and all the associated symptoms of early pregnancy may sometimes manifest themselves from ovarian and uterine irritation independent of pregnancy. It is not well, therefore, to place too great reliance upon these signs of pregnancy, whether uterine or extra-uterine. Dr. G. H. Lyman, of Boston. — The principal point seems to be with regard to the use of electricity in the treatment of extra- uterine pregnancy, and hence the importance of early diagnosis, At the time when electricity would be of the greatest service the diagnosis,is not so easy. The suspicion of extra-uterine preg- nancy is not so very strong, and frequently these cases go on un- diagnosticated until the cyst ruptures. Early diagnosis, therefore, becomes a matter of special importance. As will be recollected by the Fellows, Dr. Reeves, of Dayton, Ohio, read a paper before this Society on extra-uterine’ pregnancy, since published in the fourth volume of its Transactions, and in connection with this dis- DISCUSSION. 241 cussion it may not be uninteresting to read a few remarks there- from. After giving the clinical history of his. case Dr. Reeves says, “I will occupy your time and attention with but a few re- marks upon this case, first, in regard to diagnosis, the most im- portant point of all. If we relied upon the authorities of only a few years ago, there could be no diagnosis in this case because at too early a period and because absolute evidence of preg- nancy was wanting. Thus, Stoltz would not admit the supposi- tion of extra-uterine pregnancy until a diagnosis of pregnancy had been made by the indubitable signs of feeling the fetal parts, or movements, or hearing the fetal circulation. But we were already in advance of this in 1867, when Dr. Stephen Rogers, of New York, saw that attacks of colicky pain, accompanied by a sanguineous discharge, the symptoms of pregnancy being present, were ‘almost certainly indicative of extra-uterine pregnancy.’ ” I think, Mr. President, this remark is one worthy of being borne in mind, particularly as it comes from one of our most shrewd and careful observers. Dr. W. T. Howarp, of Baltimore. — My experience with extra- uterine pregnancy has been confined to the observation of three cases. But I think that the diagnosis at the present time with what light we have upon the subject from the observations of such writers as Parry, Thomas, and others, should be made with certainty in almost all cases. The first case which I saw was in consultation with Dr. Brewer, of Baltimore. There was a large tumor behind the uterus, and the question arose whether it was a fibroid or whether it was extra-uterine fetation. I was con- vinced that it was a case of extra-uterine pregnancy, and I de- sired to introduce a probe to establish the diagnosis, but this was refused, and I would not say positively, without such an examina- tion, that it was one of extra-uterine fetation, which, however, the autopsy proved to be the case. The next case was one which I saw in consultation with Dr. Stephenson. The woman was thirty-nine years of age, and I was the sixth physician, I think, who was called to see her. I re- garded it as a case of abdominal pregnancy, and the post-mortem examination revealed the existence of the fetus within the ab- dominal cavity. The third case was one that I saw with Dr. Wilson, and to which reference has already been made. In that instance, also, I had no difficulty in reaching the conclusion that it was extra-uterine pregnancy. In regard to diagnosis, I would VOL. VII. 16 o 242 EXTRA-UTERINE PREGNANCY. refer to a clinical lecture which was delivered by Dr. Goodell and published in the “ Medical Record,” January, 1880. Dr. Goodell states that in his case of suspected extra-uterine pregnancy he distinctly heard both the fetal heart and the “placental bruit.” In this case I listened carefully, and although I could hear the fetal heart, with abnormal distinctness, the uterine souffle I could not hear. In extra-uterine pregnancy Barnes states that although the “ placental souffle ” has been heard with unusual intensity, it is rarely heard in abdominal pregnancy. Dr. Goodell heard the “placental bruit,” and the results showed that it was not a case of abdominal pregnancy ; and I think it is an important point in diagnosis, namely, that when in any case of suspected abdominal pregnancy the fetal heart is heard distinctly, and you cannot hear the uterine souffle, that in itself should go far in settling the diag- nosis. Dr. GOopELL. —I think, Mr. President, that the point made by Dr. Howard with reference to diagnosis is a very important one. ‘The so-called placental souffle is a misnomer, as it is really uterine and not placental. Hence, as long as we do not have uterine tissue involved we cannot have the so-called placental bruit. 2HE INFLUENCE OF THE CONSTANT USE OF HIGH-HEELED FRENCH SHOES UPON THE HEALTH AND FORM OF THE FEMALE, AND UPON THE RELATION OF THE PELVIC OR- GANS. BY SAMUEL C. BUSEY, M. D., Washington, D. C. THE foot and its coverings is not a new subject. Far more attention has been given, however, to the style and display of the covering than to the comfort and physical well- being of the foot. The “ Athenzum” attributes to Pliny the statement that shoes were invented by Boethum, but intimates that sandals in some form have been in use since the original pair discovered the difference between ‘the flower-carpeted paradise and the hot sands and sharp stones of that dreary plain.” The ancient Egyptians made them of leather, and for the priests of palm leaves and papyrus. The Hebrews made them for soldiers of iron and brass, but for others of linen and wood; and the lovers displayed their gallantry by engraving the likenesses of the adored ones upon the soles of their foot-dress, ‘“‘so that the pathways of the lovers became the picture-galleries of the loved.” The ca/cei, with uppers and soles of leather, were worn by those who walked much. The solee, which were variously ornamented, were for use in the house. The red or purple shoe was first worn by the kings of Alba, and last by the old Roman dandies. Then followed the sharp-toed shoe and half-boots of old Germans ; the high-heeled, long buskins, and the shoe with leather soles of the Roman women, which enabled the wearer to move about at home without any other foot-covering. The old bark shoe was probably the progenitor of the French sabots, which were 244. INFLUENCE OF HIGH-HEELED FRENCH SHOES. ‘in common use and very fashionable throughout Europe during the ninth and tenth centuries. During the reign of William Rufus, a famous beau, surnamed the Horned, in- troduced the long-pointed toes, twisted like a ram’s horn ; and during the time of Richard II. the toes were lengthened _ so as to be fastened to the knees by chains of silver and gold. For three centuries the church and public officers inveighed against this fashion, but not until 1463 was it prohibited by an act of Parliament. Afterwards fashion and taste expressed their extravagance in increasing the width of the toe of the shoe, which Queen Mary was com- pelled to restrict to six inches; and then followed the elegant buff-colored shoes, with enormous and lavishly em- bellished tops. The heel at first was a’device to make short men look tall, and, like the other parts, has under- gone many changes to suit the whims of fashion and taste. The French high heel worn by women is not only very high, but also narrow, and inclines from behind forward, so that its inferior extremity (Onimus), instead of being under the calcanean tuberosity, is directly under the plantar arch ; so that increased height, with diminution of the size of the foot, is secured. This style was introduced during the Regency. Under Louis XIV. the heel was high and cir- cular, but not oblique. During the reign of Louis XVI. this objectionable style began to disappear, but has been again revived and is perhaps more general now than at any previous time. During all these periods the feet were the objects of the most conspicuous vanity, fantastic con- ceit, and costly decoration. At some of the barbaric courts the soles of the shoes worn by men were made of plates of silver or gold, and the brilliant material of those worn by the ladies was half covered with precious stones. Even as late as the time of George III. a young married couple was presented at court wearing shoes with buckles worth two hundred thousand pounds. Popular patterns have, at dif- ferent times, been designated by the names of prominent persons, or for a special class of the nobility, but only in a single instance known to the writer has a prince or em- SAMUEL C. BUSEY. 245 peror derived his name from the style and material of the shoe, and that one the brutal Caligula. In the seventeenth century the patterns were greatly modified, and made more simple and less ostentatious, but with little regard to the physical well-being of the foot. Towards the close of this century Camper published his work on the best form of shoe, in which he discussed the question from the stand- points of anatomical construction, utility, and comfort. Every intelligent observer must have recognized the potent and pervading influence of prevailing fashions and common customs upon the human mind and body. Few, if any, can alienate themselves from the insidious and ever- changing agencies of association, example, and observation. Habit is not less potential in producing modification of form than in effecting alteration of single parts and dis- turbance of the functions of special organs. Everywhere, among all civilized nations, in all countries and climates, in every sphere of life and grade of society, in all trades, oc- cupations, and professions, individuality is characterized by diversity of form, inequality of mind, gradations of caste, and variations in temperament, disposition, and constitution. If it were not so, human life would be simply the monoto- nous change from birth to death. The causes that have produced these inequalities and dissimilarities in the descendants of a common parentage are as numerous and multiform as the distinctive differences of individuality. Nevertheless, we recognize types that dis- tinguish races, nations, communities, and families. These types refer to modifications of form, and to the mental and personal qualities that characterize peoples, not individuals, and are the results of a complex and constantly changing combination of influences in long-continued, persistent, and habitual operation. The variations in form of the types of the different races and families are far less marked than their social, mental, and personal qualities. It is not possible, at this time, to 1 The historic details have been collated and condensed from Cam- per, Dowie, Onimus, and the American Cyclopedia. 246 INFLUENCE OF HIGH-HEELED FRENCH SHOES. trace the gradual, imperceptible, and progressive evolution of these types of form, or to determine the combination of influences, or even the most constant or potential factor of any group or succession of circumstances, which have established the forms now accepted as the standard of race and family development. The deviations from these types of species and families that distinguish individuality are even more numerous, diversiform, and variable than the differences of types of form; and their causes are equally diversified and com- posite, but very frequently can be ascertained with an ap- proach to accuracy. The evolution of the typical and individual forms of the female sex have, undoubtedly, been influenced, and in a measure determined, by the same general order and suc- cession of events and circumstances of life; but the ana- tomical differences and peculiar physiological functions have so marked the general contour of form that conceal- ment of sex is almost impossible, however skillful the effort to escape detection. These characteristics are not so ap- parent during the earlier years of life, and it is not improb- able that if the physical, mental, and moral training were alike in both sexes subsequent and mature development would exhibit, in the general outlines of form, fewer and far less obvious dissimilarities. Age, pregnancy, and maternity are manifest and admitted agencies in the causation of deviations of the female form. Stature and the habits of posture and carriage are perhaps equally potential. The development, tone, and exercise of muscles ; sparseness, redundance, and distribution of adipose tissue ; laxness or tension of articulations ; the mobility of joints, and degree and extent of the normal curves, are also factors, operating either singly or conjointly, sometimes as primary, and at other times as correlative and compensative, agencies. Asymmetry, either connate or acquired, is the most common of physical defects. Lateral asymmetry is the ordinary result of over-use or disuse of corresponding parts. Disproportion between the trunk and lower extremi- SAMUEL C. BUSEY. 247 ties is more frequently a natural defect of embryonic and pre-natal development, and is a characteristic of some spe- cies and of many families. From the foregoing considerations it must appear that the study of the natural history of the evolution of the types, variations, and individualities of form would involve an extensive research in ethnology; the determination, grouping, and sequence of causes; and an examination of the mechanism of the human frame and its adaptation to the exigencies, mutations, and successions of life. Into such an inquiry I do not propose to énter. The study of the influence of a single factor, such as I have indicated, is embarrassed by all the conditions of life to which I have referred. Hence the dogmatic assertion of any general law, applicable alike to the different types and diversities of form, is unattainable. Experimentation is im- practicable, except under circumstances that would admit of the comparative management of two identical forms, under like conditions and development, from early life to maturity, and even to advanced life: the one being subjected to the artificial props beneath the plantar surface, and the other left to bear her weight upon the unprotected soles of the feet. Of the first, numerous illustrations in process of continuous development are supplied in every town and village in the country. To secure the latter would prove a difficult task in this esthetic age. I must therefore be content with a cursory and general presentation of the subject, and the conclusions reached through the processes of observation and inductive reasoning. Paget has supplied the following description of a perfect female foot: “Great breadth and fullness of instep, a well- marked great toe, a long second toe, projecting a little be- yond the great toe, and a very small, or in some cases almost suppressed, little toe.” The foot is divided into the tarsus, metatarsus, and toes ; and the sole is so formed that we rest upon the heel, the articulation of the instep with the toes, and, externally, upon the tuberosity of the fifth metatarsal bone. The bones of the foot form a double 248 INFLUENCE OF HIGH-HEELED FRENCH SHOES. arch, the inner span extending from the heel to the distal end of the first metatarsal bone, and the outer span from the heel to the fifth metatarso-phalangeal articulation. The elongation of this arch is of a twofold character: first, by flattening under the weight of the body, and consequent re- cession of the toes and heels, and lengthening of the foot forwards and backwards; the second, at the articulations of the instep and toes, when the toes are turned upward, and is due to the hinge-like nature of these joints. When the toes are stationary upon the ground, elevation of the heel will produce elongation backwards. This backward elongation is to a considerable extent compensated by the tension of the muscles of the sole upon the heel bone, and the consequent elevation of the height of the arch. This double-spanned arch also possesses lateral expansion. The feet and legs constitute a complex arrangement of levers with movable fulcrums, hinge-like and socket joints, surrounded by elastic and elongating structures of very variable strength and tensile mobility, so that every devia- tion of the base of support is so quickly compensated that equipoise is maintained. In walking, the heel touches the ground first, and supports (Onimus) the whole weight of the body fora moment. A little later the point of the foot touches, and assists in preserving the equilibrium by increasing the base. During the second movement of walking the heel is raised (see Figs. 2 and 3), and the weight of the body is shifted more and more to the centre of the foot and to the toes, the latter spreading and pushing the body forward. This last is the movement which displays to the greatest advantage the suppleness and elasticity of the articulations of the foot, and the adaptation of the arch to receive the weight of the body and to transfer it to its distal pier, while the body is being moved forward by the same act. It is the execution of this movement which gives to the gait of women that elegance and those grace- ful undulations which are so attractive. Comparative ob- servations show that high and narrow heeled shoes not only displace the supporting base and upper part of the = SAMUEL C. BUSEY. 249 foot, but so modify the movement that there is no longer succession of contact and pressure. Practically both piers of the double-spanned arch strike at the same time, and from the moment of contact the weight of the body is upon the distal pier (Fig. 3) and toes. Hence, walking, instead of being undulating, is stiff and hobbling, and the body advances by jerks. \B 16 h po ow - = IN | R oUt. q! i] \ i] ! i | i} i] t I | H S| (From CAMPER.) The bones of the instep are capable of but very little movement. When standing, the heel bone (V / J, Fig. 1), the joint at XK, and the great toe, A C, touch the support upon the line A B. When the feet are shod according to the present fashion, the line A B is made to assume the concave form shown in Fig. 3 by BV Tu. The instep 250 INFLUENCE OF HIGH-HEELED FRENCH SHOES. is made more convex and rounded, which is specially es- teemed by a certain class as a peculiar beauty, and the foot is actually shortened (see A &, Figs. 1 and 2). In those long accustomed to such shoes it is more than probable (Camper) that the heel bone receives the astragalus (4, Fig. 1) upon the eminence J/ Z, and the astragalus (4, Fig. 3) is bent downwards. This is most apt to occur in young persons, while the neck of that bone remains carti- laginous. The constant elevation of the heel places the body of the pedestrian in the same position as when stand- ing upon an inclined plane, which is not only a weak atti- tude to sustain weight, but very fatiguing to the muscles thus called into action, and compels the lifting of the knee higher. It imposes also a greater expenditure of force, because a new start is made on ‘stilts from a comparative state of rest at every step. Again, the heel is so shaped and located (Dowie) that it forces up the key-stone of the arch, and weakens the whole structure. If the arch needs support the span of the support ought not to be less than that of the arch, yet the mechanical construction of the shoe heel and shank not only ignores this principle, but may. in- jure an arch needing strength. The alteration of the nor- mal line of the sole of the foot, caused by the rigid fixation. of the arch in this strained position, produces atrophy of the muscles of the heel, instep, and ankle, because of the comparative disuse; weakens the lateral and longitudinal arches ; increases the curve of the sole, giving rise to a rocking motion and jolting gait, retarding progression and consuming muscular force; bends the toes upward, thus injuring the muscles of the sole by too continuous exten- sion, and those above by excessive contraction; injures the fleshy part of the great toe by too great and constant pressure; cramps the toes; diminishes the elasticity of the foot ; prevents elongation of the arch, and the ready adap- tation of the system of levers to the variations of stature ; calls into action strained muscles, and imposes upon them unaccustomed movements; and so disturbs the natural bearings of all the parts as to interfere with the general health. SAMUEL C. BUSEY. 251 A comparison of the normal or perfect female foot and the malformed foot represented in Figs. 2 and 3 ought to convince the most enthusiastic devotee of the evil effects of the French high-heeled shoe. A further examination of the diagrams will show that the toes may also be greatly distorted. The continuous pressure upon the joints of the instep and toes and the tension of the muscles and tendons of the sole of the foot produced by the misplaced heel dis- torts the toes, as shown by the lines D fe in Fig. 2, and a Pc in Fig. 3, so that the tread of the foot, represented in length by the line A J, is shortened by the distance A e in Fig. 2, and Wc in Fig. 3. The astragalus receives at R (Fig 3) the weight of the body, which is transmitted along the lines R B and R A. If the hollow of the foot should be made to touch the ground, the line A B would be lengthened by the distance from A to X. The conditions of superincumbent weight, which would thus flatten the arch and increase the length of the foot, might exaggerate the deformity shown in Fig. 3 in a foot geared in this style of shoe. The diagrams show, furthermore, that the measurements taken in the air, as is usual, of feet thus distorted, are necessarily too short, and the feet will be cruelly pinched in the erect position be- tween the lines V B and A O (Fig. 2) by shoes made by such measures. The casual observation of awkwardness and unsteadiness of carriage of the wearers of high-heeled shoes, and the occasional occurrence of injuries to the feet and ankles at- tributed to their use, had long ago impressed me with the belief that the inexorable precept of fashion had lengthened the shoe heel far beyond the conveniences of easy and graceful locomotion, and that results would follow their continued use other, and perhaps graver, than the callosi- ties, bunions, in-growing nails, sprained ankles, and painful calves which so frequently torment the votaries of this rep- rehensible practice. But not until I had seen, under advan- tageous circumstances, not long ago, at a fashionable sum- mer resort, the most advanced style of full toilet foot gear, 252 INFLUENCE OF HIGH-HEELED FRENCH SHOES. did I appreciate the probable extent of its influence upon the growing form of the female. It had become the custom for the lads and misses of all ages from five years to early puberty to assemble, during the evenings, in the parlor, and engage in the dance. This company comprised many different sizes and forms, which exhibited the grades and phases of childhood development in great variety. The feet and ankles of the larger number of girls were geared in shoes with heels so high and slender as to fasten them in the position as if always walking down-hill, the toes being pushed more and more forward. The rigid fixation of the feet in this unnatural position diminishes their size, les- sens the spring and elongation of the double and elastic arch of the instep, and confines the muscles, tendons, liga- ments, and bones in strained relations, impeding, if not arresting, the processes of formation, waste, and repair. It disturbs the articulation of the diversely shaped surfaces of the many small bones comprising the instep, destroys the easy, free, and elastic mobility of the tarsal and metatarsal joints, and transforms the tarsus, metatarsus, and phalanges into a rigid body not unlike a shoemaker’s last. The ex- cessive elevation of the heel displaces the centre of gravity, which should coincide with the centre of movement, and transfers the weight of the body, for the most part, from the heel to the metatarso-phalangeal articulations, — joints arranged with shallow sockets to facilitate movement in every direction, and to expedite progressive motion, but not to bear the burden of the body-weight. ’ The movement, attitude, and poise of those whose feet were thus tackled with fashion’s latest and choicest pattern of high-heeled shoes were in marked contrast with those of the less ostentatiously dressed, who retained the free and natural play of their muscles and joints, and the capacity and elasticity of motion and posture which restore the body to its balance from any slip or vacillation without apparent effort. The movements of the former were stilted, uneasy, restrained, and executed with caution, under mental strain and with unnecessary expenditure of force. As I sat, even- SAMUEL C. BUSEY. 253 ing after evening, in that gay saloon, a silent and unknown spectator, I could see the gradual effacement of the merry dimples and glow of health from their cheeks, the deepen- ing lines denoting wear of body and tire of nerve, and the pallor of distress creeping over their youthful faces, as they limped or staggered to places of rest. The physical well-being of the feet is a necessary and important part of the general sanitation of health. Pedes- trian exercise is the great promoter and conservator of functional activity and constitutional vigor. To enjoy it, and to realize the benefit to the fullest extent, the feet must be healthy and the foot-tackle free and easy. Sore, con- tracted, and crippled feet, strained and stiffened joints, altered and displaced articulating surfaces, restrained mo- bility, and alteration of the line of gravitation (any one or all of which results may find their cause in too early and too constant use of high-heeled shoes) impede and augment the fatigue of locomotion, and make walking exercise pain- ful. Per contra, they conduce to the acquirement of un- gainly habits of carriage ; to disproportion of the component parts of the body ; and to a sedentary life, with its manifold disturbances of the animal economy. Yet how many mat- rons throughout the land will entail upon the mothers of coming generations some one or more of these injuries, with the long train of consequent sufferings, rather than abandon the fashion of a shoe! The injuries are not, however, confined to the feet, their joints and component structures. During the same series of observations I had the unusual opportunity of studying the influence of heel-elevation upon the general outlines of the body; for the exuberance of fancy in toilet was not limited to esthetic decorations of the calves and feet, nor were the devotees of extreme styles narrowed to the ages of growing and immature girls. I could outline the com- parative increase of the ankle, knee, and ilio-femoral flex- ures, and the exaggeration of the curves of the spinal column. These alterations of the natural angles and curves give the fore and aft outline of the general contour an in- 254 INFLUENCE OF HIGH-HEELED FRENCH SHOES. and-out or zigzag course. The degree of the angles and radii of the curves vary according to stature, form, and size. The law of adjustment seeks compensation for the primary deflection by exaggeration of the nearest flexure in the opposite direction. The elevation of the heels displaces forward the base of the line of gravitation, and transfers greater weight to the distal extremity of the plantar arch. The equilibrium of the body can only be maintained by in- crease of the natural bendings and curves along the line of the bony framework. These angles and curves are usually so concealed or obliterated by the necessary coverings and decorations of the figure that the effect upon the attitude and pose of person is not necessarily either displeasing or unattractive. The opportunities for embellishment are rather increased than diminished. Art and nature may become co-laborers in the display of artistic costumes and in the arrangement and deception of adornments, if taste and delicacy are not outraged. The exaggeration of the dorso-lumbar curve! gives fullness to the buttocks, rotun- dity and plumpness to the abdomen, elongates the chest, and increases the prominence of the bosom; to which in some are added, by the compensating change in the posi- tion of the head, elevation of the face, and rounding and filling out of the neck and throat, with effacement of the depressions and irregular outlines, — the whole imparting to the general carriage an air of haughtiness and command, which happily is often modified and softened by the innate womanly virtues which find expression in the language of the face and tongue. But I am seeking to present the sub- ject in its physical, and not in its decorative, aspect. The uterus occupies nearly a central position in the pel- vis, is “delicately and unstably poised,” and is supported “on every side by the soft and elastic structures which everywhere surround it as closely as if it were enveloped in a fluid.” Its longitudinal axis is coincident with or parallel 1 This “ peculiar bending of the back in the lumbar region ” Onimus calls ‘* ’ensel/ure, from its resemblance to the appearance of a horse’s back which has been accustomed to the wearing of a saddle.’’ — SAMUEL C. BUSEY. 255 to the axis of the plane of the pelvic brim, forming, with the vagina anteriorly, and upon itself at the junction of its cervix and body, very obtuse angles. So that the line of gravitation, which, because of its position and attachments, is through its longitudinal axis, would, according to nat- ural laws, be vertical through its centre of gravity. Its centre of gravity, being supposed (Duncan) to be the cen- tre of its mass, must be above, and the vertical line of gravity must be anterior to, the cervical attachments. The PLANES OF THE PELVIS, wITH HorRIzon. A B Horizon. C D Vertical line. A BT Angle of inclination of pelvis to horizon, equal to 60°. BIC Angle of inclination of pelvis to spinal column, equal to 150°. CIF Angle of inclination of sacrum to spinal column, equal to 130°. EF Axis of pelvic inlet. Z M Mid-plane in the middle line. NV Lowest point of mid-plane of ischium. » (From PLayFair.) plane of the brim inclines (see diagram No. 4) at an an- gle of 60°, and the longitudinal axis of the womb, vertical to this plane, inclines at an angle of 30°. This relation, though not mathematically accurate as thus expressed, is the generally accepted rule of normal anatomical relation in the erect position of the body, except so far as it may be dis- 256 INFLUENCE OF HIGH-HEELED FRENCH SHOES. turbed by the exigent oscillations, within a limited are, of a body so delicately poised amidst contiguous organs subject to such fluctuating conditions as the female pelvic viscera. Then, so long as the coincidence or parallelism of these axes is maintained, so long will the uterus approach the horizontal line, in direct proportion with approximation of the plane of the brim to the vertical line; consequently, as the inclination of the plane of the brim increases or dimin- ishes, so, reversely, will the uterus, through its long axis, approach or recede from the vertical line. The weight of the trunk is balanced upon the ilio-femoral articulations, and ‘“‘the centre of gravity of the parts above is (Duncan) nearly vertically over these articulations.” The line of gravitation and the axis of the body,! though not universally believed to be coincident lines, are, with suffi- cient accuracy, represented by a vertical line bisecting a horizontal line passing through the centre of the ilio-femoral articulations. The centre of gravity and line of gravitation vary with every backward and forward movement of the trunk upon these joints; and the inclination of the womb follows the variations in the inclination of the pelvis, ac- cording to the law as previously stated. In an elastic and flexible body, like the human form, with its numerous deviations from a straight line, nature re-adjusts disturb- ances of equipoise by compensating alterations of the bend- ings and flexures. The question now arises, How are these relations of the natural conformation influenced by the excessive and con- stant elevation of the heels by the use of high-heeled shoes ? 1 In the diagram of Hodge (Déseases Peculiar to Women, pp. 317 and 328), the axis of the body is represented by a line touching the anterior surface of the third lumbar vertebral articulation, and passing through the body of the ossa pubis. In his System of Obstetrics, p- 30, Hodge says, ‘‘ The axis of the body, when in the erect position, may be represented by the line of gravity. This line of gravity, or ver- tical line extending from the top of the head to the ground, passes through the lumbar vertebrz, the base of the sacrum, and cavity of the pelvis a little anterior to the tubers of the ischia, bisecting a line drawn through one acetabulum to the other.” —— SAMUEL C. PUSEY. 257 The primary deflection of the line of gravitation takes place at its base. The ilio-femoral articulations being the pivot upon which the body is balanced, and the fulcrum of its support, and the long arm of the lever being all that part of the stature above these ball-and-socket, and most movable of the limb-joints, readjustment of equipoise is necessarily most easily and quickly restored by increased flexion at the hip, with displacement backwards of the pelvis, which sooner or later will find its compensation in exaggeration of the dorso-lumbar curve. The law of compensation which determines other and permanent alterations of form is well defined, though subject to many variations dependent upon size, height, general conformation, and habit of carriage. This law may be briefly stated as follows : Every primary curvature is compensated ! by a second and generally equal curve in the opposite direction, usually occupying the part of the column immediately adjoining the first, and may fol- low the column in extended sequence of two, three, and even four deviations. The compensation in lordosis is ob- tained by increased inclination of the pelvis. The ordinary anterior curvature in the loins involves a corresponding displacement of the pelvis backwards, and more especially when the lumbar curve is itself compensatory and conse- quent upon too great inclination of the pelvis. The latter is most frequently the primary deviation. Pelvic inclina- tion and dorso-lumbar curvature bear a direct and posi- tive relation to each other, the excess in either being com- pensated by a corresponding excess in the other, so that cause and effect react upon each other, producing increased backward displacement of the pelvis and greater spinal curvature. In curvature of the lumbar region forwards, and “in excessive inclination of the pelvis, with which the lumbar curve coexists and to which it is due,” the chest is increased in length; and while the breadth of its lower part is strikingly greater than natural, it is very pointed above, and flattened from before backwards. Of course the ordinary movements of expansion and contraction of 1 A summary of the conclusions of Rokitansky. VOL. VII. 17 258 INFLUENCE OF HIGH#*HEELED FRENCH SHOES. the chest are disturbed, the diaphragm is depressed, the abdominal organs are displaced downwards, and the ver- tical pressure of the superincumbent viscera upon the pel- vic organs is increased. This pressure does not impinge upon the top of the fundus of the uterus zz s¢tu naturalt, but upon its posterior surface. The tendency, therefore, of (Hodge, Duncan) all pressure from above, the accumulated weight of the organs, aided by the contractions of abdomi- nal muscles, is to press the fundus downward towards the pubis, and to carry the cervix towards the hollow of the sacrum. When the organs are healthy and in a natural position the forward proclivity of the fundus is prevented by the presence of the bladder and small intestines in front, and the ascent of the cervix is resisted by the mass of in- testines in Douglas’s cul-de-sac. ‘The bladder (Aveling), when filled, is a heavy organ. In the erect posture, when the pelvis is normally inclined, it rests upon the pubes ; but when the pelvis is tilted back, the whole weight of the urine gravitates directly into the pelvic cavity, and presses upon the anterior wall of the vagina. Should this be weakened by disease or child-bearing, it gradually descends and allows the bladder to fall back, describing in its progress an arc of a circle around the pelvic bones, to which it is anteriorly attached.” Thus in cases of excessive pelvic in- clination the viscus, which is directly instrumental in the redression of the womb and in the preservation of its mo- bility, becomes a potential factor in establishing a mal- position, and complicates the uterine displacement with frequent, difficult, and painful micturition. Cystitis, as the necessary result of incomplete evacuation, may also add its chain of suffering, unsatisfactory cure, and frequent re- lapses. The rectum is an important organ, and it is not improbable that the disturbance of its postural relation with the sigmoid flexure by excessive inclination of the pelvis may promote the establishment of the habit of constipation, which is so common among females, and so often the cause of no less intractable, but even more painful, affections. The uterus is so delicately poised zz stu naturali that SAMUEL C. BUSEY. 