There was some offensive discharge from the right antrum into the right nasal cavity, which made it necessary to remove the plate, and use antiseptic and cleansing washes every two or three days. While the plate was in position the patient was able to go down town, and could take fluid and semi-fluid nourishment with comfort.

generation of the Ovary," and assumes first, "That you must have often met with it in your practice," which fact we think you will settle adversely in your own minds without long comment since it is acknowledged by competent authority to be seldom recognized before removal. Many ovaries contain ten or twenty cysts or more and yet are so small and The plate was left in situ until October 20, associated with so little structural change as when it was removed in the presence of Drs. to attach no significance either clinically or Guibor, Alexander, Munn, McCarter, and otherwise. Even some of the larger, simple myself. The patient was examined by all cysts, whose walls are very thin are with no present, and we found perfect union without little difficulty diagnosed before removal either deformity, loss of tissue, teeth or motion, ex- through the rectum or vagina, save in some cept the right upper lateral incisor, canine and very exceptional cases. first bi-cuspid teeth were pressed slightly inward so the articulation was not perfect; but the patient was directed to use occasional outward pressure on these teeth, to use only soft foods, and be careful of the articulation, in masticating any food; also to use the mouth washes for a few days. The patient was seen a few times until October 26, when he was discharged. His appearance at that time being indicated by Fig. III. October 28 he resumed his work, and now his articulation is as perfect as before the injury was received.

Chronic Ovaritis Versus Cystic Ovaries.

BY H. C. CROWELL, M. D., KANSAS CITY, MO.

The object of this paper is briefly to consider certain positions and takings, in a paper read before the South Kansas District Medical Society, held in Wichita, May 14, 1889, and reported in the July number of the Kansas City Medical Record.

The next statement made by the writer is "That you have probably read very little upon this subject in your works on gynæcology,' which implies either that you have been a poor student, or that the literature is very meagre on the subject, and he further expresses surprise that so little has been written upon diseased conditions of the ovary, while other diseased conditions of the generative system of women have received much learned attention, and attributes this neglect to the fact "That book-makers are not as a rule, objective students of medicine, especially at the bed-side or in the post mortem room." In answer to this statement we beg leave to refer the writer of the paper to such works or workers as Tait, Olshausen, Schroeder, Emmett, Thomas, Wiley, Polk, Goodell, and others, all of whom we are compelled to believe are emphatically students of objective medicine and no mean pathologists.

He further refers to the pathology assuming that "It is involved in a good deal of obscurity I have been prompted to a consideration of at present and is probably dependent on a the paper above referred to, believing that it good many causes or at least more than one.” was not founded altogether on facts and con- We cannot better express the substance and sequently must be more or less misleading, concerted opinion of numerous pathologists especially to those whose opportunities of ob- and gynæcologists, especially, who have writservation of like cases shall have been more ten upon this subject of cystic disease of the limited than those of the writer above referred ovaries, than by quoting W. Gill Wiley, of to. First, then, in order that the reader may New York, who says, "Cystic disease if it the better understand the full intent of this exist is due to long continued congestion of paper it will be necessary that we quote ver- the ovary, intestinal inflammation following batim or in substance the assertions of the pa- slowly. The successive phenomena in the per under consideration. history of these cysts of the follicle, are, hyThe author entitled his paper Cystic De- pergenesis of the epithelial elements, sclerosis.

66

graafian follicle, were it not for the fact that every possible gradation may be observed between them and the very smallest cysts. In addition ovula can be detected in the smaller cysts."

of the follicular walls, degeneration of the ovarian stroma permit us to quote Olshausen, epithelium, liquefaction of the exuded or re- who says, "It would be well-nigh impossible tained exudate and hemorrhage." No obscur- for us to regard the large cysts as dilated ity seems to exist in the minds of these authors; all agreeing that cystic degeneration of the ovary is due to dilatation of the graafian follicle being easily traceable, even to those of large size. Schroeder shows that ovaries which are situated beneath peritonitic callosities are not infrequently infiltrated with small cysts, due probably to the fact that it prevents rupture of the follicle.

The paper further states that "It is never known before puberty nor after the menopause." That there are exceptions will be seen by referring to works upon the develop ment of graafian follicles which show that they are formed often long before the birth of the child, sometimes presenting dropsical conditions or distensions producing cysts of a very considerable size in very young children. These statements are vouched for by Curllinworth, Virchow, DeSinety and others.

The entire sentence from the paper under consideration reads, "the ovarian cysts does not begin in the graafian follicle, but in the ovarian stroma, and is therefore closely allied to the connective tissue tumors with glandular hydræmia.”

