the same as that of the other form of cancer, and consequently need not
be given in detail. The main symptom is hemorrhage, with an abundant
and stinking sanious discharge.
DIAGNOSIS.--In examining with the finger and with both hands it will be
found that the uterus is movable and not much, if any, enlarged. If the
case is of the ulcerated variety, the finger may not detect the lesion;
if, on the contrary, there is a fungus, it will at once detect it.
Should the deposit not project from the os externum, the finger may not
recognize its presence. Upon exposing the cervix to view in the
ulcerative variety an ulcer of a light ash-color will be seen,
presenting an irregular outline slightly excavated, and if the probe is
applied to it the bottom and sides of the ulcer will be found of the
same firmness and consistence as the uterine tissues. It is not
indurated. If a fungus exists, it can be seen and examined. When not
bleeding it is also ash-colored. The {280} consistency of the
projecting mass is sometimes tolerably firm, but more frequently it is
quite frail and gives way under moderate pressure. Should the deposit
be inside of the uterus, the os will be slightly dilated and filled
with a gray substance.
The probe will readily pass through this frail material and enter the
uterine cavity. In cases presenting such an appearance the cavity is
generally enlarged and filled with this fungous deposit. These facts
may be ascertained by the use of the probe while the parts are exposed
to view.
The microscope will verify and correct our diagnosis. For microscopic
examination some substance from the surface of the ulcer or fungoid
projection may be collected and submitted for inspection. The
appearances are nests or spaces of greater or less size filled with
epithelioid cells.
PROGNOSIS.--Without judicious treatment practised at an early period
epithelioma may be said to be invariably fatal. There is, however, much
promise of great amelioration in this form of disease with the present
improved methods of treatment, and in some cases we may succeed in
effecting a permanent cure.
TREATMENT.--The general palliative treatment is the same as that
described in the other form of cancer, and need not be repeated. While
I have failed to see any other than palliative effects result from
amputation of the cervix and excavation of the body of the uterus in
the first form of cancer described, I have seen cures of epithelioma
effected by thorough extirpation of the diseased mass. One of these
cures was in a case where the disease was confined to the posterior lip
of the cervix; another, where the deposit apparently occupied the whole
surface of the mucous membrane of the body and cavity of the cervix. In
other cases I am sure the life of the patient was prolonged and her
comfort greatly enhanced. I am persuaded, from a good deal of
observation, that the younger the patient the more promising the result
of operations. The worst and most rapidly fatal cases of epithelioma I
have seen have been in patients beyond the menopause. This is contrary
to what I have witnessed in the other form of cancer, as in it the
younger the patient the more rapid the progress of the disease and the
least beneficial the operations were.
After a trial of the several methods pursued in the removal of
epithelioma, and the different instruments used for the purpose, I
prefer using the scissors, aided by hooks and vulsellum, to cut away as
much of the diseased tissue and the sound structure upon which it is
implanted as possible, and then burn the surface with the cautery in
some of its forms or the strong caustics. When the disease is confined
to the cervix, the whole of the intravaginal portion should be cut away
and the excising process carried as high up as possible, carefully
avoiding the peritoneal cavity on the one hand and the bladder on the
other. With the cervix exposed and fixed by a vulsellum, the
sharp-pointed curved scissors may be insinuated beneath the external
covering, and the tissues removed by pieces until the operation is
completed. When the utmost attainable portion is thus removed, I prefer
applying to the whole of the cut surface pellets of absorbent cotton
thoroughly moistened with the solution of the pernitrate of mercury
(the acid nitrate, as it was formally called), and then filling the
upper part of the vagina with dry absorbent cotton, {281} tightly
packing it so as to absorb any of the free acid. This last is necessary
to defend the sound parts from the superfluous cauterization which
would otherwise follow. The dressing may be removed in twenty-four
hours, and the whole of the surgical cavity as well as vagina washed
out with pure warm water twice a day afterward. If the cavity thus
formed does not fill up, and the surface assumes a malignant aspect, it
should be scraped out with a view to remove its entire surface and
treated again with the acid. This last operation may be repeated again
and again. It will sometimes be found that the cavity will grow less
after each scraping with the sharp curette, and finally fill up.
