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There was some offensive discharge from generation of the Ovary,” and assumes first, the right antrum into the right nasal cavity, “That you must have often met with it in which made it necessary to remove the plate, your practice,” which fact we think you
will and use antiseptic and cleansing washes every settle adversely in your own minds without two or three days. While the plate was in long comment since it is acknowledged by position the patient was able to go down town, competent authority to be seldom recognized and could take fluid and semi-fluid nourish- before removal. Many ovaries contain ten or ment with comfort.
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 in- The next statement made by the writer is ward so the articulation was not perfect; but “That you have probably read very little upon the patient was directed to use occasional out this subject in your works on gynæcology," ward pressure on these teeth, to use only soft which implies either that you have been a foods, and be careful of the articulation, in poor student, or that the literature is very masticating any food; also to use the mouth meagre on the subject, and he further expresswashes for a few days. The patient was seen es surprise that so little has been written upa few times until October 26, when he was on diseased conditions of the ovary, while discharged. His appearance at that time other diseased conditions of the generative being indicated by Fig. III. October 28 he system of women have received much learned resumed his work, and now his articulation is attention, and attributes this neglect to the as perfect as before the injury was received. fact “That book-makers are not as a rule, ob
jective students of medicine, especially at the Chronic Ovaritis Versus Cystic Ovaries. bed-side or in the post mortem room.” In
answer to this statement we beg leave to refer BY H. C. CROWELL, M, D., KANSAS CITY, MO.
the writer of the paper to such works or work
ers as Tait, Olshausen, Schroeder, Emmett, The object of this paper is briefly to consid- Thomas, Wiley, Polk, Goodell, and others, all er certain positions and takings, in a paper read of whom we are compelled to believe are embefore the South Kansas District Medical phatically students of objective medicine and Society, held in Wichita, May 14, 1889, and no mean pathologists. reported in the July number of the Kansas He further refers to the pathology assuming City Medical Record.
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 .
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; graafian follicle, were it not for the fact that all agreeing that cystic degeneration of the every possible gradation may be observed beovary is due to dilatation of the graafian folli- tween them and the very smallest cysts. In cle being easily traceable, even to those of addition ovula can be detected in the smaller large size. Schroeder shows that ovaries cysts." which are situated beneath peritonitic callo- The entire sentence from the paper under sities are not infrequently infiltrated with small consideration reads, "the ovarian cysts does not cysts, due probably to the fact that it prevents begin in the graafian follicle, but in the ovarian rupture of the follicle.
stroma, and is therefore closely allied to the conThe paper further states that “It is nective tissue tumors with glandular hydramia.” known before puberty nor after the meno- The last clause is contradictory and ambigpause." That there are exceptions will be uous, not expressing any comprehensible or, seen by referring to works upon the develop recognized pathological condition, since conment of graafian follicles which show that they nective tissue tumors can not be associated are formed often long before the birth of the with glandular hydræmia in as much as they child, sometimes presenting dropsical condi- contain no glandular structure and since hytions or distensions producing cysts of a very dræmia signifies simply watery blood. We considerable size in very young children. think further comment unnecessary to demonThese statements are vouched for by Curllin- strate the exact similitude in pathological worth, Virchow, DeSinety and others. 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 Many diseased conditions of the ovary are stroma,” in answer to which we would refer to so nearly allied that a differentiation becomes the classification based upon the opinion of a task such as few are competent to undertake all pathologists of distinction previous to 1886, being as they are obscure in symptom and as follows:
removed from easy access to the obscure, First.—Distention and coalescence of gra- That such is the case is simply evident when afian follicles.
we peruse the literature upon the subject. Second.—Degeneration of undeveloped gra- What almost innumerable operations have afian follicles, (ordinary multilocular tumors.) been performed for the relief of neuroses sup
Third.—Development of remnants of the posed to have their origin in the ovaries? and wolffian bodies in the hilum of the ovary, what has been the result in by far the larger (papillomatous tumors.)
majority of operations? The ovary has only Fourth.-Malignant development of connec- presented evidence of health when viewed mative tissue of the ovary.
croscopically and microscopically, presenting These four classifications represent the com- no diseased condition save perhaps a few cysts bined and established opinions of to-day. Thus such as are found in all ovaries removed durwe see that none of these authorities admit of ing the period of sexual activity. The result an implication of the ovarian stroma save in of such operations has also demonstrated that the malignant form which does not concern the neuroses for which the ovaries were reus in this connection. In further proof of the moved still remain in a large per cent. fact that ovarian cysts do not originate in the 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 re- Sixth-Disease is protracted lasting sometimes sulting in the formation of cysts which are not accompanied, per se, by reflex nervous Seventh--the same obtains in chronic ovaritis. symptoms.