259 it is probably never at rest during the life-time of a woman. The varying conditions of vesical repletion and collapse, of rectal emptiness and distention, and the movements of respiration keep it constantly moving up and down a plane acutely inclined to the line of gravitation, and to and fro on its transverse axis. This mobility and incessant movement constitute the necessary and most essential method of uterine hygiene. It is this local exercise that promotes healthy circulation, expedites the processes of change and repair, prevents congestion, maintains normal nutrition, and preserves functional activity. The vascular, postural, and nutritive disturbances grow- ing out of deflections of the skeleton, which I have at- tempted to show may find their starting point in too great and habitual elevation of the heel, are not necessarily confined to the bladder, uterus, and rectum. All the tis- sues and organs, the vagina, ovaries, Fallopian tubes, liga- ments, and fascize, may become involved. Hyperemic con- ditions, distortions, and displacements, either singly or collectively, may follow in an extended sequence of local and general disorders, but menstrual disturbances and vaginal discharges are probably more common. To enumerate these affections would extend this paper beyond a reasonable limit. I might show that diminished mobility of the uterus and excessive inclination of the pel- vis, with other and consecutive alterations of form, enter also into the causation of posterior deviations and descent. The moment the fundus, in posterior oscillation, passes in the arc of rotation beyond the point of greatest tension of the round ligaments, that moment their action carries the fundus down the arc of rotation towards Douglas’s cul-de- sac. This movement would be aided by vesical repletion, deflection of the line of gravitation and of the vertical press- ure of the superincumbent viscera, transference of the in- testines from the anterior to the posterior surface of the womb, and by relaxation of the abdominal walls. The equipoise of the body upon the ilio-femoral articu- lations must be preserved, and Duncan has called attention 260 JZNFLUENCE OF HIGH-HEELED FRENCH SHOES. to the fact that, while “the small and especially short- bodied women” seek the readjustment of the centre of gravity by moving backwards the head and shoulders, “the tall and long-bodied” seek it by moving forward the sup- ports, which is accomplished “by diminishing the angle which the pelvis forms with the horizon.” This change in the pelvis is analogous to that taking place in old age, when the forward stoop is counterbalanced by it. The same dis- tinguished authority points out the fact that when adjust- ment is effected by backward inclination of the head and shoulders the hips become prominent, indicating “a prob- able considerable obliquity of the pelvis.’ In the other class the hips are flattened, indicating lessened obliquity and elevation of the pelvis. These mal-relations of the pelvic and corporal axes are consequent upon pregnancy, and may also follow acquired habits of carriage and posture, such as I have suggested ensue from the constant and habitual elevation of the heel. I might also trace the obstacles which excessive inclina- tion of the uterus and consequent backward displacement of the os and cervix present to the transmission, tubulation, and lodgment of the sperm cell, impeding the processes of insemination and fecundation, and producing sterility. I need not pause to consider the obstructions to parturition which excessive pelvic inclination may offer, or to trace them back to the gearing of the feet in earlier life. They are sufficiently obvious to every obstetrician. Onimus says the local and functional troubles are fre- quently mistaken for strange manifestations of hysteria, varying according to the temperament and predisposition, and very often concealing the true nature and origin of chronic invalidism. In Paris young girls often complain of violent pains in the muscles of the leg, which extend ‘along the external region of the calf to the thigh, A sharp pain from the sole of the foot to the external malleo- lus is the most frequent initial symptom. The articulations of the knees are many times equally painful, simulating the condition one feels after descending from a high mountain. SAMUEL C. BUSEY. 261 which has occupied several hours. But the long peroneal muscle is the one most often affected, because it is most fatigued by the irritation transmitted by its tendon from its insertion at the great toe along the plantar arch. The con- stant tension of certain muscles to maintain the equilibrium, rendered necessary by the height of the heel, produces painful cramps and a sensation of constriction, even when ‘not walking, and young girls are compelled so seek relief from the lancinating pains by rest in bed. It is easy to comprehend how the general health may be influenced by such functional and local disturbances, and when such con- ditions exist in women, where the nervous systems are always waiting for an opportunity to become troublesome, we may look for serious pathological consequences. In the foregoing presentation of the subject I have en- deavored to confine the discussion to the physical aspect of the question, and to trace out the relation of cause and effect which may subsist between the prevailing fashions of foot gear and many of the maladies which come under the observation of the gynecologist. Norte. — The illustrations exhibiting the alterations in the outlines of stature have been omitted, because the artist neglected to take the pho- tographs of the nude figures, with and without the shoes, in corre- sponding positions. The differences were sufficiently marked to show the changes in the form of the female, caused by the use of high-heeled shoes. An effort will be made to supply such illustrations at a subse- quent meeting. DISCUSSION. Dr. Forpyce Barker, of New York. For several reasons I fear I shall be unable to add anything of scientific value to the paper. All must have been charmed with its literary style and excellence, and in regard to its scientific value it seems to me to be most able. I cannot detect any fallacy in that respect, and must accept every statement and deduction made by the author of the paper. But a great many times in my life I have been forcibly struck by the fact, that, practically, the results are quite different from what science teaches us they should be. 262 INFLUENCE OF HIGH-HEELED FRENCH SHOES. With regard to this very matter, it is now some twelve or fifteen years since what are known as the Louis Quinze high-heeled shoes came into fashion in this country, and having had more or less of the high-heeled c/ente/e I have been watching their effects for some time. We have many American women who go abroad and bring back French fashions and French shoes, and they have been worn amongst us abundantly for at least eight or ten years. But it is a singular fact that the fashion has been slow in getting into England. This depends no doubt upon the shoemakers largely, for this year on my visit abroad I found that in France the high heels are being cut down, while in England and Scotland high heels are worn very much more than any other kind by society women. Now this is all due to the tyr- anny of the shoemaker. Asarule the feet of English women are not remarkable for their beauty, nor’ have English women generally a graceful walk, but when the fashion was peculiar to France it was surprising to see those women walking upon the beach at Dieppe, Scoville, and other fashionable watering places, and to notice the gracefulness of their walk, although they had had on these excessively high-heeled shoes. At the same time I must confess that I was not particularly struck with the graceful- ness of the walk of the English women with their large-soled and flat-heeled boots. Then again, I have heard a story that a lady who had been wearing these high-heeled shoes went to one of the most celebrated orthopedic surgeons in New York City for some spinal trouble, and when, after examining the case, he found that she was wearing a pair of these fashionable shoes, he immedi- ately seized them and with language more forcible than elegant pulled off the heels and flung them away, following them with a shower of denunciations, and prophesying all sorts of ill results should the abominable fashion be continued. I have heard him speak in the most eloquent terms concerning the evil conse- quences attendant upon the wearing of high-heeled shoes. Now I think that the most graceful gait and movements which I have ever seen have been in those who have worn high-heeled shoes. I dare say that no one would question the grace and elegance of movement of such actresses as Ada Cavendish, Sarah Bernhardt, and many renowned ballet-dancers and others who have been ac- customed to wearing high-heeled shoes. Now this is all wrong, because it is against what science teaches us. For many years I have been accustomed to watch this class of patients to see what symptoms would occur among those who did wear high-heeled SAMUEL C. BUSEY. 263 shoes that did not develop in those who did not wear such foot gear. I should like to know whether any one has noticed that the people in that class of, society who wear high-heeled shoes have affections of the pelvic organs or other difficulties traceable to this cause, and I hope the question may be answered, as I see there are some here who have had a large experience with surgical conditions outside of those belonging to gynecology. According to science there should have been produced some spe- cial ills, and I think Dr. Busey has most ably proved that the elevation of the heels, with the changes which they produce, ought to be followed by all these changes in the angles and curv- ature of the body which he so logically and clearly describes. In early life, some thirty years ago, I commenced putting down a series of subjects upon which I hoped at some time to write a paper, but which I have never done. Among the subjects which I there noted down was that of “the influence upon the health of women produced by the caprices of fashion.” It is needless for me to say that I have not yet completed my paper upon that sub- ject, but the point that struck me with reference to a great many of these fashions was, that although we may preach concerning them, we cannot control them ; women have a sharp instinct, and will so array themselves as to make themselves attractive for the other sex. Whatever may be the fashion that is introduced, if it will not accomplish this they give it up at once ; but what- ever fashion does bring about this result it would be fasts for science to attempt to combat. I am glad, however, that this paper has come up, for I hear remarks constantly made of the evil which certain fashions of this kind produce not only in this country but in France, and I hope that he paper will be thor- oughly discussed. Dr. T. G. THomas, of New York. I shall have but little to say upon this subject, for I feel very much with reference to it as one of the Senators did in the time of Mr. Webster, who said that he had intended to reply to Mr. Hayne, but that Mr. Webster had embodied all that he had to say, and had said it in just the way he intended to say it. I may say the same with reference to the remarks which Dr. Barker has made, that he has expressed my ideas exactly, and I shall therefore have but little more to say. I feel that the paper read by Dr. Busey should . be published in non-medical journals as well as in medical ones. It should be published in journals which will reach the masses of the people; because it so fully and so clearly lays before them 264. INFLUENCE OF HIGH-HEELED FRENCH SHOES. the evils attending upon the fashion mentioned. But I think that the paper is weak in some few points which I shall now proceed to mention. I think that the health of our women depends very greatly upon the development which they receive in youth, and I believe that such games as croquet and lawn tennis have done more for the health of American women than many volumes could have done upon this subject, even when indorsed by the statements of physicians. What will contribute most to the health of our women will be to make popular such exercises as will render it impossible for our girls to wear tight clothing or similar injurious styles of dress. Such a paper should set us to thinking. It is one which will do much good, and it should be thoroughly and fully considered. But there is this to be remarked, that a woman who has tender and badly shaped feet, whose spine is not per- fectly straight, is the woman who of all others we may expect to have uterine disease, for the reason that she will develop badly, and the pelvic organs among others will suffer to a greater or less degree. JI admit all this, upon which the. value of the paper depends, but I am afraid there is an inherent weakness in the subject. JI have watched patients who used high heels, and have watched them with special reference to the influence which this particular fashion might have upon the pelvic organs. I have felt that it should be bad, and that women who wear high- heeled shoes should surely have uterine displacement, but I have been surprised to find that those women do not have such dis- placements. I have been fully prepared to believe in the direct influence of high-heeled shoes upon the pelvic organs, but I have been disappointed with regard to it, although I have had under observation women who have indulged in this pernicious habit for years. I believe the reason is, that these women did not begin to wear such shoes in early childhood. I should say that the general influence certainly is very deleterious indeed, but that the direct influence, that is, that the spine is affected, or that the pelvic organs are affected, and that the disorder can be distinctly traceable to this habit, I have not been able to determine. I do not wish in any way to weaken Dr. Busey’s paper, but I simply wish to state the facts as I have observed them. I cer- * tainly think that the habit is a most injurious one, and that in an indirect way it is one of the methods by which the system be- comes depreciated, and renders women the prey of pelvic dis- eases. DISCUSSION: 265 Dr. Munpt, of New York. I would like to challenge one statement made by Dr. Busey, and that is with reference to a mass of small intestines being in the cul-de-sac. As a fact there are no small intestines in the cul-de-sac, as has been satisfactorily shown by Dr. Noeggerath and others. I think it is a wrong im- pression that the cul-de-sac always contains loops of intestines, for I have distinctly felt them but twice in the examination of over 5,000 women, most of whom were examined many times. Dr. VAN DE WarKER, of Syracuse. I would remark that some very eminent authorities figure loops of intestine in the cul-de-sac. It is certain that there is a great deal of dissenting opinion upon that point, although I think the majority express it as Dr. Mundé does, that as a rule the cul-de-sac is empty. Dr. Busrty. Perhaps I laid too much stress upon the point which Dr. Mundé raised. Nevertheless, it is not the universal opinion that no intestines are found in Douglas’s pouch. It may be his observations have been in one direction, and those of others have been different. It is not in this connection a ma- terial point whether small or large intestines are there ; there is something there which is constantly subjected to changes in position. In reply to Dr. Thomas I will add that it is impossi- ble to say definitely what the precise effect would be because of the diversities of form ; a certain figure might be injured by the constant elevation of the heel, while another form or figure, differing in size and stature, would be affected differently, or might not be affected at all. There is no doubt in regard to the influence of changing the line of gravity and transferring the basis of support forward. No one doubts the injury of such a change upon the feet and effect upon the normal curves of the spine. The other inferences which I have made are simply deductions, not positive conclusions, The probabilities are, that if medical men will bear them in mind they may in future find a more constant relation between cause and effect than is now recognized. I think if Dr. Thomas would take the profile figure of a female who has been wearing high-heeled shoes for a long time and then remove the shoes and take another profile view he would find an important change in the normal contour. [Dr. Busey then ex- hibited photographs of a girl who had been wearing high-heeled shoes for a long time.] Dr. Thomas believes that the introduc- tion of games and other athletic exercises are best directed to 266 INFLUENCE OF HIGH-HEELED FRENCH BOOTS. sustaining the health of our women. I agree with him in that respect, and not only because of the exercise, but it necessarily dispenses with the use of uncomfortable shoes. Such games pro- hibit the use of this injurious foot-gear as well as other injurious habits of carriage. Dr. THomas. I admitted all these things and accepted what Dr. Busey states with regard to the effect of wearing high-heeled shoes, but I simply made the statement that I did not find the results which he had expected would be found as directly trace- able to it. Dr. Bussey. I think if it could be possible for Dr. Thomas to have two similar female figures photographed at different peri- ods from the age of five up to the age of sixteen years, one hav- ing worn high-heeled shoes, so that he could be able to compare them, that he would find a marked difference in their contour. Certainly there would be a change in the inclination of the pelvis, and my inference was that there would be a corresponding change in the position of the pelvic organs. MECHANICAL THERAPEUTICS OF VERSIONS AND FLEXIONS OF THE UTERUS. BY ELY VAN DE WARKER, M. D., Syracuse, NV. Y. Tue mechanical therapeutics of uterine displacements is yet unsettled. No department in gynecology has been the object of greater interest, and no department of sur- gery in general has stimulated an equal inventive activity. With all this array of invention the mechanical problems involved are not advanced, nor the question of utility in any manner settled. It is doubtful if in the whole range of gynecology a subject can be brought up that will elicit such hostile criticism on one side, and such cordial approval on the other; but among the avowed friends of mechanical therapeutics there is even more irreconcilable conflict as to the mere forms of appliances, so that while the inflam- matory and mechanical schools of pathology stand at op- posite poles of science and practice, the former is yet more hopelessly divided against itself. There must be some reason for this state of affairs among a class of men, of whom I think I may say, that they are the peers of any for close and conscientious ob- servation. It is possible that this difference among those who practice mechanical reposition of displaced uteri comes from over-confidence in their methods, and the disap- pointment that is sure to result from this mental attitude. As a method of treatment a pessary can be no more blindly relied upon than a splint in a case of fractured limb. It requires to be used with intelligence, watchfulness, and with due regard to the conditions, changeable and obscure 268 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. as they often are, which demand its use. Do pessaries generally accomplish the purpose for which they are em- ployed? This question is always in order, and brings us into the strife waged between the hostile schools. I have here proposed the problem from its mechanical stand-point, and in this view of the subject it must be answered. What- ever may be your theory of uterine pathology, if in any case a pessary has been applied, have you fixed for yourself an ideal standard of mechanical effect, and has this stand- ard been reached? Dealing, as we are here, with mechani- cal agencies, and from which we ought to expect results that may be formulated with precision, it is singular how difficult it is to reach this ideal standard. My opinion is that this uncertainty results, in the first place, from expect- ing too much from the use of the pessary, and in the sec- ond place, from selecting an improper agent for want of more clearly defined ideas upon the absolute limitations imposed upon the action of pessaries, and which must gov- ern the mechanical results to be attained. That this con- fusion of ideas concerning these absolute limitations is one of the causes of failure is proved by the vast number of appliances invented, and the constant revival of obsolete forms of instruments to accomplish two simple mechanical results, —the straightening and lifting the uterine body either forward or backward. It is for the purpose of demonstrating this part of my subject that I have been careful to illustrate this mono- graph with nearly every form of pessary for the correction of versions and flexions of the uterus, to serve both as a guide and a warning to all who wish to invent a pessary. These illustrations are well worth study. They express to us graphically the history of a phase of thought. They show to us how the minds of many men seeking a single object halt at the same point, or revolve round a common centre. We can see in this apparent confusion of forms a common thought which links together the various groups, and a little study will show us that the members of these groups, into which I have divided them, are not different ELY VAN DE WARKER. 269 instruments, but simply different expressions of the same form. In studying the mechanical principles involved in the theory of the pessary two things must be clearly defined: First, the limits imposed by the uterus and its appendages upon the mechanical agencies acting upon it; and, sec- ondly, the action of the mechanical forces under these limi- tations. These limits, both in their mechanical and uterine relations, are fixed and absolute. They are not to be evaded by skill, or ingenuity, and ought to be clearly understood. One is, however, reluctantly forced to conclude that the majority of pessaries are invented either in ignorance or defiance of these limits, and as if the only restriction upon their action was that of gravity. And first, the limits imposed by the uterus and its ap- pendages. Given a flexed or versant uterus, the problem is to restore it mechanically to a position which approxi- mates the normal, or if that is not possible, then to a suffi- cient extent to relieve symptoms. Now the normal position has never been, and cannot be, defined, simply for the reason that it is one of movement, not of stability. To be more exact, we may say that the mean of this mobility is the nor- mal, but in reality we cannot apply this mean position to any one woman any more than we can apply the average expectation of life to any given healthy individual. The difference between what is called a version and a normal movement, which may be equivalent to it in angular dis- placement, lies in the fact that the abnormal position is one of stability independently of the forces which induce changes of uterine position, and to which the healthy organ is responsive in a normal manner. A version, then, is a position of immobility not from fixation but from habit. If we restore this position to one that approximates the nor- mal mean we restore its mobility, and if this restoration is effected by mechanical agencies it must be with reference to this natural endowment of the organ. The correction of a flexion or version of the uterus me- chanically, with certainty, comfort, and safety to the sub- 270 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. ject, depends in the first place upon a few fixed and absolute conditions which cannot be violated. I enumerate them :— (a.) The limits imposed by uterine mobility. (2.) The limits imposed upon the action of pessaries by the vagina. (c.) A pessary must be adjusted with proper regard for the safety of the pelvic soft parts. (d.) A pessary must be so adjusted as not in any way to retard or arrest the function of any pelvic organ, nerve, or vessel. These must be considered in order to clear the way for the study of the pessary as a mechanical appliance in its various groups and classes. (a.) The Limits imposed by Uterine Movements upon the Action of Pessaries.— Nothing can be clearer than the statement that every mechanical means of support applied to the uterus must act without restraint upon those move- ments essential to the normal functions of the organ. If we regard the manner in which the uterus is supported, we shall see that one of the results of this method of suspension is extreme normal mobility in every direction. It is necessary to call attention here to but one fact, namely, that these supports are not attached to any fixed centre of suspension, but are distributed over a large part of the surface of the uterus. The idea of Aran and of those who follow him, that the uterus has a fixed centre of rotation, —an “axe suspenseur,’ — must, in view of this fact, be wrong. The uterus has an eccentric or cam-like movement, which may be defined by the expression that as the fundus is elevated the organ sinks in the pelvis, and that it is displaced later- ally in a direction opposite to that of its anterior rotation. In Fig. 1 I have endeavored not to exaggerate this ec- centricity of movement. The straight lines 1, 2, 3, express the uterine axes of various abnormal positions, while the dotted line e e would express the arc described by the fun- dus during these movements if the uterus moved upon a fixed centre of rotation. But what I believe to be the fact, that each change of position has its own centre of suspen- ELY VAN DE WARKER. 27% sion, is shown by the lines which represent the arcs de- scribed by the vaginal portion instead of the fundus, which latter movement is defined by the shaded line 1°, 3°. Thus, the curve 6 expresses the movement in the 3° of retrover- sion, the curve a by the 2°, and the curve ¢ by the 1°, while the curve d shows the movement of the vaginal portion in the 2° of anteversion. Fic, tr. If the uterus moved upon a fixed centre of rotation it would be comparatively easy to so adjust mechanical sup- 272 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. port as to accommodate these movements; but, this not being the case, it is a matter of extreme difficulty. Of equal importance to the proper application of the pes- sary are the minor uterine movements. These are the vari- ous respiratory movements involved in the acts of respira- tion, articulation, coughing, and the like; postural move- ments, and those of walking and abdominal expulsion. Several years ago I gave this subject a careful study by means of the recording mercurial manometer, and which, owing to the medium! through which I sought the public, is but little known among those interested in gynecological study. It is almost impossible to give an idea of the char- acter of these movements without reproducing a few of the manometrical tracings published in my former monograph. Fic. 2. FIG. 4. Fig. 2 is a tracing of easy respiration movement; Fig. 3 is an articulation curve; Fig. 4 is the record of uterine 1 New York Medical Journal, April, 1875. ELY VAN DE WARKER. 273 movement in the act of coughing, and Fig. 5 that of walk- ing. Fig. 6 represents the movements of the mercury in the manometer during voluntary expulsive effort. Fic 5. Fic. 6. It is of the highest practical importance in this relation to realize that the mechanical force involved in these ute- rine movements varies from less than one to about seven pounds, as actually measured by a column of mercury. If we regard the results arrived at by Poppel! and Duncan,? that the minimum force exerted during labor is equivalent to four to eight pounds, as at all correct, the remarkable fact is forced upon us, that there exists in the average woman, non-pregnant, voluntary expulsive force equivalent to an easy labor, and which she may exert at any time. In view of this fact it is not singular that uterine displace- ments play so large a part in the sexual disabilities of women, and that their mechanical correction is a matter of difficulty. 1 Monatsschrift fiir Geburtskunde und Frauenkrankheiten, Ba. 22, S. 8. 2 Researches in Obstetrics. VOL. VII. 18 274 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. Much of the pain and tenderness that develops from wearing a pessary are the result of the mechanical restraint imposed upon this free mobility. Even when over-disten- tion or stretching of the vagina is an evident element in the intolerance of the pessary, it is difficult to eliminate the restrained movements of the uterus as a co-factor to this result. From what the tracings of the manometer have taught me, I should say that at least three quarters of an inch ought to be allowed for unrestrained uterine movement in adjusting the pessary. Anything less than this would be certain to interfere with the movements of the organ, es- pecially in movements of the uterus attending defecation and forced inspiration and coughing. The fact must not be lost sight of anywhere in this paper, that I am speaking only of the mechanical correction of versions and flexions. (5.) Limits imposed upon the Action of Pessaries by the Vagina. — These limits are absolute and cannot be evaded. ~ After we have elevated the uterus mechanically to the limits of the vagina, direct action of the instrument ceases, and if beyond this point any further effect is produced, it is by evoking the operation of other agencies. From the de- scription of many of the version pessaries, it is clear that the inventor and the practitioner who use them expect that by means of a curve, or the pressure of the upper extremity of the pessary, the depressed fundus of a versant uterus may be raised. by the direct action of the instrument. But this is impossible. When the upward pressure is arrested by the vagina, it is evident that movement in this direction ceases. What has been accomplished so far has been a lifting upward of the vaginal vault, and to a corresponding degree that of the uterus in its same relative displacement, while the anterior wall is placed upon greater tension than the posterior, being the shorter limb of the vaginal curve. This simple upward pressure would relieve a retroverted uterus just as effectually if the force was applied in front of the vaginal cervix as behind it. This being the condi- tion of affairs when the vaginal limits interpose further up- ELY VAN DE WARKER. 275 ward movement, the vaginal walls themselves become the agents of any further change induced in uterine position by prolonging the upward pressure. To illustrate, let us take the familiar example of the Hodge closed pessary — lever, as it is improperly called, — by which instrument the force is applied to the posterior cul-de-sac, and the uterus lifted until the slack of the posterior vaginal wall is taken up, when, the same force being continued, the vagi- nal neck is drawn backward, the fundus moving to the same extent forward, if the uterine body is of normal consistency, by the vagina drawing over the upper end of the pessary as though it were a pulley. With this action of the pos- terior we always find the anterior vaginal wall under more or less tension, which could not be‘the case otherwise. This law is taken advantage of in nearly all version pessa- ries in use, but, unfortunately, the action is confounded with a lever instead of a lifting force. In the normal relation of the parts the vaginal roof with the uterus may be raised one inch and a half to two inches, and this not at the ex- pense of the elasticity of the passage, but by the erasure of its folds) Any mechanical elevation of the uterus to this extent must result in absolute fixation, and in a short time become intolerable if not dangerous. In every application of a pessary the mechanical walls must be regarded as a part of the mechanism involved. I believe this rule to be true in every successful replacement of a version, and it is by bringing into play this pulley-like action of the vagina upon the lower uterine neck that we are enabled to extend the action of a pessary beyond the limits of the vaginal sac. Any attempt by mere force to get a direct action of a pessary upon a depressed uterine fundus is practically violence to the vaginal tissue, and pre- vents the participation of its walls in the mechanical action of the pessary. This explains the difference in the action of pessaries in retroversions and anteversions of the uterus. In the former we bring into action the posterior vaginal wall upon the uterine neck with great facility ; while in the latter, the anterior wall being shorter it draws the uterine 276 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. neck forward to a much less extent. This action is also antagonized by the posterior vaginal] wall, more or less, de- pending in a great measure upon the fact whether the anteversion pessary passes into the posterior cul-de-sac or not. In case the instrument places the posterior wall of the passage upon the stretch at the same time lifting force is directed against the anterior wall, the strain of the in- strument is in opposite directions, and the lift upon the anterior wall is reduced to nothing. Any instrument de- vised upon this plan can be compared to nothing else than a man trying to lift himself over a fence by pulling up upon the straps of his boots. The vaginal limits to the action of a pessary are more marked in anteversion than in retro- version, and the same law holds that the fundus cannot be lifted except the cervix be drawn forward to an equal de- gree. That under the most favorable circumstances this is more difficult than in retroversions is shown by the prone- ness of the anterior wall to ulcerate under the action of an anteversion pessary. These remarks are true only of versions, and do not in any way apply to the correction of flexions. We have ab- solutely no means of redressing flexion mechanically from the vagina alone. I say this after a careful study of the subject extending over many years, and after experimenting with every form of pessary that gave the least promise of success. We may operate with the same results upon the vaginal portion mechanically in both versions and flexions ; the cervix moves to the same extent under the operation of the same force in both forms of uterine error. While the fundus is rotated in proportion to the cervical move- ment in version, and thus the displacement more or less corrected, in flexions the organ makes a partial rotation corresponding in extent to the movement of the cervix, but is still flexed. It may be said in objection to this idea, that vaginal supports of various kinds do relieve the symptoms in cases of uterine flexions. This is true; but this relief is given not by correcting the flexion, but by lifting the ute- rus, and thus partially relieving the vessels and nerves of ELY VAN DE WARKER. 