If the disease is developed in the cavity of the uterus, Simon's sharp
curette should be used to scrape out and destroy the whole mucous
membrane. When this is done the cavity should be carefully filled with
the cotton pellets saturated with pernitrate of mercury, as recommended
for the cervical operation. And this operation should be repeated also
with the same thoroughness as at first as soon as evidence of a return
is manifested. When the scraping and cauterizing have been beneficial
the uterine cavity will become smaller, and when the discharges
indicate a reproduction of the morbid deposit the surface to be
operated upon will be sensibly diminished, until finally it will be
apparently almost closed. I say almost, because one of my patients,
while she seems to have been cured, still menstruates.
While I do not pretend that many of these cases can be thus cured, I am
sure some of them can be. Hence I do not hesitate to recommend an
effort to be made in all cases in which the disease has not spread to
the adjoining organs or tissues. When a cure is not thus effected, such
great amelioration will so often occur as to make an operation
justifiable.
The hemorrhages encountered in these operations are generally
unimportant, but occasionally so much blood will be lost as to require
hæmostatic measures. The practitioner should therefore be supplied with
an astringent tampon and use it if necessary.
If an operation for the complete extirpation of the uterus is ever
justifiable for malignant disease, I think it is in this form. The
operation which I think the simplest and easiest to accomplish is that
performed first in this country, so far as I know, by S. C. Lane of the
Medical College of the Pacific, and in Germany by Langenbeck.
{282}
DISEASES OF THE OVARIES AND OVIDUCTS.
BY WM. GOODELL, M.D.
The ovaries are two almond-shaped glands attached to either side of the
womb by a ligament of contractile tissue called the ovarian ligament,
and they are enclosed between the two layers of the peritoneum known as
the broad ligament. It has recently been contended that this
envelopment in the broad ligament is not a complete one, but that the
peritoneum is absent from the posterior surface of the ovary. This has
been denied, but even if it be so, the fact does not seem thus far to
have any physiological or any pathological bearing.
The ovarian nerves and blood-vessels run between the two layers of the
broad ligament, the former coming chiefly from the renal plexuses of
the sympathetic, the latter from the spermatic arteries. The ovaries
being themselves movable bodies and attached to a movable organ, the
exact position of which remains yet a moot question, their own natural
situation has not yet been authoritatively determined. His,[1] from an
examination of three suicides, holds that the ovary in the adult virgin
hangs with its long diameter almost vertical, and with one side against
the wall of the pelvis, but below the brim, the free border being
behind and the attached end below. Each oviduct is looped over the
ovary, rising along the front and falling over behind it. Hence the
ovary lies on the fimbriæ which turn back and spread over the summit of
the ovary. The ovaries are generally situated on a level with the inlet
of the true pelvis, the left one being in front of the rectum, the
right one surrounded by a coil of small intestines. When healthy they
keep so high up as to be beyond the reach of the examining finger, and
consequently they are not impinged upon during coition.
[Footnote 1: _British Medical Journal_, Dec. 10, 1881, from _Archiv f.
Anat. u. Entwick._, 1881, Nos. 4 and 5.]
The important and special function of the ovaries--that of secreting
and excreting the Graäfian follicles or ovisacs--and their monthly
engorgements are the causes of many of the diseases to which they are
subject. Hence it is that affections of the ovary, being due most
commonly to perverted function, rarely occur before puberty.
Malformations.
Absence of the ovaries is a congenital condition very rarely met with.
It is usually associated either with the absence also of the womb or
{283} with an imperfect development of the other portions of the sexual
apparatus. The breasts will be flat, the vagina generally imperforate,
the vulva small, the pubic hair absent, and sexual feeling wanting.
Menstruation never takes place. Very commonly the growth of the body is
arrested, and the stature is dwarfed to that of a child. Occasionally,
however, there is an approach to the masculine type in the size, the
figure, the voice, and in the growth of hair on the face and on the
body.
