On taking the chair, Dr. BARNES said:

I do not know how I can express my thanks for the very unexpected honor of being called upon to preside over this Section-one of the most important connected with this Congress. In England we recognize the value of this branch of study, but there is no country that can claim superiority over America in the development of the science of Obstetrics. Your writers are acknowledged as authorities, and, as you are in the lead, it is incumbent upon you to cultivate and improve your discoveries. It is incumbent upon us all to cultivate the practice of obstetrics, for it lies at the very root of the human race. I have been asked why I did not attend a congress in St. Petersburg, which may be called a great medical centre. I preferred to come here, and yet it seems singular to leave the centre and come to what we might call the outside. It is no slight task to spend three weeks of one's holiday on the stormy ocean, but our assembly to-day is an event-it might be called an epoch-in the History of Medicine. I cannot sufficiently express my sense of the honor conferred upon me. I hope to hear some interesting discussions upon the topics brought before us, and have no doubt that I shall go back to my home wiser than when I came.

THE CAUSES AND TREATMENT OF NON-PUERPERAL HEMORRHAGES OF THE WOMB.

BY

WILLIAM H. BYFORD, M.D.,

PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN IN THE CHICAGO MEDICAL COLLEGE.

THE short time at my disposal makes it impossible for me to give anything more than a brief outline of the etiology and therapeutics of uterine hemorrhage, and I shall, therefore, confine myself to a succinct expression of the views which may be fairly sustained by our present knowledge of the subject.

Without stopping to discuss at length the meaning of the terms applied to uterine hemorrhages, I may say that I shall use the words "uterine hemorrhage" and "metrorrhagia" in the same sense, and shall apply them to such losses of blood as occur between the menstrual periods, or in unusual amounts at the time of the periods themselves. An excessive, or too long-continued, flow of blood at a menstrual period is practically neither more nor less than metrorrhagia, originating in like causes, and amenable to the same treatment.

CAUSES OF METRORRHAGIA.

Non-puerperal hemorrhage is properly regarded as a symptom, and the consideration of its causes brings to our attention a great variety of local and general pathological conditions. Exceptional cases of metrorrhagia sometimes result from direct violence to the uterus, or from sudden and severe shocks to the system, which apparently act upon the uterus in common with other organs, and cause it to bleed because of its inherent tendency to do so. The pathological causes which induce uterine hemorrhage do not always-perhaps do not generally-act singly, but two or more of them are found associated in most cases, some being essential, and others merely auxiliary. The uterus, by virtue of the conditions upon which menstruation depends, is naturally a hemorrhagic organ; and it is in consequence of its anatomical and physiological peculiarities that the ordinary and frequently acting causes of uterine hemorrhage are rendered so potent and effective.

The more obvious phenomena of menstruation are doubtless the result of a definite reflex nervous influence exerted by the ovaries upon the uterus. Although this influence is more distinctly manifested in the great hyperemia which precedes the occurrence of the catamenial discharge, and the changes in the utricular glands and mucous membrane of the womb, yet it is unquestionably constant in its action and parallel in this respect to that which presides over the motions of the heart, the arteries, and the alimentary canal. Generated in the nervous apparatus of the ovaries, and contemporaneous with the changes called ovulation in those organs, this influence is probably conveyed by afferent nerves to the genito-spinal centre (the existence of which was first established by

Budge, of Greifswalde'), or to some other reflecting ganglion, whence it is sent back to the uterus, giving rise to a wonderful series of tissue-changes during the month. Some of these changes have been lucidly described by Dr. John Williams, in the Obstetrical Journal of Great Britain and Ireland, and by our own talented young countryman, Dr. Engelman, in his recent essay upon the subject, published in the American Journal of Obstetrics. These changes are aptly termed by Aveling, nidation and denidation.