277 the organ. In proof of this I may mention an experience which I have often verified, that a simple globe pessary will afford this relief better than any of the complicated vaginal pessaries I have ever used, and in which case there can be no question that the flexion remains unchanged. These facts ought to teach us not to attempt to correct a flexion of the uterus by means of any force limited wholly by the vagina. (c.) A Pessary must be adjusted with a Proper Regard for the Safety of the Soft Parts. — Much of the ill repute attached to the pessary comes from the frequently published cases of injury to the vagina due to this instrument. There are two elements in this result of wearing a pessary. The most important one is injury due to an improperly fitted in- strument. This is not usually such a misfit as to be intol- erable to the patient at once, for in such a case the misfit is its own remedy, but is of such a character that at first no ill effects are noticed, and the patient only becomes gradu- ally aware that mischief is being done. Pressure needs but to be continuous to result in ulceration. A pessary that fills the vagina so closely that no play of the vagina upon the points of bearing is possible may very quickly result in erosion or ulceration. A pessary so large, or of such a kind, as to cause uterine fixation constantly exposes the woman to this danger. It may, on the other hand, be so small that erosion of the vaginal wall may result. The instrument gets out of position and is crowded across the vaginal passage, so that the tissues are confined between the extremities of the pessary on one side and the pelvic hard parts on the other. This question of fit is even more difficult to get a correct idea of than that of selecting a proper pessary to accomplish the object in view. Nothing but practice will enable one to acquire a skilled touch in this matter of a safe and proper fit. Secondly, a pessary may be of a proper kind, and perfect in its adjustment, and yet do harm by imprudence in its use. Of this nature, no doubt, are many of the cases of injury that we read about. It has not been unusual in my 278 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. experience to remove a pessary which the patient had placed by her physician a year or more before. In the ma- jority of cases such a long continuous wearing of a pessary is the result of the carelessness or willful stubbornness of the patient. I remember an instance in my own practice which illustrates this. I was called by my friend, Dr. M. B. Fairchild, to see a patient, who, in consequence of a flexion of the uterine neck, suffered severe dysmenorrhea. I in- troduced an intra-uterine stem, which gave complete relief to pain and the locomotor symptoms. I left Dr. Fairchild directions about the removal of the instrument, but was surprised by the doctor informing mea year after, that he could not remove the stem, as the patient would not per- mit it. She dreaded the return of her old symptoms. I. wrote her, as she lived at a distance, drawing as vivid a picture as possible of the consequences which might result from her stubbornness. She answered me that she was perfectly well, and she was sure that nothing had happened as I described, because she felt so well in the pelvic organs. It was six months after that I succeeded in getting the stem. Happily no bad consequences resulted from this continued wearing of the stem for a year and a half, and which I am sure was the result of the principle upon which I make and use my form of this instrument. A patient needs to be informed about the care of her person while wearing a pessary, and to regard herself as constantly under treatment. It is often necessary to give her very plain and positive instructions upon the matter of occasional examinations, and removing and cleaning the pessary. Pessaries are sometimes made of material that requires constant care. Pure gum or soft rubber instru- ments are very liable to become offensive and cause an irritating discharge, and which, in some patients, unless careful attention is given to hygiene, will result in vaginal erosion. (2.) A Pessary must be so adjusted as not in any way to vetard or arrest the Function of any Pelvic Organ, Nerve, or Vessel, —It would hardly seem ‘necessary to give this sub- Scam . re ELY VAN DE WARKER. 279 ject any place, for the reason that the proposition is so self- evident that no argument can make it clearer; yet, in the majority of cases, defeat in the use of the pessary comes from this source. An instrument may be theoretically cor- rect as to form, or its form may be entirely wrong, and in both instances be equivalent to the same error through vio- lation of this law. We may know that this condition is being violated by the symptoms resulting from the pres- ence of the pessary; or, at least, we may assign this as a cause when there is a peculiar wearing sacralgia, fixed, or radiating down the limbs, supra-pubic pain and tenderness, urine incontinence, or dysuria, pain in defecation or in pos- tural changes, and increased general nervous irritability. All these evidences of pelvic disturbance, except that of the bladder, may result from the violation of one function of the pelvic organs, namely, uterine mobility. As this will be referred to repeatedly later, it need not be taken up here. The next important organ liable to be disturbed by the pessary is the bladder. Some forms of the instrument which are very useful, like the elastic ring and the original form of the Hodge, are disposed to excite functional disturbance of this organ by the lower end tilting against the base of the bladder or upper urethra. It is remarkable how slight a pressure will do this if it is continuous. Force directed against the base of the organ will cause strangury, and upon the upper urethra will produce incontinence, so that it is not difficult to judge from the symptoms the point that is exposed to pressure. It is frequently one of the difficult points in the fit of a pessary to so shape its lower extremity as to avoid bladder disturbance. The rectum is rarely disturbed by the pressure of a pes- sary through its anterior wall, except in cases of fecal accu- mulation when the rectal contents are apt to lodge above the bow of the instrument, and when strong effort is made at defecation the pessary is sure to be seriously displaced. This is one of the chief causes of expulsion of intra-ute- rine stems that depend upon small vaginal supports for their retention. JI have seen hemorrhoids which were in a great 280 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. measure ascribable to the backward pressure of a pessary on the vaginal wall. The simple ring is quite liable to do this, especially when too small, as the upper or posterior part is forced down, and the anterior upward, behind the pubes, thus placing the instrument at right angles nearly to the posterior wall, the hemorrhoidal veins bearing the greater part of the pressure. The same is liable to occur in case of very short vaginas, in spite of the greatest care. Sacralgia is rather a symptom of erosion, or ulceration at the posterior cul-de-sac, than of undue force. Pressure, from the presence of a pessary, so great as to excite neu- ralgia of the sacral nerves, could not be borne at all, and thus would suggest its proper remedy. The sacral pain is evidently reflex, of a nature similar to that due to erosion of the cervix. Any form of instrument may excite ulcer- ation of the vaginal walls if allowed to remain too long, as I have already said. I have known dysmenorrhea excited by obstruction to the menstrual flow. Intra-uterine stems are prone to do this when too large, or when the vaginal portion of the stem fits too closely about the os externum. Stems, as made by the instrument makers, are nearly one half too large, as arule. A sharp or long anterior curve to the Hodge form of instrument may cause the same ob- struction by pressing the walls of the vaginal cervix to- gether. A very slight obstruction to the escape of the menstrual flow will excite expulsive pain. This fact must be always remembered, and precautions taken at the first signal of disturbance. Pain excited in the pelvis during postural changes is strong evidence of an ill-adjusted or improper pessary. This must never be overlooked or made light of, and the patients told, as they often are, that they will get used to it after a time. Even if no physical harm results, moral in- jury will be sure to follow as the patient is made uneasy and anxious. It is a wise precaution to have the patient put herself in a variety of postural changes, such as sit- ting, walking, standing, and bending forward, after a pes- sary is first introduced, in order to test this point, and any complaint attended to at once. = ELY VAN DE WARKER. 281 Many pelvic conditions, such as peri- or parametritis, tumors, hematocele, and ovarian tumors and displacements, may act as absolute limitations to the action of a pessary, but they are of such a nature as to require no special men- tion here. The variety of pessaries is so great that an attempt to describe them without a proper classification would be vain. One might as well make a scientific description of a family of animals without grouping it into genera and species, as to make a mechanical analysis of pessaries without dividing them into groups and classes. When I had gathered together my immense material of pessaries, I found that I had entered a new field of research, and that whatever I intended to say and do within the lim- its of this field may have been said and done before me; still it was all confusion because no one had studied it asa whole, and arranged and grouped its facts. This was al- together a different matter from looking at the pessary singly, or in its purely practical relations. Further, un- less one confined a paper of this sort to the limits of a mere catalogue, it would require a volume to separately analyze the mechanical principles of each instrument. It was a matter of considerable study to adopt a system of classification. An arrangement based purely upon the few mechanical elements involved would not only be diffi- cult, but, as this was in. a certain sense a pioneer paper, it was liable to excite considerable controversy, as such a classification would frequently lead me to view an instru- ment in a totally different manner from the inventor. Fi- nally, I adopted the plan of defining three principal groups by the aid of the very manifest mechanical elements in- volved, and about which there could be no difference of opinion, and of describing the several classes under these groups by the mechanical results, or uterine changes in- duced by the presence of the instrument, instead of still further refining upon the minor mechanical principles shown by the various classes in each group. 282 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. CLASSIFICATION OF VERSION AND FLEXION PESSARIES. Group I.— Those pessaries combined with support ex- ternal to the body. Class 1. The simple intra-vaginal pessary with external support. é Class 2, Those that combine a pessary acting by me- chanical displacement with support external to the body. Class 3. Those that combine absolute uterine fixation of the cervix with external support. Group II. — Pessaries acting wholly intra-vaginally. Class 1. Those pessaries acting by displacement. Class 2. Those pessaries that move the vaginal cervix by action of the vaginal walls in a direction opposite to the movement of version of the fundus. Class 3. Those which retain the vaginal cervix in a fixed position, and thus prevent rotation of the uterus. Group III.—Pessaries acting within the body of the uterus — intra-uterine stems. Class 1. Intra-uterine stems with support external to the body. Class 2. Intra-uterine stems combined with various forms of vaginal pessary. Class 3. Self-retaining intra-uterine stems. Class 4. Diverticulating intra-uterine stems. Class 5. Intra-uterine stems with simple vaginal attach- ment necessary for retention. GROUP I.— Support ExTERNAL TO Bopy. Cuiass 1.— Simple Intra-vaginal Pessary with External Support. Name. Ee Plate. | Figure. Reference. Priestley. Retroversion. | XII. I Cat. Obstet. Instruments, Obstet. Soc. Lond., p. 180, Fig. 178, 1867. Priestley, modified by | Retroversion. | XII. 2 Thomas, Prac. Treat. Dis. Women, Cutter. p- 379, Fig. 142, ed. 1872. The same. Retroversion. | Text. 7 The same. Cutter. Retroversion. | XII. 3 Uterine Ver. and Flex., 1876, p. 20, Fig. 4. . | : ELY VAN DE WARKER. 283 Cuiass 2.— Displacing Pessary with External Support. Form of Dis- placement. Plate. Name. Figure. Reference. Priestley, modified by | R etroversion. {an Thomas op. cit., p. 379, Fig. 14. Thomas. Text. Cuiass 3. — fixation of Cervix with External Support. Form of Dis- : Name. placement. Plate. | Figure. Reference. Wade. , A.andR. flex. | XII. = Amer. Jour. Obstet., 1878, p. 710. and version. ; Cutter-Thomas. Anteversion. | Text. 9 Towa op. cit., ed. 1880, p. 423, 1g. 166. Weber. Retroversion. | Text. 9a Tiemann’s Cat., Part III., Fig. 4282. GROUP II. —INcLUDES ALL THE INSTRUMENTS THAT ACT WITHIN AND ARE LIMITED BY THE VAGINA. Cuass 1.— fessaries acting by Displacement. Form of Dis- | piate, Figure. Reference. Name. placement. Page. Retroversion. | Text. II N. Y. Med. Record, May 9, 1876. Pallen. Anteflexion. Text. 12 Reynder’s Catalogue. Cole. Anteflexion. Text. 14 Med. and Surg. Rep., June 4, 1881. Cole. Retroversion. | Text. 15 Loc. cit. Hitchcocks. Anteversion. | Text. 13 Trans. Am. Med. Assoc., xv., 104, 105. Smith, Heywood. Retroversion. | Text. 16 Prac. Gynecol., p. 108, 1878. Thomas. Anteversion. Text. 17 Thomas, op. cit., p. 422, Fig. 163, 1880. Gehrung. Anteversion. | Text. 18 St. Louis Med. and Surg. Jour., July, 1877. Vulliet. Anteversion. XIV. 5 Trans. Obstet. Soc. Lond., xvii., 64. Thomas. Anteversion. | Text. { Bs Tiemann’s Cat., Part III., p. 89. Hewitt, modified by | Anteversion. Text. 21 Op. cit., Part III., p. 89. Thomas. Hewitt. Anteversion. XIV. I Hewitt, Dis. of Women, p. 523, Fig. 77: F é ; Hewitt, modified by | Anteversion. | XIV. { a Beigel, Die Krankheiten d._weib- Beical 3 lichen Geschlechtes, Bd. i., S. 180, iB es: : Fig. 1, A. and B. Hewitt, modified by | Anteversion. XIII. II Archiv f. Gyniakol., Bd. iv., S. 387, Schultze. Figs. 1 and 2. 22 Thomas. Anteversion. Text. {33 Thomas, op. cit., p. 422, 1880. 24 Thomas. Anteversion. Text. 25 Thomas, op. cit., p. 421. Galabin. Anteversion. XIII. 7 Obstet. Trans., Lond., xviii., p. 177, 1876. Gehrung. Retroflexion. | Text. 28 St. Louis Med. and Surg. Jour., ; July, 1877. Gehrung. Anteflexion. Text. 27 Loc. cit. Pallen. Retroversion. | Text. 26 Am. Jour. Obstet., July, 1877. Studley. Anteversion. XIII. 9 Am. Jour. Obstet., Jan., 1879. Thomas. Anteversion. XIV. 8 Thomas, op. cit., p. 363, Fig. 126, 1872. Clay. Retroversion. | XIV. 9 Copied from Beigel, op. cit., Bd. i., S. 275, Fig. 92. eee es EE 284 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. Ciass 2.— Lessaries that act upon the Uterus by exciting Action of the Vaginal Walls. Name. Hodge. Hodge, modified by Hewitt. Hodge-Smith. Hodge-Thomas. The same. Chamberlain. Carroll. Woodward. Scattergood. Schultze. Thomas. Form of Dis- placement. Retroversion. Retroversion. Retroversion. Retroflexion. Retroflexion. Retroflex. and version. Retroflexion. Retroflexion. Retroversion. Retroversion. Retroversion. Plate. | Figure. i I XIII. 2 3 XIII. 4 XIII. { 5 Text. 30 Text. 31 32 Text. { 33 Text. 34 Text. 35 XIII XIII. 10 XIV. 4 Reference. Hodge, Dis. of Women, 415, Fig. @yi0s Ge Hewitt, op. cit., p. 521, Fig. 74. Thomas, op. cit., p. 446, Fig. 184, 1880. Thomas, op. cit., p. 446, Fig. 185. Same reference. \ N. Y. Med. Record, viii., 396, 1873. N.Y. Med. Record, March 30, 1878. N. Y. Med. Jour., October, 1876. Thomas, op. cit., 380, Fig. 144, 1872. Archiv f. Gynikol., iv., 387, Figs: 1 and 2. Thomas, op. cit., p. 378, Fig. 140, 1872. Cuass 3.— Pessaries that fix the Vaginal Cervix and prevent Rota-— tion of the Uterus. Name. Hoffman. Hurd. Woodward. Fowler. Fitch. Thomas. Schroeder. Studley. Form of Dis- placement. Retroversion, { Retroflexion. Anteflexion. Anteflexion. Anteversion or flexion. Anteversion or flexion. Anteversion. Retroflexion. Retroversion. Plate. | Figure. Text. 36 XII. Text. 37 Text. 38 Text. 39 Text. 40 XII. XIV. 6 Reference. Thomas, op. cit., p. 375, Fig. 136, 1872. Thomas, op. cit., p. 395, Figs. 150, 151. N. Y. Med. Jour., October, 1876. Ut. Displacements Considered, Pam- phlet, Youngstown, Ohio, 1881. Til. State Med. Soc. Trans., 1875, p- 207. Thomas, op. cit., p. 421, Fig. 158, 1880. Dis. Female Sex. Organs, p. 175, Fig. 60. Am. Jour. Obstet., January, 1879. GROUP III.—INTRA-UTERINE STEMS. Cuiass 1.— Stems having Support External to the Body. Name. Simpson The same. Kiwisch. Valleix. Kilian. Cutter. Beigel. Form of Dis- placement. Version and flexion. As above. Version and flexion. Version and flexion. Version and flexion. Flexion. Flexion. Plate. | Figure. Text. 41 2 Fi; ie Ls I I II. ie III. I {ie 40 LO 2 Ill. 2 Reference. Simpson, Obstet. and Gynecol., p. 703, Fig. 27. Winckel, Die Behandlung d. Flex. d. Uterus, S. 19, Taf. I. Winckel, op. cit., S. 20, Taf. I., Fig. Vv. Winckel, op. cit., S. 20, Taf. II. Fig. VIII. Cutter, Ut. Versions and Flex., p. 89 (modified). Beigel, Krankh. d. weiblich. Gesch., ii. Bd., S. 243, Fig. 71. ELY VAN DE WARKER. 285 Crass 2.— Jntra-uterine Stems attached to various Forms of Vaginal . Lessary. Name. Pee Plate. | Figure. Reference. Detschy’s Hystero- | Version and IV. I Schmidt’s Jahrbiicher, Bd. 83, p. 321 mochlion. flexion. (1854). The same; another | Version and VI. 6 Thomas, op. cit. (Wieland and Du- form. flexion. brisay), p. 393, Fig. 149, 1872. Schultze. Flexion. VI. 5 Segre f. Gynak., Bd. iv., 414, Fig. 14 Schultze. Flexion. VI. 7 Sehultee, loc. cit., Fig. 15. A Amann, Zur. mechanischen Behand- Amann. Flexion. VI. 2 { B lung d. Versionen u. Flexioneu d. Uterus, p. 45, Fig. 7 Simpson, modified by | Flexion. VII. I Beigel, op. cit., Bd. ii., ‘p. 244, Fig. 73. Martin. Hewitt. Flexion. VII. 2 Beigel, op cit., Bd. ii., p. 245, Fig. 74. Winckel. Flexion. VII. 3 Winckel, Die’ Behandlung d. Flex- ionen d. Uterus, p. 23, Fig. 18. Winckel, _modifica- | Flexion. VIII. I Winckel, op. cit., p. 23, Fig. 15. tion of ema : , A Chadwick Flexion. VII. 3 Trans. Am. Gynecol. Soc., vol. ii., Dp. 444. Cutter. Flexion. VIII. 4 Cutter, op. cit., p. 128, Fig. 26. Schultze. Flexion. VIII. 5 Schultze, Archiv £. Gynak., Bd. iv., : p: 413, Fig. 13. Winckel. Flexion. VIII. 2 Winckel, op. cit., p. 23, Fig. 16. Studley. Flexion. VIII. : Am. Jour. Obstet., January, 1879. ao Flexion. TX 3 Hodge, Dis. of Women, pp. 411, 415. Barnes. Flexion. IX. 3 Barnes, Dis. of Women, p. 614. Williams. Flexion. IX. 4 ee hd Soc. Lond., vol. xiv., Kinloch, modification : 42 rane & (op ne Assoc., 1875, p of Hodge-Simpson. Retroflexion. | Text. { 43 261, Figs. 2 ig ; Thomas. Anteflexion. Text. 44 eae s Gc, , Part III. +) DP. 89, Fig. Thomas. Anteflexion. Text. 45 Fitheeaa Prac. Treat. Dis. of Women, p- 428, Fig. 169, 1880. Thomas. Anteflexion. Text. 46 Thomas, op. cit., p. 428, Fig. 169, 1880. Mossman. Retroflexion. | Text. 51 Letter from Dr. B. E. Mossman, Greenville, Pa. ; Thomas. Lateroflexion.| Text. 52 Thomas, op. cit., p. 452, Fig. 197, 1880. 47 ar Van de Warker. Anteflexion. Text. e sie ca Med. Jour., vol. xxiii., p. 561, 50 Ciass 3.— Self-retaining Form of Intra-uterine Stem. Name. pais pt Die Plate. | Figure. Reference. Unknown. Anteflexion. Text. 53 Tiemann’s Cat., Part III., Fig. 425. Squarey. Any flexion. IX. { 2 Lond. Lancet, 1874, p. 49- Van de Warker. Anteflexion. Text. 54 N. Y. Med. Jour., October, 1873. 286 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. Cuiass 4.— Spring Intra-uterine Stems. Form of Dis- Name. placement. Plate. | Figure. Reference. ss Ante or retro- ‘ x Verhand. d. Gesellschaft f. Geburts. einsch. flexion. see 2 4th yr. Taf., Figs. I., I1., IIT. Kiwisch-Mayer. Ante or retro- XI \é Winckel, op. cit., Fig. VII. : ; flexion. 5 Wright. Antéeseeion: x. te eee Ut. Disorders, p. 86, Lond. i see coon Anteflexion. X. 4 Belgas op. cit., Bd. ii., p. 248, Fig. 78. eigel. Chambers. Ante or retro- | X. 5 Obstet. Jour. Gr. Br. and Ire., vol. i., 4 flexion. p- 22. Aveling. Ante or retro-| X. 6 Trans. pO bstet: Soc. Lond., vol. vii. 3 flexion. p- 15 Simpson. Anteflexion. X. I Dende Tee 1866, p- 531- Ciass 5.—JLntra-uterine Stems with Simple Vaginal Attachment LVecessary for Retention. Form of Dis- Name. placement. Plate. | Figure. Reference. Simpson. a ete en Vv. { ee Winckel, op. cit., Figs. II., III. Simpson. The same. V. 3 Beigel, op. cit., 240, Fig. 68. Simpson. The same. V. 4 ay, Dis. of Women, P- 779, Ig. 141. Simpson. The same. V. 5 Simpson, op. cit., p. 778, Fig. 140. Lazaruvyitch. Retroflexion. | V. { eae Obstet. Soc. Lond., vol. xi., Schroeder, after + | Anteflexion. V. 8 Schroeder, Dis. of Women, Ziem- Simpson. ssen’s Cyc., Eng. ed., p. 174, Fig. 59- Peaslee, after Simp- | Retroflexion. V. 9 Trans. Med. Soc. S. N. Y., 1866, p. son. 100. Tait, after Simpson. | Anteflexion. VI. I Cheer Jour. Gr. Br. and Ire., vol. i., p- 180. Conant. Retroflexion. | VI. 3 Tiemann, Cat., Part III., Fig. 422. Edwards. Retroflexion. VI. 4 Tiemann, Cat., Part III., Fig. 427. Braun, C. presen 4 VII { i Winckel, op. cit., Figs. XIII., XIV. Martin, E. Anteflexion. VII. 6 Winckel, op. cit., Fig. XV., et Mar- tin, Neig. u. Beug. des Ut., p. 78. Sims. Ante- orretro-| Text. 57 Also published. flexion. k ern aciae! Retroflexion. | port. { ron Med. and Surg. Jour., April, Donaldson. Ante-orretro-| Text. 58 Donaldson, Contributions to Prac. flexion. Gynecology, p. 61. This classification may appear complicated ; but take all of Group III. as an example, and we perceive that each of the classes is designed to act upon different principles, either in the correction of uterine distortion or of reten- tion. With these differences I do not see how the classi- fication of this group could be simplified. The same may ELY VAN DE WARKER. 287 be said of Group II., which is exceedingly difficult to clas- sify and describe. Group I., comprising all those pessaries that act upon the uterus by support external to the body, represents one of the oldest forms of version and flexion pessaries. Much of the disrepute historically attached to the intra-uterine stem came from its fatal connection with this means of re- tention. The theory upon which this group of instruments was based was becoming obsolete, when it was revived by securing a place in Dr. Thomas's text-book. The simplest form of this group is Class 1, being a sim- ple firm loop passing into the posterior or anterior vaginal cul-de-sac, and retained in place by elastic support connected with an abdominal belt. Its modern form, known as Cutter’s pessary, is a survival of an old form (Pl. XII, Fig. 1), which gained no repu- tation. It was invented by Priestley. This theory is connected with another principle of mechanical change in uterine position, that of displacement. This consti- tutes Class 2 (Fig. 8). I apply the term dis- placement to the introduction of any mass within the grasp of the vagina, sufficiently large to elevate the vaginal vault and displace the uterus from any position it may oc- cupy in the direction of the least resistance. This im- plies freely movable walls. In combination with the Priestley form of instrument, the principle of its action is violated, for, the posterior vaginal wall against which the bulbous enlargement A, Fig. 8 (Pl. XII., Fig. 4) impinges, is fixed by the strong 288 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. upward pressure of the external support, while the mass A displaces the cervix forward in the ratio of its bulk, and the posterior vaginal wall antagonizes this forward movement by backward traction in proportion to the upward pressure of the external support. This enlargement of the upper part of the instrument was added, probably, for the purpose of increasing the bearing surface of the loop, seen to better advantage in Fig. 7, and thus obviating one of the dangers of this form of instrument, ulceration of the vaginal wall. It will be seen, however, that, from the counter strain upon the posterior vaginal cul-de-sac, it is exposed to more dan- ger from this form than from Class 1 of this group. . In Class 3 we have presented a still more dangerous instrument (Pl. XII, Fig. 5), in which the upper part is formed into a coil which encircles the cervix, and thus causes absolute fixation. In this form by Wade we have united every bad principle that can be combined in a pes- sary. In another pessary (Cutter, Pl. XII., Fig. 3) we have nearly the same form with less incarceration of the ute- rine neck. In this class, in which absolute fixation is the distinguishing trait, we must also include Thomas’s mod- ification of Cutter’s pessary. In this instrument there is an anterior loop prolonged backward until it meets the descending limbs, which connect it with the external sup- port (Fig. 9).1 It is designed to correct intractable forms = of anterior displacement, but in view of the limits to upward displacement due to the anterior vaginal wall, it is difficult to under- stand how it could materially change the relative position of the uterus with safety to the part. There is necessary only a brief comment upon this group of pessaries. Nothing but an extraordinary combination of pelvic con- ditions would warrant the use of a version or flexion pessary that violates every rule for the proper adjustment of the instrument. Certainly, if the “physician possess po& Fig. 9. 1 Thomas, Pract. Treat. on Dis. of Women, p. 423, 1880. ELY VAN DE WARKER. 289 only little skill in the use of pessaries,’ he had better em- ploy an internal pessary, but not one connecting externally with a band. This form violates the law of uterine mobil- ity ; it interferes with the function of near parts, and by over-tension tends constantly to weaken the vaginal column. The principle involved in the mechanism of this group be- longs to the correction of total prolapsus uteri, and even here it is not easy to get the subject to wear the instru- ment. A form of pessary that must be classed among those having support external to the vagina is Weber’s (Fig. 10). Here the T-shaped part passes in the posterior cul-de-sac, and is designed to correct a retroversion, and is kept in place by the stem passing backward over the perineum and attached to what resembles a pile instrument inserted in therectum, The ideaisanold one. Bond! invented a pessary of the same character. | Weber’s instrument is shown here asa me- chanical curiosity, and as an evidence of what absurd things have been, and probably will be again, invented and called pessaries. Group ITI. includes all the instruments that act within, and are limited by, the vagina, and are the most useful and scientific of all me the mechanical means for overcoming a ee version. Notwithstanding the great variety of outline pre- sented by the members of this group, the mechanical ele- ments involved are few, and we may thus reduce them to comparatively few classes. It is difficult to demonstrate these mechanical elements, and equally so to prove the re- sult of these elements upon uterine position. It is evident that the inventors have in many instances taken a wholly different view, both of the principles of construction and of the effects gained, from myself. And this seems the proper place to ask the indulgence of all my friends who have in- vented pessaries, and which I may classify and comment upon in a manner that does not meet with their approval. 1 Am. Four. Med. Sciences. April, 1849. VOL, VII. 19 290 MECHANICAL THERAPEUTICS OF VERSIONS, ETC Class 1.— Those pessaries acting by displacement, re- duced to the simplest proposition is that of one bulk dis- placing another. This implies a more or less fixed point, that of counter-pressure, and the movement of contiguous parts in the direction of the least resistance. We may be able to get my idea of the theory of mechanical displacement from the diagram (Fig. 11). The cube &, £, £, is forced up in the elastic tube A, B, #, G. The line C D repre- sents the direction of the least resistance, and the line A B the direction of counter-resistance. It follows, there- DB Fic. 11. fore, that as the line A B cannot yield, and as the cube is forced onward, the yielding will be in the direction of C, the least resistance; the line 7 H is deflected in a manner represented by the dotted lines corresponding in direction to the upper angle of the cube. The extent of deflection in the line 7 H would be limited by the amount of com- pensation in the line /G, and would be at its limit an absolutely fixed quantity. The lines A, B, /, G, may express the vaginal walls, and ELY VAN DE WARKER. 29I for the cube we may substitute any possible form of pes- sary that, by mere bulk, will displace the line Z, H, which expresses the vaginal vault. Theoretically I have repre- sented the displacing force as a cube; in practice it would make no difference what shape the displacing body may have, provided it is of such a shape as to displace or sepa- rate widely the vaginal walls. So far as results are con- cerned, the instrument may as well have been made solid. One of the most perfect of this type is Page’s “dumb-bell,” (Fig. 12). There is no attempt to disguise its action, and it represents all the others of this class here figured. (Fig. > SS Fig. 14. Fic. 15. 13), Pallen’s anteflexion, and (Fig. 14), Hitchcock’s ante- version, act upon the same principle. Fic. 17. 292 MECHANICAL THERAPEUTICS OF VERSIONS, ETC.' A more modern type under this class and group has the displacing force acting from its bulk combined with an elastic or spring force. Of this nature are Cole’s ante- version (Fig. 15) and retroversion (Fig. 16), Heywood Smith’s retroversion (Fig. 17),,and Thomas’s anteversion (Fig. 18). Under the most favorable circumstances it is diffi- cult to estimate accurately the value of a spring force; but when a force of this nature is concealed in the vagina we have triple difficulties to contend with ; we are in doubt as to the tension of the spring, also as to the degree of force opposed to it, and lastly, that this opposing force is con- stantly, and to an unknown extent, changing in intensity. An elastic force is one that living tissues cannot contend with. They must yield before it. Witness the effect of the elastic ligature in surgery. On these grounds one would say that such an instrument as Fig. 15 represents could not be worn with comfort or safety, especially as the anterior wall is exposed, which is prone to ulcerate un- der the best conditions. Fig. 17, Heywood Smith’s, being a retro- version instrument, combines a de- |} fective theory with a defective principle ; the lower bow, having somewhat the Hodge form, carries the posterior vaginal wall back- ward, but the tendency of the vag- inal cervix, to follow it, and thus elevate the fundus, is defeated by the upper bow which crowds it forward and expends the force of the instrument upon the posterior cul-de-sac. Fic. 19 ELY VAN DE WARKER. 293 The antetype of this form of forward displacement pes- sary is Priestley’s, shown in Fig. 19. It is simply an ex- aggeration of the modern form, and is figured here for its historical interest. The displacement of the anterior vagi- nal wall is so great that probably it could not be borne but for a few hours. This displacement theory is generally applied to forward displacements, and. is assigned any form of action to suit the idea of the inventor. In theory these instruments are suf- ficiently correct ; but in practice it is surprising to what a limited extent the uterus may be lifted by a displacing force acting upon the anterior vaginal wall. If we conceive the upper angle (C) of the cube in Fig. 11, so turned that it will displace the line / G, the extremity of the line G@ be- ing fixed, we shall understand how slight will be the deflec- tion that will result. Displacement will result in little more than tension. Fic. 20. Fic. 21. Fic. 22 Fic. 23. 2904. MECHANICAL THERAPEUTICS OF VERSIONS, ETC. For introduction or withdrawal. Fic. 25. y yy ie ————_ ri Lop a a Pessary in situ. == Fic. 26. Fic. 28. Fig. 20 is Gehrung’s anteversion ; its antetype may be seen in Pl. XIV., Fig. 5, in Vulliet’s form, which has also been used in prolapsus, and in which it proved useful for its powerful displacing qualities. Figs. 21 and 22, Thom- as’s anteversion, must, when open as in Fig. 22, place the anterior vaginal wall under such tension as to defeat the purpose for which it was applied. Fig. 23 is Thomas’s mod- ification of Hewitt’s pessary, and is the most scientific ap- plication of this mechanical principle. We see its original form in diagram in Pl. XIV., Fig. 1, and in the same plate, Figs. 2, 3, Beigel’s modification is shown. By comparison with Thomas we see that the latter has diminished lateral displacement by contracting the ascending and descending ELY VAN DE WARKER. 295 limbs, which is an improvement. Pie 1 Pk SC. ista still further modification, that of Schultze, with displa- cing power greatly lessened by lowering the apex. In Figs. 24, 25, 20, Thomas’s anteversion is represented in different positions, Fig. 26 shows the instrument in position, and gives the reader a realistic idea of its displacing qualities. pecan et) Another of Thomas’s ne “s, anteversion pessaries is A ite *, shown in Fig. 27. It is a : essentially the same as s , Fig. 24 in action, and is .-’ probably the parent idea. It is defective by fixing the vaginal cervix in its upper portion, when the cervix ought to be allowed to move downward and forward as the fundus uteri ) is gaised,\. Ine Pi, Joliis) (Biss 7: teeny = Galabin’s anteversion pessary is AS shown. Radically it is con- ag structed upon the theory of Hew- ee Soe it's. It is a curious fact’ that, a “ie a s by curving down the extremity 4, Kg Gehrung has converted it intoa =, retroflexion pessary. Galabin an- ¢ tedates Gehrung about a year. |} Gehrung’s retroflexion instrument, ' Fig. 30, and his anteflexion, Fig. ! 29, are excellent types of this | class. For anteversion, Fig. 29 is fully equal to that of Hewitt, or Thomas’s, Fig. 27; but for anteflexion, unless in a very re- laxed organ, it could , avail nothing. Pal- len’s_ retroversion, Fig. 28, combines the . - Semee? Fic. 30, 2096 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. Hodge form with displacement. Notwithstanding the dif- erence in form, and the absence of the spring attachment, the effect is that of Heywood Smith’s, Fig. 17. Pl. XIII., Fig. 9, shows Studley’s anteversion, which is constructed upon the excellent plan of an adjustable dis- placement force in the upright tongue, the only instrument of the kind yet constructed. y Class 2. — This is the most inter- \ esting class of this group, and with the widest range of usefulness. The vaginal wall is, by this class of instruments, made to play its part in the reposition of a retro- verted or anteverted B uterus. The law of: uterine mobility is taken advantage of to replace and retain the organ in a position that ap- proximates the norm. Hodge disclosed to gynecologists this wide field of uterine mechan- ical therapeutics. Yet Hodge did not seem to have a clear idea of the principle upon which his pessary acted. If its mechanism was that of a, leverage it could act upon the vaginal cervix alone, and, by displacing it, the cervix alone responded to the movement, the position of the fundus remaining unchanged, thus relatively increas- ing the retroversion, or the organ rotated upon its long axis, depressing the fundus, and actually increasing the retroversion. It seems almost self-evident that, upon this theory, the Hodge instrument could not replace a retro- verted uterus. ry: = ELY VAN DE WARKER. 297 The diagram, Fig. 31, is an attempt to demonstrate the theory of action of this class of pessaries. Conceive of an elastic tube defined by the lines Bb, Z, Z, and that a force within it is acting in the direction of A C,; if this force is prolonged in the direction of Cit will deflect the line 2, as represented by the dotted line at C, and thus draw toward it any point upon the line & between this point and C. Obeying this movement, the line D Z will assume the position of #, turning upon its axis of rotation at Com- pensation for the movement of Z toward C is gained by the movement of the line /in the direction of G. This seems to my mind the only way in which pessaries of this class can operate beyond the limits of the vagina. It is equally evident to me that these instruments are useful only in ver- sions. In case of flexions, the axis of the uterus, expressed by the line D Z, will respond to the movement of the vagi- nal cervix, but remain in its distorted condition. The mere rotation of the organ will not straighten it. First in point of interest are Hodge’s instruments in their original form. Pl. XIII., Figs. 1, 2, 3. The instru- ment represented by Fig. 1 is. now but little used. It is more particularly indicated in urethral and das fond irrita- tion of the bladder. Of all instruments of the class, the Albert Smith modification of Hodge is the most univer- sally in use. The form of this modification of Hodge va- ries very greatly according to the ideas of the author who refers to it, or the instrument makers. Figs. 5 and 6, Pl. XIIL, and Figs. 32 and 33, showing Thomas’s modification of the Smith-Hodge, give a good idea of these changes 2908 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. of form. Eight other alterations in curve and lateral out- line are named and sold, but they do not deserve place here. Chamberlain’s pessary, Figs. 34, 35, is the most radical change which the Hodge form of in- strument has undergone. It can be worn with considerable comfort, but shows a marked tendency to drop down from its place, owing to the slight grasp of the vagina upon its lower limb. Carroll’s instrument, Fig. 36, is a spring pessary, and its central constriction, being firmly grasped by the vagina, gives it great Fic. 34. Fic. 35. supporting power. It cannot, in my view of its action, cor- rect a flexion. Woodward’s pessary, Fig. 37, must be classed among the modifications of Hodge- Smith. It is simply furnished with a ‘“cross-bar”’ to give additional support to the uterus. Scattergood’s Fic. 36. Fic. 37. pessary, Pl. XIII, Fig. 8, has a spring concealed in its lower limbs’ Aside from the error of its construction, it easily gets out of order, and becomes foul, ELY VAN DE WARKER. 