An arrested development or a rudimentary condition of the ovaries is a
more common malformation than the preceding one. The womb is then
infantile in size, and the vulva and vagina are small and the pelvis is
narrow. Puberty either fails to take place or it is postponed. When
menstruation is present it is scant and appears at long intervals.
General development is impaired, and the figure and mental
characteristics may be those of advanced childhood. Sexual feeling is
either wholly absent or very imperfect.
DIAGNOSIS.--Whenever the ovaries are wanting, their absence cannot be
positively made out by a digital examination of the parts, for even
fully-formed ovaries often elude the finger. The diagnosis depends
mainly on the symptoms previously given. If the ovaries are
rudimentary, the finger passed high up the rectum while the woman is
anæsthetized will sometimes recognize them. But the diagnosis rests
usually on some manifestation of puberty, and the greater these
manifestations the greater the curability.
TREATMENT.--For the complete absence of the ovaries all treatment is of
course useless. Whenever these organs are in a rudimentary condition
more can be done for the woman, but success is by no means assured.
Every treatment that tones up the body is of service. The rest-cure,
with its accessories of massage, general faradization, and
over-feeding, promises much. Electricity has done good when one pole is
applied directly over an ovary and the other pole placed either on the
sacrum or on the cervix uteri. It is still more efficacious when the
reophore in the form of a properly insulated sound is passed into the
uterine cavity. Should the interrupted current fail to do good, the
galvanic current may cautiously be tried.
From the vascular and nervous kinship between the ovaries and the womb
all stimulants to the latter tend to invite blood to the former, and
from this flux may come growth. It is therefore good practice to
irritate the womb by tents, by applications of iodine and of silver to
its cavity, and especially by the use of galvanic stems. The marriage
relations sometimes quicken dormant ovaries into life, and development,
followed by pregnancy, has been the result. But the remedy is a
hazardous one, for if the sexual sense be not awakened, as often it
will not, the union leads to much unhappiness.
Inflammation of the Ovary; Ovaritis.
Acute inflammation of the ovary rarely exists per se, but it is by no
means an infrequent accompaniment of pelvic peritonitis and pelvic
cellulitis, the causes of each being the same. It is then so masked by
the {284} greater inflammation that its symptoms are lost in the
general ones. Following the same course as that of pelvic
inflammations, it begins with fibrinous exudation and ends either in
resolution or in suppuration, or in chronic hypertrophy.
The TREATMENT of this inflammation is the same as that of pelvic
inflammation--viz. rest, poultices, vaginal injections of hot water,
and morphia and quinia in large doses. Sometimes the local abstraction
of blood will be useful. Should pus form, it must be evacuated by the
aspirator, and preferably per vaginam. After such an inflammation, and
especially if caused by gonorrhoea, the ovary usually remains
permanently injured, its functions being crippled by fibrous bands,
adhesions, hardening of its stroma, and thickening of its investing
peritoneum. If both ovaries be thus affected, sterility inevitably
ensues.
Chronic Ovaritis.
By chronic ovaritis is meant either persistent congestion of the
ovaries, or such tissue-changes in the stroma or in the follicles of
the ovary, or in both conjointly, as are brought about from a previous
attack of acute inflammation or from persistent hyperæmia. In its early
stages it appears to be characterized by passive congestion, followed
by infiltration of sero-sanguinolent fluid and by increase in bulk.
Later on, if the congestion be not dispersed or it passes the
health-limit, it becomes formative, or nutritive; the capsule thickens,
the follicles enlarge, and a general hypertrophy takes place. According
as the brunt of these changes falls on the stroma or on the follicles,
the degeneration is termed either interstitial or follicular. When the
stroma is chiefly attacked, the ovary becomes hard and rugous; when the
follicles are diseased, they increase in size, and one or two of them
are usually found to be distended into miniature cysts. There are
indeed good reasons for the opinion that an ovarian cyst is a dropsy of
many ovisacs, and is caused by ovaritis. The left ovary is the one more
commonly affected--a fact accounted for by the pressure of the
distended rectum and by the emptying of the left ovarian vein into the
renal vein instead of into the vena cava, which is the course of the
ovarian vein on the right side. It is a very common form of disease,
very rarely coming from an acute attack, but starting subacutely with
all the symptoms of chronicity.