A few days before the menstrual flow makes its appearance, the whole uterus, and especially its mucous membrane, becomes greatly hypertrophied and very vascular; when the discharge begins, the membrane is invaded by fatty degeneration. This process is so rapid that, in four or five days, the entire mucous membrane disappears, leaving the muscular structure of the inside of the uterus exposed, while some remnants of the utricular glands are left, and found entangled among the denuded fibres. As soon as the monthly flow ceases, a reproduction of the membrane is commenced, and it continues to grow until at the end of twentyeight days its menstrual maturity is attained. Accompanying these changes in the cavity of the uterus are others equally remarkable, affecting all the other tissues of the organ. The blood vessels become enlarged, and circulate an increased amount of blood; the fibrous tissue is developed beyond its inter-menstrual condition; while hyperesthesia indicates extraordinary nervous endowment. In fact a true hypertrophy of the uterus occurs. During the discharge, the process of involution reduces the organ to its smallest dimensions, and the hemorrhage ceases. The culmination of this hypertrophy in the discharge of blood from the uterus is doubtless not merely an accompaniment, but a consequence of the breach of capillaries in the mucous membrane. These of course are physiological phenomena, but I desire to invite attention to the fact that they strongly resemble pathological conditions, and would be so considered in any other organ in the human economy. Moreover the dividing line between health and disease in uterine hemorrhage is as difficult to trace as that between sanity and lunacy.

It is not difficult to understand that an exaggeration of the hyperæmia, or an unusually rapid disintegration of the uterine mucous membrane, would cause more than a normal amount of flow; nor that a want of accordance in time might be followed by the same result. Indeed most cases of uterine hemorrhage are traceable to conditions which disturb the equilibrium of these phenomena. The causes which thus act are varied and numerous.

Morbid nervous influences which increase the discharge of blood from the uterus, sometimes emanate from the nervous centres, and hence may be properly termed centric; much more frequently, however, they are reflected through the nervous centres from other and sometimes distant organs, and these last are entitled to the denomination of reflex or eccentric nervous influences.

Mental and emotional excitement emanating directly from the brain, and cerebral and spinal excitement originating in inflammation or functional exhaustion of the brain or spinal cord, are examples of centric etiological influences. Many years ago I witnessed the ravages of an

Ueber das Centrum genito-spinales des N. sympatheticus. Virchow's Archiv f. Path. Anat. und Klin. Med., Band XV., S. 115-126, and Chicago Journal of Nervous and Mental Diseases.

epidemic of cerebro-spinal inflammation, in which uterine hemorrhage was of almost universal occurrence among those adult females who fell under its influence.

Morbid reflex nervous influences afford a more numerous class of causes. First among them, both in frequency and importance, are those arising from abnormal conditions of the ovaries, such as congestion, inflammation, displacement, and erotic excitement. Next to the influence of these bodies is that exerted by the mammary glands. Menstruation is generally more profuse when it occurs during lactation. The effect of mammary irritation in causing congestion of the uterus, and thus promoting hemor rhage from it, is well illustrated by the familiar fact that sinapisms or blisters applied to the breasts will often cause metrorrhagia. Vesical irritation or inflammation, which gives rise to tenesmus; rectal irritation, as from the presence of hemorrhoids, or ascarides; and dysenteric inflammation, through the reflex influence which they exert upon the uterus, are generally recognized causes of uterine hemorrhage. Among other reflex causes may be mentioned certain forms of indigestion, hepatic congestion and inflammation, and some of the disturbances of the small intestines, as may also strong impressions upon the cutaneous surface, as from cold, or from the long-continued application of heat in warm climates and seasons.

All of these last-mentioned causes I think act through the reflex system of spinal nerves, and perhaps also through the agency of the sympathetic ganglia which perform a reflex function between the viscera. The morbid effects of the various reflex nervous impressions are rendered more effective and intense by the presence of such uterine diseases as predispose to hemorrhage by increasing the vascularity of the uterus.