299 One word as to the general principle of construction of pessaries of this class. A pessary upon the Hodge plan retains its position in proportion to its amount of reversed curve. The Hewitt form (Pl. XIII., Fig. 4), while it cor- rects the uterine position perfectly, is constantly getting out of place, owing to the slight amount of curve. The same may be said of the Schultze instrument (Pl. XIII, Fig. 10); although the inventor endeavored to secure vagi- nal grasp by twisting the pessary twice upon itself in its long diameter, yet the general contour is straight, and the pessary easily drops out of place from supra-pelvic pres- sure. If, however, the curve is too great, it interferes with the traction exerted by the vaginal vault upon the cervix, and puts such a strain upon the walls of the passage that it cannot be borne. The third class of this group is quite a modern and use- ful one. The distinguishing trait is the mechanical fixation of the vaginal cervix, so as to limit its lateral and antero- posterior rotations. This class has considerable reputation among those who have a prejudice against the intra-uterine stem of replacing a flexed uterus, and certainly, from their ability to firmly fix the cervix, they come nearer to this re- sult than any other class of vaginal pessary. Many of these instruments combine other mechanical principles, but it is doubtful if these complications add any efficacy to the pessary. Of Hoffman’s pessary (Fig. 38) would accomplish consid- erable uterine rectification if it could be retained in proper adjustment. When small it is crowded too far back in the posterior cul-de-sac, and when of full size is not worn with comfort. The uterine neck, even when the central opening is of sufficient size, is pressed down with force enough to retard the circulation, and the discharges of the part add to danger of erosion. Soft rubber is always a bad material for a pessary. Hurd’s instrument (Pl. XII. Fig. 6) carries out the same idea in a better way. It is polished and vulcanized, and more easily kept clean, but its effect upon the inclosed vaginal cervix is the same as 300 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. the Hoffman. Unlike the latter it is very easily introduced and removed, while the Hoffman is, after being worn some Fic. 38. Fic. 40. : time, held with a vice-like grasp, owing to atmospheric pressure. Woodward’s instrument (Fig. 39) is a modified Hodge, with an arched bar in front of the posterior curve which impinges upon the anterior vaginal wall. In very sensitive parts it cannot be borne. Fowler's (Fig. 40) has great reputation, and is a very useful instrument. The bow form is the one represented, and in my own experience is not an improvement. Fitch (Fig. 41) and Studley’s (Pl. XIV. Fig. 6) are instances of the endless combinations which may be made on the Hodge form. The fixation in this combination is too great to be used with either comfort or Fic. 42. safety in the majority of cases. Thomas’s anteversion (Fig. 42) is another variation of the principle of the Hodge, but fixation is very much less than in the two last examples, on account of the shorter projection into the grasp of the va- gina. Schroeder’s eccentric ring (Pl. XIL., Fig. 7) combines ELY VAN DE WARKER. 301 displacement with fixation, and is given for the purpose of showing the way in which the various groups merge into each other. All the instruments of this class might be used in cases where sensibility and engorgement of the parts are removed, and the case has settled down into hope- less displacement. Even here they are attended with one great drawback. In cases selected as above, the patient ought to be able to remove and adjust her support at her own option. I have found it very difficult to instruct the average woman to do this with this class of pessary. Group III. — This group includes all those instruments known as intra-uterine stems. They are almost exclusively used for the correction of flexions of the uterus. Within their sphere they are theoretically the most perfect, practi- cally the most useful. It is one of the oldest forms for the correction of versions or flexions of the uterus. In 1843 Simpson showed to the Medico-Chirurgical Society of Edin- burgh both forms of the intra-uterine stem ; while it was not until 1846 that Kilian introduced his elytromochlion. Both these instruments were followed by a numerous progeny. Gynecologists have been loath to abandon the mechanical theory of the intra-uterine stem. They have Fic. 43. Fic. 44. thus thought to evade supposed dangers by giving the in- strument a great variety of forms. No advance has been made upon the first form of Simpson. To him we owe 302 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. the instrument, and to him also we owe its most dangerous variation. Class 1 in this Group III. is that form of the intra-uterine which is secured in place by support external to the body. Fig. 43, known as Cutter’s, is one of its modern forms, By comparing it with Fig. 44, Simpson’s “third form,” it will be seen that the variation is not material. Another slightly modified form of Simpson’s instrument, copied from Winckel, is shown in Figs. 2, 3, 4, Pl. I. This author is in error in assigning the instrument of Kiwisch five years priority over Simpson’s pessary.1 Kiwisch’s in- strument (1847) is shown in Fig. 1, Pl. I.; Valleix (1850), Figs. 1, 2, Pl. II., has an inflatable rubber ring attachment, but it does not act as a guard against the dangerous pene- tration of the intra-uterine part of the instrument. Kilian (1849), Fig. 1, Pl. III., is of the same dangerous character. Beigel has invented the most inoffensive instrument of the class. It consists of an intra-uterine stem attached to an inflated rubber ball, and the tube through which the ball is inflated is caught up in a belt around the waist (Pl. III, Fig. 2.) These instruments are figured in the interest of history rather than as being of any practical value. They vio- late every law governing the use of the intra-uterine stem. This group of pessaries owes its ill-repute to one of this class, —that of Valleix. I know of no good author who recommends theiremployment. There will probably never be a revival of this form. Class 2. — Intra-uterine stems combined with various forms of vaginal pessary :— Fic. 45. Fic. 46. 1 Selected Obstet. and Gynecol. Works of Sir J. Y. Simpson, p. 706. New York. 187I.. ELY VAN DE WARKER. 303 Fic. 54. 304 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. This combination is made for the purpose of correcting the tendency of a corrected flexion to result in a version. A simple intra-uterine stem may straighten a flexed organ, but of itself has no power to lift the depressed fundus. Al- most any simple vaginal pes- sary that will correct a version — especially a retroversion — may serve for the vaginal at- Fic. 55. tachment. Two rules must govern us in the selection of the combined instrument: That the vaginal pessary does not produce undue uterine fixation ; and that the intra-uterine stem be not too rigidly attached to the pessary. Kinloch’s instruments (Figs. 45, 46) are good examples of what a pessary of this kind should be. Fig. 47 is very liable to produce undue uterine fixation, but it will be ob- served that the stem has no fixed attachment, but plays in a cup-shaped depression between the limbs of the pessary. The pessary is by Dr. Thomas, and is, I suppose, aban- doned by him, as it has no place in the later editions of his book. As it is offered to the trade, however, it is worth a notice. Thomas’s other forms of anteflexion stem pessa- ries (Figs. 48, 49) are theoretically perfect. A lateroflexion stem pessary by the same author (Fig. 55) meets all the limitations which govern the use of these instruments. Mossman’s pessary (Fig. 54), notwithstanding its novel pro- file, is a modified Hodge; its improvement consists in a jointed stem, and by the freedom of movement to the stem by its attachment to the pessary. It strikes me, however, that less tension would be exerted upon the os externum if the stem was planted in the centre of its disk instead of posterior to it, and if the lower part of the pessary was curved the reverse of the upper part the bladder and ure- thra might be saved possible pressure. The instrument ZLY VAN DE WARKER. 305 deserves trial. Bad examples of this form are seen in Figs. I, 2, Pl. 1X.— the Hodge-Simpson form. In this instance intra-uterine stem and pessary must move together, and the uterus be constantly subjected to a double strain. The Barnes pessary shows a similar instrument with this error corrected (Fig. 3, Pl. 1X). The Williams (Fig. 4, Pl. 1X.) and Winckel’s (Fig. 2, Pl. VIII.) have the stem resting upon a perforated elastic diaphragm. Winckel’s pessary, notwith- standing the great size of the ring, can conserve no other purpose than the simple one of sustaining the ring. Stud- ley’s pessaries (Figs. 6, 7, Pl. VIII.) have the stems sup- ported by elastic bands crossing from limb to limb of the Hodge-Smith instrument, and are nearly ideally perfect. Schultze’s (Fig. 5, Pl. VIII.) for anteflexion, must be an ex- ceeding difficult pessary to adjust, while the larger part of the figure of eight must exert an undue tension on the an- terior vaginal wall. Winckel’s modification of Valleix’s pes- sary (Fig. 1, Pl. VIII.) must, from the size of the ring to which the stem is tied by strings, rather tend to increase the tendency to retroversion. Chadwick’s form (Fig. 3, Pl. VIII.), would evidently serve a very useful purpose when the tendency to retroversion is not strong. Winckel’s orig- inal form (Fig. 3, Pl. VII.), the Simpson-Martin (Fig. 1), and Hewitt (Fig. 2, Pl. VII.) possess the common error of drawing the vaginal cervix forward, and thus tend to re- trovert the uterus, instead of carrying the vaginal portion backward, a movement opposite to that of retroversion. Schultze’s form (Fig. 5, Pl. VI.) has the stem attached in too rigid a manner, as well as having the error in construc- tion of those last mentioned. Another form by the same au- thor (Fig. 7, Pl. VI.) for anteflexion has the stem rotating upon a shaft between the limbs of a Hodge pessary, and its movement controlled by an extension of the stem at nearly right angles to it from the under side. Detschy’s, of which two forms are given (Fig. 1, Pl. IV., Fig. 6, Pl. VI.), is an exceedingly dangerous form, and too strong language cannot be used in its condemnation. Strong language is happily not required; the instrument is obsolete. Cutter’s VOL. VII. 20 306 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. pessary (Fig. 4, Pl. VIII.) is a most unfortunate combination, every law governing the proper use of a pessary is violated in its construction. Another form of stem of this class consists of such a vaginal extension of the stem itself that the version is corrected by the same means which removes the flexion. Amann’s intra-uterine stem (Fig. 2, a and 4, Pl. VI.) for anteflexion has the stem terminate in a flattened disk extending into the vagina parallel to the axis of the stem. After the stem is introduced the vaginal. part is wedged backward by cotton, and the uterus maintained in an erect position. The instrument is very perfect in theory, _ but requires constant attention from the physician to keep the cotton in place. Taken altogether, grouped and clas- sified, it is a stem pessary belonging to Group II., Class I, acting by displacement. My own form of pessary of this class is shown in Figs. 50, 51, 52,53. A light stem rests before a shelf turned at right angles to a broad disk, 6. The tendency to anteversion of the uterus after the stem is in position forces the disk 6 against the posterior vaginal wall, thus holding the uterus at about a normal in- clination, while the posterior vaginal surfaces give an elas- tic and yielding support to the disk. The stem has great freedom of movement upon the vaginal attachment. As shown in the cuts, the disk may be given various forms to meet the requirements of different cases. Introduction is very simple; a wire is inserted into the part D of the stem (Fig. 50), and the stem is introduced as though it werea sound ; after introduction the vaginal attachment is run on the wire as a guide, the end D is inserted into the opening of the disk,and the wire removed. The stem is worn with great comfort, especially in irritable bladder. The instru- ment was published in 1876. Class 3, Group III. The self-retaining form has but few varieties. These instruments are designed for flexion of the uterine cervix, and especially of the vaginal portion. Methods of simple self-retention are out of the question in flexion located at the os internum, or of the uterine body ; for, when situated at these points, uterine expulsive effort ELY VAN DE WARKER. 307 is, at times, so strong that every form of intra-uterine stem may be expelled. When the flexed point is at the lower neck, the relative position of the organ above may be normal, This normal, forward inclina- tion permits the os externum to rest lightly against the posterior vaginal wall in such a manner that a light intra-uterine stem may be prevented dropping out. An instrument such as is shown in Fig. 56 is very useful for this Fic. 56. purpose, and is worn with the greatest ease and comfort by young girls, who are sometimes the greatest sufferers from flexion of the vaginal neck. Fig. 57 represents a form of my own which I occasionally use. The upper part of the stem is perforated, through which passes a short piece of pure gum tubing. It works very well in cases in which an intra-uterine stem has been worn for some time, and the ex- pulsive irritability of the organ diminished. As flexions at the os internum or uterine body are those forms of dis- tortion in which we simply correct a flexion that we may contend afterward with a version, this, or any other form of self-retaining stem, is contra-indicated. Squarey’s instru- ment is represented by Figs. 5, 6, Pl. IX. The pessary is flexible, and is introduced stretched out as in Fig. 6; by withdrawing the extending force the upper part of the tube expands, as shown in Fig. 5. The pessary has given excel- _lent results in the hands of the inventor. Class 4.— The Spring, or Diverticulating Intra-uterine Stem. This class is also a self-retaining form, but it differs so widely from Class 3 that it deserves separate study. While upon the subject of the displacement pessary with spring 308 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. action (Group II., Class 1), I referred to the difficulty of estimating the force of a confined spring, and the injury that elastic pressure was prone to inflict upon the soft parts. These objections hold good with double force when this elastic pressure is confined within the comparatively un- yielding uterine cavity, and acts upon tissues disposed to resent continuous pressure. How slight this force may be, and yet excite uterine expulsive effort, the elasticity of the small cross-section of tubing in my own self-retaining form has convinced me. I generally found that these were not well borne unless previous tolerance had been gained by the use of the sound, or simple intra-uterine stem. The idea of holding the instrument in place by elastic separating intra-uterine branches of the stem is an old one. In 1850 Kiwisch invented one of this class, which, regarded across the great space covered by achievement rather than by time, and which divides the present from the past in the history of gynecology, seems an impossible thing to apply to the uterus. Figs. 1, 2, 3, Pl. XL, give a fair idea of the instrument. The dividing branches a are drawn together by the cord 4, operated by a screw at 2, in the handle ¢ e, Fig. 3 shows the handle as removed from the canula zc, and Fig. 2 represents the intra-uterine branches spread apart zz situ. Figs. 4, 5, Pl. XI., exhibits Carl Mayer's im- provement, which consists in guiding the cord over the convexity of the branches, instead of the concavity as shown at #, a, Fig. 1. The instrument is given here for its his- torical importance. It is an interesting fact in the history of these two instruments, that their descriptions appear as consecutive articles in the same number of the “ Verhand- lungen.” Fig. 1, Pl. X., exhibits Simpson’s pessary; the springs are compressed for introduction by a ring, and released by drawing upon cords attached to the ring and passing through its vaginal bulb. It is figured full size, and is a pow- erful instrument. Fig. 2, Pl. X., represents Wright’s, and is a much less objectionable pessary than that of Simpson. It is introduced by means of a handle that compresses the ELY VAN DE WARKER. 309 blades, which is figured at A. Fig. 3 shows the instrument in position. Fig. 4 of the same plate is Chambers’s modi- fication of the last inventor’s pessary, still further modified and figured by Biegel. It is difficult to understand the im- provement over the original form of Wright’s. Fig. 5, Pl. X., is the form of Chambers’s. It is introduced by means of the handle A, which draws down the flange C as the handle is removed. It is well tolerated, and its field of use- fulness, like that of all this class, except its Kiwisch and Mayer forms, is in flexions of the lower portions of the uterine neck, where the tendency to version is slight or wanting. Fig. 6 represents Aveling’s pessary. The blades are confined by passing through a short canula, and are released by forcing the spring forward by means of the handle B, The action of the canula is well shown at A. Wright’s and Chambers’s instruments have been exten- sively used in England, and are quite well borne. The cer- tainty of retention, especially in cases of dysmenorrhea due to flexion of the lower neck, has tended to make them pop- ular. Other forms of self-retaining stems, or with simple vaginal attachments for retention (Class 5), not rately be- come displaced just at the moment when they are most needed. My own experience of these pessaries shows that _ menstruation, while the instrument is worn, is more pro- fuse and lasts longer than when the simple stem is em- ployed. Careful supervision must be had over the patient while wearing instruments of this class. Class 5. —Intra-uterine Stems with Simple Vaginal At- tachment necessary for Retention. This class includes the ideally perfect intra-uterine stem. In all those cases in which a corrected flexion does not result in a version of such a degree that its replacement is required, this form of instrument is indicated. The vaginal part is added to the intra-uterine for the purpose of retaining the latter in posi- tion, nothing more. The greatest confusion has prevailed as to the size of the vaginal attachment necessary to ac- complish this purpose. The illustrations of this class exhibit the great diversity in size. Asa rule, the vaginal 310 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. attachment should be no larger than is necessary to retain the stem in position ; that is, to resist the force of gravity and the uterine expulsive force. If there is any excess in size over this, normal uterine mobility is restricted, the function of the near parts may be disturbed, or the vaginal part may become displaced by expulsive efforts in defe- cation. The form which I have used for many years, and after numerous trials of other instruments, is shown in Figs. 58 and 509. The stem in Fig. 58is actual size. I have the stems made after measurements of the uterine cavity. Sometimes, but rarely, the stem is made one fourth or three eighths of an inch longer, but never of greater diameter than in the cut. A wire is run into the end a, the cervix is exposed by a Sims’ speculum, and firmly held by atenaculum, and the stem intro- duced in the same manner as a sound. The flange, also actual size, nabs is slid over the wire through its central opening @ until it is placed upon a@ of the stem (Fig. 58). i | times difficulty is met in passing the flexed point ; Fic. 5s. this case a sound with proper curve is first Hees and the uterus straightened, and held in that position for a minute or two, when, on the next trial, the stem will prob- ably pass easily into the uterine cavity. If, however, it should not, use the sound a second time. Patience and gentleness of manipulation must be cultivated as an art by the physician who aspires to treat uterine flexions success- fully. I have, on very few occasions, used a flange larger than that shown in Fig. 59. It will happen now and then that the flange and stem will get displaced. The remedy is a simple one: replace them, remembering that if a stem is so securely held in place by vaginal attachment that it cannot become displaced it is probably too good a fit, and the patient cannot wear it. ELY VAN DE WARKER. 311 Fig. 60 represents Dr. Sims’ intra-uterine stem. I have never used it, and am not aware that Dr. Sims has ever formally brought it before the profession ; but the instru- ment has too many merits to neglect giving it a place ina monograph of this description. It deserves attention for the free motion of the stem upon the retaining portion, certainty of retention furnished by a ring over a solid vagi- nal part, and is evidently easy to introduce. Fic. 60. Fig. 61 represents Donaldson’s pessary. It is a very recent invention, and deserves notice on account of the ingenious attachment of the intra-uterine stem to the retaining portion. The stem is fixed in the centre of a rubber diaphragm, which allows free movement in any direction. Another advantage has been noticed with reference to several other instruments, namely, the superior retaining power of an open or horse-shoe Fic. 61. form over a disk or solid retaining part. One disadvantage it possesses in common with all forms of intra-uterine stems in which the stem is a permanent attachment to the retaining part. It is difficult to introduce the latter into the vagina while the former is being introduced into the uterine cavity. In some cases it is difficult to in-" 312 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. troduce even a sound, and in cases in which the vagina is narrow, as in virgins, who are very frequent subjects for intra-uterine stems, there is no room for the retaining por- tion, which ought, on this account, to be a separate part of the instrument. Simpson’s forms of pessaries of this class are shown in Figs. 1, 2, 3, 4,5, Pl. V. They are among the oldest forms of the instrument. Indeed, to Simpson we owe the first practical use of the intra-uterine stem; that he abandoned the idea later in life is evidence of his too indiscriminate use of it, rather than of any fault in the method itself. Fig. 4, Pl. I, shows another form of Simpson’s pessary. Cazarewitch’s pessaries are exhibited in Figs. 6, 7, Pl. V. Fig. 6 is made of glass, and shows a twisted form, the ad- vantage of which is doubtful. The pessary represented by Fig. 7 is hollow, which, I think, is the result of a mistaken idea of the office of the stem. Shroeder’s form (Fig. 8, PI. V.) is closely after the model of Simpson. Fig. 9, Pl. V., expresses Peaslee’s pessary. It also follows the model of Simpson (Fig. 3, Pl. V). The second bulb is attached for the purpose of retention. It is a very useful pessary, and holds its place securely. The hinge attachment for reten- tion purposes is useless. The vaginal part is sure to col- lapse from the pressure of the passage. Conant’s (Fig. 3, Pl. VI.) and Edwards’s (Fig. 4, Pl. VI.) are examples. Tait’s pessary, another model after the design of Simpson, is, from the structure of its bulb, held in place very imper- fectly. It is shown in Fig. 1, Pl. VI. C. Braun’s stem (Figs. 4, 5, Pl. VII.) has the retaining part in the form of a small globe detached from the stem, and perforated so that it may be attached to the stem. Its distinctive feature is the extreme curve of the stem. Curved stems are worn with great comfort. In very acute and strong flexures it is necessary. The normal uterus is not a straight organ, and the perfectly adapted stem ought to conform to this normal curve. FE. Martin’s pessary, shown in Fig. 6, Pl. VIL, closely follows the model of Braun. In both these pes- saries there is evidently no advantage to be gained in the globe form of the retaining part. Fg i Bs Pl. II. * ; Aa rel Fig. R: — ~ x . as SAN, xs SSN. Se SENS Sie Ma - . ~ » ~ . apn na — ~ ie » ~ . . » ~ ~ Sead “~ NO a ie ~ ty ~ ~ = ~ ~ . = —— aoa ee ee ae a a a ae Ee ~ Poe wy ied a a a I 2 Se SN a ee ae - 7 2 - Po ae 7 = ati = 2 ig . \ \ . a: i) \ \ ‘ ool a iin pire dt * - ) mts a) “: ? ? ' i ‘vt re eee ia r 7 4X a gtd i a e HN i oi ‘ i ‘* . : 3 ‘¥ ‘ t ¢ ,. , 4 - / . - ' i . 5 : - ‘ . , Fig.2 Fig. Fig. 8 Fig.9 PILVG #ig.3 N Ma Pe MOP ee tere aay ae ee, en Pa vali 2 aps a oe) at ay! ». oy: ‘ ‘| ; ‘ : ve - <« ‘ - fae Oo res eS Fig Fig4 MO ney Vv as) | TTT HUTT | ns eee Le N . = ee DISCUSSION. 313 DISCUSSION. Dr. H. F. Campsett, of Augusta, Georgia. —I believe that uterine displacements, as they are the most frequent, are the most important gynecological questions with which we have to deal. I have listened with great interest to the paper just read by Dr. Van de Warker, and there are but few points upon which I dis- sent entirely, while there are many points which I would like to discuss, but can scarcely touch upon. In the first place, in a uterine displacement, the idea. of the fitting of a pessary has al- ways been quite repugnant tome. The term “fitting a pessary,” in any sense of the close application of a thing to the thing con- taining it, is what I have always disliked as entirely inapplicable to the conditions ‘contemplated. Whenever a pessary is intro- duced in a manner so as to /#, we shall certainly make what Dr. Van de Warker very properly calls “ fixation of the uterus,” which is, in every sense of the word, an abnormal condition of the womb. Ido not know how, in the application of a pessary, we can properly adjust its proportionate size, and the support which it is to give, unless the womb be replaced previous to the intro- duction of the instrument. Simply placing the patient upon the back, and ascertaining the character of the displacement, will give no adequate idea of the support demanded by the require- ments of the case. If applied in this position it will be found, I have no doubt, that if a pessary of two inches in length or diam- eter would fit tightly, one of one inch would fit almost as tightly, and that one three inches in length would fit but a little more tightly. Therefore, it must be seen, that until after full replace- ment of the womb, we cannot know how to adjust the mechanical support required in any given case. In order to illustrate this principle, I formerly announced this proposition : that “to intro- duce a pessary to support a dislocated uterus before replacing the womb is as unscientific as it would be to apply splints to a fractured limb before reducing the fracture.” This principle will be found fully stated in vol. i. of ‘Gynecological Transactions,” 1876, in connection with which methodical directions are given for the introduction of every variety of internal support after genupostural replacement, and while the patient is still in the knee-and-breast posture. First, then, replace the womb, putting 314 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. it as near as possible to the full limit of its moorings. This full replacement can only be made in the genupectoral posture. Now we can find out what room has been left for the pessary. When this has been done, select such an instrument as will fill the cav- ity left by the retirement of the womb somewhat loosely. If you estimate that the length or diameter of the instrument should be two inches, two and a half inches, or three inches, select one a little within the size, and then introduce it while the patient is still in the genupectoral, or knee-and-breast posture. The pes- sary must now be so placed that its upper segment will rest in the posterior cul-de-sac of the vagina, and upon the cervix uteri, while its anterior segment is held by the finger of the operator against the pubic wall of the pelvis. While still thus held the patient is directed to rise to the evect-kneeling posture, in order that the womb may settle down upon the pessary, and be sup- ported by it. Many patients, being already in a kneeling pos- ture, do not understand the request to rise to the evect-hneeling posture —‘‘Madam, I mean the position of little Samuel.” As most ladies are quite familiar with the well-known picture or plas- ter cast of the devout child, the required posture is at once recog= nized by her assuming this erect position, and we have the pes- sary fixed by the uterus settling down upon it. A pessary is nothing more than a crutch for a too heavy womb and a weak- ened state of the ligaments, and the zdea/ treatment of uterine displacements by pessaries would comprehend the removal of the crutch at night, and its application again in the morning. This is not practicable, as few women can properly replace their pes- saries. To come as near this zdea/ as possible, I instruct patients who have worn pessaries all day to uzship or loosen them up at night by getting on the knees and breast, and letting air into the vagina with a tube-repositor. ‘This is like laying aside the crutch for the night ; the rim no longer presses on the posterior cul-de- sac. When she rises in the morning the crutch action of the pessary is again resumed, and she wears it all day without chafing unduly the tissues of the vagina, or cervix uteri. Now, with regard to the stem pessary, it is one of the most un- fortunate of expressions to call it “‘a pessary.” It is not a pes- sary. A pessary is a thing to support. It is, as I have said, a crutch to keep up a heavy womb, and to supplement and strengthen a relaxed state of the ligaments. But a stem is good for nothing for that, and was not designed for any such purpose. It is simply DISCUSSION. 315 a splint fora broken womb. There is a break comparable to what surgeons call “ green-stick fracture,” just at the point where that hinge-like curvature exists. It is just like green-stick fracture in a broken arm, in which, unless you put upon the outside a sup- porting splint, the deformity will remain unrelieved. So it is with the stem pessary. It operates upon the principle of an in- ternal splint to straighten and support the womb until it can get well. There is danger in the stem, even when we properly rec- ognize it only as a splint. To attempt to introduce this little straight instrument into a crooked and tender canal is apt to produce traumatic inflammation ; the canal should be straight- ened as much as possible in its introduction, and the patient should be regarded as under actual observation and treatment as long as the splint is used. I agree with Dr. Van de Warker, that there is no form of vagi- nal appliance which will ever straighten a flexed womb. Itisa distorted womb. There is an intrinsic deformity produced by disease, and simply holding it up won’t straighten it. I do not belong to the inflammatory or to the mechanical school. I hope that we all belong to both. Of course there are inflammatory conditions which have preceded, and which accompany, and which result from uterine displacements ; and of course, also, these are to be treated. But just now we are discussing the mechanical side of the question. The stem is not necessarily injurious, if the woman is properly treated on the idea that it is a splint to be carefully applied to straighten and keep straight a broken womb. - I believe that when we come to regard all pessaries proper as crutches to support a too heavy womb, with a weakened set of ligaments, and all stems no longer pessaries, but as splints to cure a broken womb, we shall have reached the true position. Dr. H. P. C. Witson, of Baltimore.— There is no subject in gynecology of greater interest to me than displacements of the uterus and their rectification. When I meet with a lacerated cer- vix, thanks to our President, I know what to do with it. If I have to deal with a sharp anteflexion, I think I know how it should be treated. If I have acase of intra-uterine fibroid or a vesico-vaginal fistula to treat, I think I know what should be done ; but when I come to a uterus which is displaced, it is all a matter of experiment, from beginning to end, as to whether I shall succeed in rectifying it or not. I have found, in my ex- perience, that I cannot tell exactly, at first, what kind of a pes- 316 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. sary should be used. I have very, very rarely produced any benefit by treating an anteflexed uterus with a pessary. My suc- cesses have been more in the treatment of retroverted, or retro- flexed, or perhaps prolapsed uteri, than in cases of anteflexion ; and yet I never know exactly, when I treat such a case, what pessary will answer best. I am sometimes obliged to introduce five, six, or eight instruments before I get the proper one for the case. One may measure accurately the length,of the vagina, or estimate as accurately as possible the resistance of the ligaments, but you cannot tell, until you have tried, what kind of an instru- ment would be necessary to keep the uterus up in its proper posi- tion. Not infrequently I receive letters asking me to send a pes- sary which will fulfill certain conditions, but it is impossible for me to do so. ‘here is no definite rule for the use of these instru- ments. There is one rule, however, which I have derived from practical observation, and it is this: If, after replacing the uterus, and adjusting a pessary, I can pass my finger comfortably between the pessary and the vaginal wall, I have come to believe that it is not apt to do any damage. ‘Therefore, when I introduce a pes- sary for any form or displacement, the last thing done is to pass my finger between the instrument and the vaginal wall. If it passes easily I am satisfied that it willdo no harm. We are some- times obliged to use instruments which our judgment tells us are larger than should be used. In some cases there is thickening of the broad ligaments or of the recto-uterine ligaments, or other pathological changes have taken place, such as have held the uterus down months, or even years, and we wish to raise it into position. To do this we are obliged to stretch these tissues, and work the uterus up gradually, little by little, and ultimately we can perhaps introduce a pessary which will hold the uterus in position and at the same time not press unduly upon the sur- rounding parts. In such cases we may temporarily introduce: an instrument which aids us in overcoming these contractions, but it must be carefully watched, and the patient kept under constant observation ; and at the same time other means than the mechan- ical treatment must be adopted, such as various local applica- tions with the use of internal remedies. The principle laid down by Dr. Van de Warker is that the uterus should be movable. We should never use a pessary sufficiently long or broad to hold a uterus in a fixed position, as it is more or less mobile ; and nothing which overcomes its mobility, and fixes it, can be DISCUSSION. 