Cases of Organic Diseases of the Womb and its Appendages. By WALTER CHANNING, M. D.-Chronic organic affections of the womb and of its appendages have long been the reproach of medicine. They, many of them, tend to death, are malignant, and, having a bad name, little more is done for them than to make them as tolerable to the sufferer as well may be. Dr. Wm. Hunter, in a manuscript lecture of his on cancer of the womb, in my possession, makes many sensible remarks on the best mode of retarding those processes which always end in death. Thus he advises abstinence from animal food. except fish now and then, and of these recommends such only as are of white flesh, and have the least flavor-are the least stimulating, in other words. He is particular in his rules about dress, and especially directs that women with functional or organic disease of the womb or its appendages, and those, too, who would escape these, should wear flannel drawers. Rest, also, is among his prescriptions, and sarsaparilla his principal medicine. But Dr. H. says nothing about cure. His means have in view only to retard the advance of destructive processes, as ulceration in cancer, and so to prolong life. He does not look to cure, as among the purposes of treatment in such diseases. He would mainly labour to make a life of daily suffering more tolerable than without his agency it might be.

Osiander, of Gottingen, labored to cure, to remove radically, malignant diseases of the womb. He cut away diseased portions, and with a bravery which was always tempered with wisdom, and guided by the best knowledge of what he meant to do, and how it should be best done. He was often successful. McDowell, a physician in our western wilds, determined to do something to prevent the fatal issue of diseased ovaries, and in pursuing this purpose extirpated them, with a success, and in numbers, and under circumstances, which made an epoch in that department of surgery. Dupuytren and others followed Osiander in excising the mouth, the neck, or larger portions of the womb, but they were not very successful. Lizars, and quite lately Gray, have followed McDowell in his operations, but with less success.

Occasionally a case is referred to, of removal, either spontaneously, or by, or after the employment of medicine, of these diseases. I have thus known a cauliflower excrescence removed by ligature, without return of the disease. I have known very striking effects follow the internal and external use of medicine for tumors which for the most part are regarded as incurable, and which are passed by without exciting any remedial regard. Sir Astley Cooper somewhere speaks of the professional negligence of these diseases. Is it right to abandon their subjects, simply because such diseases have got a bad name? I have always treated them as I would other diseases. My attendance on them has been regular, and means have been put into use. The attendance has ceased, because at length it has appeared obvious that no benefit was coming of treatment, or the patient, or more frequently her friends, have thought farther care, or farther expense, unnecessary.

I will, in more or less detail, refer to some cases of reputed malig. nant diseases of the womb, and of its appendages, which have come under my notice, and for which means have been used, with a view to curative agencies.

Cases of Cauliflower Excrescence.

CASE. I.-Mrs. Tumor small, insensible, springing from the os uteri. Drain of watery fluid from vagina constant and great; occasionally hemorrhage; much exhaustion, and evident sinking from disease. A ligature was applied round the tumor. It came away, bringing a few shreds only of what it had surrounded. Discharge ceased. Upon examination no tumor was to be discovered. The os uteri from whence it sprang, was found healthy. Strength returned, and the patient after a time left the city without complaint. I have not heard of her since.

CASE II.-Mrs. M The history of this case is very much the same with that above given. There was an insensible tumor springing from the os uteri, irregular in its outline, or rough from small projections. Watery drain constant from vagina-at times hemorrhage. Ligature was applied, and in a few days came away, bringing scarcely anything with it. The noose had sticking to it some very small remnants of the large tumor which it had surrounded. This woman recovered perfectly.

CASE III.-Mrs. This woman had a tumor like those above described, and with like symptoms. She died exhausted by discharge of water and hemorrhage. I saw her after death. Scarcely any appearance of tumor was discovered. In this case ligature was not applied.

CASE IV.-Mrs. K. I was desired in December, 1846, to visit Mrs. K. I found her in bed, thin, pale and sallow, and apparently suffering from some chronic and exhausting disease. She said she was over 40 years old, had been married ten years, and had never had children. Her complaint, she continued, was a tumor of the womb, which was of more than a year's notice by her. At times much hemorrhage occurred from it, and at all times a watery discharge. Of late this had become so great as to exhaust her exceedingly, and she thought that it would be impossible for her to survive many weeks if it continued. It was sufficient to wet forty large towels a week, sometimes eight in a day. It was water, without colour, without smell, and without mucus. The disease was in no sense, or in itself, a painful one. It pressed against the sacrum and produced pain in that bone, and it obstructed much the rectum, and so troubled its functions. She added, that within a short time emaciation had rapidly increased, and her strength had failed. She wanted to live. She would endure anything that she might live. I have heard the desire to live expressed by many, and when death was near at hand by cause of sudden diseases, or accidental occurrences, without precursory disease; but I never heard it utter itself with such emphasis as it spoke from that woman. She had a face which expressed in the strongest manner her whole feelings, and

having passed her hand over it as if to remove from it whatever might diminish the power of what she had to say, bent her eyes upon me as I leaned over the foot-board of her bedstead, and said, "Have you the heart, Sir, to do an operation which may save life, though it be at the risk of taking it? That is the question which I want answered, and in the most distinct manner." I said that I believed I was equal to my whole professional obligation, and would state to her what might be my duty specially to her, after I had learned by an examination what was her disease, and that I would act as that duty seemed to me to demand. She said that her case had already been examined, but no operation recommended, but she could not yet give up. She begged me at once to make the examination which was to settle the course I was to pursue.

