GEN

No 2.

general health. The great frequency of uterine and ovarian diseases in our country is, unthe time at which they are attaining their highdoubtedly, due to the fact that young girls, at est physical development, are kept in school, or practicing on the piano, thus developing the nervous system at the expense of the physical. It is probably due to such a course of education that the great majority of ovarian troubles arise. We find the women who have been most distinguished in their school-work suffer, in after years, from a condition which will continue with them during the remainder of their lives. We have had, in this patient, still greater injury, in the fact that she has been called upon to exercise the highest functions previous to the complete development of the organs. She complains of distress and pain; it is not, however, actual pain she suffers under examination, so much as it is the influence upon her highly nervous condition, which gives rise to the fear that she is about to be hurt; in other words, it is fear from which she suffers. While we are not able to distinguish any enlargement of the pelvic organs by the abdominal palpation, we are enabled to notice, by inspection, a distension of the ab

ENTLEMEN: The patient I bring before you this morning is a woman, 25 years of age; married at 13; gave birth to a child at 14. She menstruated a few times before her marriage, and enjoyed good health until three years ago. Menses, irregular; the last sickness continued from the 11th of September to the 3d of October. The point to which I wish to direct your attention is her age-13 years when married, gave birth to a child at 14, and, hence, was called upon to perform the highest functions at an age at which these organs are attaining their full development. Is it any wonder that she should suffer from diseased conditions of the pelvic organs? Is it not surprising that she does not suffer from diseases of far greater gravity than that of which she complains? Every individ-dominal walls. In looking over her abdomen, ual is certainly better off who is not called upon to perform the highest physical functions at so early an age-at one in which we could not expect such organs to have attained their complete development. The influences of the organ upon the general health of the individual are very marked, so that, as a result of disturbance that takes place, we shall have an imperfect development, that must affect the

any

* Clinical lecture delivered at the Medico-Chirurgical Hospital.

This is a

we see the changes which have taken place in
the skin; thus, there is a dark line running
from the navel to the symphisis.
condition which takes place as a result of preg-
nancy; it is, however, not a pathognomonic
symptom, inasmuch as it may occur as a result
of other diseased conditions of the uterus,
particularly of fibroid growths. The scars
you see upon either side are known as striæ,
and result from the distension or stretching of
the skin of the abdomen. These, too, are not

Where the abdomen is very greatly distended with ascites, however, there may be a possibility of error in the fact that the mesentery is not sufficiently long to permit the intestine to float up to the surface, and there is a layer of liquid several inches in depth intervening between the wall and intestine. In such cases percussion lightly made will give dullness, while pressing the hand deeply into the abdomen, percussion, dispelling the intervening fluid will give reso

necessarily indicative of pregnancy, as they | broadened. In percussion, the point of greatmay arise from any abdominal distension, est resonance, or, rather, where the resonance is such as fibroid tumors, ovarian growths, obe- most distinct, is the summit of the distension, sity, ascites, or any condition which leads to while it is absent around the sides of the absufficient distension to result in the rupture of domen. The line of resonance changes with the skin-layers. When these striæ are recent, the position of the patient. The resonance in they present a reddish appearance; when the such cases is due to the fact that the intestines, result of former distension, they are white, being filled with gas, float to the surface; in pearly, or glistening. In an abdominal ovarian tumors or cysts, on the other hand, growth, the inspection of the abdomen en- over the summit of the tumor there is dullness ables you to form an idea as to the character upon percussion, while there is resonance in of the growth-whether it is symmetrical or one or the other flank, occurring more particuirregular, or projecting largely to one side. larly in the inguinal region opposite to that in The discolorations on the skin will indicate which the tumor began; due to the fact that, the possibility of inflammatory conditions as the tumor increases in size, it pushes the inwithin the pelvis which have led to the appli- testines upward, and to the opposite side. In cation of blisters, or other counter-irritants. these cases, change of position has no influence The position of the distension will enable you upon the percussion sound. to form an idea as to the particular organ involved, or as to the relation of the abdominal growth to the contents of the cavity. Having carefully inspected the abdomen, we next proceed to obtain a more definite idea as to the character of the possible growth; this is done by placing the hand or hands upon the abdomen, and practicing what is known as palpation. In doing this, it is important to direct the attention of the patient from what is being done, as otherwise, if she is nervous, she will involuntarily contract her muscles, and render it difficult to outline or determine the structures within the cavity. She may complain of pain and distress when it is mere sensitiveness, and the fear of being hurt. The patient may sometimes be directed to breath with the mouth open, and take a deep inspiration, and let it all be expelled; the better way, however, is to place her upon her back, with a pillow under her head, with the limbs drawn up, and then, by directing her attention to other mat-the passage of blood through the uterine sinuses. ters, make a careful examination. By this In women pregnant, by auscultation we may step we are enabled to determine the size of not infrequently hear the fœtal heart sounds, a the growth, its regularity, whether it is solid symptom which is absolutely indicative of pregor fluid, its mobility, its relation to the viscera nancy and cannot be mistaken for any other. of the abdomen. Another procedure, that in In this individual patient our examination has many cases is of great value, is that known as not disclosed any enlargement of the abdomen percussion; it is of importance in the investi- other than that which arises from the relaxation gation of the fluctuating tumors; thus, it may, of the abdominal walls. Introducing the finger in some cases, be difficult to determine whether into the vagina, we endeavor to determine not the fluctuation is due to ascites or to an ovarian only the position of the uterus, but its condition. cyst. In ovarian cyst, unless in single cysts or We find the vagina is relaxed, without, however, unilocular cysts, the wave of fluctuation will any protrusion of the posterior wall. Introducbe short; it is not felt entirely across the abdo-ing the finger farther to the upper part of the men. In ascites, the abdomen is flattened and | vagina, we find the cervix is situated somewhat