317 regarded as a proper pessary, except perhaps under the circum- stances which I have just mentioned. But I must return to the first statement, that after all it is an experiment as to what pes- sary we shall introduce, and what pessary will finally be best adapted to the case. No pessary should be allowed in the vagina, if it is at all uncomfortable to the woman. If uncom- fortable, it is evidence that it is wrong. Nowoman should realize that she has a pessary in the vagina, and that is a practical rule which I never fail to recognize. Dr. Paut F. Munpé, of New York. — The subject of adapting pessaries to uterine displacements is so wide that it would be im- possible to cover it in,one session. The point seems to be to make out what is the normal position of the uterus, and then we shall be able to understand what is abnormal, and find remedies for it. I do not agree with Dr. Van de Warker regarding the normal position of the uterus. He thinks that it is anteflexed. Dr. VAN DE WARKER. — Simply curved forward, not anteflexed. Dr. Munp£. — Very well; I should regard that as the normal position. Having fixed the normal position, the question arises, what shall we do for a displacement of the uterus, whether it be anterior or posterior? I may say that it seems to me that the anterior displacements do not demand mechanical treatment, as a rule, by means of intra-vaginal pessaries with or without abdom- inal support, unless there be combined with such displacement, whether anteversion or anteflexion, a certain amount of sink- ing of the uterus, so as to produce dragging upon the uterine ligaments, and pressure upon the bladder. Whenever there is such a forward displacement combined with sinking, perhaps sufficient to produce pressure upon the bladder, that uterus needs a support. In such cases we elicit symptoms from the pa- tient, and we give relief with a support. I would differ with Dr. Van de Warker, and also Dr. Camp- bell, who regard it as impossible to lift up the fundus, in a case of anteflexion, without a stem pessary. I would not like to sub- scribe entirely to the ground taken by our honored President that the stem pessary is an invention of the evil one, because I have seen the stem pessary do very well under certain circum- stances ; but I have found it, as Dr. Goodell once expressed it, a most useful instrument to watch, otherwise I should not dare to employ it. I think that, by the use of Thomas’s cup pessary, the fundus can be raised gradually, month by month, by lengthening 313 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. the anterior portion of the cup, and after a while the fundus of the anteflexed uterus can be raised until it is nearly straight. I have two cases to prove this, — not many to be sure, but in one the patient became pregnant after a sterility which had existed for several years, whether in consequence of this method of treat- ment I will not say, but certainly the uterus gradually became straight. These are exceptions, it is true; and, as a rule, in order to straighten an anteflexed uterus, I think it is necessary to put the stem pessary into the uterus. Whether we cure the patient by that mode of treatment is quite another thing. The advantage of treating the patient in this manner may be doubtful, while the risks are quite equal to the benefit. But if the patients can en- dure the stem, they will improve; if they cannot, and this un- fortunately is the rule, no other method will cure them. A few years ago I was very favorably impressed with Gehrung’s pessary, but after a little time I found that it would rotate in the vagina, and I was obliged to abandon its use. Thomas’s open cup pessary works better for cases of simple anteversion. At the same time I believe it acts by lifting up the entire uterus, as much as it does by supporting the fundus alone. As for retro-displacements, if I could treat them and get as much benefit.as I can in treating anterior displacements, I should ~ consider that I had made great advance in the mechanical treat- ment of uterine diseases. In making this admission, I refer chiefly to cases of retroflexion. It may be my fault that I do not have better success ; perhaps I have not looked over the large number of pessaries sufficiently. I have examined many, and I find few which work well in cases in which the uterus is retro- flexed. I do not think that our methods for retention of the organ in this form of displacement are at all proportionate to the wants of our patients. Of course, it is a primary rule that before the introduction of a pessary the uterus should be replaced, but, after having replaced the uterus, it is not so easy always to find _a pessary which will keep the organ in position. One of the mod- ifications of Hodge’s pessary answers the purpose as well as any other, so far as my experience goes. But I am looking for a pessary which will always keep the fundus up in cases of chronic retrofiexion. If a woman have a uterus which is entirely irre- placeable, there may be adhesions, and we must first use other means for bringing it into position. Thus, we may columnize the vagina, as we have heard it called. But it is a difficult thing DISCUSSION. 319 to bring the womb into position in these cases. Dr. Campbell speaks of the genupectoral position, and when it was first brought forward I hailed his discovery with great joy and delight. Acci- dentally I happened to discover the same method of treatment in a case of retroversion of the gravid uterus, and, for a time, I resorted to it with considerable enthusiasm. I tried it over and over again, and it succeeded and it failed ; and, so, I think it will be found that it often succeeds and often fails. This is not at all detracting from his discovery, but it is simply stating that there is no rule without an exception. When I use a retroflexion pessary, I always direct the patient to assume the genupectoral position at least once a day, and when the instrument is removed. The lever action of the Hodge pessary is too great a subject to be discussed at this time. Dr. Van de Warker believes that it is not so great as we have been disposed to accept. I think that, the uterus having first been replaced, we have, in the Hodge pessary, a lever action upon the posterior surface of the uterus, which keeps the fundus anteverted ; and I believe, also, the backward elonga- tion of the vaginal vault by the pessary assists the lever action by drawing the cervix toward the sacrum. I have found in a certain number of cases, chiefly those in which there were adhesions of the uterus and a short posterior vaginal pouch, that Dr. Ephraim Cutter’s supporter (an ordinary vaginal pessary with an external band) was effectual in lifting up the fundus. I have now three patients who are wearing this instrument with benefit, in whom all previously used vaginal pessaries failed. When I published my book, I had not met with cases which led me to believe that the instrument possessed special value. Dr. G. H. Lyman, of Boston. —I had hoped, Mr. President, to hear a little more about pathology in these cases. There was one idea spoken of which, I think, we must always keep in mind, and that is this matter of fixation of the uterus. We are apt to forget that the uterus is not a fixed boay. Ido not know how many hundreds of pessaries have been invented, and what is the treason? The reason is that no one has yet found an instrument which fulfills the indications or answers the purpose for every case. And they cannot do so because there are no two cases which any one pessary will suit. I never invented a pessary, thank Heaven, but my habit has been to mould one, and I gen- erally take the first one I can get hold of — Hodge’s, perhaps, answers as well as any — and adapt it to the apparent indications 320 MECHANICAL THERAPEUTICS OF VERSIONS, ETC. of the case which I am treating. Correct treatment involves careful study of the pathology of displacements. My opinion with regard to pessaries is, that they constitute the smaller part of the treatment of displacements. You meet with a displaced uterus, and it is in a fixed position ; what is the cause of it? We perhaps cannot find the original cause if it has lasted for some time, but there is always, nevertheless, some cause for it ; and my practice has been not to resort to pessaries in the first place, but to look for this cause, and see if there is not some method of overcoming the condition other than by resorting to mechanical treatment. Iam satisfied that in very many cases, if not in all, when we investigate the antecedents, we shall find that the entire condition is due to previous cellulitis. Our President struck that keynote years ago, and I think, when I first heard it, it made more impression upon me than anything which I have learned from him—and that is saying a good deal. I do not think it is worth our while to go into the subject of this man’s pessary, or that man’s pessary, but each case has its own peculiarities, and if mechanical support is to be resorted to, you must fit your own pessary. As already said, I generally employ Hodge’s pessary, because it can be distorted and turned, and twisted and moulded, so as to be adapted to almost any case. Dr. Van de Warker’s classification of pessaries is all very interesting, and it gives us the action of mechanical forces ; but in each case it will finally, I think, be demonstrated that we must go back to the cause of the displacement, and endeavor to find out what it is that keeps the uterus in its malposition, and having found that out, then deter- mine whether or not we can get rid of it. If the cause is remov- able, when it has been removed we can keep the uterus in posi- tion without difficulty. Dr. VAN DE WARKER. — With reference to the criticism offered by Dr. Campbell on the term “fitting the pessary,” it is simply a fit and nothing else. It is as much a question of fit as it is to go to a shoe store and get a shoe which fits the foot. I never un- derstood for a moment that the uterus was not to be replaced be- fore the introduction of the instrument. Dr. Campbell’s inge- nious method of replacing the uterus is one well worthy of trial. I wish to say, in addition to Dr. Campbell’s remarks, that my own experience has proved to me that the only means of treating and straightening a flexed uterus is by means of the intra-uterine stem, and when it is properly adjusted, and the case is adapted DISCUSSION. 321 to it, it is safe and proper to be used. But the subject must not be lost sight of, and I think this rule applies just as effectually to any other mechanical means of replacing the uterus. The pa- tient should understand that she is continually under treatment. With regard to Dr. Wilson’s rule, that if the finger can be passed easily between the pessary and the vaginal wall, it prob- ably will do no harm. I think this rule will hardly hold true. I do not think that this gives room enough. We must make allow- ance for all the points which are exposed to pressure, and the mere fact that we can pass the finger is not a safeguard that it is properly fitted. You may do injury with such precaution on ac- count of the expulsive forces in the pelvic cavity. Dr. Mundé has referred to the normal position of the uterus. In fact there is no normal position, for the normal position is one of mobility. It is certainly difficult to say exactly what is meant by the lever action of Hodge’s pessary. [Dr. Van de Warker illustrated, by a diagram on the blackboard, what he believed to be the action of Hodge’s pessary.] My paper was not designed to be so practical as theoretical. I designed the introductory part to be partly practical, but with regard to the subject of the pessary, the use of this instrument must be studied separate and distinct from the pathology and the etiology of uterine displace- ment. We must study it as we would the action of opium or castor oil, separate from the pathological conditions in which we are going to use these medicinal agents. VOL. VII. 21 A NEW METHOD OF OPERATION FOR THE RELIEF OF RUPTURE OF THE PERINEG@ THROUGH THE SPHINCTER AND Beer BY J. COLLINS WARREN, M. D., Boston, Mass. THE operation to be described is intended chiefly for the most serious cases of rupture, where not only the sphincter muscle, but also a portion of the anterior wall of the rectum has been torn through. The rent in these cases usually in- volves that portion of the rectal wall which bounds the per- ineal body posteriorly. During the process of cicatrization there is little or no union of the sides of the rent, but the recto-vaginal septum is drawn downwards by cicatricial con- traction, and is thus made to cover a considerable portion of the exposed rectum. The outlets of the vagina and rec- tum are, however, continuous, and form at the vulva a large cloaca. Fig. 1 shows the vul- va, with the labia drawn apart so as to display a considerable portion of the posterior wall of the vagina. Below, between the letters A and B, we see also a portion of the posterior wall of the rectum bounded above, in the picture, by the semi-circular margin of the septum, and below by the retractedsphincter muscle. Fic. 1. Ff COLLINS WARREN. 323 The weak point of every operation hitherto devised lies in the management of the rectal wound. The perineal body is not situated in front of the rectum, but forms, as it were, the floor of that cavity, which at this point takes a sudden curve backward to reach the anal orifice. A freshly united linear rectal wound at this point must, therefore, present itself at right angles to the axis of the rectum, and must sustain the full force of a column of gas or feces coming down from above. If the wound be a long one and the perineal body not sufficiently thick, the point of least resistance will be in the direction of the vagina, and a recto-vaginal fistula may result. Emmet, who, it must be acknowledged, has done more than‘any other surgeon to place this operation upon its present comparatively firm basis, has sought to overcome this source of danger by drawing down the edge of the septum to the sphincter muscle by means of his bag-string suture, and thus do away with a rectal wound as completely as possible. The moment, however, the edge of the septum has been re- leased from its cicatricial bands by the scissors, it begins to withdraw itself to its original position ; a point much fur- ther inside the pelvis than one would imagine who judged by its position in the cicatrized state. The tension of the recto-vaginal septum when drawn still further down by the bag-string suture is greatly increased, and displays itself first when the parts have become swollen by inflammation, the lower stitches being frequently sucked up, as it were, into the rectum; later, when the tissues are softer, the stitches cut through and the rectal wall retracts, forming an open wound in the rectum and exposing the lower portion of the perineal body. If we extend the line of the axis of the rectum downwards through the perineal body, we shall find that it emerges usually between the second and third stitches externally. It is at this point that the contents of the rectum force their way out, so far as the writer’s experi- ence goes, and establish a fistulous opening around which the freshly united tissues gradually melt away. The prin- ciple of the method described in this article consists in 324 A NEW OPERATION FOR RUPTURE OF PERINEUM. shutting out the rectum entirely by a flap operation, so that it shall no longer enter as an element to be considered in the healing process. The material of which the flap is com- posed is that usually cut away by the scissors, and consists of vaginal and vulvar mucous membrane, and also of a cer- tain amount of cicatricial tissue which is to be found at the margin of the rent. The flap is formed by dissecting the “butterfly” from within outward, preserving the materials just mentioned in one continuous mass, the pedicle being formed by the entire free margin of the septum (Fig. 1, A 4), a hinge on which the flap is swung over so as to ex- clude the rectum from view. The dissection will be per- formed with greater ease and nicety if the knife is used, and should be made chiefly from the sides in the manner indi- cated in Fig. 2. In reflecting the central portion it is im- portant to avoid “ button-hole- ing;” and for this purpose it is well to keep the septum be- tween the thumb and fore- finger of the left hand, lib- erating the flap by gentle strokes of the knife to and fro, while the tissues are made tense by traction on the flap with the forceps in the hands of an assistant. The dissec- tion should stop just short of the free margin so as to leave it intact, otherwise the pedi- cle of the flap would be sev- ered; on the sides the dissec- tion is carried down sufficient- ly far to expose the ends of the ruptured sphincter muscle. We have now not only the customary butterfly, but, in ad- dition, a twin butterfly hanging from its lower edge and forming a sort of apron (Fig. 3). A portion of the vaginal and vulvar mucous membrane has been folded over as in turning out one side of a hat-lining, and the vaginal mem- Fic. 2. F COLLINS WARREN. 325 ‘brane becomes now a portion of, and continuous with, the anterior rectal mucous membrane.! The bowel now termi- nates in a sort of fimbriated ex- tremity. This flap is redundant not only in length but in breadth, and must, therefore, be thrown into longitudinal folds and be pressed downwards, while the twisting of the first stitch brings the divided ends of the sphinc- ter together over it. After the remaining stitches have been taken we find the end of the flap still projecting at the ante- rior margin of the anus. It is well not to trim this off short, as subsequent retraction will draw a considerable quantity of it into the rectum; on the other hand, if all is left, the flap is unnecessarily long and the tip of it is liable to slough. It can be disposed of by folding in longitudinally, as when we pinch the lower lip together between the thumb and finger, and stitching the apposed raw edges ; or it can be spread out in a fan shape, and adjusted to a short curved incis- ion through the edges of the skin at the bottom of the wound, as in Fig. 4. This curved incision might be contin- ued all round the anus and the free margin of rectum, then readjusted so as to be more evenly distributed around the circle. The anus would then have exactly the appearance of an artificial anus as after colotomy, but such an additional dissection is hardly neces- sary. When the flap has been formed and allowed to drop down over the rectum, the cavity of the bowel is no FIG: longer seen and in finishing the operation we have a prob- Fic. 3. 1 This method was first proposed by the writer in the Boston Medi- cal and Surgical Fournal, January 3, 1878. 326 A NEW OPERATION FOR: RUPTURE OF PERINEUM. lem almost as simple to perform as the formation of a peri- neum when the sphincter has not been ruptured.! The general plan of taking stitches is shown in Fig. 3. It will be noticed that undue constriction is avoided, there being no necessity for the use of the bag-string suture, and the thickness of the perineal body is preserved. These deep sutures are so arranged as not to touch the flap or septum that it may have free play to assume its normal position, or that the flap may not be so restricted as to endanger its vitality. The adoption of the flap as a feature of the operation consequently involves a radical change in the method of taking stitches as laid down by Emmet. For these sutures annealed copper wire, silver-plated, is used of No. 29, Brown and Sharp gauge; the next finer grade used at the hospital, No. 24, though taking less room, being lia- ble to break. Before they are twisted a few superficial cat- gut sutures are taken in the vaginal mucous membrane for greater security from vaginal discharges. The first patient operated upon by this method was thirty-one years of age, and*had sustained a severe laceration of the perineum involving the sphincter and rectum, during along and difficult labor three months before her entrance to the hospital. She was in a poor condition and anemic, but complained of no uterine symptoms, and desired an op- eration for relief from the incontinence of the rectum. As a preliminary step in the operation, the sphincter was thor- oughly stretched by seizing the free ends and pulling upon them much as one would pull molasses candy. The opera- tion was then performed in the manner above described. The portion of the flap projecting from the anus being found unnecessarily long was trimmed slightly and then folded on itself longitudinally, and the raw edges were sewed together, giving it the appearance of a small hemor- 1 As a convenient way of distinguishing the two varieties of rupture, the writer would suggest : that those cases in which the perineal body alone has been torn be called “ simple rupture of the perineum; ” and in those cases in which there has been a laceration of the sphincter or rectum, the term “ compound rupture of the perineum ” be used. 5 COLLINS WARREN. 327 rhoid at the anterior margin of the anus. During the oper- ation the exposed surfaces were irrigated by a warm stream of carbolized water (1-200) flowing from a fountain syringe, and a narrow strip of lint soaked in carbolized oil was placed on each side of the sutures after the operation and renewed daily for almost a week. The wound was thus kept in per- fectly aseptic condition, and instead of the customary smart reaction there was scarcely a perceptible rise in the tem- perature, the thermometer ranging as high as 100.2° F. on one evening only. Vaginal douches were used after the second day, and the urine was drawn regularly with the catheter. A special feature of the after treatment was the det; a free use of milk, prescribed generally as a convenient form of liquid diet, has the great disadvantage of being followed by a large accumulation of fecal matter, the fatty portions being rolled together in hard or putty-like masses, which subjects the delicate union to a severe strain and may de- stroy it altogether. This peculiarity of milk as an article of diet in the sick-room has not been sufficiently recognized. Its extensive employment in diseases of the intestinal canal will doubtless be somewhat curtailed when this fact is more fully appreciated. The proportion of residual material in different forms of food is a point in the regulation of the diet which should receive more attention than it has hith- erto. A liquid diet from which milk was rigidly excluded was prescribed in this and the other cases. It is well to be- gin this regimen the day before the operation, and for the first twenty-four hours after it to give little else than cracked ice and small doses of some fluid beef extract. The discomforts and dangers of flatus are also avoided. The following is the diet list of the case above mentioned : First day, beef tea Zviii., brandy 3ii. Second day, beef tea Zxvi., brandy Ziii. Third day, beef tea 3xxxii., cup of tea without milk for break- fast. A few days later beefsteak was given, at first in small 328 A NEW OPERATION FOR RUPTURE OF PERINEUM. quantities, and broths were substituted! The stitches were removed on the fourteenth day, and the perineum was found to be firmly united throughout. The projection at the anterior margin of the anus had retracted so as to be imperceptible. As an experiment the bowels were not moved until the twenty-first day, and then, following a small dose of oil, an abundance of soft, slippery, and well formed scybala, in other words normal feces, was discharged. In the second case the patient, thirty-five years of age, had a rupture of three and a half years’ standing, which had been operated upon twice without benefit, the incon- tinence of the rectum being still complete; the rupture did not, however, extend beyond the sphincter. The en- tire flap made in the operation in this case was allowed to remain, and subsequently a portion of the tip about the size of a pea sloughed and was removed. Union of the perineal body was complete and there was absolutely no febrile dis- turbance. The same antiseptic precautions were observed during the operation and after treatment as in the first case. The stitches were removed on the twelfth day, and the bowels were moved by a small dose of oil on the twen- tieth day, the evacuations being normal in character. The third case was one of the most aggravated forms of rupture one has an opportunity to see. It had existed but three months and involved the anterior wall of the rectum for a considerable distance from the anus. On separating the labia a large cloaca was disclosed, lined, particularly posteriorly, by a membrane in a state of irritation, a gran- ular condition existing at some points. The patient was kept under preparatory treatment for two weeks to restore the parts to a healthy condition, The method of operating was precisely the same as in the other cases. The flap pro- jecting at the anus, after the wound was closed, was folded on itself and held together by two fine silver sutures, The diet consisted chiefly of beef tea and chicken broth. The character of the bill of fare can be varied considerably, and * A similar diet is also prescribed by the writer after operations on the rectum and uterus. FJ COLLINS WARREN. 329 even solid food be taken at an early day, provided milk in every form is rigidly excluded. As illustrative of the ten- dency of the septum to retract, it may be mentioned that the flap was gradually sucked up into the rectum during the healing process, and was subsequently found nearly an inch from the outer margin of the sphincter. It could be felt in the rectum for some time as a little polypoid tumor, but eventually disappeared. If the tip of the flap was at this point, its base must have been situated from two to three inches from the sphincter muscle, showing how far the edge of the recto-vaginal septum withdraws into the pelvis when it has been liberated from its cicatrized position. The ther- mometer registered 100° F. on the second evening only. The stitches were removed on the thirteenth day, and the bowels were moved by an enema on the twenty-first day, when an abundant and natural evacuation occurred. No cathartic was given and no opiate was necessary, except one sub-cutaneous injection of one sixth of a grain of morphine the day following the operation. The body was not com- pletely restored, but the union of the rectum and sphincter and a considerable portion of the body took place. The points which the experience of the writer has shown to be of value in the treatment of this injury are: first, the restoration of the recto-vaginal septum by a flap, which does away with a rectal wound and with tension of the septum also ; and secondly, the selection of an appropriate diet by which the character of the fecal discharges can be con- trolled. The plan, adopted by some operators, of having frequent and early movements of the bowel during the pro- cess of union does not seem to be in accord with good sur- gical principles, which recognize rest as a most important factor in the healing of a wound. It was designed to avoid a danger which with appropriate diet will not occur. The diet here recommended would doubtless be well adapted to such a method if it were thought desirable. The antiseptic douche, although it favors hemorrhage, keeps the parts well cleaned during the operation, and prevents inflammatory re- action, which, however, may be partially accounted for by 330 A NEW OPERATION FOR RUPTURE OF PERINEUM. the lack of tension in the tissues. The stitches were kept in somewhat longer, as is the habit of the writer, than is customary. Experience shows that they do no injury, and serve a useful purpose in preserving the shape of the peri- neal body. The patients were all seen six months after the operation, and each one expressed herself highly pleased with the result. Note. Since this paper was written, further experience in sev- eral cases shows the method of handling the flap as given in Fig- ure 4, to be quite satisfactory. It is not necessary to dissect down the entire butterfly, but the dissection may be begun high enough on the vaginal wall to secure a sufficiently long flap, The denudation can then be continued with the scissors. Emmet’s plan of drawing down the vaginal mucous membrane by the upper stitch so as to cover the vaginal portion of the perineal body has been tried in two cases, with satisfactory re sults. MEASUREMENTS OF THE UTERINE CAVITY IN: ‘CHILDBED! FOURTH AND FIFTH SERIES OF ONE HUNDRED AND EIGHT CASES EACH. BY WILLIAM L. RICHARDSON, M. D,, Boston, Mass. ArT the annual meeting of this Society, held in Baltimore in 1879, my colleague, Dr. A. D. Sinclair, presented the measurements of the uterine cavity made in one hundred and eight patients who had been delivered at the Boston Lying-in Hospital. These measurements were made under our direction, and at the annual meeting held in 1881 he presented two additional series of one hundred and eight cases each. This paper contains a fourth and fifth series of similar measurements. In each series. we have given the same number of cases merely with a view to uniform- ity. These tables and analyses are the work of Dr. A. A, Jackson, one of the house physicians, and the averages have been calculated with a great deal of care and accuracy. The average depth of the uterine cavity in the first series of cases was 3.02 inches; second, 3.04 inches; third, 3.73 inches ; fourth, 3.67 inches; fifth, 3.31 inches. It has not been deemed advisable to attempt any general deduction from these observations until we were able to present the analysis of one thousand cases. When that number is reached I hope that the general average will be of some practical value to the profession. 332 MEASUREMENTS OF THE UTERINE CAVITY. TABLE I.— MEASUREMENTS OF THE UTERINE CAVITY IN CHILDBED. Primipara Primipara. Multipara. Primipara. Primipara. Multipara. Multipara. Primipara. Multipara. Multipara. Primipara. Primipara. Primipara. Primipara. Primipara. Primipara. Multipara. Primipara. Multipara. Multipara. Multipara. Primipara. Primipara. Primipara. Primipara. Primipara. Primipara. Primipara. Primipara. Multipara. Primipara. Primipara. Multipara. Primipara. Multipara. Primipara. Primipara. Primipara. Multipara. Primipara. Primipara. Primipara. Primipara. Multipara. Primipara. Primipara. Multipara. Primipara. Multipara. Primipara. Primipara. Primipara. Primipara. Multipara. Age. Duration of Labor. First | Second Stage.| Stage. him.) h. m. 9. te 0 39-45 I-15 12.30 1.10 5.30 1.30 ? ; 12. +17 4.15 +42 23-20 45 24. 2.15 10.10 +17 ? 2.40 10.30 8.55 8.15 37 ? +10 16.25 +54 3-45 25 16.30 2.13 De ? 5-25 +10 13.30 2.50 16.50 5-2 16.50 X77, 7. -28 11.30 2.27 11.45 I.12 14. 1.15 ries t. 5+25 3. 1.45 .10 13. .20 16.20 1.30 8.53 .20 3-20 2.30 55 +10 4015 2.24 4 2. II.15 2.15 9-35 +25 10. 4. 7-50 -10 5-30 .10 2-45 | 3-45 1.30 +25 7-30 a 18. +15 4.20 ? 7-40 +50 15-40 +20 9.30 +40 4. +30 17-20 +50 25. 3-30 8. +35 Day of Meas- urement. Length of Uterine Cay- ity in Inches. 34 Www PP opi Ll ol an ol PEARWWWWHWWHWWWWR DR RH ake Position of Uterus at Time of Measure- ment. Left lateral deviation. Normal. Normal. Anteflexion. Normal. Anteflexion. Anteflexion. Anteflexion, Normal. Normal. Normal. Normal. Normal. Normal. Anteflexion. Normal. Normal. Normal. Normal. Retroflexion. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal, Post-partum Condition. Remarks. Forceps. Child premature; 6} months. Ovaritis; perineum torn 1 inch. Cystitis; perineum torn x inch. Version. Stellate fissure of cervix. Perineum torn # inch. Slight laceration of perineum. Perineum torn 1 inch. Precipitate labor. Left lateral cervical lacera- tion. Face to pubes. Pleurisy; perineum torn % inch. Perineum torn $ inch. Lateral cervical fissure. Mammary abscess. Slight tear of perineum. Bright’ s disease. Perineum torn $ inch. Slight tear of perineum. Cystitis. Perineum torn 4 inch; ad- herent placenta; cystitis. Phlebitis. Membranes adherent; lacer- ation of cervix. Forceps; perineum torn $ inch; cystitis. Foot presentation. Version. Slight tear of perineum. Perineum torn } inch. Slight cervical fissure. Perineum torn } inch. Cervix slightly fissured. Perineum torn inch. WILLIAM L. RICHARDSON, M. D. 333 MEASUREMENTS OF THE UTERINE CAVITY IN CHILDBED — Continued. o n & | Primipara 2s or © | Multipara S) a 54 | Primipara. 55 | Multipara. 56 | Multipara. 57 | Multipara. 58 | Primipara. 59 | Primipara. 60 | Primipara. 61 | Primipara. 62 | Primipara. 63 | Multipara. 64 | Multipara. 65 | Primipara. 66 | Primipara. 67 | Multipara. 68 | Multipara. 69 | Multipara. 7o | Primipara. 71 | Primipara. 72 | Primipara. 73 | Multipara. 74 | Primipara. 75 | Primipara. 76 | Primipara. 77 Primipara. 78 | Multipara. 79 | Multipara. 80 | Multipara. 81 | Multipara. 82 | Primipara. 83 | Primipara. 84 | Multipara. 85 | Primipara. 86 | Primipara. 87 | Primipara. 88 | Multipara. 89 | Primipara. go | Primipara. gt | Primipara. 92 | Primipara. 93 Primipara. 94 | Primipara. 95 Primipara. 96 | Primipara. 97 | Primipara. 98 | Primipara. 99 | Primipara. 100 | Primipara. ror | Primipara. 102 | Multipara. 103 | Primipara. 104 | Primipara. 105 | Primipara. 106 | Primipara. 107 | Primipara. 108 | Primipara. Duration of Labor. First | Second Stage.| Stage him.| him : I.I - ; 5 9.50 +30 4. 37 6.30 Te 12.30 2. 16.5 1-55 9-30 +30 6.45 ? 3. Ts 9. -30 5-45 4-45 7s Be 9. 1.17 2.50 +20 2.48 ? 6.30 I. 6.30 +50 16.30 +30 4-15 +45 g-30 2.30 II. 1.10 19. 4.30 19-30 +30 21.45 -40 13-45 +20 6. I. 9: +30 12.40 +15 5-15 +15 21.10 25 8. 1.25 12.35 -40 28.30 7°55 3-15 +15 14. 50 oy 1.40 6.30 +35 7-15 +10 10.30 °45 56.30 I. 8. 1.30 28.5 -40 4.50 +10 7-45 +15 5-15 +35 23-15 I. 10.30 3-25 5-25 +15 1-45 +30 18.30 +55 18. 1.15 21.30 2.45 12.30 1.10 13-30 5-35 Day of Meas- urement. Length of Uterine Cay- ity in Inches. CofentaletoltCofstco} COCO} RW WW RO Position of Uterus at Time of Measure- ment. Normal. Anteflexion. Normal. Normal. Normal. Normal. Anteflexion. Normal. Normal. Normal. Anteflexion. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Anteflexion. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Anteflexion. Anteflexion. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Post-partum Condition. Remarks. Breech presentation. Melancholia. Slight cervical fissure. Perineum torn 4 inch. Perineum torn 3 inch. Child still-born; footling; forceps; prolapse of cord; cervix fissured; perineum torn. Secondary hemorrhage. Tonsillitis. High temperature; offensive lochia. Perineum torn # inch. Cystitis. Slight lateral cervical fissure; perineum torn } inch. Perineum torn 3 inch. Left lateral cervical fissure. Slight right cervical fissure. Slight lateral cervical fissure. Secondary hemorrhage. Perineum torn # inch. Perineum torn } inch. Perineum torn 1 inch. Slight cervical fissure; per- ineum torn $ inch. Perineum torn } inch. Perineum torn 3 inch. Still-born at 7 months. Perineum torn } inch. Perineum torn } inch. 334. MEASUREMENTS OF THE UTERINE CAVITY. Analysis of the. 108 cases gives the following results : — I. Average age of the 108 cases was 23.28 years. 2. Average age of 75 primipare was 21.75 years. 3. Average age of 33 multiparz was 26.75 years. 4. Average number of days in childbed when uterine cavity was measured was 18.86 days. 5. The uterine cavity measured 2? inches in 2 primipare, 1 multipara. The uterine cavity measured 3 inches in 6 primip., 4 multip. The uterine cavity measured 31 inches in 4 primip., I multip. The uterine cavity measured 3} inches in 6 primip., 4 multip. The uterine cavity measured 3} inches in 7 primipare. The uterine cavity measured 33 inches in 6 primip., 8 multip. The uterine cavity measured 33 inches in 1 primipara. The uterine cavity measured 33 inches in 17 primip., 3 multip. The uterine cavity measured 34 inches in I primip., 1 multip. The uterine cavity measured 4 inches in 13 primip., 5 multip. The uterine cavity measured 4} inches in 4 primip., 4 multip. The uterine cavity measured 41 inches in 6 primip., 1 multip. The uterine cavity measured 42 inches in 2 primipare. The uterine cavity measured 4} inches in 6 primipare. The uterine cavity measured 43 inches in 1 multipara. 6. Average day on which the 2? in. measurements were made (p. 24, Mal), 2.07, 7. Average day on which the 3 in. measurements were made (p. 23.83, M. 19.25), 22. 8. Average day on which the 3} in. measurements were made (p. 22.50, mM. 14), 20.80. g. Average day on which the 3} in. measurements were made (p. 19.33. m. 18.25), 18.90. Io. The 3} in. measurement was made on the 14th day. 11. Average day on which the 3} in. measurements were made (p. 23-33, M. 17.12.). 12. The 33 in. measurement was made on the 17th day. 13. Average day on which the 33 in. measurements were made (p. 20.65, m. 19), 20.40. 14. Average day on which the 3% in. measurements were made (p. 14, : Te ZO) 76 15. Average day on which the 4 in. measurements were made (p. 18.92, m. 19), 18.94. 16. Average day on which the 4} in. measurements were made (p. 15.75, m. 14), 14.8. 17. Average day on which the 4} in. measurements were made (p. 15.17, m. 13), 14.86. 18. Average day on which 42 in. measurements were made, p. 14.50. 19. Average day on which 44 in. measurements were made, p. 17.33- 20. 2I. 22. ae: 24. 25. 26. 27. 28. 29. 30. 31. 32. 33: 34. 35+ 36. 37: WILLIAM L. RICHARDSON, M. D. 335 The 48 in. measurement was made on the 12th day. Average length of the uterine cavity in 108 cases, 3.67 inches. Average length of the uterine cavity in 75 primiparz, 3.74 inches. Average length of the uterine cavity in 33 multipare, 3.52 inches. Average length of uterine cavity in 46 cases (26 primip., 20 mul- tip.), measured within 16 days, 3.71 inches. Average length of primipare, 3.85 inches ; average length of mul- tiparz, 3.71 inches. Average day on which the uterine cavity was measured in 37 pri- miparz, with more or less laceration of the perineum, 19.95. Average length of uterine cavity, 3.68 inches. Average day on which the uterine cavity was measured in 13 mul- tiparze, with more or less laceration of the perineum, 17.23. Average length of uterine cavity, 3.70 inches. Average day on which the uterine cavity was measured in 5 pri- miparze, with more or less laceration of the cervix uteri, 16.40. Average length of the uterine cavity, 33 inches. Average day on which the uterine cavity was measured in 5 mul- tiparze, with more or less laceration of the cervix uteri, 17.20. Average length of the uterine cavity, 3.32 inches. Average day on which uterine cavity was measured in 3 primipare, with more or less torn perineum and lacerated cervices, 19. Average depth of uterine cavity, 44 inches. One multipara, with torn perineum and lacerated cervix, had a uterine cavity of 44 inches on the 13th day. Case XXII. One primipara with high temperature, pleurisy, ane- mia, and lacerated perineum, had a uterine cavity which meas- ured 3 inches on the sSoth day. Case XXXV. One primipara with adherent placenta, lacerated cervix, torn perineum, cystitis, and offensive lochia, had a ute- rine cavity which measured 43 inches on the 22d day. Case XXXVIII. One multipara with adherent membranes, lacer- ated cervix, offensive lochia, and very severe after-pains, had a uterine cavity which measured 3} inches on the 25th day. Case LVI. One multipara with melancholia, pyrexia, and offen- sive lochia, had a uterine cavity which measured 4 inches on the 38th day. Case LXII. One primipara with prolapsed cord, a still-born foot- ling, post-partum hemorrhage, lacerated perineum and cervix, tenderness, and odor, had a uterine cavity which measured 4} inches on the 17th day. Case LXXIII. One multipara with adherent placenta, torn peri- neum, high temperature, and tenderness, had a uterine cavity which measured 33 inches on the 15th day. Case CII. One multipara with septicemia, had a uterine cavity which measured 3 inches on the 29th day. 336 MEASUREMENTS OF THE UTERINE CAVITY. TABLE II.