Eighth-Not always, applies to both condiAmong the large number of neuroses caused tions in the larger proportion of cases. by ovarian hyperæmia or chronic ovaritis may Ninth-Usually begins as acute ovaritis or in be mentioned vaso-motor and cardiac disturb- some adjacent acute inflammatory disease. ances, hysteria, epilepsy, mania, melancholia, Tenth-Patient generally arrives at concluneuralgias, spinal irritations, irritable bladder, sions agreeing with her social position and rectum, &c., &c.
environments. Is treated as her physician Since we have seen that chronic ovaritis is in his wisdom deems advisable. the cause of far the larger part of the suffering Eleventh-Touch of the womb causes pain by and subjective symptoms to be ascribed to causing a strain or pressure upon ovaries. ovarian disease, it may not be amiss to com- Twelfth-The same holds true in ovaritis. pare some of these symptoms with those of Since comparing the above symptoms we cystic disease of the ovaries as set forth in the are struck with their similarity and the proba“ paper above referred to, (see comparative table ble impossibility of an easy diagnosis of cystic herewith.)
degeneration of the ovaries from its clinical CYSTIC DEGENERATION OF THE OVARIES. history, and it becomes the more so when we First--Always very painful.
remember that the very large majority of soSecond-Pain greatest at menstrual period. called cystic ovaries demonstrate but minor Third-Menstrual flow usually increased and development of cysts, large cysts being found prolonged.
but once in 200 Fourth--Pain begins with the congestive stage quently.
cases or perhaps less freof menstruation and ceases with its cessation.
Under differential diagnosis the author states Fifth-Never begins until puberty is reached. that versions or flexions may be confounded Sixth-Ceases with the cessation of the mens- with cystic disease of the ovary, fibroids, &c., trual function.
which would seem to be a strain upon the imSeventh-Is entirely painless during pregnan- agination. He recommends Sims' position for cy and lactation, if such should occur.
the examination and differentiation as well as Eighth—Comes on suddenly and usually with for the purpose of determining the size of the great violence, though not always.
organ, whether cysts exist and if adhesions Vinth-Symptoms are those of actual inflam
are present, asserting that as good and commation at the beginning, or when new plete a knowledge may be gained by such exgrowths occur.
amination as one could obtain of articles on a Tenth—The patient generally supposes that table with his eyes blind-folded and a glove she has inflammation of the womb, or some
on his hand. displacement, and is generally treated for it.
First in regard to Sims' position; the princiEleventh-Touch of the womb is painful.