The last clause is contradictory and ambiguous, not expressing any comprehensible or, recognized pathological condition, since connective tissue tumors can not be associated with glandular hydræmia in as much as they contain no glandular structure and since hydræmia signifies simply watery blood. We think further comment unnecessary to demonstrate the exact similitude in pathological origin and character between cystic ovaries At this point the author inserts a compari- and ovarian tumors, and since we fail to obson between cystic ovaries and ovarian tumors. serve the difference histologically or pathologiIt is apparent to every one that in order that cally, we can not grasp the signifiance of comeither condition obtain there must be a dis-paring cystic ovaries with ovarian tumors, nor turbed condition of histological elements, in are we able to ascribe these symptoms to cystic explanation of which, the author of the paper ovaries or does the author in his table of cominforms us "That ovarian cysts do not begin parison. in the graafian follicle, but in the ovarian stroma," in answer to which we would refer to the classification based upon the opinion of all pathologists of distinction previous to 1886, as follows:

Many diseased conditions of the ovary are so nearly allied that a differentiation becomes a task such as few are competent to undertake being as they are obscure in symptom and removed from easy access to the obscure,

First. Distention and coalescence of gra- That such is the case is simply evident when afian follicles.

Second.-Degeneration of undeveloped graafian follicles, (ordinary multilocular tumors.) Third. Development of remnants of the wolffian bodies in the hilum of the ovary, (papillomatous tumors.)

we peruse the literature upon the subject. What almost innumerable operations have been performed for the relief of neuroses supposed to have their origin in the ovaries? and what has been the result in by far the larger majority of operations? The ovary has only

Fourth. Malignant development of connec- presented evidence of health when viewed mative tissue of the ovary.

These four classifications represent the combined and established opinions of to-day. Thus we see that none of these authorities admit of an implication of the ovarian stroma save in the malignant form which does not concern us in this connection. In further proof of the fact that ovarian cysts do not originate in the

croscopically and microscopically, presenting no diseased condition save perhaps a few cysts such as are found in all ovaries removed during the period of sexual activity. The result of such operations has also demonstrated that the neuroses for which the ovaries were removed still remain in a large per cent. of such cases, though some are benefited

beyond a doubt. The most common con- Fourth-Pain most severe first two days of dition found however, consists in a hy- menstruation. peræmia or chronic ovaritis. This con- Fifth-Occurs almost exclusively during percondition becomes so prominent that we can iod of sexual activity. dismiss from consideration those changes resulting in the formation of cysts which are not accompanied, per se, by reflex nervous symptoms.

First in regard to Sims' position; the principle which prompted the invention of the speculum and position bearing the name of Sims, contraindicates its utility for purposes of diagnosis in this particular instance since First-Fixed pain in one or both ovaries. a gravitation from us renders organs under Second---Pain severe, usually lasts through any condition inaccessible, less so, hence we menses, most severe first two days. would recommend the dorsal position aided by Third-Menstruation generally disturbed and the Volsellum forceps attached to the cervix excessive. uteri thereby enabling us to draw down the

Second-That certain physical conditions found in the ovary in the form of cysts are not of great clinical importance, and as usually observed are unrecognizable by the average or even the best physical diagnosticians.

uterus and its appendages within a possible ing failures in such attempts, which, thereby reach in a large majority of cases. We are bring discredit upon the profession at large. compelled to believe that there was a lack of seriousness on the part of the author of the paper when he asserted that these diagnoses were as simple as determining articles upon a table with eyes blind-folded and a gloved hand. Certain it is that my own experience and observation which has not been limited, does not endorse such a statement, and that our most eminent gynææcologists have been chagrined to find no adhesions where they had been anticipated and confidently expected, and vice versa. If now we should concede to cystic disease or degeneration of the ovaries the same symptoms as obtained in chronic ovaritis, what is to

be the treatment? The author would lead us to believe that there was but one alterna

tive, namely extirpation. Shall we extirpate at once? Experience teaches that many of these cases of chronic ovaritis may be, if not cured so ameliorated, that life is bearable and thus avoid subjecting them to the dangers of abdominal section. The operation of laparoto

Third-Making diagnosis so eminently easy in conditions which, to our best talent are not easy, is misleading and destined to confuse

those who undertake it.

Fourth-To refer those who are interested in

the subject to the literature, before accepting statements which carry a shadow of doubt to every reasoning mind.

Fifth-An endeavor to bring the pendulum back to a median position from which it has swung, with some, so strongly in favor of ovarian disturbance. castration, for every vague and undefined

Chronic Cervical Endometritis.

BY J. W. M'CRACKEN, M. D., OF STERLING.

ety at Newton, Kan., Nov. 11, 1889.

my as introduced by Hegan, Sail and Battey, Read before the South Kansas Medical Socihas been a great boon to suffering women when judiciously applied, but it was not introduced for castration of every woman who should suffer from some ovarian disturbance, nor especially for the removal of cystic ovaries. We have found that the cystic condition was discovered after operations had been performed, and that no symptoms could be fixed upon cystic ovaries of themselves independent of other diseased conditions. Such was the case in Hegan's first operation, the cyst being found after the removal of the ovary.