— MEASUREMENTS OF THE UTERINE CAVITY IN CHILDBED. Primipara or Multipara. Primipara. Primipara. ia | No. of Case. Primipara. Primipara. 3 4 s | Primipara. 6 | Primipara. 7 | Multipara. 8 | Primipara. 9 | Multipara. 10 | Primipara. rr | Multipara. x2 | Multipara. 13 | Primipara. 14 | Primipara. 15 | Primipara. 16 | Primipara. 17 | Multipara. 18 | Primipara. 19 | Multipara. 20 | Primipara. 21 | Multipara. 22 | Multipara. 23 | Primipara. 24 | Primipara. 25 | Multipara. 26 | Primipara. . 27 | Multipara. 28 | Multipara. 29 | Primipara. 30 | Primipara. 3r | Primipara. 32 | Primipara. 33 | Primipara. 34 | Primipara. 35 | Primipara. 36 | Primipara. 37 | Primipara. 38 | Primipara. 39 | Multipara. 40 | Primipara. 41 | Primipara. 42 | Multipara. 43 | Primipara. -44 | Primipara. 45 | Primipara. 46 | Primipara. 47 | Primipara. 48 | Primipara. 49 |M ultipara. 50 | Primipara. 51 | Primipara. 52 | Primipara. 53 | Primipara. 54 | Multipara. Age. Day of Meas- urement. Length of Uterine Cay- ity in Inches. Duration of Labor. First | Second Stage.} Stage. him. | he m. 4. 5 6.20 +20 aan I-15 3-50 +20 17-40 6.40 13-55 “45 7-20 +20 10.30 2.5 15-45 +15 3-45 “15 6.5 +15 22.10 55 3-15 -50 15.5 +20 16. +30 30. “45 35° +10 7-15 1.25 12.40 -10 6. Tie 1.30 5 7- +15 5-30 +15 2.30 “45 9. 25 20.20 35 5:45 +55 16. 3 19. 1-5 21.30 4. 16.20 1.5 11.20 +30 3. T-55 8. 1.30 13. 7-5 Il. 20 I2. 1.20 14.30 2.10 6.30 1.20 20. 1.35 8.30 ais 8.50 +25 10.30 -40 8 30 Ze ? ? 25-30 2.55 12.45 1.5 4.30] 1-55 2.10 +50 13. 3-35 26.15 15 20. 1.25 18.45 aes 5.40 025 WONWWWW HN BARA empl oe Bie Set Bata WOWNNWENDWWNHWHOWWARWOWWWWWWWW Br aPaanon SSR eHiel Position of Uterus at Time of Measure- ment. Normal. Normal. Normal. Normal. Normal. Normal. Anteflexion. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Normal. Post-partum Condition. Remarks, Still-born at 8} months. Secondary hemorrhage; per- ineal laceration. Cervical fissure; puerperal septicemia. Lateral cervical fissure, Perineum torn. Perineum torn. Lateral cervical fissure. Post-partum hemorrh perineum torn; cervix lace erated. Lateral fissure of cervix. Perineum torn, Fissure of cervix. Perineum torn. Port-partum hemorrhage 3 fissure of cervix. Cervical fissure. Cervical fissure. Cervical fissure. Cervical fissure. Tear of perineum; ovaritis. Cervical fissure. Cervical fissure. Perineal tear. Cervical fissure. Cervix lacerated. Cervix lacerated. Eclampsia; manual dilata- tion ; version ; cervical fis- sure; perineum torn. Perineum torn ; rheumatism. Perineum torn; lateral cer- vical fissure. Perineum torn. Cervical fissure. WILLIAM L. RICHARDSON, M. D. 537 MEASUREMENTS OF THE UTERINE CAVITY IN CHILDBED — Continued. 3 Duration | | 8.8] Position of & a of Labor. Ol Ses ep aaa ae a EI a Sax : Post-partum Condition. a or Age. “5 /S en Ee Remarks. ~ | Multipara. First | Second | 5,£| #5.g| Measure- 5 Stage.| Stage. |S 5) 35 > ment. h.m.| hem 55 | Primipara. | 21 | 11-30 2.30 I2 3% | Normal. t 56 | Multipara. | 26 | 6. .20 | 14 | 3% | Normal. Perineum torn. 57 | Primipara. | 24 | 14.30 9.28 24 34 | Normal. Forceps; perineum torn ; cervix fissured, 58 | Primipara. | 20 | 5.30] 3.2 17 | 4 Normal. Cervical fissure. 59 | Primipara. | 22 | 6. 7-10 | 17 | 34 | Normal. Cystitis. 60 | Primipara. | 23 | 14.13 -55 | 20 | 34 | Normal. 6x | Primipara. | 24 | 29.30 | 1-25 14 | 3% | Normal. ; 62 | Primipara. | 19 | 25.15 | 1-23 | 17 | 3% | Normal. Perineum torn. 63 | Multipara. | 28 | 7.10 20 | 22 | 32 | Normal. ; p 64 | Primipara. | 23 | 10. 1655 20 34 | Normal. Twins; cervical fissure. 65 | Primipara.| 19 | 16.30 | 2-10 | 33 | 2% | Normal. 66 | Primipara. | 18 | 5.30] 1.40 | 18 | 34 | Normal. 67 | Multipara. | 26 | 5. ae ma 1.3 Normal. 68 | Primipara. | 18 | 15.45 .20 16 2% | Normal. Perineum torn; cervical fis sure ; mammary abscess. 69 | Primipara. | 20 | 15.15 .30 | 13 | 2% | Normal. Syphilis ; ;_child putrid. zo | Primipara. | 24 | 32.15 +25 14 | 2 | Normal. Cervical fissure. 7 | Primipara. | 19 | 25.30] 1-20 | 15 | 34 | Normal. 72 | Primipara. | 18 | 3.5 3: 43 | 14 | 34 | Normal. Cervical fissure. 73 | Primipara. | 21 | 3.30 25 | 3 Normal. Perineum torn. 74 | Primipara. | 20 | 29. z ‘58 | 13 | 3% | Normal. Perineum torn. 75 | Primipara. | 23 | 5.30 -20 | 13. | 34 | Normal. Cervical fissure. 76 | Multipara. | 23 | 5.20 1.35 13 4 Normal. 77 | Multipara. | 26 | 8. 2.35 | 13 | 34 | Normal. Perineum torn; cervical fis- sure. 78 | Multipara. | 24 | 2.30 .10 14 | 3% | Normal. Perineum torn. 79 | Primipara. | 27 | 15.50 | 2.5 23 3z | Normal. Perineum torn. Primipara. | 19 | 17.30 1.45 15 34 | Normal. 81 | Multipara. | 28 | 2.30 45 18 | 34 | Normal. Cervical fissure. 82 | Primipara. | 24 | 1.50 520 _|, 2x 3% | Normal. Perineum torn. 83 | Primipara. | 19 | 17.45 -30 | 20 | 3% | Normal. Perineum torn. 84 | Primipara. | 18 | 8 20 1.40 16 | 2% | Normal. 85 | Primipara. | 26 | 18.45 2.23 15 2% | Normal. Perineum torn. 86 | Multipara. | 23 | 14.35 -15 | 13 | 2% | Normal. 87 | Primipara. | 20 | 29.30 .20 | 16 Bg Normal. 88 | Primipara. | 23 | 10.45 .10 14 2 Retroversion.| Tonsillitis ; cervical fissure. 89 | Primipara. | 21 | 15.40 +40 13 3% | Retroversion.| Perineum torn. go | Primipara. | 23 | 23. +50 12 4 Retroversion.| Perineum torn; cervical fis- sure. gi | Multipara. | 32 | 9.50| 25 12 | 3% | Retroversion.| Perineum torn; cervical fis- sure. 92 | Primipara. | 18 | 14. -35 | 16 | 44 | Retroversion.| Cervical fissure. 93 | Primipara. | 25 | 26. 1.35 15 4 Anteversion. | Cervical fissure. : 94 | Primipara. | 22'| 21-10} 3.25 | 18 | 4 Anteversion. | Cervix lacerated; perineum 95 | Primipara. | 19 | 20.10] 1.30 | 15 | 4% | Anteversion. | Cervical fissure. g6 | Primipara. | 22 | 26.5 25 14 3 Anteversion 97 | Multipara. | 27 | 13.5 +15 16 3 | Anteversion. . 98 | Primipara. | 24 | 11-20| 2.45 12| 4 Anteversion. | Cervical fissure. 99 | Primipara. | 19 | 8.30 45 14 | 3% | Anteflexion. | Cervical fissure. . roo | Primipara. | 26 | 11.50 40 | 15 | 4% | Normal. Perineum torn; deep cervi- cal fissure. — ror | Primipara. | 38 | 49. 2.5 14 | 3% | Normal. Forceps; perineum torn ; ; cervical fissure. 1o2 | Multipara. | 28 | 15.15 35 16 3 Normal. 103 | Primipara. | 31 | 1-30] 215° | 15 3} Normal. Cervical fissure; cystitis. 104 | Primipara. | 24 | 18.40] 6.15 16 | 3 Normal. Cervical fissure. 105 | Primipara. | 28 | 10.50 5 12 3 Normal. Perineum torn. | 106 | Primipara. | 23 | 6.5 3. 14 | 3% | Normal. Cervical laceration. 107 | Multipara. | 26 | 4.10 10 | 13] 34 | Normal. : > 108 | Multipara. | 24 | 12. 2.15 14 | 3% | Normal. Cervical laceration. VOL, VII. 22 338 MEASUREMENTS OF THE UTERINE CAVITY. Analysis of 108 cases gives the following results : — I. Goa a 21. Average age of the 108 cases was 24.08 years. Average age of 81 primiparz was 22.68 years. Average age of 27 multiparee was 25.48 years. Average number of days in childbed when uterine cavity was measured was 16.83 days. The uterine cavity measured 21 inches in 1 multipara. The uterine cavity measured 2} inches in 8 primipare, 1 multipara. The uterine cavity measured 2? inches in 7 primip., 2 multip. ~ The uterine cavity measured 3 inches in 9 primip., 2 multip. The uterine cavity measured 3} inches in 20 primip., 8 multip. The uterine cavity measured 3} inches in I primipara. The uterine cavity measured 34 inches in 15 primip., 9 multip. The uterine cavity measured 3? inches in Io primip., 3 multip. The uterine cavity measured 4 inches in 5 primip., I multip. The uterine cavity measured 4} inches in I primipara. The uterine cavity measured 44 inches in 4 primipar%e. The 2} in. measurement was made on the 28th day. Average day on which the 2} in. measurements were made (p. 18.62, m. 14), 18.11. Average day on which the 23 in. measurements were made (p. 17-714 Ms 13.33). tO.7 75 Average day on which the 3 in. measurements were made (p. L555 Ero) Toric. Average day on which the 3} in. measurements were made (p. 18.1, Mm. 16), 17-5: The 3} in. measurement was made on the 28th day. Average day on which the 3} in. measurements were made (p. 17, m. 14.22), 15.96. Average day on which the 33 in. measurements were made (p. 15.40, m. 16.66), 15.69. Average day on which the 4 in. measurements were made (p. 15, m. 13), 14.66. The 4} in. measurement was made on the 15th day. Average day on which the 44 in. measurements were made, 15.25. Average length of the uterine cavity in 108 cases, 3.31 inches. Average length of uterine cavity in 80 primipare, 3.34 inches. Average length of uterine cavity in 28 multipara, 3.29 inches. Average length of uterine cavity in 61 cases (43 primip., 18 mu- tip.) measured within 16 days, 3.34 inches. Average length of primipare was 3.36 inches ; average length of multiparz was 3.31 inches. Average day on which the uterine cavity was measured in 14 pri- mipare, with more or less laceration of the perineum, 19.74. Average length of uterine cavity, 3.25 inches. 22. 23. 24. 25. 26. a7 28. 29. WILLIAM L. RICHARDSON, M. D. 339 Average day on which the uterine cavity was measured in 2 mul- tipara, 14.5. Average length of uterine cavity, 33 inches. Average day on which the uterine cavity was measured in 18 pri- mipare, with more or less laceration of the cervix uteri, 16.11. Average length of the uterine cavity, 32 inches. Average day on which the uterine cavity was measured in 9 mul- tiparze, with more or less laceration of the cervix uteri, 15.89. Average length of the uterine cavity, 34 inches. Average day on which the uterine cavity was measured in 14 pri- miparz, with more or less torn perineum and lacerated cervices, 15.36. Average length of the uterine cavity, 33 inches. Case XLV. One primipara with eclampsia, manual dilatation and version, torn perineum, and lacerated cervix, had a uterine cav- ity which measured 3+ inches on'the 15th day. Case LXIV. One primipara with twins, marked edema of feet and legs, large amount of albumen and casts, and a fissured cer- vix, had a uterine cavity of 3} inches on the 2oth day. Case LXVIII. One primipara with torn perineum and lacerated cervix, mammary abscess, high temperature, had a uterine cav- ity of 22 inches on the 16th day. Case CI. One primipara, delivered by forceps, with torn peri- neum, lacerated cervix, had a uterine cavity which measured 3} inches on the 14th day. SURGICAL OPERATIONS .ON THE PEENVIC ORGANS OF PREGNANT WOMEN. ‘BY MATTHEW D. MANN, A.M., M.D., Buffalo, N. Y. WHETHER or no it be best to operate on a pregnant woman is a question which will often force itself upon the attention of the surgeon. While sometimes the exigencies of the case will make clear his line of action for him, still he is certain to meet with occasions when he will be cailed upon to decide as to the propriety of operating, and where the nature of his decision will have a most important influ- ence on the welfare of his patient. These occasions, to be sure, are rare; but this very rarity implies want of expe- rience, and leads the surgeon to desire some guide, or some reliable observations, by the study of which he may come to an intelligent and safe decision. If he seeks to be gov- erned by the rules of the books, or by the experience of others, he will find very little written to guide him, and very few recorded observations from which to draw conclusions. It is for the purpose of adding to our scanty stock of knowl- edge on this subject, and to enable us to deduce certain rules for our guidance in practice, that I have collected the cases here reported. As the pregnant woman has generally been considered by the operating surgeon as a sort of a moli me tangere, the reports of operations performed during this condition are necessarily rare, and the operations are either those done un- wittingly or those rendered imperative by the nature of the case, If this be so of operations in general, it is still more so if we limit our investigation to operations involving the MATTHEW D. MANN. 341 pelvic organs. We then find the material to be very scanty and widely scattered. To collect a sufficient number of cases, I addressed letters to certain prominent gynecolo- gists,! asking for the results ef their experience, and have been thus furnished with quite an array of cases never before published. A number replied that they had never met with any cases, and among these were some of our most busy operators, To the cases thus collected I have added some taken from our current literature, and a few from my own experience. My attention was first drawn to the subject by a case, to be detailed later, in which I repaired a torn cervix, and the woman, to my great surprise, bore twins at full term, about seven months. later. This I at first considered a lucky chance, but since I have collected the material for this paper, have somewhat changed my mind. The question of performing ovariotomy during pregnancy presents so many points of a special nature, and has already received so much attention, that its discussion will be put outside of our present limits. The reasons why operations have been avoided during pregnancy are based on the varied and striking changes which take place in the woman’s organism with the advent of conception. I need only recall them to mind. The blood is altered both in its constituents and in its quantity. The red corpuscles become fewer, and the white more nu- merous. The blood also contains more of water and fibrine, and less of albumen and iron. To accommodate this changed condition of the circulating medium, the heart itself undergoes certain modifications. Its cavities are dilated, and there is hypertrophy of the left ventricle. As a result of the addition to the quantity of the blood, as well as the changes in the heart, we have increased arterial ten- sion. The glandular and nervous systems also undergo very marked alterations. 1 To the gentlemen who have thus kindly interested themselves in my behalf I wish to extend my sincerest thanks. In many instances I know it involved a great deal of personal trouble, which is fully appre- ciated. 342 SURGICAL OPERATIONS ON PREGNANT WOMEN. But it is in the genital organs that we find the greatest changes. With the fixation of the impregnated ovum in the uterine cavity there is renewed activity in the formative processes in all the organs involved in the nourishment and expulsion of the growing fetus. The uterus at once in- creases in vascularity, and its ultimate fibres begin to grow in every direction. The blood-vessels increase in size and number, while the lymphatics, which were previously small and unimportant, become greatly hypertrophied and increased in number. The connective tissue around the uterus, and in the broad ligaments, is also hyyertrophied and softened. Changes of the same nature take place co- incidently in the vagina. All these metamorphoses, both those in the general organ- — ism and those in the special organs involved, would seem to invite accident in the event of an operation. The in- creased arterial tension, as well as the enlargement of the vessels, and the general softening of the tissues, would all seem to make probable the occurrence of more than the usual amount of hemorrhage, and make its arrest very diffi- cult. The enlarged lymphatics would certainly open the doors to the rapid and easy absorption of septic material, while the quickened cell growth, as well as the increase in the number of white corpuscles in the blood, might lead us to expect a considerable tendency to pus formation. But above all these a friorz objections stands out — the great and undoubtedly real one —the danger of interfering with the growth of the product of conception, or, in other words, the danger of producing an abortion. There is little use in arguing about this, for the well-known differences -which exist in individual tendencies and predispositions render all of our reasoning vain. As long as one woman aborts from a misstep while her neighbor goes through a severe accident without any interruption in the progress of the utero-gestation ; as long as this is so, —and we are un- able to explain the causes of the difference in the results, — so long will we be unable to predict with certainty the re- sults of an operation to be performed on the genitals of a MATTHEW D. MANN. 343 pregnant woman. But while this must in general be admit- ted, still, from a careful study of the physiology of the parts involved, and from the consideration of the results already obtained by operators, we may be able to give a certain amount of probability to our prognostications which will enable us to act intelligently in any given case. In addition to the changes already described as taking place in the uterus, we have the great change due to the presence in its cavity of a growing body. This of course produces a dilatation of the cavity pave passu with the growth of the ovum. In this dilatation, however, the cervix takes little or no part. While the cervical tissues increase to a certain extent, the growth is in no wise commensurate with the increase which takes place in the parts above the inter- nal os. By the end of the fourth month the cervix has attained its full size, and thereafter remains unchanged until the beginning of labor. These points, although long con- tested, are now very generally considered to be settled. With the growth of the cervix occurs that peculiar soften- ing of the tissues, which is so characteristic of the preg- nant condition. It will be seen then that an application may be made, even up into the cervical canal, without in any way neces- sarily involving the integrity of the ovum; and the same is true of a cutting operation, provided the internal os is not too nearly encroached upon. While this is true ina strictly anatomical sense, the peculiarities of the individual, already alluded to, or, in other words, the susceptibility of the reflex centres, introduce an element of uncertainty. As the uterus is left, the nearer we approach the vulva the less does this element of uncertainty enter into the case, the less danger is there of provoking uterine contractions. The stage of the pregnancy is also an important element in the question. It is generally well recognized that in the earlier stages, and at the menstrual epochs, uterine con- tractions are more easily excited, and abortions more apt to occur than in the middle periods. The same is true toward the end of pregnancy, though after the child is viable, its expulsion is a matter of less importance. 344 SURGICAL OPERATIONS ON PREGNANT WOMEN. Having grouped together the arguments against operating on the genitalia of a pregnant woman, it would be unfair not to give the points which might be urged in favor of the choice of this time for operating. The greater amount of fibrine in the blood might, by in- creasing its coagulability, counteract the supposed hemor- rhagic tendencies. The increased cell growth might also be thought to favor repair and aid primary union ; and also in the case of plastic reparative operations to so aid the growth of the newly-formed connective tissue as to make it suffi- ciently strong to endure the strain necessarily brought to bear upon it in the labor. These are scarcely arguments, and would not count unless there were other and mightier reasons for choosing pregnancy as the time for operating. We have then two aspects of the question before us for discussion: The influence of pregnancy on operations in general ; and The effect which operations have on preg- nancy. First let us see what have been the results of operations on other parts of the body. The general feeling on the subject is doubtless well ex- pressed by Dr. Priestley when he says: “It is generally supposed that no operation should be performed during pregnancy, even removing a tooth.” Paget, however, says that pregnant women bear operations well. Cohnstein con- cludes, from the consideration of a number of cases, that repair goes on unimpeded, union by primary intention being rare, but suppuration sometimes very profuse. As regards the second question, Cohnstein found that after operations and injuries pregnancy terminated naturally in 54.5 per cent. of all cases. Massot concludes that ordinary surgical operations do not interfere with pregnancy, unless they ma- terially and permanently disturb the uterine circulation, or excite uterine contractions by reflex irritation. Verneuil has observed a great number of traumatic lesions in preg- nant women, and considers that temperature is the great factor in determining the results, whatever be the cause of the febrile action; if 40° C. (104° F.) be reached, as a gen- eral rule, abortion and death follow. M. Nicaise expresses MATTHEW D. MANN. 345 the opinion that the nearer the lesion is to the genital organs, the greater is the danger of abortion, an opinion reéchoed by nearly every writer on the subject, and sup- ported by Cohnstein’s statistics. In them he shows that of the 45.5 per cent. in which abortion occurred, in 32 per cent. the genito-urinary organs were involved in the opera- tion. In Massot’s statistics the percentage of abortions in the two classes of cases are about the same. He collected 214 cases; of these 83 were accidents, and 131 operations. Of the 131 operations, 62 involved the genital organs, and 69 did not. Of the 62, 41 recovered, 66.1 per cent, and 19 aborted, 30.6 per cent. While of the 69 general operations, 47 recovered, 68 per cent., and 21, or 30.4 per cent., aborted. These, then, are the general conclusions to which previ- ous investigators lead us. As far as operations on the pelvic organs are concerned, they are based on too few cases to be at all conclusive, and fail to lay down any rules for practice. I propose, therefore, to examine all the cases which are ac- cessible, grouping them according to the organs which they involved, and try to draw some practical lesson from their consideration. OPERATIONS ON THE VULVA. Abscesses of the vulva are not very uncommon during pregnancy. Cohnstein and Massot have collected a number of cases as follows :— One case by Grenser, successful. Two by Verneuil; first case (144),! abortion and death ; patient was in the sixth month. There was in this case an abscess of the ovary and tube, probably due to the same cause as the abscess of the vulva, namely, gonorrhea. This ruptured into the peritoneal cavity and caused death. There was, however, an angeioleucitis and lymphadenitis starting from the labial abscess, which may have been the cause of the abortion. Second case (146), in seventh month ; was successful. Després (145), two cases successful. Petit, one case (147), in the fourth month. Spontaneous rupture, re- 1 Numbers after cases refer to Massot’s work. 346 SURGICAL OPERATIONS ON PREGNANT WOMEN. covery. Five cases in all, with one abortion followed by death. The others healing quickly, and without accident. Tumors of the Vulva. Cohnstein finds a case recorded by Simon, in which the lower half of the right labium was amputated for a large sarcoma in the second month of the pregnancy. The wound healed rapidly, and the pregnancy was not interfered with, but the sarcoma returned before labor set in. Dr. Parvin! reports a very interesting case, as follows : — “The patient, about twenty-four years old and pregnant for the first time, was found to have a large labial cyst. ‘The tumor was first noticed at the age of fourteen, about the time of the first menstruation, but grew very slowly until after marriage. When she became pregnant it grew very fast, doubling in size within three or four months. I saw her when about four months ad- vanced in pregnancy ; removed about one third of the cyst wall, — after exposure and evacuation of its contents, —and then filled the cavity with lint. The patient did well, and did not miscarry. The tumor was the size of a large orange.” Dr. Paul F. Mundé sends me the following : — “A colored woman, aged twenty-four, had borne four children, and had one miscarriage. During her first pregnancy, six years before, she noticed an enlargement of the labia. It subsided after the birth of her child, but during the second pregnancy it again developed. When seen it was of the size of the fist. It involved the nymphe, clitoris, and labia majora. From being ulcerated it caused a great deal of pain. She was then four months pregnant. In view of the probable rapid growth of the mass (which was recognized as an elephantiasis of the vulva), and on account of the suffering it caused, its removal was deter- mined upon in spite of the known pregnancy. The operation took place June 18. Elastic ligatures were used over three needles, transfixing the tumor transversely. ‘The mass was then excised above the ligatures. There was no hemorrhage. After the removal of the ligatures, a dozen or so spurting arteries were 1 Dr. Parvin also reports a case of amputation of the breast for can- cer, and of the leg for malignant disease, with good results in both cases, and without inducing abortion. MATTHEW D. MANN. 347 caught and tied, and the wound closed by twelve sutures. Union almost by first intention, except in the tracks of the ligatures, which came away on the tenth day. No interruption of the pregnancy.” A somewhat similar case is reported by Churchill (157). The patient was in the seventh month. The nymphe and clitoris were hypertrophied, forming three large tumors, the central one being as large as aturkey’s egg. This tumor only was removed, by ligatures and excision, three days afterward. The patient recovered perfectly. Massot (156) quotes from Aubenas an account of a large lipoma of the vulva. It weighed three pounds, was re- moved, and patient made a good recovery. Of Venereal Warts or Vegetations of the vulva, Massot has collected a number of cases. Velpeau (148), in 1845, removed an enormous vegetation. Considerable hemorrhage followed, and some days after abortion with recurrence of hemorrhage; recovery. Gailleton (149) reports three cases where he removed vegetations unwittingly during pregnancy ; two of his cases miscarried. Chassaignac (150) had a case where, after trying acetic acid and Vienna paste, he used a great number of ligatures. The patient was five months advanced, and made a good recovery without miscarriage. In a second case (151) at the third month he used the linear écraseur with satisfac- tory results ; no hemorrhage or abortion. Demeaux (152) met with a case where the vegetations, in two masses, reached from the mons veneris to the peri- neum, each one as large as a man’s fist. The operation was performed in the fifth month, the tumors being excised and the hemorrhage stopped with difficulty with perchloride of iron. The hemorrhage recurred in the night, and again the next day. The wound was all healed on the eighth day, and the patient was finally delivered at term. Demeaux (153) also operated on a mass as large as a fist. The patient recovered quickly and went to term. Despreés (154) reports a case of a “ douguet de végétations”’ 348 SURGICAL OPERATIONS ON PREGNANT WOMEN. as large as the head of an adult. The patient was twice operated upon when in the fifth month; hemorrhage was considerable, but she recovered and went her full time. He reports also (155), that he has removed very large vege- tations from six patients, being from three to seven months advanced. All were primiparz, and from seventeen to twenty years of age. None of them aborted. Violet and Tilleaux also report two cases each, in which they removed large vegetations without accident. Total, nineteen cases of vegetations of the vulva, with three mis- carriages. Unfortunately, of the cases which miscarried we have no details. Here we have twenty-eight cases in which operations of more or less severity were performed on the vulva, and in only four instances were there any bad results ; the others recovered without interruption of the pregnancy. As has been already said, one of the fatal cases was so from com- plications not connected with the operation. THE PERINEUM. The operation of Perincorrhaphy is so very common that it is not at all surprising that a certain number of opera- tions performed during pregnancy are reported. Dr. Good- ell met with two cases, one three months pregnant. She went to term, and, by making bilateral incision, he saved the raphe. The other went to term, but the effect on the restored perineum is unknown. He noticed a good deal of hemorrhage during both operations. Dr. J. R. Chadwick sends a case as follows: — “The patient was one in the country, whom I had never seen before. Two weeks later, after she had suffered from severe ab- dominal pain, I was hastily summoned, with the information that the operation seemed to be a success, but that the attending physician had that morning discovered something resembling a sloughing coil of intestines protruding from the vulva. This he had carefully pushed back. On uncovering the woman I found a two and a half months’ fetus hanging by the navel-string. I have since learned that, in extracting the placenta, a part of the united perineum was torn out.” ~~ MATTHEW D, MANN. 349 Dr. G. R. Shepherd, of Hartford, Conn., sends me the following very interesting case : — “Mrs. A., aged twenty-eight, mother of two children, sustained a double laceration of the cervix in her first confinement, the per- ineum being also torn completely through the sphincter. The extent of the injury was recognized at the time, but no immediate surgical measures were adopted beyond confining the knees with a bandage, and consequently her second pregnancy, at the expi- ration of fourteen months, found her with the lips of the uterus widely separated and everted, though entirely covered with healthy mucous membrane. The sphincter ani was unable to retain either flatus or moderately fluid evacuations. She did not mis- carry with her second child, but was confined at full term. Six months later she presented herself for operation upon the cervix. Menstruation had recurred, though irregularly, during her second lactation, and consequently I found it impossible to know just when to expect it ; but as her stay in the city was necessarily lim- ited, I operated on the 2oth of September, 1881, a little over six weeks from the last menstrual period. Pregnancy not being sus- pected, the uterine sound was carried to the fundus at the time of the operation, and again two weeks later, when the stitches were removed. The nausea and vomiting that followed the operation were very annoying, and continued to recur every few days for two or three weeks'after the removal of the stitches. Her breasts began to enlarge and became sensitive, and, when I decided to operate upon the perineum on the 18th of October, she was feel- ing quite confident (and I very strongly suspected) that she was pregnant.” “Both operations were successful, and pregnancy progressed without interruption. She left for the West in November. Her husband, a physician, watched her carefully, and wrote me, after the period of quickening, that he expected her confinement early in May, 1882, and stated that in her condition it was a great com- fort to have the complete control of her sphincter, which the op- eration had given. In March she decided to return East for her confinement, but while on the way was attacked with pneumonia, and died at Montreal. I observed no greater care in this case than is my custom, and noted nothing at the time of the opera- tion that was at all unusual. Regarding the question of hemor- rhage, I can simply state from memory that, if anything, there was less than usual, though not markedly so.” 350 SURGICAL OPERATIONS ON PREGNANT WOMEN. It may be objected to this case that it is not a fair one to draw conclusions from. A woman who, while pregnant, could bear the passage of the sound to the fundus on two different occasions could hardly be made to abort. Dr. Reamy gives the history of two cases as follows :— CasE I. — Mrs. F., aged twenty-eight, mother of two children, the youngest thirteen months old. During her first labor she suffered a laceration of the perineum, dividing the external sphinc- ter, but not the recto-vaginal septum. She consulted me March 1, 1879 ; was then suffering from the symptoms usual after such an accident. Deformity of the vaginal entrance very marked, also considerable prolapse of the posterior vaginal wall. Vaginal contractility much impaired, greatly annoyed by the escape of wind from the vagina, especially when lying upon the side. Uterus slightly prolapsed ; slight erosion of os. Much mental depression. Perineorrhaphy decided upon. Operated April 3, 1879 ; five sutures removed on the eleventh day ; results perfect. At the date of the operation menstruation, which, had been quite regular for several months, was due in fifteen days. It did not, however, appear, and time proved that she was pregnant. She was delivered January 5, 1880, of a healthy child — weight, nine pounds — without any laceration of the perineum. I obtained from her and her husband the following facts: Previous to the operation, her child had been weaned three months. Her hus- band had been absent during the three weeks immediately pre- ceding the operation, arriving at home April 1. Connection took place on the nights of the 1st and 2d ; the operation was on the 3d of April. Intercourse was not again had until six weeks sub- sequently. The child was born two hundred and seventy-four days from the date of the operation. Consequently, insemina- tion, if not pregnancy, occurred before the operation was done. While this can hardly be called an operation during preg- nancy, still it illustrates very forcibly the strength of the new adhesions formed during this period, there having been no rupture of the new perineum, notwithstanding a nine pound child. Case II.