Upon examination I found a tumor filling the vagina, and which was most developed in its sacral aspect. It was hard and perfectly insensible. It was not regular in its outline, but had projections, and superficial, and deep sulci between its rounded and ridge-like inequalities. It was of a greyish colour, and the discharge from it was an inodorous, colourless water. I said I saw nothing in the character of the tumor to forbid an operation. I described to her the operation, the ligature, and stated that it would give her little or no pain. I learned that a professional friend of great surgical knowledge and reputation had been asked to see her, but had not called, and said that I would request him to see her, as I wished to have his opinion of the operation I had in view. He called the next day, and wrote me that he thought the tumor presented no objections to the ligature, that an operation in the case might be done, but that inflammation might follow, and the tumor might re-appear. This opinion was stated to Mrs. K. She determined to submit to the operation, and to abide the issue.

A ligature was passed round the tumor, in the close of December, and it was purposely applied as high as it could be done. It was not found so easy to do this as was supposed, and as those who never made the attempt may imagine. The tumor filled the vagina. It was exceedingly irregular in its outline. The double canula of Gooch was used, and easily carried along the fingers, to the root of the tumor. The attempt now to separate the two, by keeping one fixed, and sweeping the other horizontally round the tumor, was embarrassed by many obstacles. It was at length done, and the silver clasps carried along the tubes to make them again one instrument. The ligature was now drawn tight and secured. Some pain followed this part of the operation, but soon subsided. It resembled the dragging sensation which I have heard complained of in other cases. The next day I found the instrument very far out of the vagina, and upon examination discovered that the ligature did not embrace the whole of the tumor, but had been carried by the canula into one of the deep depressions of the tumor, instead of encircling the base. I state this thus particularly, as a caution in applying the ligature round uterine tumors, especially malignant ones, which are much more apt to be

irregular in their outline than are the non-malignant. Said a physician who very kindly assisted me in this operation, let those who are astonished at a failure in doing such an operation try to do it themselves, and they may learn that there are difficulties in the way they hardly dreamed of. The ligature was now removed, and then applied again, and with entire success. It was tightened every two or three days, and each time showed that there was a gain on the tumor. Some days the ligature could be drawn an inch before it stopped. Generally not so much. There was always pain on drawing the ligature. It, however, was never a permanent pain, or of any long continuance. An opiate was often given to remove it, and doubtless made the time of suffering shorter. The instrument began at length to project farther and farther from the vagina. The ligature showed by its length that very little of the tumor remained encircled by it. I now examined the vagina, and found it empty. I could feel nothing but the canula, and a small loop of ligature encircling a portion of the original tumor which had not disappeared. The os uteri, excepting this spot which looked to the sacrum, was perfectly smooth and even in its outline, not a shred of tumor remaining except at the point referred to, and this was firmly within the grasp of the ligature. There was no discharge from the vagina. There had been scarcely any since the ligature was applied. What discharge did take place was the liquified tumor as it was cast off by the living textures from which it had been separated by living agencies. Nothing like a tumor had been thrown off. The ligature was now daily tightened, and I daily looked for its coming away. On the twenty-second day from the use of the canula, I found Mrs. K. in unusual spirits, and hiding something under the bed-clothes as I entered. I asked what it was. She at once drew out the instrument, which she said had come away that morning, and which she was now rubbing very carefully to restore to it its original brightness. I asked if anything had come away with the ligature. She replied, yes, and showed me a thin small mass, like dense membrane, on a towel. Upon examination I found that portion of the tumor remaining, round which I felt the ligature, of the size say, of one joint of the thumb, projecting from the posterior lip of the os uteri. I asked how it happened that the instrument had come off before separating the tumor. She said that she felt a strong desire to rise from bed to evacuate the bowels, and that, in suddenly moving, the instrument had been caught in the bed-clothes and was torn away from the vagina, giving her exquisite pain. I made no attempt to re-apply the ligature, for such was the stiuation of the remaining portion of the original disease that I did not believe that a ligature would hold on it.

Mrs. K. now rose from bed. Took exercise. Got excellent appetite. Gained flesh, and felt well. Not the smallest drain occurred from the vagina of water, of pus, or of blood. Her feet and ankles swelled, but at length this swelling disappeared. But after some weeks signs showed that the disease had returned. There was again water, and blood, and pain. She began to fail, and in five months.