iodine glycerin or ichthyol glycerin and packing, and cicatrices cut out or incised and stretched (p. 345). The many reflex neuroses are treated as hysteria, especially with nitrate of bismuth, nitrate of silver, acetate of zinc, ammonia, castoreum, and valerian. During the hysterical attack nothing should be done, as any interference only serves to make the condition worse.'

C. Pelvic Phlebitis.

Pelvic phlebitis is a rare disease. It is primary in puerperal cases, the inflammation starting in the sinuses of the uterus. In this variety the inflammation begins in the internal coat, and soon a thrombus forms in the lumen. The inflammation spreads outward, and may implicate the connective tissue.

In non-puerperal cases it is exceedingly rare, and begins as periphlebitis, an affection following secondarily on acute cellulitis.

Congestion of the pelvic veins is very common, and the presence of phleboliths in the veins at the base of the broad ligament is not a rare occurrence. This congestion, which must not be confounded with phlebitis, is often much relieved by lifting the uterus with a pessary, and thereby giving a straighter course to the veins.

Pelvic phlebitis blends always with cellulitis, and clinically they cannot be distinguished.

D. Pelvic Lymphangitis and Lymphadenitis.

In the anatomical part (p. 62) we have seen that the uterus is exceedingly rich in lymph-spaces and lymph-vessels, uniting in trunks which traverse the broad ligament and lead to the different glands in the pelvis. The lymphatics from the upper three-fourths of the vagina go the same way, while those from the vulva and the lower fourth of the vagina go to the superficial inguinal glands, that communicate with the deep inguinal glands, from which other vessels go to the external iliac glands. Those from the tube and the ovary traverse the broad ligament, and go through the infundibulopelvic ligament to the lumbar glands.

The inflammation may extend from any part of the genital tract into the broad ligament and the peritoneum, causing lymphangitis, lymphadenitis, cellulitis, or peritonitis.

The lymphatic vessels play a very important part in the propagation of infection in the puerperal state, and the inflammation following is then acute.

In this connection it is quite interesting that Freund states that in Strassburg they do not see the attacks described by Charcot in Paris-an experience which is shared by many others in other places.

2 See Garrigues, "Puerperal Infection," Hirst's Amer. System of Obstetrics, vol. ii. pp. 290-378.

In non-puerperal cases lymphangitis and lymphadenitis also exist, but seem to be rare, or so blended with other pelvic inflammations that they seldom can be discovered. Many authors do not mention the affection at all; others have little to say about it or are doubtful as to its existence. In a gynecological practice extending over more than twenty years, in which I have examined I do not know how many thousand women, I have never found a case myself, unless a few in which the gland on the side of the isthmus was swollen belonged to this category. One was kindly demonstrated to me by Dr. P. F. Mundé in 1883, but, although I felt the small tumors behind the uterus, I am not sure that they were swollen lymphatic glands. But the disease having been described by such excellent observers as Courty, Championnière, Mundé, A. Martin, and others, each of whom claims to have seen, if not many, at least a certain number of cases, I do not doubt its existence, and shall here give a résumé of their descriptions.

The non-puerperal form is either acute or chronic, more frequently the latter. Lymphadenitis is characterized by the occurrence of small, rounded, irregular, uneven tumors, varying in size from a pea to a small hazelnut, and situated to the sides of the isthmus of the uterus, more frequently on the right, or on the posterior surface of the uterus. They are loosely connected with the latter and the vagina. Most authors claim only to have felt from one to three such tumors, but Mundé has found at least twenty on the posterior surface of the uterus, and Martin speaks of glands in the broad ligaments forming rows like strings of pearls of moderate size.2

Now, there is this objection to the theory of looking upon these tumors as glands, that only those glands which I have mentioned in the anatomical part have been found in the pelvis by anatomistsnamely, Championnière's gland at the side of the isthmus, the obturator gland, the external iliac glands, the internal iliac glands, and the sacral glands. On the posterior surface of the uterus there are none; but, on the other hand, there are large plexuses of lymphatic vessels; and those small tumors felt clinically above the posterior vault of the vagina are probably clusters of swollen lymph-vessels or pouch-like dilatations of such vessels, just as we find them in puerperal cases, in which they may reach the size of a cherry. The same explanation holds good for the rows of swellings felt in the broad ligament.