— Mrs. G., aged twenty-four, mother of one child two years old, came under my care in January, 1881. She was two months advanced in pregnancy, and was reduced to a mere skel- MATTHEW D. MANN. 351 eton, having vomited daily, often as many as twenty times a day for the past month. She was of the poorest class, and consulted me at the Good Samaritan’s Hospital. The perineum had been torn at her labor through the anal sphincter, the rent in the bowel extending half an inch, but the internal sphincter was, of course, not totally destroyed. Her condition, however, had been miserable, for, as she was compelled to wash for a living, uterine prolapse, with all its concomitants, had occurred. Pessaries had proved to be of no use. At the examination I found the os pro- truding slightly beyond the external vulvar wall, considerably eroded, with some leucorrhea. As she could not leave her family to enter the hospital, I determined to operate at her home. After keeping her in bed but one week, with the hips elevated and daily applications of cotton pessaries saturated with glycerine, carbolic acid, and tannin, the condition was so far improved that I operated, doing my own modification of Emmet’s operation for restoring the perineum in cases involving the bowel. Vomiting ceased within twenty-four hours after the operation. The sutures were allowed to remain fourteen days. The result was perfect. She was kept in bed for three weeks after the removal of the su- tures. The uterus was supported by a hard rubber bow pessary until the fifth month of gestation, when it was no longer needed. Vomiting never returned, and her general health became good. I delivered her of a male child weighing nine and a half pounds, August 21. There was very slight laceration of the perineum, of no importance. It was due to the fact that I had carried the base of the perineal body very far forward in the operation for its restoration. This case not only shows the harmlessness of operating on the perineum during pregnancy, but it also gives us an indication for operating, and, like the previous case, illus- trates the behavior during labor of a perineum only six months old, and made during pregnancy. The late Dr. J. C. Nott met with a case of which the following is an abridged account: Mrs. L., aged thirty-seven, excessively fat and very short, general health very poor, two children, the last twelve years before. At that time the perineum was torn down to the sphincter ani. When seen she had not menstruated for eight years. The uterus 352 SURGICAL OPERATIONS ON PREGNANT WOMEN. was very small, the uterine sound passing only two inches. A large cicatrix over the perineum was in a state of extreme hyperesthesta, Following two sponge tents a slight bloody flow occurred, but was not repeated. Four months later the perineum was operated upon, Drs. Sims and Thomas assisting. Pregnancy unsuspected. But Dr. Nott says: “Even if I had suspected pregnancy, I think the operation would have been justifiable, as her general health demanded relief, and it was clear to my mind that she could not, in her condition, carry a child to term.” Union was solid, and the soreness and morbid sensibility disappeared. ‘Has not felt so well for years.” Two months after the operation she aborted. Dr. Nott was charged with ignorance and malpractice in this case, because he did not know that she was pregnant, and because he operated during pregnancy. The experience of later operators, already detailed here, fully justifies Dr. Nott, when he says: “ Although I would not have performed the operation without a consultation if I had been aware of pregnancy, still I believe her case to be a strong exception to the general rule forbidding it, and would unhesitatingly have advocated the operation.”” With the results now before us it would hardly be necessary to call the consultation. The occurrence of the abortion at so late a date after the operation could not possibly have been attributed to its effects. Dr. Sims, in speaking of this case, declares that he has repeatedly performed the operation on pregnant women, and would not have hesitated here for a moment. In Dr. Chadwick’s case there is no certainty that the abortion depended on the operation on the perineum. Al- though Dr. Chadwick does not state it, there is a possi- bility that he passed the sound, and that the abortion was due to that fact. These six cases, if we throw out Chadwick’s, are strongly in favor of the harmlessness of operations upon the per- ineum of a pregnant woman, should the occasion arise. All that were delivered seem to show that we may expect the newly-formed perineum to successfully withstand the MATTHEW D. MANN. 3590 shock of labor. Dr. Reamy’s second case and Dr. Nott’s case both give indications for the performance of the opera- tion during pregnancy. VAGINA. Venereal Warts in the vagina as well as on the vulva oc- curring during pregnancy are apt to increase very rapidly, and may be so numerous as almost to be a cause of ob- struction during labor. The first case of the kind I ever saw I treated with palliatives, astringents, etc., being fearful of serious results if I attempted to remove the growths. Later, however, emboldened by the success of my operation on the cervix of the pregnant uterus, I determined to oper- ate. A young woman who had acquired gonorrhea shortly after being impregnated for the first time offered an oppor- tunity. My reasons for operating were, that the warts were so numerous and large as to almost block up the vagina. I found it impossible to cure the gonorrhea while the warts were there, and feared that if left until labor set in, the dis- tensibility of the vagina would be interfered with, and that the advancing head would tear off the growths, leaving open the mouths of the lymphatics and blood-vessels, by which the absorption of septic material would be favored. I feared also for the child’s eyes, if the infective discharges were left, and also that the disease might extend into and through the uterus, producing a pelvic peritonitis. I had no difficulty in scraping out the growths with the curette and my finger. The hemorrhage was rather free, but was readily checked by introducing a large cylindrical speculum, and painting the whole vaginal surface with a forty-grain solution of nitrate of silver. A few other applications of silver were made in the same way, and the patient was en- tirely cured, and went through her confinement without difficulty. Dr. Chamberlain, at a meeting of the New York Obstet- rical Society (April 19, 1881), spoke of having seen exten- sive venereal vegetations removed, under very similar cir- cumstances, from the vulva and vagina without bad results. VOL. VII. 23 354 SURGICAL OPERATIONS ON PREGNANT WOMEN. Hildebrandt mentions a case by Levy, of Munich, where, after removal of the warts, he cauterized the base with nitrate of silver, and washed out the vagina with lead water. The patient made a good recovery, but four weeks later there appeared on various parts of the body numerous wart- like excrescences, which remained until delivery, and disap- peared soon after. Hildebrandt declares that he has fre- quently seen these growths disappear during the lying-in period, with cleanliness and rest; but for the reasons already given I should prefer to remove them at once. The cases detailed here, together with those already men- tioned. in speaking of operations upon the vulva, in which the same indications exist, would seem to offer basis enough for such a conclusion. Applications. — For the relief of the very troublesome dis- charges which sometimes cause a great deal of annoyance during the later months of pregnancy, and which I have considered as due in part, at least, to increased vaginal con- gestion and exudation, I have a number of times used ni- trate of silver solutions in the way already indicated, with only good results. Of operations on the vagina proper there are not many to report. Cohnstein remarks that he has never seen any bad results follow the puncture of small cysts in the vaginal walls. Dr. Protheroe Smith mentions having punctured an abscess as large as an orange in the posterior vaginal wall, at the sixth month of pregnancy, without bad results. Dr. Bixby sends me the report of a case of vaginal poly- pus :— “The tumor was nearly as large as a fist. The subject a stout, full-blooded woman. Notwithstanding the employment of an écraseur, the hemorrhage required the tampon. I saw the case in consultation. A few days later I learned that she had mis- carried at the third month, greatly to my surprise, as I had not the faintest suspicion of pregnancy. Others had seen her before me, and possibly for differential diagnosis the uterine sound may have been used. She made a good recovery.” It is too bad that some of the conclusions to be drawn MATTHEW D. MANN. 355 from this case are invalidated by the uncertainty as to the passage of the sound. This applies to many of my cases, as in very few of them was the pregnant condition sus- pected. Massot has collected a number of cases of this sort. One (158) was an obdurator hymen, cut in the third month, without any bad results. He has collected also three cases of polypus of the vagina. The first (160) was a woman aged twenty-three, in the seventh month of pregnancy. The tumor was outside the vulva, but was at- tached bya long pedicle to the posterior wall of the vagina ; it was much larger than a hen’s egg. It was tied, and cut on the fourth day afterwards. Recovery complete. The second case (161) was in Dr. McClintock’s practice in 1857. Woman inthe ninth month of pregnancy. Tumor attached to the posterior wall of the vagina. It was the size of a small hen’s egg, and was sloughing. It was removed, and the patient returned home. Labor came on in a month after the operation, and the patient died in thirty-four hours, apparently of what we would now call septicemia. There was an ulcer on the posterior wall of the vagina, where the tumor had been. The third case (162) was six months pregnant. The tumor was attached by a large, firm pedicle to the anterior wall of the vagina, and was the size of a duck’s egg. The pedicle was tied, and the tumor cut off. She recovered, and was delivered at term. Dr. C. C. F. Gay, of Buffalo, kindly sends me a reference to a case published by him, with notes of the subsequent history of the case. Mrs. G., aged thirty-five, had had pro- cidentia complete for thirteen years ; had had five children, three of them since the occurrence of the procidentia. The os protruded two and a half inches beyond the vulva. She was operated upon in June, 1871, according to Em- met’s method for narrowing the anterior vaginal wall. Union was perfect, and the patient relieved of her pro- lapse. Seven months later she was delivered of twins, at full term, one dead and one living. Dr. Bartow, who at- tended her, is under the impression that the newly attached tissues were torn apart at the labor. In 1876 she was seen 356 SURGICAL OPERATIONS ON PREGNANT WOMEN. by Dr. Bartow, and the procidentia was found to be as bad as ever. If stenosis of the vagina, due either to bands ora circu- lar stricture, is discovered during pregnancy, Cohnstein advises that they should at once be cut with the probe- pointed bistoury, and says that no harm is likely to come of it. Verneuil’s case, to be related later, leads to a rather different conclusion. Ata meeting of the New York Obstet- rical Society, Dr. F. Barker related a case where the most marked cicatricial contraction of the vagina gave way, and easily dilated before the advancing head. This would seem to show the uselessness of operating in such cases before labor sets in. Dr. Campbell’s second case of vesico-vaginal fistula bears upon this point, and corroborates Dr. Barker’s views. He writes of this case: “ This rapid softening and stretching of nodular tissue (cicatricial) in the vagina on the occurrence of labor I think I have seen remarked upon by authors, though I cannot recall by whom. Occlusions of the vagina from inflammatory and traumatic causes are, I think, far more common in the African race than in the white. I have had many cases in negro women, and none in white, except in connection with a vesico-vaginal fistula. I was requested to operate on a favorite servant of a planter for occlusion of the vagina, many years ago. She was preg- nant, and the operation was thought necessary to admit of safe delivery. She was taken in labor at term, and was delivered without difficulty, and so rapidly that the phy- sician did not arrive until it was over. If there be a con- genital atresia the case would be different, and might call for an earlier operation. Herzfeld reports a case, but the atresia was only discovered two weeks before labor, and was left until labor began, when it was torn with the fingers and the forceps applied. Of seven operations on the vagina, only one resulted in an abortion. The result in Massot’s second case is hard to explain, and it is difficult to say how much the old ulcer had to do with the fatal result. Hemorrhage seems to have been the principal difficulty, but in only one case (Bixby’s) MATTHEW D. MANN. 357 was it severe. The method of operating in the other cases of tumor (ligature) may have had something to do with the results obtained. Vesico-vaginal fistula operations during pregnancy make rather a bad showing. Dr. H. F. Campbell, of Georgia, reports to me two cases operated upon unwittingly in the second and third months of pregnancy, as follows : — CasE I.—I was requested to operate upon a case of vesico- vaginal fistula in a colored woman (mulatto), aged thirty. She had had several difficult labors, but had not borne:a living child. In her last labor forceps had been used, late in the protracted labor, and it was after this parturition that the fistula was ob- served. Bozeman’s operation was performed, by which a consid- erable opening was perfectly closed. The hemorrhage was very severe, and much trouble was experienced in arresting the flow, to effect proper approximation. This was explained some five or six weeks after, when quickening took place, and the woman was found, unexpectedly to herself and to the physicians, to have been pregnant at the time of the operation. I do not remember any symptoms after the operation simulating labor pains, or pains threatening abortion. Being unaware of her condition, if such symptoms occurred they were not recognized. Dr. Joseph A. Eve, who had charge of the case, had deter- mined, in view of the woman’s contracted pelvis and her uniform dystocia, to practice induced labor at the seventh month. It is my impression that spontaneous premature labor occurred at a viable period, and the woman was safely delivered, for the first time, of a living child. She did well after that labor, but died after a subsequent one, at full term, in childbed. CasE II. — Mrs. J. was the subject of a vesico-vaginal fistula, with considerable opening, near the das fond of the bladder. The accident resulted, I have no doubt, from delay in applying forceps when imperatively demanded. I failed in my first opera- tion on account of fibrous bands distorting the vagina and drag- ging on the line of union. Only a small portion of the fistula remained open. After some six months or more, she returned for a second operation. I found the vagina still imperfectly pre- pared for the operation, the obstructing bands being a little less troublesome than before. Being apparently in the best of health, and in good condition otherwise, as I thought, for the operation, 35 8 SURGICAL OPERATIONS ON PREGNANT WOMEN. I concluded to attempt the closure of the fistula. The ordinary operation, with silver-wire sutures, was performed. The bands were relieved by incision and stretching. Much troublesome bleeding attended every step of the operation, in contrast with the former one, in which no very serious hemorrhage had taken place. This we attributed, at: the time, to the free incision of the constrictions. The sutures were finally satisfactorily applied, and the patient put comfortably to bed, with Sims’ catheter in the bladder. Before we left the house, she began to complain of great distention of the bladder. Though bloody urine had flowed freely through the instrument, there was no blood in the vagina from the incisions ; and not suspecting any unusual hem- orrhage, we attributed her discomfort to other causes than disten- tion of the bladder with blood. Returning some two hours after- ward, we found the patient in an alarming condition. She com- plained of distention more than ever. She was extremely feeble, pulse almost imperceptible, skin cold and clammy. She was nau- seated, and had vomited frequently. There was a large quantity of blood in the urinal, with but little or no urine. The vagina was filled by the distended bladder, which projected as a tumor at the hypogastrium. We made efforts at breaking up the clots, with the view of washing out the bladder, but the process was too slow and uncertain, in view of her low condition and the prob- able continuance of the hemorrhage into the bladder. ‘The su- tures were therefore removed as rapidly as possible, and the finger introduced into the bladder through the fistula, and the clots broken up and washed out with fresh warm water, and then iced water was used against the bleeding. So low was the patient that I did not dare to leave her, even after the bleeding had ap- parently ceased, without means to secure her against further loss of blood. Pledgets of lint, soaked in moderately strong solu- tions of Monsell’s salt, were passed from the vagina through the fistula into the bladder, packing and distending the opening so as to compress the cut edges. She made a good recovery, and returned home. Though not suspecting it at the time, Mrs. J. must certainly have been in the early period of pregnancy. Shortly after returning home she felt motion. Refusing induced abortion, she was allowed to go to full term, and returned to Augusta to be delivered, by Dr. Eve and myself. I knew the va- gina was terribly obstructed by the fibrous bands and adhesions, and I had a helpless horror of the approaching event, — catas- MATTHEW D. MANN. 359 trophe, as I considered it. Labor came on suddenly, and she sent for Dr. Eve and myself, at the same time. We had expected a most protracted and difficult obstructed labor : first, because the former labor had required forceps ; and secondly, because of the occluded condition of the vagina. When I arrived, Dr. Eve was already on the ground, but, with all his readiness, he had failed to be “in at the birth,” which it seemed to me was likely also to be the death. Labor had been accomplished with the most fearful suddenness. We found the woman almost dead, — cold and pulseless, as if after a most exhausting hemorrhage. We found that she had not bled excessively, and we both came to the conclusion that her condition was the result of shock, depend- ent on the rapid labor, under circumstances so adverse, namely, the condition of her vagina and the existence of the fistula. The patient recovered, but the fistula remains unhealed. This is certainly a most remarkable case. It is contrary to the general expectation that such a hemorrhage should not have resulted in an abortion, nor should we expect so pre- cipitate a labor in a vagina so constricted as this must have been. M. Verneuil reports a case of a strong, robust country woman admitted to the hospital in November, 1875. Her last labor was eighteen months before, and since then she had suffered from a vesico-vaginal fistula. There was a sort of diaphragm across the vagina. As this was quite thin, he tore it with the aid of a speculum and his fingers. Two or three days later there was edema of the labia ma- jora. The vagina was congested, with abundant bad-smell- ing secretion. Vulva very tender and swollen. She was ill three weeks. On her recovery she insisted upon an op- eration. This was done January 12th, five sutures were introduced, and all went well until the third day. Then there was a slight bloody discharge, which soon became a hemorrhage, with large clots, and an ovum of the second month was expelled. Stitches were removed January 16th. Union complete, notwithstanding all. Verneuil remarks that the case shows both the danger and the harmlessness of pregnancy in its effects on operations. 360 SURGICAL OPERATIONS ON PREGNANT WOMEN. W. Schlesinger met with a case in which the woman had been delivered six months before, by craniotomy, with the result of a large vesico-vaginal fistula. She had not men- struated since confinement, but denied pregnancy. The cervix was greatly diseased, and, owing to the position of the fistula, was much in the way, bleeding profusely at the prick of the tenaculum. While the stitches were being put in, a great amount of edema of the cervix and vaginal | walls was developed. The operation lasted an hour, and was completely successful. The patient remains well, hav- ing gone through her labor at term without difficulty. She must have been from two to three months pregnant at the time of the operation. Massot mentions a case (159) of fistula, treated by Rey- bard’s forceps or clamp. The patient was three and a half months pregnant, and aborted the night following the op- eration (the clamp being removed at that time). The continued presence of an instrument in the vagina, irrita- ting the vagina and cervix, may have affected the result. Pregnancy was unsuspected. Here we have five cases operated upon: two in the sec- ond month, two in the third, and one in the fourth. Two aborted ; in two there was no union; the rest succeeded, but in two cases after a severe hemorrhage. Hemorrhage more or less severe, once nearly fatal, is mentioned in four of the cases. Such results are not very favorable, and would hardly induce any one to perform the operation dur- ing pregnancy, except from the most pressing necessity. Hemorrhage from operations on the vagina is just what we might expect. The extreme vascularity of the vagina during pregnancy, giving rise to a peculiar bluish color, has often been noticed, and is laid down in the books as one of the cardinal signs of pregnancy. It stands for the red flag of danger. RECTUM. Operations on the rectum seem to be somewhat dan- gerous: Després (104) converted a recto-vaginal fistula into an MATTHEW D. MANN. 361 ano-perineal. fistula in a woman three months pregnant. No bad results followed, and the patient was delivered at term. Dr. Engelmann is the only one, as far as I can learn, who has boldly advocated operating on a fistula during preg- nancy. His case was a large, transverse recto-vaginal fis- tula, which had previously been operated upon by Dr. Greiner, of St. Louis. As the doctor wished Dr. Engel- mann’s assistance in the second operation, and as he was about to leave town for a long stay, he advised operating at once, although the woman was between five and six months advanced. “The operation was successful, healed kindly, and was not ruptured in the following delivery, which occurred at term. The patient was a strong, healthy woman, and has remained well since.” Compare this with a case by Dr. Cazin, in which he per- formed forcible dilatation of the sphincter ani, for fissure of the anus, in a young girl, and where abortion followed quickly, she being in the early stages of pregnancy. 669, 7or.—Sechultze, B. S._ Ueber Dysmenorrhoe in Verbindung mit Lagever- anderungen des Uterus. Wien. med. Bl. IV. 1451-1484.—Stout, S. H. Dys- menorrheea. Tr. M. Ass. Georgia. Az- gusta. XXXII. 166-172. ELECTRICITY. See Galacta- gogues, and Labor. EMBRYOLOGY. ; Kucher, J. Description of an ovum of the second week of pregnancy, with re- marks on the decidua reflexaa Am. J Obst. WM. Y. XIV. 408-414. 1 pl. EMBRYOTOMY. CurArA, D. Le indicazioni dell’ embriotomia. Milano. 8° GRENIER, EUGENE. *Etude sur une modification apportée au man- uel opératoire de la céphalotripsie et de l’embryotomie. aris. 46 pp. ply 4c NO 57: Davis, M. L. Case of embryotomy. Quart. Tr. Lancaster City & Co. M. Soc. 1880-81. I. 79-81.—Eustache, G. Paralléle de ’embryotomie et de l’opération césarienne. Tr. Internat. M. Cong. 7 sess. Lond. IV. 397-399. — Wilmart, L. MDystocie par angustie pelvienne; em- bryotomie. Presse méd. belge. Brux. XXXIII. 289. EMMET’S OPERATION. See Cervix Uteri, Laceration of the. EMPHYSEMA during Labor. Hubbard, T. W. Emphysema in parturition. Brit. M. J. Zond. II. 897. ENCEPHALOCELE. See Brain, Hernia of the. EPILEPSY. Terrillon. Note sur un cas d’épilep- sie d’origine utérine. Ann. de gynéc. Par. XV. 401-408. ERGOT. MassoT, ACHILLE. *Des acci- dents causés par l’ergot de seigle dans. la pratique des accouche- ments. aris. 64 pp. 4° No. Pipino, W. C. Injudicious use of ergot in labor. St. Louis M.& S.J. XL. 393-396. ERYSIPELAS. Rowe, F. H. Erysipelas and puer- peral fever. Obst. Gaz. Cincim. 1881- 82. IV... 317. ESTHONIANS. VON SCHRENCK, AUGUST. *Stu- dien uber Schwangerschaft, Geburt und Wochenbett bei der Estin, nebst Untersuchungen iiber das Becken derselben. Dorfat. 1880. C.Mat- tiesen. 375 pp. 8° EVOLUTION, Spontaneous. BONCINELLI, F. Del parto per la spalla e del modo di favorirlo e praticarlo. Fivenze. 8° [Repr. from: Imparziale. XXI.] FALLOPIAN TUBE. Barton, J. K. Rupture of Fallopian tube. Tr. Obst. Soc. Loud. 1880. XXII. 2.— Bruni, G. Sulla metro-salpingite. ‘Riv. clin. di Bologna. 3s. I. 470-481. —Burnier, H. Ueber einen Fall von Pyosalpinx mit Durchbruch in die Bauch- hohle. Ztschr. f. Geburtsh. u. Gyniak. Stuttg. VI. 252-260.— De Coninck. Kystes développés dans les trompes de Fallope. Ann. Soc. d’anat. path. de Brux. 1879. XXVIII. 62. — Doran, A. Papilloma of the Fallopian tube, asso- ciated with ascites and pleuritic effusion. Tr. Path. Soc. Lond. 1879-80. XXXI. 174-179. 1pl.—Dunean, J. M. On open Fallopian tube. Brit. M. J. Lond. I. 383. — Mermann, A. Todtliche Perforation einer Tube bei Salpingitis nach Herunterziehen des Uterus. Centralbl. f. Gynak. LezJz. V. 513.—Skene, A. J. C. Dropsy of the Fallopian tube. Am. J. Obst. WV. ¥. XIV. 877.—Tait, L. A case of removal of the uterine ap- pendages. Brit. M. J. Lond. I. 766. — Thomas. Fibro-cyst of the Fallopian tube. N. York M. J. XXXIV. 67.— Thomas, C. H. Patulous Fallopian tubes. Phila. M. Times. 1881-82. XII. 469. FETUS. HEYDER, HERMANN. *Unter- suchungen iiber den Wechsel der Lage und Stellung des Kindes in den letzten Wochen der Schwanger- schaft. [Halle.] —Sims, J. T., and G. W. Farrar. — Wilmart, L., et A. Feigneaux. Eclampsie puer- pérale; accouchement prématuré provo- qué; guérison. Art méd. Srawx. 1881- San Peevey ve78. PUERPERAL DISEASES. OPPENHEIMER, L. S. Puerperal Epilepsy and Protracted Gestation. 8° Louzsville. 1880. Repr. from: Am. Pract. 1880. Garcia de Castro, J. Metroperito- nitis puerperal; abcesso consecutivo ; aber- tura del mismo en la region infra-umbilical ; curacion. Gac. méd. de Sevilla. III. 121-124.— Griswold, R. W. Puer- peral malarial lactarial mammarial neural- gia! Am. M. Bi-Weekly. . Y. XIII. 1-4.— Hanot. Métrorrhagies apres l’ac- couchement; coagulations sanguines dans la veine fémorale droite et les veines du petit bassin; embolie de l’artére pulmo- naire; mort subite. [From: Arch. gén. de méd.] Arch. de tocol. Par. VIII. 54- 63.— Harvey, T. P. Puerperal embol- ism (?) with hemorrhage; recovery. Brit. M. J. Lond. 1. 805.— Holmes, E. L. A case of puerperal retinitis; blind- ness; color- blindness; recovery. Arch.* Ophth. WV. VY. X. 421.— King, E. W. Puerperal pelvic cellulitis. Louis- ville M. News. XII. 242-244. — Korte, W. Ueber Gelenkentziindungen im Wo- chenbette. Ztschr. f. Geburtsh. u. Gynak. Stuttg. VII. 224-226. — Legendre. tat puerpéral; rougeole; bronchio-pneu- monie; embolie pulmonaire. Rapport par R. Moutard-Martin. Progrés méd. Par. IX. 342.—Murray, R. M. Ona form of post-partum incontinence of urine, and its treatment by faradaism. Tr. Edinb. Obst. Soc. VI. 39-46.— Prideaux, E. Acase of cerebral embolism fourteen days after confinement. Lancet. Lond. GYNECOLOGICAL INDEX. II. 663.—Riez. Métro-péritonite puer- pérale compliquée de perforation intesti- nale. Ann. Soc. d’anat. path. de Brux. 1878. XXVIII. 119-123. — Ripley. Labor at full term; subsequent condition of the placental site. Med. Rec. WV. ¥. XX. 692.—Sochaff, N. A. Zamietka o poslierodovome diphteritie poloviche chastei jentshini. [Diphtheritis of sexual organs in women after child-birth.] Vrach. St. Petersh. Il. 561.—Somerville, R. Two cases of puerperal hematocele. Tr. .Edinb. Obst. Soc. VI. | 50-56.— Wilmart, L. De l’action de la glace et du sulfate de quinine dans le traitement de la péritonite puerpérale; trois observa- tions. Presse méd. belge. Brux, XXXIIL. 161-163. PUERPERAL FEVER. See, also, Erysipelas. ScHMIDT, J. B. *Beobachtun- gen iiber die im Winter 1878-79 in der Kreis-Entbindungs-Anstalt zu Wirzburg aufgetretenen Erkran- kungen an Puerperalfieber. 89 Wirzburg. 1880. FICHET. Une épidémie de fievre puerpérale a Pont-Saint-Ours. His- toire naturelle de ce village. JVe- vers. 8° THORBURN, JOHN. On Metria; and on the Dual Clinical Charac- teristics of Metrial Blood-poison- ing. Manchester. A. Ireland & Co. 20 pp. 8° Bennet, E. H. Puerperal malarial fever. Coil. & Clin. Rec. Phila. II. 128. —Bernardy, KE. P. Recurrence of puerperal fever. Tr. Phila. Obst. Soc. (1380). 6-13.—Bleynie pére. Con- sidérations pratiques sur l’infection putride puerpérale. Rey. méd. frang. et étrang. Par. Il. 620-628.— Brennecke. Ein Beitrag zur practischen Loésung der Puer- peralfieberfrage. Berl. klin. Wcehnschr. XVIII. 363-370, 384-387. — Brene necke. Ein Beitrag zur Prophylaxis des Puerperalfiebers. Berl. klin. Wcehnschr. XVIII. 38-40.—Desplats, H. La- vages phéniqués intra-utérins dans les cas de fiévre.puerpérale. J. d. sc. méd. de Lille. III. 452-470.— Eade, P. Two cases of puerperal fever; which recovered under the repeated local use of a strong solution of carbolic acid. Brit. M. J. Lond. 1. 116.—Elliot, G. T. A ré sumé of 26 cases of puerperal fever, which have occurred in the Lying-in Ward of the Charity Hospital, from Sept. 2oth, 1880, to Feb’y tst, 1881. N.Orl. M.& S.J. N. s. IX. 46-56. — Felsenreich, A., und J. Mikulicz. Beitrage zur Kennt- niss und chirurgischen Behandlung der puerperalen Pyohaemie mit Einschluss einiger progredienter nicht metastatischer Entziindungsprocesse im Puerperium. Ztschr. f. Heilk. Prag. II. 112-153.— Hubert, E. De infection puerpérale; pluripare; bassin de 75 millm.; présenta- tion O. C. G.; transforation; infection puerpérale; mort. J. d.sc. méd. de Lou- vain. VI. 13-23.—Maughs. Puer- —— ——— ee ee Ce ee ee ee ee ees ce a GYNECOLOGICAL INDEX. 469 peral fevers. St. Louis Cour. Med. VI. 335-341. — Masini, A. Nota riassun- tiva intorno ad alcuni studii sperimentali sopra l’infezione puerperale. Salute: Ita- lia med. Genova. 28. XV. 201.— Masini, A., e/ a/. Studi sperimentali sulla infezione puerperale. Sperimentale. Firenze. XLVI. 161-176. — MeFallis, D. Puerperal fever; its specific character, pathology, and treatment. Rocky Moun- tain Med. Rev. Denver. 180-81. I. 431-430. — Ojeda, J. M. Fiebre puerpe- ral; muerte. Rev. méd.de Chile. Sazz. de Chile. 1878-79. VII. 142-145.— Preuse sen; Anzeigepflicht bei Erkrankungen an Rachenbraune (Diphtheritis) und Kind- bettfieber im Reg.-Bez. Erfurt. Deutsche Med.-Ztg. Berd. VII. 711. —Ramella, A. Caso de aplicacion del forceps ; fiebre puerperal consecutiva curada por la re- sorcina. Union méd. Cardcas. I. 129. — Rothe, C. G. Beobachtungen an seinem falle von Puerperalfieber, zur Be- leuchtung der Natur dieser Erkrankung. Memorabilien. Heibr. N. F. I. 257- 265.—Spiegelberg. Ueber die Ent- wickelung der puerperalen Infection. Jah- resb. d. schles. Gesellsch. f. vaterl. Kult. 1880. Berl. LVIIL. 49-51. —Trush, J. Concerning the prophylaxis of puer- peral fever. Obst. Gaz. Ciucinz. _18S0- St. III. 578-593.— Veit, J. Ueber puerperale Infectionen mit langerer Incu- bationszeit. Zschr. f. Geburtsh. u. Gynik. Stuttg. VI. 378-394. 3 tab. — Vejled- ningen for Jordemd¢dre til Forebyggelse af Barselfeber. Ugeskr. f. Leger. A7/o- benh. 4. III. 449-451. — Wallace, KE. Child-bed fever. Clin. News. Phi/z., II. 243-247.— Whayne, A. B. Puer- peral fever. Med. Herald. Lowzsuille. 1881-82. II]. 120-122.— Winckel, F. Mittheilungen iiber die Erfahrungen mit der, seit dem ersten April 1880 im Kéonig- reich Sachsen, eingefiihrten Instruction fiir die Hebammen zur Verhiitung des Kindbettfieber. Tr. Internat. M. Cong. zsess. Lond. IV. 382-386. PUERPERAL INSANITY. Caron, A. Manie puerpérale compli- quée de septicémie puerpérale: guérison. J. d. sages-femmes. Par. IX. 290.— Carr, J. M. Puerperal insanity, Cin- cin. Lancet & Clinic. N.s. VII. 537- 542.— Lee, C. P. Puerperal mania. Kansas M. Index. fort Scott. II. 200- 208. PUERPERAL METRITIS. Pietrzycki, M. Case of puerperal metritis followed by abscess. Pacific M. & S. J. San Fran. 1881-82. XXIV. 54-57-—,Wazmnots, L. Métrite puerpé- rale; traitement par la quinine et les i injec- tions intra-utérines d’acide phénique; gué- rison. Presse meéd. belge. Brux. XXXIII. 361-363. PUERPERAL METRO - PERI- TONITIS. BomptIaANI, ArtTuRO. La irriga- zione intrauterina continua nel trattamento chirurgico della metro- peritonite puerperale. J7/i/ano. 8° [Repr. from; Ann. di Ostet.] Ojeda, J. M. Metro-peritonitis puer- peral; curacion. Rev. méd. de Chile. Sant. de Chile. 1878-79. VII. 145.— Olayo- Gutierrez. Metro - peritonitis puerperal sobreaguda ; muerte. Rey. méd. de Chile. Sant. de Chile. 1878-79. VII. 146-144. —Ventura Carvallo. Metro- peritonitis puerperal; muerte. Rey. méd, de Chile. Sant. de Chile. 1878-79. VII. 177-179 PUERPERAL SCARLET FE- VER. LEGENDRE, HENRI. *Etude sur la scarlatine chez les femmes en couches, avs. “112 pp: 3) ch. ° Holst, J. Vier Beobachtungen von Wochenbettscharlach nebst Bemerkungen. St. Petersb. med. Wehnschr. VI. 447- 449.-—Sykes, W. Scarlatina in a puer- peral female; short period of incubation ; death. Brit. M. J. onda. S158. PUERPERAL SEPTICEMIA. Ashton, IL. Puerperal septicaemia with diphtheritic membrane covering entire vaginal canal and os uteri. Virginia M. Month. Richmond. 1881-82. VIII. 732-734. De la C. Villaseca, J. Septicemia agudisima; aplicacion de for- ceps; muerte. Rev. méd. de Chile. Sant. de Chile. 1878-79. VII. 141.— Dono- van, W. A case of puerperal septica- ‘mia; prolonged high temperature; recov- ery. Brit. M. ie Lond. 1. 118.— Vitzmaurice, N. F. H. Puerperal septicemia; recovery. Brit. M. J. Lond. Thpanro2. — Negri, P. La cura locale della setticemia puerperale. Ann. di ostet. Milano. Il. 208-211. Adso, Reprint. —Parish, W. H. Some points in the consideration of puerperal septicaemia. Cincin. M. News. N. s. X. 361-369. —Smith, A. H. The relation of clean- liness to the prevention of puerperal sep~ ticzemia; a clinical lecture. Med. News and Abstr. Phila. XXXIX. 579-587. PUERPERAL STATE. See, also, Antiseptics. BucKLeER, T. H. On the Post- parturient Pathology resulting from Imperfect Uterine Contraction after Childbirth, and on Involution Com- plete and Incomplete. Jz his: Strangulated Veins of the Uterus, and Other Papers. 8° Cambridge. 35749: Forster, EDwArD JAcon. The Necessity of using the Long Nozzle in making Intra-uterine Injections after Confinement. Read before the Obstetrical Society of Boston, Mar. 12, 1881. Cambridge. River- side Press. 8pp. 8° Hermes, Max. *Acute Miliar- tuberculose des puerperalen Uterus unter den Symptomen eines Puer- peralfiebers. LZrlangen. 1880. Junge & Sohn, 23 pp. 2 tab. 8° 470 PycuLau, E. *Zur Casuistik der Scarlatina im Puerperio, Dor- pat. 8° Bennett, A. H. Chronic hemiplegia originating during the puerperal state. brit. M. J. Loud. I. 261-265. — Coles, W. The management of the breasts. St. Louis Cour. Med. VI. 289-301.— Cuzzi, A. Duvuecasidi recidiva di febbre da ma- laria dovuta al traumatismo del parto. Spallanzani. Modena. 2s. X. 12-18.- — Depaul. Accidents puerpéraux. Gaz. d. hop. Par. LIV.. 675.— Letulle. Recherches sur |’état du cceur des femmes enceintes ou récemment accouchées; de la dilatation du cceur dans la grossesse et les suites de couches. [From: Arch. gén. de méd.] Arch. de tocol. Par. VIII. 155- 171.— Loéhlein, H. Uebersicht iiber die Therapie der Puerperalkrankheiten. Aerztl. Vereinsbl. f. Deutschl. Zezz. X. 178-181. — Lothrop, f. Notes on puer- peral cases. Buffalo M. & S. J. 1880- 8:1. XX. 529-537-— Macdonald, A. Note on the presence of sugar and of albumen in the urine of the lying-in woman. Tr. Edinb. Obst. Soc. VI. 168. —Mac- kintosh, E. &. Mental excitement in the lying-in, its importance with regard to maternity hospitals. Edinb. M. J. 1881- 82. XXVII. 899-904. 1 ch.— Mans delstamm, L. Zwei Fille von metas- tatischer Augenentziindung im Puerperium. Klin. Monatsbl. f. Augenh. Sztg. XIX. 285 - 287. — Moutard - Martin, R. Rapport sur l'état puerpéral; rougeole ; bronchio-pneumonie; embolie pulmonaire. Bull. Soc. anat. de Par. 1880-81. LV. 539-542. Murray, R. M. Ona form of post-partum incontinence of urine, and its treatment by faradaism. Edinb. M. J. 1880-81. XXXVI. 9097-913. — Napier, A. D. L. Clinical observations on puer- peral temperatures. Tr. Edinb. Obst. Soc. 150-162.—Napier, A. D. L. Clinical observations on puerperal temper- atures. Edinb. M. J. 1881-82. XXVII. 312, 436.—Olshausen, R. Ueber die Pulsverlangsamung im Wochenbett und ihre Ursache. Centralbl. f. Gynak. Lezfz. 49-53-— Palmer, C. D. Vaginal and uterine injections in the puerperal state. Cincin. Lancet & Clinic. N. s. VI. 565.— Richardson, W. L. Acute jaundice after labor. Boston M. & S. J. CIV. 246.—Stoltz, J. A. Puerpéra- lité. N. dict. deméd. et dechir. prat. Par. XXX. 87-145. — Westmoreland, R. W. Puerperal deformities; a source of serious nervous disturbances. Atlanta M. &S. J. 1881-82. XIX. 264-267. PUBRPERAL PYEMIA. Bleynie pére. Considérations pra- tiques sur l’infeection putride puerpérale. J. Soc. de méd. et pharm. de la Haute- Vienne. Limoges. VI. 6-14.— Bopp Ein schwerer Fall von Pyimie im Wochen- bette. Breslau. aerztl. Ztschr. III. 223. — Burrage, R. L. A case of acute pyemia foliowing labor. Tr. M. Soc. N. Jersey. Mewark. CXV. 254-263. PYOMETRA. ARNING, E. metra lateralis *Kin Fall von Pyo- mit epikritischen GYNECOLOGICAL INDEX. Bemerkungen zur Differentialdiag- nose complicirter Falle. 8° Strass- burg. 1880, Galabin, A. L. Case of pyometra. Tr. Obst. Soc. Lond. (1880), XXII. 239-241. — Howitz, F. Laparotomi for pyometra i et hdjre Uterushorn. Gynaek. og. obst. Medd. Ajyobenh. III. 3 Hit. 7°-75- QUADRUPLETS. Clark, J. M. Quadruplets. Am. M. Bi-Weekly. JV. Y. 1881-82. XIII. 49. QUININE. Boceaccini, V. Dell’ azione oxito- cica del chinino e sua intossicazione. Arch. clin. ital. Roma. XI. 252.—Cullen, P. Is quinine an abortifacient? Indian M. Gaz. Calcutta. XVI. 279.—Del- thil. Accidents causés par le sulfate de quinine chez les femmes qui le mettent en flacon. France méd. Par. II. 388.— Poweil, W. M. Does quinine affect the gravid uterus? Med. Brief. S¢. Louzs. DXF 134: QUINTUPLETS. Moffitt, J. Quintuple birth Med. & Surg. Reporter. Phila. XLIV. 334. RECTUM, Excision of the. Putti, M. Estirpazione del retto e del setto retto - vaginale con successiva vagino-plastica. Bull. d. sc. med. di Bo- logna. 