Many pathological conditions which conduce to the production of uterine hemorrhage, independently of direct nervous influence, act by increasing the hyperemia of the uterus. When the mucous membrane is granulated, or is the seat of inflammation, of fibrous polypus, or of malignant fungus, the circulation of the uterus is increased, and harmony in the process of nidation disturbed; and these conditions will be accompanied by an unusual and long-continued flow of blood. Subinvolution, congestion and inflammation, hyperplasia, tuberculosis, cancerous and fibrous deposits in the muscular structure, and chronic and acute endometritis, in addition to preventing the normal deciduous changes in the mucous membrane of the uterus, maintain a permanent hyperæmia, and thus render the womb prone to large losses at each return of the menstrual period. We have in fact abundant reasons for assuming that chronic hyperemia, no matter how produced, will, by virtue of the malnutrition connected with it, prevent menstrual changes from being effected in an orderly manner, and thus render the mucous membrane more frail in organization, and consequently incapable of resisting the force of vascular pressure to which it is periodically subjected.

Besides the causes of uterine hyperemia last alluded to, and existing within the tissues of the womb, there are many other outside pathological conditions acting in a different way. Some of these cause venous hyperæmia by mechanical retardation of the circulation, while others give rise to both arterial and venous hyperemia by nutritional attraction, and others again cause arterial hyperemia alone, by forcing unusual amounts of blood into the organ. Among the most frequent and important causes of venous retardation are displacements and flexions of the uterus-procidentia, retroversion and retroflexion-the former by stretching the

veins and rendering their course more tortuous, the latter by twisting them and thus lessening their calibre; exudations into the cellular tissue and peritoneal pouch, from cellulitis and local peritonitis, and effusions of blood in the cul-de-sac of Douglas, in retro-uterine hematocele, by pressing upon the veins, prevent a free return of blood from the uterus, and thus cause venous hyperæmia. Retardation of movement in the uterine veins may also be caused by obstruction to the venous circulation quite remote from the womb, as by the pressure of a tumor upon the ascending vena cava, by a loaded condition of the large intestines, by dislocation or enlargement of the liver, by obstruction to the free passage of blood through the heart from valvular disease, and even by certain pulmonary affections.

In the class of causes giving rise to both arterial and venous hyperæmia, may be mentioned fibrous, fibrocystic, polypoid and fungous growths of the fibrous structure of the uterus. These all increase the flow of blood to and through the vessels of the uterus, both arteries and veins are increased in capacity, and to these changes is added general hypertrophy. In these cases, the hyperemia of all the tissues is sometimes enormously great, and the losses of blood are proportionally large and dangerous; the hemorrhage, unlike that from venous obstruction, is not checked by the emptying of the vessels, but continues until the arterial and cardiac visa-tergo is weakened by approaching syncope.

Causes producing arterial hyperæmia alone, are hypertrophy of the heart, general plethora, febrile excitement, and violent exercise. The uterine hyperæmia in these cases is caused by unusual arterial and cardiac pressure alone. When not attended by local pathological conditions, the hemorrhage in these cases is not apt to be serious.

Other not uncommon causes of hemorrhage from the womb are various diseases of the blood. Among these may be mentioned scurvy, leucocythæmia, chlorosis, albuminuria and syphilis. It is not likely that the vice in the composition of the blood is the sole causative influence operating in the above-named conditions. In scurvy, for instance, we know that the solid tissues-whether as a primary condition or as an effect of the blood-changes-are diseased, the capillaries more fragile than natural, and consequently less capable of resisting the cardiac impulse. As evidence that the vicious condition of both blood and solid tissues is the cause of uterine hemorrhage in scurvy, the well-known fact may be added that bleeding is very easily provoked in other mucous membranes. It is the more likely to take place from the mucous membrane of the uterus, because of the great normal fluctuations in the circulation of that organ, and also because the vitiated state of the blood would naturally cause disturbance in other conditions attendant upon menstruation, especially the decidual changes. It will be seen therefore that the peculiarity in the operation of this variety of cause, is not due to the presence of local or general hyperemia from retardation of the venous circulation, or from arterial and cardiac pressure, but is due to the tendency of the blood to escape through the walls of the vessels, and to the inability of the capillary tubes to resist the circulatory force ordinarily applied to them.

As another cause of hemorrhage from the womb, must be mentioned the well-known law of the human system to continue a long-established habit, after the original cause is removed. This is probably the only rational explanation of those rare uterine losses which are sometimes observed in pregnancy, and in cases where both ovaries have been re