ple which prompted the invention of the Twelfth--Rectal touch gives great pain, es- speculum and position bearing the name of pecially when the ovary is pressed upon. Sims, contraindicates its utility for purposes
CHRONIC OVARITIS-OLSHAUSEN. 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
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
Second-That certain physical conditions seriousness on the part of the author of the found in the ovary in the form of cysts are not paper when he asserted that these diagnoses of great clinical importance,and as usually obwere as simple as determining articles upon a
served are unrecognizable by the average or table with eyes blind-folded and a gloved hand even the best physical diagnosticians. Certain it is that my own experience and ob
Third-Making diagnosis so eminently easy servation which has not been limited, does not in conditions which, to our best talent are not endorse such a statement, and that our most easy, is misleading and destined to confuse eminent gynæcologists have been chagrined to those who undertake it. find no adhesions where they had been antici
Fourth-To refer those who are interested in pated and confidently expected, and vice versa. the subject to the literature, before accepting
statements which carry a shadow of doubt to If now we should concede to cystic disease
every reasoning mind. or degeneration of the ovaries the same symp
Fifth-An endeavor to bring the pendulum toms as obtained in chronic ovaritis, what is to back to a median position from which it has be the treatment? The author would lead
swung, with some, so strongly in favor of us to believe that there was but one alternative, namely extirpation. Shall we extirpate
castration, for every vague and undefined
Shall we extirpate ovarian disturbance. at once? Experience teaches that many of these cases of chronic ovaritis may be, if not cured so ameliorated, that life is bearable and
Chronic Cervical Endometritis. thus avoid subjecting them to the dangers of
BY J. W. M'CRACKEN, M. D., OF STERLING. abdominal section. The operation of laparotomy as introduced by Hegan, Sail and Battey, Read before the South Kansas Medical Socihas been a great boon to suffering women ety at Newton, K'an., Nov. 11, 1889. when judiciously applied, but it was not introduced for castration of every woman who
The disease entitled as above, with its intishould suffer from some ovarian disturbance, mately associated morbid conditions, probably nor especially for the removal of cystic ovaries. requires more study and attention from physi
We have found that the cystic condition cians than any other one disease with which was discovered after operations had been per
woman is afflicted, As woman, from the time formed, and that no symptoms could be fixed she reaches puberty on through all the mutaupon cystic ovaries of themselves independent tions of her checkered career, until she passes of other diseased conditions. Such was the the climacteric, absorbs a large share of the
So does the case in Hegan's first operation, the cyst being physician's time and study. found after the removal of the ovary.
above designated disease, and associated ills, All cases presenting symptoms sufficient to
demand a large share of the time, labor and suggest operative interference should be thought of the gynæcologist. It would be thoroughly analyzed, eliminating all causes
impossible to intelligently consider chronic other than those of local character, especially to the corporeal extension of the same disease,
cervical endometritis without giving attention the inherited tendencies.
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 but little for our purpose as to these fine dis- According to Dr. Palmer the steps in pathotinctions, as to the preponderance of diseased genesis are: locality, only so far as it shall influence our 1. Increased and altered secretion, incident judgment in diagnosis or our adaptation of to the changes in the Nabothian glands. treatment. In thus electing to place the in- 2. Erosion of the epithelium. volvement of the cervical canal prominently
3. Granular degeneration of the villi of the before you I would not forget the gravity of
mucous membrane. the corporeal trouble when it does exist. Do
4. Dilatation to the os externum and lower lins holds "that endometritis is necessarily the cervical canal. starting point of every parenchymatous inflammation of the uterus or peri-uterine tis
5. Eversion of the cervical mucous mem
brane. -sues, and that when such lesions of these
6. Follicular ulceration and degeneration. tissues disappear, chronic endometritis usually remains.” Dr. Palmer, Am. Sys. Gyn., says
While this may be the usual order of symp“It is more than probable that chronic in- toms in which morbid action is manifest, they flammation of the mucous membrane of the are not necessarily present in all, or even a cervical canal and the exterior of the infra- majority of the cases which we are called upon vaginal cervix is the most frequent disease of to treat. the female pelvic organs." James H. Bennett
In regard to the pathology of cervical endosays “inflammation of the cervix, and
metritis there seems to be more harmony than.
especially 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 alkaline, like the white of egg, then thicker, all the diseases of the genital system of the more tenacious, and adhesive; still later, albufemale this is without doubt the most frequent, minous, loaded with epithelial cells. May 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 acute metritis, subinvolution, areolar hyper- uterus.
In this disease 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
Natural feebleness of constitution. structure existing in the body and cervix,
The various diatheses and blood diseases: coupled with the exposed relations of the cer
Impoverishment of system from any cause. vix to other parts, as the rectum loaded with
Excessive lactation. hard and fæcal matter; the womb pressed
Frequent parturition. down by its increased weight, and the pressure
Use of instruments. of corset and skirts; the cervix resting on tis
Subinvolution and too hasty getting up sues acting to close the os, to the passage of after confinement. normal or pathological secretions; their reten
Acute endometritis. tion within the cavity of the neck, with its fold
Versions and flexions. ed and reticulated mucous membrane and deep- ! These various conditions act to disturb the ly imbedded glands with thin patulous mouths. nervous system, interfere with the circulation Also from injuries during coitus or labor and and nutrition of the lining membrane of the the extension of gonorrheal inflammation. uterus and specially that of the cervix.