A third possibility is that the small tumors may be due to localized perilymphatic inflammation.

A. Martin thinks that cellulitis often begins as lymphadenitis, the gland suppurating and pouring its contents into the connective tissue

1 P. F. Mundé, Amer. Jour. Obst., 1883, vol. xvi. p. 1018.

2 A. Martin, Frauenkrankheiten, p. 323.

of the broad ligament. Even without such suppuration and rupture it is very likely that cellulitis often starts from perilymphangitis.

Etiology. The inflammation of the lymphatics is caused by endometritis either catarrhal or non-specific purulent or gonorrheal. Lymphadenitis may also be due to syphilis or scrofula, when it is apt to be combined with adenitis in other parts of the body.

Symptoms. The patient complains of a pain deep in the pelvis, rather to one side, especially the right, extending to the pubes and the obturator foramen or downward and backward to the coccyx, and of a tenderness rendering coition painful. There is no rise in temperature. The parametrium is swollen and tender, but without effusion. The uterus is movable, but its movement causes pain. It is enlarged, tender, and often retroflexed. The ovaries are also swollen and tender. Behind and to the sides of the uterus are felt the above-described small tumors, which are very tender and somewhat movable, or a bundle of tender, movable cords which impart a feeling like a bunch of angle-worms.1

Diagnosis.-The tumors are much smaller and situated lower down. than the ovary, not so movable, and when pressed do not cause the sickening pain elicited by pressure on the sexual gland.

Their own mobility and the mobility of the womb distinguish them from cellulitis.

The movable, worm-like cords are pathognomonic of lymphangitis. Treatment. When endometritis is the cause, it should be treated according to the rules laid down for that disease (pp. 392 and 399). Iodine (p. 165) and ichthyol glycerin (p. 173) should be used in the vagina. Packing of the vagina (p. 173) gives much relief and makes the swelling disappear. Iodoform suppositories (p. 218) are useful both as anodynes and as resolvents. It is recommended to use inunctions of Ung. hydrargyri (20 parts) and Ext. belladonnæ (1 part) on the hypogastric region. Galvanism has also proved beneficial. In extreme cases it may be justifiable to try to favor involution of the hyperplastic uterus by amputation of the cervix (p. 428). If the patient is affected with scrofula or syphilis, the usual remedies for those diseases should be combined with the local treatment.

The great tenderness of the tumors, even in chronic cases, speaks also against their being glands, for chronically inflamed lymph-glands, which are so common in scrofula and syphilis, are not sensitive to touch.

CHAPTER VIII.

SARCOMA AND CARCINOMA OF THE PELVIC PERITONEUM AND CONNECTIVE TISSUE.

CANCER of the pelvis is usually only part of a similar affection spread over a larger territory or a direct propagation by continuity from neighboring organs. Thus, carcinoma of the broad ligament appears in connection with the same affection in other parts of the peritoneum, or begins as carcinoma of the uterus or the ovary. But both sarcoma and carcinoma may start as a primary disease in Douglas's pouch, and carcinoma may begin in the lymphatic glands. Sarcoma may form a large tumor behind the uterus, pushing this organ forward. Medullary carcinoma often appears as a relapse in the cicatrix after removal of the carcinomatous uterus.

The malignant nature of these affections is proved by the cachexia which rapidly follows their advent. It is rarely possible to do anything of therapeutical value for them, except in the cases of relapse after hysterectomy. A patient who has had her uterus extirpated should be examined every few months for many years, and as soon as a local relapse appears the diseased tissue should be cut away and the wound cauterized.'

CHAPTER IX.

HYDATIDS (ECHINOCOCCI) OF THE PELVIS.