CAUSATION.--Whatever induces a lasting congestion of the reproductive
apparatus tends to create ovaritis--a torn cervix, a lacerated
perineum, an arrest of involution after labor, dysmenorrhoea, and
uterine tumors, flexions, and displacements. Barren women are very
liable to this disease, and so especially are women who shirk maternity
by preventive methods; for in both the menstrual congestions continue
without that much-needed break which gestation and lactation bring, and
in the latter the sexual congestions arising from incomplete
intercourse are not relieved. So repeated erectility from self-abuse,
by ending in a passive congestion of the womb and of the ovaries, will
tend to produce this lesion. The prevalence of this habit in unmarried
women is, I think, very much overrated, and yet I have seen from this
cause several cases of ovaritis accompanied with prolapse of the
ovaries. In one the ectropion {285} of the cervical mucosa was so
marked that it leads me to think that this is the cause of the
occasional inversion of the womb in virgins. My notebook shows also
cases of ovaritis from such imperfect sexual relations as come from the
ill-health or the advanced age of the husband, and not a few from
immoderate sexual intercourse. Some of the most common causes of
chronic ovaritis are emotional in character, such as long engagements,
disappointments in love, single life, the reading of corrupt
literature, unhappy marriages, nerve-exhaustion, and hysteria. These
causes operate by producing circulatory disturbances which keep up a
constant congestion of such exacting organs as the ovaries.
SYMPTOMS.--Pain in one or in both ovarian regions, especially in the
left one, is a prominent symptom. It is increased by walking or by
standing, and is lessened by the recumbent posture. Starting usually
from the ovary, it radiates to the small of the back or down the inner
side of the thigh. It often begins from a week to ten days before the
monthly period, and goes on increasing until the flow appears, when it
commonly abates. Menorrhagia may usher in the disease, and may continue
during the remainder of menstrual life, which then is usually
prolonged. Ordinarily, however, menstruation becomes scant and
irregular, postponing rather than anticipating. Sometimes amenorrhoea
takes place. Sterility is usually present, and so almost always is
nerve-exhaustion with all its emotional manifestations. Pressure over
each ovarian region elicits pain and causes a contraction of the rectus
muscle on the affected side. The finger per vaginam or per rectum will
often discover behind the cervix uteri or to one side of it the very
tender ovary, of the form and size of an almond. Pressure on it gives a
sickening pain, very unnerving in its character. Reflex nervous
symptoms are very common, especially those of hysteria. In the form of
pain they show themselves in backache, spine-ache, nape-ache, and
headache; in pain under the left breast, in the scalp on the top of the
head, and in the stomach, bowels, womb, and coccyx. Nervous dyspepsia
is common, accompanied by costiveness, nausea, vomiting, flatulent
distension, and noisy eructation. Wakefulness and bad dreams are not
infrequent. Other reflex neuroses may appear, such as paralysis or
spasm of the sphincter muscles, the latter producing asthma,
dysmenorrhoea, irritable bladder, and painful defecation. Then, again,
there may be nervous disturbances, taking the form of low spirits,
violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive
mental aberration.
PROGNOSIS.--This disease is rarely fatal, but it is always very
stubborn, and often incurable. The patient grows anæmic and she tires
on the slightest exertion. Very soon nerve-exhaustion with its protean
symptoms sets in. She takes to her back and becomes a sofa-ridden
invalid. If the patient has contracted the habit of taking stimulants
or anodynes, her chances for recovery will be greatly lessened.
TREATMENT.--The pelvic organs should be carefully examined, and any
discoverable lesion of the womb and of its annexes be remedied. Pelvic
engorgement must be met by keeping the bowels soluble, by scarification
of the cervix, by large vaginal injections of water as hot as can be
borne, and by vaginal suppositories of belladonna and by rectal ones of
iodoform. Tenderness and hardness in either broad ligament is first
treated by applications of a strong tincture of iodine both to the roof
of {286} the vagina and to the skin overlying the ovarian regions.