6s. WII. 153-164. Adso, Re print. RESPIRATION, ARTIFICIAL. Champneys, F. H. Second com- munication on artificial respiration in still- born children; the expansibility of various parts of the lungs, an experimental in- quiry. Brit. M. J. Zond. I. 722. SACRUM, Abnormities of the. Lambl, D. Primitive Spondylolysis und deren Verhiltniss zur Steatopyga an der hottentottischen Venus. Centralbl. f. Gynak. Lez. V. 256-259, 281-287. Also, Reprint. SEXUAL INSTINCT, Dayton, W. A. Effects of the abuses of the sexual instinct in females. Med. Rec. WV. Y. XX. 593-597- SMALL-POX. Day, R. H. Small-pox pustulation in the foetus in utero; a replyto R. McSherry. Maryland M. J. Salt. 1881-82. VIII. 443. SPECULUM. Auvard, A. Quelques modifications au speculum Cusco. Bull. gén. de thérap., etc. Par. Cl. 442-447-— Battey, hk. A new perineal retractor. North Car. M. J. Wilmington. VIII. _16.— Hunter, A.S. Modification of Erich’s self-retain- ing Sims’s speculum. N. York M. J. XXXIV. 178.— Lebedeff, A. Modi- fication des Simon’schen Speculum. Arch. f. Gynaek. Berl. XVII. 350-354. 1 pl. — Lévy, E. Note sur un nouveau spe- culum vaginal. Rev. méd. de lest. Nancy. XIII. 751-755. Neale, R. How to renovate a speculum. Med. Times & Gaz. Lond. II. 107¢ GYNECOLOGICAL INDEX. STERILITY. CioziER, Il. *De la stérilité dans ses rapports avec l’inflamma- tion chronique de la muqueuse du canal cervical. aris. 79 pp. 4° No. 80. GRETSCHER DE WANDELBURG, A. D’une cause peu connue de stérilité. Jz his: Mém. de méd. et chir. 8° aris. i Allen, R. C. Sterility; with a few clinical observations upon its cause and treatment. Homeop. J. Obst. WV. Y. 1881-82. III. 52-57.— Wigginton, R. M. Six cases of sterility. Tr. M. Soc. Wisconsin. Milwaukee. XV. 130- 136. STRYCHNINE. Morton, A. S. Strychnia poisoning during the fifth month of pregnancy; re- covery. [No abortion.] Lancet. Loxd. tae 570= SUPERFETATION. Harter, J. F. An obstetrical case. [Superfcetation.] Obst. Gaz. Czzcin. IV. 8.— Oliver, F. W. A case of super- foetation. Coll. & Clin. Rec. Phila. II. 50. SYMPHYSEOTOMY. MorisaNI, J. Sulla _sinfisioto- mia. Milano. 8° D’Urso, E. Contribuzione alla sinfisiotomia. Parto difficile per eccessivo sviluppo fisiologico del feto. Bart. 16°. Morisani, O. Sulla sinfisiotomia. Gior. internaz. d. sc. med. MNafoli. N.s. Til. 1148-1150. Adso, Ann. di ostet. Milaxo. III. 615-618. A dso, translation in Ann. de gynéc. Par. XVI. 440- 443- SYMPHYSES, PELVIC, Relaxa- tion of. Coniglione, A. Contribuzione allo studio del rilasciamento delle sinfisi pubica e sacro-iliache. Gior. internaz. d. sc. med. Napoli. N.s. III. 264-266. SYPHILIS. Von Hecker. Ueber Syphilis wah- rend der Schwangerschaft und ihre Bezie- hung zur Frucht. Wien. med. Bl. IV. 1147—1150. — Mazzitelli, P. Della in- fluenza della gravidanza sulla sifilide, e ris- pettivamente della influenza di questa sul frutto del concepimento. Movimento. Napoli. 2s III. 557-565. — Spill- mann, P. Rétrécissement du vagin sur- venu chez une femme atteinte de syphilis tertiaire ; dilatation consécutive et méca- nique du canal de l’urétre. Ann. de der- mat. etsyph. Par. 2s. II. 324-327. TABLES AND CHAIRS. Sellman, W. A. B. A new gynz- cological table. Tr. M. & Chir. Fac. Maryland. Salt. LXXXIII. 252-254. TANSY. Smith, T. C. Poisoned by tansy, 471 taken to procure abortion. Detroit Lancet. 1881-82. N.s. V. 147. TENACULUM. Sve Cervix Uteri, Medication and Manipulation of the. TENTS. Lusk, W. T. Septicemia and death following the repeated introduction of sponge and tupelo tents. Am. J. Obst. N.Y. XIV. 666. TETANUS, Puerperal. Kuhn. Ein Fall von Tetanus puer- peralis. Arch.f. Gynaek. Ber/. XVIII. 495-497: — Kuhn. Ueber einen Fall von Tetanus puerperalis. Wien. med. Bl. IV. 1599- THERMOMETRY. Marchionneschi, O. Termometria in ostetricia. Ann. diostet. Milano. III. 26-37. UTERUS, Involution of the. Mitsom, C. Contributions clin- iques al’étude de Vinvolution uté- TING; eLya77 wet -UTERUS, Medication of the. De FourcauLp, V. Etude sur les pulvérisations intra-utérines. Paris. 8° Witson, H. P.C. Uterine Dil- atation, with a New Instrument. New York. Wm. Wood & Co. 9 pp. 8° [Repr. from: Am. J. Obst. 1881.] Bompiani, A. La irrigazione intra- uterine continua nella endometrite settica e il trattamento chirurgico della metroperito- nite puerperale. Ann. di Ostet. J7ilano. III. 133-143.— Adso, [Transl. from the Italian by R. Fauquez.] Rev. méd. chir. d. mal. d. femmes. Pav. III. 312-323.— Campbell, W. M. On cases of dan- gerous symptoms following the use of the uterine sound. [Abstr.] Liverpool M.- GYNECOLOGICAL INDEX. Chir. J. I. 67-71.— Chamberlain. ‘the dangers of vaginal injections. N. York M. J. XXXIII. 457. Adso, Am. J. Obst. WW. Y. XIV. 879—88x.— Cowan, G. Martin’s rubber bandage as a utero-abdominal supporter. Am. J. Obst. NV. Y. XIV. 871-873.— Kocks, J. Ueber ein verbessertes Mutterrohr und die Vaginaldousche wahrend der Menstrua- tion. Centralbl. f. Gynak. Lez. V. 449-452. Lemmon, J. M. Death rom vaginal injection. Louisville M. News. XI. 280.—Mann, J.D. Ute- rine electro-therapeutics. Lancet. Lond. II. 48, 129.—Martin, A. Zur intra- uterinen Behandlung. Ztschr. f. Geburtsh. u. Gynak. Stuttg. VII. 1-13.—Mo- pales Perez, A. Porta-causticos — la cavidad del cuello uterino. Gac. Méd. Catal. Barcel. I. 341.—Opie, T. Notes on twenty-seven Cases, in which the intra-uterine douche was given in the Ma- ternity Hospital, Baltimore. Maryland M. J. Balt. 1881-82. VIII. 176, 196.— P. Del’emploi du coaltar saponiné dans la thérapeutique utérine. Progrés méd. Par. 1X. 549. Adso, Union méd. Par. 3 s. XXXI. 545.—Picard, G. H. Vaginal irrigation. Kansas M. Index, Fort Scott. 1. 287-296.— Prochow- nik, L. Ueber die Auskratzung der Gebarmutter. Samml. klin. Vortr. no. 193. Leipz. (Gynaeck. No.57. Pp. 1511- 1530.) —Schiffers. Medication intra-utérine; sa valeur en ce qui concerne Pemploi des médicaments liquides sous forme d’in- gall J. d’accouch. Lzége. II. 51, 63- — Smith, J. WV. On the use of Jen- nison’s tube. Boston M. & S. J. CV. 84.— Stucky. J. N. Dangers attend- ing the use of vaginal injections. Louis- ville M. News, XI. 230-232-— Von Teutleben. Eine neue Methode der intrautennen Applikation des Eisenchlorid. Centralbl. f. Gynak. Leifz. V. 569.— Thomas, Cc. H. Mechanical dilators in gynzcological practice. Phila. M. Times. 1881 —- 82. XII. 431 — 433- — Walion. Du cathétérisme utérin ou hystérométrie au point de vue médico-légal. Ann. Soc. de med. de Gand. LIX. 117-122. UTERUS, Mucous Membrane of the. Paladino, G. Della caducita del parenchima ovarico e de] rinnovamento to- tale dello stesso mercé ripetizione del pro- _cesso di primordiale produzione. Gior. Internaz. d. Sc. Med. Na#olz. N.s. III. 785-795: — Planteau, H. Recherches surla muqueuse utérine de quelques ani- maux a placenta difus. J. de l’anat. et physiol., etc. Par. XVII. 253-282. 2 pl. UTERUS, Prolapse of the. Hersst, PHILIPP. *Historisch- kritische Darstellung der Opera- tionen des Prolapsus uteri. a//e. E. Karras. 32 pp. 8° SIGNORET, S. *Du traitement du prolapsus utérin par les appa- reils contentifs. aris. 48 pp. 4° No- 391. 479 Berlin, Fanny. Three cases of complete prolapsus uteri operated upon according to the method of Léon Le Fort. Am. J. Obst. WV. ¥. XIV. 866-870.— Boyd, J. P. A clinical study of pro- lapsus uteri. Med. Ann. Albany. II. 89-95.— Campa. Descenso brusco y retroversion del utero por causa accidental ; oscuridad de los s{ntomas ; pardlisis de la vejiga ; retencion de orina; curacion. Cron. Méd. Valencia. 1880-81. 1V. 289-295. —Faucon, A. Traitement de la chute de l’utérus; (amputation du col dela ma- trice par le thermo-cautére, combinée avec le cloisonnement du vagin selon le procédé du professeur L. Le Fort). Arch. de tocol. Par. VIII. 265-279. Also, J. d. se. méd. de Lille. I1I. 649-663. Adso, Re- print. —Fauquez, R. Chute compléte de V’utérus. Rev. méd.-chir. d. mal. d. femmes. Par. III. 433-436.—Gala- bin, A. L. Multiple vesical calculi the sequel of prolapsus uteri. Tr. Obst. Soc Lond. (1880). XXII. 106-108. —Gomez Torres, A. Tratamiento del descenso uterino. Génio Méd.-chir. Madrid. XXVII. 217, 245, 260. — Guéniot. Rapport sur un travail de M. Eustache, intitulé: Du traitement de la chute de ma- trice par le cloisonnement du vagin; modi- fication au procédé du professeur Le Fort. Bull. et mém. Soc. de chir. de Par. N. s. VII. 826-828.— House, A. F. The operative treatment of prolapse of the vagina and uterus. Am. J. M.Sc. Phila. N. s. LXXXII. 39-50.— Levy, F. Den operative Behandling af Prolapsus uteri. See og. obst. Medd. K7bbenh. III. Pt. 2. 7-53.—Neugehauer, L. A. Einige Worte tiber die mediane Vagi- nalnaht als Mittel zur Beseitigung des Gebarmuttervorfalls. Centralbl. f. Gynak. Lei~z. V. 3, 25.— Wallace, J. On the radical cure of prolapse of the uterus. Liverpool M.-Chir. J. I. 30-43. —Wein- lechner. NHochgradiger Vorfail der vor- deren und hinteren Schcidenwand und des Uterus, weicher durch die Col porrhaphia anterior und posterior nach Hegar und durch die Amputation der Vaginalportion geheilt wurde. Ber. d. k. k. Krankenanst. Rudoiph-Stiftung in Wien (1880). 417- 419. — Wolfe, S. A complicated case of prolapsus uteri. Med. & Surg. Reporter. Phila. XLIV. 220. UTERUS, Retrofiexion of the. Dusois, A. *De la rétrofiexion dans ses rapports avec l’arrét d’in- volution de Jutérus apres l’ac- couchement et l’avortement. avis. opp. 4° No. 433. 5 Alberts, O. Zur Retroflexio uteri. Berl. klin. Wchnschr. XVIII. 712-714. — Courty, A. Traitement de la rétro- flexion de l’utérus. J. de thérap. Par. VIII. 281,327. Adso, Reprint. — Vede- ler. Retroflexio uteri hos Diegivende. Norsk. Mag. f. Legevidensk. Chris- tiania. XI. 669-685. UTERUS, Retroversion of the. CovrToux, L EONCE. *De la ré- troversion utérine a ]’état de va- 480 * cuité, son traitement mécanique. Paris. 38 pp. 4° Banning, E. P., Sr. Retroversion, with utero -rectal adhesions, successfully treated. N. York M. Times. 1881-82. IX. 147.—QLeonard, C. H. An in- teresting case of backward displacement of the womb and a new instrument for its replacement. Tr. M. Soc. Mich. Lansing. VIII. No. 1. Pp. 48-55.—Sabin, R. Hi. Retroversion of the uterus. Med. Ann. Albany. II. 150-154. UTERUS, Rupture of the. Ames, R. P. M. Rupture of the uterus, Am. J. Obst.. WV. ¥..- XIV. 361-395-— Dunlop, W. M. A case of rupture of the uterus. Lancet. Lozd. Il. 135.—Dougall, J. Rigid cervix, procidentia, and rupture of uterus during labour. Glasgow M.J. XVI. 23-25.— Ermolaeff, A. S- Sluchai razriva matki ote rodove, vizdorovlenie [rupture of ute- rus in labor]. Ejened. klin. gaz. S¢. Pe- tersb. [. 366-308. —Felsenreich, T. Beitrag zur Behandlung der Uterusrupture durch Drainage. Wien. med. Wchnschr. XXXI. 570, 588. —Felsemreich, T. Beitrag zur Therapie der Uterusruptur. Arch. f. Gynaek. Berl. XVII. 490-501. — Felsenreich, T. Ueber einen Fall von spontan geheilter Uterusruptur. Wien. med. Presse. XXII. 82.— Garrigues. Complicated rupture of the uterus. Med. Rec. V. VY. XIX. 634.—Garrigues, H. J. Rupture of the uterus. [Case.] Med. Rec. WV. VY. XIX. 351.—Von Hecker, C. Ueber einen Fall von spontaner kompleter Uterusruptur mit Aus- gang in Genesung durch Drainage. Cen- tralbl. f. Gynak. Lezfz. 225-228. — Hofmeier, M. Zur Aetiologie der Ute- rusrupturen. Centralbl. f. Gynik. JZesfz. V. 619-623. — Howard, W.T. Three fatal cases of rupture of the uterus, with laparotomy. Tr. Am. Gynec. Soc. 1880. Bost. V. 145-166. Adso, translation in Arch. de tocol. Par. VIII. 577-594.— Heucher, J. Howto prevent rupture 0 the parturient uterus. Am. J. Obst. V. ¥Y. XIV. 627-644.—Mann, J. Bei- trag zur Behandlung der Uterusruptur durch Drainage. Centralbl. f. Gynik. Leipz. V. 377-380.-— Moore, D. W. Rupture of the uterus [a second time}; re- covery]. Tr. M. Soc. Wisconsin. J£7- waukee. XV. 128.—Mundé, P. F. Case of rupture of the parturient uterus. Am, J. Obst. JV. ¥Y. XIV. 401-408. — Mundé, P. F. Rupture of the uterus. N. York M. J. XXXIII. 458.—Ram- saur, G. A. A deceptive pregnancy. Med. Bull. -PAda. Ill. 37.-—Rich- ardson, W. ©. A case of rupture of the uterus. Homaop. Cour. $7. Loves. I. 294-296. — Techernovoi-Popovoi. Polnii razrive matki, [Case of rupture of uterus] Vrach. S72. Petersd. 477: —Thompson, J. H. A case of rup- ture of the uterus. N. Eng. M. Gaz. Bost. XVI. 365-367.— Von Weber. Zwei Uterus - Rupturen. Prag. med. Wehnschr. VI. 373, 384.— Willett, E. M. Rupture of uterus; gastrotomy and recovery. Mississippi Valley M. Month. Memphis. 1. 5-10. GYNECOLOGICAL INDEX. UTERUS, Subinvolution of the. Alcorn, E. Uterine sub-involution; its pathology and treatment. Obst. Gaz. Cincin. IV. 61-64.—Chalot. Indi- cation de Vergot de seigle dans la sub-in- volution utérine aprés 1’accouchement. Gaz. hebd. d. sc. méd. de Montpel. III. 38-40. —-Fauquez. R. Métrite paren- chymateuse chronique consécutive a l’arrét de régression de l’utérus apres l’accouche- ment et la fausse couche, compliquée d’en- dométrite avec ulcération du col. Rey. méd.-chir. d. mal. d. femmes. Par. IIT. 673-678. —Fauquez, R. Métrite pa- renchymateuse chronique par arrét de ré- gression de l’utérus aprés les accouche- ments; endométrite limitée au canal cer- vical avec hypertrophie de la muqueuse. Rev. méd.-chir. d. mal. d. femmes. Par. Ill. 439-441. -Fauquez, R. Meétrite parenchymateuse chronique par arrét de régression de Vutérus aprés les accouche- ments, a la phase congestive de la premiére période; ceufs de Naboth. Rev. méd.- chir. d. mal. d. femmes. Pav. III. 490- 493. — Fauquez. R. Métrite parenchy- mateuse chronique par arrét de régression de l'utérus aprés les accouchements ; endo- métrite de la muqueuse du corps de l’uté- rus. Rey. méd.-chir. d. mal. d. femmes. Par. Il. 497-500. — Fauquez, BR. Métrite parenchymateuse chronique par arrét de régression apres l’accouchement et la fausse couche, suivie d’antéflexion. Rev. méd.-chir. d. mal. d. femmes. Par. III. 659-671. -Frommel. Ueber puerperal Uterusatrophie. Berl. klin. Wehnschr. XVIil. 7or.—Greene, J. 8S. Sub- involution of the uterus and neurasthenia. Boston M.& S. J. CV. 121-124. Aédso, Report. ‘ UTERUS, Superinvolution of the. Coles, W. Post-partum atrophy of the uterus. St. Louis Cour. Med. VI. 110-119. Discussion. 176-178. Adso. Reprint. UTERUS, Syphilis of the. FOuULQUIER, JULES. *De la sy- philis utérine secondaire. /arzs. 41 pp. 4° UTERUS, Tumors of the. BROWKILLO, J. *De Vextirpa- tion partielle des polypes utérins volumineux a large pédicule. Paris. 39 pp. 4° CaNnEvA, G. La trementina ; sua azione nella cura del cancro ute- rino. JZilano. 8° CHorTin, &. L. D) J. Duveancer de l’utérus et particuliérement de Vanatomie pathologique et des com- plications de cette affection. Lid/e. oO Fapsrl, E. F. Estirpazione di un mioma intra-uterino per mezzo dell’ ansa galvanocaustica. Bologna. 4° [Repr. from: Mem. d. Accad. d. sc. d. Ist. di Bologna.] GYNECOLOGICAL INDEX. 481 FRANK, E. *Ueber die Opera- tion complicirter Fibromyome des Uterus, insbesondere iiber die En- twickelung von Hautemphysem nach der Operation. 8° Mainz. 1880. MERKEL, G. H. Fibroid Tumors of the Uterus and Ovaries. JSos- ton. 8° Oums, EpmMuND. *Zur Casuis- tik, Diagnose und operativen The- rapie der festen Uterustumoren. Dorfat. Schakenburg. 86 pp. 8° PrEGOoUD, ALBERT. *De la va- leur des courants continus dans le traitement des tumeurs fibreuses de Vutérus. Paris. 43 pp. 4° SCHWARZENHOLZER, A. Zur Er- gotinbehandlung der Myofibrome des Uterus. 7Z7ziding. 8° Allende Padin, ‘R. Polipo uterino voluminoso. Rev. Méd. de Chile. Sazt. de Chile. 1878-79. VII. 363-370. 1 pl. —Amand. Fibrome intra-utérine; ex- traction; guérison. J. d. sc. méd. de Louvain. VI. 417-419.— Bar, P. Ob- servations pour servir a l’histoire de l’évo- lution des tumeurs pendant Ja grossesse. Par. 8° [Repr. from: Ann. de gynéc.] — Babes, V. Hamuykepletek méhizom- dagokban. [Fibromyomata of fundus of uterus.] Orvosi hetil. Budapest. XXV. 1205-1210. — Benicke. Uterus mit einem in Verjauchung begriffenen Myom- rest und mit multiplen Eiterheerden in der Umgebung. Ztschr. f. Geburtsh. u. Gy- nak. Stuttg. VI. 414.— Berthault. Myome hydrorrhéique de Vutérus, ablation d’un polype utérin; péritonite purulente; mort; autopsie. Bull. Soc. anat. de Par. 1880. LV. 318-322.— Boisliniere. Uterine polypus. St. Louis Cour. Med. - 237-—Borner, E. Ueber das sub- serése Uterus - Fibroid. Samml. klin. Vortr. No. 202. Leifz. (Gynik. No. 58, 1531-1566). —Brichetti, L. Di un voluminoso mioma uterino. Osservatore. Torino. XVII. 81-86.— Chambers, T. Fibro-cystic disease of the uterus. Tr. Obst. Soc. Lond. (1880). XXII. 159. 1pl.— Clark, ©. S. A case of uterine pe olypus complicating pregnancy. Am. M. i-Weekly. MW. Y. XIII. 217-—Co- lomiatti, V. Contribuzione allo studio dei tumori dell’ utero. Salute: Italia Med. Genova. 2s. XV. 105. Adso, Arch. per le Sc. Med. Yorino. V. 1-23. 1 pl. —'Czerny, V. Ueber die Enukleation subperitonealer Fikrome der Gebarmutter durch das Scheidengewolbe ; vaginale Myo- motomie. Wien. med. Wchnschr. XXXI. 501, 525. — Davezac, J- Sarcome uté- tin; métrorrhagie ‘constante; péritonite tuberculeuse ; mort; autopsie. J. de méd. de Bordeaux. 1881-82. XI. 34-36.— Davis, H. Intra-uterine fibroid tumor, sessile 3 its entire discharge by exfoliation promoted by incisions of “graduated depth into the growth. Lancet. ZLoxd. I. 866. —Davy, R. B. Subperitoneal fibro- cystic tumor of the uterus. Cincin. Lancet & Clinic. N.s. VII. 94-96.— Dawe “= VOL. VII. 31 son, B. F. Uterine fibroid removed by the galvano-cautery. Am. J. Obst. WV. ¥. XIV. 421.—Despres. Polypes_ uté- rins; corps fibreux pédiculés. Union méd. Par. 3s. XXXII. 109-114. — Després. Tumeur fibreuse volumineuse de l‘utérus, enlevée a V’aide de 1’écraseur linéaire segmenté. Bull. Acad. de méd, Par. 2s. X. 1376.—Dubrueil, A. Note sur la thérapeutique des polypes fi- breux de l’utérus. Gaz. hebd. d. sc. méd. de Montpel. III. 529.—Eddowes, A. Fibro-cystic tumour of the uterus; opera- tion; death. Lancet. Loud. I. 212.— Emmet, T. A. Submucous uterine fibroid. N. York M. J. XXXIV. 176. —Eulberg. Ueber die Indicationen zur Myomotomie nach Martin. Prakt. Arzt. Wetzlar. XXII. 28, 49-53, 97,121, 146, 169. — Exstirpatio fibromatis uteri. Aerztl. Ber. d. k. k. allg. Krankenh. zu Prag, (1878). _ 1880, 264. — Fauquez, KR. Polype fibreux sous-muqueux engagé entre les lévres du col; amputation par “la liga- ture élastique. Rev. méd.-chir. d. mal. d. femmes. Par. III. 436-439.— Formad, H. F. Soft fibroma of uterus. Phila. M. Times. 1880-81. XI. 316.— Fort. Enorme tumeur fibreuse de lutérus; opé- ration; guérison. Rev. méd.-chir. d. mal. d.femmes. Par. III. 561-564. —God- son, C. Remoyal of fibrous outgrowth from the fundus uteri; recovery. Tr. Obst. Soc. Lond. (1880). XXII. r11- 114.— Goodell, W. Intramural uterine fibroid. Tr. Phila. Obst. Soc. (1880). 14. — Gorvits, M. I. Nagnoenie stenok kistom jaichnika s klinicheskoi tochki zrenija [Suppuration of cystoma ‘ of uterus]. Vrach. Sz. Petersé. II. 661, 681, 698.— Grammatikati, J. Ein Myoma cervicis uteri cavernosum. Arch. f. Gynaek. Berl. XVII. 139-143. 1pl.—Grant, J. A. Case of uterine fibrous polypus. Canada Lancet. Torozto. 1880-81. XIII. 197-—Guéniot. Mé- thodes opératoires applicables a l’ablation des polypes de l’utérus; procédé d’excision a Vaide du constricteur ou serre-nceud. Bull. Acad. de méd. Par. 25s. X. 1248-1259. Adso, Thérap. contemp. Par. I. 689-697. Adso, Ann. de gynéc. Par. XVI. 331-349.—Hanahan, R. B. The successful removal of a sub-peritoneal fibroid of the uterus, with remarks. Med. Rec. MV. Ye. XX. 710.— Hanks. Uterine fibroid. N. York M. J. XXXIV. 68.— Hicks, J. B. On uterine con- tractions. Lancet. Zond. II. 568.— Howitz, F. Tre Tilfelde af Laparo- tomi for fibrfse Svulster. Gynak. og obst. Medd. Aydbenh. III. Pt. 2. 57-72.— Hubert, E. Des polypes de la matrice. J. d.sc. méd. de Louvain. VI. 161-168. —Hue, J. Présentation d’un myome utérin détaché spontanément et en état de décomposition putride. Union méd. de la Seine-Inf. Rouen. XX. 45-50.-—Jace cubasch. Ueber Uterus - Fibrome. Charité-Ann. 1879. Berl. VI. 320-341. —Jacubasch. Vier Fille von Uterus- sarcom. Ztschr. f. Geburtsh. u. Gynak. Stuttg. VII. 53-69. 1 pl.—Janvrin. Fibroid tumor of the uterus. N. York M. J. XXXIV. 69.—Kohn, M. Polip tozyskowy. Przyczynek kazuist. do roz- 482 poznawania i lecz. krwotokéw macicznych. [Polypus and hemorrhage of uterus.] Przegl. lek. Kvrakéw. XX. 533, 550.— Krasinoi, T. M. Sluchai samorodnago obratnago razvitija fibromiomi matki poslie rodove. [Case of myoma of uterus, re- turning after delivery.] Vrach. Sz. Pe- tersb. II. 361.—Labat. Observation de fibrome utérin dont la lente élimination, en accumulant les produits septiques dans la cavité utérine, amena une _ péritonite mortelle. [Rap. par Bazy.] Bull. Soc: anat. de Par. 1880. LV. 345-348.— Labbe, L. Traitement des _polypes fibro-utérins. Bull. Acad. de méd. Par. 2s. X. 1289-1301.—Leecoq. Tumeur utéro-ovarienne; hernie ombilicale étran- glée; rupture transversale de 1|’intestin; opération ; anus contre nature; mort; au- topsie. Bull. Soc. anat. de Par. LVI. 119-122. — Lussana, F. 11 metodo della escisione dei polipi uterini del dott Gio- vanni Comi. Gazz. Med. Ital., Prov. Ve- nete. Padova. XXIV. 203. — Martin, H.N. Hydatids of the uterus. Homceop. j. Obst. 4. ¥._ 1881-82. III. 29-31. — Maslovski, V. Ke ucheniou o slizis- tich polipach polisti matki. [On the mu- cous polypi of the uterus.] Vrach. Vaidom. St. Petersh. VI. 2321, 2337-—Maslov= sky, W. On the development of malig- nant from non-malignant tumours of the uterus. Edinb. M. J. 1881-82. XXVII. 588-594. 2 pl.— Mays, W. H. Recurrent fibroid, or sarcoma of the uterus. West. Lancet. San Fran. 1881-82. X. 6-9. — Meredith, W. A. Large multiloc- ular fibrocystic tumour of uterus. Tr. Path. Soc. Lond. XMXII. 145-147.— Miliken, F. A. Fibroid tumor of ute- rus; hypodermic injections of ergotin; cure. Phila. M. Times. 1881-82. XII. 304.— Montgomery, E. £E. Multiple uterine fibroid partially calcified. Tr. Phila. Obst. Soc. (1880). 29-32.— Morris, H. Abstract of a clinical lecture on a case of intramural fibroid tumour of the uterus; causing intermittent retention of urine, and leading to suppuration in the left ovary and along both Fallopian tubes, to dilata- tion of uterus, acute double nephritis, and purulent peritonitis and death. Brit. M. J. Lond. 1. 793.—Mudd. Case of ex- tensive fibroid of the uterus. St. Louis M. & S. J. XL. 588-590. — Neville. Auscultatory signs In uterine tumours. Dublin J. M.Sc. 3s. LXXI. 353-362. —Nicaise. Coincidence rare dé deux tumeurs fibreuses du corps de |’utérus et d’un cancer végétant du col. Gaz. d. hop. Par. LAV. 1017.—Nicaise. Sarcome de Vutérus. Ann. de gynéc. Par. XV. 437-444. — Oettinger et Teissier. Sar- come du corps de l’utérus. Progrés méd. Par. IX. 522-524. Adso, Bull. Soc. anat. de Par. LVI. 16-21. — Palfrey. Case of fibrous polypus uteri complicated with epithelial carcinoma of the cervix; excision; hemorrhage. Students’ J. & Hosp. Gaz. Lond. IX. 42.— Palmer, C.D. Case and operation of submucous interstitial fibroid tumor of the uterus. Cincin. Lancet & Clinic. N.s. VI. 172- 177.— Pirovano, I. Cinco casos de polipos uterinos operados y curados sin accidentes. Rev. Méd.-Quir. Buenos Aires. 1881-82. XVIII. 84.— Polk, W. M. GYNECOLOGICAL INDEX. Result of operation for uterine polypus; subperitoneal fibroid of the uterus; diag- nosis of pregnancy; cracked nipple. Vir- ginia M. Month. Richmond. 1881-82. VIII. 725-742. Polk. Diagnosis of sarcoma of the uterus. N. York M. J. XXXIV. 180. Also, Am. J. Obst. WV. Y. 1882. XV. Suppl. 17.— Polk, W. M. Removal of a sarcomatous growth from the lining membrane of the uterus. Nashville J. M. & S. N. s. XXVII. 145-148. — Reber, C. T. The influence of sub-mucous fibroids on gestation and parturition. St. Louis M.& S.J. XLI. 293.— De los Rios, J. M. Caso de tumor fibroso uterino curado por inyec- ciones hipodérmicas de extracto liquido de cornezuelo de centeno. Union Méd. Caracas. I. 41.—Roehrig, A. Die Behandlung der Uterusfibromyome, nach eigenen Erfahrungen. Arch. f. path. Anat., etc. Berl. LXXXIII. 393 - 460.— Romero y Linares, A. Nuevos mé- todos de talla perineal y de ligadura de los polipos de la matriz. Corresp. Med. Bar- cel. 1880. XV. Passim: contin. in XVI. 2, 18, 26, 34, 54. —Roustan. Fibrome intra-utérin; ligature élastique appliquée dans la cavité de la matrice; guérison. Montpel. med. XLVI. 239- 244.—Sehwarz, E. Gliickliche Exstir- pation eines 45 Pfund schweren cystischen Uterusmyoms unter Anwendung der elas- tischen Ligatur. [Nebst Bemerkungen von R. Olshausen.] Arch. f. Gynaek. Berd. XVII. 424- 443.— Stillwell, W. C. A case of fibroid tumor of the uterus. Phila. M. Times. 1881-82. XII. 71.— Stoker, M. T. Remarks ona case of fibromyxoma. Med. Press & Cire. Lond. N. ss XXXI. 133-136.—Tait, L. On the relative merits of the treatment of uterine myoma by enucleation, hysterot- omy, and ovariotomy. Ann. Anat. & Surg. Brooklyn, N.Y. Ill. 2513-258. —Tauszky, R. Fibro-myoma of the uterus. Bull. N. York Path. Soc. 2s. I.. 53-— Teissier et Oettinger. Fibrome du corps de |’utérus; cancer du col ayant envahi les os du bassin. Progrés méd. Par. 1X. 741.— Thomas, T. G. Clinical lecture on subperitoneal uterine fibroids. Boston M. & S.J. CIV. 433. — Thomas, T. G._ Fibro-cystic tumor ; laparotomy; recovery. Am. J. Obst. J. Y. XIV. 875.—Thornton, J. K. Removal of uterine fibroids by laparatonyy Tr. Obst. Soc. Lond. (1880). XXII. 114-129. — Upshur, J. N. A case of calcified fibroid of the uterus, with remarks. Am, J. Obst. WV. ¥. XIV. 208=111.— Vidal Solares, F. Tumor fibroso del litero, de veintidos kildgramos de peso, tomado por un quiste del ovario derecho ; gastrotom{a ; estrangulacion parcial del tu- mor por medio de dos ligadores de Cintrac; muerte cincuenta y seis horas despues de la operacion. An. de Obst., Ginep. y Pediat. Madrid. 2 ép. I. 361-369.— Wales, P. S. A case of uterine myoma; thirty- nine inches in circumference and weighing seventeen and one-half pounds; removed by laparotomy. Med. Rec. WV. ¥. XX. 315.— Ward, C. S. Fibroma of the body and carcinoma of the cervix of the uterus. Am. J. Obst. WV. ¥. XIV. 801. — Warren, J. H. Fibroid tumors of GYNECOLOGICAL INDEX. 483 fhe uterus. Virginia M. Month. Rich- mond. 1881-82. VIII. 73-86.— Wass seige. Ablation d’une tumeur kystique, dune partie de Vutérus et de J’ovaire gauche; opération trés compliquée; gué- rison. Bull. Acad. roy. de méd. de Belg. Brux. 3s. XV. 394-409.— Weber, F. Ueber den Einfluss der Badekur in Staraja Russa auf die fibrésen Geschwiilste der Gebarmutter. St. Petersb. med. Wehnschr. VI. 367-369. — Wells, T. S. Observations on recent improvements in the mode of removing uterine tumours. Brit. M. J. Lond. 1. 909. — Wil- liams, A. W. Case of a fibro-cystic subperitoneal tumour of the uterus cured by the actual cautery. Brit. M.J. Lond. - 384. VAGINA, Abnormities of the. Heustis, J. F. Occlusion and ab- sence of vagina. Tr. M. Ass. Alabama. Montgomery. XXXIV. 499. — Von Weber. Doppelte Vagina, zwei Vaginal- theile der Cervix, ohne Septum des Ute- rus. Prag. med. Wehnschr. VI. 433- 435- VAGINA, Atresia of the. See, also, Hematometra and Hymen. Allan, W. A case of atresia vagine of seventeen years’ duration. Dublin J. M. Sc. 3s. LXXII. 281.— Bros- seau, A. T. Anomalies des organes gé- nitaux de la femme. Union méd. du Ca- nada. Montréal. X. 481-489. — Cody, |]. Traumatic atresia of vagina following parturition ; operation; cure. Lancet. Lond. Il. 666.— Earnest, J. G. A case of occlusion of the vagina. At- lanta M. & S. J. 1880-81. XVIII. 722- 724.— Earnest, J. G._ Occlusion of the vagina. Atlanta M. Reg. 1881-82. I. 139-142.—Greene, J. M. Case of atresia vagine following labor and causing retention of menstrual fluid for eighteen months. Tr. Mississippi M. Ass. /Jack- son. XIV. 133-136.— Larrivée. Oc- clusion vaginale consécutive 4 une parturi- tion; rétention du flux menstruel sans dilatation de la cavité utérine; opération. {From: Lyon méd.] Arch. detocol. Par. VILL. 112-116. — Manlius. Mechan- ical atresia vagine. [Cicatrix from impale- ment.] Boston M. & S. J. CIV. 277- —Minton, H. Atresia of the vagina. Homeeop. J. Obst. V. V. 1881-82. III. 20-29.— Quackenbush. Atresia va- gine. Med. Ann. Adéany. Il. (Tr. M. Soc. County Albany. 207 - 209.) — Riggs, C. E. Atresia of female genital tract. South. Clinic. Richmond. IV. 489-495- VAGINA, Cancer of the. Bruckner, C. Der primaire Schei- denkrebs und seine Behandlung. Ztschr. f. Geburtsh. u. Gynak. Stuttg. VI. 110- 125. VAGINA, Dilatation of the. Pfannkuch. Zur Aetiologie der temporaren Erweiterung des Scheidenge- wolbes. Arch. f. Gynaek. Berd. XVIII. 150-155. VAGINA, Foreign Body in the. Atihill, L. Hair-pin removed from the vagina after it had lain there for up- wards of sixteen years and had caused a vesico-vaginal fistula. Med. Press & Circ. Lond. N.s. XXXI. 291.— Carter, C. H. Foreign body in the vagina, re- moval after four years, and after-results. Tr. Obst. Soc. Lond. (1880). XXII. 34- 38.— Piece, A, of sponge retained in the vagina causing suspicion of cancer. Boston M. & S.J. CV. 254. VAGINA, Gangrene of the. Sve Labor, Sequelee of. VAGINA, Inflammation of the. Liandier. Note sur deux cas de phagédénisme traités avec succés par les émollients, et sur le traitement de la vagi- nite par le tamponnement. Gaz. méd. de Par. 6s. III. 312, 327.— Terrillon et Auvard. Modifications. nouvelles dans le traitement de la vaginite. Bull. gén. de thérap., etc. Par. C. 193-199. — Zweifel, P. Ueber Vaginitis emphy- sematosa und den Nachweis des Trime- thylamins in der Vagina. Arch. £ Gynaek. Berl. XVIII. 359-366. VAGINA, Medication of the. Benicke, F. Heisse Scheidenirriga- tionen bei Frauenkrankheiten. Berl. klin. Wehnschr. XVIII. 353-355.— Be= micke. Heisse Scheidenirrigationen bei Frauenkrankheiten. Ztschr. f. Geburtsh. u. Gynik. Stuttg. VI. 411.— Gare rigues, H. J. A vaginal depressor. Med. Rec. WV. VY. XX. 698.—Stein- schneider. Die permanente Irrigation der Vagina und ihre Anwendung in Fran- zensbad. Wien. med. Presse. XXII. 207, 239. VAGINA, Prolapse of the. Kraus, FRANZ. *Ein Fall von totalem Vaginalprolaps wahrend der Schwangerschaft und Geburt. Greifswald. 1880. C. Sell. 24 PEW os Fritsch. Partielle Scheidenresektion als Scheidenprolapsoperation. Centralbl. f. Gynak. Lezpz. V. 425-429. — Wein- lechner. Befund einer Colporaphia pos- terior nach 14 Jahren; Prolapsus ani durch Anwendung der Gliihhitze am Afterrande und an der umgebenden Haut (Dieffen- bach)’; geheilt. Ber. d. k. k. Krankenanst. Rudolph-Stiftung in Wien (1880). 399. VAGINA, Rupture of the. Williams, J. Rupture of vagina into Douglas’ pouch; peritonitis; recov- ery. Brit-M.J. Lond. I. 231. VAGINA, Stenosis of the. Meyer, J. Zur Casuistik der nar- bigen Verengerungen der Vagina. St. Petersb. med. Wehnschr. VI. 428. VAGINA, Thrombus of the. Stocker, S. Thrombus vaginz. Cor.- Bl. £. schweiz. Aerzte. Based. XI. 411. VAGINA, Tumors of the. CoLLarpor. *Des kystes du vagin. aris. 47 pp. 4° 484 HEINELT, FRANz. *Zur Casuis- tik, Symptomatologie und Therapie der Scheidentumoren. Grezfswald. TOSO; Cs Sell ra 7epp mor Lebedeff, A. Ueber die Gascysten der Scheide. Arch. f. Gynaek. Ser. XVIII. 132-149. 1+ pl.—Macan. Fi- brous tumour of the vagina. Dublin J. M. Sc. 3s. LXXI. 156.—Soltmann, ©. Primares Schleimhautsarcom der vor- deren Scheidenwand mit secundairem Bla- sensarcom. Jahrb. f. Kinderh. Lezfz. 1880-81. XVI. 418-424.— Watts, R. Cyst of anterior vaginal wall; developed from Gartner’s canal. Am. J. Obst. JV. Y. XIV. 848-852. VAGINISMUS. Catrin. Observations du vulvisme. France méd. far. II. 421.—Dun- ean, M. A case of vaginismus from vascular caruncle, treated with the ether cautery. Med. Press & Circ. Lond. N. s. XXXII. 191. —Engstroém, O. Nagra anmiarkningar 6fver Vaginismus. Gynaek. og obst. Medd. A7jydexhk. III. 3 Hit. 21-28.—Lougee, W. H. Va- ginismus. Am. Homeop. WV. Y. VII. 229-231. Martineau. Du vulvisme. France méd. Par. II. 241, 253, 268, 277. — Vaginisme (Le) supérieur. Gaz. d. hop. Pav. LIV. 625.— Wyman, H. C. Operation for cure of vaginismus. Detroit Lancet. 1881-82. N.s. V. 281 VARIOLOID in Pregnancy. Marx, EK. Observation de varioloide communiquée a une femme enceinte par son enfant de deux ans; accouchement gémellaire survenu entre les prodromes fébriles et apparition de |’éruption; mort rapide des deux enfants; guérison de la mere. J. de méd. de Bordeaux. 1881-82. Ol a8. VARIX in Pregnancy. Caztn, H. Des varices pendant la grossesse et l’accouchement. /a- PESOS Queirel. Des varices pendant la gros- sesse et l’accouchement. Marseille méd. XVIII. 195, 257, 325. Adso, Ann. de gynéc. Par. XV. 275-294, 338-354. VERSION. See, also, Evolution, Spontaneous. Grassi, E. Sostituzione d’una presentazione del tronco a quella originaria delle natiche avvenuta dopo la rottura del sacco. F7rezze. 8° [Repr. from: Imparziale.] Blanco y Santana, J. Caso nota- ble de distocia; version podalica, embarazo doble. Gac. Méd. de Sevilla. III. 3-5.— Gay, C. C. F. Pelvic version; report of cases, with remarks. Buffalo M. &S. J. 1881-82. XXI. 215-218. —Hanawalt, H. O. A case of version in prolapsed funis. Kansas M. Index. Fort Scott. Il. 21r5.— Hauenstein, J. Cephalic version in the postural position [szc]. Buffalo M. & S. J. 2938. — Labat, L. 1881-82, XXI. 289- Note sur la version GYNECOLOGICAL INDEX. ‘ par manceuvres externes pendant le travail. Ann. de gynéc. Par. XV. 37-44.— Lee, W. H. Spontaneous version and involution in a shoulder and arm presenta- tion. Tr. M. Ass. Missouri. Sz. Lozzs. XXIV. g6-101.—Negri, P. Del com- plemento artificiale della evoluzione spon- tanea mediante V’uncino acuto. Ann. di Ostet. Milano. III. 154-170. Also, Reprint. — D’Orsonnens, T. E. D’O. Un cas de version pelvienne spontanée. Abeille méd. Montréal. III. 388-390. —FPietri. De la version cefdlica por ma- niobras externas. Gac. Cient. de Venezuela. Caracas. 1881-82. IV. 113, 131.— Se- condipare a 7 mois de grossesse ; inser- tion centrale du placenta; présentation de V’épaule droite en 17° position ; hémorrhagie abondante exigeant une terminaison rapide ; version podalique; suites de couches heu- reuses. J. d’accouch. JZzége. Il. 141- 143- Adso, Arch. de tocol. Par. VIII. 663-672. —Stringari, F. Caso di ver- sione spontanea cefalica dodici ore dopo scolate le acque e pronta azione del bisol- fato di chinino sulle contrazioni nervose. Indipendente. Torino. 103- 107-— Stuart, J. A. E. Twins; double version. Edinb. M. J. 1881-82. XXVII. 503.— Taylor, I. K. Spontaneous ver- sion and evolution of the fetus in shoulder and arm presentations, and the manage- ment of such cases without the sacrifice of the child. Am. J. Obst. WM. Y. XIV. 525-551. * VIBURNUM PRUNIFOLIUM. Coleman, W. L. Abortion shortly after conception, and its prevention by vi- burnum prunifolium. Therap. Gaz. De- troit. N.s. II. 249-251. VIRGINITY. Burroughs, S. R. evidences of virginity. Rec. Galveston. I. VULVA, Abscess of the. Gosselin. Traitement des abcés de la vulve. Praticien. Par. IV. 161. VULVA, Cancer of the. LEHMANN, E. *Ueber Entwick- lung, Verlauf und Behandlung der Post - mortem Texas M 102-108. Carcinome an der Vulva. 8° ffalle. 1880. Kiistner, O. Zur Pathologie und Therapie des Vulva-Carcinoms. Ztschr. f. Geburtsh. u. Gynak. Stuttg. VII. 7o- 83. 1p. VULVA, Edema of the. } GAULARD. Quelques considéra- tions sur l’cedéme vulvaire chez la femme enceinte et en travail. Zzd/e. go VULVA, Inflammation of the. Parrot, J. La vulvite aphtheuse et la gangréne de la vulve chez les enfants. Rev. deméd. Par. I. 177-191- VULVA, Lupus of the. Cayla. Esthioméne de la vulve (forme tuberculo-ulcéreuse). Progrés méd. Par. IX. 648. GYNECOLOGICAL INDEX. 485 VULVA, Pruritus of the. Bryson. Pruritus vulve relieved by iodide of potassium. St. Louis Cour. Med. V. 150-152.— Wiltshire, A. Clinical remarks on the diagnosis and treatment of pruritus vulve. Brit. M. J. Lond. I. 327-329- WATERS, Mineral. CauLET. Du traitement thermal sulfuré des phlegmasies péri-uté- rines. farts. 8° [Repr. from: Ann. Soc. d’hydrol. méd. de Par.] Morisani, O. Le acque carbonico- ferrate del Chiatamone in ginecologia Gior. Internaz. d. Sc. Med. Magolz. III. €03-608. — Seebohn, A. Zur Behand- lung der chronischen weiblichen Sexual- Erkrankungen mit den Kurmitteln Pyr- monts. Deutsche med. Wchnschr. Serd. VII. 268, 285. ovale it at a ie Ay J yn ans Pe 236 Oe BEG eA eZwynemeww &eweerrw bi a — tad RG American Gynecological i Society A55 Transactions Var Biological & Medical Serials PLEASE DO NOT REMOVE CARDS OR SLIPS FROM THIS POCKET UNIVERSITY OF TORONTO LIBRARY Pet) Sie. fedcauay pete PbGrbid dre, by ee wat tah oa sit i ae iaath can Fetes . a ~ ws Ces Ani titan wa ptauet wines ake sae tiog ah fo oA ob oh 32 aves vane . pal > ietahte 3s Lie aes as a ABB Weaie shiee 28 0" We piget ety Jot el ol ae 5 ae Ue ache 1 Neda wate iat rs 1 ress J ‘Be Fe olay SMR tae sae ae ed ves eet beat ii ee ies CArraArer? ELA ely Pie's iia 18 (an ad Aud BARRY ay Sais Wetican a Pesan eas at qa, A ‘4 S me rae 2H ay : ‘h 35, Ly ArAS a hs try WAN Skt i ay a Va te you RY Sng iN he ua a on i BAD ober} v Pa a Fee ar aritey Ki yates: te pan eure ve Der ten etme eee, ay qh: "ho we Nw oe « ' ws cade y ote etl nid KE Athan 4 \ wands st Wits a akin vrei irs ae aNthy, mt ® ey \ rae * "13 “yn oh eauiacdetnast SEN, MERIDEN, Oo Lovet mn Hy wei Tahar tose Wesabe heey hh, VA A Nie 4 Ash. Weis Ad D et. stot UY eh Ap Welhe OMe Gey ue Seta ube aK oN aa ee Miata ee Niet “i 4 AY i Weide Y 3 Moet aes a t iby it es Ware td Fadi vi SW Cet PS GOL VEY Hy iedti wig \ * ey AN 7 A ts uy at wey a wasp Canty 6 AEE Man iitet n Hes WIN ALA Tee Gh a EN ORIUIEN hee oi ORIN iN a Wet aus nS OD hehe bf tle Heh bf Wee ke Watlhitels wg ge ER CNRS Ag bar) Wi aM ease b a At Hau Monts oat mat We ee vale ay ?