HYDATIDS are so rare that few physicians have had opportunity to see a case, but of the entire number reported 4 per cent. were situated

1 Dr. M. D. Jones has reported a case in which a carcinomatous tumor of the size of an orange in the pelvic floor was combined with a similar affection of the ovaries. She removed all the diseased tissue, and made a microscopical examination that is of great interest, because it proves that the so-called inflammatory infiltration that surrounds a carcinoma to a distance of a quarter to half an inch is in reality a precursory stage of carcinomatous infiltration, the inflammatory corpuscles shaping themselves into the epithelial cells characteristic of carcinoma, and that the disease spreads by such cancer-cells being transmitted into the lymphatics and causing thrombosis of, and carcinomatous infection around, them (Medical Record, March 11, 1893, vol. xliii. p. 292).

2 Personally, I have only seen one case, and that was in the liver (Proceedings of the Medical Society of Kings, Brooklyn, N. Y., 1876, vol. i. No. 5, p. 123). In the above description I chiefly follow W. A. Freund, who, living for many years in an echinococcus district, has had the rare opportunity of treating eighteen cases of hydatid disease in the true and false pelvis, and who has described them in his Klinik der Gynäkologie, vol. i. pp. 299-326. Four of these he has previously described, conjointly with J. R. Chadwick of Boston (Amer. Jour. Obst., Feb., 1875, vol. vii. pp. 668-679).

in the pelvis; and the disease is by far more common in women than in men.1

Pelvic hydatids are most common in the connective tissue of the posterior part of the pelvis near the rectum, but are also found in the uterus, the ovaries, the broad ligaments, the anterior part of the pelvis, and anywhere in the bones. As a rule, the animal consists of a mother-cyst with endogenous or exogenous daughter-cysts. The multilocular, or alveolar, forin has never been found in the pelvis.

The echinococcus may enter the pelvis as a germ or reach it by extension from another part of the abdomen. Beginning in the pelvis, the cyst may rise above the superior strait or follow the connective tissue of the pelvis, press down on the perineum, grow out through the great sacro-sciatic foramen or the crural canal, and extend up on the anterior wall of the abdomen. In consequence of pressure from . neighboring organs the animal may die, the fluid become turbid, purulent, or sanious, and the vesicles be broken up into shreds. Rupture may take place into the bladder, or exceptionally into the uterus or the vagina, but never into the peritoneal cavity-the peritoneum, on the contrary, always becoming thickened. Such rupture may lead to

a cure.

Etiology. The disease is due to the entrance into the body of the eggs of the Tania echinococcus of the dog. As a rule, the entrance takes place through the mouth, but some women allowing their genitals to be licked by dogs for libidinous purposes, it is not impossible that the germs might be brought directly into the genital tract instead of passing through the alimentary canal. The disease is endemic in certain parts of the world, such as Australia, Iceland, Mecklenburg, and Silesia.

Symptoms. The disease may exist for years without impairing the general health or even causing much local trouble. Attention is first called to it when it causes dyschezia, dysuria, or dystocia, and often it gives rise to leucorrhea or menorrhagia. Later the nutrition suffers, the patient loses flesh, and she may become feverish, either when suppuration sets in or when the constitution becomes undermined. In consequence of pressure her feet may swell, her legs become paralyzed, she may have sciatic neuralgia or hydronephrosis, and even intestinal obstruction may develop. Death is often due to the presence of an echinococcus cyst in another organ.

Diagnosis.-The disease being nearly exclusively limited to certain regions, geographical considerations may give a hint as to its exist

The Icelandic physician Jon Finsen personally treated 245 cases of echinococcus disease. Of these, 172, or more than 70 per cent., were in the female sex ( Ugeskrift for Læger, 3d series, 3d vol. Nos. 5-8, Copenhagen, 1867). A French translation, made by myself from the Danish original, is found in Archives générales de Médecine, Jan. and Feb., 1869, vol. i. pp. 23-46 and 191-210).