nance.

By auscultating the abdomen, we are enabled to determine peculiar sounds, due to the passage of gas through the intestines, and in cases in which the abdomen is distended by the presence of the tumor, particularly uterine, we may hear what is known as the uterine bruit. This was formerly supposed to be the sound produced by the blood coursing through the placental sinuses, but hearing the same sound in women who are not pregnant, but are suffering from fibroid tumors, it is recognized to be

while enlarged, is regular in its outline; there is no indication that a growth has occurred in the uterus. Hence we lack this indication of the presence of the fibroid. It is true that we may have the uterine canal distended by the fibroid tumor, which is not sufficiently large to give the indication by a conjoined examination; we would expect, however, that the growth would have given rise to the disturbance of the menstruation prior to the recent hæmorrhage.

One of the first indications of intra-uterine fibroids is the presence of hæmorrhage occurring either before the menstrual period or dur

it being a fibroid growth. It should be remembered that ovarian cysts are sometimes a cause for disturbed menstruation, particularly where the ovaries have undergone marked

posteriorly, and with the posterior surface a distension of the rectum is recognized which is evidently the result of accumulation of fæcal matter. Were we not aware of the sensation produced by such an accumulation, we might suppose at first that it was indicative of the foreign growth in the pelvis. The uterus is considerably enlarged; this enlargement is firm and dense in character and the uterus is rather movable; the fundus of the uterus is also considerably enlarged, with an enlargement of the ovary upon the right side; we are unable to distinguish anything of the kind upon the left. As we have said, we notice that the fundus of the uterus is considerably enlarged. The anteflexioning the intervals. So much for the theory of is increased or intensified, producing a more marked anteflexed position. Now, with a patient presenting such symptoms, we have to consider what may be the cause of the conditions present. We have here a woman who | cystic degeneration. Hæmorrhage is a frehad a menstrual flow which continued from September 11th to October 3d, since which time, a period of some six weeks, she has not menstruated. You will ask what diseased conditions will produce this symptom, and associated particularly with an enlarged uterus. There are several diseased states that may exist and give rise to some of these symptoms. In the first place, we may have a fibroid growth in the uterus, a chronic inflammation of the organ which is sometimes known as areolar hyperplasia or sclerosis, or it may be the result of pregnancy. Favorable to the possibility of its being a fibroid growth, we have the fact that fibroids are much more likely to occur in the colored race than in the white. The former enjoy almost an equal immunity against malignant disease. The symptoms of fibroid tumors will be dependent somewhat upon their situation; thus, if they are situated in the wall of the uterus in such a way as to encroach in their further development upon the uterine cavity, they are likely to give rise to hæmorrhage as a marked symptom; if on the external surface, projecting externally, they are noticeable as an irregularity. In this patient we have had the menstrual course disturbed but once by the excessive or prolonged flow; it may be true that this is the first time in which the growth has attained sufficient development upon the mucous surface to have produced hæmorrhage. Under such circumstances, however, we should have expected the next menstrual flow to have also been present and excessive. The uterus,

quent and almost constant symptom. Such cases may be subjected to the dilatation and curetting of the uterus without any influence whatever upon the symptoms. There is, as you remember, enlargement of one ovary here, but it has not been the cause of this condition or we should have had hæmorrhage more frequently occurring. In a woman who has given birth to a child at 14 years of age, and to others subsequently, we would hardly expect that the uterus would resume readily and rapidly its normal position; the organ consequently remains in the state known as subinvolution; this condition becoming chronic, leads to substitution of the fibrous for the muscular tissue, developing what is known as a chronic inflamed uterus, or scleroid organ, or fibroid change, a condition of the uterine walls similar to that which takes place in the fibroid which is maturing. The condition is attended with more or less irregularity of menstruation, sometimes increased, at others decreased flow. The patients suffer also from profound nervous symptoms; symptoms which lead them to believe that they are the victims of organic disease of the stomach, heart, liver, or other organs. The condition is one which not unfrequently follows abortion, and, as I have not before mentioned, this patient suffered from a miscarriage three years ago, which may be an explanation of the fibroid condition now present. That this condition does exist is evident from the hard, dense feel of the fundus of the uterus, which is not characteristic of the