Flying blisters may also be placed there with benefit. Sexual
intercourse should not be indulged in unless the desire for it be
strong or there is a possibility of conception, for, by the prolonged
rest which it gives to the ovaries, pregnancy usually brings about a
cure. The patient should keep on her back during her menstrual period;
but, while rest in the recumbent posture should be taken morning and
afternoon, she should be encouraged to move about and exert herself in
some light household work, yet not to over-fatigue herself.
As far as medicines are concerned, those should be chosen which lessen
the engorgement of the reproductive organs. Thirty grains of potassium
bromide and ten drops of tincture of digitalis, given in compound
infusion of gentian before each meal, will tend to quench all
erectility of these organs. After the patient has been kept for some
time on these anaphrodisiacs, alteratives will come into play: very
good ones are ammonium chloride and mercuric bichloride, which can be
advantageously administered after the following formula:
Rx. Hydrargyri chloridi corrosivi, gr. j-ij;
Ammonii chloridi, drachm ij-iv;
Misturæ glycyrrhizæ comp. fluidounce vj. M.
S. One dessertspoonful in a wine-glassful of water after each meal.
The paregoric in this mixture helps to control the aches; the antimony
adds its quota to the needed alterative action; and the licorice
disguises the harsh taste of the ammonium chloride.
Another very excellent alterative and nervine is the chloride of gold
and of sodium. It is best given in pill and after each meal in doses of
from one-eighth to one-quarter of a grain.
As there is in this disease a craving after stimulants and anodynes,
which often degenerates into intemperance and into the opium-habit, the
physician should be very careful how he prescribes such remedies,
reserving their use wholly for emergencies.
In plethoric cases marked with menorrhagia iron is hurtful, but in
anæmic cases with scant menstruation it rarely fails to do good,
especially when given conjointly with arsenic. An excellent combination
is one part of Fowler's solution of arsenic to nine of the syrup of the
ferrous iodide. Beginning with ten drops after each meal, the patient
increases the dose daily by one drop until thirty drops are reached.
She then continues this last dose as long as it does good or it can be
borne. In stubborn cases a sea-voyage may prove of lasting benefit.
The best of all treatments, however, and by far the best, is that
devised for nerve-exhaustion by S. Weir Mitchell, which goes by the
name of the rest-cure. It consists of prolonged rest in bed, seclusion
from friends, massage, electricity, muscular movements, and a diet
consisting largely of milk. By this treatment the circulation of the
blood is made equable and the ovaries and other pelvic organs are thus
relieved of their turgescence. I have had wonderful cures from this
treatment, and can recommend it with the utmost confidence. Bed-ridden
patients have been restored to health and chronic invalids returned to
society.
Once in a while, lasting tissue-changes take place in the ovaries which
medication cannot reach. The question then comes up, whether the woman
shall be doomed to drag out the rest of her menstrual life {287}
burdened with distressing ovaralgia, with crippled locomotion, and with
pelvic aches and pains and throbs, or whether the source of all these
mischiefs, the ovaries themselves, shall be extirpated. This is a very
important question, and the removal of these organs should not be
decided upon without careful deliberation and without the conviction
that the disease is otherwise incurable.
Prolapse of the Ovary.
This displacement of the ovary is almost always one of the lesions of
chronic ovaritis, and as such might have been discussed under that
general heading. But as it displays certain symptoms peculiar to
itself, and needs a special treatment aside from the general one, it
seems to me best to describe it by itself.
At every monthly period the ovaries become turgid with blood, and from
their weight sink low down. They can then be often felt, and even
outlined, in Douglas's pouch. When this congestive period is over they
discharge their over-freight of blood and again float up out of reach.
Unfortunately, however, they sometimes keep turgid--blood-logged, so to
speak--and consequently become permanently displaced. Accompanying this
dislocation there will generally be some uterine lesion which will
stand in the relation either of cause or of effect.