All cases presenting symptoms sufficient to suggest operative interference should be thoroughly analyzed, eliminating all causes other than those of local character, especially

the inherited tendencies.

The disease entitled as above, with its intimately associated morbid conditions, probably requires more study and attention from physicians than any other one disease with which woman is afflicted. As woman, from the time she reaches puberty on through all the mutations of her checkered career, until she passes the climacteric, absorbs a large share of the So does the physician's time and study. above designated disease, and associated ills, demand a large share of the time, labor and It would be thought of the gynecologist. impossible to intelligently consider chronic cervical endometritis without giving attention

to the corporeal extension of the same disease,

also the several conditions that exist either as

Finally, the deductions which result from cause or effect. Cervical endometritis may this analysis of conditions in hand are these: exist without corporeal, but rarely the reverse. First-That one should exercise great care Aran West, Byford, Chauncy D. Polman. T. in presenting a scientific subject, that its his- D. Thomas and others, claim that chronic tory and means of recognition be clear and cervical endometritis is the most frequent of distinct, capable of application and apprecia- all uterine diseases, while its corporeal extention by those who have a reasonable amount sion or involvement is rare. Tilt and Klob of knowledge upon such matters, thus avoid- declare the latter quite common.

It matters

According to Dr. Palmer the steps in pathogenesis are:

1. Increased and altered secretion, incident to the changes in the Nabothian glands. 2. Erosion of the epithelium.

3. Granular degeneration of the villi of the mucous membrane.

4. Dilatation to the os externum and lower cervical canal.

5. Eversion of the cervical mucous membrane.

6. Follicular ulceration and degeneration. While this may be the usual order of symptoms in which morbid action is manifest, they are not necessarily present in all, or even a majority of the cases which we are called upon to treat.

but little for our purpose as to these fine distinctions, as to the preponderance of diseased locality, only so far as it shall influence our judgment in diagnosis or our adaptation of treatment. In thus electing to place the involvement of the cervical canal prominently before you I would not forget the gravity of the corporeal trouble when it does exist. Dolins holds "that endometritis is necessarily the starting point of every parenchymatous inflammation of the uterus or peri-uterine tissues, and that when such lesions of these tissues disappear, chronic endometritis usually remains." Dr. Palmer, Am. Sys. Gyn., says "It is more than probable that chronic inflammation of the mucous membrane of the cervical canal and the exterior of the infravaginal cervix is the most frequent disease of the female pelvic organs." James H. Bennett In regard to the pathology of cervical endosays "inflammation of the cervix, and especmetritis there seems to be more harmony tham exists ially of the mucous membrane which covers among authors in regard to many other it and lines its cavity is so common as to form morbid conditions. It is primarily a glandua prominent feature in uterine pathology;" lar affection or inflammation. The glands of and further, "that such should be the case is a Naboth "become swollen, enlarged, elevated,. necessary consequence of the anatomical and with dilated mouths, and in consequence there physiological conditions in which the uterus is a hypersecretion." This first is thin, glairy, is placed." Dr. T. G. Thomas claims "that of all the diseases of the genital system of the female this is without doubt the most frequent, and although not in itself a malady of danger- change to yellow and be tinged with blood.. ous character, may prove the starting point In the vagina it may be found white and coagufor some of the most serious and rebellious lated like hardened white of egg. Its acrid of uterine disorders." The occurrence of charcter cannot be overlooked; frequently chronic cervical endometritis following an causing erosion of the lower lip (posterior); of In this disease acute metritis, subinvolution, areolar hyper-uterus. we have clearly plasia, or corporeal or general endometritis is marked predisposing and exciting causes: certainly explicable on reasonable grounds. the former consists of

When we take into account the difference in structure existing in the body and cervix, coupled with the exposed relations of the cervix to other parts, as the rectum loaded with hard and fæcal matter; the womb pressed down by its increased weight, and the pressure of corset and skirts; the cervix resting on tissues acting to close the os, to the passage of normal or pathological secretions; their retention within the cavity of the neck, with its folded and reticulated mucous membrane and deeply imbedded glands with thin patulous mouths. Also from injuries during coitus or labor and the extension of gonorrheal inflammation.

alkaline, like the white of egg, then thicker, more tenacious, and adhesive; still later, albuminous, loaded with epithelial cells. May

Natural feebleness of constitution.

The various diatheses and blood diseases..
Impoverishment of system from any cause..
Excessive lactation.
Frequent parturition.
Use of instruments.
Subinvolution and too hasty getting up
after confinement.

Acute endometritis.
Versions and flexions.

These various conditions act to disturb the nervous system, interfere with the circulation and nutrition of the lining membrane of the uterus and specially that of the cervix.